Passport to Freedom

Abstract

Poly-victimization is often reported by formerly incarcerated women and leads to physical and mental health problems that interfere with daily functioning, sustained employment, and housing stability. Although reentry programs exist, few focus on the physical and emotional impact of multiple traumas. Passport to Freedom (P2F), a woman-centered, trauma-informed reentry program, was developed to support formerly incarcerated women. The pilot intervention, performed in 2017, focused on the connections between trauma and health, coping with symptoms, and managing one’s own health. To examine the effectiveness and feasibility of the intervention, we performed the current mixed methods study with two phases: (1) focus groups, and (2) sessions combining mindfulness and health promotion activities with follow-up evaluations. Participants (N = 24) showed decreased symptoms of depression and concerns of everyday stressors after the intervention. Of participants, 84% (n = 16) reported practicing mindfulness and 63% (n = 8) stated that mindfulness exercises helped with daily stress management. The P2F program offers a promising approach to support formerly incarcerated women with health self-management.

Although men are more likely to be incarcerated in the United States, the rate of female incarceration is on the rise (Carson, 2020; Heimer et al., 2023). There has been approximately a five-fold increase in women’s rates of incarceration between 1978 and 2019 (Heimer et al., 2023). At the peak of increasing incarceration rates in 2007, women’s rates had increased by 6.6 times, or 560%, compared to men’s increased rates of 3.4 times, or 240%, from 1978 (Heimer et al., 2023). Increased mass incarceration of Black men in the 1980s and 1990s has been linked to punitive criminal justice responses to the crack cocaine epidemic (Walker & Mezuk, 2018). Like Black men, Black women were impacted by laws and policies that criminalized instead of helped solve the root causes of social problems (Richie & Eife, 2021). The current arrest rate for Black women is six times that of White women, and the imprisonment rate for Black women is more than twice that of White women (Carson, 2020; Heimer et al., 2023; Richie & Eife, 2021). Among incarcerated women, particularly Black women, substance use (26%) is the most frequently convicted offense (Carson, 2020).

The “school to prison pipeline” is a narrative that describes how policies and practices related to school discipline in the public school system lead to juvenile justice system involvement and decrease the chance of school success for children, especially Black children. This discussion has led to policy changes, resource allocation, and program development targeting the systemic issues affecting urban youth in America (Skiba et al., 2014). However, this discourse has primarily highlighted the needs and experiences of men. For women, the “abuse to prison pipeline” is perhaps a more accurate description of the interface with the criminal justice system experience. Studies have estimated that up to 90% of incarcerated women report a history of violence victimization (e.g., childhood sexual abuse, exposure to community violence, teen dating violence, intimate partner violence [IPV]) (Battle et al., 2003). Furthermore, many women exposed to violence also report poly-victimization, or multiple, cumulative experiences of several different kinds of victimization in separate incidents, such as sexual abuse, bullying, and witnessing violence (DeHart & Moran, 2015; Kennedy et al., 2020). Poly-victimization, particularly during childhood, is associated not only with increased incarceration risk, but also negative psychological, behavioral, and physical outcomes. Women also report cumulative trauma, defined as multiple traumas over time during different developmental stages and occurring one after another as well as simultaneously.

Removing women from society and placing them behind bars deeply impacts their lives and fractures the composition of the families, neighborhoods, and communities they leave behind. The incarceration of mothers also has a devastating impact on children. Recent data highlight that >147,000 children are under the sole custody of a mother who is incarcerated (Bronson & Carson, 2019). These children are also documented to have experienced other adverse childhood events and multiple mental and physical health problems (Turney, 2018). This number is higher (31%) than data from the early 1990s. Upon reentering the community, women have the same expectations as their male counterparts: secure, consistent, and safe housing; food; clothing; and employment for themselves and any dependents.

There are many interventions nationwide that assist formerly incarcerated individuals reintegrate into their communities following periods of confinement. Most interventions are tailored to male participants (Berghuis, 2018). Similar interventions targeting women, although there are few, do not address the chronic histories of poly-victimization, leading to missed opportunities to connect trauma to healing.

The current study tests the feasibility and effectiveness of the Passport to Freedom (P2F) program, a woman-centered, trauma-informed reentry program designed in 2017 by a collaborative, interprofessional team of nurse clinicians, public health professionals, social workers, and women’s advocates. Driven by the goal to provide women with a safe environment to process cumulative lifetime trauma, P2F aims to provide women with skills and strategies to not only manage physical and mental health but also provide a platform to flourish in their communities.

THEORETICAL FRAMEWORK

The Eco-Social Trauma Intervention Model, which was originally adapted from the Socio-Ecological Model for violence prevention, developed by the Centers for Disease Control and Prevention (CDC), guides interventions that promote trauma recovery on four eco-social levels: individual, interpersonal, community/organizational, and societal (CDC, 2022; Gultekin et al., 2019). The first is the individual level, which includes biological and personal history factors that impact whether an individual perpetrates or experiences violence. Individual factors include age, educational level, income, substance use, or history of abuse. The interpersonal level examines close relationships that impact risk of violence experience, such as close peers, partners, and family members. The third level, community, explores settings where social relationships occur, such as schools, workplaces, and neighborhoods, to identify characteristics of settings that are connected to experiences and perpetration of violence. The broadest societal level examines factors, such as social and cultural norms and policies related to health, economy, education, and social welfare, that influence economic or social inequalities faced by different groups (CDC, 2022).

The original socio-ecological model delineated by the CDC (2022) has been used across multiple populations informing IPV and trauma research. These populations include men, women, heterosexual, and lesbian, gay, bisexual, transgender, and queer populations who have experienced violence or coercive control (Hardesty & Ogolsky, 2020).

METHOD

Design

A mixed methods design was used to develop the intervention and pilot the program to determine preliminary evidence of effectiveness and feasibility. Phase 1 included intervention development using two focus groups. Through incorporated feedback and direction from the focus groups, literature, and chosen experts, six P2F sessions were designed. Phase 2 implemented the six-session series with a group of 24 women who had reentered society within the previous 6 months. A thorough evaluation was performed at the end of each session and 1 month aft er the last session.

Phase 1: Intervention Development.

Focus groups were used to obtain insight from formerly incarcerated women and professionals who work directly with formerly incarcerated women. The first focus group comprised nine key informants who worked directly in programs supporting formerly incarcerated women in Maryland. The key informants held positions with reentry programs, career development, parole and probation, and a transitional housing program. The key informant focus group emphasized the importance of building trusting relationships early, examining mental health needs, educating on substance use and addiction management, and providing career training to assist women in returning to the workforce.

A second focus group comprised eight formerly incarcerated women who had recently returned to the community. Participants discussed the struggle to reestablish suitable support systems conducive to their hopes for a better path aft er incarceration. Sobriety was also a major component women emphasized for a proper transition. As a mandate for many released under the parameters of parole and probation, sobriety was directly tied to incarceration freedom. Substance use for many was a coping mechanism and familiar part of their environment prior to incarceration. Many women spoke eagerly of new tools and resources that could better assist with stress relief and management of emotions, such as anger and depression. They encouraged assessments of current participant circumstances, resources, and referrals catered to participant needs, and strategies to restore self-esteem and self-efficacy. Consistent with the key informant focus group, participants highlighted career training, housing, substance use support, and social service assistance as critical components.

A key theme throughout both focus groups was the importance of recognizing the individual characteristics of the recovery stage. For example, a woman 6-months post-incarceration living in a transitional housing program may be more focused on sobriety and child reunification, whereas a woman 4-years post-incarceration living and working independently may prioritize pursuing education and healthy relationships with her family. All areas of recovery are important and critical for proper reentry, but the variety of resources needed may differ.

Although physical lifestyle changes are an important component of successful reentry, participants expressed prioritization of cognitive and mental readiness. Fears associated with reentry and reverting to behavior that had initially led to incarceration were prominent. In addition, employment and stable income was a high priority; participants discussed financial security’s role in decreasing dependence on family members, increasing likelihood of sobriety, and boosting self-confidence during reentry.

Findings from focus groups were contextualized within levels of the Eco-Social Trauma Intervention Model. Six sessions incorporating the components of self-regulation, relationship promotion, safety planning, identity formation, and life history processing were developed. Table A (available in the online version of this article) provides an overview and the system level addressed by each session.

Phase 2: P2F Intervention Sessions.

P2F session content was further refined by combining previously used evidence-based interventions and incorporating focus group input. Six sessions were designed to last 90 minutes. Sessions were held at a residential reentry program, a university-based community center, and a residential substance use program. Each session began with a mindfulness activity, followed by the session content, and concluded with a mindfulness activity that connected the session content and the opening mindfulness activity. Main topics for the six sessions were: (1) Mindfulness; (2) Health; (3) Healthy Relationships; (4) Family Matters; (5) Career Planning; and (6) Reflection.

Sample and Recruitment

A variety of strategies were used to recruit women for the P2F program. Flyers were distributed to reentry programs, substance use programs, parole officers, and probation officers. Interested women were contacted by a study team member, who explained the study, answered questions, and obtained a signed informed consent form if women indicated they wished to enroll in the P2F program. Individuals who did not speak English or were aged <18 years were excluded. The first cohort included women participating in a comprehensive residential reentry program, the second cohort included women who were referred by a Baltimore City government reentry program, and the third cohort included women who had histories of incarceration and were participating in a residential substance use program.

Implementation of Sessions

The intervention was delivered as six sessions for three different cohorts of women (N = 24) for a total of 18 sessions. All sessions were delivered using the same curriculum content and session format. Each 90-minute session began and ended with mindfulness exercises facilitated by a social worker with a background in mental health. Following the opening mindfulness exercise, the nurse and community outreach coordinator presented specific content for the session. At the start of the first P2F session, all participants received a journal to record thoughts from each session. During each session, women received a light healthy snack, handouts for community resources specific to each session topic, and completed post-session evaluations. Aft er each session, women were provided transportation and a $15 gift card.

Session 1.

This session aimed to create a safe space and provide a basic understanding of mindfulness by debunking myths about mindfulness and culture, connecting mindfulness to physical health and healing, and incorporating the practice into daily life. The group created collective agreements, or rules of engagement, for the sessions that remained throughout the course of the program. To promote mutual respect, a “talking piece” was used to identify the speaker and signal others to listen (Brown & Di Lallo, 2020). The first group activity included defining personal freedom and each participant was instructed to express their life experience by creating three drawings: a picture of where they are now in their life, their biggest worry, and a picture of their life with this worry resolved. This activity allowed the women to reflect on current worries while providing a safe space to share their feelings.

Session 2.

The aim of this session was to instill a level of personal empowerment and health promotion. The session opened with a mindfulness Qi-gong exercise, a traditional Chinese practice (van Dam, 2020), and each woman was invited to share where discomfort could be found in their bodies while the facilitator demonstrated movements and breathwork to alleviate discomfort. They created body maps using crayons and colored pencils to display how stress and trauma impacts physical and mental health by connecting feelings and sensations with specified areas of the body. Collectively, the group discussed the meaning of health prevention, identified barriers to maintaining health, and strategized ways to overcome these barriers. As a closing, the women were introduced to the health passport, a compact resource to store health and health promotion information.

Session 3.

This session aimed to distinguish between healthy and unhealthy relationships and promote coping strategies for family conflict. The mindfulness exercise invited each woman to imagine a safe place where someone special to them was invited to join them in their guided visualization. Collectively, differences between healthy and unhealthy relationships were discussed and specific strategies to cope with relationship challenges and conflicts were identified. This session included a two-part closing mindfulness exercise. First, participants engaged in a guided meditation on setting intentions for a healthy relationship and handling tough emotions, such as guilt, anger, forgiveness, and/or healing. They then participated in an activity to release emotions that did not serve them.

Session 4.

This session aimed to promote strategies and discuss conflict with family and loved ones. The group reflected on family patterns of addiction, incarceration, and physical/mental health problems through a genogram worksheet. Through filling out the genogram, the women were able to reflect on the impact of patterns on their lives and develop strategies for moving forward. The closing mindfulness exercise focused on letting go, acceptance, and reinforcing emotions that do not serve them.

Session 5.

The purpose of Session 5 was to develop goal-setting strategies to meet the unique needs of previously incarcerated women. The opening mindfulness exercise focused on visualizing the ideal life. The facilitator assisted the group with identifying their personal gifts and purpose. On their worksheets they wrote down their gifts, what they do well, and what they bring to the world that is valuable. A speaker from a career support agency assisted the women with strategies to gain employment while recognizing the collateral consequences of incarceration history. The closing mindfulness exercise was geared toward releasing self-doubt and negative self-talk.

Session 6.

The final session served as a program reflection. Participants were given space to discuss the previous five sessions and review the mindfulness exercises learned throughout the program. The drawing activity from Session 1 was replicated and the women were able to reflect on their physical, emotional, and spiritual journey throughout the program.

Data Collection

Baseline data were collected to obtain demographic information, general health, relationship status, incarceration history, and IPV. All women used computer-assisted surveys to complete self-reported questionnaires related to depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D]), everyday stress (Everyday Stress Index [ESI]), and baseline and IPV (Severity of Violence Against Women Scale [SVAWS]) (Table 1). Women completed the questionnaires before the start of the sessions (baseline/T1) and 4 weeks aft er the completion of Session 6 (follow up/T2).

TABLE 1.

SUMMARY OF MEASURES

Measure	Description	Scoring	Reliability
Center for Epidemiologic Studies Depression Scale (CES-D)	20-item self-report measure for depression symptoms experienced in the past 1 week	4-point Likert scale (0 = rarely or none of the time to 4 = most or almost all of the time); scores are summed and range from 0 to 60, with higher scores indicating greater depressive symptoms	Internal consistency: Cronbach’s α = 0.85 to 0.90 Test-retest reliability: r = 0.45 to 0.70 (Radloff, 1977)
Everyday Stress Index (ESI)	20-item self-report measure for chronic daily stressors faced by mothers with young children	4-point Likert scale ranging from 0 (not at all bothered) to 3 (bothered a great deal); scores are summed and range from 0 to 60	Internal consistency: Cronbach’s α = 0.83 (Hall, 1983)
Severity of Violence Against Women Scale (SVAWS)	46-item scale with nine subscales that measure two major dimensions (threats and actual violence); the sexual violence subscale includes six items	4-point Likert scale ranging from 1 (never) to 4 (many times); scores range from 19 to 76 for threats, 27 to 108 for violence, and 46 to 184 for severity	Internal consistency: total scale α = 0.92 to 0.96 for female college students, α = 0.89 to 0.96 for community women (Marshall, 1992)

Data Analysis

Before data analysis procedures, data were assessed for quality and completeness. Data were explored to ensure statistical assumptions were met and descriptive statistics were assessed to characterize the study sample. Changes in mean measurement scores for depression, stress, and IPV that occurred pre- and postintervention were assessed through Wilcoxon signed rank tests across all three cohorts. Repeated-measure mixed-effects regression models using all available data were used to derive mean estimates for change in outcome over time and their associated 95% confidence intervals and p values, assuming unavailable outcome values were missing at random. The 2-sided alpha was set at 0.05 to determine statistical significance, and all analyses were conducted using SAS version 9.4.

Ethical Approval

Before any aspect of the project began, ethical approval was obtained from the University’s Institutional Review Board. Initial approval was granted to conduct the focus groups and subsequent approval was obtained to conduct the intervention sessions.

RESULTS

Participant Demographics

The P2F was offered to three different cohorts of women for a total of 24 women. Results reported are from all three cohorts (Cohort 1: women participating in a comprehensive residential reentry program; Cohort 2: women referred by a Baltimore City government reentry program; Cohort 3: women with histories of incarceration participating in a residential substance use program). Participants were primarily African American (50%, n = 12), with more than one third being Euro American (37%, n = 9); 50% (n = 12) were aged between 25 and 34 years; and 50% (n = 12) had at least a high school/GED education (Table 2). Approximately one half of women had intimate partners and three fourths were mothers. One third (33%, n = 8) of women reported that this was their first incarceration. Most women went to prison due to drug offenses and most were using prescribed medications to treat their depression. At baseline, most (79.2%) reported being in a drug treatment program and approximately one half had abusive partners (45.8%, n = 11). Approximately one quarter (24%) of the women reported being in relationships with IPV and participating in drug treatment programs at baseline. This proportion of women experiencing IPV and attending drug treatment programs increased at follow up (33%) (Table 3). Among the community group, only one woman was in a treatment program. Looking at attendance of ≥80% (five to six sessions), women further along in their recovery had a higher attendance rate (87%) compared to women in the initial phase of recovery (40%), with women from the community having the lowest attendance rate (33%).

TABLE 2.

PARTICIPANTS’ DEMOGRAPHIC CHARACTERISTICS (N = 24)

Characteristic	n (%)
Racea
African American	12 (50)
White	9 (37.5)
More than one race	2 (8.3)
Educational levela
Less than high school	5 (20.8)
High school graduate/GED	12 (50)
Some college	4 (16.7)
2-year degree	1 (4.2)
4-year degree	1 (4.2)
Age (years)
18 to 24	2 (8.3)
25 to 34	12 (50)
35 to 44	4 (16.7)
45 to 55	6 (25)
Partnered	11 (45.8)
First incarceration	8 (33.3)
Have children	19 (79.1)
Housing status: transitional	12 (50)
Program participation: completed six sessions	11 (45.8)

^aMissing data from one participant.

TABLE 3.

MENTAL HEALTH AND PARTNER STATUS: BASELINE AND FOLLOW UP

Characteristic	n (%)
	Baseline (N = 24)	Follow Up (N = 15)
Prescription depression medicationsa	14 (58.3)
Drug treatment programa	19 (79.2)
Intimate partner relationship	11 (45.8)	11 (73.3)
Drug treatment program and intimate partner violence relationship	6 (24)	5 (33.3)

^aData not collected at follow up.

Participant Outcomes

Examining pre-post mean scores for the entire sample revealed decreased scores on the SVAWS, depression, and stressors (Table 4). Although differences in pre-post scores were not statistically significant, women reported the biggest decrease for IPV (66.6 vs. 59.7) and limited changes in scores for depression (26.4 vs. 23.5) and stressors (42.6 vs. 43.5). These reported depression scores in clinical settings are high and at a threshold that indicates the need for additional referrals and resources. These scores also reflect that many of the women were also engaged in drug treatment programs and taking medications for depression.

TABLE 4.

PRE-POST VIOLENCE, DEPRESSION, AND STRESSOR SCORES

Measure/All Cohorts	n	Median	Range	Mean	95% CI	p
SVAWS
Pre	11	59	46 to 105	66.6
Pre, where post value was available	6	66	46 to 98	70.7
Post	9	50	46 to 123	59.7
Post, where pre value was available	6	51	46 to 123	65
Differenceb	6			−5.7		0.91a
Model-based mean differencec	14			−7.1	[−25.2, 11]	0.41
CES-D
Pre	24	24.5	5 to 51	26.4
Pre, where post value was available	15	25	5 to 42	24.3
Post	15	24	3 to 51	23.5
Differenceb	15			−0.9		0.73a
Model-based mean differencec	24			−1.7	[−8.7, 5.2]	0.61
ESI
Pre	24	43	15 to 72	42.6
Pre, where post value was available	15	45	32 to 72	46.5
Post	15	40	26 to 74	43.5
Differenceb	15			−3		0.81a
Model-based mean differencec	24			0.43	[−7.3, 8.2]	0.45

Note. CI = confidence interval; SVAWS = Severity of Violence Against Women Scale; CES-D = Center for Epidemiologic Studies Depression Scale; ESI = Everyday Stress Index. The ns for Pre and Post indicate the number of participants providing baseline and follow-up data, respectively. When both Pre and Post values are available, the “n for Pre, where post was available" and “n for Post, where Pre was available” are equal. “Post, where pre value was available” is missing for the CES-D and ESI; thus, mixed-effects modeling inferences are based on the entire participant pool.

^aWilcoxon signed rank test.

^bBased on participants with both Pre and Post data, with “Mean” representing the direct difference between the corresponding values in the “Pre, where Post value was available” and “Post, where Pre value was available” rows.

^cDerived from modeling using all available data, accounting for missing data under the assumption of missing at random. The inference from mixed-effects modeling is not applicable to participants without Pre or Post data.

Participant Perceptions of the P2F Program

Slightly less than one half (45.8%) of the sample attended all six intervention sessions. In general, women reported being very satisfied with the content from the sessions. Among participants, 84% stated that they would recommend the program to other women, 84% stated they had practiced the mindfulness exercise they had learned in the sessions, 63% agreed that the mindfulness activities helped them manage their stress, and 68.4% strongly agreed that the sessions would be helpful to their transition back to society aft er they completed the program. Comments from the women, submitted with post-session evaluations and from postintervention, reflected their satisfaction with the P2F program:

The P2F Program improved my life on a day-to-day basis because it mainly helped with my coping skills. A few things that stick out from time to time was how powerful and worthy I felt once I left the groups. I believe that I can deal with real life situations because of this group.

The meditation helps me still today mainly when dealing with my child. I now know how to take time out to breathe my way back into reality. I thank [the] P2F program and the staff from this group for changing my life forever.

Post-session focus groups with the women provided the team with valuable insights for subsequent development of the P2F program. Women wanted more sessions, longer sessions, and extended time to practice using genograms and mindfulness activities.

DISCUSSION

Participation in the P2F intervention was a positive experience among formerly incarcerated women, demonstrating trends in decreased IPV experiences, improved depression symptoms, and decreased stress. Our program provided behavioral skills, such as journaling and mindfulness, to cope with the stress of participants’ everyday lives. In addition, the program was tailored to the reentry experience unique to the lives of many women living in our communities.

Characteristics of the P2F program participants are similar to national data for incarcerated women. Participants were primarily low-income women with less than a high school education, were caring for children, and most were incarcerated related to drug offenses. Most participants were in drug treatment programs and taking antidepressant medications. Women reported high depression scores upon entering the study, which in clinical settings would meet the threshold that would activate referrals for additional assessments and resources. These data also reflect that many of the women were also engaged in drug treatment programs and taking medications for depression. The decrease in depression scores pre- and post-P2F sessions, although not statistically significant, is encouraging and suggests that adding mindfulness strategies may complement other aspects of drug treatment programs (Derlic, 2022). Similarly, patterns of decreased IPV scores and stress scores also suggest that inclusion of activities that encouraged women to examine family relationships (genograms) as well as sources of stress as mindfulness strategies to manage conflict might be important and complementary additions to drug treatment program curricula. Of importance is the inability to reach statistical significance due to the pilot nature of the intervention and small sample size. Future investigation may reveal significant results supporting the findings of the current study.

P2F has some similarities to other evidence-based interventions aimed at addressing trauma among incarcerated or previously incarcerated women. A recent review of the literature (Berghuis, 2018; King, 2015; Roe-Sepowitz et al., 2014) included several of the existing research-based interventions and concluded that studies using one of four different manualized interventions appeared to have a positive impact on posttraumatic stress disorder (PTSD) symptomatology compared to the treatment as usual groups.

Most of the interventions described in the review also targeted incarcerated women and were developed specifically to address PTSD and co-occurring substance use. Seeking Safety delivered the content of their intervention in 90-minute sessions three times per week over 12 weeks. Helping Women Recover/Beyond Trauma incorporated mindfulness meditation, cognitive-based therapies, and experiential therapies, such as art or guided imagery, in 12 sessions in a prison-based therapeutic community. Other psychoeducational approaches, such as Esuba, were delivered in 10 sessions addressing a variety of topics related to various types of abuse to teach healthy communication and anger management skills (Roe-Sepowitz et al., 2014). Beyond Violence is a trauma-informed and gender-responsive intervention for women who have committed violent crimes, with a goal of preventing further aggressive behavior and recidivism, addressing links between violence, mental health, and substance use; influence on family and other community relationships; and health, offered over 20 weeks. P2F addressed many of the components of the trauma related to PTSD and mental health issues for incarcerated women. However, P2F was specific to assisting women to transition back into communities. It was not a therapeutic group or substance use program. Participation complemented other comprehensive services women were receiving, addressed how trauma impacted all aspects of life, and connected women to other services. The eco-social trauma informed approach used in P2F and the preliminary results show a similar positive impact on the women and their mental health outcomes.

Women who participated in P2F were enrolled from different settings. Many of the women were recruited from residential drug treatment programs. A smaller group was recruited by referrals from a municipal reentry program. Comparing outcomes of the women suggested that P2F can be a complementary addition to existing residential treatment programs because these women have the advantage of knowing each other, prior experience with participating in group activities, living on-site where the P2F program sessions were offered, and maintaining connections with other professionals critical to their transition back into the community. In contrast, women not in residential programs came together as a group of strangers at our community center, and some struggled with issues related to housing, childcare, finding continued support for their drug recovery, and increased accountability to their parole or probation officer about how they are spending their time. However, this latter group of women formed a supportive group and actively engaged in the sessions. Post-session evaluations revealed that despite some of the challenges these women faced, they found the sessions helpful and were able to practice mindfulness strategies between sessions. Integrating peer support strategies in recovery can facilitate social connectedness and resilience to challenging life circumstances faced by many formerly incarcerated women (Shalaby & Agyapong, 2020).

P2F program participation was different across settings. The residential treatment programs represented different stages of recovery. Some of the women were in programs for residents who had progressed from the initial phase of recovery, whereas women in other residential programs included pregnant women, who were deferred from prison to the program and were in the first phase of their recovery. Attendance rates were aligned with stability and recovery trajectories as well as place of residence, which suggests that resources related to stable housing and support for drug recovery make it easier for women to participate in the P2F program. However, participants from the community may need additional support to attend P2F or similar programs, such as conveniently located meeting places at convenient times, as well as assistance with transportation, food, and childcare. P2F made all of these supports available to participants.

Lessons Learned and Next Steps

Lessons Learned From Key Informants.

Together our team has learned much about work with this population of women experiencing high levels of structural vulnerability. While working with key informants, we learned that there are few programs that address issues around trauma and provide useful strategies, such as mindfulness, to help women manage the feelings and behaviors related to unresolved issues of trauma. Study findings also emphasize the need to identify and work with their transition coordinators who are assigned to support women as they prepare to leave prison. Partnerships with other reentry programs were also recommended.

Lessons Learned From Women.

The P2F program was well received by women, and many women said they wanted longer and more sessions. Women believed that the culturally relevant and all-female team of professionals of diverse backgrounds made a difference. Women found it useful to see how unresolved trauma issues were affecting their thoughts and behaviors, and that the mindfulness activities were useful to help them manage on a day-to-day basis. Although women in residential and transitional housing programs may have been easier to reach and for the P2F program to take the sessions to their facilities, women who were not enrolled in programs were harder to reach. These women may be more likely to “fall through the cracks,” return to prison, and therefore have a greater need for participation in P2F.

LIMITATIONS

It is important to acknowledge some limitations of the current study. The small sample size, comprising only 24 women, prevents generalizing findings to a broader population. Consequently, larger sample sizes are essential to enhance result reliability. Despite the exploratory and pilot nature of the study, its findings serve as a valuable foundation for future research. Moreover, the relatively brief duration of the P2F program may not have sufficiently addressed the complex needs of formerly incarcerated women. To substantiate the intervention’s effectiveness, further research with larger samples and extended follow-up periods is warranted.

CLINICAL IMPLICATIONS

The unique aspects of this program that focused on trauma and its impact on health and well-being and the use of mindfulness activities to manage stress-related symptoms provided formerly incarcerated women with lifelong strategies that complement existing programs. This promising intervention strategy needs further rigorous testing with larger, more diverse groups of women with more attention to retention and removing barriers to attendance.

The current study was more exploratory in nature because it was a pilot study. However, the P2F intervention will be further tested and expanded to be used across a wider range of populations, including women who reside in emergency shelters and formerly homeless women who live in permanent housing through housing assistance programs. There is a need for more rigorous research on trauma-informed interventions with larger, more diverse samples and comparison groups of incarcerated women (King, 2015). Evidence-based, trauma-informed approaches must be integrated into support programs for incarcerated women returning to the community and provide women with the knowledge and skills to address mental health issues and stressors that might increase their risk for returning to prison.

CONCLUSION

P2F, which was added to existing services for previously incarcerated women and provided women practical strategies to use, had a positive impact. Specifically, P2F highlighted the importance of providing tangible and actionable strategies to address feelings and behaviors that result from experiences of trauma, as well as the importance of working in partnership with staff members already assisting incarcerated women with reintegration into society. These two elements must be incorporated into future psychiatric and mental health practices and intervention development to assist women with understanding the far spread implications of trauma, equip them with skills to promote their mental well-being, and allow for a fluid transition back into society.

Table A. Passport to Freedom Session Description.

Session Topic	Session 1 Mindfulness	Session 2 Health	Session 3 Healthy Relationships	Session 4 Family Matters	Session 5 Career Planning: Goal Setting	Session 6 Reflections
System Level Addressed	Individual	Individual	Individual Interpersonal Community Organizational	Individual Interpersonal	Individual Community Organizational Societal	Individual
Session Purpose	□ Basic understanding of mindfulness   □ How mindfulness can help reduce stress   □ Debunk myths   □ Describe the impact mindfulness has on overall health	Opening mindfulness exercise	Opening mindfulness exercise	Opening mindfulness exercise	Opening mindfulness exercise	Opening mindfulness exercise
Goals of Session	Purpose: Equip women with basic understanding of mindfulness and to guide in the practical application for nurturing safe space and reduction of stress	Purpose: Empower participants with health promotion information and strategies to meet their health care needs.	Purpose: Enable participants to distinguish between healthy and unhealthy relationships, and identify strategies to cope with conflicts with family, friends and loved ones.	Purpose: Promote strategies to reduce actual/potential conflicts with family members and loved ones.	Purpose: Provide career goal setting strategies to meet the needs of formerly incarcerated women.	Purpose: Provide safe space for participants to reflect on experiences in the study; share feedback; review skills and topic takeaways for their personal journey after the study.
Session Activities	Goals: Create safe space and group norms as foundation for engagement. Introduce mindfulness exercises as easy to use methods to reduce long-term effects of trauma.	Goals: Increase health promotion and health maintenance behaviors by acknowledging actual and potential barriers and providing specific strategies to overcome these challenges.	Goals: Provide specific strategies to nurture healthy relationships and manage unhealthy relationships.	Goals: Discuss impact of family patterns and provide specific strategies for handling tough emotions and promoting change.	Goals: Identify career goals and be provided with strategies to gain employment while recognizing the collateral consequences of previous incarceration.	Goals: Hold safe space for genuine reflection and practicing gratitude; review mindfulness techniques; commit to implement into daily life; review tools and life improvement knowledge and application after the study; provide opportunity to maintain connections.
Outcomes Measured	Objectives: Participants will be able to gain an understanding of mindfulness and its impact on their emotional and physical healing; understand what mindfulness is and why it helps; debunk myths; breathe mindfully; apply breathing techniques to daily life and life perspectives.	Objectives: Participants will be able to identify challenges they face while trying to take care of their health care; identify strategies to overcome those challenges; describe how to use the provided Health Passport, which they can use to store and track health information.	Objectives: Participants will be able to distinguish between healthy relationships and unhealthy relationships; discuss strategies to help nurture positive, healthy relationships; discuss strategies to cope with and overcome identified challenges and conflicts.	Objectives: Participants will be able to identify family patterns and learn strategies for change. Participants will be able to describe the impact of these patterns on their life.	Objectives: Participants will be able to identify paths to various and nontraditional career options for women; discuss collateral consequences of incarceration when seeking employment; describe steps in seeking employment. Make participants aware of career planning resources available in the community for formerly incarcerated women.	Objectives: Participants will be able to express their thoughts and feelings about their experiences in the program; practice mindfulness exercises learned; exercise constructive criticism and gratitude; consider long lasting bonds with fellow participants.
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