Comprehensive Guide to Post-Traumatic Stress Disorder

DOI 10.1007/978-3-319-08613-2_57-1
# Springer International Publishing Switzerland 2015

PTSD Behind Bars: Incarcerated Women and PTSD

Susan Hatters Friedmana,b*, Stephanie Collierc and Ryan C. W. Halld,e,f
a
Auckland Regional Forensic Psychiatry Services, Mason Clinic, Auckland, New Zealand
b
University of Auckland, Grafton Campus, Grafton, Auckland, New Zealand
c
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
d
Department of Medical Education, University of Central Florida College of Medicine, Lake Mary, FL, USA
e
Department of Psychiatry, University of South Florida, Tampa, FL, USA
f
Barry University Dwayne O. Andreas School of Law, Orlando, FL, USA

Abstract
Women in prison often have significant trauma histories, and PTSD is much more common among female
inmates than in their community counterparts. Among female prisoners, PTSD is the second most
common disorder, after substance use disorders. In this population, PTSD is often comorbid with
substance use disorders, personality disorders, serious mental illnesses, and HIV. Pharmacotherapy
options are limited in prisons, impacting treatment options. As well, psychotherapy usually must occur
within group settings in prison, posing unique challenges in this population.

List of Abbreviations
AA Alcoholics Anonymous
ADHD Attention deficit hyperactivity disorder
BPD Borderline personality disorder
CBT Cognitive behavioral therapy
DBT Dialectical behavioral therapy
HIV Human immunodeficiency virus
PD Personality disorder
PTSD Post-traumatic stress disorder
SMI Serious mental illness
SSRI Selective serotonin reuptake inhibitor
SUD Substance use disorder

Introduction
Prison is primarily meant as a place to punish perpetrators of criminal acts. However, its other goals
include protection of the public, the reformation of the criminal into a member of society, and the
reduction of re-offending.
Rates of incarceration among women are on the rise, internationally (Strathopoulos 2012). In women’s
prisons, mental illnesses are more common than among women in the community. Consistently in women’s
prison populations, there is an overrepresentation of women who are under-educated and unemployed,
with limited social support (Tye and Mullen 2006; Lynch et al. 2014; Strathopoulos 2012). As well, women

*Email: susanhfmd@hotmail.com

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Table 1 Current rates of PTSD among female inmates

Country Current prevalence of PTSD among female inmates (%)
United States 29–51
China 11
Australia 29
New Zealand 17
This table presents rates of current PTSD among female inmates, as reported in international studies

in prisons are consistently noted to have high rates of victimization (both in childhood and as adults) and
other traumas in their backgrounds.
Women in prison usually have less serious criminal offending histories than men in prison
(Strathopoulos 2012). Yet, women in prison are more likely than their counterpart males to have mental
health problems, physical health problems, and trauma histories (Lewis 2006). Female inmates’ mental
health backgrounds are not only different from those of male inmates, but they are also different from
non-incarcerated females (Lewis 2006; Zlotnick et al. 2003, 2009; Pelissier and Jones 2006; Colosetti and
Thyer 2000; Drapalski et al. 2009; Wolff et al. 2012; Cole et al. 2007). PTSD is highly prevalent across
samples of incarcerated women, second only to substance use disorders.

Traumatic Exposure Among Incarcerated Women

Rates of exposure to trauma among women in prison are approximately twice as high as those of women
in the community. A recent case-control study (N = 200) found that the odds of trauma ranged from 1.7 to
3.7 in the incarcerated female group (Grella et al. 2013). A Chinese study of 471 female prisoners found
82 % of the women had a past experience of trauma (Huang et al. 2006). Similarly, a recent Ohio study
found that 72 % of 391 women prisoners reported having been sexually violated (McDaniels-Wilson and
Belknap 2008).
In a recent Iowa study of those entering state prison, women more frequently reported experiencing
traumatic events than men (77 % vs. 61 %) (Gunter et al. 2012). The most commonly reported traumas
were assaults, followed by accidents and witnessing trauma of another. Trauma predicted suicide risk, as
well as anxiety, psychosis, mood, ADHD, and antisocial PD (Gunter et al. 2012).
Another recent American study comparing male and female inmates (N = 266) found that 95 % had
experienced a traumatic event. Female inmates had higher rates of sexual trauma throughout their lives
and higher rates of PTSD (40 % vs. 13 %). Sexual trauma was a significant predictor of PTSD among
women (Komarovskaya et al. 2011). In a study in Atlanta’s urban low-income population, civilian PTSD
was significantly associated with elevated risk of incarceration and violent charges (Donley et al. 2012).
Incarceration and violent charges were associated with both childhood and adulthood trauma (Donley
et al. 2012).

Prevalence of PTSD Among Female Prisoners

Rates of PTSD among women prisoners are approximately double the rates of their counterparts in the
community (Table 1) (Fazel and Baillargeon 2011). A systematic review of the worldwide literature
regarding PTSD among prisoners included only two studies that met the authors’ inclusion criteria,
included both men and women sentenced prisoners, and reported rates of current (rather than lifetime)
PTSD (Goff et al. 2007). Using a New Zealand sample, 17 % of incarcerated females had current PTSD,

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while 9 % of incarcerated males did (Simpson et al. 1999). Similarly an Australian sample found 29 % of
incarcerated females had current PTSD, as did 10 % of corresponding males. These rates are clearly
higher than rates in the community (Goff et al. 2007).
Over a third (36 %) of the incarcerated women met criteria for PTSD in another Australian study (Tye
and Mullen 2006). The American study of nearly 500 female prisoners from four localities (Lynch
et al. 2014) found that 29 % of incarcerated women met current criteria for PTSD.
Among (N = 387) incarcerated women in an American maximum security prison, 44 % met PTSD
criteria. The severity of the PTSD correlated unsurprisingly with the likelihood of receiving PTSD
treatment in prison (Harner et al. 2013). In the aforementioned Iowa study, 30 % of the female inmates
and 17 % of the males met PTSD criteria (Gunter et al. 2012). Similarly another recent American study
(N = 203) found that 51 % of female prison inmates met criteria for PTSD, despite many more having
experienced trauma across their lives (Warren et al. 2009). Those with PTSD had higher numbers of
lifetime traumas on average and more frequent BPD (Warren et al. 2009).
In total, the lifetime prevalence of PTSD for the female prisoner population is thought to be as high as
30–42 % (Lewis 2006). Similar to the prevalence data of other mental illnesses, these numbers vary by
geographic location. The aforementioned Chinese study found a lifetime prevalence of PTSD of 16 % and
a current prevalence of 11 % (Huang et al. 2006).

Challenges of Diagnosing PTSD in the Prison Setting

PTSD is paradoxically considered to be both over- and underreported in female inmate populations
(Oguntoye and Bursztajn 2009), since diagnostic criteria are based on self-report of symptoms. Over-
reporting of symptoms in the forensic setting may be used for purposes of secondary gain, such as
obtaining damages compensation or disability income. Inmates who meet diagnostic criteria for PTSD
usually do so by endorsing the majority but not all of the symptoms in each of the three categories
(re-experiencing, hyperarousal, and avoidance). This is of particular relevance in the detection of
malingering, when pan-endorsement of all symptom clusters may occur.
Underreporting is also common in correctional settings, as inmates may attempt to hide their symptoms
(both past and present) in an attempt to avoid re-traumatization or to avoid being seen as weak or
vulnerable. Women prisoners with PTSD may have learned to minimize their symptoms in order to
maintain their functioning in prison. The prison environment may also trigger PTSD symptoms through
interactions with officers and inmates.

Trauma and “New” PTSD in Female Prisoners

Although most female inmates with PTSD were traumatized prior to incarceration, a subgroup of women
experience trauma while incarcerated. The experience of incarceration may be traumatic in itself, with
sexual assaults perpetrated by both inmates and guards (Oguntoye and Bursztajn 2009). An American
study including 564 female inmates found that 24 % had been victimized over the course of 6 months
(Blitz et al. 2008). Women prisoners with a mental illness (including PTSD and SMI) were 1.7 times as
likely to be victimized by another inmate than those without mental illness (Blitz et al. 2008). Incarcerated
men and women in midwestern American prisons reported in a survey that many had been forced or
pressured to have sex against their will, while incarcerated. And only half of those who reported this in the
survey had told anyone at all (Struckman-Johnson et al. 1996). A recent study found that though rates of

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violence within prison were high, experiencing trauma symptoms did not predict being either the victim or
the perpetrator of such violence in prison (Brown 2011).
The risk for retaliation in prison may also prevent the reporting of trauma. Thus, female inmates may be
reluctant to seek psychiatric treatment, and they may be unwilling to discuss their exposure to trauma in
the prison setting. However, alternatively, for a subset of female inmates, the prison has been reported to
be a safer environment with fewer barriers to care, compared to the community setting (Warren et al. 2009;
Drapalski et al. 2009). Those who are known to have been victimized in prison should be screened
for PTSD.

PTSD and Comorbid Substance Use Disorders Among Female Prisoners

In female prisoners, PTSD is the second most common diagnosis after SUDs. Approximately one-half of
incarcerated women were under the influence of alcohol or drugs at the time of their offense (Zlotnick
et al. 2009). The prevalence of substance use disorders is much higher than for women in the community.
Between 10 % and 24 % of female prisoners are estimated to have alcohol use disorders, and 30–60 % of
incarcerated women misuse or are dependent on illegal drugs at the time of incarceration (Fazel and
Baillargeon 2011).
Women with PTSD are at greater risk for comorbid SUDs compared to women without PTSD (Salgado
et al. 2007). PTSD has been hypothesized to mediate the relationship between trauma and substance use,
as drugs and alcohol are often used to cope with PTSD symptoms. PTSD is associated with higher rates of
risky behavior including prostitution, intravenous drug use, and unprotected sexual intercourse. Women
who use substances are often victimized through exposure to risky situations, and women who have been
victimized have an increased risk of SUDs (Lewis 2006).
It has been estimated that more than 50 % of all incarcerated women in substance abuse treatment
programs meet criteria for current PTSD, and an additional 10 % meet criteria for lifetime PTSD (Zlotnick
et al. 2009). Women with comorbid PTSD and SUD have higher rates of inpatient psychiatric admissions,
interpersonal problems, domestic violence, homelessness, and HIV seropositivity compared to women
with either disorder alone. Women with comorbid PTSD and SUD also tend to have a greater use of
services and poorer outcomes in the community (Lewis 2006). Most women who self-referred for trauma
treatment were found to have comorbid PTSD and SUD (Wolff et al. 2012). Women with comorbid PTSD
and SUD have been found to have experienced more traumatic events in childhood, and they are more
likely to have experienced childhood sexual and physical abuse (Salgado et al. 2007). In addition, women
with comorbid PTSD and SUD are more likely to have experienced adult sexual assault than women with
SUD alone (Salgado et al. 2007).

PTSD Comorbidity with Personality Disorders Among Female Prisoners

The association between childhood abuse and the development of personality disorders is well
established. Personality disorders are also more common among incarcerated women, with rates of
43 % on screening in the aforementioned Australian study. Paranoid PD was most common, occurring
in one-third (33 %). Antisocial PD and borderline PD also occur very commonly, at 30 % and 26 %,
respectively. Finally, 12 % of the women had narcissistic PD and 6 % had histrionic PD (Tye and Mullen
2006). PTSD is particularly comorbid with borderline and avoidant PDs (Warren et al. 2009).
It is thought that an underlying PD may predispose to the development of PTSD following traumatic
events. Conversely, early trauma may lead to behavioral dysregulation and persistent maladaptive

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behavioral patterns that lead to the development of a PD. This in turn may lead to increased risk-taking
behaviors, which further increase the likelihood of traumatic events. Emotional dysregulation and
affective instability are common to both BPD and PTSD, and both may become more pronounced in
the prison setting. Personality disorders in prison can present with symptoms such as intense anger, self-
harm, rapid mood swings, and impulsivity, for example. A recent study of incarcerated women found that
“trauma was associated with impulsivity, recurrent suicidal threats/attempts, unstable mood, intense
inappropriate anger, feelings of emptiness, and stress-related dissociation or suspiciousness” (Gunter
et al. 2012). Female prisoners with cluster B personality pathology (such as BPD) report higher levels and
a greater variety of maternal and paternal physical and psychological abuse than their non-cluster
B counterparts. However, levels of childhood sexual abuse appear to be similar for both groups (Loper
et al. 2008).
Early prolonged exposure to trauma is common among female inmates. These factors are predictors of
complex PTSD, characterized by more severe symptomatology, as well as enduring personality changes.
These individuals have more symptoms of affect dysregulation, dissociation, and somatization. This is of
particular importance in the prison setting, as self-destructiveness, chronic pain, poor anger modulation,
suicidal behavior, excessive risk taking, and interpersonal relationship difficulties are prevalent. Women
with complex PTSD are known to have poorer treatment outcomes. As such, addressing dissociation and
interpersonal relationship problems in these inmates may be warranted prior to attempts at treatment of
PTSD (Hebert et al. 2007).

Comorbidity of Serious Mental Illness and PTSD in Female Prisoners

Women in prison have higher rates of almost every mental illness than women living in the community. In
fact, a recent Australian study found that 84 % of female prisoners met criteria for a mental disorder. When
substance use disorders were excluded, still 66 % of incarcerated women met criteria for a mental disorder
(Tye and Mullen 2006). Similarly, in a recent American study (Lynch et al. 2014), 91 % of female
prisoners met criteria for any lifetime mental illness, with 70 % meeting criteria for a mental illness in the
past 12 months. A large minority (43 %) of incarcerated women met lifetime criteria for SMI (including
schizophrenia and psychotic disorders, bipolar disorder, and major depressive disorder), and 32 % of the
women met current criteria for SMI. In addition to this, the comorbidity was striking – 29 % of the women
met lifetime comorbidity criteria for SMI and PTSD, and 14 % of the incarcerated females had both a
current SMI and current PTSD (Lynch et al. 2014).

PTSD in HIV-Positive Female Inmates

Female offenders are more likely to be infected with HIV than male offenders in the United States (Lewis
2006). Further, incarcerated women with HIV have higher rates of PTSD than their noninfected coun-
terparts. Among incarcerated women who are infected by HIV in the United States, rates of PTSD are
estimated to be as high as 74 % (Salgado et al. 2007). A history of trauma is linked with subsequent risk
behavior including intravenous drug use, prostitution, and unsafe sex with partners at high risk for
HIV. Further, PTSD is associated with prostitution and receptive anal sex in the 5 years before incarcer-
ation and may contribute to risky sexual behavior (Hutton et al. 2001). Within prison, the use of
non-sterile injecting equipment is the most important independent risk factor for transmission of HIV
and viral hepatitis (Fazel and Baillargeon 2011).

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In the United States, HIV-positive women with lifetime PTSD are more likely to have a history of
arrests for prostitution, high-risk sexual behavior, and intravenous drug use (Lewis 2005; Hutton
et al. 2001). HIV-positive women with PTSD are also more likely to have other comorbidities including
cannabis use disorder, major depression, and antisocial PD (Lewis 2005).
The diagnosis of PTSD in HIV-positive inmates may pose treatment challenges. PTSD is associated
with poorer outcomes from HIV reduction interventions, as well as noncompliance with medical
management of HIV (Lewis 2005). HIV risk reduction efforts among female prisoners should therefore
screen for the presence of PTSD. Similarly, incarcerated women with PTSD should be evaluated for a
history of risky behaviors and HIV status.

Treatment of PTSD in Incarcerated Women

Treatment for PTSD in incarcerated settings can be extremely challenging for a myriad of reasons (Lewis
2006; Wolff et al. 2012). In addition to high rates of comorbidities, many have already had some
experience with psychotherapy (e.g., court-ordered diversion programs, AA, detox, community mental
health) which was often not effective or not completed, placing them at higher likelihood to be “treatment
refractory” or “treatment resistant” (Lewis 2006; Saxena et al. 2014; Peltan and Cellucci 2011). However,
some women may seek out treatment for the first time while incarcerated –when they would have
otherwise avoided it – due to fewer concerns about stigma while incarcerated or perhaps a new realization
that help is needed given the circumstances (Drapalski et al. 2009; Peltan and Cellucci 2011). All of this
effects potential treatments and response rates for this population and may also necessitate additional
resources for the successful treatment of PTSD (Lewis 2006).
In the correctional system, working with female inmates is often erroneously seen as less difficult (e.g.,
lower physical threat), lower status (e.g., less likely working with people who committed high-profile
crimes), and more likely to result in staff burnout due to emotional fatigue, often related to unique case
management concerns (e.g., incarcerated mothers, pregnant inmates) (Lewis 2006; Drapalski et al. 2009).
In addition to preventing or reducing staff burnout, additional training and staff supervision is often
needed in female correctional facilities to address potential transference/countertransference issues which
can occur in this patient population (e.g., power differential between staff and inmates, sexual “acting out”
with other prisoners/group members/staff as part of PTSD re-victimization) (Lewis 2006). Staff in
correctional facilities must communicate and work as a cohesive unit to help prevent splitting and
manipulation and to help maintain safety of the facility.
In order to provide treatment to female inmates, one must understand that there may be differences in
the population and therapeutic resources available based on location, past court experiences, and types of
offenses committed (Peltan and Cellucci 2011). For example, in a jail setting, inmates can be remanded,
awaiting trial with uncertain lengths of stay (because of the possibility of being bonded out). This may
preclude their ability to complete a treatment program. In a jail setting women may experience the
additional stress of an unresolved case and uncertainty regarding their schedule due to the unpredictability
of court (Drapalski et al. 2009). Post-conviction jail inmates have often been found guilty of lower-level
offenses (misdemeanors) and/or have a short length of sentence (e.g., typically less than 1 year). In
distinction, individuals in prison usually have a sentence of over a year, have been convicted of a serious
felony charge, and may be stratified into low, medium, or high security placement which may limit
movement and potentially treatment options such as groups (Ford et al. 2013). Jails are often more
unstable environments, with rapidly changing populations which leads to greater potential for contraband
(e.g., drugs), outside influences (e.g., street gangs), and overcrowding (Drapalski et al. 2009). Although
similar concerns may exist in prisons, longer lengths of incarceration allow for the establishment of a more

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Table 2 Limitations to providing mental health services in correctional facilities

Medical Difficulties maintaining confidentiality
Medication contraindication/abuse potential (benzodiazepines, amphetamines)
Correctional operations Some jurisdictions do not offer treatment groups to pretrial detainees
“Muster freezes”/limited access to see/treat prisoners
Financial limitations resulting in mostly group therapy rather than individual therapy
Lack of full-time mental health staffing
Limited medication formularies
Correctional culture Stigma from being seen as a mental health patient by guards/other inmates
Lewis 2006; Colosetti and Thyer 2000; Drapalski et al. 2009; Wolff et al. 2012; Cole et al. 2007; Kinsler and Saxman 2007;
Peltan and Cellucci 2011
There are multiple unique limitations for mental health practitioners practicing in prisons, which are listed in this table

permanent culture. This includes prison gangs, friendships, and intimate relationships. Prison inmates
may have a long time before release, which may lead to more behavioral problems since inmates may
have less incentive for good behavior.
Despite barriers to the provision of mental health services (Table 2), treatment may improve the
efficiency of correctional facility and improve safety by decreasing suicides, reducing behavioral prob-
lems, improving adjustment to the facility, and lowering substance use within the system (Lewis 2006;
Zlotnick et al. 2009; Cole et al. 2007; Kinsler and Saxman 2007; Hicks et al. 2010).
Although there is a clear need for mental health treatment in inmates, there are difficulties in providing
evidence-based treatment to an incarcerated population. Many treatments are studied in only voluntary
outpatient settings, and they are not normed on a prison population facing different stressors and
comorbidities, with limited supports and resources available to them (e.g., access to family) (Leigh-
Hunt and Perry 2014; Lewis 2006; Ford et al. 2013; Dixon et al. 2005). For example, many studies on
prolonged exposure therapy were done in outpatient settings and did not include patients with significant
drug abuse histories (Lynch et al. 2012; Colosetti and Thyer 2000). In addition, studies done in
correctional facilities may have methodological flaws for reasons such as limited sample size, lack of a
control group, and difficulties in maintaining study design or accurately assessing effect due to frequent
absenteeism inherent in correctional facilities (e.g., lockdowns, transfers, court hearings, disciplinary
actions preventing participation in groups) (Zlotnick et al. 2003; Saxena et al. 2014; Colosetti and Thyer
2000; Drapalski et al. 2009; Wolff et al. 2012; Cole et al. 2007; Ford et al. 2013). In addition, previous
studies have primarily focused on male prisoners (Friedman et al. 2013; Leigh-Hunt and Perry 2014;
Lewis 2006; Zlotnick et al. 2009; Wolff et al. 2012; Ford et al. 2013; Dixon et al. 2005).
In a very broad sense, there are two standard types of treatments for PTSD whether an individual is
incarcerated or not: psychopharmacologic and psychotherapy (Leigh-hunt and Perry 2014; Wolff
et al. 2011; Nucifora et al. 2011; Hall and Hall 2013a, b). The two medications with FDA approval for
the treatment of PTSD are the SSRIs paroxetine and sertraline (Hall and Hall 2013a; Asnis et al. 2004).
Both are generic, have low potential for abuse, have a relatively safe side effect profile, and are available
in most correctional pharmacies (Hall and Hall 2013a; Asnis et al. 2004). Additional off-label medications
are used to treat PTSD or target its symptoms (Hall and Hall 2013a; Asnis et al. 2004; Chapter on
Treatment of PTSD in elderly). Although quetiapine is not an FDA-approved treatment for PTSD, it is
commonly prescribed in the community for PTSD and generalized anxiety disorders (Ahearn et al. 2011;
Maher and Theodore 2012; Hermes et al. 2013; Maglione et al. 2011). Adjunct medication use may be
more limited in correctional settings due to attempts to limit “black market” supplies, potential for abuse,
public concern regarding over-medication, or potentially dangerous side effect profiles (Hall and Hall
2013a; Wolff et al. 2011). Bupropion and quetiapine (which are not considered to be drugs of abuse in

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Table 3 Prison nicknames for psychotropic medications

Quetiapine (Seroquel)
Quell
Suzie Q
Q
Q-ball
Squirrel
Snoozeberries
Baby Heroin
Bupropion (Wellbutrin)
Wellies
Dubs for “W”
Barnies (after Barney the dinosaur, due to purple color)
Alprazolam (Xanax)
Zannies
Zanni bars
Zanbars
Blue footballs
Clonazepam (Klonopin)
K
Kpin
Prisoners often have given nicknames to psychotropic medications, which are listed in this table after the generic name (with
the brand name in parentheses)

non-incarcerated populations) and benzodiazepines (which have abuse potential in all populations) have
an underground “value” in correctional facilities either to ameliorate the withdrawal effects of other
substances (e.g., bupropion to reduce methamphetamine withdrawal) or be crushed up and snorted to
obtain an altered state (Table 3) (Tamburello et al. 2012; Reeves 2012; Sansone and Sansone 2010; Hillard
et al. 2013). It has been estimated that up to 69 % of medications prescribed in incarcerated settings are
“diverted or misused” (Hillard et al. 2013; Lewis 2006). This can be either a voluntary diversion (by the
person who is being prescribed the medication) or it can be a coercive diversion where the individual is
threatened (Hillard et al. 2013; Lewis 2006). Misuse and over-prescription of medications had become
such a concern that the New Jersey prison system issued guidelines stressing non-pharmacologic
treatments for insomnia, which led to a 38 % decrease in prescription of benzodiazepines and a 59 %
decrease in prescription in quetiapine (Reeves 2012). This highlights that factors other than medical
judgment can affect the treatments of PTSD for incarcerated persons.

Practice and Procedures

Research on treatment of PTSD in incarcerated women has focused primarily on psychotherapy (Leigh-
Hunt and Perry 2014; Nucifora et al. 2011; Hall and Hall 2013a, b; Wolff et al. 2011). Often the therapies
studied are more regimented or formulated therapies, such as CBT or workbook-based treatments (Leigh-
Hunt and Perry 2014; Lynch et al. 2012; Saxena et al. 2014; Cole et al. 2007). In addition, due to the high
comorbidity of PTSD in female prisoners, many programs incorporate treatment of other conditions such
as BPD or SUD (Lewis 2006; Lynch et al. 2012; Lanza et al. 2014; Zlotnick et al. 2009; Saxena
et al. 2014; Drapalski et al. 2009; Wolff et al. 2012; Bradley and Follingstad 2003; Cole et al. 2007;

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Table 4 Concerns about groups in correctional settings

Maintenance of group cohesion due to random/uncontrollable absences (e.g., court, segregation, disciplinary actions, bail,
transfers)
Groups competing with other activities (e.g., work details, education programs, other therapies like AA)
Maintaining therapeutic control versus becoming venting session
Prevention of groups being “hijacked” by sociopathy
Maintaining an open and non-threatening environment without reprisals
(Wolff et al. 2012; Drapalski et al. 2009; Cole et al. 2007; Ford et al. 2013; Hall and Hall 2013a)
Some of the many challenges of running treatment groups for PTSD among women prisoners are listed in this table

Table 5 Groups in correctional settings work best when

Voluntary
Have an attendance policy (e.g., how to make up session, option for voluntarily withdrawal, understanding that too many
absences results in removal from group)
Selective in initial formation to prevent, limit, or address sociopathy, coercion, or outside influences such as gang affiliation
from undermining the group dynamics
Bradley and Follingstad 2003; Wolff et al. 2012; Cole et al. 2007; Hicks et al. 2010
This table lists characteristics of successful group therapy in correctional settings

Ford et al. 2013; Hick et al. 2010). Due to financial limitations and large volumes of women needing
services, often these psychotherapeutic treatments are done in groups (Lynch et al. 2012; Saxena et al.
2014; Cole et al. 2007; Ford et al. 2013). While the advantages of individual therapy using CBT or
prolonged exposure therapy for the treatment of PTSD has been well documented, group therapy in
correction settings may not work as well (Tables 4 and 5) (Leigh-Hunt and Perry 2014; Hall and Hall
2013b; Lynch et al. 2012; Colosetti and Thyer 2000; Ford et al. 2013).
Several types of named regimented therapy have been specifically studied for incarcerated females with
PTSD (Table 6) (Lynch et al. 2012; Lanza et al. 2014; Zlotnick et al. 2003, 2009; Wolff et al. 2012; Saxena
et al. 2014; Hien et al. 2004; Salgado et al. 2007; Ford et al. 2013). Many studies have involved a
standardized program with workbooks, groups of three to eight individuals, meeting one to three times a
week for 60–150 min for 8–16 weeks (Lynch et al. 2012; Lanza et al. 2014; Zlotnick et al. 2009; Cole
et al. 2007; Ford et al. 2013). Generally those who did best with the treatment were individuals with better
emotional control or ones able to learn control within a short time of initiation of treatment (Bradley and
Follingstad 2003; Ford et al. 2013). The program groups varied on how much they would involve trauma
exposures (Lewis 2006; Lynch et al. 2012; Bradley and Follingstad 2003; Cole et al. 2007; Karlsson
et al. 2014; Ford et al. 2013). Some studies noted it was difficult for participants to engage in traditional
exposure therapy exercises due to lack of privacy, limited ability to do “homework” exercises, high
dropout rate due to distress on re-exposure, concerns over initiation of exposure therapy worsening SUD
or behavioral problems, and concerns about the general incarceration environment being too threatening/
stimulating to allow for the prolonged exposure therapy to successfully work (Lynch et al. 2012; Wolff
et al. 2012, 2011; Saxena et al. 2014; Colosetti and Thyer 2000; Bradley and Follingstad 2003; Karlsson
et al. 2014; Ford et al. 2013; Kinsler and Saxman 2007). Generally, the programs focused on teaching
relaxation techniques, emotional regulation/impulsivity control, coping strategies, relationship skills, and
psychosocial education (Lewis 2006; Lynch et al. 2012; Zlotnick et al. 2003, 2009; Saxena et al. 2014;
Wolff et al. 2012; Bradley and Follingstad 2003; Cole et al. 2007; Ford et al. 2013). Although many
studies have found benefits to these groups, some studies noted that the results were not as positive as
hoped for (Lynch et al. 2012; Colosetti and Thyer 2000; Wolff et al. 2012; Hien et al. 2004; Cole
et al. 2007; Ford et al. 2013). In some cases, studies found conflicting results for comorbid conditions

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Table 6 Therapies studied in prison

Acceptance and commitment therapy: uses acceptance and mindfulness strategies increase flexibility of thought but not
change thoughts
Dialectical behavior therapy (DBT): cognitive behavioral therapy-related therapy where the individual works to gain mindful
awareness, emotion regulation, the ability to avoid labile or intense moods, and interpersonal effectiveness
Expressive writing: trauma exposure-based therapy in which an individual writes about a trauma and the emotion it produces
Gender responsive substance abuse treatment: manualized treatment group therapy, led by women focusing on fostering
healthy relationships, in a non-confrontational approach to substance abstinence, trauma, mental illness; with a
non-hierarchical structure
Group cognitive therapy: formulized group involving education, identification of negative scheme, and reformulation of
beliefs
Narrative exposure therapy: cognitive behavioral exposure therapy aimed at individuals who have suffered severe and
repeated trauma where one constructs a chronological narrative of her life story with a focus on the traumatic experiences
Seeking safety: present-focused manualized CBT-style therapy for PTSD and substance abuse done over 2 months with
bi-weekly group sessions focusing on psycho-education, coping skills, and connection between trauma and substance use
Supportive group therapy: focused more on current stressors, identification of health coping mechanisms, and problem
solving
Trauma Affect Regulation: Guide for Education and Therapy (TARGET) – manualized group therapy focusing on enhance
affect regulation, identification and modulation of negative emotion, and sustaining positive emotion without trauma memory
processing
Trauma incident reduction: rapid therapy where an individual re-experiences the traumatic event within a safe environment
and process the associated emotional and psychological issues
Treatment of PTSD in prison populations is unique for reasons enumerated in the chapter. However, research is limited
regarding treatment programs in this population. This table lists those which have been studied in prisons

(e.g., one condition improved but the other did not) or little to no improvement from the beginning to the
end of treatment (Lynch et al. 2012; Zlotnick et al. 2009; Wolff et al. 2012; Cole et al. 2007; Ford
et al. 2013). Even when there was a lack of statistical improvement, it was usually noted that participants
generally fared the same as or slightly better than the untreated control groups or treatment-as-usual
groups (Lynch et al. 2012; Zlotnick et al. 2009; Wolff et al. 2012; Cole et al. 2007; Ford et al. 2013). There
may have been methodological problems with some of the studies which limited the findings of positive
results – such as inclusion of sub-threshold PTSD cases, under-powered study sizes, participants sharing
materials with treatment-as-usual control groups, and limited time of follow-up (Lynch et al. 2012;
Zlotnick et al. 2009; Cole et al. 2007; Ford et al. 2013).

Key Facts of PTSD Among Incarcerated Women

• Rates of PTSD among female inmates are more than twice the rates of PTSD among women in the
community.
• Because PTSD diagnosis is often based on self-report of symptoms, among a prison population with a
potential motive to malinger, rates may be artificially high. One should consider whether a patient may
be over-endorsing symptoms, when considering malingering.
• Alternatively, women may underreport symptoms due to avoidance of the topic.
• More than half of all incarcerated women in substance abuse treatment programs meet criteria
for PTSD.
• Comorbid conditions are often linked to traumas and stressors common to female inmates including
domestic violence, homelessness, loss of child custody, engaging in acts of prostitution, and risk-taking
behavior such as IV drug use leading to health consequences like HIV.

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• Incarcerated women with HIV have higher rates of PTSD than incarcerated women without HIV, and
incarcerated women with PTSD have higher rates of HIV than those without PTSD.

Summary Points
• This chapter focuses on unique aspects of prevalence, diagnosis, and treatment of PTSD among
incarcerated women.
• PTSD is the second most common disorder after substance use disorders in the female prison
population.
• The types of abuse seen in prisoners often date to early childhood, and patterns of trauma are often
repetitive and long standing.
• Personality disorders and serious mental illnesses are commonly comorbid with PTSD among female
prisoners.
• PTSD pharmacotherapy in correctional settings is limited due to medication diversion, potential for
abuse, and concern about “over-medication.”
• Psychotherapeutic treatment of PTSD in prison often needs to occur in groups.

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