Reducing the Methodological Heterogeneity ("Noise") in the Literature Predicting In-Prison Interpersonal Harm in Male Populations.

Interpersonal harm is a preventable public health problem. A growing body of literature shows persistently elevated exposure rates to physical and sexual victimization during incarceration. Yet how to prevent interpersonal harm during incarceration has proven far more elusive. A public health approach to prevention offers promise. To develop effective prevention strategies, the public health approach begins with defining and measuring the problem, followed by identifying risk and protective factors for the problem. The dynamic literature on in-prison interpersonal harm includes both parts of the public health approach but theoretical and methodological "noise" in this literature limits its instrumental utility to build effective prevention strategies. Herein, we critically review this evidence base (15 peer-reviewed articles published since 2000 with samples of 1,000+) to isolate the noise and the substance. We, then, minimize the methodological noise by testing for risk factors using self-report data that is representative of an entire U.S. state prison system for men and best data collection practices. Multilevel logistic regression is used to predict four types of interpersonal harm using theoretically grounded individual and prison-level covariates that are supported by the empirical literature. We conclude with recommendations for building an evidence base from which to develop prevention strategies that would create and sustain custodial conditions for people to be safe and healthy while incarcerated.

Validation and measurement invariance of the childhood trauma questionnaire short form among incarcerated men and women in Spain.

BACKGROUND: Childhood trauma is highly prevalent among incarcerated individuals and contributes to a range of negative outcomes. Assessing traumatic childhood events in prison settings requires valid, reliable, and effective instruments. OBJECTIVES AND METHODS: This study evaluated the performance of the Childhood Trauma Questionnaire - Short Form (CTQ-SF), originally developed and validated in English, within a sample of incarcerated men and women (n = 1118 and n = 207, respectively) in six Spanish prisons. RESULTS: The results indicated that the CTQ-SF had an acceptable fit in our sample. However, the internal consistency of the Physical Neglect subscale was found to be deficient (α = 0.57), especially among women (α = 0.43). This finding aligns with previous research across different contexts, which may signal weaknesses in the original construction of this subscale. The CTQ-SF demonstrated limited invariance between men and women, with only configural invariance being achieved, constraining the comparisons that can be made across sexes. In the absence of scalar invariance, comparisons of factor means to assess severity may be misleading, and caution is recommended when comparing prevalence estimates for men and women in Spanish prisons. Nonetheless, our findings support the convergent validity of the CTQ-SF, as trauma severity showed moderate correlations with depression, anxiety, stress, and aggression. CONCLUSIONS: These results underscore the importance of evaluating the performance of instruments across various cultural contexts and populations to ensure the validity of study conclusions.

Patterns of Childhood Adversities and Their Associations With Adult Victimization Among Incarcerated Men and Women in Spanish Prisons.

Adverse childhood experiences (ACEs) are prevalent and have long lasting effects. There is evidence of gender differences in exposure to different types of ACEs, with women experiencing higher levels of sexual abuse and cumulative adversity than men. Despite this, most research examining patterns of adversities have used joint samples, assuming that men and women have comparable profiles. The current study examines if distinct profiles of childhood adversities exist for men and women and analyzes their associations with multiple forms of interpersonal victimization during adulthood. Participants were 2,709 residents (91.6% men and 8.4% women) from eight prisons in Spain, who completed a self-administered survey. Latent Class Analysis revealed different patterns of childhood adversities for men and women. For both groups, higher adversity was associated with interpersonal harm during adulthood.

The Prevalence of Prison-based Physical and Sexual Victimization in Males and Females: A Systematic Review and Meta-Analysis.

This systematic review investigated the prevalence of prison-based interpersonal harm by type of victimization (physical and sexual) and sex, along with the heterogeneity among studies using meta-regression. Using Preferred Reporting Items for Systematic Reviews and the Meta-Analysis guidelines, 24 articles met the selection criteria. Study quality was assessed using the Joana Briggs Institute (20.8% deemed low quality, 33.3% moderate, and 45.9% high). Searches were conducted in Criminal Justice Abstracts, PsycINFO, PubMed, and Web of Science. The 24 articles comprised 36 separate samples inclusive of 23,967 incarcerated individuals. The random-effects pooled prevalence estimate of prison-based physical victimization was 18.8%, with slightly higher rates for females (20.3%) than males (18.1%). For sexual victimization, the pooled prevalence estimate was 12.4%, with higher rates among females (15.3%) than males (9.7%). For females, younger individuals reported higher rates of physical and sexual victimization and studies using smaller samples had higher rates of physical victimization. Rates of physical and sexual victimization for men were higher if perpetrators included residents and staff, the recall period was since admission, data was collected using self-administered surveys, and in low-quality studies (sexual victimization only). Rates of prison-based interpersonal harm, while high, varied significantly by type of victimization, sex, and study methodology. High heterogeneity will be reduced only if future studies adhere to best methodological practices in defining and collecting data on interpersonal harm and consistently test risk and prevention factors instrumental to prevention efforts. Study limitations include the exclusion of unpublished and non-English-language studies, small sample sizes for female studies, and methodological "noise" within the literature that reduce predictive precision.

Childhood Abuse Classes for Incarcerated Men and Women: Are There Unique Gender Patterns in Abuse Classes?

Childhood adversity is predictive of poorer health and behavioral health outcomes in adulthood. Males and females are known to experience different types of childhood adversity, with females experiencing more sexual and emotional harm in childhood. Latent class analysis (LCA) has been used to identify patterns among types of childhood adversity. These studies have constructed class structures using single gender or blended gender samples. Class structures based on blended gender samples, however, may misrepresent the nuances of gender-specific adversity histories through averaging, potentially distorting the relative need for gender-specific types of intervention. This study investigated whether latent class structures of childhood abuse are equivalent for incarcerated males and females. Our sample included 4,204 residents (3,986 males, 218 females) drawn from a single prison system. Residents completed an hour-long audio computer-assisted self-interview that included questions on 10 types of childhood abuse, depression, and anxiety symptoms, the Beck Hopelessness Scale (BHS), Buss-Perry Aggression Questionnaire, and Criminal Sentiments Scale-Modified (CSS-M). Overall, female residents were both more likely to experience childhood abuse and have more extensive victimization experiences. Small subgroups of males, however, had even more extensive victimization experiences. Abuse patterns for males and females, while optimally clustering in four classes, are rather unique, especially for higher abuse classes, in terms of distribution of membership and types of abuse. These differences may matter in terms of identifying the relative need for therapeutic intervention among incarcerated males and females and targeting those interventions in ways that reflect the gradient and density of therapeutic need. The next step is to test whether using blended or gendered latent class structures matters in terms of predicting outcomes, such as prison-based behavioral health problems, suicidality, and victimization.

Latent class analysis of self-reported substance use during incarceration: Gender differences and associations with emotional distress and aggressiveness.

INTRODUCTION: We know little about the prevalence and patterns of substance use during incarceration, and we know even less about comparative substance use patterns by gender. To address these gaps in the literature, this study used latent class analysis (LCA) to identify substance use subgroups of incarcerated men (n = 1118) and women (n = 207). METHODS: The study drew data from six prisons in Spain. Participants completed a self-administered questionnaire with items probing for types of drugs used in the past three months, depression, anxiety, stress symptoms, aggressiveness, and perceived social support. RESULTS: Substance use was common among incarcerated men and women, with tobacco, cannabis, and sedatives being most prevalent. LCA revealed different patterns of substance use by gender. Four- and two-class solutions best fitted the data for men and women, respectively. Aggressiveness and depression were associated with high depressant use membership for men. Among women, aggressiveness and anxiety symptoms were positively associated with high polydrug use membership. CONCLUSIONS: The prevalent and patterned use of substances inside Spanish prisons and their association with aggressiveness and depression elevates the risk of harm during incarceration. In the interest of safety and wellness, correctional behavioral health services should include and expand the availability of gender-specific integrated mental health and substance use interventions that address maladaptive behaviors such as aggression.

Violence Against Incarcerated Women: Predicting Risk Through the Lens of Childhood Harm.

Victimization is common inside prisons and much remains unknown about the predictors of violence against incarcerated women. A sample of 564 incarcerated women was used to examine the link between in-prison victimization, childhood (physical, sexual, and emotional) harm, and mental illness. Nearly half or more of women reported childhood harm and over one-quarter experienced in-prison victimization. Childhood harm fell into four latent classes and low sexual abuse and high abuse classes predicted resident-on-resident sexual victimization, as did single types of childhood harm. Current depressive symptoms and perceptions of overcrowding predicted physical and sexual victimization perpetrated by residents and correctional staff.

Understanding Polyvictimization in Prison: Prevalence and Predictors Among Men Inmates in Spain.

Victimization-physical, sexual, and emotional-is part of prison life for a sizable proportion of incarcerated people. Research has primarily focused on the prevalence and predictors of physical or sexual victimization inside prisons located in the United States. Very little prison-based victimization research has been conducted in other countries, and even less has examined the clustering patterns of victimization (referred to as polyvictimization), and whether different demographic, behavioral health, and criminal risk factors are associated with polyvictimization. This article explores variation in victimization patterns during incarceration in Spain, and whether there is variation in the demographic, behavioral, and criminal risk factors predicting one type (physical, sexual, or emotional); two types (physical and sexual, physical and emotional, or sexual and emotional); or three types (physical, sexual, and emotional), as well as the number of different types of victimization distinguished by type of perpetrator. Self-report data were collected from 2,484 male inmates housed in eight adult prisons in Spain. More than half the sample reported at least one type of victimization, and one quarter reported two or more types of victimization. Polyvictimization was found to be strongly associated with prior childhood and adulthood victimization experienced in the community. These findings have significant policy and practice implications.

The association between substance use and physical victimization among incarcerated men in Spanish prisons.

Physical victimization and substance use are common behaviors inside prisons. Yet little is known about whether there is an association between substance use and physical victimization among male inmates. We examined the absolute and relative association between substance use (prior to, during, and both prior to and during incarceration) and physical victimization while incarcerated. For this study, 2484 men (mean age of 36.3years; SD=11.1) were sampled from eight prisons located in Spain. Information was collected using self-report questionnaires probing experiences of physical victimization while incarcerated and substance use prior to prison and during the past six months in prison. We found that the rates and likelihood of physical victimization were greater for male inmates who used substances at any time, compared to non-consumers of substances but were highest for male inmates who used exclusively in prison or both prior to and in prison. These findings suggest the need for immediate prevention steps including comprehensive screening and segregation practices; better drug interdiction practices; and more evidence-based substance abuse treatment with and without integrated trauma treatment to ensure public health and safety.

Screening for Substance Use Disorder Among Incarcerated Men with the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST): A Comparative Analysis of Computer-Administered and Interviewer-Administered Modalities.

Substance use disorders are overrepresented in incarcerated male populations. Cost-effective screening for alcohol and substance use problems among incarcerated populations is a necessary first step forward intervention. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) holds promise because it has strong psychometric properties, requires minimal training, is easy to score, is available in the public domain but, because of complicated skip patterns, cannot be self-administered. This study tests the feasibility, reliability, and validity of using computer-administered self-interviewing (CASI) versus interviewer-administered interviewing (IAI) to screen for substance use problems among incarcerated men using the ASSIST. A 2×2 factorial design was used to randomly assign 396 incarcerated men to screening modality. Findings indicate that computer screening was feasible. Compared to IAI, CASI produced equally reliable screening information on substance use and symptom severity, with test-retest intraclass correlations for ASSIST total and substance-specific scores ranging from 0.7 to 0.9, and ASSIST substance-specific scores and a substance abuse disorder diagnosis based on the Structured Clinical Interview (SCID) were significantly correlated for IAI and CASI. These findings indicate that data on substance use and symptom severity using the ASSIST can be reliably and validly obtained from CASI technology, increasing the efficiency by which incarcerated populations can be screened for substance use problems and, those at risk, identified for treatment.

SCREENING FOR PTSD AMONG INCARCERATED MEN: A Comparative Analysis of Computer-Administered and Orally Administered Modalities.

Trauma exposure is overrepresented in incarcerated male populations and is linked to psychiatric morbidity, particularly posttraumatic stress disorder (PTSD). This study tests the feasibility, reliability, and validity of using computer-administered interviewing (CAI) versus orally administered interviewing (OAI) to screen for PTSD among incarcerated men. A 2 × 2 factorial design was used to randomly assign 592 incarcerated men to screening modality. Findings indicate that computer screening was feasible. Compared with OAI, CAI produced equally reliable screening information on PTSD symptoms, with test-retest intraclass correlations for the PTSD Checklist (PCL) total score ranging from .774 to .817, and the Clinician-Administered PTSD scale and PCL scores were significantly correlated for OAI and CAI. These findings indicate that data on PTSD symptoms can be reliably and validly obtained from CAI technology, increasing the efficiency by which incarcerated populations can be screened for PTSD, and those at risk can be identified for treatment.

Implementation and effectiveness of integrated trauma and addiction treatment for incarcerated men.

A controlled trial of Seeking Safety (SS) and Male-Trauma Recovery Empowerment Model (M-TREM) examined implementation and effectiveness of integrated group therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) on PTSD and mental health symptoms plus self-esteem and efficacy for incarcerated men. The study sample (n=230) was male inmates 18 years or older who were primarily non-white, high school graduates or equivalents, had childhood trauma histories, committed violent crimes, had serious mental illnesses, and resided in a maximum security prison. Incarcerated men, who screened positive for PTSD and SUD, were assigned randomly (n=142) or by preference (n=88) to receive SS or M-TREM, with a waitlist group of (n=93). Manualized interventions were group-administered for 14 weeks. Primary outcomes were PTSD and other mental health symptoms. Secondary outcomes were self-esteem, coping, and self-efficacy. SUD outcomes cannot be measured in a correctional setting. Implementation feasibility was exhibited by the ability to recruit, screen, assign, and retain participants. Effectiveness findings depended on sample, design, and method for analysis. Using a waitlist control group and no follow-up period, we found no aggregate effect of treatment on PTSD symptoms, although, when disaggregated, M-TREM was found to improve PTSD severity and SS improved general mental health symptoms and psychological functioning. Using intent-to-treat and completer analyses, no significant differences were found in the relative performance between SS and M-TREM on primary or secondary outcomes. When longitudinal data were maximized and modeled in ways that reflect the hierarchical nature of the data, we found that SS and M-TREM performed better than no treatment on PTSD severity and secondary outcomes, and that treatment benefits endured. Findings cautiously support implementing either Seeking Safety or M-TREM to treat incarcerated men with co-morbid PTSD and addiction problems.

Trauma exposure and posttraumatic stress disorder among incarcerated men.

Trauma exposure and trauma-related symptoms are prevalent among incarcerated men, suggesting a need for behavioral health intervention. A random sample of adult males (N = 592) residing in a single high-security prison were screened for trauma exposure and posttraumatic stress disorder (PTSD) symptoms. Trauma was a universal experience among incarcerated men. Rates of current PTSD symptoms and lifetime PTSD were significantly higher (30 to 60 %) than rates found in the general male populations (3 to 6 %). Lifetime rates of trauma and PTSD were associated with psychiatric disorders. This study suggests the need for a gender-sensitive response to trauma among incarcerated men with modification for comorbid mental disorders and type of trauma exposure. Developing gender-sensitive trauma interventions for incarcerated men and testing them is necessary to improve the behavioral health outcomes of incarcerated men who disproportionately return to urban communities.

Mental health specialized probation caseloads: are they effective?

With the large and growing number of persons with mental illnesses under probation supervision, a form of specialized probation called specialized mental health caseload (SMHC) has been implemented. This study explores the effectiveness of a prototypic SMHC implemented statewide. A quasi-experimental design was used to compare criminal justice, mental health, and community engagement outcomes among three caseloads: a newly established SMHC supervising no more than 30 clients per officer (N=1367); an established SMHC supervising roughly 50 clients per officer (N=495); and a traditional caseload of clients receiving mental health treatment and supervised by officers with average caseloads of over 130 clients (N=5453). Using a mixed methods approach, we found that the SMHC was implemented with high adherence to fidelity, and comparisons based on different caseload samples generally support the effectiveness of the specialized mental health caseload, particularly on criminal justice outcomes. Future studies using random assignment are needed to examine the connection among mental health symptoms, compliance with treatment and probation supervision, and recidivism.

Envisioning the next generation of behavioral health and criminal justice interventions.

The purpose of this paper is to cast a vision for the next generation of behavioral health and criminal justice interventions for persons with serious mental illnesses in the criminal justice system. The limitations of first generation interventions, including their primary focus on mental health treatment connection, are discussed. A person-place framework for understanding the complex factors that contribute to criminal justice involvement for this population is presented. We discuss practice and research recommendations for building more effective interventions to address both criminal justice and mental health outcomes.

Prevalence and correlates of criminal victimization among new admissions to outpatient mental health services in Hawaii.

Adults with serious mental illness (SMI) experience criminal victimization at rates higher than the general population whether they reside in the community or correctional settings. This study examines the past-six month prevalence and correlates of criminal victimization among a large community sample (N = 2,209) of consumers with SMI newly admitted to outpatient mental health services during 2005 through 2008. A cross-sectional design was used with self-report and clinical data collected from administrative records. Victimization was determined by responses to direct questions about experiences in the previous 6 months with respect to victimization of a non-violent and/or violent crime. Socio-demographic, clinical and criminal correlates of victimization were abstracted from a quality of life survey and clinical assessment interview conducted at admission. Overall, 25.4 % of consumers reported being a victim of any crime (violent or non-violent) in the past 6 months, with 20.3 % reporting non-violent and 12.3 % violent victimization. The risk of victimization was elevated for those who were female, White, not taking atypical psychotropic medication, not feeling safe in their living arrangement, and were arrested or homeless in the six-months prior to engaging in mental health outpatient treatment. Policy and practice implications of these findings are discussed.

Practice informs the next generation of behavioral health and criminal justice interventions.

Specialized interventions, such as police and jail diversion, mental health courts, specialized probation, forensic assertive community treatment, designed to engage justice-involved persons with serious mental illnesses, have expanded over the past two decades. Some of these "first generation" interventions have demonstrated efficacy and several have earned recognition as evidence-based practices. Yet, overall, they have not appreciably reduced the prevalence of persons with serious mental illnesses involved in the criminal justice system. To understand how to make the next generation of interventions more effective, a survey of a national sample of community-based programs serving these clients was conducted. Surveys were completed on-line by direct service staff affiliated with 85 programs and collected data on the characteristics and needs of the client base; characteristics and challenges associated with difficult-to-engage clients; service needs and obstacles; and recommendations for improving program effectiveness. A sample of the survey participants (19 programs from 18 states) attended a day-long workshop to discuss the survey findings and ways to improve treatment adherence and client services. Respondents reported that their clients have a constellation of problems with different origins, etiologies, and symptoms, often crossing over the boundaries of mental illness, addictions, and antisocial pathologies. According to the practitioners working with justice-involved clients with mental illnesses, responding effectively requires knowledge of many different problems, expertise to respond to them, and an understanding of how these problems interact when they co-occur. The poly-problems of these clients suggest the need for an integrated and comprehensive approach, which is challenged by the fragmented and diverse ideologies of the behavioral health, criminal justice, and social service systems.

Effectiveness of cognitive-behavioral trauma treatment for incarcerated women with mental illnesses and substance abuse disorders.

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 disorder (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 experienced 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.

Childhood and adult trauma experiences of incarcerated persons and their relationship to adult behavioral health problems and treatment.

Rates of childhood and adult trauma are high among incarcerated persons. In addition to criminality, childhood trauma is associated with the risk for emotional disorders (e.g., depression and anxiety) and co-morbid conditions such as alcohol and drug abuse and antisocial behaviors in adulthood. This paper develops rates of childhood and adult trauma and examines the impact of age-of-onset and type-specific trauma on emotional problems and behavior for a sample of incarcerated males (N~4,000). Prevalence estimates for types of trauma were constructed by age at time of trauma, race and types of behavioral health treatment received while incarcerated. HLM models were used to explore the association between childhood and adult trauma and depression, anxiety, substance use, interpersonal problems, and aggression problems (each model estimated separately and controlling for age, gender, race, time incarcerated, and index offense). Rates of physical, sexual, and emotional trauma were higher in childhood than adulthood and ranged from 44.7% (physical trauma in childhood) to 4.5% (sexual trauma in adulthood). Trauma exposure was found to be strongly associated with a wide range of behavioral problems and clinical symptoms. Given the sheer numbers of incarcerated men and the strength of these associations, targeted intervention is critical.