Intervention Summary

Helping Women Recover and Beyond Trauma

Helping Women Recover: A Program for Treating Substance Abuse and Beyond Trauma: A Healing Journey for Women are manual-driven treatment programs that, when combined, serve women in criminal justice or correctional settings who have substance use disorders and are likely to have co-occurring trauma histories (i.e., sexual or physical abuse). The two programs can be delivered conjointly as one intervention (as in the case of the research reviewed for this summary) or separately as independent, stand-alone treatments. The goals of the intervention for women in a criminal justice or correctional setting are to reduce substance use, encourage enrollment in voluntary aftercare treatment upon parole, and reduce the probability of reincarceration following parole. The trauma-informed treatment sessions are delivered by female counseling staff (who may be assisted by peer mentors, typically women serving life sentences) to groups of 8-12 female inmates, in a nonconfrontational and nonhierarchical manner. The counselors use a strengths-based approach with a focus on personal safety to help clients develop effective coping skills, build healthy relationships that foster growth, and develop a strong, positive interpersonal support network. Helping Women Recover and Beyond Trauma sessions use cognitive behavioral skills training, mindfulness meditation, experiential therapies (e.g., guided imagery, visualization, art therapy, movement), psychoeducation, and relational techniques to help women understand the different forms of trauma, typical reactions to abuse, and how a history of victimization interacts with substance use to negatively impact lives. The intervention is delivered through 1.5-hour sessions that occur once or twice each week. The Helping Women Recover program consists of 17 sessions organized around 4 domains: (1) Self, (2) Relationship/Support Systems, (3) Sexuality, and (4) Spirituality. The Beyond Trauma program consists of 11 sessions organized around 3 domains: (1) Violence, Abuse, and Trauma; (2) Impact of Trauma; and (3) Healing From Trauma. Although the intervention in the research reviewed by NREPP was designed for women in a criminal justice or correctional setting, a community version of the intervention also is available. The community version has been delivered in residential and outpatient substance abuse treatment settings, mental health clinics, and domestic violence shelters.

Descriptive Information

Areas of Interest	Substance use disorder treatment Co-occurring disorders
Outcomes	1: Substance use 2: Aftercare retention and completion 3: Reincarceration
Outcome Categories	Alcohol Crime/delinquency Drugs Treatment/recovery
Ages	26-55 (Adult)
Genders	Female
Races/Ethnicities	Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Correctional
Geographic Locations	No geographic locations were identified by the developer.
Implementation History	Helping Women Recover has been implemented in more than 1,100 criminal justice programs with over 29,000 women and in more than 2,200 community-based programs with over 24,000 women. Beyond Trauma has been implemented in more than 1,500 criminal justice and community sites with 30,000 women. In one women's prison in California, over 500 women have participated in the program. The Helping Women Recover and Beyond Trauma intervention also has been implemented in Canada (New Westminster and Vancouver, British Columbia; Winnipeg, Manitoba; Halifax and Yarmouth, Nova Scotia; and Ottawa, Ontario) and in Ireland (Cork, Dublin, and Galway). The Beyond Trauma curriculum has been taught in graduate schools of social work in Berlin and Bremen, Germany.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	The Beyond Trauma curriculum has been translated into German.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Messina, N., Grella, C. E., Cartier, J., & Torres, S. A randomized experimental study of gender-responsive substance abuse treatment for women in prison. Journal of Substance Abuse Treatment, 38(2), 97-107.

Outcomes

Outcome 1: Substance use
Description of Measures	Substance use was measured with the drug use composite score from the Addiction Severity Index (ASI) Lite. The ASI Lite is a shortened version of the ASI, a semistructured interview instrument that evaluates the severity of psychosocial problems across seven life domains: medical, employment, alcohol, drugs, legal, family/social, and psychiatric. Composite scores of 0 to 1 are generated for each domain, with higher scores reflecting greater problem severity. Assessments occurred at baseline (entry into a prison-based therapeutic community [TC]) and at two postparole follow-up points: "6 months" (which occurred, on average, at 8.8 and 9.8 months after parole for the intervention and comparison groups, respectively) and "12 months" (which occurred, on average, at 15.5 and 13.9 months after parole for the intervention and comparison groups, respectively).
Key Findings	In a randomized clinical trial, female inmates who had a substance use history and were scheduled for parole within 24 months were randomly assigned to one of two 6-month prison-based TCs: an intervention group receiving Helping Women Recover and Beyond Trauma or a comparison group receiving standard treatment. From baseline to the 12-month postparole follow-up, women in the intervention group had a larger decrease in drug use composite scores than their counterparts in the comparison group, after controlling for ethnicity, marital status, and employment (p < .03).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.3 (0.0-4.0 scale)

Outcome 2: Aftercare retention and completion
Description of Measures	Aftercare retention and completion were measured as the total number of months in the first episode of community residential aftercare treatment following parole and as the successful completion of this treatment, respectively. Information was obtained from archival data (aftercare treatment admission and discharge records) available in the California Department of Corrections and Rehabilitation's Offender Substance Abuse Tracking System and from treatment providers. Records were obtained at the end of the study for the 12-month period following parole.
Key Findings	In a randomized clinical trial, female inmates who had a substance use history and were scheduled for parole within 24 months were randomly assigned to one of two 6-month prison-based TCs: an intervention group receiving Helping Women Recover and Beyond Trauma or a comparison group receiving standard treatment. Retention in the first episode of residential aftercare treatment following parole was longer for women in the intervention group than it was for women in the comparison group (2.6 vs. 1.8 months; p < .05). Additionally, women in the intervention group were more than 4 times as likely as women in the comparison group were to successfully complete this aftercare treatment episode following parole (odds ratio = 4.60; p < .05). These differences in retention and completion were associated with medium effect sizes (Cohen's d = 0.58 and 0.67, respectively).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.5 (0.0-4.0 scale)

Outcome 3: Reincarceration
Description of Measures	Reincarceration was measured using archival data available in the California Department of Corrections and Rehabilitation's Offender Based Information System. Records were obtained at the end of the study for the 12-month period following parole.
Key Findings	In a randomized clinical trial, female inmates who had a substance use history and were scheduled for parole within 24 months were randomly assigned to one of two 6-month prison-based TCs: an intervention group receiving Helping Women Recover and Beyond Trauma or a comparison group receiving standard treatment. A smaller percentage of intervention group than comparison group women were reincarcerated (31% vs. 45%; p < .05) during the 12 months following parole. During this time, intervention group women were 67% less likely than comparison group women were to be reincarcerated, after controlling for ethnicity, marital status, and living situation (odds ratio = 0.33; p < .05). This group difference was associated with a small effect size (Cohen's d = 0.28).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult)	100% Female	48% White 26% Hispanic or Latino 17% Black or African American 9% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Substance use	3.2	2.5	1.4	2.2	2.2	2.5	2.3
2: Aftercare retention and completion	2.3	2.8	1.4	2.2	2.7	3.5	2.5
3: Reincarceration	2.9	2.9	1.4	2.2	2.7	3.0	2.5

Study Strengths

The ASI Lite drug use composite score, when calculated for the past 30 days, has good reliability. Treatment provider logs and administrative databases are valid measures of documented service utilization, and some client reports were cross-checked with this documentation. Similarly, administrative databases of the State's Department of Corrections and Rehabilitation are valid measures of arrests and incarcerations. The treatment was manual driven, and assessments were conducted by research assistants, not the interventionists, which minimized therapist bias. The researchers carried out random assignment successfully in a prison environment and prevented cross-contamination between the intervention and comparison groups by having completely separate TC treatment environments, which controlled for many potential confounding variables.

Study Weaknesses

Baseline ASI Lite data were collected retrospectively for 30 days and 6 months before incarceration with no clear reliability and validity support. Six-month postparole data were collected for a follow-up period during which access to drugs was controlled for about half of the study participants, who typically entered a residential aftercare treatment service immediately after parole. Although the interventionists were occasionally observed by the developer of the intervention and lead researcher, they did not receive systematized oversight with coaching or feedback. In addition, the researchers did not measure intervention fidelity or therapy exposure, nor did they rate the prison TC core processes that were intended to be altered through the implementation of the trauma-informed model. The first aftercare service, which was usually residential and the longest treatment episode, imposed a controlled environment on clients and was more proximal to the 6- and 12-month follow-up periods; thus, it is possible that the substance use and reincarceration outcomes can be attributed to retention in aftercare services rather than the preceding in-prison intervention. The follow-up rate at 12 months following parole was slightly low at 76%, and both the 6- and 12-month follow-up assessments were conducted during large time windows. The within-subjects repeated measures analysis of the ASI Lite drug use composite score did not include clients with missing data and did not control for time in a controlled setting at each follow-up.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Beyond Trauma materials:

Assessment of Skills--Beyond Trauma
Beyond Trauma: A Healing Journey for Women--Bibliography
Beyond Trauma: A Healing Journey for Women--Implementation Guidelines
Covington, S. S. A Healing Journey: A workbook for women. Center City, MN: Hazelden.
Covington, S. S. Beyond Trauma: A Healing Journey for Women facilitator's guide. Center City, MN: Hazelden.
Covington, S. S. Beyond Trauma: A Healing Journey for Women [PowerPoint slides].
Hazelden (Producer). Beyond Trauma: A Healing Journey for Women client video [DVD]. Center City, MN: Hazelden.
Hazelden (Producer). Beyond Trauma: A Healing Journey for Women facilitator video 1 [DVD]. Center City, MN: Hazelden.
Hazelden (Producer). Beyond Trauma: A Healing Journey for Women facilitator video 2 [DVD]. Center City, MN: Hazelden.

Helping Women Recover materials:

Assessment of Skills--Helping Women Recover
Covington, S. S. A woman's journal. San Francisco: Jossey-Bass.
Covington, S. S. A woman's journal--Special edition for the criminal justice system. San Francisco: Jossey-Bass.
Covington, S. S. Helping Women Recover: A Program for Treating Addiction. San Francisco: Jossey-Bass.
Covington, S. S. Helping Women Recover: A Program for Treating Substance Abuse--Special edition for the criminal justice system. San Francisco: Jossey-Bass.
Covington, S. S. Helping Women Recover: A trauma-informed approach [PowerPoint slides].
Helping Women Recover--Implementation Guidelines

Materials for both programs:

Gender-Responsive Program Assessment
Gender-Responsive Program Assessment (Abbreviated)
Helping Women Recover and/or Beyond Trauma--Implementation Form
Services for Women and Girls Trauma-Informed Inventory

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
4.0	3.5	2.3	3.3

Dissemination Strengths

Program materials are well written, logically sequenced, comprehensive, and straightforward. They include useful tips for effective group facilitation, and they anticipate and answer questions that clinicians and program supervisors may have in regard to the intervention. The program developer provides on-site training that is tailored to the needs of the implementing organization, along with phone- and email-based support during implementation. Several tools are provided to support quality assurance.

Dissemination Weaknesses

No training specifically designed for program supervisors is available to help them provide clinicians with ongoing guidance, ensure clinicians' continued competence, and support those at risk for secondary trauma. No guidance is provided for using quality assurance tools or for using the data derived from these tools to determine the program's impact.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Helping Women Recover facilitator's guide (includes one participant workbook)	$195 each	Yes
Helping Women Recover participant workbook	$26.95 per participant	Yes
Beyond Trauma facilitator's guide	$89.95 each	Yes
Beyond Trauma participant workbook	$9.95 per participant ($79 for 10)	Yes
Beyond Trauma facilitator DVDs (two)	$225 per set	No
Beyond Trauma client DVD	$99 each	No
2-day, on-site Helping Women Recover facilitator training	$4,000-$10,000 depending on location, trainer, and site needs	No
2-day Helping Women Recover facilitator training, located at various sites across the United States	$100-$200 per person depending on location	No
Annual 3-day Helping Women Recover facilitator training in Minneapolis, MN	$159 per person	No
2-day, on-site Beyond Trauma facilitator training	$4,000-$10,000 depending on location, trainer, and site needs	No
2-day Beyond Trauma facilitator training, located at various sites across the United States	$100-$200 per person depending on location	No
Annual 3-day Beyond Trauma facilitator training in Minneapolis, MN	$159 per person	No
On-site, email, and phone consultation	Varies depending on site needs	No
Quality assurance tools	Free	No

Additional Information

Discounts are available for program materials purchased either in large quantities or as a set.