This series of posts explores whether involuntary confinement and incarceration constitute appropriate responses to the challenges faced by women involved with the criminal justice system. The first post reviews what is known about the effectiveness for women of mental health, trauma and substance use treatment in a prison or prison-like facility. Women who have lived through these sorts of programs share their experiences and viewpoints in later posts.
Under the direction of the Baker Administration, the Commonwealth of Massachusetts is poised to spend $50,000,000 building a new prison for women. While the planning is proceeding without public input, the (meager) statements issued by the Baker Administration emphasize mental health services and treatment for women suffering from substance use and trauma. The idea seems to be that this will be a “good” prison with an explicit therapeutic mission – a mission that rests on disproven assumptions that healing can take place in situations of coercion and confinement.
In Massachusetts (and nationally), women of color, as well as LGBTQ+ women are significantly more likely than white and heteronormative women to be sent to jails and prisons. Across all demographic groups, Massachusetts women are nearly always incarcerated on minor, non-violent charges (including violating probation) and serve sentences of less than one year. The vast majority of criminalized women live with health challenges and experiences of abuse and assault. In the wake of these experiences, many have spent years or decades cycling through juvenile facilities, drug treatment centers, and homeless and battered women’s shelters — both before and after stints of incarceration.
Mental Health and Trauma-Informed Care in Prisons
Oxford University psychiatry and psychology researchers Isabel Yoon, Karen Slade and Seema Fazel carried out the most comprehensive and systematic review of randomized clinical trials of psychological therapies in prison. While several types of therapies showed a moderately positive short-term effect, the studies clarified that these effects were not sustained even three to six months later.
The experiences in women’s prisons are consistent with Yoon, Slade and Fazel’s findings. In a 2020 study of women’s mental health service utilization in prison, Severson, Toman & Alvarado found that mental health services can be useful in terms of protecting some women from some of the strains of being in prison! There is little evidence, however, that these services are of much benefit post-release.
Several studies look more specifically at gender-sensitive and trauma-informed programming in prisons. In one of the most rigorous studies of the field, Rachael Swopes, Joanne Davis and James Scholl evaluated a four-month integrated trauma and gender-sensitive treatment program called Helping Women Recover/Beyond Trauma (HWR/BT), which was supplemented with modules on domestic violence, relapse prevention, and a 12-step program. Ninety-five incarcerated women who participated in the program were matched with 56 incarcerated women in a control sample. No differences were observed for posttraumatic stress disorder (PTSD) symptoms and substance-related self-efficacy, depression, dissociation, tension reduction, or anxious arousal. In other words, the program had no impact on the women who went through it.
These findings should not be surprising. Prisons are challenging settings for trauma-informed care. Even when efforts are made to decorate the common areas and limit the obvious presence of locks and bars, prisons are full of trauma triggers such as unexpected noises, sounds of distress from other people, barked orders, and looming threats of punishment for breaking any one of myriad rules, not to mention pat-downs and strip searches. During incarceration women lose custody of their children, their privacy, social interactions, freedom of movement, and control over time and personal space. Combined with the constant threat of punishment for failure to obey orders, this oppressive environment means that prisons are not conducive to healing from trauma. “For women with serious mental illnesses or other trauma symptoms, restrictive housing can aggravate these symptoms,” explains Barbara Owen, professor of criminology at California State University.
Substance Use Treatment in Prison
Studies of prison-based substance use treatment offer similar conclusions. Nena Messina, William Burdon and Michael Prendergast compared six- and 12-month reincarceration data for 171 participants in an intensive therapeutic community drug treatment program versus a control group of 145 women who did not go through the program at the Central California Women’s Facility. Findings showed no differences between the drug treatment group and the comparison group with regard to six- and 12-month return-to-custody rates. (In contrast, success on parole was strongly associated with participation in community–based services.)
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More broadly, in a review of studies of court-mandated drug treatment of various sorts, Andreas Pilarinos and colleagues found that forced treatment not only does not improve outcomes for substance use but actually leads to higher levels of mental duress. Being ordered into an in-patient facility is associated with persistent homelessness, higher rates of relapse, and increased risk of overdose after discharge. In fact, in Massachusetts people who were involuntarily committed were more than twice as likely to experience a fatal overdose as those who completed voluntary treatment.
What We Know: The Best Available Research Does Not Support Invoking Treatment as Justification for Incarcerating Women
When I began reviewing the literature using the standard academic search engines, I was optimistic about identifying a solid corpus of high quality research that could inform plans for the new facility for Massachusetts women.
After many hours of reading, however, it became clear that nearly all studies are plagued by low rates of participant retention, short-term tracking of outcomes, short-sighted definitions of effectiveness (for example, defining effectiveness by measuring how many people complete a program rather than whether completing a program leads to lasting benefits), and unproven assumptions regarding causation (the chicken and egg quandary). For more on these issues see Werb et al 2016; Yoon, Slade & Fazel 2017
The most rigorous studies are consistent in finding no medium or long-term therapeutic benefits for women who participate in mental health or substance use treatment in prison. This is the case both for conventional treatment programs and for trauma-informed and gender-sensitive treatment.
This research is critical as the Baker Administration moves forward with plans for what is being touted as a kinder and more therapeutic women’s prison. The scholarly literature makes it abundantly clear that women are likely to suffer trauma and re-traumatization when they are locked up, lose their bodily autonomy, and are separated from their children. Prison and involuntary prison-like residential facilities are not and cannot be useful settings for healing from experiences of violence, exploitation and abuse. Even with the kindest of intentions, incarceration is not therapeutic.
I wish to thank my friend and colleague Rachel Roth for helping think through and edit this post.
Check out “No New Jails. Period” regarding a previous plan to build a correctional facility to provide Massachusetts women “access to vital medical services.” Also, see “Civil Commitment: If You Build It They Will Come” for analyses of earlier plans to build additional facilities to confine individuals for civil commitment in the Commonwealth.