Journal of Anxiety Disorders 26 (2012) 703–710 Contents lists available at SciVerse ScienceDirect Journal of Anxiety Disorders Effectiveness of cognitive–behavioral trauma treatment for incarcerated women with mental illnesses and substance abuse disorders Nancy Wolff a,∗ , B. Christopher Frueh b,c , Jing Shi a , Brooke E. Schumann a a Center for Behavioral Health Services & Criminal Justice Research, Rutgers, The State University of New Jersey, 176 Ryders Lane, New Brunswick, NJ 08901, United States b Department of Psychology, University of Hawaii, 200 West Kawili Street, Hilo, HI 96720-4091, United States c The Menninger Clinic, 2801 Gessner Drive, Houston, TX 77080, United States a r t i c l e i n f o Article history: Received 20 October 2011 Received in revised form 3 June 2012 Accepted 6 June 2012 Keywords: Trauma PTSD Serious mental illness Female inmates Seeking Safety a b s t r a c t An open trial design was used to examine the implementation and effectiveness of a cognitive–behavioral intervention (Seeking Safety) for comorbid post-traumatic stress disorder (PTSD) and substance use dis- order (SUD) for incarcerated women with Axis I mental disorders who self-referred for specialty trauma treatment. The study sample was female inmates aged 18 and old who were primarily minority, had expe- rienced childhood-based trauma, committed violent crimes, had a serious mental illness, and resided in maximum, medium, and minimum compounds of a women’s prison. A total of 74 women completed the group intervention, with the average attending 23 of the 28 sessions (82%). Implementation feasibility was demonstrated by the ability to recruit, screen, assign, and retain participation. Effectiveness was supported by changes pre–post intervention on the PTSD Checklist (ES = 0.56) and Global Severity Index (ES = 0.47). Of the 19 completers with PCL scores of 50 or higher pre-intervention, 16 (84%) had scores below 50, the “cut score” consistent with or supportive of a PTSD diagnosis. Three-quarters or more of participants reported that Seeking Safety was helpful in each of the following areas: overall, for traumatic stress symptoms, for substance use, to focus on safety, and to learn safe coping skills. Future directions include the need for larger scale randomized controlled trials in medium or maximum security prisons and fidelity evaluations of non-research dissemination efforts. Published by Elsevier Ltd. 1. Introduction Incarcerated women report high rates of physical, sexual, or emotional abuse during their formative years and often into adult- hood (Wolff, Shi, & Siegel, 2009), mental illnesses (Covington, 2003; Wolff, 2008), and addiction problems (Bloom, Owen, & Covington, 2003). Overall, half or more of incarcerated women reported expe- riencing at least one traumatic event in their lifetime (Sacks, 2004). Rates of trauma are highest among incarcerated women with men- tal disorders. An estimated 74.3% of incarcerated women with a mental disorder experienced a traumatic event prior to age 18, with 60.5% also reporting a traumatic event after age 17. The compara- ble rates for incarcerated women without a mental disorder were 48.2 and 41.9%, respectively (Wolff & Shi, 2009). Prevalence rates for physical and sexual victimization among female inmates were also found to be significantly higher for inmates with a mental dis- order than those without a mental disorder, and these rates were higher than those reported for community samples (Blitz, Wolff, & Shi, 2008; Wolff, Blitz, & Shi, 2007). ∗ Corresponding author. Tel.: +1 732 932 6635; fax: +1 732 932 1233. E-mail address: nwolff@cbhs.rutgers.edu (N. Wolff). Not surprisingly, the prevalence of post-traumatic stress dis- order (PTSD) among incarcerated women is also elevated. Teplin, Abram, & McClelland (1996) estimated rates for current PTSD among female jail detainees at 23.3% the second most common behavioral health disorder (with the first being substance use disorder (SUD)). PTSD and SUD often co-occur in incarcerated (Wolff et al., 2011; Zlotnick, 1997) and community samples (Helzer, Robins, & McEvoy, 1987; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kulka et al., 1990). Based on a sample of 209 incar- cerated women who self-referred for trauma treatment, 79% were found to have comorbid PTSD and SUD (Wolff et al., 2011). In com- munity samples, women with current PTSD were 1.4–5.5 times more likely to have a co-occurring SUD than their counterparts without PTSD (Helzer et al., 1987; Kessler et al., 1995; Kulka et al., 1990). A recent epidemiologic study of a sample of female inmates seeking trauma treatment found that two-thirds of these females had a serious mental illness (67%); 88% had PTSD (full or sub- threshold) and significant and complex histories of traumatic event exposure and 87% had a SUD (Wolff et al., 2011). The epidemiologic evidence indicates a clear need among incarcerated women for trauma-informed behavioral health inter- ventions. In response, guidelines published by the National Institute of Corrections called for integrated interventions that 0887-6185/$ – see front matter. Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.janxdis.2012.06.001