Female Ex-Offender Perspectives on Drug Initiation, Relapse, and Desire to Remain Drug Free

Abstract

Recently-released homeless women residing in temporary residential drug treatment programs are at a critical juncture in the process of recovery, transition and reentry. The purpose of this study was to explore factors influencing initial use of drugs and relapse triggers among a sample of incarcerated women exiting jails and prisons, and who are residing in a residential drug treatment (RDT) program and preparing for reentry into their communities. Among this population, relapse to drug use and recidivism are common. A qualitative study was conducted utilizing focus groups to understand the perspectives of formerly incarcerated, currently homeless women residing in a RDT program. Content analysis generated the development of three broad categories: a) factors associated with first drug use; b) factors involved in relapse; c) factors influencing desire to remain drug free. A discussion follows highlighting the importance of targeted interventions at RDT sites that integrate physical, psychological and social needs to optimize reentry into communities. This would include a focus on building self-esteem, life skills, and providing access to resources such as housing, employment, and healthcare.

INTRODUCTION

California holds the third largest population of female inmates in the United States (US) (Carson, 2014); over the last decade, the incarceration of women has risen by 25 percent (Garcia & Ritter, 2012). As the fastest growing inmate population in the nation (Carson & Golinelli, 2013), black women are imprisoned at nearly twice the rate of non-Hispanic white females (Carson, 2014). Homelessness becomes a reality for many women exiting jail or prison if they do not have adequate familial or social support, lack of housing opportunities, employment and other factors (Metraux & Culhane, 2004). In fact, some authors charge that successful reintegration requires a myriad of support which includes personal, material, and legal resources (Pogorzelski, Wolff, Pan, & Blitz, 2005).

Intertwined Relationship of Drug Use and Homelessness among Women

While drug triggers are not well understood among women on parole and probation during reentry, homelessness is a complicating factor. Studies have shown that substance-using women offenders have complex needs which may result from homelessness, mental and physical health disorders, low employment, histories of abuse, and early involvement with the criminal justice system (Grella & Greenwell, 2007). Qualitative studies investigating risk and protective factors among male and female ex-offenders revealed that drug relapse often occured in the context of poor finances, an environment laden with drugs, drug trafficking, and having drug –using acquaintances (Binswanger et al., 2012). Aside from drug use, factors which trigger the transition into and out of homelessness among women include family problems in the previous 3 months, losing custody of their children, relationship breakdown, and worsening health (Kemp, Neale, & Robertson, 2006).

Social and Familial Protective Factors for Women against Drugs and Recidivism

As compared with their male counterparts, women have diminished access and support, be it familial or state-sponsored (Mallik-Kane & Visher, 2008). While female ex-offenders struggle with enhancing self-efficacy and abstinence from drug use during the difficult transition back into society (Pelissier & Jones, 2006), parental role dynamics and/or intimate partner relationships appear to be important predictors for sustained reintegration within communities (Benda, 2005).

Although the data are varied, it has been suggested that adults who form quality bonds may desist from crime due to unofficial social controls (Devers, 2011; Huebner, DeJong, & Cobbina, 2010). In a study of imprisoned women, having children incentivized them to stop engaging in criminal activity (Enos, 2001). In another study, substance-abusing female offenders who expected to live with their minor children following release from custody were more likely to enter a therapeutic community (Robbins, Martin, & Surratt, 2009). In fact, an inverse relationship exists between both recidivism and having children and recidivism and having a non-criminal romantic partner, suggesting that women are intrinsically protected by these social and familial arrangements (Benda, 2005). However, the experience of being overwhelmed with actual challenges and barriers to transition easily lead to relapse of drug use (Phillips & Lindsay, 2011).

Drug Treatment as a Protective Factor against Recidivism

The United States (U.S.) Department of Justice found that after one year, the female recidivism rate was 34.4%, with three quarters of female state prisoners being rearrested within 5 years of release; one quarter of those ex-offenders were arrested for drug crimes (Durose, Cooper, & Snyder, 2014). A systematic review of recidivism prevention programs among women found that female offenders who undertook substance abuse treatment were 45% less likely to reoffend after their release from prison compared to female offenders who did not participate in any form of substance use treatment

There is a dearth of analysis, and classification of the experiences, barriers and service needs of formerly incarcerated, currently homeless women. It remains unclear what in fact works to prevent ongoing drug use and recidivism among women offenders (Tripodi, Bledsoe, Kim, & Bender, 2011). This analysis thus has implications for treatment, successful reentry and long-term rehabilitation for drug using women offenders as they approach the end of their jail terms.

Need for Gender Responsive Programs

More than half (55%) of all women in jail in California were convicted for non-violent drug or property crime (California Department of Corrections and Rehabilitation, 2011). Women are also more likely than men to have committed drug-related crimes (21.7% vs. 14.7%) as compared to violent crime (39.4% vs. 59.8%) (California Department of Corrections and Rehabilitation, 2011). As policies and programs designed for male offenders may have little relevance to women offenders (Wiewel & Mosley, 2006), gender-specific assessment and treatment (Messina, Burdon, Hagopian, & Prendergast, 2006) are critical areas of need. A small, but growing volume of gender-responsive literature demonstrates a nascent comprehension of the realities of women’s lives, and considers women offenders a unique population with divergent risk factors as compared to men (Bloom, Owen, & Covington, 2003). It is suggested that female pathways to prison may be slowed with interventions that deal with personal histories of trauma, abuse and other risk factors that may lead to substance use (Salisbury, Van Voorhis, & Spiropoulos, 2009).

The purpose of this paper was to explore first person accounts of the factors which influenced drug initiation and relapse, as well as a decision to remain drug free among a sample of recently released homeless women, residing in a residential drug treatment (RDT) program.

METHODS

Design

Qualitative study utilizing focus groups was conducted to understand the perspectives of recently released female ex-offenders residing in a RDT. Female ex-offenders who were determined to be homeless by their self-report, who resided in the RDT program, and were currently on probation and parole were further considered for enrollment in the focus groups. In total, three focus groups were conducted with a total of 18 women, aged 23 to 53. This study was approved by the University of California Human Subjects’ Protection Committee.

Community-based participatory research (CBPR) guided all aspects of the study beginning with the conceptualization of the study, its design, continuing with implementation and subsequent evaluation. Based on principles of equity and collaboration (Israel, Schulz, Parker, & Becker, 1998), CBPR included early discussions of the research team and the RDT facility about research collaboration.

Formative Collaboration

In preparation for a former study of male parolees, the Principal Investigator and her co-investigator (Co-I) collaborated with the Director and several members of the administrative team. This collaboration led to a successful grant funding by National Institutes of Health (NIH) for a five-year study focused on homeless men who were released from jails and prisons (2008-2012) (Nyamathi, Marlow, et al., 2012; Nyamathi et al., 2014; Nyamathi et al., 2015). As the male parolee study was being implemented, female residents of the RDT questioned why they were not able to participate in the male study. Focus group sessions with several female residents in a RDT program (Salem, Nyamathi, Idemundia, Slaughter, & Ames, 2013) led the way to on-going discussions with the administrative community at the RDT about the design of a Female Ex-Offender study.

Ongoing discussions with the administration of the RDT led to the development of another grant application for women which included a co-developed intervention for women focused on dealing with past trauma, and factors which served as barriers to ongoing recovery and becoming drug free once integrated into their communities. This study was subsequently funded by the National Institute on Drug Abuse (NIDA) in 2014 as a randomized clinical trial focusing on decreasing drug use and recidivism among homeless female offenders recently released from jails and prisons.

Once funded, the investigators continued formative work to continue to refine the intervention with ongoing interaction of the administrators and residents of the therapeutic community. A number of meetings were organized by the PI and Co-I to discuss the implementation of the study at the RDT site, the staff that would support the investigators, and suggestions and recommendations about selecting successful former residents to be research staff in the project. In addition, next steps were discussed in the formation of a Community Advisory Board (CAB), its membership, and engaging female residents of the RDT in focus groups to further refine the developing intervention program. The participants of the CAB were recommended by the Director of the facility and his staff. This formative work led to the final refinement of the intervention focused on delivering a mindfulness approach (Chapman, 2006; Dimeff & Linehan, 2001) which would complement the services offered at the RDT program.

Sample and Setting

The 18 women enrolled in the study met the following eligibility criteria: a) 18-50 years old; b) self-reported as homeless at the time of release from jail or prison; c) currently on parole and/or probation; and d) affected by drug use. Exclusion criteria included persons judged to be cognitively impaired by the research staff. The women were enrolled from one of two RDT programs. Both sites offer structured drug and alcohol treatment services, as well as group classes, and preparation for reentry into the community. All participants who approached the researchers were eligible for the study. No women refused or dropped out of the focus group study.

Community Advisory Board (CAB)

As part of the CBPR process, a CAB was convened with a total of 8 persons, of whom one woman was a graduate of the program. Also included were directors of the representative RDT programs, and a female administrator of one RDT. The PI and three Co-Is also attended these CAB meetings.

The CAB members conducted a number of activities which were critical in moving the research study forward. These included a review and modification of the semi-structured interview guide (SSIG) which framed the questions that the researcher and her facilitator asked, and provided an understanding of the assessed needs of the women as it related to access to care, ongoing need for support for remaining drug free, and ideas for promoting sustainability. See SDC. Over time, the CAB also reviewed the baseline questionnaire and suggested modifications needed. We likewise discussed the staff roles and staff interview time and discussed selection of candidates after interviews were conducted. Finally, the design of the intervention programs were agreed upon based on transcription notes from the focus group sessions.

Procedure

Recruitment for the focus groups was facilitated by posting of flyers in the residential area of the facility as approved by the University of California Human Subjects’ Protection Committee. This committee ensures the rights of participants in all research studies are being protected. The setting for the study was in a private research coordinating room in another facility office building across the street from the residence. Among female residents who expressed interest in the study, two female researchers (AN and BS) announced the purpose of the research in small group meetings, and among the women who wanted to participate, met with each potential participant in a private location to get to know the women personally and to inform them about the proposed focus group study planned, the time involved and planned procedures.

Among those still interested in the study, the researchers provided an oral informed consent, followed by a brief screening questionnaire which assessed eligibility to participate in the study. The researchers who have over a decade of years of conducting focus group methodology, arranged a meeting time for the participants in small groups which were held in a private location at the primary RDT facility. The three focus group discussions were audio recorded with permission of the participants and field notes were captured by the second researcher during the focus group and after the sessions were completed.

A short sociodemographic survey was then administered one-on-one with the participant in a private location. The screening compensation was $3.00 and those who participated in the focus group discussion received $15.00. The focus group sessions, conducted by the researchers named above, lasted about one hour and fifteen minutes. The researchers agreed that data saturation had occurred.

Data Analysis

Two researchers and two research assistants were involved in the conventional data analytic process. The coding process and analysis preceded using content analysis as the theoretical orientation. This process continued simultaneously with data collection until unique categories that were derived from the data were identified. The transcripts were summarized and recurrent content determined and then validated with 2-3 participants drawn with permission from the previous sessions. The participants verified that the findings were true to their knowledge and experience. In these interviews, participants were given clusters of data segments from the transcripts and asked to identify which words and phrases accurately reflected their own experiences.

This inductive process resulted in participant comments being categorized and counted. Content analysis encompasses: a) selecting the unit of analysis (responses to questions and topics that come up); b) creating and defining the categories; c) pretesting the category definitions and rules; d) assessing exhaustiveness and exclusivity of the schema; e) revising the coding rules, if necessary; f) pretesting the revised category schema; g) coding all the data and counting occurrences, and h) reassessing consistency in coding decisions and congruence between claims about the data and reality (Downe-Warmboldt, 1992).

Trustworthiness of the data (Lincoln & Guba, 1985) and control for naturalistic inquiry was ensured by dependability, confirmability, credibility, and transferability. Dependability was established through saved taped recordings and transcriptions to affirm the consistency of interpretations. Confirmability involved reflexive examination, commentaries, and an audit trail. Credibility of the data was established by using the technique of debriefing. Transferability was established by reviewing this analytical process and ensuring that conceptual dimensions were grounded to the data. Sample characteristics, frequencies, percents and means were used to describe chronological age, ethnicity/ race, country of birth, education level and length of time homeless.

RESULTS

The mean age of the 18 female participants was 38.0 (range 23-53; SD 10.68); the majority was African American/Black (50.0%), Hispanic/Latino (22.5%), or White (22.2%), while over half were unemployed (61.1%). Over three quarters had children (72.2%). Women’s discussions surrounding substance use and risk for recidivism pertained to three broad categories: a) factors associated with first drug use; b) factors involved in relapse; and c) factors influencing desire to remain drug free.

Factors Associated with First Drug Use

Several women spoke about the factors and circumstances to which they attribute led to their initiation into drug and alcohol use. In particular, the women discussed a) curiosity, b) negative life circumstances, and c) personal choices as factors associated with their first drug use.

Curiosity

Two women implicated feelings of curiosity as factors that led to their first drug use. As one woman described:

So you know, I hate, I hate drugs. I’m not the one that used because I like to or because I love to [use drugs]. I use it because of curiosity…. I tried it when I was 15 [years old]. Curiosity killed the cat.

Another spoke about similar feelings of curiosity:

[There] are a lot of different reasons. Some reasons may be peers, their associations, and then you get involved because of your association. One other is curiosity.

Negative Life Circumstances

According to three women, a range of negative life circumstances may have been associated with first drug use. One woman described how people may attribute their drug use to different life events:

Once you do become an addict…then it becomes a lot of different reasons why you picked back up to use. It could be out of boredom. You’re overwhelming yourself with doing too much. It could be relationships. It could be family problems. It could be any little thing. It could be somebody smoked a cigarette and you smell it and it smells a certain kind of way.

It is worth mentioning that this respondent emphasized that a life event need not be traumatic for it to be associated with drug use. Rather, small, mundane events, such as the experience of boredom may be an associated factor.

Personal Choices

It is noteworthy that among the women who spoke about factors involved in their first drug use, all took ownership of their choices, highlighting that their drug use was a result of their own volition. Accordingly, ‘personal choices’ is included here as a factor. One woman asserted the element of choice in her drug use:

You know when I first started, didn’t nobody forced me to smoke it. It was me. I had a choice to not even do that. And when I get out of jail, I had a choice not to go back to the neighborhood to smoke. It wasn’t about being forced. So that’s when I knew I had a problem. I needed help. I wasn’t forced to smoke. I did. So I’m not going to say it was nobody else’s fault. It was mine.

Another woman described a similar perception of her role in initiating drug use:

…for the most part, it’s a mind control thing because it wasn’t forced upon me either. It was my choice. And it was my choice to continue doing it. It was my choice to go to the dope man to buy it. It was my choice to do everything that I did to fall into addiction.

Factors Involved in Relapse

Discussions surrounding factors involved with drug relapse after serving time were rich and reflected multiple perspectives. Women presented four factors which were related to relapse: a) Desire to Numb Pain and Challenging Life Experiences; b) Lack of Resources; and c) Desire for Internal Locus of Control.

Desire to Numb Pain and Challenging Life Experiences

Several women associated their desire and tendency to numb pain with relapses into drug use. Concomitantly, women reflected on their awareness that learning how to confront pain was essential to avoiding relapse in the future. As one woman explained:

That’s a big thing in your addiction. You don’t feel. It’s like I’m quick to run from things. I don’t like feeling feelings, so that’s why I use drugs, just to numb myself. No matter if it was for a man, whatever you should be, I used the drugs just to numb myself and to continue going through each day. So that’s the biggest issues for me is learning how to deal with feelings, learning how to feel feelings, and be okay with feelings.

For another woman, drugs helped numb and normalize discomforting feelings she had when she was around people. For her, drugs made her feel normal, and an aid to feel comforted. For others, drugs helped the women to deal with a sense of hypersensitivity:

For me personally, I’m real-- I’ve been my whole life since I was little. I’ve been-- I’m really hypersensitive in every which way… and drugs numbed that.

For several women, challenging life experiences also served as triggers for drug use. For example, one woman spoke about turning to drugs in the process of coping with family issues, as RDT programs do not allow the residents to “just get up and go when you have a family matter”. Instead, women turned to drugs to numb the pain. Another woman cited the pressures of being a gang member as a trigger for using drugs and as a “slippery place” to be:

…But I know how my peer pressure was from being a gang member. So when you’re around these individuals, we call them slippery places in recovery. I can’t afford going around slippery places. If I stay in slippery places, I end up in slippery penitentiaries…

Lack of Resources

Lack of resources such as social support, employment, and finances was implicated by several women as a factor in relapsing to drug use.

For example, one woman described feeling as though she had no one to turn to when dealing with the urge to use drugs. Comments were shared such as, “How do I go up to this person, hey, I have this urge. What can I do? And there’s nowhere to turn.”

This lack of social support was also exacerbated by feelings of isolation within prison which resulted in an inability to communicate and develop intimate relationships. For some women, this led to the need to substitute drugs for feelings of loneliness and isolation.

…You know [being in prison] made me isolate myself. It made me close myself up. It made me hide within myself. So when I came back to society, it was even harder for me to trust people. You know when I would get high, I would just put on, you know, like my earphones, you know, and just sit at a bus stop…or just go do my little, you know what I’m saying…because I didn’t want to let anybody in…. So my communication skills were way off.

Furthermore, unemployment and lack of financial resources pushed women coming out of jails and prisons for opportunities that promised ‘quick money,’ such as selling drugs as they felt unable to make themselves feel productive. As one woman stated, “we don’t have the knowledge and education we need because it’s hard, you know… Just being out of prison and stuff, it makes it harder”.

For them, even selling dope was an opportunity to get quick money.

With regard to challenges associated with re-entering society after incarceration, women reported varied experiences. Lack of social support, lack of resources, lack of structure, and stigma were among the challenges women spoke about. One woman’s experience reflected several of these challenges; however, discrimination and stigma associated with having been incarcerated seemed to be at the root of these challenges.

As one woman stated, “It’s either hard finding employment or its hard being trusted… you know, given a job opportunity because of our backgrounds or you know some of the discrimination in society.

Desire for Internal Locus of Control

One woman spoke in detail about how incarceration with overwhelming long periods of strict constraints and structure led to old patterns of drug use. Her perception was that when “you just put us in these little cells…, eventually when we get out, … and we’re going to go do the same thing that we were doing.

For another woman, her drug use allowed her a sense of control over something in her life. In the face of being victimized and blamed as a survivor of sexual assault, this sense of control was empowering as her perception is that being raped was her fault, or that she was looking for sex. Instead, victimized women receive comfort knowing that using drugs is under their control.

Most of us feel that we don’t have control of our lives …. I can control when I’m going to get my next high. I can control what I’m going to do for money to get high, you know, because I have control over that. I didn’t have control of being abused or…being taken advantage of.

Factors Influencing Desire to Remain Drug Free

According to the women, several factors contributed to a desire to remain drug free. Among these were: a) Reaching a Breaking Point; b) Children and Family Commitments; c) Focusing on the Self; and d) Spiritual Beliefs.

Reaching a Breaking Point

Several women described a breaking point at which they realized that they wanted to make a change in their lives. Though diverse in terms of the circumstances involved, these breaking points were typically marked by feelings of distress and a realization that things were out of control. For one woman, getting arrested was the breaking point at which she decided she wanted to stop using drugs. Getting arrested was a necessary first step.

Another woman decided she was ready for change after experiencing challenging times being homeless. She recanted how she would be sleeping in vacant houses or cars and had to hustle to sell drugs. Soon a realization occurred that she wanted more in life. “So when I …went in, I set a goal for myself”.

For others, the psychological distress experienced within the prison system propelled them to change her drug use pattern:

Being on lockdown, being confined within a little space does not help an individual get their mind together. It does not help an individual put a plan for the future out. It just-- it mentally destroys you.

Children and Family Commitments

Several women noted that taking account of their children’s needs and their commitments towards their families motivated them to make a change.

One woman cited her transition into the role of a grandmother as a turning point: You know what, I’m a grandmother now. And so when I was in prison this time, I learned that I had like six grandchildren and it’s like wow, so it’s you know, I’m ready. I just can’t keep doing-- not only that, health issues. I’ve got rheumatoid arthritis. I’m losing my teeth. My eyes are going bad. So you know, I mean I can’t keep…

Another woman spoke about how her readiness to change stemmed from a desire to be a better mother to her children:

For me, you know, it’s like staying off is just looking at the past, all the things I did and things I missed out on, you know. I have three children who I totally abandoned to drugs …who ended up losing their father in a motorcycle accident while in prison. And so that’s my motivation, my inspiration is just to be that mom now you know.

Focusing on the Self

According to the women, along with a concern for children and family commitments, a focus on the self is imperative to readiness for change. One woman explained how framing her desire for change as something she was doing for herself, rather than for anyone else, helped her avoid relapse. For example, the choice of going to an all mother and children drug rehabilitation program vs a single women program was an easy choice for one woman as she wanted a single woman focus to focus on herself only.

Spiritual Beliefs

A number of women spoke their relationship with God and the role of their connection with spirituality in deciding not to relapse into drug use. For one woman, turning to God marked the turning point in her drug use. Spiritual beliefs were also instrumental in sustaining the positive changes the women made in their lives. Women described different spiritual practices as tools for maintaining abstinence. These included using meditation “to feed my spirit” and to “help center me”.

For other women, faith in a higher power was the primary reason for wanting to change, “It’s not right to live the life that I was living, you know. And probably my desire to wanting better is from a higher power…being spiritual, religious, whatever.”

DISCUSSION

Recently-released homeless women residing in temporary RDT programs are at a critical juncture in the process of recovery, transition and reentry. The purpose of this qualitative study was to understand perspectives of the women as it related to exploring drug initiation and relapse triggers involved in abstinence and the factors impacting desire to remain drug free. Content analysis generated the development of three broad categories: factors associated with first drug use, factors involved in relapse, and factors influencing desire to remain drug free.

Our findings revealed that women disclosed that they initiated drug use because of curiosity, negative life circumstances, and personal choices. Curiosity has been noted by scholars as a precipitating cause of substance use (Vandrey, Dunn, Fry, & Girling, 2012). In particular, antidrug public service announcement campaigns have been developed to aid in helping adolescents and young adults, “Just Say No” to drugs (Fishbein, Hall-Jamieson, Zimmer, von Haeften, & Nabi, 2002) with varied outcomes. However, developing programs which encourage ex-offenders to serve as peer health educators and to discuss the negative effects of curiosity and drug use with other women may improve and sustain positive health outcomes.

Further, our findings suggest that negative life circumstances such as familial challenges and traumatic life experiences have similarly been described among these women as contributing to substance use. It is plausible that these experiences result in negative coping behaviors such as drug and alcohol use due to limited perception of other effective options. Future research needs to provide training and skill-based opportunities for women to learn about more problem-focused coping responses.

In this study, ineffective coping also related to relapse as women sought drugs again to numb pain. Future intervention research is needed to help women identify feelings and ways to cope with negative life experiences. Other aspects of relapse which were cited by women included not having adequate support related to employment, finances and people whom they could trust and turn to in times of distress. During the reentry period, many women faced challenges seeking employment due to a history of incarceration. Previous research have also validated the desire for women to be employed (Salem et al., 2013); however, employment opportunities were limited for those with a history of incarceration. For some women, lack of adequate financial resources resulted in relapse due to the need for “quick money.” Future research necessitates connecting formerly incarcerated women with a network of providers which can provide opportunities for long term employment and continued training.

Other triggers of drug use included gang involvement. Previous research has found that gang affiliation increases the likelihood for continued drug use due to the need to engage in crime (Sanders, Lankenau, & Jackson-Bloom, 2010). In fact, others have found that weak ties to parents, school, and conventional peers increase the probability of the initiation and continuation of deviant behaviors such as drug use and crime (Cepeda, Saint Onge, Nowotny, & Valdez, 2015). Further, it is important to note that others have found that drug scene familiarity and exposure to gang violence are often interconnected (Volkmann et al., 2013). Intervention programs which focus on helping recently released ex-offenders gain a sense of control over positive decision making support the theoretical framework that underpins this study and resonates with the needs articulated by the participants.

Our findings similarly revealed that change was precipitated by a critical juncture in many women’s lives where an internal desire for change after a breaking point was reached. For these women, the desire for cessation of drug use was specified. This was often experienced by women after reaching rock bottom due to selling their bodies for drugs, and living in vacant houses. Readiness to change is at the heart of the Stages of Change Model (TTM) (Prochaska & Levesque, 2002) which explores behavioral readiness to change based on the immediacy, time urgency, or treatment issues experienced (Brown, Melchior, Panter, Slaughter, & Huba, 2000). Integrating and applying TTM to this population may be a worthy endeavor to understand areas of need and help women move towards behavior change.

The findings of this study may translate into the design of workshops or focused programs which would enhance successful integration into the community. These can include programs in which women preparing to be integrated into the community can role play effective coping strategies that enhance effective communication and problem-solving skills and that foster networking, positive social support, and trajectories of incremental employment opportunities Marlow et al. (2012) have reported the aggressive communication and behavioral stance of ex-offenders do play a role in being protective while the person is in prison. However, these behaviors result in further aggressive actions and re-incarceration while out in the community and do not foster connectivity and garnering social support. A focus on non-violent communication and reframed positive coping responses, and an awareness of positive social supports is worthy of consideration, both in promoting positive integration and reducing risk of recidivism.

In this study, women also described that children and family commitments, along with focusing on self and spiritual beliefs helped lead to change. The voices of these women about their experiences and their desire for a better life should be encouraged by drug treatment providers, academicians, and society at large. Clearly the literature demonstrates the relationship between support provided to keeping families together and decreased recidivism of the parent (Bales & Mears, 2008) and successful community integration (Visher, Kachnowski, La Vigne, & Travis, 2004).

While the literature is limited on the impact of prison-based parenting programs conducted with rigorous clinical trials, as well as measurement of mother and child outcomes is rare (Eddy et al., 2008), a focus on out-of-prison programs is becoming increasingly recognized as critical. This is due to the strong association of parental criminality and later child delinquency (Eddy & Reid, 2003). However, limiting issues which prevent success in this area include needing to deal post incarceration with the problems that led them to prison initially, such as poverty, unstable housing, substance use and unemployment (Brown & Bloom, 2009). Thus the need for wrap-around services is critical.

As it relates to recommendations for forensic nurses, future programs should focus on engaging families and ex-offenders to assist in developing workshops that would best facilitate ex-offender/family integration. Further, enhanced communication and coping skills, self-esteem building, and buttressing of job skills and social support are all interpersonal and behavioral areas that are needed to be integrated in RDT programs. Finally, it is important to assess the effectiveness of these transformative changes (family integration, stable housing and stable job opportunities) on reduced recidivism.

This study is limited to women aged 23-53 in two residential drug treatment facilities in Los Angeles and includes women both on probation and parole. Based on the differences in type of conditional release, it is plausible that differences may similarly exist in terms of intervention needs which were not necessarily captured in these analyses. Despite these limitations, our work extends previous findings; in particular, women transitioning out of prison and jail, on conditional release and currently homeless, are faced with a critical mass of needs. Given these findings, multidisciplinary academicians, service providers and policy makers need to address the shortage of resources, treatment programs in an effort to facilitate reentry.

Table 1.

Sample Characteristics among Homeless Women on Parole and/or Probation (N=18)

Measure	Mean	SD Range
Age Range	37.67	10.68 (23-53)
Homeless, Years	5.58	5.71 (0-19)
	N	%
Race/ Ethnicity
African American/Black	9	50.0
Hispanic or Latino	4	22.2
White	4	22.2
Asian	1	5.6
Children
Yes	13	72.2
No	5	27.8
Religion
Christian	7	38.9
Protestant (such as Baptist, Methodist)	4	22.2
Catholic	2	11.1
Other	4	22.4
None	1	5.6
Ever been employed
Yes	15	83.3
No	3	16.7
Measure	N	%
Employment
Unemployed	11	61.1
Not working	3	16.7
Disabled	1	5.6
In school	1	5.6