Pilot test of 12-step linkage for alcohol-abusing women in leaving jail.
ABSTRACT Background: More than a million US women are detained in jails each year; many have alcohol use disorders (AUDs). AUD intervention with pretrial jail detainees presents a logistical challenge due to limited jail stays and lack of resources for postrelease treatment. The availability, no-cost entry, and promise of anonymity of Alcoholics Anonymous (AA) make it a highly accessible resource for underserved populations. However, the outreach of AA volunteers into jails (as opposed to prisons) has been limited, and incarcerated women are unlikely to seek out strangers for help after release. This study pilot tested an enhanced referral approach introducing a 12-step volunteer to a woman in jail who would attend a meeting with her after release. Methods: Participants were 14 unsentenced female pretrial jail detainees with AUD. Intervention consisted of introducing participants detained in jail to female AA volunteers who could accompany them to an AA meeting after release. Assessments took place at baseline and 1 month after release. This uncontrolled pilot study evaluated the feasibility and acceptability of this enhanced referral approach. Pre-post alcohol use, drug use, alcohol problems, and AA attendance are also reported. Results: Enhanced referral was feasible and acceptable. Many (57%) of the 14 participants who met with AA volunteers in jail were in contact with those volunteers after release from jail. Participants had significantly fewer drinking days, heavy drinking days, alcohol problems, and drug-using days during the postrelease follow-up than they did before jail detention. Conclusions: Providing linkage between women in jail and female AA volunteers who can accompany them to a postrelease meeting is achievable, and may be a disseminable and low-cost method to improve alcohol outcomes in this vulnerable population.
- SourceAvailable from: Jennifer Johnson[Show abstract] [Hide abstract]
ABSTRACT: Abstract Objective and Method: In this article, I review my research applying interpersonal treatments and interpersonal principles from psychotherapy for major depression and substance use to broader public health goals for incarcerated women and other vulnerable populations. Results: A public health focus has led me to expand the boundaries of psychotherapy research to include partners such as prisons, parole officers, and bachelor's level providers; behaviors like risky sex; service delivery challenges; and ultimately to research with an eye toward informing policy and advocacy. Conclusions: A public health perspective provides context and rationale for conducting sound psychotherapy research; the combination of public health and psychotherapy-specific perspectives can lead to novel research.Psychotherapy Research 11/2013; · 1.75 Impact Factor
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ABSTRACT: Incarcerated women with co-occurring mental health and substance use disorders (COD) face complex psychosocial challenges at community reentry. This study used qualitative methods to evaluate the perspectives of 14 prison and aftercare providers about service delivery challenges and treatment needs of reentering women with COD. Providers viewed the needs of women prisoners with COD as distinct from those of women with substance use alone and from men with COD. Providers described optimal aftercare for women with COD as including contact with the same provider before and after release, access to services within 24-72 hours after release, assistance with managing multiple social service agencies, assistance with relationship issues, and long-term follow-up. Providers also described larger service system and societal issues, including systems integration and ways in which a lack of prison and community aftercare resources impacted quality of care and reentry outcomes. Practice and policy implications are provided.The Journal of Behavioral Health Services & Research 03/2014; · 0.78 Impact Factor
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ABSTRACT: Purpose ‐ The purpose of this paper is to explore treatment needs and factors contributing to engagement in substance use and sobriety among women with co-occurring substance use and major depressive disorders (MDDs) as they return to the community from prison. Design/methodology/approach ‐ The paper used qualitative methods to evaluate the perspectives of 15 women with co-occurring substance use and MDDs on the circumstances surrounding their relapse and recovery episodes following release from a US prison. Women were recruited in prison; qualitative data were collected using semi-structured interviews conducted after prison release and were analyzed using grounded theory analysis. Survey data from 39 participants supplemented qualitative findings. Findings ‐ Results indicated that relationship, emotion, and mental health factors influenced women's first post-prison substance use. Women attributed episodes of recovery to sober and social support, treatment, and building on recovery work done in prison. However, they described a need for comprehensive pre-release planning and post-release treatment that would address mental health, family, and housing/employment and more actively assist them in overcoming barriers to care. Practical implications ‐ In-prison and aftercare treatment should help depressed, substance using women prisoners reduce or manage negative affect, improve relationships, and obtain active and comprehensive transitional support. Originality/value ‐ Women with co-occurring mental health and substance use disorders are a high-risk population for negative post-release outcomes, but limited information exists regarding the processes by which they relapse or retain recovery after release from prison. Findings inform treatment and aftercare development efforts.International Journal of Prisoner Health 11/2013; 9(4).
Thi s art i cl e w as dow nl oaded by: [Brow n Uni versi t y]
On: 03 Jul y 2014, At : 08:32
Publ i sher: Rout l edge
Inf orm a Lt d Regi st ered i n Engl and and W al es Regi st ered Num ber: 1072954 Regi st ered of f i ce: M ort i m er House,
37-41 M ort i m er St reet , London W 1T 3JH, UK
Subst ance Abuse
Publ i cat i on det ai l s, i ncl udi ng i nst r uct i ons f or aut hor s and subscr i pt i on i nf or m at i on:
ht t p: //www. t andf onl i ne. com /l oi /wsub20
Pi l ot Test of 12- St ep Li nkage f or Al cohol - Abusi ng
W om en i n Leavi ng Jai l
Jenni f er E. Johnson PhD a , Yael Chat av Schonbr un PhD a b & Mi chael D. St ei n MD b c
a Depar t m ent of Psychi at r y and Hum an Behavi or , War r en Al per t Medi cal School , Br own
Uni ver si t y , Pr ovi dence, Rhode I sl and , USA
b But l er Hospi t al , Pr ovi dence, Rhode I sl and , USA
c Depar t m ent of Medi ci ne, War r en Al per t Medi cal School , Br own Uni ver si t y , Pr ovi dence,
Rhode I sl and , USA
Accept ed aut hor ver si on post ed onl i ne: 30 Apr 2013. Publ i shed onl i ne: 03 Mar 2014.
To ci t e t hi s art i cl e: Jenni f er E. Johnson PhD , Yael Chat av Schonbr un PhD & Mi chael D. St ei n MD ( 2014) Pi l ot Test of 12- St ep
Li nkage f or Al cohol - Abusi ng W om en i n Leavi ng Jai l , Subst ance Abuse, 35: 1, 7- 11, DOI : 10. 1080/08897077. 2013. 794760
To l i nk t o t hi s art i cl e: ht t p: //dx. doi . or g/10. 1080/08897077. 2013. 794760
PLEASE SCROLL DOW N FOR ARTICLE
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SUBSTANCE ABUSE, 35: 7–11, 2014
Copyright C ?Taylor & Francis Group, LLC
ISSN: 0889-7077 print / 1547-0164 online
Pilot Test of 12-Step Linkage for Alcohol-Abusing
Women in Leaving Jail
Jennifer E. Johnson, PhD,1Yael Chatav Schonbrun, PhD,1,2and Michael D. Stein, MD2,3
ABSTRACT. Background: More than a million US women are detained in jails each year;
a logistical challenge due to limited jail stays and lack of resources for postrelease treatment.
The availability, no-cost entry, and promise of anonymity of Alcoholics Anonymous (AA)
make it a highly accessible resource for underserved populations. However, the outreach of
AA volunteers into jails (as opposed to prisons) has been limited, and incarcerated women
are unlikely to seek out strangers for help after release. This study pilot tested an enhanced
referral approach introducing a 12-step volunteer to a woman in jail who would attend a
meeting with her after release. Methods: Participants were 14 unsentenced female pretrial
jail detainees with AUD. Intervention consisted of introducing participants detained in jail to
took place at baseline and 1 month after release. This uncontrolled pilot study evaluated the
feasibility and acceptability of this enhanced referral approach. Pre-post alcohol use, drug
use, alcohol problems, and AA attendance are also reported. Results: Enhanced referral was
feasible and acceptable. Many (57%) of the 14 participants who met with AA volunteers in
jail were in contact with those volunteers after release from jail. Participants had significantly
fewer drinking days, heavy drinking days, alcohol problems, and drug-using days during
the postrelease follow-up than they did before jail detention. Conclusions: Providing linkage
between women in jail and female AA volunteers who can accompany them to a postrelease
meeting is achievable, and may be a disseminable and low-cost method to improve alcohol
outcomes in this vulnerable population.
Keywords: Alcohol abuse, alcohol dependence, Alcoholics Anonymous, criminal justice,
jail, 12-step, treatment, women
More than a million US women are detained in jails each
year;(1)nearly half meet criteria for alcohol use disorders (AUDs;
47%(2,3)). Interventions targeting AUD among women detained
in jails are needed, but the logistics of substance use intervention
with pretrial jail detainees are challenging. In contrast to prisons
where longer stays afford opportunities for alcohol treatment and
postrelease treatment planning, the weekly turnover rate in jails is
65%.(4)Because women may be detained in jail only a few days and
School, Brown University, Providence, Rhode Island, USA
2Butler Hospital, Providence, Rhode Island, USA
3Department of Medicine, Warren Alpert Medical School, Brown Uni-
versity, Providence, Rhode Island, USA
Correspondence should be addressed to Jennifer E. Johnson, PhD, De-
partment of Psychiatry and Human Behavior, Brown University, 700 Butler
Drive, Providence, RI 02906, USA. E-mail: Jennifer Johnson@brown.edu
release times are unpredictable, professional in-jail alcohol treat-
ment is often infeasible and unavailable, and postrelease alcohol
treatment planning is difficult.(5–7)Furthermore, accessing profes-
sional alcohol treatment after returning to the community can be
formidable due to cost, long wait times, unfamiliarity with agencies
or providers, and transportation difficulties.(7,8)
Postrelease AA attendance is associated with improved drink-
ing outcomes for women leaving jail,(9)as well as in community
samples.(10–14)Furthermore, because they are free and widely avail-
able,(15)12-step programs, including Alcoholics Anonymous (AA),
can successfully overcome many postrelease barriers to services.
However, incarcerated women’s fear and distrust of strangers inter-
feres with their utilization of postrelease resources, including AA
meetings. For example, in the days and weeks after community
reentry, formerly incarcerated women will engage with providers
or others they already know and trust, but are unlikely to reach out
to strangers for help.(16–18)In one study of women leaving prison,
women were provided with cell phones programmed with phone
numbers of familiar prison counselors and other resources, includ-
ing a local organization that would pick them up and take them to
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their first postrelease AA meeting. All women called the familiar
counselors and none the organization at which they did not know
anyone, despite the promise of having someone accompany them to
a meeting.(18)Thus, face-to-face contact with incarcerated women
has a powerful influence on the resources that they are willing to
utilize after release.
AA has developed a specialized Corrections Committee that
brings AA meetings into prisons throughout the United States.(19)
semi-permanent AA groups in jails.”(20)In addition, even if an AA
meeting occurs in jail, there is no opportunity for an incarcerated
woman to have one-to-one communication with an AA volunteer
during incarceration or for her to meet with that same volunteer
after release. As a result, as a woman returns to the community, she
is expected to initiate contact with unfamiliar individuals to support
her recovery, a daunting task.
Studies in nonincarcerated populations have shown that inten-
sive referral to AA results in dramatically increased rates of meet-
ing attendance and involvement in 12-step groups(21)and enhances
likelihood of abstinence.(21,22)These “intensive referral” conditions
provide phone or personal contact with AA members. In contrast to
intensive referral, participants provided only with meeting lists and
reasons to attend AA are unlikely to attend.(21–23)This uncontrolled
referral approach, introducing a 12-step volunteer to a woman in
jail and organizing recontact between the two after release from jail
to attend meetings together. We also report pre-post alcohol use,
drug use, alcohol problems, and AA attendance.
Participants were 14 unsentenced female pretrial jail detainees in a
local correctional facility who (1) were at least 18 years old; (2) met
DSM IV (Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition) criteria for alcohol abuse or dependence in the 6
months prior to being jailed; (3) were interested in attending 12-
step meetings after release; and (4) expected to be released from
jail to the community within the next month. Participants were not
excluded for concurrent drug use, except for opiates. Women with
opiate use in the past 6 months were excluded due to their high rate
of relapse without opiate agonist treatment.
Potential participants were informed about the study through
announcements made in jail housing units by research staff, who
described the study as an opportunity to be connected with an AA
volunteer in jail to plan attendance at a meeting after release. A re-
search assistant (RA) met individually with interested participants
to explain more about the study and to conduct informed consent
procedures, which highlighted the voluntary nature of study par-
ticipation and the study’s Certificate of Confidentiality. There were
no legal and minimal financial ($30 for the postrelease assessment)
incentives for participation. The study was conducted under insti-
tutional review board (IRB) approval.
Existing community resources
In acknowledgement of the problem of linking individuals from
controlled settings to AA meetings, AA has developed subsidiary
groups of volunteers in nearly every state who serve incarcerated
persons reentering the community by being available to take them
sidiary groups are only available after release; they do not enter the
jails. Because of the AA 11th tradition of “attraction” (“Our public
relations policy is based on attraction rather than promotion”(15)),
the outreach of these AA volunteers into jails has typically been
limited to the provision of cards or pamphlets, requiring a recently
released inmate to initiate contact with the organization by call-
ing a toll-free number after release to seek support and resources.
Because women leaving jail are unlikely to call strangers for help
as they reenter the community, they make only limited use if this
valuable, free community service.
self, they also prescribe nonaffiliation (“An A.A. group ought never
us from our primary purpose”(15)). This means that outside individ-
uals (clinicians, researchers, etc) cannot prescribe what AA volun-
alcoholic”(24)who is in jail, if an outside entity identifies women
who would like to meet with them to learn more about AA. Our
AA volunteers and women in jail who wished to meet with them.
On days where female AA volunteers were available, the study
RA recruited and assessed potential participants in the morning to
study participant and the AA volunteer and briefly explaining that
and (3) the volunteer’s role was limited to attempting to increase
the participant’s familiarity with AA meetings and accompanying
her to agreed upon AA meetings to help her feel comfortable. The
RA also provided the woman with a current AA meeting book, and
informally together for a median of 30 minutes (range: 15–60), typ-
ical of an AA 12-step call. Discussions covered common topics in
and volunteer’s previous experiences with AA, kinds of meetings
the participant might like, meetings they might be able to attend to-
was not dictated by the research staff.
Research staff regularly monitored jail discharges and let each
woman’s volunteer know when the woman was released. Because
women did not always have reliable access to make outgoing calls,
the volunteer then called the study participant to set up a time to
accompany her to her first AA meeting. After this first meeting, the
relationship between the volunteer and the participant could end or
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continue by phone or at meetings, at the volunteer and woman’s
Recruitment, training, and supervision
Because it violates the AA principle of “affiliation,” study staff
were interested in the AA message. Volunteers were female, had at
had previously indicated a willingness to accompany women to
meetings after release from jail, prison, or residential treatment as
part of a standard AA service; however, meeting with women in
jail to enhance postrelease linkage did not occur prior to the study.
The AA volunteer coordinating that standard community service
matched other volunteers to study participants based on availability
and geography, when possible.
Measures and Analysis
Study assessments took place at baseline (in jail) and 1 month after
release from jail. At baseline, the alcohol use disorder module from
the Structured Clinical Interview for DSM-IV (SCID(25)) was used
to assess current alcohol abuse/dependence. Feasibility measures
included the ability of volunteers to enter the jails, their ability to
meet with women prior to jail release, and rates of contact between
and a modified End of Treatment Questionnaire (ETQ(27)). The
Timeline Followback (TLFB)(28)was used to assess alcohol using
days, heavy drinking (defined as 5+ standard drinks) days, days
attending 12-step meetings, and days using drugs in the 6 months
of Problems (SIP(29)) assessed alcohol problems at baseline and
follow-up. Intake and follow-up scores for continuous measures
(e.g., SIP) were compared using paired-sample t tests. Intake and
signed rank tests.
The average age of the sample (N = 14) was 34.7 (range: 18–49).
Three participants were Hispanic, 2 were African American, and
1 identified as mixed race. None were married, and most (12) had
legal income of less than $10,000 per year. Only 4 (29%) were em-
ployed. Three were charged with drug possession, 4 with probation
violation, 3 with simple or domestic assault, 2 with robbery, 1 with
shoplifting,and1withreceiving moneyunder falsepretenses.They
had a median of 5 (range: 0–10) prior arrests with a median of 2
(range: 0–10) prior incarcerations. Most (13) met criteria for mod-
erate to severe alcohol dependence and 1 met criteria for alcohol
Of the 30 women screened for the pilot study, 12 were excluded
(6 were moved to prison or released before assessments could be
completed, 3 had no alcohol use, 2 had opiate use, and 1 was not
women met eligibility criteria, signed consent, and were enrolled
in the study. The first 6 participants were part of a “pilot phase”
used to establish logistics of coordinating visits with the AA vol-
unteers. During this phase only 3 participants met volunteers while
incarcerated due to scheduling difficulties that were resolved in the
subsequent “established procedures” phase. For example, because
women were released so quickly, we stopped recruiting participants
unless we had a volunteer scheduled come to the jail within the next
24 hours. We were not able to obtain follow-up interviews with any
of the 3 women who were promised a visit from a volunteer but did
from the 14 participants whom volunteers were able to visit in jail.
Of the 14 women who saw AA volunteers in jail, 10 (71%)
completed the 1-month follow-up interview (including 1 woman
who was rearrested), 1 woman was not released from jail, 1 died,
and 2 were lost to follow-up. Eight of the 14 women (57%) were in
contact with their AA volunteer after release from jail an average
of 4 times. Meeting data were available for the 10 women who
provided follow-up data. Of these 10 women, 8 went to at least one
12-step meeting. Four of the 10 went to at least one (range: 1–5)
meeting with the AA volunteer they met in jail.
Of the 30 women screened for the study, only 1 declined partici-
pation. None of the enrolled women declined an in-prison meeting
with an AA volunteer. Client satisfaction (CSQ-8-R) scores aver-
aged 26.5 (SD = 3.4) on a scale from 8 to 32, for good to excel-
lent satisfaction, overall. When asked what was most helpful about
meeting with the volunteers, written ETQ responses indicated that
volunteers were “good to talk to,” that “at group meetings we felt
like a family,” that the volunteer “made me try harder to stay sober”
and “not think of another drink,” “she was nice and very informa-
tive about AA and especially women’s groups what she is involved
in,” “hearing the volunteer’s story and seeing how people really do
care and take time,” and “them reaching out and asking if we need
help—knowing people care;” 2 women did not comment. When
asked what was least helpful, 6 women had no comment, 1 cited
difficulty finding a steady AA group, and the other 3 would have
liked to have had more time with the volunteer either in jail or after
Drinking and drug use outcomes improved significantly from base-
line to 1-month follow-up (see Table 1).
The advantages of AA, such as its long history, availability, no-cost
entry, and promise of confidentiality/anonymity, make it a highly
accessible resource for underserved populations. We posited that
more likely to access it after release. Results indicate that providing
linkage between women in jail and female AA volunteers who can
Many (8; 57%) of the 14 participants who met with AA volunteers
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Means and Standard Deviations at Baseline and
(N = 14)
after release (N = 10)
% drinking days
% heavy (5+ drinks) drinking days
% days attending AA
% drug using days
Alcohol problems (SIP)
∗P < .05;+P = .051.
in jail were in contact with those volunteers after release from jail.
Although this is not perfect linkage, it is a vast improvement from
the 0 of 22 women who initiated calls to a the same group of
volunteers after release from prison in a previous study,(18)despite
of AA and being provided with cell phones programmed with the
volunteer group’s number.
Our work(16–18)and others’(30,31)has indicated that women in the
criminal justice system respond strongly to the quality of helping
relationships. For example, formerly incarcerated women are will-
ing to reach out to people perceived as familiar and trustworthy
(“we will call you because we know you and trust you”(18)), but have
described personal unfamiliarity and lack of trust as a large barrier
time to come and meet with incarcerated women individually was
meaningful to study participants as reflected in their perceptions of
the most helpful aspects of the AA linkage intervention. Further-
more, a focus on transitional relationships to increase incarcerated
women’s abilitytoaccess resourcesatcommunityreentryisconsis-
emphasize the importance of respectful relationships, female role
models, and empowerment.(32)
This study has several strengths. Jails serve the large majority
of the incarcerated population each year and present unique service
in jail rather than prison.(33,34)This study is also the first to test the
feasibility of a 12-step linkage approach in a criminal justice pop-
ulation, potentially mitigating a critical barrier to AA attendance.
Because the linkage provided in this pilot study is simple, requiring
logistical coordination and explanation of roles, it could be per-
formed by a jail volunteer coordinator rather than trained substance
abuse counselors, bypassing many of the cost and dissemination
obstacles that impede the widespread adoption of evidence-based
interventions in the criminal justice system. The study’s limited
exclusion criteria, the existence of subsidiary groups of AA mem-
bers willing to accompany individuals to meetings after release in
most states, the design of the linkage intervention to be consistent
with AA traditions, and the requirement of no specialized exper-
tise on the part of jail staff to implement the intervention increase
The study also has limitations. It is a small (N = 14), uncon-
it is impossible to tell whether the significant pre-post changes ob-
such as the experience of being jailed. In addition, AA volunteers
must be true to 12-step principles, limiting what can be asked of
them during a research study. Because of these principles, discus-
sions between volunteers and study participants cannot be manual-
ized, standard fidelity rating (eg, with audiotapes) is not possible,
after release were clustered within 3 of the 5 volunteers. Thus, this
ing a pressing need in a low-resource setting under real-world con-
tructure, this enhanced linkage approach is feasible and acceptable,
and could be easily disseminated across criminal justice settings.
This study was funded by the National Institute of Drug Abuse
(NIDA; K23 DA021159; Principal Investigator: J. E. Johnson).
NIDA was not involved in the conceptualization, data collection, or
writing of the manuscript.
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