Justice-Involved, Sexually Victimized Women’s Perspectives on the Acceptability of Receiving Trauma-Focused Therapy in Prison

Abstract

Incarcerated women report high rates of sexual victimization. Interviews with 63 previously incarcerated women survivors of sexual violence explored perceptions toward receiving trauma-focused therapy while incarcerated and postrelease trauma-focused therapy utilization. Nearly all participants (97%) recommended that trauma-focused therapy be available to incarcerated women. Most believed that prisons are acceptable places to receive trauma-focused therapy, without qualification (65%); some reported mixed feelings or indicated acceptability but identified factors that would increase acceptability (33%). Notably, most were currently experiencing trauma-related symptoms, but few had attended trauma-focused therapy following release. Findings indicate that access to prison-based trauma-focused therapy is necessary and acceptable.

Incarcerated women report high rates of sexual victimization during both childhood and adulthood. A recent systematic review which aggregated results from 28 unique, large sample studies of incarcerated women found that the prevalence of sexual victimization was 50–66% in childhood, 28–68% in adulthood, and 56–82% for lifetime (Karlsson & Zielinski, 2020). Victimization in both childhood and adulthood was also common, ranging from 12% to 58% across the six studies that examined reoccurrence across developmental periods. The two studies which examined sexual victimization in the period immediately prior to incarceration found that 12% had been victimized in the 6 months prior (Warren et al., 2002) and 27% had been victimized in the 12 months prior (Tripodi & Pettus-Davis, 2013). Studies that compared incarcerated women to community-dwelling women or incarcerated men found that incarcerated women consistently reported higher rates of sexual victimization, with especially elevated rates of childhood sexual assault (Komarovskaya et al., 2011; McClellan et al., 1997; Severson et al., 2005).

Women with histories of sexual victimization are more likely to develop psychiatric symptoms and substance use problems (DeHart et al., 2013; Harner et al., 2015), which increase the risk of criminal justice involvement and incarceration (Kennedy et al., 2020). In addition, childhood victimization and substance use have been found to be associated with adult violence perpetration and justice involvement in women (Saxena & Messina, 2021). Such findings have prompted researchers to suggest that sexual victimization is a pathway to incarceration unique to women (Karlsson & Zielinski, 2020) and the standard principles which guide corrections-based interventions are tailored to incarcerated men and do not address or account for the experiences of incarcerated women (Messina et al., 2020; Messina & Esparza, 2022). Women who are incarcerated demonstrate exacerbated current and lifetime rates of many mental health problems, including posttraumatic stress disorder (PTSD), major depressive disorder, dysthymia, and drug and alcohol use disorders (Karlsson & Zielinski, 2020)—a pattern that is consistent with research findings on survivors of sexual violence more generally (Dworkin, 2018; Dworkin et al., 2017).

The disproportionally high rates of sexual victimization and associated mental health problems among incarcerated women indicate a need for interventions that can help justice-involved women recover from experiences of sexual violence. Indeed, there are a growing number of therapeutic interventions targeting trauma recovery that have been developed for and/or evaluated with incarcerated women trauma survivors including Seeking Safety (Najavits, 2002; Zlotnick et al., 2009; Zlotnick et al., 2003); Helping Women Recover/Beyond Trauma (Covington, 2003, 2008; Messina et al., 2014); Healing Trauma (Covington & Russo, 2011; Messina & Zwart, 2021); Esuba (Bedard, 1999; Bedard & Pate, 2014; Bedard et al., 2003); Beyond Violence (Covington, 2013; Kubiak et al., 2016); Trauma Affect Regulation: Guide for Education and Therapy (TARGET; Ford et al., 2013; Ford & Russo, 2006); and Survivors Healing from Abuse: Recovery through Exposure (SHARE; Karlsson et al., 2014; Karlsson et al., 2015; Karlsson et al., 2020; Zielinski et al., 2021). One of these interventions, SHARE, was even specifically developed for incarcerated women survivors of sexual trauma (Zielinski et al., 2016). However, women’s perspectives on the opportunity to receive trauma-focused therapy—which directly addresses traumatic event memories and/or thoughts and feelings related to trauma (Watkins et al., 2018)—in prison have been underexplored, and there is a need for more research on this topic.

Need for Incarcerated Women’s Perspectives on Receiving Trauma-Focused Therapy

Prisons differ dramatically from the community-based settings in which many interventions for trauma survivors have been developed. Although incarceration can be a time of increased safety from physical or sexual violence and even health improvements for some women (Alves et al., 2016; Bradley & Follingstad, 2001; Douglas et al., 2009; Goomany & Dickinson, 2015; Harner & Riley, 2013), it is a time of increased risk of further traumatization for others (Miller & Najavits, 2012) and is overall a time of limited privacy, power, and control. Thus, it is possible that prisons could be viewed by incarcerated women as an unacceptable context to receive therapy for trauma sequelae. At times, prior literature questioned whether it is appropriate to offer certain kinds of evidence-based interventions for trauma sequelae (e.g., exposure-based therapy) in prison due to concerns about the risk of experiencing additional traumatic events and the possibility that receiving trauma-focused therapy could be destabilizing (Miller & Najavits, 2012; Wolff et al., 2015). However, few studies have directly queried incarcerated and/or justice-involved women to determine if prison is perceived to be an acceptable place for trauma-focused therapies—a literature gap that this study sought to fill.

Intervention Acceptability and Treatment Outcomes

A critical element of any health intervention is the acceptability to potential recipients. Acceptability is a “multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention” (Sekhon et al., 2017, 2018). Intervention acceptability is important because it is known to influence treatment enrollment, completion, and outcomes. Studies find that patients are more likely to adhere to treatment recommendations and have good clinical outcomes if they consider the intervention acceptable (Fisher et al., 2006; Hommel et al., 2013; Williams et al., 2016).

Patient preferences are also a critical component of evidence-based practice (Masic et al., 2008). This is especially so for mental health interventions, as patients’ attitudes toward treatment have a direct impact on factors such as therapeutic alliance, a key mechanism of change in psychotherapy (Horvath et al., 2011; Lindhiem et al., 2014; Roos & Werbart, 2013). Multiple meta-analyses of patients’ attitudes toward mental health interventions suggest that their perspectives on treatment have a significant impact on engagement, dropout, and likelihood of clinical improvement (Swift & Callahan, 2009; Swift et al., 2018).

While many researchers use variables like number of dropouts, rates of uptake, and other measures of observed behavior to infer acceptability of the intervention (Sekhon et al., 2017), these kinds of proxy measures are vulnerable to influences aside from acceptability. For example, using dropout as a proxy for intervention acceptability does not take into account the reason for patients’ treatment discontinuation other than acceptability, such as discontinuation of treatment because they believe that their condition improved and treatment is no longer needed (Sekhon et al., 2017). This suggests that asking participants their impressions of interventions, during intervention development and/or after intervention implementation, would be of value when evaluating acceptability.

Existing Research on the Acceptability of Receiving Trauma-Focused Therapy in Prison

Although therapy for trauma sequelae can reduce mental health symptoms in prisons, very few studies have asked incarcerated people to share their views on the acceptability of receiving such interventions in that setting. There is also, more generally, a paucity of literature on the adaptability and acceptability of behavioral health interventions among incarcerated women. One study by Abad et al. (2013) found that previously incarcerated women viewed incarceration as a conducive environment for positive behavioral changes due to the safety offered by the setting; the availability of educational and therapeutic resources; and separation from harmful social contexts in the community. Participants in the study also highlighted many barriers to accessing needed mental health care outside of prison and emphasized the importance of programmatic access during incarceration (Abad et al., 2013). Similarly, focus group interviews investigating incarcerated women’s perspectives on the acceptability of therapies targeting risky sexual behaviors secondary to sexual trauma found that women perceived health programs offered within prisons as opportunities to increase understanding of health issues and make positive changes in their lives (McCauley et al., 2020).

Even fewer studies have investigated incarcerated women’s perception of the acceptability of therapy specifically for trauma recovery related to sexual violence victimization. However, the limited research that exists found that interventions such as these are acceptable among justice-involved women (Zielinski et al., 2020, 2021). For example, in a qualitative study of corrections stakeholders’ perceptions of the factors that are necessary to successfully implement trauma therapies within prisons, Zielinski et al. (2020) found that buy-in from key stakeholders—including incarcerated women who might benefit from therapy—was an important factor for successful intervention. All incarcerated women interviewed believed sexual trauma interventions should be offered within prisons to incarcerated persons who might benefit from them, regardless of whether they had received the therapy themselves (Zielinski et al., 2020). These findings were echoed in Zielinski et al. (2021) study investigating treatment outcomes for incarcerated women who received eight sessions of an exposure-based group therapy for sexual violence, which found that almost all participants (96.7%) would recommend group-based sexual trauma therapy within a carceral setting to other incarcerated persons. Similarly, focus group interviews of incarcerated women who received Healing Trauma, a brief, trauma-specific intervention for justice-involved women, also revealed positive feedback related to the program’s structure, content, and benefits (Gajewski-Nemes & Messina, 2021). Similar positive reactions were also reported by incarcerated women who received Healing Trauma while in a segregated housing unit (Sigler et al., 2020).

It should be noted that the participants in all four of these studies (Gajewski-Nemes & Messina, 2021; Sigler et al., 2020; Zielinski et al., 2020,, 2021) were still currently incarcerated in the facility where they received the treatment, raising the possibility that participants may not have felt free to share their perspectives fully. Additionally, all participants in Zielinski et al. (2021) study, all in Gajewski-Nemes and Messina’s (2021) study, and most in Sigler et al. (2020) study were treatment completers and therefore perspectives from individuals who either chose not to join or dropped out of the treatment were not represented. Thus, there remains a need for research on the acceptability of providing trauma-focused therapy in prisons with women who are not under carceral control and who vary with regard to whether they have or have not completed such an intervention while incarcerated.

The Current Study

This study sought to expand knowledge about the acceptability of prison as a place for trauma-focused therapy delivery from the perspective of women survivors of sexual violence who have been incarcerated. We also sought to understand the longer-term outcomes of women who do and do not receive trauma-focused therapy to promote sexual victimization recovery while in prison, including whether they report lingering effects of sexual violence 3–5 years following prison release and whether they have accessed trauma-focused therapy postrelease if indicated. Our research questions were:

1. Do previously incarcerated women survivors of sexual violence find prison to be an acceptable place to receive trauma-focused therapy?

2. Do previously incarcerated women receive therapy focused on trauma recovery, if needed, after returning to the community?

We chose to focus this study on women with a history of sexual violence victimization, given the high prevalence of these experiences among incarcerated women. We focused on understanding women’s reactions to receiving trauma-focused therapy in prison because prison is an unconventional context for trauma-focused treatment.¹ Additionally, justice-involved women are key stakeholders, and their perspective of the acceptability of trauma-focused therapy in correctional facilities may have implications toward treatment outcomes and adherence.

Methods

Participants

Participants in this study were 63 women with preincarceration histories of sexual violence victimization. All had been incarcerated in a minimum security, single-sex prison in a Mid-southern United States state 3–5 years prior to their study participation. We focused on recruiting based on prior incarceration in this prison because it had continuously offered SHARE,² an exposure-based group therapy for incarcerated women survivors of sexual violence, since 2012. This design ensured that all participants had the opportunity to participate in an evidence-informed treatment for sexual violence sequelae while incarcerated and thus could speak from experience on considerations related to their decisions to participate or not participate while in prison. However, there were no restrictions on or requirements regarding further arrest or incarceration history, and many participants had been incarcerated in other jails and/or prisons (n = 37; 59%).

Participants were mostly White (n = 52, 83%) and non-Hispanic (n = 56, 89%), consistent with the population demographics of the correction center during the dates from which the sample was drawn (approximately 91.2% White/non-Hispanic, 4.9% Black, 1.5% Hispanic, and 2.4% Other).³ Participants had an average age of 37 (range = 20–55). Approximately half the sample (n = 27, 43%) participated in SHARE while incarcerated. Ten participants (16%) were reincarcerated at the time of their participation. Per a self-report questionnaire administered by the research team, many participants screened positive for at least one psychiatric condition per validated screening measures: 37% for depression (n = 23), 44% for anxiety (n = 28), and 46% for PTSD (n = 29).⁴

Procedure

To facilitate study recruitment, the researchers were provided with a cohort list of all women who were incarcerated in the target prison between January 2012 and May 2017. We then used a variety of strategies to reach out to women in this cohort including direct contact through publically available information (e.g., phone, social media, jail and prison rosters), snowball sampling, and broader community outreach (e.g., placing flyers at targeted locations, asking organizations that serve previously incarcerated women to share information about the study). For cohort members who were located in the community, the research team completed a brief orientation to the study purpose and a brief screening for eligibility via phone. For cohort members who were located in carceral facilities, we coordinated with facility administration to schedule in-person study interest meetings and proceeded to eligibility screenings for interested participants. Eligible participants were over the age of 18, proficient in the English language, previously incarcerated at the target prison between January 2012 and May 2017, and had a history of sexual violence victimization prior to incarceration. We aimed to enroll approximately even numbers of participants who had and had not completed SHARE to ensure representation from both women who had and who had not had the experience of actually receiving a trauma-focused therapy for sexual violence sequelae while incarcerated.

Once screened for eligibility and consented, participants completed a semi-structured qualitative interview and self-report questionnaire with a member of the research team. Participants could complete the qualitative interview in-person or over the phone at their convenience. Responses to the interview questions were audio-recorded and transcribed. Interviews averaged about 50 min in length. The self-report questionnaire was administered aloud to the participant by a researcher in-person or over the phone, completed by the participant via an online survey link, or completed by the participant on paper and mailed back to the research team. All participants were compensated $30–$50 for their time. All study procedures were approved by the Institutional Review Board of the University of Arkansas for Medical Sciences.

Measures

Qualitative Interviews.

We used a semi-structured interview guide to evaluate participants’ perspectives on prison as an acceptable place for trauma-focused therapy and on their postrelease experiences with trauma-focused therapy after return to the community. The interview guide also included a broad range of questions regarding participants’ perceptions of their current physical and mental health needs and their current and past healthcare access and engagement; these broader results are reported elsewhere. For the purposes of this study, all participants were asked the following questions:

• 1Would you recommend that women who are incarcerated have trauma treatment programs available to them?
• 2Do you think that prison is an acceptable place to get treatment for traumatic experiences?

To understand participants’ likelihood of receiving trauma-focused therapy postincarceration—particularly given the possibility that they would report that prison was an unacceptable place to receive such treatment—we also asked:

• 3Did you receive any trauma treatment since leaving [prison]?
• 4Have you thought about getting trauma treatment? (asked if question 3 was answered “no”).

In addition to the above, we also asked all participants a fifth question—whether they were currently experiencing any lingering, negative effects of any lifetime trauma. The purpose of this item was to contextualize participants’ responses to questions about seeking trauma treatment postrelease (i.e., if participants denied lingering effects, the meaning of not seeking trauma treatment postrelease would be different than if they endorsed lingering effects). During the screening process and the interviews, researchers defined trauma to participants as experiences that involved actual or threatened death, serious injury, or threats to their physical integrity, including sexual assault or abuse.

Self-Report questionnaires.

The questionnaire recorded demographic information and asked participants to describe mental and behavioral health symptoms as described in note ⁴.

Analytic Approach

To quantify frequencies reported in qualitative interview data, the researchers coded responses to the four interview questions as “yes,” “no,” “mixed feelings,” or “not applicable.” “Mixed feelings” were coded if a participant qualified their responses to questions 1 or 2 (e.g., “yes, but…” or “no, if…”) with additional stipulations or expectations. “Yes” and “no” were coded if a participant was resolute in their response without identifying a qualifying factor. “Not applicable” was coded only in response to question 4 and only if question 3 was coded as “yes.” Researchers divided the interview records and coded responses individually, meeting regularly to discuss ambiguous responses or other discrepancies. The researchers then totaled the frequency of each response and quantified the results. Then, in a process of open coding, emergent themes and exemplary quotes were identified. For all interview questions, researchers compared responses between SHARE participants and non-SHARE participants (see Table 1). Responses to the interview questions did not differ between White, non-Hispanic participants and participants who identified as non-White and/or Hispanic.

Table 1.

Interview Responses by SHARE Participation.

	SHARE participants, n = 27				Non-SHARE participants, n = 36
Interview questions	Yes (%)	No (%)	Mixed feelings (%)	Unknown/not reported (%)	Yes (%)	No (%)	Mixed feelings (%)	Unknown/not reported (%)
Would you recommend that women who are incarcerated have trauma treatment programs available to them?	96	0	4	0	97	0	0	3
Do you think that prison is an acceptable place to get treatment for traumatic experiences?	63	0	37	0	67	0	31	3
	Yes (%)	No (%)	N/A (%)	Unknown/not reported (%)	Yes (%)	No (%)	N/A (%)	Unknown/not reported (%)
Did you receive any trauma treatment since leaving [the target prison]?	33	67	—	0	19	78	—	3
Have you thought about getting trauma treatment, if last question answered “no”?	11	48	33	7	28	31	19	22
Do you feel that you are currently dealing with any lingering effects of the trauma you have experienced in your life?	89	11	—	0	83	17	—	0

Note. SHARE = Survivors Healing from Abuse: Recovery through Exposure.

Results

Attitudes Toward Trauma Treatment in Prison

Participant interview responses were largely in support of access to trauma therapy in prisons, especially if the women believed the prison focused primarily on rehabilitation as opposed to punishment, like the prison where SHARE was offered. There were some mixed responses when participants considered whether prisons, more generally, were an acceptable place to receive trauma therapy. Responses to each interview question are reported below.

Recommendations on availability of trauma treatment in prison.

An overwhelming majority of participants, 97% (n = 61) responded that they would recommend that incarcerated women have trauma therapy available to them. This was true for both the participants who had decided to enroll in trauma-focused therapy (i.e., SHARE) and the participants who had decided not to enroll in trauma-focused therapy during incarceration (see Table 1). Participants largely reported that trauma therapy offered in prisons was an opportunity for women to receive support in a safe, controlled environment, learn to cope with traumatic experiences, and potentially avoid further traumatization. One participant said, “There’s women in there that’s been through more than I have. And if they’d been through more than I have, then they definitely need some way to get help so they won’t go back out there and go through more.” This belief was echoed by other participants who felt that offering trauma therapy could reduce the likelihood of returning to patterns of behavior that may increase the risk of experiencing more trauma postrelease. One said, “If they’re not able to get the help they need, to figure out what’s going on, or why it’s going on, or why it’s happening, who’s to say it’s not going to happen again? Or who’s to say they’re not going to repeat the same patterns that lead them down that path to get to what happened?”

The need for programming to address trauma sequelae was salient across interviews, specifically in relation to the cyclical nature of victimization, substance use, and reincarceration. Many participants stated that periods of incarceration present a unique opportunity to confront issues that contribute to criminal justice involvement, such as drug use, and in doing so believed they could avoid falling back into criminalized behaviors upon release. For example, one participant said,

There’s so many people that end up getting out, and they re-use, and they go back, and it becomes like an open door, like they go in and out, in and out, in and out, in and out. They do that for years and years … and they don’t really work on who they are, and what they’re going through, and what they’ve been through, why they were in there. So, they still use all that stuff to keep them high.

Again, speaking to the relationship between trauma, substance use, and incarceration, another participant said,

I think a lot of the reasons women end up in prison stem from their trauma. I didn’t just become an addict because I thought it was going to be fun. The traumas I went through led me to that road. Had I got help for them traumas, maybe I would have never went down that road. Had I actually got help for most of my traumas when I got back out, I probably wouldn’t have went back to prison.

One woman even suggested that trauma therapy while in prison could be a better alternative to community-based therapies because the mandatory chemical-free environment would allow them to focus on treatment. She said,

I think it’s better to do [trauma-focused therapy] in prison than outside. I just think that women that have been through trauma or traumatic experiences, when they’re incarcerated, they’re clean and honest and more … able to work through things than on the outside. So it helps them to hopefully prevent going back or getting in more trouble if they work through some of those things while they’re in there.

In addition to one participant whose response is missing, one participant reported mixed feelings when asked if she would recommend incarcerated women have trauma therapy available to them. This participant was concerned that sharing about traumatic experiences in prison, even in a therapeutic environment where confidentially was expected, made her vulnerable and that her experiences would be “weaponized” by her peers. The participant described a situation in which things she shared in confidence were used against her by peers and publicly shared, which she explained was traumatizing for her. In light of her negative experience, she ultimately said, “Yeah, I would [recommend trauma therapy], it’s just—be careful … I would say do it, but don’t be saying anything that makes you vulnerable that could extend your time.”

Acceptability of trauma treatment in prison.

Most participants (65%, n = 41) felt prison, without further qualification, was an acceptable place to receive trauma therapy. There were only marginal differences when responses were broken down by SHARE participation (Table 1). Many who answered with an unqualified “yes” spoke about the “safety” of prison as a context for treatment and the time they had to focus on their own development, away from the distractions they might encounter in the community. Regarding prison, one participant said, “It’s a safe environment, and it’s there. You’re inside. It gives you time to focus on yourself and your problems and to think about things … Having those kind of programs available to you is just like blessings in your face.” Another said, “I think it’s a very safe place because we’re sober. We’re not going to go out and drink or use, and if we’re triggered, then we’re in a safe, controlled environment.”

In addition to correctional facilities being viewed as a safe place to receive trauma therapy, some women highlighted the importance of having a significant amount of uninterrupted time to dedicate to therapy and the ability to “work on yourself,” as one participant put it. Another participant said, “When you’re in prison, you’re locked up, and when they offer groups, you go to them just so you’re not bored. But you learn at the same time. So you’re kind of, I mean you’re taken away from society, in a place for a certain amount of time … you might as well take advantage of them while you’re there.” Another explained how she was more likely to engage with treatment while incarcerated, saying “I wasn’t going to get treatment outside of facilities, but whenever I got locked down and sat down somewhere, I started. So anywhere is a start. Anywhere is better than nowhere.” Another participant said, “You have time on your hands. Why not better work on yourself?”

While most participants deemed prison an acceptable place for trauma therapy, a third of the participant sample reported having mixed feelings or said “yes” but identified qualifying factors that would make treatment more acceptable (33%; n = 21). Most mixed feelings were related to differences across prisons, with some participants describing the target prison—where SHARE was offered—as markedly different compared to other prisons in the state, considering its emphasis on rehabilitation. One participant said,

…it was a rehab facility. They sent you to class, they teach you to learn about what things that we weren’t able to do on our own anymore. How to deal with life, how to cope with life. An actual prison, I would have no idea. I mean, I would assume so, but I’ve never been to actual prison, and I don’t know … I’ve had two of my girlfriends go multiple times and to know that they went multiple times tells me that they didn’t learn anything, you know?

Another participant echoed this view, saying, “Depends on where you’re at really. [Other state prison], no. Nope. Not at all. You’re going to learn more ways to be a better dope dealer or cook better drugs or get better connects.”

Other participants who expressed mixed feelings were more so concerned with the safety and quality of the trauma therapy being provided. One woman stated, “It can be, it can’t be. It depends … on where you’re doing, where you’re at in prison. It depends on how serious the group is that you’re in and how much the teacher is into it and how well she does and all sorts of stuff.” While another participant answered in the affirmative, she also identified certain qualifiers, “Sure … with the right person, with the right therapist, with safe people.”

Of note, no participants reported that they would not recommend trauma therapy be offered to other incarcerated women, and none reported that trauma therapy was unacceptable to offer in prisons under all circumstances.

Trauma Treatment and Lingering Symptoms After Release

Most participants reported that they had not engaged with trauma therapy after releasing from the target prison where SHARE was offered, and most who had not received trauma therapy reported that they had also not considered getting any treatment focused on trauma recovery. Yet, most participants reported they were experiencing lingering, negative effects related to past traumatic experiences. Emergent themes contributing to reduced trauma therapy utilization are reported in the section below.

Postrelease trauma treatment.

Of the 63 participants in this study, only 16 (25%) reported receiving some form of trauma therapy since release. Participants who had attended trauma-focused therapy (i.e., SHARE) during incarceration were slightly more likely to have attended trauma therapy than non-SHARE participants (Table 1) following their release from the target prison. Participants who reported attending trauma-focused care after their release described their treatment as occurring in drug court, faith-based counseling services, and outpatient counseling. Other women denied receiving treatment specifically for trauma but mentioned that their needs were being met in other ways, like in recovery support groups or through medication management by a primary care provider.

As a follow-up to contextualize these responses, participants were asked if they participated in six relatively common evidence-based trauma therapies (i.e., cognitive processing therapy [CPT], prolonged exposure [PE], eye movement desensitization and reprocessing [EMDR], Beyond Trauma, Skills Training in Affective and Interpersonal Regulation [STAIR], and Seeking Safety). Whenever possible, researchers described each treatment and showed a visual aide of the treatment materials to participants. Despite our efforts to identify participation in these common evidence-based therapies, most participants were unable to say with certainty if they had formally received one of these treatments or heard of it. Notably, many participants—even women who endorsed receiving trauma-focused treatment—were not familiar with these therapies, indicating (a) they may not know what sort of therapy they are engaging with or (b) they are not receiving evidence-based therapy in the first place.

Of the 46 participants who had not received trauma therapy since their release from the target prison, just over half (52%; n = 24) had not considered getting additional treatment, over a quarter (28%; n = 13) had considered it, and nine responses (20%) were unknown or not reported. Non-SHARE participants were less likely to have received trauma therapy since their release from the target prison, with an approximately equal number having considered and not having considered seeking it. See Table 1 for more detail.

Whether or not they had considered trauma therapy after release, women often described similar reasons for not receiving it. Several participants referenced ongoing substance use as a factor for not seeking treatment, saying, “I self-medicated” and “I fell back in my addiction.” Others expressed that seeking trauma therapy was not their priority. One woman said, “I had never thought of specifically going for that reason because I felt like I had other train wreck stuff that’s more immediate.” Some women expressed having a difficult time focusing on their own issues, saying, “I wasn’t focused on my healthcare this year … every time I do have a girlfriend, I don’t pay attention to myself. It’s more about the other person. I think that’s just part of being an addict … You’d rather have somebody else’s problems than face your own.” and “I don’t want to focus on myself. I want to focus on others, and there’s a lot of shit that I do need to process, but I’m like, I’d rather help someone. I don’t know. I like to take the focus off myself.” Some participants described feeling as though they did not need or want additional trauma therapy, and others described more practical barriers, like lack of health insurance or transportation.

Lingering symptoms of trauma.

Significantly, 86% of participants reported experiencing lingering, negative effects of the trauma they had experienced in their lives. Many described symptoms consistent with posttraumatic stress. One participant explained, “I can be just in the middle of a setting with friends, and all of a sudden something will pop in my head from a bad experience, and I’ll have this rush of anxiety come over me.” Another shared a similar experience, saying, “Anxiety. Horrific anxiety. I used to be extremely outgoing and now I have antisocial behavior. It triggers, what is it, flashbacks, I guess? Those kind of things where it just takes your breath away and you don’t even remember.”

Other participants described instances of feeling unsafe in the presence of men or feelings of distrust in relationships based on past experiences of abuse. For example, one participant said, “Sometimes I’m just nervous, or a thing that wouldn’t bother me before, like my honey gets up behind me and gets on my neck, and it freaks me out … I just don’t like people behind my shoulder.” Another woman, who was reincarcerated at the time of her interview, said,

The CO [corrections officer] … reminds me of my ex-husband, and I just will not even conversate [sic] with them. That’s something that’s stupid, but I do it … I will get very nervous around men, and one of the … The disciplinary dude’s a man, and I … oh my gosh. I just can’t see him. He tried to hand me something the other day because he’s my boss too. I took two steps away from him.

Residual feelings of depression, guilt, and social isolation following traumatic experiences were also reported. One participant stated, “I’m extremely depressed since my husband committed suicide … I have trust issues … I have commitment issues … I have reoccurring nightmares … there’s a lot of regret, you know, residual effects that I still deal with on the daily. Guilt, average guilt.” Another woman said,

I blame myself a lot, I’m really hard on myself. The depression that comes along with that, being unmotivated, it definitely hurts the relationship I have with my boyfriend especially, and family members. I feel like I don’t trust anybody anymore and I’ve completely just like let go and disengaged with society. I guess, I’ve kind of isolated myself and don’t talk to my friends as much, and like you mentioned nightmares and flashbacks. I actually have to take medication for nightmares because I would have nightmares, night terrors, every night due to the trauma … a lot of those things affect me still today.

Discussion

This study explored the perspectives of women survivors of sexual violence who were previously incarcerated in a prison where they had the opportunity to participate in group trauma-focused therapy. We were interested in how this population felt about the availability and the acceptability of trauma therapy in correctional facilities, as well as their utilization of trauma therapy during and after incarceration. Findings reveal that previously incarcerated women—both those who had and had not participated in trauma-focused treatment while incarcerated—were overwhelmingly in support of access to such treatment in prisons, particularly in prisons that focused on rehabilitation. This is consistent with past research that found that women who participated in a group-based sexual trauma therapy while incarcerated would recommend such therapy within a carceral setting to other incarcerated persons (Zielinski et al., 2020,, 2021).

Many participants agreed that accessing trauma therapy in the community after incarceration was a challenge and periods of incarceration can be a time of relative stability where they have advantages not always available in the community—namely, time to spend on themselves, sobriety, and safety from potential abuse. There is both evidence of drug and alcohol use (Carson, 2021) and the potential for abuse (Owen et al., 2017) in prisons; however, as experienced and reported by the participants in this study, community settings are also not necessarily free from drugs, alcohol, or abuse. The integration of evidence-based trauma therapy in prisons would increase opportunities for women to receive treatment they would otherwise have limited access to in the community, a finding also supported by Abad et al. (2013). Participants who identified qualifiers which would make prison a more acceptable setting for receiving trauma therapy were mainly concerned with where, how, and by whom the therapy would be administered, with some women expressing uncertainty with prisons that do not emphasize rehabilitation. This concern highlights facility culture, facilitator fit, and intervention quality as factors of high importance to this population. Additional research is needed to explore perceptions of women with experiences of incarceration in different types of carceral settings (e.g., jails, other prisons, work release centers, and reentry centers) to better understand the facility characteristics that influence residents’ acceptability of trauma-focused therapy being offered there.

Furthermore, we found that both women who did and did not participate in trauma-focused treatment while incarcerated were experiencing ongoing negative symptoms of trauma exposure after release, most of whom did not seek or continue treatment postrelease. Reported lingering effects were varied, but participants often described experiencing issues related to low self-esteem, nightmares, flashbacks, trust, drug use, personal safety, and relationships. This supports past research highlighting the pervasive, negative impacts of trauma in this population (DeHart et al., 2013; Harner et al., 2015) and supports findings which detail reduced access to care and health service utilization postrelease (Abad et al., 2013). Zielinski et al. (2021) agree that concerns for safety in prisons, such as those referenced by Miller and Najavits (2012) and Wolff et al. (2015), are outweighed by evidence for positive treatment outcomes and the opportunity to treat an underserved population at a time when they have fewer environmental barriers and more time to prioritize their own health. Ultimately, our study revealed that most women want trauma therapy to be offered in correctional facilities, even if they feel some prisons are not the most optimal environment for treatment.

Limitations

The findings reported herein are not without limitations. While racial and ethnic minorities, particularly Black men and women, are disproportionally affected by incarceration, the sample included in this study were all individuals previously incarcerated in a prison with a predominantly White resident population which resulted in a heavily White sample. Studies of justice-involved people with greater racial, ethnic, and socioeconomic diversity are needed to elucidate how responses to these questions may vary among populations with different social and geographical contexts.

The target prison where this sample was previously incarcerated is rehabilitation-focused, and findings may not be generalizable among women with other prison experiences. Though many participants in this study emphasized that their time at the target prison was an opportunity to receive trauma-focused treatment in a safe, drug-free environment and away from external stressors, other prisons may not afford residents this same opportunity. Future research should include perspectives from individuals with histories of incarceration in other prisons and further evaluate under what conditions justice-involved people find trauma-focused treatment acceptable. Additionally, this study focused on elucidating women’s thoughts about trauma-focused therapy access in women’s prisons; therefore, findings are not intended to be generalized to men’s prisons.

Finally, recruitment efforts were concentrated around those with active social media profiles, which potentially excluded those without an active online presence or reliable access to the internet.

Implications and Future Directions

These findings provide support for increased access to evidence-based trauma therapy in correctional facilities. When asked whether prisons were an acceptable place to receive trauma-focused treatment, most women’s concerns centered on whether the facility focused on rehabilitation and whether they would be conducive environments for trauma recovery. This concern implies a need for broad prison reform to underscore incarceration as a point of intervention for issues related to trauma, mental illness, and substance use and not merely a punitive measure to deter crime. It also suggests that the culture of a correctional facility should be considered when preparing to implement trauma-focused treatment, as it will likely factor into how acceptable the therapy is deemed by the individuals who could benefit from participation.

Future research in this area is needed to explore the acceptability of trauma-focused treatment in prisons that are not rehabilitation focused like the prison in the current study. It will also be important to examine gender differences and ask incarcerated men about their perception of receiving trauma therapy in correctional facilities. Furthermore, future research should explore isolated components of acceptability, like affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy to further elucidate the broader perspectives reported here (Sekhon et al., 2017, 2018).

There is also evidence in these findings to support increasing access to evidence-based trauma therapy for previously incarcerated women in the community. We know from this study that our sample did not receive these services after incarceration. Although incarceration can function as a needed point of intervention for people who are already there, prison should not be the only environment where programming for trauma sequelae is accessible to justice-involved populations. Future research should investigate what strategies, such as integrated healthcare models and increased and prolonged access to reentry support and resources, could improve access to needed treatment for justice-involved populations and how technology, such as telehealth, could be leveraged to overcome barriers. Such findings would be of interest to any communities whose goals are to more effectively treat the source of problems which contribute to substance abuse and other criminalized behaviors, divert people from the criminal justice system, reduce recidivism, and reduce incarceration rates overall.

Biographies

Marley F. Fradley, BS, is a research associate at the University of Arkansas for Medical Sciences. She has worked on projects that examine life outcomes associated with trauma, mental and behavioral health disorders, healthcare disparities, and incarceration. Her primary research interests lie in understanding and reducing perceived barriers to care in underserved and marginalized populations, as well as exploring the links between trauma and comorbid psychiatric diagnoses.

Kathryn Allison, PhD, MPH, CHES, is a research assistant professor in the Department of Health Behavior and Health Education at the University of Arkansas for Medical Sciences Fay W. Boozman College of Public Health. Specializing in implementation science and qualitative research methods, her work centers on studying the implementation of technology-based interventions and treatment services in settings that reach underserved populations, including criminal justice settings and emergency departments, particularly for survivors of sexual violence and individuals at risk for suicide.

Mollee K. Steely Smith, PhD, is a NIDA-funded T32 postdoctoral fellow in the Translational Training in Addiction Program at University of Arkansas for Medical Sciences. She is interested in research involving the intersections of health and justice involvement. Her specific research focus is the health of justice-involved women as it relates to mental health and substance use as well as during pregnancy and postpartum.

MeeSoh Bossard, MA, is a licensed clinical social worker at the Chicago Center for Evidence Based Treatment. She is interested in better understanding the unique treatment needs of sexual assault survivors, particularly those with intersectional marginalized identities. MeeSoh received her BA in comparative human development and master’s in social work from the University of Chicago. Upon graduation, she completed her research fellowship and advanced clinical fellowship in Kumasi, Ghana and Little Rock, Arkansas.

Melissa J. Zielinski is an associate professor and clinical psychologist in the Department of Psychiatry at the University of Arkansas for Medical Sciences, where she directs the Health and the Legal System (HEALS) Research, Practice, and Policy Lab. She focuses her work on interventions to reduce the burden of traumatic stress exposure and sequelae on individuals and communities—particularly for people who use drugs, have posttraumatic stress disorder (PTSD), and/or are incarcerated. She has worked extensively with legal settings (e.g., prisons, drug treatment courts, jails, reentry centers) on implementation of evidence-based therapies for trauma and PTSD.