Meeting the Needs of Justice

Involved Women:

A Local Health Department’s

Experience

June 2013

Presented by Rita Nieves, RN, MPH, LCSW

Bureau Director, Addictions Services

Boston Public Health Commission

Presentation Goals

Provide background and context about the needs of justice involved women

Provide overview of Safe and Sound Return Project study and significance

Describe challenges and barriers these women face in re-entering the community from incarceration

Discuss implications for policy, treatment and research

A Growing Problem

Over the past decades, the number of incarcerated women has increased significantly. 1

Women now represent 7% of total incarcerated population.

A total of 112,822 women were incarcerated in federal and state prison systems at the end of the year 2010.2

1 (Sabol & Couture, 2008) .

2 (Guerino, Harrison, & Sabol, 2011). .

3 (Sabol, West, & Cooper, 2009).

.

Nature of Problem

Majority of women are incarcerated for drug and property related crimes in comparison to men, whose majority are incarcerated for violent crimes1

Women of color are disproportionally affected by incarceration: the rate for black women is 3.8 times greater than the rate for white women and Hispanic women at 1.6 times. 2

More than half (65%) of women in state correctional facilities are mothers to minor children.3

Have consistently documented higher rates of substance use disorders, mental health problems and extensive histories of childhood and adulthood trauma in comparison to male offenders and women in the general population.4

.

1 (Sabol, West, & Cooper, 2009).

2. (Sabol, Minton, & Harrison, 2007).

3. (Allard & Lu, 2006).

4. (Abram, Teplin, McClelland, & Dulcan, 2003; James & Glaze, 2006; Karberg & James, 2005; Wolff, Frueh, Shi, Gerardi, Fabrikant, & Schumann, 2011

.

What is Safe and Sound Return?

Safe and Sound Return (SSR) is a program designed to

meet the needs of women re-entering the community

from incarceration who have a history of substance abuse.

Developed through funding from Substance Abuse and

Mental Health Administration (SAMHSA).

Implemented within the Boston Public Health

Commission’s (BPHC) outpatient substance abuse

treatment program for women.

Provided specialized outpatient substance abuse treatment

to justice involved women.

Project Goals

Through the development of a multi-agency service network, enhance BPHC’s capacity for serving women recently released from jail or prison

Improve women’s treatment outcomes and overall family functioning and successful community re-entry by providing them with outpatient substance abuse treatment and reentry case management support services that are: ◦ comprehensive and integrated

◦ high quality

◦ culturally competent

◦ gender-specific

◦ trauma-informed

Services Provided

Biopsychosocial Assessment

Individualized Treatment Planning

Individual and Group Counseling

Case Management including assistance with housing, education, childcare, etc.

Wraparound support services including childcare, T (public transportation) passes and meals to support engagement in the program

Key Interventions Delivered

Trauma Recovery & Empowerment Model (TREM): 25-session psychoeducational

and skills-building group

Mindfulness-Based approach to Relapse Prevention (MBRP): 8-session skills

building group for stress reduction and relapse prevention

Spirituality in Recovery: 6-session intervention designed to assist clients in evaluating

their spiritual traditions and defining the meaningful and helpful components of those in

order to increase their sense of spirituality and support their recovery process

Economic Success and Recovery: 8-session educational curriculum designed to

assist women in examining how money management is related to the recovery process,

and basic financial management skills to support their recovery

Women's Leadership and HIV/AIDS Prevention Training Institute: 5-session

intervention that teaches women how to utilized leadership skills to protect themselves

from HIV and STIs.

Substance Abuse and the Brain: 5-session intervention that teaches women of the

effect of drugs on the brain's structure and functioning.

Re-entry Entrepreneurship Training

Developed by Northeastern University Institute on Urban Health Research in collaboration with the College of Business Administration.

Goal: To assist women following release from incarceration and provide a model for an effective and workable reentry program based upon entrepreneurship education and practices.

Why Entrepreneurship?

Entrepreneurship programs have been shown to work in the reentry process for incarcerated women by: a) providing alternative employment; b) improve the self-image; and c) empowerment. Sonfield (2008)

Lindah and Mukamal (2008) have shown that many incarcerated women have extensive experience as entrepreneurs but have been involved with illegal businesses related to criminal activities.

Entrepreneurial programs have been established for women in New York, Maryland, Virginia, Ohio, and Oregon and for men in Texas, Illinois and New Jersey.

These programs report that a high percentage of prisoners upon re-entry either start their own business, usually successfully, or are good employees in established business.

Overview of Intervention

Participants receive 10 half days of intensive entrepreneurship training including:

Required skills for developing entrepreneurial potential; generating ideas and defining the business; opportunity analysis business roadmap and building a new venture team

Applied learning through work on individual and group projects with NEU MBA identify business opportunities and develop business plans

Concentrated 2-day session focused on starting a successful business, organizing the venture and project presentations

Lessons Learned

Implementation was successful despite longer-than-anticipated development phase

Ongoing challenges to recruitment

◦ Required intensive participation of 10 half-day

sessions in the context of an already demanding schedule of intervention services presented challenges for many women to participate

Became clear that this part of the program might be best suited for delivery at a later stage in treatment.

Participant Testimonial # 1

Tawanda’s Story: Tawanda, a participant in the original Entrepreneurship Pilot, shared that she has been dealing with a lifelong struggle with addiction. Between short periods of sobriety, she spent many years cycling in and out of the criminal justice system for various crimes related to her substance use. Prior to participating in SSR and Entrepreneurship, she expressed living a life of overwhelming “insecurities” and a lack of “courage” to move forward with her life. “I felt stuck and not good enough.” Of her experience in Entrepreneurship, she explained that the training “changed her life” and gave her “hope and promise to have a new life”. Specifically, she stated that the training helped her to “open-up to communicate with others and to go back to school for my GED”. Today, because of SSR and the training she received through Entrepreneurship, Tawanda says she has a voice, a family and a future. She is currently attending GED classes four days a week and has been in recovery for over one and half years; her longest period of sobriety ever. She also makes gift basket to sell volunteers and gives speeches to the new SSR/Entrepreneur participants and has spoken in ENT graduations.

Participant Testimonial #2 Crystal’s story: At age 19, Crystal was homeless, running the street and

using “all kinds of drugs”. It was this lifestyle that led to her spending nine months in the South Bay House of Corrections for drug possession. In finishing out the last nine months of her sentence at McGrath House, a pre-release program for women re-entering the community from incarceration; Crystal met a counselor from the SSR project who was running a trauma recovery group on-site for women living in the house. Upon her release from McGrath House, Crystal remembered the counselor and the program, and decided to continue her treatment with the SSR Project. It was here that she was invited to the join the Entrepreneurship Training program. When speaking of the Entrepreneurship Program, Crystal shares that it helped her to “find herself” and gave her the confidence to see that she could “do a lot of things that she never realized she had the ability to do”. It was this new found confidence and hope for the future that led her to re-establish her relationship with her family and move back to Maine where she was able to re-gain custody of her 3 year old son and began the process of going back to school. Today, Crystal is 25 years old and has been sober for over two years. Her hope for the future is to finish school and get her bachelor’s in psychology with a concentration in substance abuse so she can help young kids from going down the same path she did.

Participant Testimonial # 3

Brittany’s Story: Brittany, now a pregnant mother of two, began drinking at age ten. In August 2011 at age 27, she was arrested and detained for possession of heroin. When she was released, she came to the Mom’s Project and found out about the SSR project. Today, Brittany, who has been sober for over 14 months, has successfully completed all program phases, including the Entrepreneurship Training program. Of her experience at Safe and Sound Return, Brittany says that the structure and information she received there are the tools that she had been missing to living a healthy and sober life. And when asked what she learned through Entrepreneurship, Brittany shares that she “learned more about herself and what she was capable of”. She also expressed her desire that the program help her reach her goal to someday become a substance abuse counselor and work with kids because “that’s where it starts”, and that if someone had been there for her at the age, her life would have been different.

LOGIC MODEL

Resources (Inputs)

•Staff

• Interdisciplinary & diverse team: H. Amaro, PhD; R. Nieves. RN, MPH Director of BPHC, Bureau of Addictions Services; Clinical Coordinator; Clinicians; Reentry and Recovery Coach; Clinicians; Evaluation Team; Consultants; Suffolk County House of Correction; Framingham Correctional Institution; Interagency and Interdisciplinary Resource Team; Other resources at BPHC; Health & Social Service Agencies

Program Components

(Activities)

•Enhancements to systems linkages elements

•*Implement SSR and develop offender reentry treatment partnership that links reentry planning, community-based substance abuse treatment and other services.

•*Implement formal mechanisms for discussion & planning of service coordination and integration (IRT and training activities)

•Enhancements to service level elements

•*Integrated, comprehensive, gender specific outpatient treatment services for women with co-occurring SA & MH services that integrate trauma, mental health, substance abuse, employment, housing, HIV prevention, and community integration (APIC model case management, TREM, WLTI, MBRP, Entrepreneurship interventions)

•Service Expansion

•*Increase BPHC’s capacity to serve an additional 195women

Outputs

(Objectives)

•Build BPHC’s capacity to address treatment needs of women with co-occurring SA & MH.

• Improve access to reentry community based services for women and their families.

•Enhance system/linkages and services and treatment elements.

• Increase clients’ and family members’ participation in SSR service coordination, treatment and integration activities.

• Improve client’s coping and stress management skills.

Outcomes(Goals)

•Outcomes:

•*Reduce alcohol and drug use and addiction severity

•*Improve mental and physical health

•*Reduce trauma exposure and trauma symptomatology

•*Reduce drug and sexual HIV risk behavior

•*Improve social functioning such as increase in employment and reduction in criminal activities

Key Stakeholders Organization Responsibility

Boston Public Health Commission Provide direction, coordination, monitoring, and

evaluation of projects long term sustainability

Ensure project participants access to BPHC’s continuum

of gender specific addiction treatment services

Coordinate all systems/linkages activities proposed by

SSR

Ensure reentry services are provided in a comprehensive

and integrated manner

ABCD, Health Services Provide outreach and recruitment and reentry planning at

Suffolk House of Corrections, MCI Framingham, and pre-

released women at McGrath House

Correctional facilities Connecting women to substance abuse services post-

release

South Bay House of Corrections (SBHOC) Work closely with SSR staff and ABCD Reentry Case

Manager to facilitate recruitment of project participants

Facilitate referral of project participants to substance

abuse education, skills building, and psycho educational

groups within SBHOC

The Institute on Urban Health Research at

Northeastern University

Conduct the evaluation and implementation of reentry

entrepreneurship training program

Northeastern School of Business Assist in the development and implementation of the

Entrepreneurship program

SAMPLE CHARACTERISTICS

Baseline Sample Follow-up Sample p-value*

n % n %

127 100 84 100

Age 0.60

18-29 41 32.3 26 30.9

30-39 49 38.6 35 41.7

40+ 37 29.1 23 27.4

Race-ethnicity 0.63

Latina 24 18.9 16 19.1

White, non-Hispanic 61 48.0 38 45.2

Black, non-Hispanic 42 33.1 30 35.7

Puerto-Rican 0.69

Yes 20 15.8 14 16.7

No 107 84.2 70 83.3

Education 0.18

< 8th grade 7 5.5 7 8.3

9-11th grade 43 33.9 25 29.8

High school/GED 49 38.6 33 39.3

> High school/GED 28 22.1 19 22.6

SAMPLE CHARACTERSITICS, CONTINUED Baseline Sample Follow-up Sample p-value*

n % n %

Pregnant 0.36

Yes 10 7.9 7 8.3

No 117 92.1 77 91.7

Number of children 0.67

0 19 15.0 11 13.1

1 17 13.4 11 13.1

2 31 24.4 23 27.4

> 3 59 46.5 38 45.2

Unknown/Missing 1 0.7 1 1.2

Any child living with someone else due to a

court order

0.47

Yes 43 33.9 31 36.9

No 50 39.4 33 39.3

Unknown/Missing 34 26.8 20 23.8

Summary of Findings

Found significant improvements from baseline to 6-month post-assessment in the following areas:

◦ severity of PTSD

◦ mental health symptoms

◦ perceived stress

◦ housing

◦ arrest

◦ sexual risk behavior

A positive trend between measures at treatment entry and at 6-month follow-up was found in substance use coping behaviors.

Participants who stayed in the program longer than 180 days showed a significantly greater improvement than women with shorter stays.

Obstacles to

Effective Reentry

Strategies Utilized

Lack of coordination

between correctional

institutions and community-

based treatment and services

Developed formal mechanisms between correctional and treatment

institution staff, community based agencies and community

treatment staff to facilitate discussion and planning of service

coordination, integration and policy issues

Relapse and Recidivism Provided gender-culturally tailored relapse prevention approaches

designed specifically for criminal justice populations including skills

building groups on substance abuse education and relapse

prevention planning to address triggers, cravings, handling high-risk

situations, building drug-free friendships, strategies to face

reunification with family members who actively use substances or

who condone substance use within the home and examining

alternative safe and drug free housing arrangements

Low levels of education and

unemployment

Addressed special needs of women including childcare,

transportation, job preparedness and coaching, outstanding issues

related to criminal records and development of realistic goals based

on their current level of skills and experience history.

Lack of Safe and Affordable

Housing

Developed housing plans before release from incarceration in order

to identify safe and drug-free living arrangement;

Established partnerships with local housing and publicly subsidized

housing agencies; and

Provided housing case management and advocacy

Significance

Results highlight an urgent need for

comprehensive gender-responsive

trauma-informed substance use and

mental health treatment services that are

integrated with case management

designed to respond to a wide range of

needs of women who have been recently

released into the community from

incarceration.

LESSONS LEARNED AND IMPLICATIONS

Finding Recommendation

Need to continue to identify effective

strategies to engage and recruit women

re-entering the community from

incarceration into services.

1. Ensure ongoing training of program staff on

outreach and engagement strategies for women in

the target population

2. Continue to enhance and expand early

engagement activities prior to women’s release

and enhance recruitment efforts for post-release

services

Wraparound services connecting pre-

and post-release services are critical to

continued participation post-release.

Allocate additional resources and support to provide

enhanced support services to women in the areas of

housing, educational/vocational and job training.

Engagement of family members and

current partners remains a challenge.

Especially when family members may present risk to

women’s recovery and long-term sobriety, helping

them to build other supportive relationships and

networks is key.

High rates of trauma and co-occurring

substance abuse and mental health

problems among suggest a continued

need for integrating trauma-informed

services and enhancing recovery

support services into post-release

substance abuse treatment.

Continue to invest in programs and professional

development to increase and further develop

programs’ capacity to provide integrated, trauma

informed treatment services and comprehensive

recovery support services that respond to a wide

range of needs among women in reentry.

Q & A