Part I—Setting the Stage for Treatment

Chapter 1—Women Offenders and Addiction: Research Findings

How best to treat women in our prisons and jails is a new and significant concern for U.S. policymakers. The number of women incarcerated in the United States—once a minuscule number—tripled in the 1980s alone. In the 15 years from 1980 to mid-1995, the number of women incarcerated in U.S. prisons rose by 460 percent, compared to an increase of 241 percent for men (BJS 1995b). The same pattern appears with the jail population. More than three times as many women were in jail in mid-1997 as in mid-1985 (BJS 1998a). On average, the number of women in jail has grown by 10 percent each year from mid-1985 to 1997 (BJS 1998a). These figures represent high present and future costs for these women—both in terms of separation from their families and children and in their inability to contribute economically to U.S. society.

Most of the women entering our criminal justice system are young—under 40 years old—and 8 of every 10 are parents. New findings show that up to 80 percent of the women offenders in some State prison systems now have severe, long-standing substance abuse problems. In 1986, Congress significantly increased the penalties associated with crack cocaine. With the setting of mandatory minimum sentences and “three strikes and you’re out” laws, many women are now being incarcerated who would previously have remained in their communities under criminal justice supervision.

Many of these women are arrested for drug offenses and crimes committed to support their drug habits, in particular theft and prostitution. The drug-dependent women being drawn into U.S. jails and prisons suffer from the multiple risk factors that complicate substance abuse in women—factors of poverty, psychosocial problems, mental illness, histories of trauma and abuse, and involvement in abusive relationships. Many were sexually abused as children.

The Center for Substance Abuse Treatment (CSAT) is convinced that these addicted women can be helped through comprehensive programs designed specifically for women, treating the factors associated with women’s substance abuse. Evidence shows that effective treatment programming does empower these addicted women offenders to overcome their substance abuse, to lead a crime-free life, and to become productive citizens. Effective women-centered treatment—whether in a prison or community setting—benefits a woman and her children and represents a small investment but enormous savings for U.S. society. It costs considerably less to treat a woman than to build a jail cell to incarcerate her or to pay for a foster care placement for her child. Treatment is likely to offer long-term positive outcomes for the woman, reducing both her addiction and her criminal activity.

CSAT supports the concept that drug-dependent women should have access to—and be strongly encouraged to receive—comprehensive drug abuse treatment. That treatment should be available in the most appropriate location for the woman, whether that location is in prison, jail, or in a community setting with ongoing supervision. Whenever possible, treatment should be provided in the community, so that the woman’s family can remain intact and the woman has the chance to become sober and drug-free under real life conditions.

CSAT is supporting a number of women’s programs in prisons and jails, as well as community corrections treatment networks, based on this comprehensive approach to treating women. CSAT encourages all correctional systems, in States and local communities, to adopt this comprehensive approach for women in their jurisdictions. CSAT believes the following reasons are compelling.

Reason 1: Substance abuse is driving the explosion of incarcerated women into prisons and jails.

Women offenders have traditionally represented a small proportion of the total offender population. But over the past decade, the number of incarcerated women has dramatically increased, expanding at rates far higher than for males. The number of women in jails rose from 15,900 in 1983 to 51,600 in 1996—a 9.5 percent increase per year; women now account for more than 10 percent of the inmates in U.S. jails (BJS 1998b).

This surge of women into jails and prisons has been correlated with the legal system’s increasingly punitive response to drug-related behavior, and with the lack of viable treatment and alternative community sanctions for women (Owen and Bloom 1995). Even with the large increase in incarcerated women, the total number of women prisoners is not large compared to men. The numbers of incarcerated women total more than 78,000 in prison and 59,000 in jail (BJS 1998a).

According to Drug Use Forecasting (DUF) data, more than half of women in 20 of 21 cities test positive for illicit drugs at the time of their arrests. The most common drug used by women is cocaine. In 12 cities, more than three-quarters of women arrestees test positive for illicit drugs (NIJ 1997) and, in most cities, a higher percentage of women than men test positive for multiple drugs. Recent State studies show very high percentages of woman offenders who have drug problems or are in the criminal justice system for crimes related to their substance abuse.

• In Massachusetts, the Massachusetts Committee on Criminal Justice estimated that 90 percent of women prisoners in 1993 had alcohol or drug problems.
• In New Jersey, 85 percent of women offenders are in the correctional system for drug-related offenses—78 percent for drug-related crimes and an additional 7 percent for selling drugs for profit (Gonzalez 1996).
• In Iowa, 61 percent of the female prison population isincarcerated for an offense directly related to substance abuse (Hudik 1994).

Minority women are being disproportionately affected. The increasing incarceration of women offenders has had a particularly grave impact on poor women of color. By 1994, the proportion of African American females incarcerated in the United States was seven times higher than for white females. The rising use of crack cocaine among minority women in poverty appears to be a major factor. During the last decade, the number of African American inmates in State, Federal, and local jails and prisons has grown at a faster pace than for non-minority inmates. The number of black (non-Hispanic) women incarcerated for drug offenses in State prisons increased by 828 percent from 1986 to 1991 (Mauer and Huling 1995).

Without treatment, incarceration becomes a “revolving door” for substance-abusing women. Addicted women offenders need substance abuse treatment in order to begin their recovery process and then to maintain abstinence. Addicted women who have not received appropriate treatment end up back on drugs and incarcerated because they are unable to stay “clean” (drug-free) and sober. These women then cannot meet the terms of their probation or they commit new crimes to support their habits.

Probation violators are a rapidly growing segment of the prison population. In Delaware in 1993, probation violators made up 23 percent of all prison admissions. and the woman has the chance to become sober and drug-free under real-life conditions. Based on standardized screening criteria, more than 70 percent of these violators were found to need residential substance abuse treatment—the most intensive level of treatment (Peyton 1994). Among New Jersey women offenders, 63 percent of those incarcerated for violating probation had been imprisoned originally for a drug offense.

Reason 2: Substance-abusing women involved with the criminal justice system have alcohol and other drug (AOD) problems that are severe and chronic.

Several measures show that women offenders are more likely than male offenders to use drugs, they use more serious drugs than male offenders, and they use them more frequently. Women are more likely than men to be under the influence of drugs at the time of their crimes (Bureau of Justice Statistics [BJS] 1992; National Institute of Justice [NIJ] 1991, NIJ 1997).

A number of States are now using standardized instruments to screen all offenders in their correctional systems for AOD problems. These assessments show that the substance abuse problems of incarcerated women are chronic and severe, indicating the need for comprehensive, intensive treatment. Examples of State findings include:

• Delaware: Among incarcerated women in prison, 26 percent meet the screening criteria for long-term residential treatment (compared to 12 percent of men). An additional 44 percent of women meet the criteria for short-term residential treatment, and 7 percent need intensive outpatient treatment. Only 9 percent of Delaware’s incarcerated women need no treatment (Peyton 1994, p.12).
• Illinois: Among women inmates who report a dependence on any drug within the prior year, 86 percent meet screening criteria for residential rehabilitation (a severe level of dependency), 11 percent need intensive outpatient treatment (a moderate level of dependency), and 3 percent require outpatient treatment for a mild level of dependency (Illinois Criminal Justice State Plan 1995).

The Illinois Department of Corrections finds that women enter prison at a more advanced and severe stage of drug abuse than men. Addicted women offenders therefore need longer treatment. Women who stay in Illinois’ in-custody treatment program for at least 90 days are less likely to recidivate than those in treatment for shorter times. Further, women who complete the treatment program are even less likely to recidivate (Illinois Criminal Justice State Plan 1995, p. E-4).These Illinois findings underscore the importance for programs to motivate women into treatment. Women often “self-select” their length of stay in treatment, since treatment is generally voluntary. Women who drop out can be assumed to be less motivated to change their behavior than the women who stay.

Reason 3: Women offenders suffer from a constellation of high-risk factors associated with both substance abuse and relapse.

Women prisoners in the United States have many similar characteristics across the country, according to national surveys conducted by the Bureau of Justice Statistics (BJS 1992, 1994, 1995a) and the American Correctional Association (ACA 1990). For the high proportion of women with severe substance abuse problems, substance abuse complicates and exacerbates other problem areas, such as family problems, lack of economic self-sufficiency, physical and sexual abuse, and the inability to cope with caring for children. To help women recover and prevent relapse, treatment needs to help women address all these issues.

The women experience a host of psychosocial and medical problems, including physical and sexual abuse and victimization. Imprisoned women come mainly from poverty. Female prisoners have very low incomes, are disproportionately from minority groups, such as African American and Hispanic, tend to be under-educated and unskilled, and have sporadic employment histories. Imprisoned women are mostly young, single heads of households. More than three-quarters of all women in prison have children, and two-thirds of the women have children under the age of 18 (BJS 1994). Women prisoners also have a host of medical, psychological, and financial problems and needs (Owen and Bloom 1995).

Mental health problems are common. Among women in jail nationally, more than one in three inmates reports having received treatment for a mental or emotional problem other than drug or alcohol abuse. Approximately 1 in 4 female inmates has received counseling, 1 in 4 has taken medication prescribed for mental or emotional problems, and 3 in 20 women have been admitted to a mental health facility and stayed at least overnight (BJS 1998b).

More than 80 percent of female jail detainees suffer from one or more lifetime psychiatric disorders, according to a random study of nearly 1,300 detainees awaiting trial at the Cook County jail (Teplin et al. 1996). This study, one of the first to survey mental health problems of women inmates, found that major depression and substance abuse were the most common problems. More than 70 percent of those surveyed were dependent on drugs or alcohol or both. In addition, one-third (34 percent) were suffering from post-traumatic stress disorder (PTSD)—a common aftermath of physical and sexual abuse or rape. The rates of PTSD did not vary by age, race, or education. Almost one-fifth (17 percent) had experienced a major depressive episode, with 14 percent having a depressive episode in the 6 months before arrest.

Bleak as these figures are, the researchers felt they may be low because of underreporting of drug abuse, their inability to interview some severely disturbed women, and the fact that some women found their traumatic event(s) too upsetting to discuss (Teplin et al. 1996). The researchers point out that, in practice, few jails currently have the budget to treat the mental disorders of the growing female population. In this Chicago study, 80 percent of the women with major depressive episode and 41 percent of those with drug and alcohol abuse/dependence were arrested on nonviolent misdemeanor charges. These women, as well as nonviolent felons, could be treated outside the jail after pretrial hearings, if a community-based program were available to treat released jail detainees, with their often complicated diagnostic profiles and special treatment needs (Abram and Teplin 1991; Teplin 1984).

Similar findings emerged in the Women Inmates’ Health Survey (WIHS), the first large-scale epidemiologic study of women prison inmates in the United States, which was conducted by the Research Triangle Institute. Using DSM-III-R criteria, the WIHS interviewed virtually all of the 805 women felons entering North Carolina prisons over a 17-month period. Compared with women in community epidemiology studies, the women inmates had high rates of substance abuse and dependence, of antisocial and borderline personality disorders, and somewhat higher rates for mood disorders. The highest lifetime prevalence rates were for drug abuse and dependence (44 percent), alcohol abuse and dependence (39 percent) and major depressive episode (13 percent) (Jordan et al. 1996). Only 11 percent of the women were incarcerated for a violent offense.

Inmate profiles show multiple problems. A profile of the typical woman prisoner, compiled by the New Jersey Department of Corrections, highlights the intensity of the problems these women face (Gonzalez 1996). The profile is based on screening of all women offenders with the Addiction Severity Index (ASI)— a widely used, validated instrument for assessing addiction and associated problems. In New Jersey (where 85 percent of women offenders are incarcerated for an offense related to their drug use), the typical woman offender:

• Is approximately 30 years old and is incarcerated for a drug-related crime or selling drugs for profit.
• Spends approximately $1,000 per week to support her addiction. She has been addicted an average of 9 years. She is likely to have used cocaine or heroin on a daily basis (70 percent of those using drugs report daily use, with 23 percent using drugs more than three times a day). The typical woman offender also uses alcohol in conjunction with other drugs.
• Has worked at primarily unskilled or semiskilled labor for minimal wages. When working, she has not exceeded 24 months of consistent employment at any one job.
• Failed to complete high school or complete any type of technical trades education.
• Is a single head of household with minor, dependent children.
• Has experienced emotional, physical, or sexual abuse.
• Is likely to have grown up in a home with an alcohol- or drug-abusing adult (43 percent lived with an alcoholic relative and 45 percent lived with a drug-abusing relative).

Reason 4: Women offenders require specialized, women-specific substance abuse treatment.

Women offenders need specialized treatment for their substance dependency. Traditional substance abuse treatment models were originally designed for men; they address alcohol and drug addiction from a male perspective. Women’s substance abuse is different. Addiction tends to occur more rapidly for women than for men, to involve more than one mood-altering substance, and to produce serious medical consequences over a briefer period of time. Women are more likely than men to have co-morbid psychiatric disorders.

Typically, women offenders with substance abuse problems have been victims of violence— physical abuse, domestic violence, and rape. On the basis of compiled studies, Mondanaro et al. (1982) conclude that 46 percent of all drug-dependent women have been victims of rape and from 28 to 44 percent have been victims of incest. Evidence suggests that these figures are even higher among incarcerated women. For example, a study in California prisons showed that nearly 80 percent of women inmates have experienced some form of abuse, including:

• Physical abuse: 29 percent report being physically abused as children and 60 percent as adults
• Sexual abuse: 31 percent report being sexually abused as a child, including incest, and 23 percent as adults
• Emotional abuse: 40 percent report emotional abuse as a child and 48 percent as an adult (Bloom et al. 1994).

The psychological impact of this violence includes depression, post-traumatic stress disorder, and low self-esteem. The study of pretrial detainees in Chicago’s Cook County jail showed that one-third, a “striking” percent, had post-traumatic stress disorder (PTSD)—with most of these women being the victims of rape or other violent assault (Teplin et al. 1996). In the study of convicted female felons entering prison in North Carolina, 30 percent of the women reported having experienced both a traumatic event and six or more PTSD symptoms in the past 6 months (Jordan et al. 1996). The CSAT prison and jail grantees report that up to 90 percent of women in their programs have been physically or sexually abused, and that these addicted women offenders feel powerless and victimized.

By the mid-1970s, women’s treatment experts had begun calling for treatment programs designed to address women-specific issues—those issues directly related to women’s substance abuse. Odyssey House—one of the first treatment centers to offer programs for addicted women and their children—described the situation:

Addicted women—especially those with children— face a unique set of problems which in the past have precluded successful treatment outcomes: a male-model approach to therapy; programs with inadequate knowledge, capacity, and resources to meet the special needs of women; the chronic medical and complex psychosocial problems unique to women; and the pressure of dependent children (Kandall 1996, p. 207).

Today’s treatment programs for women offenders can be designed to address the special needs of these addicted, impoverished, and undereducated women. New women-specific programs are designed to empower the woman and help her learn to trust and bond with other women for support. When possible, there is an effort to strengthen the woman’s relationships with her children and to reunify her family.

The new approaches also help women offenders develop the coping and life skills they need to build a productive and self-sufficient future. These skills extend to many needed areas—to parenting, controlling anger and stress, learning to identify personal cues of relapse, and managing a budget. And the programs try to prepare a woman, through education, vocational tests, and nonstereotyped job training, for a place in the labor market.

Reason 5: Few appropriate treatment programs for women now exist within the criminal justice system.

Nationwide, there is a lack of comprehensive treatment services available for women offenders. Programs often accept women without offering specialized services for them. Relatively few treatment programs are geared to the special needs of women, fewer still accept women and their children, and even fewer treat pregnant women. Generally, the only services offered by 90 percent of prisons are drug education or mutual-help groups, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Unfortunately, these programs by themselves do not provide the kind of intensive, comprehensive substance abuse treatment and medical attention that many women need to overcome addiction.

An American Jail Association survey in 1992 of 1,737 jails, with 57 percent responding, revealed that only 28 percent of the Nation’s jails offer drug abuse programs for men and women offenders, including 12-Step volunteer groups; only 19 percent fund drug treatment programs. More than 80 percent of programs operate with a volunteer staff (Peters et al. 1992). A 1989 BJS study of women in jails (BJS 1992) found that

• 42 percent of women reported daily drug use, but only 11 percent were participating in drug programming.
• 13 percent of the women are self-reported alcoholics; 10 percent participated in alcohol programming.

Most prison and jail programs are not intense enough to meet the needs of women offenders who have severe and long-term substance abuse problems. Intensive residential rehabilitation— the form of treatment needed by most women offenders—is not widely available in correctional settings. In prisons nationwide, fewer than 9 percent of women offenders receive residential treatment (BJS 1994).

There is also a severe deficiency in comprehensive programming that includes family unification and parenting components. In a survey done by the Office for Treatment Improvement (OTI) in 1992, one-half of all State facilities reported a lack of mother/child programming, including playrooms and residential care. Another one-third of State facilities reported that their programming in parenting skills, relapse prevention, and sexuality was inadequate to meet the demand for services (OTI 1992).

A study of four California prisons for women showed existing prison programs are unable to satisfy the demand for treatment from their women prisoners. Programs have long waiting lists that prevent many women from participating. Programs that address parenting or substance abuse have the longest waiting lists; up to 450 inmates are waiting to participate in these programs (Bloom et al. 1994).

The number of treatment programs for female drug-abusing offenders has been increasing. But because the numbers of drug-abusing women offenders keeps rising, the National Institute of Justice reports that the increased number of programs has not significantly reduced the gap between those needing and receiving services. In fact, the percentage of drug-abusing female offenders being served, relative to those in need, is probably no greater than in the late 1970s (NIJ 1994).

Reason 6: Most women offenders do not receive continuing care upon release into the community—a service essential for maintaining recovery and reducing recidivism.

Continuing care after offenders return to the community is recognized as one of the most critical needs for those with substance abuse problems (ONDCP 1992, p.71; NIJ 1991). However, a 1992 survey of State prisons found fewer than one-half of States provide this aftercare for women, with only one-third arranging for day treatment, transitional living services, or residential treatment in the community. In another survey of 336 women’s programs in jails and prisons made in 1993, Prendergast et al. (1995) report that continued care facilities are very limited in communities, serving only a fraction of the women who require aftercare. For example, the California Department of Corrections contracts with only one community-based program for incarcerated mothers and their young children. This program has a total statewide capacity of just 100 women and their children (Bloom et al. 1994, p.13).

Fewer than half of both jail and prison programs report that they make arrangements for transition services other than substance abuse treatment (Prendergast et al. 1995). These other needed transition services would include safe and sober housing, financial assistance, medical care, and case management.

Reason 7: Substance abuse treatment, especially a continuum of care, is effective in reducing AOD abuse and recidivism.

A large body of research demonstrates that treatment of their substance abuse reduces offenders’ use of drugs and alcohol, and also reduces their recidivism. Women who relapse are about seven times as likely to have a new arrest as those who do not use drugs during the post-release period (Martin and Scarpitti 1993).

The Drug Abuse Treatment Outcome Study (DATOS), the most recent comprehensive national study on the effectiveness of community-based drug treatment in the United States, corroborates the findings of earlier large-scale research studies. These studies are the Drug Abuse Reporting Program (DARP), which examined outcomes for clients entering treatment in 1969-74, and the Treatment Outcome Prospective Study (TOPS), which examined outcomes for clients treated in 1979- 81. All three studies—DARP, TOPS, and DATOS—demonstrate that drug treatment works to produce positive changes in both drug use and criminal activity (Simpson 1984; Hubbard et al. 1989; Hubbard et al. 1997).

DATOS assesses the outcomes of clients treated during 19911993 in 96 community-based treatment programs in 11 major cities. The DATOS study followed up 3,000 randomly selected clients at 1 year after treatment. These clients, treated in four different treatment modalities, all showed large and significant improvements; their drug use, illegal activities, and psychological distress were each reduced on average about 50 percent (Hubbard et al. 1997). Clients improved regardless of the form of treatment. Findings for clients (34 percent of whom were women) in two common treatment modalities were:

• Long-term residential treatment, with 35 percent of clients referred by the criminal justice system. Clients showed a 67 percent drop in the number of weekly cocaine users, a 53 percent decline in heavy drinkers, a 61 percent decline in illegal activity, a drop from 77 to 35 percent in those jailed in the year before versus after treatment, a decrease in those with any arrests from 56 to 31 percent, and a decline of 46 percent in suicidal thinking.
• Outpatient drug-free treatment, with 42 percent of clients referred by the criminal justice system. Clients showed a 57 percent drop in the number of weekly cocaine users, a 64 percent reduction in weekly marijuana users, a 52 percent decline in heavy drinkers, a 36 percent decline in illegal activity, a drop from 69 to 25 percent in those jailed in the year before versus after treatment, a decrease in those with any arrests from 37 to 21 percent, and a decline of 42 percent in suicidal thinking (Hubbard et al. 1997).

As in the other national research studies, the DATOS study found that the length of time clients stayed in treatment was directly related to improvements in their follow-up outcomes (Hubbard et al. 1997). In both the residential and outpatient treatment, clients who stayed in treatment for 3 months or longer had significantly better outcomes regarding their drug use and illegal activity; posttreatment outcomes continued to improve as time in treatment increased. The study found that programs varied widely in their ability to retain patients over time. Programs achieving longer treatment retention rates had better client-counselor relationships, provided a wider range of services, and showed a higher rate of client satisfaction with the program (Simpson et al. 1997).

For incarcerated offenders, the strongest, most consistent pattern of success comes when offenders receive a full continuum of treatment. This continuum starts with appropriate screening and treatment during custody and is followed by post-release treatment in the community (Lipton 1995). For those substance-abusing women offenders who do not need to be incarcerated, the continuum would begin after their screening, when the woman is assigned to enter either a community residential treatment facility or an intensive outpatient treatment program combined with supervision in the community.

Incarcerated women with severe substance abuse problems need intensive residential treatment programs, such as therapeutic communities (TCs). The effectiveness of prison TCs has been well documented. There have been four large-scale research evaluations of TC programs for offenders, three of which include women. These program evaluations all demonstrate the same consistent find-ings—that prison-based TCs can produce significant reductions in recidivism rates among chronic drug-abusing offenders; successful outcomes continue over time. Success is related to how long the
offender stays in treatment. For example, New York’s Stay n’ Out prison TC was effective in reducing recidivism rates, while prison counseling groups did not. Findings were:

• Among women who stayed in treatment less than 3 months, 79 percent had positive parole outcomes (compared to 40 percent positive outcomes for men)
• For women spending 9 to 12 months in treatment, 92 percent had favorable outcomes on parole (compared to 77 percent for men).

The Forever Free prison treatment program—one of the CSAT-supported women’s projects described in this Guide—found this same type of pattern regarding continuum/time in treatment.

• Among graduates of the Forever Free program, more than two-thirds of those who voluntarily enter residential treatment in the community are successful on parole, compared to half of the graduates who enter community outpatient or no treatment (Prendergast et al. 1996).
• Of those recommitted to prison after receiving community treatment, more than two-thirds are returned for a technical violation rather than a new offense, compared to half of those who did not receive community residential treatment.
• Women who complete 5 months or more of residential treatment have better parole outcomes. The reported use of drugs in the past year is also much lower for women in the residential treatment group than for others. It is important to note that these women could self-select to enter residential treatment after their release from prison. A woman’s motivation to change her behavior is a significant factor in positive treatment outcomes.

Reason 8: Treating women while in custody benefits the woman, the institution, and society.

In-custody substance abuse treatment, including short-term interventions directed at motivating a woman into treatment, offers multiple benefits—for the woman, the correctional facility, and society. This period represents an opportunity to use “constructive coercion” to motivate a woman offender into entering treatment and continuing treatment after her release to the community. Research over 25 years has shown that the longer addicted offenders stay in treatment, the better the outcome—both in terms of reduced recidivism and substance use (De Leon 1984; Wexler et al. 1988b; Anglin and Hser 1990). Those who are coerced into treatment do at least as well as voluntary clients—and sometimes do better—because the coerced clients tend to remain longer in treatment than those who volunteer (De Leon 1988; Platt et al. 1988; Hubbard et al. 1989; Leukefeld and Tims 1988, 1990).

The woman offender benefits from in-custody programs. While a woman is in prison, there is the time and opportunity—perhaps for the first time—for comprehensive treatment. In a prison situation, time is one of the few resources that most inmates have in abundance. There are no competing demands of children, work, and neighborhood peer groups. Intensive programs, such as residential TCs, present other new opportunities—to interact with “recovering addict” role models, to acquire prosocial values and a positive work ethic, and to initiate a process of education, training, and understanding of the addiction cycle (Inciardi et al. 1994). Many young women, facing incarceration for the first time, are humiliated and frightened. This is an ideal opportunity for them to be introduced to treatment and to the possibility of help and hope in their lives.

Ethnographic studies of street addicts, who are heavily involved in crime to support their habits, show that this group does not seek treatment of their own volition (Lipton 1995). The correctional system removes women from an environment in which they are using, and from its accompanying stresses and strains. For many, this may be the first time in years that they have been drug free and thinking clearly. It also gives many women a respite from a destructive lifestyle in which they pay for drugs through prostitution and abuse. Incarceration represents a forced, artificial removal from a woman’s substance-using lifestyle. As one program director put it, “This is a brief window of opportunity to make significant contact with a woman—to reach out and motivate her to seek help.”

The correctional system benefits from treatment programs. Establishing a drug treatment unit can bring positive benefits to a correctional facility. Substance abuse treatment programs, especially in women’s prisons, provide an opportunity for growth and rehabilitation for the women. The programs promote responsible, mature inmate behavior, increase safety for security staff, and provide a positive structure for the offender’s time in custody and in the community after release.

Research shows that treatment programs have fewer disciplinary infractions and correctional management problems than other units. Prison therapeutic communities (TCs) have been found to be the most drug-free and trouble-free sectors of the institutions in which they are housed (Hooper et al. 1993). Infractions of prison rules, as well as threats of violence, also decline (Lipton 1995). The CSAT-funded women’s programs demonstrate this. In the first 2½ years of operation at the Philadelphia OPTIONS program, disciplinary reports went from 10 to 12 per month down to 0 to 2 per month. In addition, when drug treatment programs and random urinalysis are introduced to a facility, both drug use and drug dealing (rampant in some prisons) decline (Vigdal and Stadler 1989).

The community benefits from increased public safety and decreased crime. The research shows unequivocally that substance abuse is related to crime. The cost to society of this crime is enormous, not only in money but in the emotional and physical suffering of victims. Although women offenders are much less involved in predatory crime than their male counterparts, research suggests that the frequency with which women commit crimes is approaching that of men (Anglin and Hser 1987).

CSAT’s first large-scale national study of clients in publicly funded treatment programs—the National Treatment Improvement Evaluation Study (NTIES)—bolsters the often-repeated finding that AOD treatment reduces subsequent crime among substance-abusing offenders. Most important, this large-scale study showed that substance abuse treatment reduces subsequent crime on an impressive scale. Among 1,374 women clients in this study, preliminary results demonstrate large decreases in the clients’ involvement in violent crime, illicit drug distribution, and prostitution after both residential and outpatient treatment (CSAT 1995b). The percentage of clients involved in prostitution was reduced from 28 percent before treatment to 7 percent some 12 months after treatment ended (CSAT 1995b). The final NTIES report shows that, before treatment, more than 50 percent of women clients reported having been involved in some form of illegal activity. After treatment, arrests dropped by 67 percent; there was a decrease of 82 per-Numerous State studies also cent in women selling drugs, a show that treatment effectively decrease of 88 percent in those reduces the level of crime among reporting shoplifting, and a decrease of 89 percent in reports National Association of State of “beating someone up” (CSAT Alcohol and Drug Abuse 1997a).

Numerous State studies also show that treatment effectively reduces the level of crime among addicted users. A report by the National Association of State Alcohol and Drug Abuse Directors (NASADAD) details positive results of treatment in reducing crime among treated offenders in 13 States (Young 1994). Table 1 shows selected examples of State outcome data.

Table 1 State data on treatment and reduction in crime

Reason 9. Treatment saves money.

It costs less money to treat a woman offender for substance abuse than to incarcerate her. Effective treatment results in savings to society that outweigh the costs of treatment by a factor of at least 4 to 1. These are the costs for incarcerating and treating a sub-stance-abusing woman:

• Incarceration. It costs from $20,000 to $30,000 per year to incarcerate a woman in prison or in a women’s jail (Lord 1995; Gray et al. 1995). It costs $54,209 per bed to build a new State facility and $78,000 per bed for Federal facilities (CSAT 1995a, p. 13). California alone, which now has about 11,500 women prisoners (Department of Corrections 1998), has had to build two new State facilities with more than 3,000 beds for women (Austin et al. 1992).
• Foster care for children. Foster care for the child of an incarcerated woman adds $3,600 to $14,000 a year, excluding administrative costs, to that total (Lord 1995; American Public Welfare Association 1995).
• In-custody AOD treatment. Residential treatment programs can be operated in jails or prisons for about $3,000 to $9,000 per inmate per year in addition to the costs of incarceration (Lipton 1995). The program’s total cost would depend on the type of program, on the mix of professional clinical staff and certified AOD counselors, and on the size of the caseload.
• TC treatment. Therapeutic communities, the most intensive form of in-custody treatment, can be provided at reasonable cost. In Illinois, a 250bed TC housed within a medium security prison costs approximately $790,000 annually, or about $3,200 per inmate per year (CSAT 1995a). These costs include a process and outcome evaluation and post-release case management. No capital costs associated with program startup, incarceration, or security are included.

Most of the CSAT-supported prison and jail programs described in this Guide are mid-to long-term TCs. CSAT’s experience reinforces the finding that TCs in the criminal justice system can be operated at quite reasonable cost. Housing, program facilities, and security are provided by the institution. Among the CSAT-supported women’s programs, the daily cost per inmate for incarceration averaged $51. The average cost of treatment per day for each woman was $9.22. For individual TCs, the range in cost was as follows:

• Daily cost per client for incarceration: $50 to $75
• Daily cost per client for treatment: $9 to $18.27 (CSAT 1998)

Treatment in community settings is less expensive than the combined cost of incarceration and treatment. Approximate treatment costs in the community would include:

• Residential AOD treatment in the community. Residential drug treatment for a woman in the community will cost from $17,000 to $20,000 per year.
• Outpatient treatment in the community. Outpatient treatment costs about $2,700 per year. For the women addressed in this Guide—offenders with chronic, severe substance abuse problems—outpatient treatment after release from custody should also be combined with safe, sober housing and a graduated system of urine monitoring, supervision, and social services.

Successful AOD treatment of offenders creates cost savings to society. What does treatment mean in terms of dollars saved to society? One overview of AOD treatment for offenders concluded that the savings these programs produce—in costs related to crime and drug use—pay for the cost of treatment in about 2 to 3 years (Lipton 1995).

The President’s Commission on Model State Drug Laws (1993), in an extensive review of the socioeconomic benefits of addictions treatment, concluded that

… given the very high risk behavior of many narcotics addicts with criminal justice involvement, and given also the ability of quality treatment to diminish [intravenous] (IV) drug use and its attendant risks for HIV transmission, it is almost certain that the total benefits to society, estimated to be in ratios as high as 4:1, are seriously underestimated. When the potential effects of narcotic drug use, cocaine addiction, or HIV positivity on fetuses carried by pregnant addicts is factored in, true cost-benefit analysis (CBA) ratios must be much higher than even the positive ones adduced here (pp. 6-30).

Among more than 4,400 clients served in CSAT-funded programs, treatment reduced by 59 percent the percentage of those who had sex for drugs or money and reduced by 54 percent the percentage of those who had sex with an IV drug user (CSAT 1997). A few States have begun to calculate the savings for their citizens of treating substance abusers. Following are three examples.

• California—Taxpayers save $7.14 in future costs for every dollar invested in treatment. Most of these savings come from reductions in crime. The cost of treating approximately 150,000 clients was $209 million. The benefit to California taxpayers, in the first year after treatment, was approximately $1.5 billion (National Opinion Research Center and Lewin-VHI, Inc. 1994).
• Minnesota—Annual savings from treating 18,400 clients total $39.2 million; $8 million of this is the savings from reduced arrests, excluding DWI arrests (Turnure 1995).
• Oregon—The State justice system is estimated to save approximately $14 million per year from the fewer arrests, convictions, and incarcerations resulting from completed AOD treatment. In the 3 years subsequent to treatment, only 6 percent of clients who complete treatment are incarcerated in the State prison system, compared to 12 percent who terminate without completion. At an average of $50 per day for incarceration, treatment saves an estimated $59,300 per 100 clients who successfully complete treatment. When theft and victim costs are included, the total savings for Oregon reach $32.2 million per year (Finigan 1995).

Table 2. Potential health and social savings from successful treatment of AOD abuse among women

Treatment saves money in health and social costs. When women offenders go untreated for their addiction, society also pays a heavy cost in health and social damage. These are young women, likely to become preg nant, many of whom pay for their drugs through high-risk sexual behavior. More women than men in correctional settings now test positive for the human immunodeficiency virus (HIV) (Vlahov 1990). If this lifestyle is not interrupted, these women are at risk of HIV not only for themselves but as a conduit to their babies and to their sexual contacts. The lifetime cost of treating a single HIV-positive individual suggests what a large payoff there can be for effectively treating a substance-abusing woman offender. Table 2 illustrates the extent of potential health and social savings when a woman is effectively treated.

For both male and female offenders, their untreated addiction exacts a high social cost. With men, their higher rate of violent crime creates major costs to society. Substance-abusing women are responsible for much less social cost resulting from violent crime than men are. However, untreated addiction among women exacts a deep and tragic social cost. For these women, the costs are compounded not only by the health and personal damage to themselves, but by the serious and potentially permanent damage that is done to the physical and emotional health and wellbeing of their children, as well as the disintegration of their families. Effective treatment for women offenders is an important means of building parenting skills, reuniting families, and strengthening the potential and future of the children.

For the children of substance-abusing women, treatment can often save the costs of providing foster care, as well as the future social costs that society may pay for the emotional damage endured by these children. As women drug offenders have been swelling prison populations, an increasing number of children are being cast adrift. When mothers are incarcerated, only 25 percent of the children live with their fathers and the rest go to relatives or foster care. The National Council on Crime and Delinquency (NCCD) estimates that on any single day in 1991, there were
approximately 125,000 minor children of women in adult U.S. prisons and jails, a figure that would now be higher (Bloom and Steinhart 1993). At a minimum, loss of the mother causes emotional trauma and anger for children; it can mean lasting emotional damage. The NCCD study documents the high percentage of problems among these children, from learning to behavioral and health problems.

Both States and individual comprehensive programs for women report that, as a result of treatment, women make substantial gains in all the above areas. Among CSAT-supported comprehensive demonstration programs for pregnant and parenting women, 81 percent of women referred by the criminal justice
system have no new charges following their treatment (CSAT 1995b). These comprehensive programs show impressive results in helping women to be self- supporting. The following outcomes and gains have been reported by several representative programs.

• In California, more than half the addicted women (55 percent) treated in a residential demonstration program for women and their children were supporting their children—without any help from AFDC (Aid to Families with Dependent Children)—within 1 year of completing AOD treatment (CSAT 1995b).
• In Pennsylvania, the savings generated by just two CSAT-supported treatment programs for pregnant/parenting women and their children include:
- $114,000 saved over a 1-year program from the 46 percent of participants (19 women) who became employed.
- $90,000 saved from 26 women being united with their children over a 1-year period.
- Potential savings in the millions of dollars from the delivery of 15 babies who had no complications due to substance abuse and no cases of FAS (Bair 1998).

• In Florida, the 180 women treated in a single residential program have regained custody of 580 children who were previously under State guardianship (CSAT 1995b).

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