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TPJXXX10.1177/0032885515605490The Prison JournalScott et al.
Article
The Prison Journal
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Trauma and Morbidities © 2015 SAGE Publications
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DOI: 10.1177/0032885515605490
Detainees in a Large tpj.sagepub.com
Urban Jail
Abstract
Using data from 810 women entering the Department of Women’s Justice
Services in the Cook County Jail (Chicago) from 2010 to 2013, this study
examines patterns of trauma exposure and the relationship between trauma
exposure and mental disorders. Female detainees averaged 6.1 (SD = 4.90)
types of trauma in their lifetimes, with greater trauma exposure associated
with earlier age of trauma onset, more recent trauma exposure, and higher
rates of fear for life or injury. Higher rates of trauma exposure were also
correlated with higher rates of past-year symptoms of posttraumatic
stress disorder as well as other internalizing, externalizing, and substance
use disorders. Behavioral health programming for female detainees in jail
settings should include more trauma-sensitive mental health and substance
use disorder treatments.
Keywords
trauma, addiction, female detainees, internalizing disorders, externalizing
disorders
Corresponding Author:
Christy Scott, Lighthouse Institute, Chestnut Health Systems, 221 West Walton, Chicago, IL
60610, USA.
Email: cscott@chestnut.org
Since the 1980s, the number and proportion of incarcerated women in the
United States have increased steadily. The war on drugs and punitive crime
control policies were largely responsible for narrowing the gender gap in cor-
rectional populations (Minton, 2012). Women have outpaced men in terms of
not only their comparative growth in jails and prisons (Bureau of Justice
Statistics, 2000; Harrison & Beck, 2004), but also the range and severity of
their behavioral problems. Many more women are in local jails than in state
and federal prisons (Beck, & Karberg, 2001), and these women’s problems are
particularly abundant and serious with respect to substance use and other psy-
chiatric disorders (Green, Miranda, Daroowalla, & Siddique, 2005; National
GAINS Center, 2004).
Current Study
Based on this previous research, the current investigation explored women’s
histories of trauma and current psychological distress using baseline data
from the Recovery Management Checkups for Women Offenders (RMCWO)
experiment (Scott & Dennis, 2012). Specifically, the current study was
designed to illuminate the exposure of female detainees to a wide range of
traumatic events (numbers and types) and the relationship between exposure
to trauma and internalizing (e.g., PTSD and mood disorders) and externaliz-
ing (e.g., attention-deficit/hyperactivity disorder [ADHD] and conduct disor-
der) disorders, as well as alcohol and other substance use disorders.
Method
Procedures
The data for this study were drawn from the RMCWO experiment (Scott &
Dennis, 2012), which included an evaluation of the risk of recidivism for
women entering Cook County Department of Corrections’ (CCDOC) sub-
stance use treatment program. Conducted under the supervision of the
Chestnut Human Subject Institutional Review Board and an independent
Data Safety Monitoring Board, women were recruited for extensive, confi-
dential interviews in accordance with the standards of the Committee on
Human Experimentation. Independent research staff collected the data and
provided the women with informed consent, assuring them that their partici-
pation in the study was voluntary. The data were collected under a federal
certificate of confidentiality to prevent any subsequent forced disclosure of
participants’ responses. Participants were offered refreshments, allowed to
take breaks, and provided an incentive. Overall, the process was a respite
from the typical jail routine.
Recruitment Site
The women were recruited while awaiting the disposition of their cases in the
CCDOC. The CCDOC is the largest single-site jail in the United States in
terms of daily population and rated capacity, houses an average of nearly
10,000 detainees each day, and is located in the City of Chicago on 96 acres
of property (Olson, 2013). Women constitute nearly 13% of CCDOC’s popu-
lation and are charged mostly with drug, property, domestic violence, driving
under the influence (DUI)/traffic, and prostitution offenses (Escobar &
Olson, 2012). This study focused on women who participated in CCDOC’s
Department of Women Justice Services’ (DWJS) gender-specific and gender-
responsive substance abuse treatment program, which offers jail-based (resi-
dential) and furlough-based (outpatient) treatment programs for female
detainees with drug problems and nonviolent charges (Scott & Dennis, 2012).
Participants
The target population consisted of adult female detainees who were reenter-
ing the community from CCDOC’s substance abuse treatment program.
Women were deemed ineligible if they had not used substances in the 90 days
before detention, had no substance use disorder symptoms in the year before
detention, were younger than age 18, lived or planned to move outside
Chicago within the next 12 months, were fluent in neither English nor
Spanish, were cognitively unable to provide informed consent, or were
released before their 14th day in DWJS. Of the 866 women who were eligi-
ble, 810 (93%) agreed to participate and completed the initial interview. Of
those, 3 women did not complete the trauma exposure section. Hence, the
final sample consisted of 807 women.
Most of the participants (82%) described themselves as African American,
followed by 9% as Caucasian, 5% as Latina, and 4% as other/mixed. A small
percentage (6%) of the women were between 18 and 20 years old, 20% were
21 to 29 years old, 29% were 30 to 39 years old, 34% were 40 to 49 years old,
and 11% were 50 years old or older. Nearly three fourths (72%) of the women
reported that they had never been married; 16% had been divorced,
Measures
The measures for this study were drawn from several standardized measure-
ment tools that were contained in the baseline assessment and are summa-
rized below.
Trauma exposure count. The specific trauma experiences included in the inter-
view were based on the Life Stressor Checklist–Revised (e.g., Kimerling, Traf-
ton, & Nguyen, 2006), the National Women’s Survey (e.g., Kilpatrick, Acierno,
Resnick, Saunders, & Best, 1997), and the Global Appraisal of Individual Needs
(GAIN; Dennis et al., 2003).These sources yielded a count of lifetime exposure
to 25 types of life-threatening situations (e.g., major disaster, very serious acci-
dent or fire, being physically assaulted or raped), seeing another person killed,
dead, or badly hurt, or hearing about a horrible incident that has happened to a
loved one. The count varied mostly along a single dimension (α = .97), and was
divided into optimal groups that were derived empirically by performing Chi-
Square Automatic Interactive Detection (CHAID) analyses (Biggs, De Ville, &
Suen, 1991; Ngo, Govindu, & Agarwal, 2015). CHAID creates groups based on
minimizing the within-group variance and maximizing between group variance
of a predictor and uses chi-square statistics between a criterion and the predictor
for segmentation. The percentages meeting criteria for PTSD (Table 2) and
count of 15 disorders (Table 3) were used as criterion variables and the count of
trauma exposures as the predictor. The groups that emerged from those analyses
were 0 to 1, 2 to 4, 5 to 6, and 7 to 25 lifetime exposures to trauma.
Substance use disorders. The GAIN’s Substance Problem Scale measure was
based on the recency (e.g., past month, 2-12 months, more than 12 months ago
or never) of 16 symptoms: 7 corresponding to DSM-IV criteria for dependence,
4 for abuse, 2 for substance-induced health and psychological problems, and 3
for lower severity symptoms of use (i.e., hiding use, people complaining about
use, weekly use). For each symptom endorsed, women were asked to attribute
it to one or more of the substances they had ever used (followed by probes for
“any other” until no more were endorsed). Across alcohol and other drugs
(AOD) and for six classes of substances (alcohol, amphetamine, cannabis,
cocaine, opiate, other), the women were categorized as having a disorder if they
endorsed 3 or more of the 7 dependence symptoms or 1 or more of the 4 abuse
symptoms. Symptom counts for each of the above measures had an alpha
higher than .9 and were categorized based on DSM-IV criteria.
Findings
Trauma Experiences
Overall direct exposure to trauma. As shown in Table 1, female detainees
experienced a wide range of adverse life events. Excluding their current
detention in CCDOC, nearly three-quarters (72%) reported previous stays in
Total (%) 0-1 (%) 2-4 (%) 5-6 (%) 7-25 (%)
Table 1. (continued)
Lifetime exposures to trauma
Total (%) 0-1 (%) 2-4 (%) 5-6 (%) 7-25 (%)
Total (%) 0-1 (%) 2-4 (%) 5-6 (%) 7-25 (%)
Note. Criterion D used items from traumatic stress scale for persistent blame and persistent negative emotions. No items were included for
persistent negative beliefs and expectations. For Criterion E, no items were included for self-destructive or reckless behavior.
PTSD = posttraumatic stress disorder.
Scott et al. 11
Witnessed exposure to traumatic events. Female detainees also noted that they
had witnessed several traumatic events. Such encounters can lead to emotional
distress and dysfunction. Thus, witnessed exposures to traumatic occurrences
have been incorporated in the diagnostic criteria for PTSD (American Psychi-
atric Association, 2013). Specifically, respondents reported that they had wit-
nessed a serious accident (23%), violence among family members (20%), a
robbery or mugging (16%), a person being seriously injured or murdered
(15%), or other extremely upsetting events (8%).
Total (%) 0-1 (%) 2-4 (%) 5-6 (%) 7-25 (%)
Total (%) 0-1 (%) 2-4 (%) 5-6 (%) 7-25 (%)
Note. PTSD = posttraumatic stress disorder; ADHD = attention-deficit/hyperactivity disorder; AOD = alcohol and other drugs.
aEndorsed 5+ past-year symptoms related to traumatic stress that was independent of a specific event or PTSD criteria.
15
16 The Prison Journal
Approximately 35% of the respondents met the criteria for any past-year
externalizing disorder, which included ADHD (18%), conduct disorder
(17%), and pathological gambling (2%). In addition, 39% were diagnosed
with borderline personality disorder and 11% with antisocial personality
disorder—20 and 10 times higher, respectively, than the prevalence of these
disorders in the adult general population (Lenzenweger et al., 2007).
As expected, 92% of the participants had been diagnosed with a lifetime
substance use disorder; the most common were cocaine use disorder (50%)
and opiate use disorder (50%), followed by alcohol use disorder (20%) and
marijuana use disorder (17%). Women met the diagnostic criteria for an aver-
age of 2.6 of these internalizing, externalizing, or substance use disorders;
24% had 2 disorders and 42% had 3 to 14 disorders.
Note the consistent pattern showing that the percentage of women who
met the diagnostic criteria for each internalizing disorder rose consistently
and significantly with increasing numbers of exposures to traumatic events.
For example, the percentage of female detainees who reported symptoms of
any past-year internalizing disorder increased from 3% with 0 to 1 exposure,
to 30% with 2 to 4 exposures, to 47% with 5 to 6 exposures, and to 69% with
7 to 25 exposures (p < .001). Similarly, but somewhat less dramatically, the
percentage of female detainees who reported symptoms of any past-year
externalizing disorder increased from 6% with 0 to 1 exposure, to 21% with
2 to 4 exposures, to 23% with 5 to 6 exposures, and to 38% with 7 to 25 expo-
sures (p < .001). The percentage of female detainees who reported symptoms
of conduct disorder increased from 6% with 0 to 1 exposure, to 11% with 2
to 4 exposures, to 19% with 5 to 6 exposures, and to 26% with 7 to 25 expo-
sures (p < .001). The patterns across and for specific types of substance use
disorders varied more widely, but did generally rise.
As presented in Figure 1, female detainees who reported higher numbers
of exposures were also more likely to have one or more disorders. This rela-
tionship was quite substantial and especially apparent for women who
reported 5 to 6 and 7 to 25 exposures (χ2 = 167.50, p < .001). Among the
former, 22% had 1 disorder and 47% had 3 to 14 disorders; among the latter,
12% had 1 disorder and 65% had 3 to 14 disorders. Nonetheless, in our sam-
ple many of the women had one or more psychiatric disorders, even among
those with 0 to 1 reported exposures to trauma (i.e., 32% had 2 disorders, and
10% had 3 to 14 disorders).
lifetime exposure to trauma rose from 18% with 0 to 1 exposure to 39% with
7 to 25 exposures. However, the percentage of African American women who
reported 2 to 4 exposures (24%) was lower than the percentage of those who
reported 5 to 6 exposures (20%). Among Latinas, the percentage of women
who reported 0 to 1 exposure (31%) was higher than the proportions of
women who reported 5 to 6 exposures (12%), and 7 to 25 exposures (26%).
Among women of Other/mixed race, the percentage who reported 5 to 6
exposures (52%) was nearly 6 times higher than the percentage who reported
0 to 1 exposure (9%).
A significant difference among women of different marriage status was
found (χ2 = 22.76, p < .01). For example, in the highest category of lifetime
exposures to trauma (7 to 25), those who reported being divorced/separated/
widowed also reported the highest percentage of exposures (53%), compared
with those who reported being married/living with someone (45%) or never
married (35%). Also significant was the relationship between lifetime expo-
sures to trauma and age at first drug use (χ2 = 20.00, p < .01). Most notably, a
18
Lifetime exposures to trauma
Total (%) 0-1 (%) 2-4 (%) 5-6 (%) 7-25 (%)
higher proportion of female detainees who reported that they began using
alcohol or other substances at age 13 or younger also reported the highest
percentage of lifetime exposure to trauma (7 to 25 exposures; 51%), com-
pared with those who reported that they first starting using at ages 14 to 15
(38%), ages 16 to 17 (41%), and ages 18 or older (35%).
Discussion
Women in the CCDOC experienced a variety of adverse life events. Repeated
trauma at the higher end of the frequency range was found for all measures of
trauma exposure. Their traumas were quite extensive, ranging from economic
pressures to the witnessing of violence to direct, serious victimization at the
hands of strangers and intimates, including battery, armed robbery, and rape.
All these types of violent victimizations are known to produce symptoms of
PTSD and other types of psychological distress (Breslau, Chilcoat, Kessler,
& Davis, 1999; Lurigio, 2015). Furthermore, female detainees were more
likely to experience recurrent victimizations and other adverse life events
than to experience such incidents in isolation or as rare occurrences.
As demonstrated in the current and many previous investigations, men
and women with repeated exposures to trauma appear to be at higher risk of
developing psychological problems (DeHart, 2009; Hedtke et al., 2008;
Messina & Grella, 2006; Turner, Finkelhor, & Ormrod, 2006). For exam-
ple, PTSD, depression, and substance use disorders are not only coinciden-
tal with lifetime experience of trauma but also increase with the accumulation
of different types of traumatic experiences (cf. Hedtke et al., 2008). Other
studies have found that the number of different types of interpersonal vio-
lence experienced by incarcerated women significantly predicted current
symptoms of depression, PTSD, and substance dependence (e.g., Lynch
et al., 2012). Among female inmates, experiences of interpersonal violence
are clearly linked to entry into the criminal justice system (Carlson &
Shafer, 2010).
A highly consistent finding of this study was the growing percentages of
women in categories with increasing numbers of exposures (i.e., from 0 to 1
to 7 to 25). These incremental rises were found for every type of stressor and
disorder and generally applied across race, age, marriage status, and age at
first drug use. Especially pertinent is the finding that symptoms of PTSD and
other psychiatric disorders were more prevalent among female detainees with
higher numbers of lifetime exposure to trauma. For example, 10% of the
women with no or 1 exposure to trauma reported the symptoms of internal-
izing or externalizing disorders, whereas 65% of women with 7 to 25 expo-
sures reported such symptoms—a sixfold differential.
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This research was supported by a grant
from the National Institute on Drug Abuse (No. DA011174) awarded to Chestnut
Health Systems.
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Author Biographies
Christy K. Scott, PhD, is the director of the Lighthouse Institute and the Illinois
Survey Laboratory, Chestnut Health Systems, Chicago, IL. Her research focuses on
understanding and predicting how people move through the cycles of substance use,
crime, treatment, incarceration, and periods of recovery, as well as how to experimen-
tally test strategies for improving recovery management over time. Publishing widely
on recovery management, how to achieve greater than 90% follow-up rates in longi-
tudinal studies, and intensive data collection with smart phones, she has developed
and tested different interventions for managing addiction over time.
Arthur J. Lurigio, PhD, a psychologist, is senior associate dean for faculty in the
College of Arts and Sciences and a professor of criminal justice and criminology and
psychology, Loyola University Chicago. Named a 2003 Faculty Scholar, the highest
honor bestowed on senior faculty at Loyola, he was named a Master Researcher in
2013 by the College of Arts and Sciences in recognition of his continued scholarly
productivity.
Michael L. Dennis, PhD, is a senior research psychologist at the Lighthouse Institute
and director of the GAIN Coordinating Center at Chestnut Health Systems, Normal,
IL. His research focus is understanding and predicting how people move through the
cycles of substance abuse, crime, treatment, incarceration, and periods of recovery, as
well as how to experimentally test strategies for improving recovery management
over time. He has published widely on recovery management, integrating clinical and
research assessment, measurement, intensive data collection with smart phones, and
evaluation research.
Rod Funk is a research associate at the Lighthouse Institute of Chestnut Health
Systems in Normal, IL. He holds the highest SPSS certification for data mining meth-
ods and modeling. His research interests are in the analyses of complex hierarchical
and intensive data analytic models, as well as the use of clustering techniques to
interpret heterogeneous samples and trends over time.