Randomized Controlled Pilot Study of Cognitive-Behavioral Therapy in a Sample of Incarcerated Women With Substance Use Disorder and PTSD

Abstract

This randomized controlled pilot study compared a cognitive-behavioral therapy (Seeking Safety; SS) plus treatment-as-usual (TAU) to TAU-alone in 49 incarcerated women with substance use disorder (SUD) and posttraumatic stress disorder (PTSD; full or subthreshold). Seeking Safety consisted of a voluntary group treatment during incarceration and individual treatment after prison release. TAU was required in the prison and comprised 180 to 240 hours of individual and group treatment over 6 to 8 weeks. Assessments occurred at intake, 12 weeks after intake, and 3 and 6 months after release from prison. There were no significant differences between conditions on all key domains (PTSD, SUD, psychopathology, and legal problems); but both conditions showed significant improvements from intake to later time points on all of these outcomes across time. Secondary analyses at follow-up found trends for SS participants improving on clinician-rated PTSD symptoms and TAU participants worsening on self-reported PTSD symptoms. Also, SS demonstrated continued improvement on psychopathology at 3 and 6 months, whereas TAU did not. However, alcohol use improved more for TAU during follow-up. Satisfaction with SS was high, and a greater number of SS sessions was associated with greater improvement on PTSD and drug use. Six months after release from prison, 53% of the women in both conditions reported a remission in PTSD. Study limitations include lack of assessment of SS outcomes at end of group treatment; lack of blind assessment; omission of the SS case management component; and possible contamination between the two conditions. The complex needs of this population are discussed.In 2005, the number of women incarcerated in state and federal prisons was 106,174, with an increase of 6.1% from 1995 and a 3.4% increase from 2004 (Bureau of Justice Statistics, 2005). Rates of incarceration for women continue to rise faster than for men (Bureau of Justice Statistics, 2005). In part, drug offenses have contributed to the rise in incarceration of women (Bureau of Justice Statistics, 2002). Furthermore, half of incarcerated women were under the influence of alcohol or drugs at the time of their criminal offense (Bureau of Justice Statistics, 2000), and studies have shown substantially higher prevalence rates of substance use disorder (SUD) among women in prison than women in the community (Jordan, Schlenger, Fairbank, & Caddell, 1996). In addition to SUD, many women offenders also meet criteria for a mental disorder (Jordan et al., 1996;Pelissier & O'Neil, 2000; Address correspondence to Caron Zlotnick, Butler Hospital, 345 Blackstone Blvd., Providence, RI 02906; czlotnick@butler.org. NIH Public Access Author ManuscriptBehav Ther. Author manuscript; available in PMC 2011 January 31. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptTeplin, Abram, & McClelland, 1996) and report histories of trauma (Alexander, 1996). Many women in prison-based substance abuse treatment meet criteria for current (50%) or l...

Review of group treatment for PTSD

“…All but one of these studies [12] found no significant between-group difference in PTSD symptom severity following treatment. However, most of these studies did find that PTSD symptom severity significantly decreased following treatment for both the therapeutic group and the nonspecific comparison condition [9,16,25,36]. Nonspecific comparison groups in combination with a wait list comparison group are helpful for interpreting the results of studies in which the treatments being compared do not differ from one another.…”

“…Of the 17 studies listed in Tables 1 and 2, 8 used a nonspecific comparison design. Typical nonspecific treatments in these studies included relaxation [12], psychoeducation [25,28], present-centered therapy [9,16], and treatment as usual [36]. All but one of these studies [12] found no significant between-group difference in PTSD symptom severity following treatment.…”

“…The studies reviewed were heterogeneous in terms of target therapy, comparison condition, PTSD outcome measure, and trauma sample. Of the 17 RCTs, 6 did not require a PTSD diagnosis for inclusion in the study and 2 examined a treatment that targeted symptoms other than PTSD [28][29] or focused on comorbid diagnoses such as human immunodeficiency virus diagnosis and substance abuse [25,[35][36]. We discuss these 17 studies next, with a focus on the methodological considerations that affect the interpretation of the findings.…”

“…Several of the RCTs included treatment satisfaction measures [11,13,28,31,33,36] and found that participants reported a positive experience with group treatment and a perceived benefit from the treatment. The positive treatment satisfaction ratings raise the possibility that patients are benefiting in ways that may not be captured by the outcome measures included in existing clinical trials.…”

Emotional distress and sense of coherence in women completing a motivational program in five countries. A prospective study

“…Women's psychosocial problems and needs are well documented in the correctional literature from Scandinavia (Amundsen, 2011;Cramer, 2014;Lindberg, 2005;Mathiassen, 2011;Yourstone et al, 2010), and other countries in Europe and outside Europe (Bartlett et al, 2014;Black et al, 2013;Chen, 2010;Covington, 2008, Leschied, 2011Sacks et al, 2012;Sapouna et al, 2011;Zaplin, 2008;Zlotnick et al, 2008Zlotnick et al, , 2009Van Wormer, 2010). Recently, a Norwegian study demonstrated that one out of four women reported major or moderate depression (Cramer, 2014).…”