WOMEN COPING WITH LIFE: A MIXED METHODS STUDY OF INCARCE RATED WOMEN WITH LIFE SENTENCES By Gina Lorraine Fedock A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Social Work Doctor of Philosophy 2015 ABSTRACT WOMEN COPING WITH LIFE: A MIXED METHODS STUDY OF INCARCE RATED WOMEN WITH LIFE SENTENCES By Gina Lorraine Fedock Life sentences have increasingly translated into prison stays until the end of natural life. Incarcerated women serving life sentences comprise a small, but growing, sub - population of the prison population. Women with life sentences enter prison with high rates of physical and mental health concerns, and these concerns are often chronic and recurring needs in prison. Pressing concerns include persistent depression and suicide risk factors. However, there is a lack of research focused on no existing intervention for this population of women. Thus, this dissertation seeks to enhance and broaden the knowledge base about factors that influence the mental health of women with life s entence in order to provide clarity and guide advocacy for prison - based mental health services. Also, this dissertation includes a sub - study that examines the mental health outcomes for a new intervention with this population of women. Two key theories ser ve as the foundation for this dissertation: importation theory and deprivation theory. Three sub - studies comprise three core chapters of this dissertation. Across these studies, the results highlight implications for social work practice, policy, and resea rch. Copyright by GINA LORRAINE FEDOCK 2015 iv This dissertation is dedicated to the loving memory of Katherine Luke. Katherine was a brilliant, practical, and compassionate scholar, a loving and lig ht - filled mother, and a warm and loyal friend. While our time together was brief, she had a life - changing effect on my life. Most importantly, s he showed me a path of being both a mother and an academic, of balancing professional and personal goals . Her li fe and work continue to inspire others and myself. She is greatly missed and loved. I am filled with gratitude that I knew her. v ACKNOWLEDGEMENTS While I often wanted this dissertation to write itself, it did not. This dissertation is a reflection of the professional and personal support of many people in life, as well as fundamentally the result of the support of the women in prison who shared their experiences, tried a new treatment group, and had the interest and courage to talk w ith me about their lives. They taught me so much and pushed me to grow as they grew. Their lives inspire multiple forms of social justice paths, and I hope my work contributes to the forming of a more just world. I have deep gratitude for my advisor and committee chair - Dr. Sheryl Kubiak. Thank you for all that you have done from helping me receive funding to bringing me to prison (as well as national conferences) to simply believing in me. You showed me your expertise, passion, dedication, and pathways t o success, opening door after door for me. I know such a mentoring experience is rare and I am so thankful for each and every opportunity you have given me. Working with you has allowed me to work with other distinguished experts, including Dr. Deb Bybee w hose kindness, patience, warmth, and brilliance I am so lucky to have re ceived. Also, the research team, including Liz Tillander, Woo Jong Kim , Hannah Brenner, and Katie Darcy, has brought frie ndship as well as their scholarly insights. Carmen Hillier work ed closely with me on some of the data analysis, and through her thoughtful questions and considerate insights, she helped me see the data in different and valuable ways. To all of you, I am grateful for all the experiences, and more importantly to know yo u. Also, I am thankful for the support of my entire committee. Dr. Sacha Klein has encouraged me at multiple key points in this program and consistently weaves self - care with pushing myself. Thank you for all the support you have given me (often right on time too). vi Thank you as well to Dr. Jennifer Cobbina for being accessible, open, brilliant, and kind. I am honored to have you on my com mittee and to receive your feedback . Outside of the university, I have had the great pleasure of working with Dr. Stephanie Covington which is also a true honor. Thank you for believing in me and encouraging me to see opportunities. T hank you as well to m y original research team at the University of Michigan ristie Palladino, and Dr. Caroline Bonham who provided me with not only the fundamentals of quality research, but also provided warmth, friendship, mentors hip, and kindness through the process. Personally, I am also surrounded by people with great wit, compassion, brilliance , and generosity. Thank you Dulcy Hayes, Lok - Sze Wong, Kristin Scherrer, Jenn Mann, Christine Watson, John Watson, Harry Short, Jim Ga rrett, Carmen Alvarez, Loti Walker, Josephine Boakye, Jasmine Crumsey, Alison Vacca, Mike Vacca, Gretchen Ar cher, Jen Smith, Lanice Elizabeth Armstrong, Grace Kotre, Christy Napier, and many more people who have shown up with dinner or coffee, to play games, to play with the kids, to talk methods , etc . Thank you for your friendship and in all the ways you are each uniquely you. Thank you for nurturing my soul in this process. I am deeply grateful for my friends who are truly my family too . Most importantly, t o my spouse , Shantá Robinson, thank you. The best part of this path is ast 5 years, I am so excited for our next steps and our future together. To our children, Vivian and Vincent: you are pure joy, wonder, creativity, and love. Everyday you amaze me. I love you so much and am honored to be your mama . As you tell me vii TABLE OF CONTENTS CHAPTER ONE: AN OVERVIEW OF THE DISSERTATION RESEARCH ............................ 1 I n t r o d u c t i o n . . 1 Purpose of This Dissertation ................................ ................................ ................................ ....... 4 Back ground and Overview of Women and Imprisonment ................................ ......................... 4 Pathways to crime for women ................................ ................................ ................................ ........... 6 Women serving life sentences ................................ ................................ ................................ ........... 9 ................................ ............................... 12 The current state of prisons ................................ ................................ ................................ ............ 14 Daily life in prison ................................ ................................ ................................ .......................... 15 Safety in prison ................................ ................................ ................................ ............................... 17 Inmate culture ................................ ................................ ................................ ................................ . 18 Mothers in prison ................................ ................................ ................................ ............................ 19 logical Health in Prisons ................................ ................................ ............... 20 Mental Health Treatment for Women in Prison ................................ ................................ ....... 21 Women in Prison Serving Life Sentences ................................ ................................ ................ 23 ............................ 25 Organization of the Dissertation ................................ ................................ ............................... 30 Chapter 2, Manuscript 1 ................................ ................................ ................................ ........ 31 Chapter 3, Manuscript 2 ................................ ................................ ................................ ........ 31 Chapter 4, Manuscript 3 ................................ ................................ ................................ ........ 32 Chapter 5, Discussion and Conclusion ................................ ................................ ................. 32 REFERENCES ................................ ................................ ................................ ......................... 33 CHAPTER TWO EXPLORA TION OF THE PRE - PRISON LIFE EXPERIENCES OF INCARCERATED WOMEN WITH LIFE SENTENCES ................................ ................................ .......................... 51 Abstract ................................ ................................ ................................ ................................ ..... 51 Introduction ................................ ................................ ................................ ............................... 52 Background ................................ ................................ ................................ ............................... 53 ................................ ................................ .... 54 Previous criminal justice involvement . ................................ ................................ ................. 55 Personal and familial histories ................................ ................................ .............................. 55 Substance use. ................................ ................................ ................................ ....................... 56 Mental health history. ................................ ................................ ................................ ........... 57 Pre - Prison Factors and Prison - Based Treatment ................................ ................................ ...... 57 Pre - Prison Factors for Women Serving Life Sentences : A distinct population? ...................... 58 Current Study ................................ ................................ ................................ ............................ 59 Methods ................................ ................................ ................................ ................................ ..... 61 Sample ................................ ................................ ................................ ................................ ... 61 viii Procedure ................................ ................................ ................................ .............................. 62 Lifeline Format ................................ ................................ ................................ ..................... 63 Variables for co ding ................................ ................................ ................................ .............. 63 Criminal justice history ................................ ................................ ................................ ................... 64 Personal and familial histories ................................ ................................ ................................ ....... 64 Substance use history . ................................ ................................ ................................ ..................... 65 Mental health history ................................ ................................ ................................ ...................... 66 Analysis ................................ ................................ ................................ ................................ . 66 Results ................................ ................................ ................................ ................................ ....... 68 Primary Theme : Cumulative Trauma and Adversity Throughout the Pre - Prison Life C ourse ................................ ................................ ................................ ................................ ............... 68 No safety in primary relationships ................................ ................................ ................................ .. 71 Persistency ................................ ................................ ................................ ................................ ...... 73 Sub - - Prison Lives ................................ ................................ .............. 74 Sub - Theme 1 : Abusive Relationships and the Introduction of Substance U se .................... 76 Introduction to substance use by a caregiver or partner ................................ ................................ 76 Substance use as a dynamic of abusive relationship ................................ ................................ ...... 77 Sub - Theme 2 s Risky Behaviors as Responses to and Coping Strategies for Trauma and A dversity ................................ ................................ ................................ ........... 78 Sub - Theme 3 : Missing Intervention P oints ................................ ................................ .......... 79 Substance abuse treatment services ................................ ................................ ................................ 79 Mental health treatment services ................................ ................................ ................................ .... 80 Sub - Theme 4 : End - point prison ................................ ................................ ............................ 81 Relational component to crimes ................................ ................................ ................................ ...... 81 History of abuse with co - defendant ................................ ................................ ................................ 83 Substance use at the time of the crime ................................ ................................ ............................ 83 Continuation of need for services in prison ................................ ................................ .................... 84 Discussion ................................ ................................ ................................ ................................ . 85 Implications for Social Work Theory ................................ ................................ ................... 8 7 Implications for Social Work Practice ................................ ................................ .................. 88 Limitations ................................ ................................ ................................ ............................ 89 Conclusion ................................ ................................ ................................ ............................ 90 REFERENCES ................................ ................................ ................................ ......................... 91 CHAPTER THREE : TESTING A NEW INTERVENTION WITH INCARCERATED WOMEN WITH LIFE SENTENCES: ASSESSING CHANGES IN MENTAL HEALTH AND ANGER ................................ ................................ ................................ ................................ ..................... 100 Abstract ................................ ................................ ................................ ................................ ... 100 Introduction ................................ ................................ ................................ ............................. 101 Background ................................ ................................ ................................ ............................. 101 A New Intervention: Beyond Violence ................................ ................................ ............... 104 Current Study ................................ ................................ ................................ ...................... 106 Methods ................................ ................................ ................................ ................................ ... 108 Study Design ................................ ................................ ................................ ....................... 108 Participants ................................ ................................ ................................ .......................... 108 Procedures ................................ ................................ ................................ ........................... 109 Measures ................................ ................................ ................................ ............................. 111 ix Depression ................................ ................................ ................................ ................................ .... 111 Anxiety ................................ ................................ ................................ ................................ ........... 111 Post - Traumatic Stress Disorder/PTSD ................................ ................................ ......................... 112 Serious mental illness/ SMI ................................ ................................ ................................ ........... 112 State and trait anger ................................ ................................ ................................ ..................... 112 Analysis ................................ ................................ ................................ ............................... 114 Results ................................ ................................ ................................ ................................ ..... 117 Participants ................................ ................................ ................................ .......................... 117 Preliminary Paired Sample T - Tests Results for Changes for All Women over Time ....... 117 Changes in Mental Health and Anger Outcome Variables over Time ............................... 120 Changes in Menta l Health and Anger Variables over Time by Amount of Time Served .. 121 Discussion ................................ ................................ ................................ ............................... 126 Limitations ................................ ................................ ................................ .......................... 131 Conclusion ................................ ................................ ................................ .......................... 132 REFERENCES ................................ ................................ ................................ ....................... 133 CHAPTER 4 STRATEGIES OF INCARCERATED WOMEN WITH LIFE SENTENCES ......................... 143 Abstract ................................ ................................ ................................ ................................ ... 143 Introduction ................................ ................................ ................................ ............................. 144 Background ................................ ................................ ................................ ............................. 145 ................................ ................................ ...................... 145 The role of coping strategies . ................................ ................................ ................................ ........ 146 Intrapersonal coping strategies ................................ ................................ ................................ .... 148 Interpersonal coping strategies ................................ ................................ ................................ .... 148 Coping for the Long - Term: Women with Life Sentences ................................ .................. 149 Current Study ................................ ................................ ................................ ...................... 150 Method ................................ ................................ ................................ ................................ 151 Analysis ................................ ................................ ................................ ............................... 153 Results ................................ ................................ ................................ ................................ . 154 Coping ................................ ................................ ............ 156 Entering prison as the end of life ................................ ................................ ................................ .. 157 ................................ ................................ ................................ 158 With life in prison, stay busy ................................ ................................ ................................ ......... 160 ................................ ................................ ..................... 163 Focus on internal freedom/ mental freedom ................................ ................................ ................. 164 - Activities for release ................................ ................................ .................... 167 ................................ ................................ ..... 169 Focus on external relationships ................................ ................................ ................................ .... 171 Legal involvement ................................ ................................ ................................ ......................... 173 ................................ ................................ ......... 175 ................................ ................................ ......... 176 Prison practices around treatment. ................................ ................................ .............................. 177 Treatment by prison staff ................................ ................................ ................................ .............. 179 Self - Improvement for prison ................................ ................................ ................................ ......... 180 Disc ussion ................................ ................................ ................................ ............................... 181 Implications for Social Work Theory ................................ ................................ ................. 182 x Implications for Social Work Practice ................................ ................................ ................ 184 Implications for Social Work Policy ................................ ................................ ................... 186 Limitations ................................ ................................ ................................ .......................... 187 Conclusion ................................ ................................ ................................ .......................... 188 REFERENCES ................................ ................................ ................................ ................... 189 CHAPTER FIVE : DISCUSSION, IMPLICATIONS, AND CONCLUSION ........................... 196 An Overview of the Major Findings ................................ ................................ ....................... 197 Overarching Themes ................................ ................................ ................................ ............... 199 Strengths and Limitations of the Study ................................ ................................ ................... 201 Study Limitations ................................ ................................ ................................ .................... 204 Implications for Theory and Social Work ................................ ................................ .............. 205 Implications for Social Work Practice ................................ ................................ .................... 207 Implications for Social Work Policy ................................ ................................ ....................... 208 Implications for Future Research ................................ ................................ ............................ 209 Conclusion ................................ ................................ ................................ .............................. 209 REFERENCES ................................ ................................ ................................ ....................... 211 xi L IST OF TABLES 67 Table 2: Primary and Sub - 69 70 Table 4: 110 Table 5: 118 Table 6: Paired Sample T - Te sts Results for Mental Health and Anger Measures for All 119 Table 7: Multilevel Analysis of Mental Health and Anger Outcomes over Time (2 - 121 Table 8: Multilevel Analysis of Mental Health and Anger Outcomes over Time by Length of Time Served ¹.. 122 Table 9: Coping Strategies by Perception of Life Sentence ¹.. 155 xii LIST OF FIGURES 72 75 Figure 82 Figure 4: 85 Figure 5: Simple Slope of Anxiety by Women who had Served Less Time (1) and Women who had Served Longer Time (2) ª. 124 Figure 6: Simple Slope of Anger Control Out by Women who had Served Less Time (1) and Women who had Served Longer T ime (2) ª . 125 1 CHAPTER ONE: AN OVERVIEW OF THE DISSERTATION RESEARCH Introduction Incarcerated women with life sentences are a small, but growing sub - population of adults in prison. Approximately 5% of in carcerated women are serving life sentences in the U.S., and the number of women incarcerated with life sentences has increased by 14.2% from 2008 - 2012 ( Nellis, 2013 ) . This increase has been attributed to changes in sentencing policies and practices since the 1970s that have lengthen ed incarceration periods based on types of offending such as longer sentences for repeat offending and drug offenses , and have simultaneously limited opportunities for parole ( Nellis & King, 2009 ) . Also, i n the past thirty to forty years, due to these more stringent sentencing policies and practices, the definiti on of a life sentences has changed from an indeterminate sentencing stance (i.e. until rehabilitation has occurred and thus being ) to meaning literally to the end of natural life ( Mauer, King, & Young, 2004 ; Nellis & King, 2009 ) . This means that reflective of the normative practices at the time, sentencing judges may have intended sentence ( e.g. 20 years) but did not intend a natural life sentence ( Mauer, et al., 2004 ) . However, shifts in sentencing policies and practices (such as the two - strike rule in Georgia) have altered this meaning ( Nellis, 2013 ) . For example , in California, those with a life sentence have an 18% chance of being approved for release by the Parole Board ( Weisberg, Mukamal, & Segall, 2011 ) , and in Michigan, the c hance is 9% ( Levine, 2014 ) making release a rare event . Therefore, women with life sentences are both a growing and permanent sub - population within prisons. 2 The re are multiples consequence s and concerns with this increase and they impact prisons, the community , families, and prisoners. First, the mere financial cost of incarcerating a prisoner for life is staggering. The average cost per prisoner per year is $20,000, and considering that a life - sentenc ed prisoner will age in prison and a geriatric prisoner costs $69,000 pe r year , the result is, on average, o ver $1 million in costs for a woman sentenced to life in prison ( Mauer, et al., 2004 ) . For example, in Michigan, every l ife sentenced prisoner costs taxpayers $200,000 per five years ( Levine, 2014 ) . Second, women with life sentences arrive in prison with higher rates of psychosocial needs ( Leigey & Reed, 2010 ) , and describe perpetual psychological distress ( Jose - Kampfner, 1990 ) and report a multitude of physical and mental health concerns especially as they age in prison ( Aday & Krabrill, 2011 ) , including s uicide risk ( Dye & Aday, 2013 ; Magaletta, Patry, Wheat, & Bates, 2008 ) . These needs reflect the deterioration of health in prison and the increased demands on the prison health care system as women serve life sentences. Third, a majority of mothers in prison (including women with life sentences) were the primary caregivers and daily providers for their minor - age children before imprisonment ( Glaze & Maruschak, 2008 ; Leigey & Reed, 2010 ) . Children with their mothers in prison are more than five times more likely to be placed in foster care than children with just their fathers in prison ( Glaze & Maruschak, 2008 ) . Thus, given the multitude of impediments to maintaining mothering while imprisoned, both mothers and their children face a variety of detriments from the loss of relational bonds ( Loper, Carlson, Levitt, & Scheffel, 2009 ) . Also, the burden on foster care is care caseloads (Swann & Sylvester, 2006), and over 25 billion dollars are spent on c hild welfare annua lly (Fang, Brown, Florence, & Me rcy, 2012). 3 Fourth, the United States is the country wi th the highest rate of life sentences in the world (Nellis, 2013), and recently, the European Court of Human Rights declared that all prisoners with l ife sentences have a right to a potential release from prison and a review by the parole board ( Vinter and Others v. United Kingdom, 2012 ). This case and the larger issue of the ethical nature of life sentences question the potential right to rehabilitatio n for all prisoners ( van Zyl Smit, Weatherby, & Creighton, 2014 ) , the need for international intervention with the U.S. prison system ( Bernaz, 2013 ) , and the glaring issue of the U.S. as out of sync w ith prisoner - focused human rights reforms found in other industrialized countries, such as Spain, Italy, Canada, and France (Nellis, 201 0 ). These concerns have also been evident in the particular issue of giving juveniles life sentences in prison in the U.S., calling into question the humaneness of not only this provision for youth but life sentences in general (e.g. Human Rig hts Watch & Amnesty International, 2005 .) Despite their constant presence in prisons, women with life sentences have largely been neglected and underserved by practice professionals, prison administrators and researchers ( Dye & Aday, 2013 ; Owen, 1998 ) . While they are long - term inmates in prisons, there is limited information about the psychological health of women with life sentences - both in terms of their pre - prison life h istories and their mental health in prison, especially in regards to how they cope with and respond to feelings of psychological distress ( Dye & Aday, 2013 ; Leigey & Reed, 2010 ) . Likewise , there are no existing treatment - based interventions specifically for this population ( Tripodi, Bledsoe, Kim, & Bender, 2011 ) , nor are they purposively included in samples to test interventions, and often they are denied treatment - based programming due to their life r status ( Nellis, 2012 ) . Therefore, while this is a growing popula tion, it is also a highly under studied and underserved population. Research is needed to inform service provision, 4 intervention development , and policy advocacy including a human rights agenda f or this population of women. These studies begin this research agenda through a specific focus on the psychological health of women with life sentences given the existing high rates of depression and suicide risk. Purpose of This Dissertation This dissertation study addresses t hree major gaps that are present in the literature in regards to the psychological health of incarcerated women with life sentences : (1) an exploration of the pre - prison life experiences (i ncluding mental health and substance use histories, experiences of trauma , and family adversities) that influence their psychological health in prison ; (2) an examination of mental health before and after delivery of a new intervention; and (3) an exploration of the ways that women co pe with life sentence and the influence of importation and deprivation factors . The following overview provides a background for the three manuscripts of this dissertation by summarizing what is known about women in prison in three major areas: 1 ) pre - inc arceration factors, including pathways to crime and how changing social policies have impacted women and sentenci ng; 2 ) prison factors, including historical and current descriptions eories that may Background and Overview of Women and Imprisonment Prisons are designed for prisoners for long - term confinement (i.e. prison sentences are measured in years or even life - terms), and historically for the sake of rehabilitating prisoners ( Belkna p, 200 7; Feinman, 1983 ) . Currently, women comprise approximately 7 percent of all inmates held in state and federal prisons ( Carson & Sabol, 2012 ) . Both the number and rate of 5 women incarcerated have steadily increased since the 1980s. Specifically, from 1977 to 2004, the number of women in prison expanded by 757 percent ( Frost, Greene, & Pranis, 2006 ) . Currently, the imprisonment rate for women is 65 per 100,000 residents in comparison to 59 per 100,000 residents in 2000 ( Carson & Sabol, 2012 ) and only 10 women per 100,000 residents in 1979 ( Frost, et al., 20 06 ) . Women of color have an especially higher risk of being imprisoned; women who are Hispanic have a rate of 71 per 100,000 residents and for Black women, 129 per 100,000 residents which is 2.5 times the rate for White women (51 per 100,000 residents) ( Carson & Sabol, 2012 ) . a violent offense, 29% for property crimes, 25% for drug crimes, and 8% for public order offenses ( Carson & Sabol, 2012 ) . Lastly, women in prison commonly have backgrounds of low education achievement (i.e. 44% of incarcerated women do not have a GED or a high school diploma), unemployment prior to arrest and unstable unemployment histories, previous experiences of being homelessness , histories of trauma and violence victimization, substance use, dependency, and abuse, mental health concerns, and primary parenting of minor - age children ( Belknap, 200 7; Bloom, Owen, & Covington, 2003 ; Glaze & Maruschak, 2008 ; Harlow , 2003 ; Pollock, 200 1 ) . As this increase in the number of women in prison has occurred, a new field of knowledge has also emerged to explore macro - level factors connected to the increased and intensified arrest and incar ceration of women (especially women of color). These factors include impacts of the war on drugs ( Bloom, Chesney - Lind, & Owen, 1994 ; Bush - Baskette, 2004 ) , changes in arrest and sentencing policies ( Bloom, Owen, & Covington, 2004 ; Chesney Lind, 2002 ; Mauer, Potler, & Wolf, 1999 ) and massive for - pro fit prison building ( Davis & Shaylor, 2001 ; Reynolds, 2008 ; Richie, 2012 ) . For example, in regards to arrest practices, data 6 demonstrate decreases in drug related incarcerations and a corresponding increase in the proportion of women imprisoned for violent crim e ( West & Sabol, 2008 ) . This increase has mainly been for simple assaults (versus more serious aggravated assault) and has been linked to the use of mandatory arrest policies that have been detriment in criminalizing women who are victims of intimate partner violence ( Koons - Witt & Schram, 2003 ; Kruttschnitt, Gartner, & Ferraro, 2002 ; Pollock & Davis, 2005 ; Schwartz, Steffensmeier, & Feldmeyer, 2009 ) . Also, with this increase in the number of women in prison , researchers have explored differences between men and women involved in the criminal justice system. Across studies, men and women display different frequencies in t heir types of and rationales for their crimes and have proportional differences in their pathways into crime ( Belknap, 200 7; Belknap & Holsinger, 2006 ; Chesney - Lind & Pasko, 20 13 ; Daly, 1992 ; Salisbury & Van Voorhis, 2009 ) . Women are shaped by dynamics such as trying to survive severe economic marginalization and escape viol ence from partners ( Belknap, 200 7; Chesney - Lind & Pasko, 20 13 ; Daly, 1992 , 1994 ; Owen, 1998 ) y category with the highest proportion of men (35%) was related to using violence for control and the prominent role of masculinity in promoting criminal behaviors, whereas the pathway with the largest proportion of women (37%) was based on a history of ex tensive abuse, victimization, substance abuse, mental health distress, and subsequent criminal behaviors. Pathways to crime for women . S pecific pathways to crime for women are based on the interconnections and multiple impacts of interpersonal violence, i nstitutional and organizational neglect toward women due to their social position(s), sexual exploitation and trauma, pervasive poverty, and the power of addiction ( B. Richie , 1996 ) . Based on life histories of incarcerated 7 African American women, Richie (1996) found th ese pathways to be based on complex, multi - level factors that she labels a system of . Richie (1996) describes this as: T he socially constructed process whereby African American women who are vulnerable in even when the behaviors are logical extensions of their racialized gender identit ies, their culturally expected gender roles, and the violence in their intimate relationships. (p. 4) Likewise, in a study of pathways to crime for women in prison, t he cumulative effects of trauma pervaded interactions with social systems, family and peer group relationships, home and property status, school and work performance, and involvement in faith and religious activitie s ( D. D. DeHart, 2008 ) . These effects shaped the context in which women soug ht to navigate their lives and the resulting types of gendered choices available to women , as DeHart (2008) describes : [T hey were] pushed away from pathways of legit imacy such as school and work. Their family and social networks often tended more toward perpetration or collusion than positive support. Their role models were often corrupt, and living contexts permeated with poverty, addiction, and violence. Given the r estricted options and negative crime seems more remarkable tha n having chosen such a pathway. (p.1378) Scholars have also performed intra - ways to crimes to further illuminate differences between women engaged in different forms of criminal activity, such as drug and non - drug related crimes ( Cobbina, 2009 ; DeHart, Lynch, Belknap, Dass - Bra ilsford, & 8 Green, 2013 ) . t pathways into crime, these are factors that women enter into prison with (e.g. histories of trauma) and are part of the profile s of women in prison. E xisting research spotlights the gender - specific, multiple and complex social, physical and psychological needs of incarcerated women ( Blitz, Wolff, Pan, & Pogorzelski, 2005 ; Kubiak, 2004 ; Kubiak, Beeble, & Bybee, 2012 ; Kubiak, Boyd, Slayden, & Young, 2005 ; Langan & Pelissier, 2001 ; Messina, Burdon, Hagopian, & Prendergast, 2006 ; Pelissier, Camp, Gaes, Saylor, & Rhodes, 2003 ; Salina, Lesondak, Razzano, & Weilbaecher, 2007 ; Staton - Tindall, Duvall, Leukefeld, & Oser, 2007 ; Staton, Leukefeld, & Webster, 2003 ) . In combination with gender - related social and economic marginalization, women involved with the criminal justice system present with more extensive histories of trauma and victimization, substance abuse, mental and physical health problems, and adversity than men ( Holtfreter & Morash, 2003 ; Maruschak, 2008 ; McDaniels - Wilson & Belknap, 2008 ; Messina & Grella, 2006 ; Messina, Grella, Burdon, & Prendergast, 2007 ) . For example, approximately 75 percent of incarcerated women have mental health problems versus 55 percent of men in state prisons ( James & Glaze, 2006 ) , which is also higher than women in the general community ( Jordan, Schlenger, Fairbank, & Caddell, 1996 ; Kubiak, Siefert, & Boyd, 2004 ; Teplin, Abram, & McClelland, 1996 ) . Also, women involved in the criminal justice system present with more than one mental health concern with studies often finding high er rates of co - morbidity for women than for men ( Jordan, et al., 1996 ; Sanders, McNeill, Rienzi, & DeLouth, 1997 ; Teplin, et al., 1996 ) . In a state prison amongst a sample of men and women with substance use disorders, women were significantly more likely to have major depression, PTSD, and any affective, anxiety, or psychotic disorder with over 45 percent of women with co - occurring disord ers versus only 24 percent of men (Zlotnick, Clarke, Friedmann, Roberts, Sacks, & Melnick, 2008). 9 Women serving life sentences . A growing proportion of incarcerated women have been sentenced with life sentences which for these women, means that they face the potential of living the rest of their natural life in prison. Sentencing practices around the provision of life and the meaning of a life sentence have changed over the past decades and continue to vary by state in terms of degree of frequency and stri sentences ( Nellis, 2013 ) l for a prisoner to be released from serving a life sentence is incarcerated for 29 years ( Mauer, et al., 2004 ) . As noted, life sentences vary in length and parole potential by state in terms of the political climate and crime ideology; for example, in California, only eight people with life sentences were relea sed from 1999 - 2003 (e.g. very old age or advanced terminal il lness). Approximately 5% of incarcerated women or roughly 5400 women are currently serving life sentences in the U.S., and of these, approximately 300 have Life without Parole ( Nellis, 2012 , 2013 ) . The proportion of prisoners with a life sentence who are African American (48.3%) is disproportionately higher than both community population rates and the general prison population rate ( Nellis & King, 2009 ) . In a national sample including life - sentenced women, the average age was 40 years old, and the average number of years of education was 11 years for women serving life sentences. Ove r half of the women (52%) were mothers ( Leigey & Reed, 2010 ) . A majority of women with life sentences (94%) are serving time for violent offenses which is similar to the larger population of men and women serving life sentences in terms of 10 mainly having a violent offense ( Nellis, 2013 ) . Also, a majority of women with life sentences are first time prison inmates, as seen in the limited research with samples of these women: 78% of a national sample of 99 women with life sentences ( Leigey & Reed, 2010 ) and 95% of 214 women with life sentences in one prison ( Dye & Aday, 2013 ) . In Michigan, two - thirds of all prisoners serving life sentences are serving their first prison sentence , and 49.9 % were under age 25 when they committed their offense ( C itzens A llians on P risons and Public Spending , 2013 ) . Women with life sentences are also a sub - population with significantly higher rates of adverse pre - prison life experiences including histories of parental incarceration, parental substance abuse, poverty, and childhood and adulthood abuse than men with lif e sentences ( Leigey & Reed, 2010 ) . For example, women with life sentences have significantly higher rates of pre - incarceration suicide attempts than men with life sentences; 35% of women with life sentences report such attempts in contrast to only 13.5% of men ( Leigey & Reed, 2010 ) . When compared to incarcerated women without life sentences, women with life sentences have significantly higher rates of histories of trauma specifically, sexual abuse throughout the lifetime (59.6 vs. 40.4), sexual abuse by an intimate partner (19.2 vs. 8.4), physical abuse as a child (23.2 vs. 15.3), and physical abuse by an intimate partner (54.5 vs. 41.5) . Notably, Leigey only research with this type of sample and is the only existing work that has actively contributed to a working understanding of the distinct experience s, areas of risk and needs that women with life sentences bring into prison . Within the sub - population of women with life sentences is a group of females who are serving life sentences for convictions of crimes committed when they were a juvenile - commonl Currently, 42 states have the option of imposing life without 11 the possibility of parole for youth and in 27 states mandatory sentencing policies restrict judicial discretion ( Griffin, Torbet, & Szymanski, 1998 ; Tanenhaus & Drizin, 2002 ) . Most states have a m inimum age at which this sentence can be given (for example, ages range from 12 years in Colorado to 16 in California), however in 14 states, there is no minimum age at which juveniles can be tried as adults and sent to prison for natural life ( Rainville & Smith, 2003 ) . Nationally, almost half of all juveniles sentenced to life (47.2%) are African American ( Nellis & King, 2009 ) . Likewise a majority of juvenile lifers (90.3%) are housed in adult prisons ( Nellis, 2012 ) , and in the most r ecent data available , there are approximately 180 female juveni les with life sentences, 27.5% of which are serving life without parole ( Nellis & King, 2009 ) . Juvenile female lifers also have especiall y high rates of adverse childhood events; 84.1% of juvenile female lifers have witnessed violence in their childhood homes, 79.5% have reported histories of physical abuse, and 77.3% have histories of sexual abuse ( Nellis, 2012 ) . The United States is the only country to practice sentencing juveniles with life sentences, and recently, two major Supreme Court cases questioned the appropriateness of such sentencing ( Nellis, 2013 ) : in particular, Graham v. Florida in 201 0 and Miller v. Alabama in 2012 calling into question the role of adolescent brain development on criminality, and the rightfulness of the provision of such an extreme sentence for adolescents . Overall, life sentences are increasing in the United States and at a higher rate for women ( Nellis, 2013 ) . Based on the limited available research, women with life sentences comprise a high risk population that is responding to and coping with both a new and a permanent environment when they enter prison. 12 Overview of i n Prison The prison environment is a physically, socially, and psychologically distinct location with intentional deprivations, and as such, adjustment , adaptation, and responding to this environment are challenging for inmates ( Clemmer, 1958 ; Irwin, 1970 , 1980 ; Johnson, 1976 ; Johnson & Toch, 1982 ; Toch, 1975 ) . Prisons are closed systems that function with their own lso isolated from the larger community for a significant length of time. Within such settings, rules, norms, value s , and incarceration sites, such as jails and prisons. Prisons within a contained space in which all aspects of life are dictated and regulated by authoritarian custodial staff ( Goffman, 1961 ) . Prison is designed in both physical structure and disciplinary/organization for prisoners to have a lack of privacy and restricted freedom ( Twa ddle, 1976 ) stringent regulations for prisoners that are not found in the general community, but that are often inconsistently enforced by custodial staff with varying degr ees of consequences for prisoners ( Haney & Zimbardo, 1998 ) . Historically, p risons designed and intended for women have d iffer ed from men ( Belknap, 200 7; Owen, 1998 ; Pollock, 200 1 ; Rafter, 1985 , 1987 ) , reflecting differences in gender socialization in the outside world ( Owen, et al., 2004 ; Rafter, 1985 ) . R eformatories for girls and women focused on morality, enforcing gender roles of homemaker and mother, and a restoration of femininity, as evident in the mis sions and dynamics of these prisons. For example, 13 at the National Conference on Social Welfare in 1901 - perspective that ( Fairbank, 1901 ) . In accordance to this mission, the only education offered was sewing, cleaning, and cooking ( Abrams & Curran, 2000 ; Rafter, 1985 ) . It has been arg ued ( Zaitzow, 2003 ) ; specifically, restoring femininity has been equated with creating social control over women as described by the following ( Lutze, 2003 ) : Thus, to control women in prison, is not to strip them of their womanhood, but to restore them to it - to ensure that they remain weak, dependent, passive, emotionally insecure, non - competitive (with males), heterosexual and subservient. The means utilized to accomplish this is by stripping w omen of their personal relationships, their support networks, their children, their emotional capacity to cope maturely with their situation, and their ability to control their bodies and their sexuality. Basically, the institution replicates the same sys tematic pattern of behavior used by individual men in free society to dominate individual women through domestic violence . (p. 187) Prisons for women have also used paternalism as a style of management and supervision which ( Freedman, 1984 ; Sargent, 1984 ; Watterson, 1996 ) . Likewise, while historically women in prison have been viewed as more emotionally demanding than men ( Dodge, 1999 ) , this perception persists as ( Pollock, 1984 ; Schram, Koons - Witt, & Morash, 2004 ) . 14 The current state of p risons . Criminologists, sociologists, and other scholars debate the state of the penal system given arrest policy changes, massive prison creation, and shi fts in correctional policies that have taken place sin ce the 1970s, and one thread of theory that grapples with now have a heightened focus on containment, custody, control, surveillance, and risk assessment and management with intensified bureaucratization ( Adler & Longhurst, 2002 ; Cullen, Fisher, & Applegate, 2000 ; Feeley & Simon, 1992 ; Pratt, 2000 ; Simon & Feeley, 2003 ) . The new penology discourse has emerged from the changes of truth - in - sentencing, intens ified focus on risk management and prisoner security classification, and the shift of emphasis on individual responsibility instead of institution - guided rehabilitation ( O'Malley, 1992 , 1996 , 2000 ) . The result has been an overall intensification of the harms of imprisonment ( Liebling & Maruna, 2005 ) . Specificall y, this new penology has been described as the following by Feeley and Simon (1998) : It accepts deviance as normal. It is skeptical that liberal interventionist crime control strategies do or can make a difference. Thus its aim is not to intervene in indiv or changing them. Rather it seeks to regulate groups as part of the strategy of managing danger . (p. 375) However, on the level of prison processes and daily routines, the practice interpretations and application of the new penology philosophy have variations across prisons ( Cheliotis, 2006 ; Sparks, 2000 , 2001 ) . Thus, theorists stress that not all prisons function exactly the same and have not integrated aspects of the new penology in the same ways. 15 As illustrative of the differences between new and old prisons, comparative research has (CIW) and the Valley State Prison (VSP) ( Carbone - Lopéz & Kruttschnitt, 2003 ; Kruttschnitt & Gartner, 2005 ) . CIW is the oldest all - represents the old penology. As a therapeutic institution, its physical design has been described as appearing in similar structure to a high school or hospital ( Carbone - Lopéz & Kruttschnitt, 2003 ; Ward & Kassebaum, 1965 ) . For contrast, VSP is the most recently built prison for women in California and as such, its design is m features such as excessive security (e.g. electrified fences, guard towers, armed guards), strict management, and overcrowding problems (i.e. over 3600 women are housed within the prison when the intended p opulation is 1980 women). practices. Daily life in p rison . While prisons may vary in their adherence to the new penology, prisons are closed institutions as well as nationally prevalent institutions and have some uniformity in terms of their structure and functioning. Punishment, as one of the primary functions of prisons, permeates the daily structure ( Sexton, 2012 ) ; one prisoner describes it as p. 112). As such, prison policies and practices have been described a s reinforcing a loss of freedom and pe rsonhood for prisoners, which has been historically and is 1958; Goffman, 1961; Gillombardo, 1966; Foster, 2012, Sexton, 2012.) For example, instead of referring to women in prison by name, they are referred to by their assigned inmate number which represents a loss of personhood . Prison is also a space defined by lack of privacy , as well 16 as a constant of noise and the threat of violence ( Pogrebin & Dodge, 2001 ; Pollock - Byrne, 1992 ) long people are talking from cell to cell, screaming, fighting, and the doors opened continually Daily routines are highly structured and often leave little room for prisoner choice; from wake - up time to choice of dress to diet, prisoners are instructed when, where, and how t hey will conduct themselves ( J. Irwin & Owen, 2005 ) . While prison is physically isolating from the outside world, incarcerated women are also from close involvement in the lives of others which contributes to a sense of co mmunit 1993, p. 39 40 ) . For example, women are given infractions for not correctly tucking their shirts ( Belknap, 200 7; Severance, 2005 ) . Thus, women experience a process of becoming dependent on the prison for decision making, and for the prison, this leads ocile bo ( Comfort, 2003 ) . This very structured enviro nment has been described by Sexton, 2012, p.50). Likewise, all decision making happens under a sense of surveillance from the prison and (McCorkel, 2003, p. 58). In simultaneous contradiction to the structure of daily life, the prison has also been described as constantly inconsistent in terms of the responses 17 to th e surveillance, especially in regards to the lack of all officers apply ing all rules to all inmates in all the same ways at all times ( Sexton, 2012). Women in prison thus have to be aware of changing or variable dynamics within their very structured and hi gh surveillance environment , and live in a state of persistent stress of being on heightened alert for expecting anything to transpire ( Sexton, 2012). Safety in prison . Existing research has elicited rich descriptions and helpful insights into prison experience for all women in prison. For example, some women describe prison as a safe environment - or even the safest environment that they have been in ( Bradley & Davino, 2002 ; Ferraro & Moe, 2003 ) whereas n umerous women also feel genuine and founded fear in prison and recall accounts of violence especially from prison staff ( Dirks, 2004 ; Struckman Johnson & Struckman Johnson, 2002 ) . Prison may be a site of sexual trauma as inflicted by other inmates and/or staff ( Bell et al., 1999 ; Struckman Johnson & Struckman Johnson, 2002 ; Wolff, Shi, Blitz, & Siegel, 2007 ) , as well as a si te for being re - victimized and/or triggered ( Dirks, 2004 ) as a majority of incarcerated women enter prison with extensive trauma histories. Women in prison have higher rates than men in prison of being sexual victimized by prison staff. Women are in th e victims of approximately 75% of all reported staff - perpetrated sexual victimization in prisons (Beck, 2012). Women report a range of sexual victimization experiences, from intensified surveillance during their showers to repeated sexual assaults by offic ers (Pogrebin & Dodge, 2001). Women also describe the coercion involved with these experiences; officers try to bribe women by offering needed items, threaten to write up women for false infractions if they do not addition to the sexual victimization (Pogrebin & Dodge, 2001). Some women navigate prison by exchanging sex with officers for basic goods and 18 services which makes them more vulnerable to sexual abuse and retaliation by officers if they report or do not co mply ( Greer, 2000 ; Pogrebin & Dodge, 2001 ) . Reporting sexual victimization men must often report Relationships with prison staff are also an element of surviving within prison, as a positive relationship with a correctional officer may help a woman secu re a better work position or protection from being ticketed for minor rule violations ( Trammell, 2009 ) . Inmate culture . been found for women in prison (Owen, 1998) . This culture include s establishing relationships with other inmates ( ranging from friendships to prison families to sexual or intimate relationships ), respecting inmate privacy (e.g. not asking about crime and length of sentence or status of parenting rights) and no t snitching ; not performing according to t prison ( Owen, 1998; Pogrebin & Dodge, 2001 ; McGuire, 2011 ). Women describe primarily using retaliatory violence when one of the codes is broken in prison (McGuire, 2011) , which fits with constantly present, but rather exist s as a constant potential or threat depending on the mix of inmates, interpersonal dynamics, type of prison, timing, and prison staff ( Owen, Wells, Pollock, Muscat, & Torres, 2008 ) . At the level of inmate - to - inmate, common challenges for women in prison are exploitative relationships with other inmates (especially new inmates) for the purpose of securing mon ey, food, and other provisions and verbal conflicts ( Owen, et al., 2008 ; Pogrebin & Dodge, 2001 ) . There is also a described disconnect between inmate culture/relationships and safety from prison officers/guar ds; approaching guards for help or safe concerns is seen by some women as 19 both ineffective in terms of receiving the help needed and unsafe in terms of being seen as a ( Owen, 1998 ; Owen, et al., 2008 ; Pogrebin & Dodge, 2001 ) . The result of these dynamics is that women may lack a feeling of consistent safety, or a heightened sense of self - reliance and withdraw, or an intensified reliance on relationships with other wom en in prison ( Greer, 2002 ) . Mothers in prison . that it is an ongoing, evolving process that may change over time ( Berry & Eigenberg, 2003 ) , and varies for women in prison. Some women become mothers in prison; approximately 9 percent of incarcerated women will be pregnant and give birth while incarcerated ( Knight & Plugge, 2005 ) . Not all mothers choose to maintain contact with their children. Enos (2001) has outlined four women who have an increasing commitment to and motivation for their children while terminatio connection with children before, during or after incarceration. Across studies, w omen who are mothers in prison commonly describe feeling daily stress arcerated, feeling abandoned as the child(ren) are placed with other caregivers, and striving to be a better parent while incarcerated ( Fogel, Martin, Anderson, Murphy, & Dickson, 1992 ; Foster, 2012 ; Houck & Loper, 2002 ; Pogrebin & Dodge, 2001 ) . A primary source of strength, purpose, and meaning while incarcerated , however, is wome 20 while in prison, which is dependent on having quality and frequent contact with their children ( Enos, 2001 ; Ferraro & Moe, 2003 ; Tuerk & Loper, 2006 ) . W omen have multiple challenges in maintaining contact with their children, often experience decreases in visits from their children during their prison stays , and may experience a termination of parental rights during incarceration that slows or eve ns stops visitation ( Houck & Loper, 2002 ; Tuerk & Loper, 2006 ) . Also, f for caregiver to keep children away from the prison environment and other inmates, lack of child - friendly visiting space and inconvenient vis iting hours contribute to a lack of contact between incarcerated mothers and their children ( Acevedo & Bakken, 2001 ; Baunach, 1985 ; Barbara Bloom & Stein hart, 1993 ) . Specifically, due to the lower number of women incarcerated than men, there are fewer prisons for women than men, which creates a geographic barrier to visitation, and the combination of geographical isolation and restrictive security classifications pre vents women from communicating with their children ( Pollock, 200 1 ; Themeli, 2006 ) . As part of the punishment aspect of prison, many prison policies and practices use child and family ehavioral compliance. For example, prisoners may lose ( Dressel, Porterfield, & Barnhill, 1998 ) and conditioning women to prison includes initial denial of visitation ( Kazura, 2000 ) . l Health in Prisons Women enter prison with high rates of mental health disorders and distress ( Fogel, 1993 ; Gunter et al., 2008 ; Loper, 2002 ; Messina, Burdon, & Prendergast, 2003 ) . Women have also reported higher levels of mental health distress while incarcerated in prison than previous to incarceration ( Lindquist & Lindquist, 1997 ) . Mental health distress and poor psychological health are considered common reactions to the prison environment and the drastic separation 21 from social supports ( Negy, Woods, & Carlson, 1997 ; Sheridan, 19 96 ) . Between 50 - 90 percent of incarcerated women report clinically significant depressive symptoms ( Keaveny, 1999 ; Martin, Cotten, Browne, Kurz, & Robertson, 1995 ; McClellan, Farabee, & Crouc h, 1997 ; Staton, et al., 2003 ) . For example, the Bureau of Justice utilized criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM - IV) to screen the prevalen ce of mental health problems for inmates across the U.S.; 73% of women in state prisons had a mental health problem which is six times higher than the rate of 12% for women in the community (James & Glaze, 2006). Some studies have found that initial psycho logical distress upon entry into prison significantly decreases after the first few weeks of living in prison ( Bonta & Gendre au, 1990 ; Islam - Zwart, Vik, & Rawlins, 2007 ; Paulus & Dzindolet, 1993 ) , and this initial distress to prison life . However, p ersistent psychological distress within the prison is viewed as abnormal and indicative of a potentially long - term, chronic mental health concern ( Reitzel & Harju, 2000 ) . Chronic mental health distress and poor psychological health are risk factor s for women engaging in destructive behaviors while in prison ( Boothby & Durham, 1999 ; Islam - Zwart, et al., 2007 ) . S uicide is the second leading cause of death for prisoners ( Mumola, 2005 ) , and women in prison have suicide rates that are double the rates of women in the general community and ( Dye, 2011 ) . Therefore, persistent and concerning mental health distress i s a major risk for women in prison. Mental Health Treatment for Women in Prison Treatment for women in prison is rare and often insufficient ( Sacks, 2004 ) . Based on a national survey, only 24 - 34 percent of prisoners with a mental health concern have reported receiving mental health treatment while in prison (James & Glaze, 2006). While mental health 22 care is considered a cons titutional right for prisoners, sta te prison systems vary in their funding of such services, and range from designating 5 to 43 percent of their budget on mental heal th care (Beck & Maruschak, 2000 ). Nationally, about 75 percent of correctional facilities have substance abuse counseling, ho wever, this includes a range of 8 percent to 100 percent state - wide, depending on the state (Stephan, 2008) . Likewise, with mental health services, nationally, 58 percent have men tal health counseling services while some facilities have no counseling optio ns (Stephan, 2008). Mental health treatment in prison is often logistically more accessible to women than in the community¸ yet the quality and appropriateness of this care is understudied (Blitz, Wolff, & Papp, 2006). A major concern is that overcrowding in prisons is associated with inadequate staff and fewer programs, services, and opportunities for women to gain support, either informally (e.g. from peers) or formally (e.g. with mental health profession al s) ( Borrill, Snow, Medlicott, Teers, & Paton, 2005 ) . While limited services exist for incarcerated women, the number of evidence - based interventions has increased for women in correctional settings in the past twenty years , offering more options for treatment (Dowden & Andrews, 1999; Tripodi, et al., 2011) . However, the area of intervention development and testing still remains as a vital area for expansi on in research and practice . A recent systematic review of interventions for adult women in correctional settings found that the most common goal of interven tions for women in prison is reducing recidivism rather than primarily psychological health ( Tripodi, et al., 2011 ) . A specific concern is the general lack of research and investment in suicide prevention programs for wome n in prison ( Dye, 2011 ) , and the over - reliance on male - based and overwhelming male - tested treatments ( Landenberger & Lipsey, 2005 ; Peugh & Belenko, 1999 ) . 23 Gender - responsive and trauma informed services have been strongly advocated for incarcerated women (Bloom, Owen, & Covington, 2003 ; Fournier, Hughes, Hurford, & Sainio, 2011; Laux et. al, 2008 ) g iven that motivations for, and victims of, crimes perpetrated by women frequently differ from male perpetrated cr imes ( Pollock & Davis, 2005; Kruttschnitt, 2002; Mann, 1990; Mann, 1996 ) and gender differences when comparing incarcerated men and women (e.g. Messina, Burdon, Hagopian, & Prendergrast, 2006; Raj et al., 2008; Fazel, Bains, & Doll, 2006; Kubiak, Beeble & By bee, 2010; James & Glaze, 2006) . Gender - responsive interventions focus on empowerment, improving problem solving and self - image, and self - efficacy, based on understanding the pathways to crime that are common for women and based on their high rates of vi ctimization, mental health distress and substance use disorders (Chesney - Lind & Pasko, 20 13 ; Bloom, Owen, & Covington, 2003; Green, Miranda, Daroowalla, & Siddique, 2005). Women in Prison Serving Life Sentences The actual prison experiences of women with life sentences are a neglected area of research . A consistent thread in the existing research prison environment for the long - term . For example, in a qualitative study, women with life and long term sentences reported depression, hopelessness, and anger as they described adjusting to often described by terminally - ill patients ( Jose - Kampfner, 1990 ) a life sentence is strongly connected to death, in term s of imprisonment until death. Likewise, i n recent research, a survey was given to women with life sentences and found that suicide ideation was a common and prevalent factor for women ( Dye & Aday, 2013 ) . In particular, while over 80% of the women reported histories of abuse and trau ma throughout their lifetimes, their ability to cope in prison, the presence or absence of depression, and level of support from outside 24 relationships were significantly associated factors with current suicide ideation (Dye & Aday, 2013) . More research is needed in understanding exactly what factors influence changes in with life sentences have been included in research examining the experiences of women aging in pri son, and have been shown to report significantly higher rates of mental and physical health concerns at both admission to prison and currently ( Leigey & Hodge, 2012 ) . It has been suggested that t he more time a woman serves, the more difficulty she may have psychologically and the more mental distress she may have ( Vuolo & Kruttschnitt, 2008 ) . W omen who have served longer sentences (over ten years) have reported more problems with the prison environment, such as boredom an d a dearth of educational, work, and social opportunities, with similar anxiety levels as women newly admitted to prison ( MacKenzie, Robinson, & Campbell, 1989 ) . Based on personal accounts, w omen who enter prison with a life sentence describe feeling unable to process their reality and emotionally numb ( George, 2010 ) . Likewise, given the effects of time, women with life sentences may have to face ongoing and prolonged separation from their children and cycles of hope an d disappointment about release. Therefore, psychological health may change over time, or may be difficult to improve over time for women with life sentences, and is infl uenced by contextual factors. Strikingly, women with life sentences are often excluded from treatment programming within prisons. Over sixty percent of juvenile lifers report being denied entrance into prison - based programming due to state or prison polici es, primarily because such programming is reserved for those leaving the prison ( Nellis, 2012 ) . Likewise, the vast majority of evidence - based programming for incarcerated women is intended for women preparing to re - enter the community/exit the prison and to re duce recidivism ( Tripodi, et al., 2011 ) . Women with life 25 sentences have not been considered as a target population for inte rvention, and they are rarely, if ever, included in samples of incarcerated women for new intervention development and testing. Theoretical Approach in Prison Two explanatory theories exist specifically about psychological health in prison : deprivation theory and importation theory. Deprivation theory (or has the main premise that the prison enviro ( Gillombardo, 1966 ) , deprivation theory was established with the idea that the prison deprives individuals of material goods, socia l acceptance, personal freedom, and heterosexual relationships, and these deprivations of the prison environment cause inmates to respond with depression, anxiety, anger, mental health distress, violence, aggression and oppositional attitudes ( Parisi, 1982 ; Sykes, 1958 ; Sykes & Messinger, 1960 ) . As a co mponent of predictability is linked to behavioral and emotional distress ( Glass & Singer, 1972 ; Moos, 1976 ) . psychological response . It is suggested that women in prison experience more intensely the pains of imprisonment given their higher rates of psychological distress during incarceration ( Collica, 2010 ; Fogel, 1993 ; Paulus & Dzindolet, 1993 ) . Deprivation theory predicts that the greater the level of deprivation with in a prison, the higher the rate of poor psychological health for prisoners . Because prisons have varying degrees 26 of deprivation, psychological responses are not the same across prisons ( Haycock, 1993 ) . Therefore, maximum security prisons are expected to have greater rates of poor prisoner psychological health (e.g. higher rates of mental health disorders and suicides) than medium and minimum security prisons ( Daniel & Fleming, 2006 ; Way, Miraglia, Sawyer, Beer, & Eddy, 2005 ) . However, higher levels of deprivation are also found as a result of other prison factors, and these deprivation conditions influence poor psychological health for prisone rs. For example, minimum - level security prisons with high levels of overcrowding (as measured by prison census, intended capacity and inmate - to - staff ratios) have similarly high rates of prisoner suicide as maximum security prisons ( Huey & McNulty, 2005 ) . Theoretically and based on limited - run prisons return to the free world with little or no permanent, clinically - (Haney, 2003, p. 6). Lastly, inmates who perceive the incarceration environment as not putting them in a state of deprivation have shown better rates of positive psych ological adjustment ( Gibbs, 1991 ; Wright, 1991 ) . In terms of the prison environment, many factors have been found to be associated with including: the type of correctional facility as either having a rehabilitative or custody approach ( C. Kruttschnitt & Vuolo, 2007 ; Vuolo & Kruttschnitt, 2008 ) ; the level of institutional overcrowding ( Cox, Paulus, & McCain, 1984 ; Snow, Paton , Oram, & Teers, 2002 ) ; prison, especially in regards to protection from sexual victimization ( Goodstein, MacKenzie, & Shotland, 1984 ; Slotboom, Kruttschnitt, Bijleveld, & Menting, 2011 ) ; separation from children and other outside social supports ( Fogel, et al., 1992 ; Poehlmann, 2005a ) ; and prison polic ies around visitation and social support ( Pollock, 200 1 ; Themeli, 2006 ) . A branch of deprivation 27 theory trauma deprivation (or trauma exacerbation) theory - pays particular attention to prison procedures, norms, policies and practices that perpetuate traumatic events for women in prison, such as dehumanizing and unnecessarily invasive body searches, deliberate violations of poor psyc hological health ( Moloney, van den Bergh, & Moller, 2009 ) . A main critique of deprivation theory is that the prison environment does not explain variations in prisoner psychological health for example, not all prisoners develop dep ression while incarcerated in the same prison ( Clements, 1979 ; Goodstein & Wright, 1989 ) . In particular, f eminist critiques have stressed that women in prison cannot be treated as a monolithic population with a homogenous response to prison ( McQuaide & Ehrenreich, 1998 ) . For example, some w omen enter prison and describe it as the safest place they have ever lived , whereas other women enter the same prison and perceive the structure, policies, and prison norms as threatening and unsafe; caution has been suggested in that prisons may not neces sarily be safe, but rather the perception of safety in prison may be connected to the high levels of violence women experienced in the communities and homes in which they lived before prison ( Bradley & Davino, 2002 ; Ferraro & Moe, 2003 ) . Thus, such studies grapple with disentangling the role of the prison deprivations and individual - responses to prison. Likewise, deprivation - based studies require some level of comparison (e.g. across prison security level) that may not be possible - for example, if there is only one state readily availabl e . In general, deprivation theory provides a contextual understanding of the role of the prison environment, yet 28 In contrast, i mportation theory has the premise th and past experiences determin e their psychological health in prison. In other terms, a prisoner psychologically respond to prison ( Innes, 1997 ; Irwin & Cressey, 1962 ) as these factors shape their perceptions and responses to stress from the environment ( Silverman & Vega, 1990 ) . Moreover, this perspective is driven by the underlying idea that prisoners are consistently deviant regardless of location that prisoners respond to prison similarly to how they acted in the community and factors that led to response in pr ison ( Irwin & Cressey, 1962 ) . In other words, a prisoner is perceived as having p.2). Therefore, this field of research has utilized demographics as well as factors significantly connected to criminal behaviors (e.g. substance use h istory) to predict and explain psycho logical health in prison ( DeLisi, Berg, & Hochstetler, 2004 ; Ellis, Grasmick, & Gilman, 1974 ; Harer & Steffensmeier, 1996 ) . For example, having a history of childhood abuse has been linked to both criminal behavi ors ( Heney & Kristiansen, 1998 ) and poor psychological health in prison ( Islam - Zwart & Vik, 2004 ) . Similarly, the risk factors for suicide are considered the same for outside or inside prison as they are individual - level demographic, social, psychological, and behavioral factors ( Kovasznay, Miraglia, Beer, & Way, 2004 ; Mumola, 2005 ; Way, et al., 2005 ) . Researcher s using this theoretical perspective explore the following variables: (1) age ( Craddock, 1996 ; Flanagan, 1983 ; MacKenzie, 1987 ) ; (2) race ( Flanagan, 1983 ; Poole & Regoli, 1980 ) ; (3) previous criminal justice involvement ( Loucks & Zamble, 2001 ) ; (4) personal and family histories, especially in regards to trauma ( Clements - Nolle, Wolden, & Bargmann - Losche, 29 2009 ; Gendreau, Goggin, & Law, 1997 ) ; (5) substance abuse ( Steiner & Wooldredge, 2009 ) and (6) prior ment al health disorders ( Faust & Magaletta, 2010 ) . These importation factors are often s to be assessed when women enter prison, and as evidence or rationale for criminal justice practices and policies ( Moloney, et al., 2009 ) . For example, women who are serving first - time sentences in prisons report qualitatively having a harder time psyc hologically responding to prison ( Pogrebin & Dodge, 2001 ) . Also, several forms of theory fall into the category of importation, including cumulative adversity and trauma theory ( Armour, 2012 ) . Critiques of importation theory have described t hese perspective as emphasizing prisoner pathology ( Hayes, 1995 , 1999 ; Liebling, 1995 ) which distracts from problematic environmental , function, policy, and practice factors within prisons ( Lester & Danto, 1993 ) . Likewise, importation theory has not proved as a consistently successful theoretical perspe ctive in the prevention of poor psychological outcomes, such as prisoner suicide ( Liebling, 1995 , 1999 ) . Importation factors are often described as prisoner risk factors, are disproportionately higher in populations of women in prison, and thus, women who enter prison are labe popula ( Adams, 1992 ) . The conflation of n eeds into risk factors (often framed as criminogenic risk factors) has shifted the responsibility from system - solutions to individual - level factors for women offenders to address themselves ( Hannah - Moffat, 1999 ; O'Malley, 1992 ) . For example, to prevent suicides and self - harm, prison policies promote punitive efforts, such as segregation, to punish incarcerated women who self - harm instead of improving prison conditions and expanding treatment opport unities ( Thomas, Leaf, Kazmierczak, & Stone, 2006 ) . Researchers warn that this focus on individual factors may have negative consequences for 30 women, including prolonging their stays in prison ( Kruttschnitt & Gartner, 2003 ) , and distract from harmful prison conditions . Empirical support exists for integrating both deprivation and importation theoretical perspectives. Researchers who have ut ilized variables reflective of both perspectives into in prison have found significance for both types of variables and thus, stressed the need for integrated models ( Cao, Zhao, & Van Dine, 1997 ; Dye, 2010 ; Gover, Pérez, & Jennings, 2008 ; Hochstetler & DeLisi, 2005 ; Paterline & Petersen, 1999 ) . Similarly, Vuolo and Krutttschnitt (2008) examined regression models first with importation factors on psychological health, which explained 6 percent of the variance, and second just with deprivation factor s, which explained 20 percent of the variance. When deprivation and importation factors were added into the model, the combination of the variables explained 32 percent of the variance ( Vuolo & Kruttschnitt, 2008 ) . Thus, support exists for with the utilization of both deprivation and importation theoretical perspectives. Organization of the Dissertation This multiple manuscript dissertation is intended to expand the research focused on psychological health of incarcerated women with life senten ces by increasing the knowledge about their pre - prison life experiences, the outcomes of intervention testing for this population, and advancing theory about ways that women with life sentences psychologically respond in prison . All three manuscripts are g uided by an integration of deprivation and importation 31 Chapter 2, Manuscript 1 The first manuscript is guided mainly by importation theory in a process of exploring pre - prison experiences that have been shown across a variety of studies to be significantly associated In particular, while these factors have been studied quantitatively and as separate factors in other studies , this study qualitatively examine s these factors across the pre - prison life span for each woman in order to examine themes and patterns across these factors . Exploring pre - prison life experiences of women with life sentences assists in better understandin g what risk/need factors these women present with as they enter prison and the possible intervention domains for this population. Sp ecifically, this manuscript answer s the following research question: What are pre - prison life experiences for women with lif e sentences? How do these events present in their pre - prison life courses? What intervention needs do women with life sentences have upon entry to prison? Chapter 3, Manuscript 2 The second manuscript examine s the effects of a new intervention provided to women with life sentences and in particular look at mental health from pre - intervention to post - intervention . This manuscript incorporate s both importation and deprivation based theories in this examination of the new intervention entitled Beyond Violence. mental health is examined through pre, post, and follow - up surveys with quantitative measures of specific mental health disorder symptoms. This manuscript answer s the following question s : Do mental health symptoms of anxie ty, depression, PTSD, and serious mental illness improve for incarcerated women with life sentences after participating in Beyond Violence? Do forms of anger and an ger expression change after participating in Beyond Violence? Are changes in 32 m ental health s ymptoms and anger - related outcomes for women based on the length of time served? Chapter 4, Manuscript 3 The third manuscript incorporate s deprivation and importation perspectives to qualitatively explore how women with life sentences cope in prison , especially in terms of coping with psychological distress and preventing negative psychological outcomes (e.g. depression and suicide). This manuscript answer s the following research question s : How do women with life sentences cope in prison? What importat ion and deprivation factors influence how they cope? Chapter 5, Discussion and Conclusion This final chapter summarizes the key findings within and across the manuscripts with implications for social work in the areas of theory, practice, policy, and research. 33 REFERENCES 34 REFERENCES Abrams, L. S., & Curran, L. (2000). Wayward girls and virtuous women: Social workers and female juvenile delinquency in the progressive era. Affilia, 15 (1), 49 - 64. Acevedo, & Bakken, T. (2001). The effects of visitation on women in prison. 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London: Lynne Reinner Publishers. 51 CHAPTER TWO : AN EXPLORATION OF THE PRE - PRISON LIFE EXPERIENCES OF INCARCERATED WOMEN WITH LIFE SENTENCES Abstract As the number of women incarcerated with a life sentence increases, an understanding of their pre - prison life experiences is needed in order to inform interventions for this population of wome n. This need is based on the premise of importation theory in regards to understanding women with life sentences and the common practice of denying them treatme nt opportunities. This study examined the pre - prison lives of a sample of incarcerated women with life sentences in order to look at patterns and themes across common importation factors for women in prison. The lifeline format was utilized in order to gai n an understanding of their pre - prison life course. - prison lives. The se experiences appear pivotal and connected to four sub - substance as a dynamic of abu sive relationships, (2) risking behaviors as ways of coping with and responding to trauma and adversity; (3) a lack of interventions to address their mental health and substance use; and (4) an end point of prison which women described as criminal behavior s in the context of their victimization and substance use. Implications for social work theory and prison. Lastly, a prevention perspective is presented to co nsider intervention for women outside of prison. 52 Introduction As the number of women in prison has increased over the past decades ( Carson & Sabol, 2012 ) in prison has been of interest to professionals in the areas of corrections, mental health, and elf - harm and/or harm of others, coordinating treatment for their mental and physical health while incarcerated, creating and modifying policies around psychological health treatment, and promoting rehabilitation ( Warren, Hurt, Loper, & Chauhan, 2004 ) . One major guiding theoretical perspective about ortation theory, or that a prison ( Innes, 1997 ; Irwin & Cressey, 1962 ) as t responses to stress from the environment ( Silverman & Vega, 1990 ) . Researchers using this theoretical perspective have explored demographic factors such as age ( Craddock, 1996 ; Flanagan, 1983 ; MacKenzie, 1987 ) , behavioral factors such as previous criminal justice involvement ( Loucks & Zamble, 2001 ) , substance use (Steiner & Wooldredge, 2009), and personal and familial adversity histories ( Clements - Nolle, et al., 2009 ; Gendreau, et al., 1997 ) . identifying the multiple risk factors to be assessed when women enter prison. These factors also serve as evidence or rationale for criminal justice practices and policies, including treatment and service provision decisions ( Moloney, et al., 2009 ) needs in prison, especially for women with life sentences who are a permanent and under - se rved population within prisons. 53 Background Currently, women comprise approximately 7 percent of all inmates held in state and federal prisons ( Carson & Sabol, 2012 ) . Both the number and rate of women incarcerated have steadily increased since the 1980s. Specifically, from 1977 to 2004, the number of women in prison expanded by 757 percent ( Frost, et al., 2006 ) . This exponential increase has been linked to macro - level factors, including the war on drugs with excessive arrests for drug - related offenses ( Bloom, et al., 1994 ; Bush - Baskette, 2004 ) , changes in assault - related arrest policies, especially in situations of domestic violence (Pollock & Davis, 2005; Schwartz, Steffensmeier, & Feldmeyer, 2009), stricter sentencing policies ( Bloom, et al., 2004 ; Chesney Lind, 20 02 ; Mauer, et al., 1999 ) , and massive for - profit prison building ( Davis & Shaylor, 2001 ; Reynolds, 2008 ; Richie, 2012 ) . Accordingly, the number of women incarcerated with life sentences also increased by 14.2% from 2008 - 2012, and currently, five percent of incarcerated women are serving life sentences in the United States (Nellis, 2013). Sentencing practices aro und the legal meaning of a life sentence have also changed over the past decades and continue to vary by state in terms of increasingly meant either until end of natural life, or the equivalency, in which inmates are released due to very old age or advanced terminal illness (Nellis, 2013). On average, a person serving a life sentence stays incarcerated for 29 years ( Mauer, et al., 2004 ) . One issue of specific concern with the rising number and rate of women incarcerated is that women enter prison with high rates of mental health disorders and distress ( Fogel, 1993 ; Gunter, et al., 200 8 ; Loper, 2002 ; Messina, et al., 2003 ) . Women have a lso reported a decline in mental health while incarcerated ( Lindquist & Lindquist, 1997 ) . A majority of incarcerated women report clinically significant depressive symptoms while in prison, with studies finding a range 54 from 50 to 90 percent of women reporting such symptoms ( Keaveny, 1999 ; Martin, et al., 1995 ; McClellan, et al., 1997 ; Staton, et al., 2003 ) . For ex ample, the Bureau of Justice utilized criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM - IV) to screen the prevalence of mental health problems for inmates across the U.S.; 73% of women in state prisons had a menta l health problem which is six times higher than the rate of 12% for women in the community (James & Glaze, 2006). While a majority of women experience psychological distress upon entry to prison, some women have chronic and persistent psychological distres s while incarcerated ( Bonta & Gendreau, 1990 ; Islam - Zwart, et al., 2007 ; Paulus & Dzindolet, 1993 ) , which is especially concerning as it is a major risk factor for women engaging in self - harming and destructive behaviors while in prison ( Boothby & Durham, 1999 ; Islam - Zwart, et al., 2007 ) . Indeed, suicide is the second leading cause of death for prisoners ( Mumola, 2005 ) , and women in p rison have suicide rates that are double the rates of women in the general community ( Dye, 2011 ) . experiences influence their psychological health in prison. Therefore, this field of research has utilized demographic factors (e.g. age, race) as well as factors significantly connected to criminal behaviors (e.g. substance use history) to predict and explain psychological health in prison ( DeLisi, et al. , 2004 ; Ellis, et al., 1974 ; Harer & Steffensmeier, 1996 ) . For example, having a history of childhood abuse has been linked to both criminal behaviors ( Heney & Kristiansen, 1998 ) and poor psychological health in prison ( Islam - Zwart & Vik, 2004 ) . Researchers using this theoretical perspective have found significant associations (1) demographic 55 background factors such as age ( Craddock, 1996 ; Flanagan, 1983 ; MacKenzie, 1987 ) and race ( Flanagan, 1983 ; Poole & Regoli, 1980 ) ; (2) previous criminal justice involvement ( Loucks & Zamble, 2001 ) ; (3) personal and family histories, especially in regards to adverse and traumatic experiences ( Clements - Nolle, et al., 2009 ; Gendreau, et al., 1997 ) ; (4) a history of substance use, abuse, and treatment ( Steiner & Wooldredge, 2009 ) and (5) a history of mental health disorders a nd treatment prior to prison ( Faust & Magaletta, 2010 ) . These factors are often examined as adverse pre - prison life experiences and framed as risk factors t hat can also be targets for invention or treatment while in prison. The following is a description of the existing research regarding these factors. Previous criminal justice i nvolvement . Factors such as prior arrests, previous incarceration, and family history of incarceration are commonly examined within an importation framework. Women with a first - time offense have shown higher rates of depression in prison than women with more extensive criminal justice involvement histories ( Boothby & Durham, 1999 ; McClellan, et al., 1997 ) . Also, women experiencing second - generation incarceration report poorer psychological adjustment than prisoners not experiencing second generation incarceration ( Novero, Loper, & Warren, 2011 ) . Personal and familial hi stories . Early childhood experiences of abuse, foster care, parental violence, and other difficulties are connected to clinically significant depressive symptoms for incarcerated women ( Poehlmann, 2005b ) . Child abuse histories in particular are associated with suicide attempts by women in prison ( Clements - Nolle, et al., 2009 ) . Incarcerated women report extensive histories of abuse and violence in both their childhoods and adulthoods ( Jordan, et al., 1996 ; Siegel & Williams, 2003 ; Teplin, et al., 199 6 ) at rates that are significantly higher than rates for incarcerated men ( Messina & Grella, 2006 ; Raj et al., 2008 ) and women in the 56 community ( Gorey & Leslie, 1997 ; McDaniels - Wilson & Belknap, 2008 ; Messina & Grella, 2006 ; Raj, et al., 2008 ; Tusher & Cook, 2010 ) . For example, one study of women in prison found 40 percent of women had experienced childhood sexual abuse, 55 percent childhood physical abuse, 53 percent adulthood rape, 63 percent adulthood physical abuse, and 41 percent other traumatic even ts ( Zlotnick, 1997 ) . Notably, most incarcerated women have experienced multiple adverse events otherwise known as cumulat ive adversity (Messina & Grella, 2006). In a study of over 400 women in prison, almost all women (99%) reported experiencing at least one traumatic event, and on average they reported eight traumatic events in their lifetime ( Cook, Smith, Tusher, & Raiford, 2005 ) . Such histories of trauma and adversity are connected to post - traumatic stress disorder (PTSD) which is also strongly associated with depression ( Dutton, 2009 ; Mechanic, Weaver, & Resick, 2008 ; Schneider, Baumrind, & Kimerling, 20 07 ; Temple, Weston, Rodriguez, & Marshall, 2007 ) . One study of women in prison found that 48 percent were currentl y experiencing PTSD and the odds of experiencing depression in prison were significantly higher for women with PTSD than those without PTSD (Zlotnick, 1997). Substance u s e. Substance use disorders are highly prevalent among women involved in the criminal justice system, with approximately 75 percent of incarcerated women meeting criteria for dependency ( Kubiak, et al., 2005 ) and 82 percent of women meeting criteria for a substance use disorder ( Gunter, et al., 2008 ) . Both alcohol and drug abuse and dependence rates are higher for women in prison than male prisoners and the general population ( Fazel, Bains, & Doll, 2006 ) . Substance use is connected to the time immediately before incarceration, yet is often a lifetime issue for women. Staton, Leukefeld, and Webster (2003) found that 85 percent of women in prison report multi ple substance use in the thirty days prior to incarceration and 90 57 percent report a lifetime of drug dependence/abuse problems. Furthermore, substance abuse often co - occurs with mental health disorders for incarcerated women ( Weizmann - Henelius, Putkonen, Naukkarinen, & Eronen, 2009 ) and is linked adversity (Grella, Stein, & Greenwell, 2005; Messina & Grella, 2006). Lastly, a history of substance abuse is a risk factor for suicide for women in prison ( Loucks, 1997 ) . Mental health h istory . Women enter prison with high rates of mental health disorders both currently and as a lifetime issue (Langan & Pelissier, 2001). For example, 91 percent of women entering an Iowa prison met criteria for a current mental health disorder, and 93 percent for a lifetime mental health disorder based on assessment through the MINI - Plus ( Gunter, et al., 2008 ) . Mental health disorders fou nd in women involved in the criminal justice system are linked to previous trauma and violence exposure ( Greenfield & Marks, 2010 ; Jordan, et al., 1996 ; Kubiak, Beeble, & Bybee, 2010 ; Mechanic, et al., 2008 ; Teplin, et al., 1996 ; Zlotnick et al., 2008 ) . Also, women with histories of mental he alth treatment, suicide concerns, and substance abuse prior to imprisonment utilize mental health services in prison at a higher rate than women without such histories ( Faust & Magaletta, 2010 ) mental health concerns continue in prison. Pre - Prison Factors and Prison - Based Treatment Pre - prison life factors not only influence mental health during incarceration, but have also been found to be connected to pathways to crime for women, specifically historical factors of family adversity, substance abuse, trauma, and str ained parenting ( Belknap, 200 7 ; Owen, 1998; Pollock, 200 1 ; Richie, 1 996 ). As such, they have been considered in multi ple forms of prison - based risk assessments, especially recent gender - responsive developments, in deter mining risk levels of women who are incarcerated. These assessments are part of a process of 58 determining the provision of services for women for the purpo se of rehabilitation, preventing - Moffat & Shaw, 2003; Van Voorhis et al, 2010; Wright et al, 2007). Therefore, the consideration of pre - prison factors is importan linked to creating and implementing available services and allocated treatment plans by the prison. Pre - Prison Factors for Women Serving Life Sentences : A Distinct Population? Women with life sentences are a growing sub - population of women in prisons ( Nellis, 2013 ) . Many concerns have developed in response to this rise in the number of those incarcerated with life sentences due to human right concern s, institutional costs, and questionable judicial processes (Mauer, King, & Young, 2004). One major concern is the lack of appropriate services to meet the needs of women with life sentences, especially as they age (Aday & Krabill, 2011). Overall, there is a dearth of empirical information about this population, and, as such, Only one study has examined and compared a limited number of adverse pre - prison lif e experiences for incarcerated women with life sentences to men with such sentences, as well as comparing them with other incarcerated women without life sentences ( Leigey & Reed, 2010 ) . Using a national sample with survey data, Leigey and Reid (20 10) found that women with life sentences presented with significantly higher rates of adverse pre - prison life experiences including histories of parental incarceration, parental substance abuse, poverty, and childhood and adulthood abuse than men with life sentences. When compared to incarcerated women without life sentences, women with life sentences had significantly higher rates of histories of poverty and sexual abuse (Leigey & Reed, 2010). Likewise, a recent study surveyed only women 59 with life sentence s and found high rates of pre - prison suicide - related factors; 46% of women reported suicide ideation and 44% reported suicide attempts (Dye & Aday, 2013). Also, a majority of women with life sentences are first time inmates; 78% of a national sample of 99 women with life sentences (Leigey & Reed, 2010) and 95% of 214 women with life sentences in one prison (Dye & Aday, 2013) were first - time prison inmates. Thus, women with life sentences comprise of a high risk population that is a coping with both a new a nd a permanent environment when they enter prison. Notably, only these two published studies have actively contributed to a profile, or a working understanding, of the distinct experiences, areas of risk and needs of this population based on pre - prison lif e experiences. Strikingly, women with life sentences are often excluded from treatment programming within prisons. Over sixty percent of lifers who entered prison as juveniles report being denied entrance into prison - based programming due to state or pris on policies, primarily because such treatment programming is reserved for women with shorter sentences or those being released from prison ( Nellis, 2012 ) . Likewise, the vast majority of evidence - based programming for incarcerated women is intended for women preparing to re - enter the community/exit the prison and to reduce recidivism ( Tripodi, et al., 2011 ) . Women with life sentences have not even been considered as a target population for intervention, as they are rarely, if ever, included in samples of incarcerated women for new intervention development and testing. Thus, they are both an understudied and underserved subpopulation of incarcerated women. Current Study Existing importation - focused research has identified several risk factors for poor mental health during incarce ration for women in general. Moreover, a growing body of research suggests that these risk factors occur at higher rates for women with life sentences, which is 60 concerning given the elevated risk of multiple negative outcomes, such as self - harm, suicide, a nd persistent depression. While risk factors determine treatment plans for women in prison, women with life sentences are often denied such treatment. Therefore, research is needed to inform both intervention development and treatment policy for this speci fic permanent population of women in prison. - prison life factors as distinct risk factors quantitatively (e.g. Messina & Grella, 2007). While this approach is insightful and helpful, it does not ma - prison lives which can provide greater insight into the details of life course experiences and the dynamics between factors that rovide useful insights for treatment provision for women convicted of serious offenses that result in life sentences. Thus, a goal is to not only gain knowledge of what risk factors women have, but also, how those factors were experienced in their pre - pris on lives. For example, Boyd, Hill, Holmes, and Purnell (1998) utilized a lifeline approach to understanding the context of African American wome , especially in relation to traumatic experiences, in order to better understand the dyn amics, patterns, and themes across risk factors. As this study was one of the first to illustrate the links between drug use and traumatic events in order to improve intervention targets, similar methods for women incarcerated for life sentences could prov ide insight into intervention development for this underserved population of women. This study explores the pre - prison histories of incarcerated women with life sentences through the format of constructing and analyzing pre - prison lifelines. Specifically, the following factors were included as relevant for each woman in all lifelines: (1) previous criminal justice involvement; (2) personal and familial experiences; (3) onset of substance use; (4) substance use 61 treatment experiences; (5) mental health treatm ent experiences. These lifelines were examined in - prison lives, and in particular, the dynamics of the relationships between factors. This study seeks to add to the existing knowledge about this population of w omen by providing a rich description of their pre - prison lives. The purpose is to illuminate shared themes in the pre - prison lives of incarcerated women with life sentences and inform intervention efforts for this population upon entry to prison in order t o prevent negative mental health outcomes. Methods Using clinical assessment data about pre - prison life experiences, lifelines (a specific form of timeline) of pre - prison life experiences were created for each woman in a sample of 26 incarcerated women wit h life sentences in order to examine these histories for themes and Sample This study utilized a purposeful sample of 26 incarcerated women serving life sentences n are part of a larger study looking at intervention development for women with violent offenses . Likewise, all women had been convicted of murder; however, 15 of the women serving life sentences were convicted of first degree murder (i.e. premeditated or intentional murder) and 11 were convicted of second degree murder (i.e. unplanned, unintentional murder or murder due to reckless or neglectful behavior). In this state, felony murder is considered similar to first degree murder in that the person intended to do great bodily harm, and open murder is a term used for a combination of first and second degree murder. T he sample included women ranging in age and length of time served in order to include a ars old, with a 62 range from 22 to 60 years of age, and women had served an average of 14 years in prison, with a range from 1 to 38 years. Half of the women identified their race as White or Caucasian and half identified as Black or African American. Also, 11 of the women were mothers to minor - age children, as well as 11 women were mothers of children who were 18 or older. Procedure The dat a were collected through a structured assessment tool administered to this sample of women during clinical interviews. All of the 26 women were participating in a larger intervention development study, and, as such, participated in a two - step interview pri or to the purpose and procedures and to obtain signed consent from each woman before the interview was arranged. The two - step interview process included 1) completion of a self - report assessment tool and 2) clinical interview to review this assessment. The assessment tool was routinely used within the Residential Substance Abuse Treatment unit of the prison and was created by the service provider contracted t o perform these services. The assessment tool covered a range of topics, including histories of alcohol and substance use, substance use treatment, mental health treatment, family and childhood dynamics, abuse and victimization experiences, previous crimin al justice involvement, adulthood relationships, employment, education, parenting and children, and social supports. After women independently completed the assessment tool, a mental health professional reviewed the information with them and recorded any a dditional information provided during the interview. These interviews were performed by the same with issues of substance use, mental health, trauma, and incarce ration. Each interview occurred 63 ninety minutes. After the interviews were completed, copies of the assessments with the given to the research team. Lifeline Format Data from the assessment interviews were coded by the research team to categorize each reported life event and gain consistent time/age references, as well as to ascertain the discrete or continuous nature of the event, before submitting the data to the li feline format. The lifeline is a specific type of timeline format that allows for the display of extracted and highlighted life events ( Clausen, 1997 ) in order to maintain a contextual and life course perspectiv e ( Schroots & Assink, 2005 ) . Lifelines are helpful for theory construction and gaining clinical insights for specific populations ( Gramling & Carr, 2004 ; Quam & Abramson, 1991 ) . This format has been performed in other studies of women ( Boyd, Hill, Holmes, & Purnell, 1998 ; Davies, 1996 ) , including to understand adolescent factors connected pathways to crime for women in jail ( Hanks & Carr, 2008 ) and to test the stress - diathesis theoretical perspective for wom en who use crack cocaine ( Boyd, et al., 1998 ) . Lifelines, as included in the larger category of timelines or life events calend ars, have been described as having utility and purpose in criminological research in identifying pivotal and co - occurring life events for prevention and intervention purposes ( Roberts & Horney, 2010 ) . For this study, variables within the clinical interview were coded and plotted on a lifeline organized by life years, according to age at the time of event and Variables for c oding . In order to construct the individual lifelines of pre - prison experiences, each clinical assessment was hand - coded with the following life events. If a wom an reported that an event happened, it was included on her lifeline during the age(s) that she 64 indicated. The following specific event variables have been shown to significantly influence Criminal justice h istory . incarceration, arrests, and juvenile delinquency were elicited from the clinical assessment. Women reported the year of each charge (or their age at the time of the charge) and the legal outcome. As part of this history, women were asked about their drug use in relation to their criminal activities, with yes/no questions about committing crimes under the influence, selling drugs for profit, selling drugs to obtain drugs, and stealing from friends and/ or family. Personal and familial h istories . recorded during the assessment include details about their caregivers, changes in caregivers, their relationships with romantic partners, and specific events wit hin their families. Specifically for childhood, women reported who raised them, the year when their parents separated and divorced, the year when a parent passed away, if they were adopted (and when/at what age), and descriptions of their relationships wit hin their childhood families with their caregiver(s) and sibling(s). Women also reported if and when a caregiver was incarcerated. Women were asked to elaborate on these aspects of their family histories, especially about the quality of their childhood (i. Describe the quality of your childhood caregivers. Women answered questions about specific forms of childhood adversity, including sexual abuse, witnessing parental violence in the home, physical abus e and emotional abuse. These Were you ever punished resulting in bruises, cuts, burns, or other injuries? have a pattern of making threats, putting ; for 65 sexual abuse, ; and for witnessing family vio lence, . Each question had further prompting for additional information about these experiences. c forms of trauma were elicited and included intimate partner violence, being stalked, witnessing extreme violence against another person, and being in a situation that required physically defending self or others. For intimate partner violence, the follow Did your spouse, partner, or significant other ever hit, slap or punch you during an argument? If yes, please describe Were you ever forced to have sex by a spouse/significant other? Did your partner ever have a pattern of making threats, putting you down, calling you names, or humiliating you? If yes, please explain Has anyone stalked you, caused you to feel intimated or concerned for your safety? If yes, please explain. Did you ever witness death or extreme violence against someone else? If yes, age and explain Have you ever physically defended yourself or others, which resulted in violence? If yes, describe ajor relational changes, including changes related to motherhood and parenting, were also included. Women were asked to provide the ages and quality of relationship with their child(ren). Women included information about children both living and deceased, as well as children for whom they had rights or had their rights terminated. Substance use h istory . Within the clinical assessment, women reported their histories of using alcohol , cocaine, crack cocaine , depressants, hallucinogens, heroin, marijuana, opia tes, and 66 stimulants. They included information about their age at first use, their ages during regular use of each substance, the month/year of their last use of each substance, and details of who introduced them to each substance. They were also asked to provide details corresponding life events with the onset of use of each substance. Participants were asked about any incidents of overdose (i.e. Have you ever overdosed? When? information about their substance use treatment was elicited, with questions specifically about their dates of treatment, types of treatment, length of treatment, and outcomes of each treatment experience. Mental health h istory . Each participant was asked to report details about any/each of her `psychiatric treatment experiences, including the date of each entry (month/year/ their age), the type of facility, precipitating factors, and any outcomes. These experiences included inpat ient and outpatient services with room for women to specify what type of treatment(s) they received (e.g. therapy, medication). Also, women were asked if they had a history of suicide attempts at any point in their lifetime; if a specific age or date was p rovided, this event was included within the lifeline. Analysis Analytic in duction (Katz, 1983; Ragin, 1987 ) was used to perform a systematic based on importation t heory and existing empirical evidence, the analysis process included looking for themes and patterns across and within events and life experiences, specifically how d eveloping and testing codes, theme clusters, and commonalities and differences across interviews, as is typically performed with life history interviews ( Morse & Field, 1995 ) . 67 Each woman was assigned a pseudonym for the process of analysis, which is included in the results section below. Upon entry into prison, women are assigned an identification number by the prison, and they are referred to, both by staff and other inmates, primarily by this number or their last name in prison throughout their prison stay. Since this is commonly a way to dehumanize or depersona lize prisoners (Za itzow , 2003), this study deliberately did not use identification numbers in order to refer to women throughout the analysis. Table 1 includes each Table 1 : Demographics of Incarcerated Women with Life Sentences Name (*) Race Number of Years in Prison Age at Incarceration Type of Homicide Conviction Annette Black 25 19 Second Degree Beverly Black 13 32 Felony Murder Casey White 21 17 First Degree Denise White 11 32 Felony Murder Emily White 15 23 First Degree Frederica White 20 34 Second Degree Gloria Black 24 21 Second Degree Halley White 9 25 Second Degree Irene White 2 41 Second Degree Jacqueline Black 8 46 Second Degree Kathy White 2 21 Felony Murder Lydia Black 12 40 Felony Murder Melinda White 8 26 First Degree Nancy Black 38 22 Second Degree Olivia Black 10 21 Felony Murder Pamela White 8 28 Felony Murder Paula Black 8 25 Felony Murder Rachel White 24 27 Second Degree Rita Black 16 27 Felony Murder Stacy White 24 25 Second Degree Susan Black 1 44 Open Murder Terri Black 15 20 Second Degree Tori White 11 36 Felony Murder Veronica Black 24 18 First Degree Wendy White 5 22 Second Degree Yvette Black 19 37 First Degree 68 Results adversity throughout the pre - prison were dominated by interpersonal abuse and violence. This theme of cumulative trauma and adversity thus became the organizing and primary theme from which sub - themes emerged as present in a majority of the lifelines. Specifically, the sub - themes were (1) the pivotal role of an abusive relationship in behaviors as both the result of adversity and coping strategies for trauma and adversity; (3) the lack of intervention in the form of substance abuse treatment and/or mental health treatment; and (4) the end - point of prison. A summary of these themes is pr esented in Table 2. Primary Theme : Cumulative Trauma & Adversity throughout the Pre - Prison Life Course The pervasiveness and chronic natur e of the abuse these women experienced is connected to additional dynamics in their lives, and subsequently, it was impossible to separate the role of adversity and trauma from the other aspects of their lives. Women overwhelmingly described lives of persi stent emotional, physical, and sexual abuse, beginning early in life from their caregivers and family members, and continuing into their teens and adulthoods from their intimate partners and acquaintances. As detailed in Table 3, with a majority of women r eporting childhood sexual abuse, abuse in their home during childhood, and intimate partner violence, not surprisingly, all women reported experiencing at least one type of violence . Likewise, women 69 reported experiencing additional and multiple adverse exp eriences, such as incarceration of a parent, parental or child death, or parental separation early in life. Table 2 : Primary and Sub - Themes from Analysis of the Lifelines Primary Theme: Cumulative Trauma and Adversity Across the Pre - Prison Life Course Thi s primary theme refers to the persistent presence of trauma, abuse, and adversity - prison adulthood lives, leading to a lack of safety in primary relationships . Sub - Theme Description Abusive Relationships & the Introduction of Alcohol and Other Drugs A majority of women described the person who introduced them to alcohol and/or other drugs as their caregiver and/or romantic partner. Likewise, substance use was often a dynamic of close/primary relationships for women with the ir caregivers, family members, and/or partners. Both Responses to Trauma and Adversity and as Coping Strategies Overwhelmingly, women detailed that they responded to/coped with adversity and trauma by (1) using alcohol and/or other drugs ; (2) attempting suicide ; and (3) running away from home in an attempt to be safe. Missing Intervention Points While all but one woman used substances, a limited number of women engaged in substance use treatment . Likewise, few women obtaine d mental health treatment , and most treatment services were brief and crisis oriented (specifically to address suicide attempts.) For a small number of women, mental health treatment was not even provided for suicide attempts. Thus, the lack of interventio n is the crux of this sub - theme. End Point Prison were convicted, a majority of women describe a relational component to their crime ( e.g. involvement with/for/against a person in a close, often abusive, relationship.) Likewise, many note t he role of substance use in their behavior associated with the conviction. Notably, for over half of the women, the conviction that carried a life sentence resulted in their first stay in prison. Likewise, needs continued while in prison . 70 Table 3 : % n Abuse and Adversity Histories Any Pre - Prison Victimization/Trauma 100% 26 Childhood Abuse (under age 18) Physical Abuse Emotional Abuse Sexual Abuse Witnessed Abuse in Home 65 % 69 % 81 % 58 % 17 18 21 15 Intimate Partner Violence 77 % 20 Childhood and Adulthood Victimization 73% 19 Witnessed Death or Extreme Violence 65% 17 Physically had to Defend Self 73% 19 Fa mily History of Substance Abuse/or Mental Illness 77 % 20 Mental Health History Suicide Attempt Pre - Prison 50% 13 Received Mental Health Treatment Pre - Prison 46% 12 Substance Use History Women Who Ever Used Substances 96% 25 Used Alcohol on a Regular Basis 81 % 21 Used Cocaine on a Regular Basis 62% 16 Used Crack Cocaine on a Regular Basis 5 4 % 14 Used Heroin on a Regular Basis 42% 11 Used Marijuana on a Regular Basis 96% 25 Received Substance Abuse Treatment 32% 8 Criminal History Background First Time in Prison 8 5 % 22 First Offense with Conviction 6 2 % 16 Had Previous Jail Incarcerations 23% 6 Crimes Under Influence of or for Drugs 76% 19 71 No safety in primary relationships . appeared to be sites of violence with little safety. For example, one woman summarized her childhood as: abuse m caregivers (e.g. fathers, mothers, stepfathers, boyfriends/girlfriends of parents, foster care parents, and/or grandparents), and their adolescence/ adulthood violence was main ly intimate partner violence from boyfriends and husbands. Similarly, several women noted that the loss of a parent or parents prompted entrance into unsafe home environments. One such woman was Beverly, whose parents both passed away by the time she was 4 years old. She then entered foster care homes only to experience physical and emotional abuse by her foster care parents from age 6 to when she ran away at age 15. As another example, for Wendy, it was the loss of her grandmother (her self - described ) when she was 12 years old that coincided with a series of adverse events partner violence by her boyfriend, and using substances with her mother, step - father, step - mother, uncles, and au nt. Lastly, for Tori, when her parents divorced at age 4, her mother and grandfather became her primary caregivers. Her grandfather then began molesting her at age 5 and continued for eight years. Women reported multiple perpetrators from various relationships. For Denise, by the age of 9, she was experiencing physical and emotional abuse by her mother and step - father, and sexual abuse by her grandfather. F or many women, abuse also came from distant or extended father). As an example , Nancy was sexually abused by both a cousin and a family friend throughout her childhood until age 12. Childhood and adulthood violence blurred together, as 72 women reported abuse from boyfriends occurring as young as age 13 concurrent with abuse that was occurring in their homes. As an example, at age 17, while Gloria was still experiencing sexual abuse by h er father and defending herself from his physical abuse, she was also experiencing physical ab use from her boyfriend. Figure 1 shows her lifeline to illustrate the continual abuse present in her life. While her lifeline reflects her experiences, the prese nce of relationships. Figure 1 : Lifeline for Gloria ABUSED BY PARENTS; WITNESSED FATHER HARM MOTHER (E.G. CUTTING, BEATING) OVER THE FOLLOWING YEARS ABUSED ABUSED ABUSED ABUSED ABUSED ABUSED ABUSED ABUSED ABUSED RAPED BY FRIEND'S FATHER ABUSED ABUSED ABUSED STARTED USING MARIJUNANA ABUSED ABUSED ABUSED RAPED STARTED USING ALCOHOL WITH FATHER HAD FIRST CHILD PHYSICAL ASSAULT BY FATHER HAD SECOND CHILD PREGNANT WITH THIRD CHILD CONVICTED OF 2ND DEGREE MURDER Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 73 Persistency . Due to the multiplicity of abusers, women reported multiple types of abuse with little breaks in ab use. For example, Casey was by her parents until age 5 , and then after her parents separated, was physically abused by her step - father starting at age 6. By age 12, she had been sexually abused by at least five people (including several uncles and a neighbor). At age 14, she started dating physically abusive boyfriends. Also, she began using alcohol, cocaine, crack cocaine, and marijuana, and was stalked by her drug dealer. She was sent to prison at age 17 for murder. Other than the year between ag es 13 - 14, her lifeline was dominated with multiple forms of victimization. For Rachel, her first reported abuse was being burned by a sibling at age 2, followed by a broken arm from her brother. She described witnessing domestic violence in her childhood h ome between her mother and father. After her mother passed away when she was 9 years old, in her new home, she was sexually abused by a cousin whom she lived with for eight years. She also reported protecting herself from violence from her caregiver. In he r adult years, she experienced persistent physical, sexual, and emotional intimate partner violence ( ) before being imprisoned at age 26 for murder. As yet rape baby ildhood included witnessing her mother being abused and She stated that she basically cocaine use, caring for five children (one of which passed away), and experiencing physical, emotional, and verbal abuse by her husband. Lastly, Frederica was in an abusive relationship with her boyfriend/husband from age 15 to 33 which resulted in head injuries, substance use and selling drugs, and caring for four children. She entered prison at age 33. For some women, the forms of abuse that they experienced across their pre - prison life courses did not change merely, the perpetrators changed. For example, Annette detailed being 74 own boyfriend at age 18 (the same year as her crime). Likewise, Rachel grew up trying to protect herself from her physically abusive caretaker and then at age 19 was in physically abusive intimate relationships. Therefore, a key finding was not just that all women reported experiencing abuse, but that women experienced abuse for a majority of their pre - prison lifetimes, based on the described duration and persistency. Likewise, this abuse did not often occur in just one relationship, but rather multiple relationships stretching through childhood, adolescence , and adulthood. The type of abuse was a singular type for some women, and for others, they experienced multiple forms of abuse and violence. Sub - T hemes - Prison Lives Four sub - ces of trauma and adversity with substance use, specific coping strategies, and their crime involvement. substance use and mental health treatment. These sub - theme s were present for a majority of the - prison lives. However, f or two women, only the primary theme of trauma and adversity dominated their lifelines without evidence for the sub - lives. Veronica described witnessing intimate partner violence between her parents and experiencing sexual abuse during her childhood, and then experiencing intimate partner violence from her boyfriends. Given her incarceration occurred at age 17, her lifeline was primarily filled with multip le forms of v ictimization, as seen in Figure 2 . Similarly, for Emily, she reported sexual abuse by her father at age 11, and then intimate partner violence by a boyfriend for every year from age 14 to her crime at age 22. She was the only woman who did not report substance 75 - themes, as lifelines. Figure 2 : Lifeline for Veronica As another point, one woman had limited information about the sub - themes. Lydia described childhood adversity in the form of her mother being imprisoned for manslaughter, and she detailed her abusive experiences as primarily starting at age 18 with her boy friend who PARENTS SEPARATED; RAISED BY MOTHER AND GRANDMOTHER SEXUAL ABUSE BY UNCLE; WITNESSED IPV ABUSE & WITNESSED ABUSE & WITNESSED ABUSE & WITNESSED ABUSE & WITNESSED ABUSE & WITNESSED ABUSE & WITNESSED MOTHER PARALYZED BY BOYFRIEND ABUSE & WITNESSED ABUSE & WITNESSED STARTED USING MARIJUANA IPV BY BOYFRIEND DROPPED OUT OF HIGH SCHOOL IPV BY BOYFRIEND RAPED BY UNCLE IPV PREGNANT WITH FIRST CHILD CONVICTION OF 1ST DEGREE MURDER Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 76 her as well as tried to rape her. She shared that her alcohol use lead to her use of crack cocaine age at 26 which coincided with multiple and ongoing experiences of intimate partner violence throughout her adulthood. However, she did not describe connections between the events. The only sub - theme that was blatantly present in her life was limited substance abuse treatment engagement, given that she engaged in brief court - ordered treatment. The sub - themes described below are e mbedded within the overarching theme of adversity - However, women described a range in experiencing one, many, or all sub - the mes; within this sample, women had a degr ee of heterogeneity in their pre - prison life experiences. Lifeline examples are included in the following descriptions of the sub - themes and these were chosen to show the ways that the primary and sub - Sub - Theme 1 : Abusive Relationships & the Introduction of Substance Use For a group of women, substance use, and, more specifically, the introduction of alcohol or another drug occurred in the context of an abusive relationship. Thus, two patterns emerged either solo or simultaneously for women: (1) the introduction to alcohol and other drugs by abusive people in their lives; and/or (2) the use of alcohol and other drugs as a component/dynamic of an abus ive relationship. For example, women reported an introduction to drugs and alcohol by parents and/or described later in life using a new substance with a boyfriend. Introduction to substance use by a caregiver or partner . Almost half of the women reported that they started using substances with a parent, caretaker, fam ily member, and/or example, Wendy started using alcohol with her family members at age 16 and specifically 77 cocaine with her step - mother at age 17. As for Rita, she wi tnessed her parents regularly using substances while she was a child, and at age 13, she started using crack cocaine with her mother, which develop ed into a daily habit of using after having her own child at age 14. Moreover, women specifically described t he introduction of substances by family members who displayed other abusive behaviors. Susan described her mother as the one who introduced her to alcohol at age 14; her mother also physically and emotionally abused her throughout her childhood. Several w omen named their fathers as both perpetrators of abuse and as the key person introducing them to alcohol and drugs. A key example is Halley, whose childhood was characterized by physical, emotional, and sexual abuse by her father who also introduced her to alcohol and marijuana at age 12 and cocaine at age 14. For Stacy, her father sexually abused her starting at age 7, and then started using alcohol with her at age 17. Likewise, Gloria explained that her father introduced her to alcohol, but this also occu rred alongside being by him. Substance use as a dynamic of abusive relationship . Using substances with a partner within the context of an abusive intimate relationship was prevalent as well. For example, Rita used marijuana and alcohol with her physically abusive boyfriend, and Kathy started using cocaine at age 16 with her boyfriend w ho gave her broken noses and by their boyfriends and husbands across their lifelines from the introduction of cocaine by a boyfriend at age 14 (Irene), or using with a boyfriend starting at age 28 (Jacqueline), to the introduction and subsequent daily use of cocaine and crack cocaine with a husband (Frederica). F or Denise, the escalation of drug use to crack cocaine and heroin use with her hu sband occurred 78 the same year as she perpetrated the crime that led to her conviction. Lastly, Pamela described her partner as her drug dealer who beat and stalked her when she tried to leave. Sub - Theme 2 Strategies for Trauma and Adversity Overwhelmingly, women detailed that they responded to/coped with adversity and trauma by (1) using alcohol and/or other drugs; (2) attempting suicide; and/or (3) running away from home in an attempt to be safe. A large group of women detailed that their substance use was specifically a chosen way of coping with the abuse and adversity in their lives, or as Pamela described it, and to manage, as Rachel said, of abuse or simply (Yvette). A few women were more specific about their corresponding life event that prompted substance use, such as Terri citing being molested by her step - father as the reason for starting to use marijuana and alcoh ol at age 16. Tori described using alcohol daily starting at age 5 due to and then crack cocaine after the death of her mother. After a childhood history of emotional and sexual abuse by her family, Denise specified that she st arted using alcohol at age 16 Kathy described using alcohol, marijuana, and other substances at age 13 in order to cope with molestation by her step - father, and cited using heroin at age 17 to deal with intimate partner violence by a boyfriend. Another common response to the magnitude of adversity was suicide attempts. Such attempts started during childhood for some women. For example, Olivia detailed emotional and physical abuse by her mother during childhood and then molestation b y her father, followed by attempted suicide at age 10. The sexual abuse continued she was raped multiple times over 3 - 4 79 Likewise, Pamela was sexually assaulted by a ne ighbor for four years (from age 8 - 13) and reported suicide attempts starting at age 12. For Paula, a suicide attempt occurred at age 17 after she experienced approximately two years of intimate partner violence by her boyfriend (who was also 17 years older abuse, and for Wendy in particular, having a child who was stillborn prompted her to attempt suicide at age 16. A smaller group of women reported having a coping response of runn ing away from home (e.g. a foster home or home with biological parents) as a child or adolescent due to any or multiple forms of abuse (such as Tori at age 14). For Nancy, after living with her aunt for entire childhood and experiencing sexual abuse for th e majority of this time, she ran away at age 15, which co - occurred with being raped by another adult, dropping out of school, and starting to use marijuana and alcohol. Some women reported using one or multiple coping responses, or reported multiple behavi ors occurring simultaneously. With Beverly, after running away from an abusive foster care home at age 15, she started using marijuana as a with life. Also, Susan described leaving home at age 16 due to the pervasive abuse; she was being se xually abused by two uncles and a cousin and physically abused by her mother and older siblings. She also reported starting to use alcohol, marijuana, and depressants at the same time. Sub - Theme 3 : Missing Intervention Points Substance abuse treatment s ervices . Almost all the women (25 out of the 26) reported having used substances prior to prison. The average age of the start of substance use was approximately 14 years of age, with the earliest being age 5 a nd the oldest starting age was age 18 first substance use varied in terms of type; 8 out of the 25 women first used marijuana, 5 used alcohol first, 3 used a different substance first as well as 9 out of the 25 80 women started with multiple substances (most often, alcohol and marijuana). Only 8 women received substance abuse treatment prior to prison . For women who did receive treatment, substance abuse treatment was relatively brief, lasting from a few hours to 6 months. Women reported inpatient, outpatient, and residential substance abuse treatment settings. Mostly, women cited substance abuse treatment utilization as due to court referral or probation requirements (Wendy, Tori, Lydia; Irene). Th e low number of women engaged in substance use treatment pre - prison limited the ability to under stand why women did or did not engage in services given that no defining characteristic (such as having children) appeared to shape treatment engagement except the referral aspect. Mental h ealt h treatment s ervices . Of the 26 women, almost half (12 women) r eported at least one mental health treatment encounter previous to prison. The most commonly reported reason for utilizing mental health services was related to suicide risk, including suicide attempts, ideation, and severe depression (especially during ch ildhood and early adolescence). For some women, multiple suicide attempts prompted multiple utilizations of mental health services (Halley; Irene; Olivia; Pamela; Susan; Wendy). However, suicide attempts did not necessarily dictate entrance into mental hea lth treatment services, such as with Denise and Paula who reported attempting suicide but no mental health treatment. Other specific symptom - related parental rig hts, childhood behavioral issues, and running away, along with services required due directly to abuse in the home. Regardless of the symptomatic reason they received mental health services, women often reported abuse and adversity as the precipitating fac tor for treatment although the abuse was rarely addressed from a broader or preventative approach. For example, Stacy, after her parents divorced at age 5, was sexually abused by an uncle in the same year and 81 then by a man who became her step - father at age 7; correspondingly, she entered a specialized - 11. Sub - Theme 4 : End - Point Prison While all women ended up in prison with a conviction of a violent offense and a life sentence, for a majority of women, this was their first prison stay. Only 4 women had been sentenced to prison previous to their current offense, and thus, for 22 women, their current conviction carrying a life sentence was also their first time in prison. Their cri mes appeared to occur in the context of the other previously mentioned major themes: within or as a response to abuse/victimization and/or under the influence of substance use. Relational c om ponent to c rimes . persistence abuse by those in close relationships (e.g. parents, partners), not surprisingly, the crimes that they were convicted of and given a life sentence for were described by the women as often having a relational component. Relational in this contex t means that the victim(s) of their crime was someone they were close to/had a history with, and/or that they had a relationship with their co - defendant involved in the crime. ization. For example, Jacqueline was abused physically and emotionally by her boyfriend for fifteen years, and she stabbed him, resulting in his death. As another example, Annette was convicted of the murder of her abusive boyfriend after enduring an exten sive history of childhood physical and sexual abuse. When asked about ever having to defend herself, she wrote, on that. In an attempt to leave my (childhood) abuse, I began prostitution to make money to leave the state and came across a man who tried to force me to have sex against my will. Out of For Irene , she grew up witnessing her father abuse her 82 mother and step - mother and reported that she would my st ep - Then, after 24 years of experiencing intimate partner violence, she was convicted of killing her husband. Halley described that she had to physically defend herself , and her lifeline (see Figure 3) showed a history of abuse, especially sexual abuse in early childhood. Lastly, Rachel who also had a lifetime history of physical and sexual abuse responded to the sexual abuse of her young daughter with violence against the perpetrators, which resulted in her con viction. F igure 3 : Lifeline for Halley FATHER PHYSICALLY, EMOTIONALLY, & SEXUALLY ABUSIVE ABUSE ABUSE ABUSE ABUSE ABUSE ABUSE ABUSE PARENTS DIVORCED JUVENILE COURT FOR RETAIL FRAUD INPATIENT MH CARE FOR CUTTING, DEPRESSION USING ALCOHOL & MARIJUANA WITH FATHER OUTPATIENT MH CARE FOR CUTTING, DEPRESSION USING COCAINE WITH FATHER HEAD INJURY OUTPATIENT MH CARE FOR ANXIETY, HALLUCINATIONS IPV WITH BOYFRIEND HAD CHILD CONVICTED OF MURDER OF MAN WHO RAPED HER 83 History of abuse with co - defendant . - defendants included husbands (Melinda), boyfriends (Pamela and Paula), and ex - boyfriends (Wendy). Strikingly, one woman (Olivia) described that her crime of and it ended with the murder of someone she was dating. As seen in her lifeline in Figure 4, her father had molested her for several of her childhood years until he was then imprisoned for this abuse. For Melinda, her husband was her co - defendant, and they were convicted of robbing and killing a man perhaps not coincidentally, this was a man who sexually abused her for years during her adolescence. Wendy described her crime as occurring after six years in an abusive relationship with her boyfriend. After he came to her house for his items and argued with her, he then returned to her house again with his friends and began shooting. Several people were harmed in her situation, and both she and he r boyfriend were convicted. Lastly, Beverly described being with a boyfriend who was in a gang and that she with the gang. In that lifestyle, witnessing death and violence were a which she describes as contributing t o her crime. Substance use at the time of the c rime : Substance use was noted as contributing to other risky behaviors for women, such as Tori describing of friends in order to support my alcohol and drug habits. I even sold my body for drugs and Susan reported that she A large majority of the women reported committing crimes in order to get drugs, or w hile under the influence of drugs. Frederica explained that she 84 Most of the women (19 out of 26) reported that their cu rrent case/conviction was committed while they were under the influence of alcohol and/or other substances. For example, Casey detailed that In her childhood home, but she did not describe her substance use (drinking alcohol daily starting at age 20) as related to her adversity. She also did not report intimate partner violence during her adolescence or adulthood. However, at age 36, she started using crack cocaine on a regular basis, and this use she specifically connected to her crime. She described being on crack cocaine, not sleeping for multiple days, and stabbing her friend while in this state of being. Interestingly for Yvette, it was the e scalation of substance use that prompted her criminal behaviors, and the persistency of adversity seems less apparent in her lifeline. Continuation of need for services in p rison : While the lifelines only included pre - prison experiences, it is striking th within the clinical assessment process, they also shared distressing and concerning experiences within prison. They included details of needing interventions due to poor mental health and c ontinuing (or new) substance use. Since the beginning of their life sentence, half of the women have attempted suicide and/or had major depression, which has resulted in psychiatric evaluations and medications. For example, Veronica (see Figure 2) and Hall ey (see Figure 3) attempted suicide in prison. Some women have reported starting new substances (such as heroin) and/or continuing use of substances while in prison. A common experience is for women to have participated in one 8 - week substance abuse progra m or in an Alcoholics Anonymous or 85 continue in prison and the treatment opportunities are limited, especially given the long - term and ongoing nature of their incarcer ation based on their sentence. Figure 4 : Lifeline for Olivia Discussion This study examined the pre - prison lives of a sample of incarcerated women with life sentences in order to look at patterns and themes across common importation factors for women in prison. The lifeline format provided a sobering picture of the duration of abuse and adversity ABUSED BY MOTHER ABUSED ABUSED ABUSED PARENTS SEPARATED ABUSED MOLESTED BY FATHER ABUSED MOLESTED ABUSED MOLESTED BY FATHER ABUSED ABUSED ATTEMPTED SUICIDE; MH TX FATHER IN PRISON RAPED BY MOTHER'S BOYFRIEND STARTED USING ALCOHOL ATTEMPTED SUICIDE; MH TX ATTEMPTED SUICIDE; MH TX RAPED STARTED USING MARIJUANA RAPED RAPED CONVICTED OF DRUG POSSESSION & GIVEN PROBATION DROPPED OUT OF HIGH SCHOOL STARTED USING COCAINE HAD CHILD CONVICTED OF 1ST DEGREE MURDER & ROBBERY (REPORTS SET UP ROBBERY FOR FATHER) Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 86 victimization, and these relationships commonly had the dynamic of introducing substance use. behaviors of substance use, suicide attempts, and running away. While a few women received substance use and/or mental healt h treatment, a majority of women did not receive any such intervention services before prison. Lastly, an overwhelming majority of women are serving a life sentence for their first prison sentence for crimes committed under the influence of substances as w ell as i n the context of victimization. experiences, spanning from a young age to their imprisonment, are of concern from a cumulative adversity perspective. Previous studies have found that experiencing multiple or high rates of adverse events is significantly linked with poor mental health outcomes which are also worsened by social isolation, being impoverished, and marginalized by social identities/status ( e.g. Grote et al., 2007; Lloyd & Turner, 2003; Kubiak, 2005 ). Of concern, women in this study reported high rates of suicide risk factors, including previous ideation and attempts that were both addressed and unaddressed by mental health treatment. Notably, suicide risk con tinued for half the women while in prison. While a dominant theme in this study is the persistency of abuse and adversity throughout - prison lives, women also shared that substance use was a feature of their abusive relationships as a dynamic within their experiences of abuse (e.g. intro duction to and/or using with an abuser) or in terms of being a coping mechanism for the abuse they experienced. Similar findings have been found in other studies linking trauma and adversity to risky behaviors, 87 especially substance use ( e.g. Dube et al, 20 03; Kilpatrick et al, 2000; Sharp, Peck & Hartsfield, 2012 ). In particular, sexual abuse is significantly linked to daily drug use (Sharp, Peck & seen in the cont ext of their ongoing victimization. As also seen in pathw ays research (e.g. Belknap, 2007 intertwined in their descriptions of their crimes. Implications for Social Work Theory Femin ist scholars have pushed against importation theorists for focusing on a pathology profile of women offenders ( Shaw, 1992 ) . Within i mportation theory, prisoners are often labeled factors ( Adams, 1992 ) . The conflation of needs into risk factors (often framed as criminogenic risk factors) has shifted the responsibility from system - solutions to individual - level factors for wo men offenders to address themselves ( Hannah - Moffat, 1999 ; O'Malley, 1992 ) . By examining these pre - prison life experiences in a lifeline format, the lack of interventions for substance abuse and me - prison lives and moreover, there is a lack of intervention to prevent continuing abuse and adversity. For most (if not all) women in this sample, multiple critical intervention time points (e.g. suicide attem pts) pre - prison lives without adequate intervention. Perhaps the most glaring concern is the lack of - prisons lives. Indeed, one of the key insights of a lifeline approach is that the events. It provides an opportunity for linking the story with - prisons lives beyond the individual - level, one major implication i s the need for system - level interventions, including policy and prevention focused advocacy, to 88 provide women with treatment, safety, and intervention options outside of (and prior to) prison or involvement with the criminal - legal systems. A life course pe rspective speaks to the need to de - adulthood. Recent work has posited that importation theory in relation to understanding prisoner mental health concerns may be bes (Armour, 2012, p.889) given the high rates of trauma women experience pre - prison and during are centered on their experiences of multiple, persistent, and cumulative trauma. Thus, cumulative risk theory and cumulative trauma theory may warrant a stronger incorporation in the importation theory framework. Likewise, this theory can help inform intervention dev elopment and testing, as well as future research for women in prison. Implications for Social Work Practice Women in prison with life sentences are often not eligible for treatment interventions in prison as such opportunities are designed and reserved f or women re - entering the community in order to reduce recidivism. However, given that the women in this sample had pre - prison lifelines with multiple, interacting importation factors, this population of women warrants further attention and investigation in several domains. First, more research is needed on intervention development and testing with this population while they are incarcerated. Due to the prevalence of adversity, trauma, and other importation factors, their mental health in prison may be an on going concern. As seen in research on women with life sentences and suicide (Dye & Aday, Understanding how these pre - s may 89 inform intervention development. Thus, a multifaceted intervention that addresses multiple forms of trauma experiences, coping strategies and relational behaviors (e.g. the use of violence and substances) may be helpful, especially with attention to treatment engagement given the low rate of previous treatment experiences. Second, w ith intervention development, simultaneous policy advocacy is needed to expand service provision for all women in prison. A specific facet of such service provision is the need to consider ongoing treatment options as women serve a life sentence. As a larger goal, a third area of attention is the need for a prevention - - prison lives. Relying on prison - based treatment as the primary point of in tervention is insufficient and - based approach. and that prison was the major inte rvention site, work is needed in the community to prevent women from being underserved and that are multifaceted in content with an explicit focus on reducing involvement in the criminal justice system. Limitations While this study offers insight into fut ure work, there are multiple limitations. First, this study utilized a small sample which allowed for in - depth analysis, but also does no t take into account variations across women. Future research with larger samples of women with life sentences is needed . It may also be helpful to know what factors shaped the sentencing decision for a particular woman. Future work may consider a comparative nature: for example, comparing - pris on lives, and comparing the histories of women in different states and looking at how life sentences are defined on a state - level. 90 Second, a limitation of this lifeline approach is that the lifelines were researcher - constructed. As this data was collected as part of a clinical assessment, women may not have disclosed their experiences fully, especially given the power dynamics within the prison between clinical staff and prisoners. Also, women may have limited their discussions about illegal behaviors insid e and outside of prison , such as substance use. Likewise, recall bias is a concern with life history extraction, and given some women had been incarcerated over twenty years, key life events may be missing, or misrepresented in terms of time. Future resear ch may consider a life - history interview with women with life sentences in order to verify how women conceptualize their lives and connections between events. Third, most of the va riables examined were of an adverse nature. Protective factors included were service engagements. However, additional protective factors such as resiliency and positive supports may provide additional insights and should be considered for future arenting, may provide insight into how these events influence their lives. Conclusion Incarcerated women with life sentences have been rendered invisible, isolated, and shunned through their permanent prisoner status, and they have been described as neglec ted and underserved by researchers (Owen, 1998). Examining the pre - prison lives of this population points to the overwhelming role of trauma and adversity throughout their lives, as well as the lack of intervention points prior to prison. Social work pract ice, policy, and research efforts are needed with a focus towards this population - both in prison and prior to prison. 91 REFERENCES 92 REFERENCES Adams, K. (1992). Adjusting to prison life. Crime and Justice , 16, 275 - 359. Aday, R. H., & Krabrill, J. J. (2011). Women aging in prison: A neglected population in the correctional system . Boulder, CO: Lunne Reinner Publishers. Adriansen, H. K. (2012). Timeline interviews: A tool for conducting life history research. Qu alitative studies , 3 (1), 40 - 55. Armour, C. (2012). 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However, incarcerated women with life sentences present with and report multiple persistent physical and mental health needs upon entry and throughout their stays in prison. This study tested a new gender - responsive, trauma - i nformed violence prevention intervention (Beyond Violence) that and anger expression. Pre, post, and follow up surveys were administered to two treatment groups with women with life sentences. Multilevel modeling was conducted to assess changes based on their length of time served. While significant positive outcomes were found f or all women in regards to trait anger and anger control, women who had been in prison for less than ten years started with higher scores on multiple measures and showed significant rates of change over time. This study is preliminary and offers insight in to further social work practice, policy advocacy and research for this population of women. 101 Introduction Incarcerated women serving life sentences are a sub - population in prisons that has been largely neglected by prison administrators, practice profe ssionals, and researchers (Owen, 1998; Nellis, 2013). This gap is especially evident in the general lack of evidence - based interventions for incarcerated women with violent offenses, as well as specifically, the absence of interventions tailored for this s ub - population and the lack of inclusion of this sub - population in samples testing new interventions. This lack corresponds with the common prison policy of denying or excluding women with life sentences from treatment - based interventions, as such intervent ions are commonly reserved for women re - entering the community (Nellis, 2013). However, incarcerated women with life sentences have high rates of risk factors based on their pre - prison life experiences and reports of physical and mental health needs during incarceration (Aday & Kabrill, 2011; Dye & Aday, 2013; Leigey & Reed, 2010). Given the rising number of incarcerated women with life sentences (Nellis, 2013), an intervention that is efficacious in rison may benefit not only the study examined the short - term outcomes for incarcerated women with life sentences who completed a new violence prevention intervent mental health and anger - related feeling and expressions. Background Women comprise a small fraction of those arrested (14%) and sentenced (5%) for a violent offense within the U.S. (West, Sabol, & Greenman, 2010) . A majority of women with life sentences (94%) are serving time for violent offenses and the number of women sentenced to life sentences are a growing subpopulation, rising 14% from 2008 - 2012 (Nellis, 2013). The increase 102 in the number of women with life s (such as the two - strike law in Georgia) focused on long sentences (Nellis & King, 2009). Also, the implication of a life sentence has shifted from indeterminate (i.e. until rehabilitation occurs) to literally the end of natural life (Mauer, King, & Young, 2004). While sentencing varies state to state, e released from prison on parole, whereas nine prisoners has a life sentence, either with or without parole, or as a long sentence that exceeds natural life span (Nellis, 2013). On average, a person serving a life sentence is incarcerated for 29 years with little opportunity to be released ( Mauer, et al., 2004 ) . For example, in California, those in prison with a life sentence have an 18% chance of being approved for release by the Parole Board ( Weisberg, et al., 2011 ) , and in Michigan, the chance is 9% ( Levine, 2014 ) making release a rare event. behavior and recidivism, gained often through required, formal treatment - based interventions (Chesney - Lind, 1998; Me ssina, Burdon, Hagopian, & Prendergast, 2006). In order for women to and capacity for positively managing dynamic risk factors, such as attitudes, emotionality, and coping skills, in decision - making processes related to release and risk ( Hannah - Moffat & Yule, 2011 ) . These skills and progress are often o btained through treatment - based programming while in prison. In a recent systematic review of interventions specifically for women in correctional settings in the United States, none of the reviewed interventions were primarily focused on anger management or violence prevention (Tripodi, Bledsoe, Kim, & Bender, 2011). Most of the 103 interventions concentrated on substance abuse treatment with the goal of preventing recidivism, and were designed to be delivered to women preparing to exit prison and re - enter the ir communities. (Of note, the review excluded a study by Eamon, Munchua, and Reddon (2002) that focused on an anger management intervention for incarcerated Canadian women convicted of violent and/or nonviolent offenses.) A small number of the reviewed int erventions had the (Tripodi, Bledsoe, Kim, & Bender, 2011). While none of the reviewed interventions detailed a specific focus or inclusion of women with life sen tences, this population of women could benefit from interventions aimed at improving wellbeing in prison. Women with life sentences arrive at prison with higher rates of psychosocial needs, including high rates of mental health concerns, suicide risk facto rs, and histories of sexual abuse, childhood abuse, and intimate partner violence victimization ( Leigey & Reed, 2010 ) . Based on personal accounts, women who enter prison with a life sentence describe feeling unable to process their reality and emoti onally numb, as well as easily hopeless and depressed ( George, 2010 ) . In a qualitative study, women with li fe and long term sentences reported depression, hopelessness, and anger, especially at the beginning of their sentence, as akin to the stages of grief often des cribed by terminally - ill patients ( Jose - Kampfner, 1990 ) . This process also includes perpetual psychological distress over time in prison. Women with life sentences report a multit ude of physical and mental health concerns especially as they age in prison ( Aday & Krabrill, 2011 ) . Women who have served longer sentences (over ten years) have reported more problems with the prison environment, such as boredom and a dearth of educational, work, and social opportunities ( MacKenzie, et al., 1989 ) , and one study suggested 104 that the more time a woman serves, the more difficulty she may have with psychologically responding to prison ( Vuolo & Kruttschnitt, 2008 ) . Depression and suicide risk are particular after longer periods of time in prison (Clements - Nolle, Wolden, & Bargmann - Losche, 2009) . Wome n with life sentences are in need of physical and mental health treatment opportunities in prison. The prison physical and psychological health care system may face increased demands as the number of women serving life sentences increases, both for women u pon arrival to prison and over their long - term stay in prison. Thus, given the lack of interventions for this population of women with the corresponding needs of these women, testing and evaluating a new intervention with women with life sentences fills a current gap in both research and practice, with an opportunity to advance policy advocacy efforts as well. A New Intervention: Beyond Violence In response to the need for a violence prevention intervention for incarcerated women, Beyond Violence (Covington , 2011) was developed as a gender - responsive and trauma informed intervention specifically for incarcerated women with violent offenses. Gender - responsive and trauma informed services have been strongly advocated for incarcerated women (Bloom, Owen, & Covi ngton, 2003 ; Fournier, Hughes, Hurford, & Sainio, 2011; Laux et. al, 2008 ) given that motivations for, and victims of, crimes perpetrated by women frequently differ from male perpetrated crimes (e.g. Pollock & Davis, 2005; Kruttschnitt, Gartner, & Ferraro, 2002). Also gender differences have been found in comparisons of background and incarceration experiences of men and women (e.g. Messina, Burdon, Hagopian, & Prendergrast, 2006; Raj et al., 2008; Fazel, Bains, & Doll, 2006; Kubiak, Beeble & Bybee, 2010; J ames & Glaze, 2006). Gender - responsive interventions focus on empowerment and improving problem solving, self - image, and 105 self - efficacy, based on understanding the pathways to crime common for women include their high rates of victimization, mental health d istress and substance use disorders (Chesney - Lind & Pasko, 20 13 ; Bloom, Owen, & Covington, 2003; Green, Miranda, Daroowalla, & Siddique, 2005). Beyond Violence (Covington, 2011) is based in t rauma theory (Herman, 1992,1997) and incorporates a guiding tena nt that experiences of trauma influence both perceptions of and reactions to life events (Kendall - Tackett, 2000). This trauma - informed approach incorporates an understanding that early or ongoing exposure to traumatic events can result in mental health dis tress (Breslau et al. 1999; Ehrensaft, Moffitt, & Caspi, 2006 ; Horwitz et al. 2001; Molnar, Buka, & Kessler 2001), repressed anger ( Cougle, Timpano, Sachs - Ericsson, Keough, & Riccardi, 2010 ; Neumann, Houskamp, Pollock, & Briere, 1996 ; Newman & Peterson, 1996 ; Springer, Sheridan, Kuo, & Carnes, 2007 ) and the use of alcohol and other drugs as ways of coping and responding to trauma (Hedtke et al., 2008; Najavitis, Weiss, & Shaw, 1997). Likewise, these factors have shown significant associations with violence p erpetration by women: serious mental illness and symptoms of depression, anxiety, and PTSD (Goldenson, Geffner, Foster, & Clipson, 2007; Kirby et al., 2012; Logan & Blackburn, 2009; Silver, Felson, & Vaneseltine, 2008); anger expression as highly suppresse d or highly expressed (Maneta, Cohen, Schulz, & Waldinger, 2012; Swan, Gambone, Fields, Sullivan, & Snow, 2005; Wolfe, Wekerle, & Straatman, 2004), and substance abuse (White & Widom, 2003). Also, these factors have shown significant associations when stud ied individually and when studied in tandem as a conceptual model of Snow, 2006). 106 In addition to a foundation in trauma - theory, Beyond Violence is centered in the socio - ec ological model of violence prevention (Dahlberg & Krug, 2002) endorsed and utilized by the World Health Organization. Violence is defined in this model as falling into three broad categories: self - directed violence, interpersonal violence, and collective v iolence. This model incorporates addressing risk factors for violence prevention, which are the same for violence victimization and perpetration. Likewise, the socio - ecological model of violence prevention acknowledges risk factors on individual, relationa l, community, and societal level and organizes the curriculum content into these four areas . The content of the intervention was developed after an extensive review of existing interventions, focus groups conducted with likely participants about the materi al (e.g. psycho - education and activities), and discussions with professionals (treatment and criminal justice oriented). Beyond Violence utilizes a multimodal approach and a variety of evidence - based therapeutic strategies (i.e., psycho - education, role - pla ying, mindfulness activities, cognitive behavioral restructuring, and grounding skills for trauma triggers) to address issues of mental health, substance abuse, trauma histories, and anger regulation. This 20 - session group intervention is designed to be de livered by a trained professional with a group size of 8 - 15 women. Each session lasts approximately 2 hours. Beyond victimization histories , gender socia lization, and co - occurring substance use and mental health d isorders in order to prevent future violence and Current Study Thus far, Beyond Violence has demonstrated efficacy with positively influencing - related outcomes in both the therapeutic treatment unit of prison (Kubiak, Kim, Fedock, & Bybee, 2012) and in general population (Kubiak, Kim, F edock, 107 & Bybee, 2014) with women convicted of violent offenses. For the pilot testing of Beyond Violence, three groups of women with violent offenses were utilized, which included a small sub - sample of eight incarcerated women with life sentences (Kubiak, Fedock, Tillander, Kim, & Bybee, 2014). This small sub - sample had higher scores on measures of mental health and showed a significant decrease in PTSD symptoms when compared to women without life sentences (Kubiak, Kim, Fedock, & Bybee, 2012). F eedback from the women with life se ntences in the pilot groups was elicited in order to make the Beyond Violence content applicable and relevant for women with life sentences. (Owen, Wells, Pollock, Muscat, & Torres, 2008), this study focused mainly on the mental health and anger - related outcomes of Beyond Violence with this population of women. It is seemingly the first study to utilize a treatment sample of only women with life sentences and to investigate ou tcomes specifically for these women. This study examines the short - term outcomes related to changes in mental health symptoms and anger experiences and expressions for two Beyond Violence treatment groups of incarcerated women with life sentences. The rese arch questions for this study were: 1) Do mental health symptoms of anxiety, depression, PTSD, and serious mental illness improve for incarcerated women with life sentences after participating in Beyond Violence?; 2) Do forms of anger and anger expression change after participating in Beyond Violence?. Also, based on the current research that differences may exist between women new to prison and those who have been in prison for a long period of time, the last research question is: 3) Are there differences in mental health and anger - related outcomes for women based on the length of time served? 108 Methods Study Design This study had a pretest - posttest design (Shadish, Cook, & Campbell, 2002). A survey was administered by the research staff prior to the start o f treatment, at the end of treatment, and three months following the end of treatment. A sample of 26 incarcerated women was divided into two Beyond Violence treatment groups (Group A with 14 women; Group B with 12 women) with no control group. This study was part of a larger multi - phase intervention study, and all study procedures were approved by the Institutional Review Board at Michigan State University, which included review by a prison advocate. Participants An initial random sample of 68 women with life sentences was utilized in order to form with life sentences are typically not included in treatment groups within this prison, the sample of women met the resea leadership. Correctional administrators worked with research staff to determine women who met criteria for group inclusion. Criteria included: (1) currently housed in a lower secu rity level; (2) absence of major misconduct tickets in the previous eighteen months and a need for substance abuse treatment; and (3) currently serving a life sentence (with or without possibility of parole) for a violent offense. From the list generated b y the prison administrators, women were stratified on amount of time served and then assigned to the treatment groups such that the groups were equivalent in amount of time served. Prison administrators also prohibited certain relational dynamics within th - 109 availability for group participation on the chosen day/times for the treatment; women who had wo rk conflicts were considered ineligible. Research staff held an informational meeting with the remaining eligible women (n=28) to discuss their possibility of participating in a Beyond Violence treatment group, provide an overview of the process and speci fic information about the study, and gather informed consent from women who were interested in the intervention. Of the 28 women called - out for this meeting, three women did not attend, and a second informational meeting was held with these three women at a subsequent date. After these two informational meetings, a total of 26 women agreed to participate after one woman declined to participate and one woman was ineligible. All women were living on the General Population unit of the prison. Likewise, all wom en had been convicted of murder; however, 15 of the women serving life sentences were convicted of first degree murder (i.e. premeditated or intentional murder) and 11 were convicted of second degree murder (i.e. unplanned, unintentional murder or murder d ue to reckless or neglectful behavior). The characteristics of this sample (see Table 4 ) are reflective of overall characteristics of incarcerated women with life sentences (Nellis, 2013). Procedures As is standard in intervention research (Fraser et al, 2 009), pre - and post - tests were used research team (who was not involved in the treatment groups) met with women at three time points for survey collection: (1) b efore the first group session; (2) at the end of the intervention; and (3) three months after the end of the group. The same facilitator conducted both treatment groups and had an extensive, over ten - year clinical experience background with women involv ed in the criminal justice system. The groups 110 did not occur completely simultaneously; Group 1 lasted from July - September 2012 and Group 2 occurred o from August - November 2012. Both groups met twice a week for one and half hours per session. P rison policy d ictated that women could not miss more than two group se ssions in order to participate; women attended an average of 19.42 sessions out of the 20 sessions. Table 4 : Participant D emographics a nd Background E xperiences Frequency % Conviction First Degree Murder Second Degree Murder Sentence Life with Opportunity for Parole Life without Opportunity for Parole 15 11 17 9 57.69% 42.31% 65.38% 34.62% Race Black women White women 13 13 50% 50% Time Served (# of Years Incarcerated) >10 years <10 years 10 16 38.46% 61.54% Marital Status Single Married/Partner Separated/Divorced 20 3 3 76.92% 11.54% 11.54% Mothering Children, Minors Children, Not Minors No Children 11 11 4 42.31% 42.31% 15.38% Trauma Histories Childhood Emotional Abuse Childhood Physical Abuse Childhood Sexual Abuse Any Childhood Abuse Intimate Partner Violence Adult Victimization (not - IPV) Any Trauma 19 15 22 24 19 14 26 73.08% 57.69% 84.61% 92.31% 73.08% 53.85% 100% Perpetration Histories Physical Violence (Partner) Physical Violence (Other) Both Partner and Other Uncaught Violent Behaviors 11 8 5 13 42.31% 30.77% 19.23% 50% 111 Measures The survey used at each time point included measures assessing various constructs of mental health (i.e., depression, anxiety, PTSD and serious mental illness) and types of anger and anger expressions. These measures were used to examine differences over t ime. Depression . The Patient Health Questionnaire: Depression Subscale (Kroenke, Spitzer & Williams, 2001) is a 9 - item subscale that assesses the number of depression symptoms experienced in the prior two week period. This scale has been used to measure depression with multiple population s including adults with offense histories, incarcerated youths, and incarcerated women (Domalanta, Risser, Roberts, & Risser, 2003; Kubiak, Kim, Fedock, & Bybee, 2012). erest or pleasure in doing - onses were summed to measure the severity of depression - .90 with this sample. Anxiety . The Patient Health Questionnaire: Anxiety Subscale (Spitzer, Kroenke, & Williams, 1999) is comprised of 7 - items that examine the number of anxiety symptoms over the determine if par ticipants had experienced anxiety symptoms over the prior four week period. m with a response on a 4 - - .88 with this sample. 112 Post - Traumatic Stress Disorder/PTSD . The Short Screening Scale for DSM - IV Posttraumatic Stress Disorder (modified version, Breslau, Peterson, Kessler, & Schultz, 1999) was an 8 - item measure that collected current PTSD symptoms. This measure has been used for detained youth and women involved in the criminal justice system ( Abram, Teplin, Charles, Longworth, McClelland, & Dulcan, 2004 ; Kubiak, Beeble, & Bybee, 2010 ) The first item was a screening question to determine if participants were ever exposed to a traumatic event; your life, have you ever had any experience that was considered frightening, question were then asked to answer the remaining seven items, which included items such as, Respondents provided responses on a 4 - Serious mental illness/ SMI . The K6 (Kessler et al., 2002; Kessler et al,. 2003) is a brief 6 - all mental health and examines their level of ents provided responses to items on a 5 - point Likert scale of frequency State and trait anger . The State - Trait Expression Inventory 2 (STAXI - 2; Spielberger, 1999) is used to measure the experience and intensity of anger as an emotional state and as an emotional trait. This instrument has been commonly and widely used f or the measurement of the 1 13 exp erience and expression of anger among incarcerated men and women ( Dear, Thomson, Howells, & Hall, 2001 ; Fernández - Montalvo, Echeburúa, & Amor, 2005 ; Schützwohl & Maercker, 2000 ; Suter, Bryne , Bryne, Howells, & Day , 2002). The test - retest reliability of thi s instrument has also shown to remain stable over time (Bishop & Quah, 1998; Jacobs, Latham, & Brown, 1988). The STAXI - 2 was included to explore changes in the experience of, responses to, and the expression of anger, mainly through the constructs of state anger (i.e. anger as a temporary emotional state) and trait anger (i.e. intensity of anger as a constant component of the personality). The 57 - item STAXI - 2 includes six scales, five subscales, and an Anger Expression Index. The State Anger scale assesses the intensity of angry feelings at a particular time, specifically the present moment . High State Anger scores translate to having experienc es of relatively intense angry feelings. The State Anger scale consists of 15 items in three subscales, Feeling Ang ry, Feel like Expressing Anger Verbally, and Feel like Expressing Anger Physically. - point Likert scale ranging cale ranged from .91 to .97 with this sample T he Trait Anger scale measures how the respondent feels anger over time and perceives this anger. H igh Trait Anger scores indicate that a respondent may feel frequently and persistently angry feelings and often fe e l treated unfairly by others. The Trait Anger scale consists of 10 items in two subscales, Angry Temperament and Angry Reaction. Participants rate - 114 Four sub - scales assess the expression and management of anger: Anger Expression - Out, Anger Expression - In, Anger Control - Out and Anger Control - In. Each sub - scale is comprised of 8 items. Anger E xpression - O ut measures the expression of anger toward other persons in the environment , and high scores indicat e frequent use of aggressive behaviors as an expressi on of anger . d from .61 to .77 for this sample. Anger Expression - I n measures the angry feeling s directed inwar d, and high scores correspond to having intense angry feelings, but with the tendency to suppress these feelings rather than expressing them either physically or verbally. - scale ranged from .68 to .81 for this sample. Anger Control - O ut is related to behaviorally preventing the expression of anger toward other persons or objects in the environment , and higher scores are typically fav orable as they display a monitoring of angry feelings and preventing of aggressive outward anger expression. - scale ranged from .87 to .93 for this sample. Anger Control - I n is related to the control of suppressed angry feelings by calming down or cooling off when angered. Persons with high Anger Control - I n scores tend to calm down and reduce their anger quickly . - scale ranged from .93 to .95 for this sample. For each of these sub - scales, participants rate how they generally react in certain situations on a 4 - for these four scales . Analysis Preliminary analysis was conducted using paired - samples t - tests to examine differences in mental health and anger - related measures across all participants over time. To confirm and further test these results, multilevel modeling (MLM; Raudenbush & Bryk, 2002) was used for final analysis, in effect taking into account that repeated measures are nested within individuals. MLM is currently suggested in treatment studies for an analysis of longitudinal data with 115 repeated measures (Nash, Kupper, & Fraser, 2004). The intraclass correlation (ICC) ranged from .40 to .71 for all outcome variables, indica ting that substantial proportions of variance were accounted for by grouping of observations within women, thus confirming MLM as an appropriate analytic strategy. Also, the number of months between the baseline and the end of treatment survey ranged from 2.56 months to 2.93 months, with a mean of 2.76 months ( SD =0.19) and between the baseline and final follow - up survey, the number of months ranged from 5.93 to 7.63 across women, with a mean of 6.72 months ( SD= 0.42). In addition to appropriately handling dependencies in repeated measures data, MLM allows for variability in the timing of the collection of measures across participants over time and accommodates missing data.MLM shows the relationship and type of change b examining the changes in the slope, taking into account at what point each woman started. This two - level MLM incorpo rated three assessments collected over three time points (Time=Level 1) for each of the 26 participants in the sample (Participants =Level 2). For Level 1, Time was measured as number of days since the pre - test survey and centered on the pre - test. The MIX ED procedure in SPSS was utilized for this analysis (IBM SPSS Statistics, version 22.0; Peugh & Enders, 2005). The models included random intercepts. A comparison of models with random and fixed slope effects was conducted and the model with the best fit a ccording to Likelihood Ratio Chi - Square was chosen. For all models, a quadratic term (e.g. converting time into a power polynomial) was tested, but no significant quadratic trends were found with any of the models. The results presented below are based on models with Time centered on the pre - test assessment; however, analyses were also run with the results centered on the post - tes t with similar results found. To test for diffe rences in outcomes between women 116 based on the length of time served ( short versus a long time served ) , the grouping variable was added to the best - fitting model for each dependent variable. This variable was given the label of having served more than 10 years of their life sentence. Additional analysis included probing significant 2 - way interaction effects in order to fully explore the direction and significance of the simple slopes for each group (Preacher, Curran, & Bauer, 2006). Surveys were c ollected from all 26 women at the pre and post - test time points. However, two women were unable to complete their surveys at the three month time point; one woman who undergoing chemotherapy which confined her to her cell and another woman declined to part icipate in this final assessmen t. Also, at each time point, some women chose not to answer some survey questions - however, a majority of questions were answered . Taking into account the data from all three time points, square =148.58, df = 2618, p =1.00). All c ases were included in the analysis, and in consideration of the small sample and other issues, a res tricted maximum likelihood (REML) approach was used for estimation (Snijders & Bosker, 1999). For this sample of 26 women, power estimation for multilevel analyses was conducted with Optimal Design Software (Raudenbush et al., 2011). This showed that the s ample of 26 would provide statistical of power of .8 to detect as significantly different from zero at two - tailed p<.05 a large slope effect (i.e., accounting for at least 17% of the variance with ICC of .40; 20% with ICC of .70). For detection of differen ces between groups who had served long vs. short amounts of time, the minimum detectable effects would be larger, accounting for at least 25% of the variance. 117 Results Participants Demographic and background characteristics of the part icipants are reported in Table 4 . The mean age for the sample was 42 years old ( SD = 9.48 years; range 22 - 60) and the average length of time served in prison was 14.35 years ( SD = 8.95 years, range 1 - 38 years). The two treatment groups were relatively equivalent in regards to the stratification variables used for randomization; the groups did not significantly differ in average age or length of incarceration. All women were convicted of homicide. Therefore, the analyses were conducted with data combined from both groups of women. W outcomes at pre, post, and 3 month follow - up time points are reported in Table 5 . These scores had served less than 10 years went from an average depression score of 10.10 ( SD =6.37) to 5.70 ( SD =5.52). The clinical cut - off score for major depression is 10 or higher, indi cating the average score fell below the clinical cut - off over time (Kroenke & Spitzer, 2002). P reliminary Paired Sample T - Tests Results for Changes for All Women over Time The results of the initial paired sample t - tests are reported in Table 6. For mental health measures, significant score changes were found for serious mental illness at both post - test and the 3 month follow - up time point. Significant changes in scores were also found for PTSD from pre - test to the 3 month follow - up time point. F or the anger - related measures, significant changes were found for Trait anger, as well as Anger Control In and Anger Control Out from the pre - test to the post - test time point and also from the pre - test to the 3 month follow - up time point. 118 Table 5 : Me ntal H ealth an d Anger Outcome Variables across T ime for All W omen Baseline Post - BV Follow - Up Mean SD Mean SD Mean SD Depression 1 - 9 years served 10+ years served 7.19 10.10 5.38 5.80 6.37 4.75 5.46 6.40 4.88 6.00 7.04 5.41 5.25 5.70 4.93 5.14 5.52 5.05 Anxiety 1 - 9 years served 10+ years served 5.42 7.80 3.94 4.51 4.64 3.87 4.42 5.80 3.56 4.73 5.82 3.85 4.96 4.50 5.29 5.39 5.56 5.44 PTSD 1 - 9 years served 10+ years served 6.65 9.50 4.88 5.07 5.60 3.90 5.34 6.00 4.94 4.90 5.35 4.72 4.88 4.90 4.86 4.50 4.66 4.56 SMI 1 - 9 years served 10+ years served 7.35 10.40 5.44 5.54 5.37 4.87 5.35 5.50 5.25 6.17 5.91 6.52 5.88 6.50 5.43 6.28 7.34 5.65 Trait Anger 1 - 9 years served 10+ years served 15.69 16.80 15.00 5.11 5.75 4.72 13.15 13.40 13.00 3.99 4.14 4.01 12.92 13.00 12.86 4.60 5.68 3.88 State Anger 1 - 9 years served 10+ years served 20.04 20.90 19.50 6.94 9.10 5.47 18.85 20.20 18.00 5.91 7.90 4.34 20.13 20.80 19.64 9.60 9.64 9.91 Anger Expression Out 1 - 9 years served 10+ years served 13.88 15.00 13.19 3.35 3.80 2.95 13.04 12.90 13.13 3.78 4.33 3.54 12.79 13.00 12.64 3.08 4.00 2.37 Anger Expression In 1 - 9 years served 10+ years served 16.11 18.30 14.75 4.62 5.32 3.66 15.42 17.90 13.13 4.45 4.61 3.69 17.04 17.60 16.64 5.83 5.99 5.92 Anger Control Out 1 - 9 years served 10+ years served 21.65 21.90 21.50 6.25 6.89 6.04 24.04 24.20 23.94 6.96 7.42 6.90 24.75 21.70 26.93 5.77 5.89 4.76 Anger Control In 1 - 9 years served 10+ years served 22.50 21.60 23.06 7.38 7.55 7.46 25.73 25.90 25.63 6.58 6.38 6.91 26.88 23.30 29.43 6.15 6.40 4.67 119 Table 6 : Paired - Samples T - Tests Results for Mental Health and Anger Measures for All W omen over T ime Pre/Post Tests Pre/Follow - Up Tests Pre - Test Mean (SD) Post - Test Mean (SD) Test Statistic ¹ Effect Size ² Pre - Test Mean (SD) Follow - Up Test Mean (SD) Test Statistic ¹ Effect Size ² Depression 7.19 (5.80) 5.46 (6.00) 1.65 0.32 7.19 (5.80) 5.25 (5.14) 1.68 0.34 Anxiety 5.42 (4.51) 4.42 (4.73) 1.35 0.26 5.42 (4.51) 4.96 (5.39) 0.38 0.07 PTSD 6.65 (5.07) 5.34 (4.90) 1.61 0.31 6.65 (5.07) 4.88 (4.50) 2.25* 0.46 SMI 7.35 (5.54) 5.35 (6.17) 2.11* 0.41 7.35 (5.54) 5.88 (6.28) 1.23* 0.25 State Anger 20.04 (6.94) 18.85 (5.91) 1.32 0.26 20.04 (6.94) 20.13 (9.60) - 0.297 0.06 Trait Anger 15.69 (5.11) 13.15 (3.99) 3.91* 0.77 15.69 (5.11) 12.92 (4.60) - 2.86* 0.58 Anger Expression Out 13.88 (3.35) 13.04 (3.78) 1.72 0.34 13.88 (3.35) 12.79 (3.08) 1.37 0.28 Anger Expression In 16.11 (4.62) 15.42 (4.45) 0.87 0.17 16.11 (4.62) 17.04 (5.83) - 0.62 0.13 Anger Control Out 21.65 (6.25) 24.04 (6.96) - 2.49* - 0.49 ³ 21.65 (6.25) 24.75 (5.77) - 2.05* - 0.42 ³ Anger Control In 22.50 (7.38) 25.73 (6.58) - 2.75* - 0.54 22.50 (7.38) 26.88 (6.15) - 3.07* - 0.63 *: p<. 05 , **: p< .0 1 , ***: p<.001 ¹ T - value from paired samples t - test, df =25 120 Changes in Mental Health and Anger Outcome Variables over Time The results of MLM analyses on each of the outcome measures are summarized in Table 7 . The first set of columns lists the intercept terms, which were estimated as random and centered at the pre - intervention time point. For example, o n average, the women sc ored 6.65 on the depression measure, which is significant (e.g. sig nificantly different than zero). Average scores were found to be significant for all measures, but this result is not necessarily informative. The second set of columns lists the slope coefficients describing the trajectory of change over time. In most cases, slope terms were estimated as fixed; for two dependent variables, slopes were estimated as random. The mental health outcome variable slop e coefficients were negative, indicating that the scores of mental health symptoms decreased from the pre - test to the 3 month follow up assessment. However, none of these slopes were significantly different from zero. For the types of anger related variabl es , the slope coefficients for Trait anger were also negative, indicating the desired decrease in this types of anger. This decrease for Trait a nger was significant over time. Unlike Trait anger , State anger showed an increase, yet this change was not sign ificantly different than zero. In terms of forms of anger expression , the coefficients for the variable of Anger Expression Out decreased, meaning a lessening of physical acts (such as pushing, yelling) to express anger while the slope coefficients for Ang er Expression In increased . However, neither of these changes were significantly different than zero. Lastly, the coefficients for Anger Control Out and Anger Control In increased, and for Anger Control In, this change was significant, indicating positive changes in skills of managing and defusing anger. 121 Table 7 : Multilevel Analysis of Mental Health and Anger Outcomes over T ime (2 - level Multilevel M odels) Intercept at the Baseline Time Point Time B sig se B S ig se Depression 6.65 *** 1.01 - 0.24 0.16 Anxiety 5.06 *** 0.90 - 0.03 0.14 PTSD 6.17 *** 0.90 - 0.19 0.14 SMI 6.58 *** 1.14 - 0.10 0.15 State Anger ª 19.49 *** 1.34 0.07 0.29 Trait Anger 15.12 *** 0.86 - 0.38 ** 0.12 Anger Expression Out 13.69 *** 0.65 - 0.11 0.08 Anger Expression In 15.67 *** 0.91 0.16 0.15 Anger Control Out 22.45 *** 1.22 0.31 0.31 Anger Control In 23.26 *** 1.22 0.58 ** 0.18 *: p<. 05 , **: p<.0 1 , ***: p<.001 a. For this dependent variable, the random slope model was used as it was estimated through the Likelihood Ratio Chi - Square comparison test to be the best fit. For all other dependent variables, models with a fixed slope were used as they were estimated to be the best fit. Changes in Mental Health and Anger Variables over Time by Amount of Time Served The results of MLM analyses for all measures including the covariate of length of time served are reported in Table 8 years (coded 0) and more than 10 years (coded 1). Women who had served less than 10 years started Beyond Violence with higher scores on all mental health measures . They were significantly hi gher on scores of anxiety ( - 4.08, SE =1.82, p =0.03), with scores approaching significant difference for depression ( - 3.87, SE =2.05, p =0.07) and PTSD ( - 3.37, SE =1.85, p =0.08). [Note that the negative coefficients indicate higher levels for this group, which was coded 0.] Also, for women who had served less than 10 years, t he rate of change was significantly different than zero for depression (an average decrease of 0.58 points per month, SE =0.24, p =0.02), anxiety (an average decrease of 0.47 points per month, SE = 0.21, p =0.03), and PTSD (an average decrease of 0.48 points per month, SE =0.21, p =0.03). The monthly average 122 rate of change for serious mental illness approached significance for women who had been in prison for less than 10 years ( - 0.41, SE = 0.23, p =0.08). These findings suggest that time served is a variable that could be treated similarly to a control variable. Thus, this allows for revealing the main effects of the Beyond Violence intervention. The results displays in Table 8 show that there were significant decreases in the mental health measures, indicating potential positive effects of the intervention. Table 8 : Multilevel Analysis of Mental Health and Anger Outcomes over Time by Length of Time S erved ¹ Intercept Time Years Time * Years B s ig se B sig se B sig se B sig se Depression 9.01 *** 1.61 - 0.58 * 0.24 - 3.87 2.05 0.59 0.32 Anxiety 7.54 *** 1.43 - 0.47 * 0.21 - 4.08 * 1.82 0.76 ** 0.27 PTSD 8.23 *** 1.45 - 0.48 * 0.21 - 3.37 1.85 0.49 0.27 SMI 8.72 *** 1.84 - 0.41 0.23 - 3.53 2.35 0.55 0.31 State ª 20.61 *** 2.18 - 0.00 0.47 - 1.82 2.78 0.12 0.61 Trait 16.02 *** 1.41 - 0.50 ** 0.18 - 1.48 1.80 0.22 0.24 Expression Out 14.48 *** 1.08 - 0.26 * 0.12 - 1.32 1.37 0.27 0.16 Expression In 18.28 *** 1.42 - 0.11 0.23 - 4.27 ** 1.81 0.45 0.30 Control Out 23.68 *** 1.98 - 0.08 0.25 - 2.06 2.53 0.66 * 0.33 Control In 24.45 *** 1.98 0.19 0.28 - 2.00 2.53 0.68 0.37 *: p<. 05 , **: p<.0 1 , ***: p<.001 ¹ Length of time incarcerated (Years) was categorized into 0= Less than 10 years; 1= 10 years or longer. ª For this dependent variable, the random slope model was used as it was estimated through the Likelihood Ratio Chi - Square comparison test to be the best fit. For all other dependent variables, models with a fixed slope were used as they were estimated to be the best fit. Significant interactions of time and length of time incarcerated were found for anxiety ( B =0.76, SE =0.27, p =0.008), and approached significant for depression ( B =0.59, SE =0.32, p =0.08), PTSD ( B =0.49, SE =0.27, p =0.08) and serious mental illness ( B =0.55, SE =0.31, p =0.08). The simple slopes for anxiety showed that the score for women who had served less time significantly decreased ( - 0.47, z = - 2.35, p =0.02) while the score for women who had served more time increased and appr oached significance (0.29, z=1.6743, p=0.09). The plot of changes 123 over time for both sub - groups is presented in Figure 5 . [Note that the plots are constructed with the x - axis covering the full range of time and the y - axis displaying only the observed range - this which was done to provide maximum visibility of this interaction.] For depression, serious mental illness, and PTSD, women who had served a longer period of time did not show changes significantly different from zero. In regards to the anger variab les , women who had served less than 10 years started Beyond Violence with higher scores on all anger measures, and were significantly higher on scores of Anger Expression In ( - 4.27, SE =1.81, p =0.02) than women who had served over 10 years in prison. For wo men who had served less than 10 years in prison the rate of change was significantly different than zero on Trait anger (an average decrease of 0.50 points per month, SE =0.18, p =0.009) and Anger Expression Out (an average decrease of 0.26 points per month, SE =0.12, p =0.03). Significant interactions were also found for Anger Control Out ( B =0.66, SE =0.33, p =0.05), and approaching significant for Anger Expression Out ( B =0.27, SE =0.16, p =0.09) and Anger Control In ( B =0.66, SE =0.33, p =0.07). The simple slope for Anger Control Out showed that the score for women who had served longer amounts of time significantly increased over time (0.58, z =2.59, p =0.009) and women who had served less time did not have a significant change. The plot of both sub - groups changes over time for Anger Cont rol Out in presented in Figure 6. [Note that the plots are constructed with the x - axis covering the full range of time and the y - axis displaying only the observed range - this which was done to provide maxi mum visibility of this interaction.] For Anger Expression Out and Anger Control In, women who had served a longer period of time did not show changes significantly different from zero in their scores. 124 Figure 5 : Simple Slope of Anxiety by Women who had Se rved Less Time (1) and Women who had Served Longer T ime (2)ª ª Note that the plots are aligned with the x - axis covering the full range of time and the y - axis covering only the observed points - this was done to provide maximum visibility of this interact ion. 125 Figure 6 : Simple Slope of Anger Control Out by W ome n who had Served Less Time (1) and Women who had Served Longer T ime (2)ª ª Note that the plots are aligned with the x - axis covering the full range of time and the y - axis cov ering only the observed points - this was done to provide maximum visibility of this interaction. 126 Discussion This study examined the mental health and anger related outcomes for 26 women incarcerated with life sentences who completed a new group intervention entitled B eyond Violence. Also, outcomes were assessed and compared for women based on their amount of time served in prison (i.e. women who have been in prison less than 10 years and those who have been in prison for 10 or more years). While this study had a small sample, it offers preliminary indications of intervention efficacy with this underserved population of incarcerated women, as well as provides insight into a trajectory of future work in regards to social work practice, policy, and research with women with life sentences. This new intervention displays some indications of a good fit for this population of women. Beyond Violence is a trauma - informed, gender responsive intervention aimed at violence prevention and targets improving mental health, preventing substance abuse, and lifetimes; a majority of women reported experiences of childhood emotional and physical abuse, sexual abuse, and intimate partner violence. Also, as all women were serving sentences for a conviction of murder, the core component of Beyond Violence in addressing experiences of both victimization and perpetra tion of violence appears to fit with the background experiences of this sample. These high rates of trauma experiences are similar to another study of women with life - prison life experiences ( Leigey & Reed, 2010 ), and extensive trauma histories are not uncommon for women involved in the perpetration of violence (e.g. Magdol, Moffitt, Caspi, & Silva, 1998 ; Swan & Snow, 2006 ; Temple, Weston, & Marshall, 2005 ). Therefore, for social work practice with women with life sentences (and indeed, even more generally, with women 127 convicted of violent offenses) , a trauma - informed approach should be considered as a crucial element, especially with a perspective of understanding the multiple and varied forms of violence women may have experienced. Beyond Violence is intended to decrease symptoms of mental health concerns. While the averages of the mental health outcome scores decreased over time, none of the se changes were significant for all women over time . S ub - group analyses displayed specific dynamics for women who had served less than 10 years of their life sentence. This group of women who had served less time had higher scores for depression, PTSD and serious mental illness and a significantly higher score of anxiety. Likewise, they showed a significant rate of change for depression, anxiety, and PTSD. Thes women with life sentences and suicide risk, women with less time served had a higher rate of sui cide ideation than women who had been in prison longer. However, time served was not a significant factor in predicting suicide ideation. Other contextual factors, such as level of outside support, and mental health concerns (specifically depression) shape Another study found that a longer time in prison (over 5 years) was significant with suicide attempts by women in prison (Clements - Nolle, Wolden, & Bargmann - Losche, 2009). Typically, s erving ten years or longer in prison has been co studies (e.g. Thompson & Loper, 2005). However, it is not fully understand how women serving life sentences monitor or conceptualize time what is the significance of 10 years in prison? For this sample of women, it was common practice within the prison to go to the parole board after serving ten years (regardless of the life sentence). Therefore, more information is needed on 128 prison changes with life events and environmental shifts throughout their prison stay, especially fluxes in support, changes in security levels, release related opportunities (e.g. parole board hearings, legal appeals) and prison programs (e.g. access to visitation programs). This study and existing work suggest that women may benefit greatly from intervention earlier in their prison stay, and more insight is needed into treatment engagement and response for women with longer time served. Based on a qualit ative exploration, women serving lengthy sentences who have been in prison a long time still experience persistent and daily psychological distress (in a different manner than when they first entered prison) related to the deprivations of prison ( Jose - Kampfner, 1990 ) . Interestingly, in this study, women who had served over ten years showed a significant increase in anxiety over time. This finding may suggest a need for changes within the prison environment. A co mmon coping strategy for women in prison is emotionally shutting - down as a way to stay safe (Greer, 2002). Therefore, asking women with life sentences and with a longer history of time served to examine their life histories (including trauma experiences and crime) may require additional time for processing, changes to the prison coping wi th emotional vulnerability. These needs are in alignment with the core principles of gender - responsive services within prison (Bloom, Covington, & Owen, 2003). These studies, taken together, suggest that intervention development work is needed that address experiences over time in prison and with an intervention design with multiple points of intervention. Ongoing support through peer groups, mentoring, and further treatment opportunities may be especially helpful for this population of women, as prison life both changes and remains monotonous. 129 Similarly, for the anger related variables, desired changes in the average scores occurred over time, however, only Trait Anger and Anger Control In were fo und to significantly change for all women. Trait a feeling of constant frustration. It has emerged as significantly mediating the relationship between (Shorey, Brasfield, Febres, & Stuart, 2011). Thus, it has value for a violence - prevention intervention variable. However, one aspect of Trait anger is a perceived sense of injustice (Spielberger, 1999). Given the conditions of prison in terms of overcrow ding, replicating social inequitie s ( e.g. De Viggiani, 2007 ), and human rights violations ( e.g. Culley, 2012; Greer, 2000; Labelle, 2008 ), Trait anger as both a conceptualized personality factor and as an indication of perceived injustice within the enviro nment may represent an intersection of importation and deprivation theories. Thus, anger, for some women, may be an appropriate response given the context and the concept of decreasing feelings of anger for women in prison may benefit from examination of t he personal and political context. perceptions of injustice, prison conditions, and histories of anger, as well as how they navigate these factors while incarcerated. This may also warrant a more nuanced and tailored definition of Anger Control In significantly increased, which is a desired change considering it reflects a skill in anger management (e.g. the ability to cool off, calm down, and self - regul ate suppressed anger with low anger control in addition to experiences of victimization, mental health concerns, and substance use (Swan & Snow, 2003). Therefore, Beyo nd Violence appears 130 involvement in violence. In a prison environment where women are deprived of numerous external resources, the procurement of skills in internal, or intrapersonal, management of anger is seemingly a positive gain and appropriate for the setting. Anger Control Out and Anger Control In are connected to behavioral changes in the sense of relating to the expression of feelings of anger. Notably, women with longer time served showed a significant increase in their Anger Control Out scores, which displays their ability to gain new coping skills and utilize them within the prison. Future research may benefit from exploring further how women navigate their feelings of anger within prison and how they safely express anger in an environment incompatible with emotional expression, especially anger (Greer, 2002). Lastly, while Beyond Violence offers preliminary indicators of efficacy, an overarching issue is t he need for social work policy advocacy to improve prison policies and the treatment of incarcerated women with life sentences. One tangible and crucial policy implication is the need to modify policies that restrict eligibility for women with life sentenc es for treatment - based programming within prisons. Based on a national survey, approximately 62% of prisoners with a life sentence were not involved in treatment - based programming mainly due to prison - based policies prohibiting those with life sentences fr om participating (Nellis, 2012). State - level and prison - specific policies may differ, and social workers should critically evaluate these policies for issues of inclusion and exclusion, quality and duration of treatment, and ultimate provision of treatment . Correspondingly, women with life sentences need to be considered a priority for treatment based intervention; beyond just being placed on a waitlist for group, they may benefit from opportunities to actually engage in treatment. The issue of treatment f or all women in prison is a larger concern for the field of social work to consider in the context of the new 131 containment, custody, control, surveillance, and risk a ssessment and management with intensified bureaucratization ( Adler & Longhurst, 2002 ; Cullen, et al., 2000 ; Feeley & S imon, 1992 ; Pratt, 2000 ; Simon & Feeley, 2003 ) . The new penology discourse has emerged from th e intensified focus on risk management and prisoner security classification, and the shift of emphasis on individual responsibility instead of institution - guided rehabilitation ( O'Malley, 1992 , 1996 , 2000 ) . Thus, social work policy advoc acy requires presenting an ethical, human - rights focused treatment framework (Ward & Birgden, 2007), which includes services for women with life sentences. Future research is needed to continue to ascertain the treatment needs of this sub - population and te st interventions, as well as simultaneous policy advocacy to ensure the translation of clinical research efforts into practice. Limitations As a preliminary and novel study, several limitations require attention. First, this study used a small sample from one prison, making these results non - generalizable. Likewise, the results must be viewed in light of the limited power of the sample size. However, other studies of new interventions have utilized MLM with similar sized samples in order to ascertain outcom es over time (e.g. Goodkind, 2005), and this study sought to utilize rigorous methods in order to most appropriately analyze the data. Thus, this work should be considered preliminary and guide future intervention implementation and testing with this popul ation of women. In particular, larger samples with attention to the length of time women have served will yield further examination into the efficacy of this intervention with this population of women. Given this study was performed in one state prison, de privation factors (e.g. factors related to the prison 132 outcomes. Future studies may include testing Beyond Violence at multiple prisons and within varying security l evels in order to assess these factors and compare outcomes. Second, this study did not have a control group which limits the ability to attribute the changes in measures to Beyond Violence specifically. Given few women had been in a treatment group prior to Beyond Violence, simply the opportunity to be in a group may have influenced their outcomes. Thus, future studies including a control group will allow for comparisons of results with an ability to ascertain the specific effect of Beyond Violence. Last ly, Beyond Violence is primarily a violence prevention intervention. Typically prison - based studies focused on prisoner behavioral change focus on reductions in the number of misconduct tickets as this is especially important for prison administrators (e.g . Van Tongeren & Klebe, 2010 ). For this study, the sample was ultimately authorized by prison administrators and ators Beyond Violence groups with women with non - life sentences.) Therefore, future studies can consider examining this type of outcome, with an understanding of t he often arbitrary and inconsistent nature of tickets (Acevedo & Bakken, 2003; Sexton, 2012), as well as consider Conclusion This preliminary study examines the mental health and a nger related outcomes for incarcerated women with life sentences who completed Beyond Violence. While this study directions for future research, practice, and policy f or this underserved population of incarcerated women. 133 REFERENCES 134 REFERENCES Abram, K. M., Teplin, L. A., Charles, D. R., Longworth, S. L., McClelland, G. M., & Dulcan, M.K. 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Journal of Abnormal Psychology , 113 (3), 406 - 415. 143 CHAPTER 4 : STRATEGIES OF INCARCERATED WOMEN WITH LIFE SENTENCES Abstract Incarcerated women with life sentences are a growing population within prisons that face an uncertain future of either death in prison or a potential release from prison. Likewise, they are a sub - population within prisons with high rates of mental health concerns. Coping str ategies have While other studies have looked at coping in prison for primarily women preparing to re - enter the community , this study specifically explored the coping strategies of incarcerated women wi th life sentences. Through analysis of semi - structured interviews with 23 incarcerated women with life sentences, t he main finding was the pivotal role of how women perceived their life sentence in terms of its duration. This perception ranged from a view of never leaving prison to definitely being released from prison. Distinct coping strategies were linked to each type of the perception of a life sentence. Of note, the most concerning coping strategy suicide ideation was most common for women viewing thei r life sentence as a truly life sentence, especially for women new to prison and early in their sentence. Implications for social work theory, practice, and policy are discussed. 144 Introduction Incarcerated women serving life sentences are a growing su b - population in prisons; from 2008 to 2012, the number of women with life sentences grew by 14 percent (Nellis, 2013). This increase is a reflective of a national issue as one in nine prisoners is serving a life sentence the two - strike law in Georgia and the three - strikes law in Michigan), a life sentence has shifted from indeterminate (i.e. until rehabilitation occurs) to literally the end of natural life (Mauer , King, & Young, 2004; Nellis 2013). While sentencing varies state to state, there are two main potential for a prisoner to be released from prison on paro typically devoid of that potential. On average, a person serving a life sentence is incarcerated for 29 years with little opportunity to be released ( Mauer, et al., 2004 ) . For example, in California, those in prison with a life sentence have an 18% chance of being approved for release by the Parole Board ( Weisberg, et al., 2011 ) , and in Michigan, the chance is 9% ( Levine, 2014 ) making release a rare event. high rate of physical and mental health needs. Women with life sentences arrive in prison with higher rates of psychosocial needs ( Leigey & Reed, 2010 ) . During th eir stays in prison, they describe perpetual psychological distress ( Jose - Kampfner, 1990 ) . As they age in prison, they report a multitude of physical and mental health concerns ( Aday & Krabrill, 2011 ) . One particularly c oncerning issue is the high rates of both depression and persistent suicide ideation for women with life sentences, from the time they enter prison to throughout their stay ( Dye & Aday, 2013 ; Magaletta, et al., 2008 ) ). While they are long - term inmates in prisons, there is 145 li mited information about the psychological health of women with life sentences, especially in regards to how they cope with and respond to feelings of psychological distress in prison ( Dye & Aday, 2013 ; Leigey & Reed, 2010 ) . This lack of research is part of a larger trend of neglecting and rendering invisible this sub - population of women (Dye & Aday, 2013; Owen, 1998). As more women enter prisons with life sentences, prisons will continue to experience increased demands on their physical and mental health care systems. It is imperative to better their mental wellbeing throughout their stays in prison. This study thus seeks t o address this gap in order to inform social work practice (e.g. service provision and intervention development) and policy for this population of women. Background Two explanatory theories exist specifically about factors psychological health in prison: deprivation theory and importation theory. Deprivation theory has the basic premise that the prison deprives individuals of material goods, social acceptance, personal freedom, and heterosexual relatio nships (Sykes, 1958). These deprivations of the prison environment lead inmates to respond with depression, anxiety, anger, mental health distress, violence, aggression and oppositional attitudes ( Parisi, 1982 ; Sykes, 1958 ; Sykes & Messinger, 1960 ) behavioral and emotional distress ( Glass & Singer, 1972 ; Moos, 1976 ) . Many deprivation of corre ctional facility as either having a rehabilitative or custody approach ( Kruttschnitt & Vuolo, 2007 ; Vuolo & Kruttschnitt, 2008 ) ; the level of instit utional overcrowding ( Cox, et al., 146 1984 ; Snow, et al., 2002 ) ( Goodstein, et al., 1984 ; Slotboom, et al., 2011 ) ; separation from children and other outside social supports ( Fogel, et al., 1992 ; Poehlmann, 2005 ) ; and prison policies around visitation and social support ( Pollock, 200 1 ; Themeli, 2006 ) . and past experiences determine their psychological health in prison. In other terms, a prisoner cs that determine how they psychologically respond to prison ( Innes, 1997 ; Irwin & Cressey, 1962 ) as these factors shape their perceptions and responses to stress from th e environment ( Silverman & Vega, 199 0 ) . Therefore, this field of research has utilized demographics as well as factors significantly connected to criminal behaviors (e.g. substance use history) to predict and explain psychological health in prison ( DeLisi, et al., 2004 ; Ellis et al., 1974 ; Harer & Steffensmeier, 1996 ) . For example, having a history of childhood abuse has been linked to both criminal behaviors ( Hen ey & Kristiansen, 1998 ) and poor psychological health in prison ( Islam - Zwart & Vik, 2004 ) . The role of coping s trategies . A specific factor that mediates the relationship between importation/deprivation factors and psychological health is coping strategies ( Innes, 1997 ; Sappington, 1996 ; Zamble & Por porino, 1990 ) . Coping strategies are cognitive and behavioral strategies that an individual utilizes to alleviate and manage stress ( Lazarus & Folkman, 1984 ) . These strategies vary based on the interaction of the individual and environment ( Morrow & Smith, 1995 ) , and change over time in style and personal efficacy ( Liebling, 1999 ) . Existing limited research suggests that women in prison have unique and specific definitions of coping based on their environmental factors and circumstances versus women in the community ( Kubiak , Hanna, & Balton, 2005 ) . Specific forms of coping have been linked with less mental 147 health distress for women in prison ( Negy, et al., 1997 ) . For example, women in prison are aware of stereotypes and perceptions of female inmates as excessively emotional and manipulative of staff and other inmates ( Pollock, 200 1 ; Van Wormer & Bartollas, 2000 ) . They are also aware of the institutional dangers of showing emotion in prison e.g. be ing sent to segregation for anger and thus, often attempt to show no or little emotion while incarcerated and isolate themselves ( Greer, 2002 ) . Considering women in prison are in an environment with little autonomy, control, and support, their previous community - based coping and distress management strategies may not work the same or be successful within the prison setting. These existing studies about coping in prison suggest that coping goes beyond the limited dichotomy of passive/active, emotion/problem focused , adaptive/maladaptive or avoidance/approach coping that are present in the historical and foundational coping literature ( such as Folkman & Lazarus, 1980; Moos, 1993). Avoidance coping is often associated with emotion - focused coping (Folkman & Lazarus, 19 80) that has a goal of avoiding the current stressor and trying to mitigate feelings of stress. In contrast, approach coping is compared to problem - focused coping that is actively working to alter the situation and problem - solve (Folkman & Lazarus, 1980; M oos, 1993). This form of coping has been viewed as more effective as a coping strategy (Folkman & Lazarus, 1980; Lazarus & Folkman, 1984). However, studies consequen ces of forms of coping have found that the dichotomy of forms of coping is limited in examining the efficacy of coping and that attention to context is crucial (e.g. Baynard, 1995; Hill, Hawkin, Raposo, & Carr, 1995; Shorter - Gooden, 2004) It is important t o note that incarcerated women have to cope with struggles from both 148 Negy, Woods, & Carlson, 1997, p. 225). Thus, women in prison have to test, change, and refine their coping strategies, as well as try new strategies, to see how they work and do not work within the prison context ( Greer, 2002 ) . In the existing literature, two for ms of coping strategies emerge coping strategies. Intrapersonal coping strategies . Women employ intrapersonal (or individual - level) strategies to manage their emotion al lives while incarcerated, including engaging in diversion activities (e.g. watching television or reading), spirituals interests (e.g. prayer, meditation), self - reflection (e.g. journaling), and humor ( Greer, 2002 ) . These forms of coping are in alignment with the conceptualizations of passive, emotion - focused coping or avoidance coping strategies. Intrapersonal strategies have been described by women in prison as preferable to sharing their feelings with others and as a safe way to respond to the prison environment and dynamics; this preference is shaped by mistrust of other inmates, the desire to not be seen as weak in prison, and the threat of institutional punishment for displaying negative emotions ( Greer, 2002 ) . Likewi se, these intrapersonal strategies are cited as preferable over sharing with institutional mental health staff as such visits may prolong their prison stay (e.g. may make them look not ready for release from prison). Also, these strategies help women make sense of their situation, lessen depressive feelings and establish hope for the future ( Stringer, 20 09 ) . Interpersonal coping strategies . Interpersonal coping strategies are considered as a form of active, adaptive or problem - focused coping. Women describe attempting to create and sustain relationships (especially those with their children outside of prison) as well as with other inmates despite the lack of support from the prison environment ( Coll, Miller, Fields, & Mathews, 1998 ) . 149 While women experience difficulty and distress in adjusting to separation from their children ( Fogel, et al., 1992 ; Houck & Loper, 2002 ) , having quality and frequent contact with their children decreases this distress ( Tuerk & Loper, 2006 ) . This positive effect has been attributed to mothering providing women purpose and meaning ( Enos, 2001 ; Ferraro & Moe, 2003 ) . Women rely on their relationships with other inmates in order to survive prison ( Hart, 1995; Kruttschnitt, Gartner, & Miller, 2000 ). These inmate - based relationships o ften take the form of family structures often mimicking their families in the community or family structures that allow th em to fulfill aspects that were not fulfilled in their families prior to prison ( Gillombardo, 1966 ; Owen, 1998 ; Trammell, 2009 ) . Also these relationships are in the form of friendships ( Greer, 2000 ; Owen, 1998 ; Severance, 2005 ) and intimate relationships ( Freedman, 1996 ; Hensley, Tewksbury, & Koscheski, 2002 ; Severance, 2005 ; Ward & Kassebaum, 1965 ) . They describe these relationships as crucial for dealing with separations from outside supports ( Severance, 2005 ; Trammell, 2009 ) . However, these supports can be a source of positive feelings when perceived as offering support (Levitt & Loper, 2009) as well as a source of pain, stress, and distress ( Huggins, Capeheart, & Newman, 2006 ) especially when forms of aggression and interper sonal struggle are present within these relationships (Loper & Gildea, 2004; Trammell, 2009). Overall, women who perceive themselves as having supportive relationships report lower levels of mental health distress in prison ( Asberg & Renk, 201 4 ; Bordt, 2012 ; Carcedo, López, Begoña Orgaz, Toth, & Fernández - Rouco, 2008 ; Coll, et al., 1998 ; Greer, 2000 ; Jiang & Winfree, 2006 ) . Coping for the Long - Term: Women with Life Sentences As mentioned previously, increasingly life sentences mean serving a prison sentence until the end of natural life or advanced old age (Mauer, King, & Young, 2004; Nellis & King, 2009). 150 Therefore, women with life sentences are faced with the challenge of coping with prison usually coping (e.g. Negy, Woods, & Carlson, 1997; Greer, 200 2 ), there is an absence of research about how women with life sentences cope in prison. This gap is concerning, given the evidence of persistence feelings of grief and depression reported by the women (Jose - Kampfner, 1990) and the subsequent evidence of hi gh rates of suicide ideation for women with life sentences while in psychological health and how they cope in order to improve their psychological health as they serve a life sentence. Current Study Previous work on women coping in prison with sexual victimization ( Kubiak, Hanna, & Balton, 2005 ) has provided indication of the interconnected relationship between person and environment in shaping coping responses ( Lazarus & Folkman, 1984 ) . Women in prison have specific ways of coping that take into account the dynamics of the specific pris on environment and definitions of safety unique to this environment (Kubiak, Hanna, & Balton, 2007). This perspective goes beyond the limited framework of maladapted versus adaptive coping (or passive/active coping) in order to understand the nuanced, envi ronment - specific coping of women in prison that acknowledges their individual agency, thoughtfulness, awareness of the environment, and context - specific strategies (Kubiak, Hanna, & Balton, 2007). Thus, this study incorporates a foundation in an integrati on of importation and deprivation theories, as well as seeks to expand the understanding of how women with life sentences cope with prison. Specifically, this study seeks to answer the following questions: 1) 151 How do women with life sentences cope in prison ? (2) What importation and deprivation factors influence how they cope? Method Semi - structured interviews were conducted in 2013 with 23 incarcerated women with life . This was a purposeful sample as this study is part of a larger study focused on intervention development for women with violent offenses, for which a random, stratified sample of women with life sentences was selected for involvement. A ll study procedures were approved by the Institutional Re view Board at Michigan State University, which included review by a prison advocate. The sample included women with shorter amounts of time served (less than 10 years) and longer periods of time served (over 10 across the spectrum of time in prison. sentences were approached for an individual semi - structured interview and were informed that participation was voluntary and co nfidential. No incentives were provided, as prison policy prohibited this possibility. Of the 26 women, 23 women (88%) agreed to participate in an interview; for the three women who did not participate, one woman was undergoing chemotherapy and unable to l eave her room, another was in segregation and thus unable to attend an interview, and one woman simply declined. All women in the sample were convicted of homicide; 13 women (56.5%) were convicted of first degree murder and 10 women (43.5%) were convicted of second degree murder. A majority (15 women; 65.2%) were sentenced to life with the opportunity for parole, and the remaining women (8 women; 34.8%) were sentenced to life without the opportunity for parole. A majority of the women (12 women; 52.2%) ide ntified their race as Black, with the rest of the women (11 women; 47.8%) identifying as White. Most of 152 the women (91.3%) were mothers, with over half of them with minor - age children (52.4%). The average age was 42.2 years old, with a range from 22 to 60 y ears old. Women had served a range of time in prison, from 1 year to 39 years, with an average length of stay as 15.3 years inside of prison. Most women (15 out of 23; 65%) of women had served over 10 years in prison. The semi - structured interview includ ed multiple questions ranging from their general wellbeing to specifically how they cope in prison. The questions covered the following topics: how t he women were doing emotionally; how their perceptions of their crimes have changed over time; how they wer e managing their inside and outside relationships (e.g. wi th friends, family, and staff); how their relationships have changed over time; their insights about any particular challenges of a servin g life sentence; how they handle their emotions; and any ser vice or treatment needs they have. Thus, these questions allowed for women to share about importation factors (e.g. pre - prison history factors related to their crime, relationships, trauma experiences, and substance use). Also, women could share about depr ivation factors, such as programming and prison staff. The interviews were conducted individually in a private room within the prison; however, a prison surveillance camera was in the room. Since audio and video recording were prohibited within the prison, all interviews were transcribed through dictation. When possible, the researchers conducted interviews in pairs with one researcher asking questions while the other took word - for - word notes. When only one researcher was present, she would write as the par ticipant responded and often repeat back her notes for accuracy. Such transcription methods have been used with other qualitative studies (Emerson, Fretz, & Shaw, 1995), including those with women in prison with prohibited recording practices (e.g. DeHart, 2008). The interviews ranged from approximately fifteen minutes to seventy - five minutes, and were strategically arranged to try to avoid interruptions by mandatory prison activities (e.g. 153 lockdown, count times.) Institutional Review Board approval was obt ained prior to and maintained during the duration of the study. A pseudonym was assigned to each woman in order to provide confidentiality. Analysis Based on the extensive literature about coping, inductive analysis was utilized in order to s interviews for coping strategies. Open coding and focused coding (Emerson, Fretz, & Shaw, 1995; Strau s s & Corbin, 1998) were conducted in order to explore both how women cope and influences on coping related to importation theory and deprivation theory. The first stage of analysis included coding each interview by the primary researcher and a research assistant. An iterative process of defining and refining codes occurred during the process. Multiple iterations of coding occurred in order to refine the codes, as well as explore patterns within and across cases to look for confirming and opposing themes. This constant comparative Guba, 1985, pp. 334). Initial and integrative memos were crafted throughout the process to record p atterns, as well as nuanced and disconfirming information (Emerson, Fretz, & Shaw, beliefs about their life sentence provided a visual representation of the patterns emer ging from the data. This also became a guide point for reviewing the data and codes to confirm the main patterns. The research team discussed and came to agreement regarding the co des for inter - rater reliability. The research team sought to be cautious in the analysis in regards to statements that were not clearly able to be coded or resulted in discrepancy between the researchers. These statements were re - visited multiple times and in instances during which agreement could not be 154 reached, the differences w ere recorded and the statements were not utilized for the final analysis . There was less than ten percent disagreement in regards to coding . Results with a life sentence. However, patterns emerged in the data that allowed for insight into specific forms of coping adopted by women for particular purposes. While common coping strategies emerged (e.g. avoidance) and mapped onto existing themes in the literature, the role of th e prison environment was essential to these factor determining how women cope with their time in prison was how they perceive their life sentence. This perception incorporated how long - term (or per manent) they viewed a life sentence and the level of hope that they had in regards to getting into three different categories of perceptions: (1) which is a belief that a life sentence means literal ly until the end of natural life with no or very little hope of being released from prison ; (2) which is a belief that having a life sentence means a woman has a chance at being released from prison that release is perhaps a possibility ; and (3) which is a strong belief in being released in the future. These varying perceptions of their sentence and their possibility of release were linked to distinct ways of coping and became the primary organization or structure of subsequent analysis. The Table 7 pseudonym. This visual allows for seeing the patterns between the perceptions and coping strategies. There were no explicit differences for women based their sentence as life with or ife 155 sentence, women with a sentence of life without the possibility of parole are also noted on the table. Table 9 : Coping Strategies by Perception of Life Sentence¹ Coping Strategy Perception of Life Sentence Suicide Ideation/ Self - Harm N(*) D; R(*) Avoidance of Thinking & Feeling - isolate/avoid Keep Busy/ Stay Distracted G; L; N(*); Q(*); S;T(*) R(*) Uncertain of What to Do S K(*) Internal Focus Improve Self/Mental Freedom Release - related Preparation A;B; D; F(*);I; J; W E; H;M;O(*); U(*); V External Focus Outside Relationships Legal case involvement G B; D; J;F(*) C;E;H;M; P;U;V ¹All women have been given a pseudonym. The letters in the box refer to the first letter of a throughout the paper by these assigned pseudonyms: A=Anne; B=Beverly; C=Casey; D =Denise; E=Emily; F=Felicia; G=Gloria; H=Halley; I=Irene; J=Jackie; K=Kathy; L=Lydia; M=Melinda; N=Nancy; O=Olivia; P=Paula; Q=Quinn; R=Rachel; S=Susan; T=Teri; U=Ursula; V=Veronica; W=Wendy This symbol denotes women with life sentences without the possi bility of parole (LWOP). Women reported a range of coping behaviors based on the three main perceptions of a life sentence . For women who viewed a life sentence as literally for life, the common coping strategies were suicide ideation and avoidance of th inking and feeling by staying busy with a focus on day - to - day survival. For women who viewed their life sentence as having a possibility If I get out behaviorally) with th e perspective of a long - term goal of release from prison. Lastly, for women When I leave 156 prison - improvement, as well as a foc us on outside relationships and legal case involvement. It is important to note to three key aspects to Table 9 and the results: (1) the table displays which women described a specific coping strategy and their particular perception of their life sentenc e this display is based on their current coping style ; (2) the table does not display the consistent finding was that women described a connection between suicid e ideation and a following results include historical or past descriptions of this connect ion for suicide ideation iptions of their forms of coping; (3) overall, snapshot of their current coping styles (with some reference to historical coping strategies) and focus on the pa tterns arising from the dynamics of the coping strategies and corresponding perceptions of a life sentence. Each specific perception and the corresponding coping strategies are detailed below, followed by the analysis of importation and deprivation factors that influenced these strategies. Life means Life A group of women perceived their life sentence as a permanent life in prison, meaning that they expected to eventually die in prison and saw little or no hope for release from prison. They detailed specific forms of coping that focused on intentionally avo iding thinking and feeling in regards to having a life sentence, such as with misconduct - inducing behavior (e.g. using substances, fighting), isolating from others, and staying busy. These forms of coping were focused on daily functioning how to make it in the present, with little long - term motivation or 157 little connection to long - term goals. These women also described engaging in suicide ideation, suicide attempts and self - harm behaviors when they had lost hope of leaving prison and perceived prison life as permanent. This form of coping was especially common with women new to prison with a life sentence. Lastly, some of the women with this perception said they did not know how to cope with a life sentence and felt stuck in their lives not knowing exactly ho w to act. Entering prison as the end of life . and the end of Entering prison with a life sentence was perceived as literally ending their lives outside of prison - an end to their outside community life. Also, prison life was not described as offering a worthwhile future, and correspondingly, a life sentence was equated with an end to anything positive and to a real life. As Teri descri essentially, offering no viable life worth striving for inside prison: A lot of younger women with life sentences coming in talk about how they have lost hope ame in, I needed to know that I still have a chance to have a life. (Veronica) Women with this perspective also described a lack of investment in their wellbeing and a lack of motivation for self - In the beginning, I didn't care. I was going to rot in here When I first started my bit, I felt vulnerable and hopeles 158 In particular with this perspective, women detailed engaging in problematic behavior, or behavior resulting in misconduct tickets and segregation. Partly, this was connected to the idea of prison as a negative, hopeless place to live in prison meant to live in a place of disconnection, I had a life sentence and I thought my life was over. It was hard to see any hope in the situation ive, she described her action - I kept getting sanctions. I was arguing with officers, not realizing that I would never win. anger about a life sentence that were described as norm al reaction to a life sentence in prison. As the younger women [having] a hopelessness about them and an idea contributed to them cope The feeling of b eing powerless was common amongst women new to prison with a life sentence, as a life sentence meant a loss of freedom and the possibility of leaving. was angry. I was running and trying to escape I was running in circles to try to get . (Ursula) Having a life sentence was all - in the first two isk . to women responding with suicide ideation and/or attempts. This connection was detailed by wo corresponding coping. This historical pattern was shared by Anne, Beverly, Casey , Halley, 159 in 2011, I tried to commit suicide. I Being suicidal or even more broadly, having a sense of deep hopelessness and the inability to escape the reality of pri son was described as the norm or the expectation for lifers. This was often explained as the automatic response to a life sentence, such the way I act I function normally - , even though suicide ideation was a persistent part of her life - in 150 out of 300 days, I think about killing mys elf The prison norm of suicide ideation amongst lifers was such a pervasive aspect of the prison environment that women started to believe that it was a viable option as a coping strategy. Once one woman does it, we all start thinking about it described the influence of this culture on her own psyche: There are so many suicides in here. You get here and you have a greater loss of self - worth. No one on the outside cares about you no one calling anymore, no visits and you g how they feel and that made me nervous and scared. it go on The per spective of not viewing a life sentence as permanent was explicitly linked to If I felt like I had no hope and no end to this that this is the end, then I would be more hopeless the life I would want to live For 160 everything positive you do, there are 20 other things pushing you down. Like suicide it crosses my mind. I have a strong religious background a nd a fear of God, and I still would have if I While lacking overt suicide ideation or suicide attempt, self - harming behaviors were identified by one woman (Denise) as her coping strategy. She also described this as a common strategy amongst women with life sentences as a way to cope with the reality of life in prison: Now, I am more self - destructive. When I first came in, I had a hard time. I was missing my son, dealing with a life sentence. I was a bulimic and was into self - harm. I receive any help from mental health services. Self - harm is the underside of the prison, especially women with life. A lot of us deal with eating disorders and self - destructive While t his form of coping was not brought up by any other women, this woman mentioned several times that this behavior is one in which many women with life sentences engage. With life in prison, stay busy . descr ibed trying to survive with a distinct coping strategy of trying to stay busy in their daily lives specifically in order to avoid thinking and feeling about their life sentence and the lack of possible release. This form of coping included a basic daily fu nctioning as a goal and an intentional focus on staying busy in order to pass time. Partly, women described avoiding In here, you have nothing else to do but th Notably, this form of staying busy was a day - to - day coping. Likewise, this type of coping was not described as advancing or improving women. It was a way to just do time and to get 161 live t out of a bad situation . She did not bring up any hope of being released from prison nor did she describe any form of personal change. She was sentenced to life without the possibility of parole, which may have influenced this perspective. Gloria describe I take one day at a time - - I have only been in Focusi ng on daily life in prison was explained by Nancy who felt stuck in prison for life as necessary: Everything, for me, revolves around the prison, except I also think about my family and kids, but not really in my everyday life family part of your everyday life here because it would kill you and depress you to think about how you cannot be with them every day. I try to put those things off and move past One specific way to stay busy was to start intimate or romantic relationships with other inmates. This was especially common for women new to prison with a life sentence. Many the women in here come in and start relationships. I It was particularly a norm for women new to prison to cope in this way, as Ursula h a girlfriend and then are used and abused I had real low self - esteem 162 ) Thus, some women had chosen to isolate themselves and avoid relationships (both romantic and friendship). This decision was also linked to the difficulty in getting along with different personalities that having a life sentence was often thrown in their faces as an insult by women without a life sentence. Quinn who had been in prison for almost 20 years described this dynamic as: - young ones in here now - in my unit - they are so ignorant. The first thing out of thei r my cell, watching TV with no one irritating or bothering me. Susan, who had been in for over 15 years, spoke of daily functioning as her main focus, but also felt unsure as to how to function in her daily life in prison. She specified that women with life and in particular, against so many different people. Some people bring in problems. You never know how to deal with people without reacting to every little thing e partly avoided other people as well Therefore, staying busy and alone were ways to avoid not only thinking and feeling, but also to maintain a certain type of behavior and to avoid misconducts. This was not described as for the sake of being viewed as parole - ready, but more to maintain a daily functioning devoid of conflict and distress. 163 Isolation was a pervasive sub - theme with women with this perspective example, Gloria who focused on functioning also emphasized that having visits with her mom, how I get through I [my mother] has [my son] and wants him, then he is hers lost contact or strained contact with outside s with the two oldest me no contact with them the way it is now - it is what it is Thus, there was a sense of life factors not changing with this group of women. If I get out Some women believed that they may get out of prison that a life sentence does not necessarily mean staying in prison until death. This was indicated during the interviews by women usi If I get out Everyone has some opportunity to get out. I have never had the view of being in here all my life. At first, I thought I might never get out, but then I saw lifers go home and I This perception of having a chance of being released was associated with certain copi ng strategies. The corresponding strategies were focused on self - improvement: achieving mental 164 growth and freedom and living in a way that demonstrated being ready for release. This type of coping was beyond daily functioning; it was behaviors that were as sociated with self - improvement with a long - term goal of allowing a woman to be granted release. For example, Felicia described it: I try to keep busy. I read my Word. I have gotten into toxic relationships in the past. But I had to realize that this is not my destiny. I had to focus instead on staying involved in order to better understand me and figuring out why I handle situations that way I do. I needed answers why did I get involved in something useless? Why did I feel my actions did not have serious co nsequences? Women guided by internal development/improvement used these strategies to improve themselves mentally and to prepare to get out of prison. Focus on internal freedom/ mental freedom . For this group of women, some women expressed believing in a possibility of release from prison, and while serving their time, they focused on gaining a sense of mental freedom. While women who expressed the perception of ed to understand and improve themselves by changing the way they think. For example, Wendy was her way to cope. (It should be noted that this theme was also expr essed by women believing they will actually be released from prison.) This group of women viewed serving time as an opportunity for such growth. Irene described her emphasis on personal change: Since I have been in prison, I have found Christ in my life. Before then it was only alcohol and drugs. I had an abusive boyfriend and I have never really been sober. I used from the age of 14 to the age of 45. I never relapsed because I never got sober. I never 165 really got to know who I am. I now have a sense of pea ce. I have never been this free before even though I am locked up. Out there, I was in bondage The drugs and alcohol made me mean. I never got a chance to be me. But now I know that I am not a bad I try to help others when I can. So I have finally gotten to know me. (Jackie) This group of women found ways to use their time in prison. This type of coping strategy focused on self - control and individual level freedom. Focusing on self - change was one wa y to have control over one aspect of being in prison. Emily stated: control you in here, in your head. They may have locked up my body but not my mind. - free. Likewise, despite the lack of formal treatment opportunities, this type of coping allowed women you have to figure out how to keep living and g rowing in your mind because no one is going to do that for you I just do my time and stay doing positive things. This mental freedom and self - improvement allowed a way for women to cope daily and in the long - term in order to prevent the reality of prison from disrupting their psyche, to circumvent prison equating to a dead - end: I keep busy. I always tell women without a lot of time to go t o school, get a job, stay busy. I stay busy from day to night and then I sleep. I wake up and know I did the time. I took make prison a jail, then their time gets hard . ( Beverly) 166 The women expressed that the correctional system does not offer confirmation that they trying to be ready to go even though the prison offers nothing indicative of that other non - lifer inmates reinforced that a life sentence means life, and this group of women found ways to psychologically subvert or transcend that limited belief. We have simpletons here in prison and they want to say something about my case. They will s - day I want to do something new. I was institutionalized on the outside where there w as nothing different. There was nothing I changed. I had a routine. I would get up and do drugs and get the kids up and get them to school and then do a line. I did the same things every day. I won't do it again. I won't become institutionalized . (Halley) present and future with an acceptance of the ambiguity of when she may be released - helped her in her everyday reality. This also kept her connected to her larger goal of release: table to, a reason to aspire to be better. The more quality and values that are put into it, the more 167 your circumstances as an excuse. As this last exampl e demonstrates, women who had the perception of a possible release balance immediate and future benefits to self - improvement, and in doing so, had a drive and purpose for living even while in prison. - Activities for r elease . coping strategy of preparing to footwork in case you are able to leave . any work, education, and program opportunities available within the prison. This involvement also served to keep women out of trouble with correctional staff by preventing them from behaviors they pe rceived as negative, especially substance use: I do as much as I can education, work experiences, as much as I can. The biggest thing always ready to go with clear conduct. Trying to keep my conduct clear keeps me grounded and I think before I act. I try to be ready to go. I got my Associates (degree). I programs now. I am on the softball team the softball team. (Beverly) Thus, women who engaged in this form of coping aligned their perspective of potential release with concrete behaviors. This engagement in behaviors to prepare to leave was promp ted by an internal shift in the perception of time, release, and self - I used to get high in here. I learned to stop doing those types of things when I decided I need to get 168 ready to go possibility of release was internally focused - or sentencing practices, correctional practices, etc.). was perceived as leading women to re - entry it was purposeful and meaningful in relation to long - term plans whereas the staying busy was about everyday functioning and mainly for distraction. With this perspective of potenti al release, everyday activities were linked to a greater purpose of helping women achieve release. Also, it served the purpose of allowing women to make individual - level meaningful changes in their behaviors. This type of coping emphasized personal develop in prison for over 15 years described: was tired of living as that person, as a person not giving a hay about anything, like I was still 15 or 16 years old. Moreover, this perspective gave women motivation to change and engage in different behaviors at the core, to actually change themselves. This allowed them to see themselves as good pe this perspective and resulting coping strategies changed how the women viewed themselves, as I never got a chance to be me. But now I know that I am not a bad person. I think By living a different life inside prison, women saw themselves as fundamentally different and as capable of different activities and even different lives. Women detailed wanting to show t hemselves, their children, and the correctional staff that they were capable of change and acting in different, improved ways in order to promote release 169 from prison. In some ways, the way women described this level of change and form of coping was similar My focus now is to go home to my daughter. This has to stay #1. If I get in a relationship, then that person will take the focus from what matters. Prison relationships are m essy made me stronger and made me see either I can choose to stay here and be a part of this world or show change and be part of society. I have to show where my mind is. I need to When I leave prison Lastly, women who firmly believed they would be released from prison focused on internal self - improvement and parole - ready behaviors, legal case involvement, and external If I go home When I get out Oliva; Paula; Ursula). This group of women holds a strong belief that the y will go home and had similar coping strategies to the women who believe they might be released. For example, in regards to the mental freedom, this is not the end for me. I am not going to be mise Also, in regards to preparing for release, this group of women described similar behaviors geared towards showing they have changed in positive ways. The main difference was a specific focus on actually being released. For example, Halley described her actions as distinctly tied to re - Now I'm getting my GED. I am taking technical and food classes. When I get out Some women described self - change as personally benefici al and the result of getting out as self - directed and in their control. For example, as Emily described it, 170 I do things for me - it has to better me not just for the purpose of them. I have to have goals, plan Similarly, Olivia expressed I have claimed my time and I am working towards getting out. out get no tickets. This group of women not only tried to act in ways that promote release, but they also tried to avoid losing a release that seems feasible. For example, Veronica expects to leave prison because of a federal appeal and she stated: I keep up that mindframe. Now, when I think about doing something, I think what will it get me for t With this group of women with a perception of leaving prison, this perception appeared to be linked to at least some sens e of miscarriage of justice in their case that will be revealed with time. As Melinda described: - To be clear, this group of women did not believe they were completely innocent of any crime or undeserving of prison time. They specifically felt that a life sentence was the error and injustice. This group included women with both first and second degree murder - thus both intentional and 171 unintentional murder . Likewise, many women had co - defendants in their crimes, blurring t he lines of responsibility for the homicide for which they were convicted. angry in general about my situation - Therefore, perceiving the provision of a life sentence as excessive and unjust was part of perceiving an eventual release for some women. Focus on external relationships . While all the women shared about their status with relationships outside of prison, this group of women who believed that they will leave prison explicitly discussed outside supports as a crucial part of coping. It should be mentioned as well that some wom en who believed they might be released also relied on outside supports as a coping strategy. One role of outside relationship was providing support in ways that the prison does not offer to focus women and to give them hope and perspective outside of the c urrent prison situations and environment of hopelessness. Denise repeatedly spoke of the pivotal role of outside relationships: There was a point in time when it seemed like every officer was against me. I felt like it was an explosive environment. The off icers were cussing at me. My fiancée reminded me about what I working for/towards - in my room until everything boiled over and the officers found someone else to pick on. My family is pivotal to maintaini In part, their self - growth focus was described as motivated by and focused on being of benefit to their outside supports. Ursula stressed that 172 as a person. If I am not strong enough, then I get stagnated. I sit back and get selfish, start thinking about it. I have to remind myself that my daughter needs me. Their descriptions of self - growth in the context of benefiting outside relationships offered a - Veronica described: I now picture a future in my mind, before I either. I have higher goals and standards now. I had none before. I am responsible for job never crossed my mind. Now, I th ink about it all the time. I want to have family and my daughter deserves that. Also, this hope of getting out allowed for planning for healing relationships with estranged children. Thus, women expli citly crafted ways to mend these relationships post - release, as detailed by Emily: me help place to stay. 173 Most of the women relying on their outside relationships had a perception of a strong chance of getting out of prison. However, throughout the sample of women, outside relationships were described as precarious. These relationships were described as subject to change and termination, especially as the longer women a re in prison, the greater the risk of them experiencing a death of a support or a reduction in visits. This precarious nature was understood by women, even those early in their sentence. Rachel who had served two years in prison stated: Family support is b they are always crying on the phone. For awhile I was in a space where there was no work pay - which is barely anything. The burden has been lifted since my sister got a job. If you are here for awhile, then people forget about you. That - or something along those lines. A common experience for women with life sentences who are mothers was a loss of cont act and/ still I have no coping skills for th is - and the less money you get. changes either negati vely or positively in these supports. Legal i nvolvement . Women perceiving that they may be released expressed a belief that doing good activities in prison will be or would most likely be rewarded with release. This perception was primarily focused on sel f - control over daily activities. In contrast, women who believed they are going home and who focused primarily on legal involvement as a way to cope 174 I am working on getting my case overturned. There is no evidence supporting my case. I was wrongfully ntailed multiple steps of attempting legal remedies and this involvement offered both current and long - term goals: I try to stay motivated. I try not to get depressed. I have been doing work on my case and trying to get back to court. I have had to save mo ney for a lawyer and I have been trying to get re - My co - (Melinda) Legal case work provided women the opp ortunity to carry out concrete steps that gave them hope of the possibility or the perceived inevitableness of release. Veronica described her home with my dau Daily activities were thus focused on making movement in the process of release. As Ursula also something positive to do. To lay down your options is to see an open door Thus, changes in state policies and legal representations were potential opportunities for women to attempt further legal change for their ca ses. For example, Paula, who has been in for Another woman, Emily, was sentenced for second degree murder and had served 22 years. However, during her time s erved, state sentencing practices had changed so that there was 175 a newly established 15 year cap for second degree murder sentences. She spoke of organizing with her family to write letters and asking for release. Also, Ursula was given a life sentence when she was a juvenile and in the context of a federal lawsuit about juveniles and life sentences, she believed she was because the department of corrections was motion for re - I Coping In regards to importation factors that influenced how women with life sentences experience prison, these factors were coded in relation to answers to specific questions (such as about their crime or family), as well as throughout the entire interview. None of the questions hey primarily shared about trauma from previous relationships (e.g. with family of origin, intimate partners and children) as most of us have experienced [rape], by our husbands, fathers, mothers - and any abuse really, and especially the kind attached to our cases and Casey shared this sentiment here because of bad relation The women described their histories of interpersonal n Beverly) , who are parenting their children). This was especially present in reg ards to relationships within prison. These histories were described as perpetuating abusive relationships inside of prison with other inmates. As Kathy described: 176 people. W e need to know how to experience new things we are used to being hurt. We excuse. We need to learn how to keep ourselves safe. Likewise, they described previous substance use (e.g. I had been getting high since I was 14 years old , Irene) and their previous offense(s) history as influencing their coping strategies. suicide ideation and daily functioning. For example, Nancy who experienced suicidal ideation described accepting things in the past and then also learning how to move on from the past. We are the past life, especially in terms of re - experiencing traumatic memories. In summary, importation factors were present in all of the Deprivation Factors and Coping they perceived as inherent to their sentence. For Kathy in particular, she had a expressed a great deal of uncertai nty about her future and expressed feeling almost paralyzed by not knowing the Do I feel I will stay in here for the rest of my life? No. Do I know fe? No. So, what do I 177 do? s not only a deprivation of release from prison, but also a deprivation of rehabilitative services within prison as these services were reserved for women leaving prison. Prison practices around treatment . Women described wanting rehabilitation and having an understanding of prison as a potential site for rehabilitation but not as a site of rehabilitation for them due to their sentence. Only two of the women in the sample had been able to participate in a formal treatment group through the prison and both of these women had served over 20 years with only one treatment group experience. A majority of the women had never been in a formal prison - based treatment group. They commonly stated that the prison does not offer rehabilitation opportunities (e.g. mental health services, treatment groups, and educational opportunities) inclusively and consistently to women with life sentences. Priority was given to women re - classes, or eve This sentiment of opportunities as elusive was shared by multiple women, as ifers s? They will die here. because we are lifers were perpetually waiting for a treatment group opportunity, which was a key aspect of 178 rehabilitation and would i ncrease the chance of getting out of prison. Kathy further described that n something different with my life. described relying on themselves for rehabilitation, which for some women, was not something , and Ursula stated, There was a sub - set of women who relied on themselves for guiding and ensuring their rehabilitation. For example for Veronica who believed that she will leave prison, she stated that meeting and I never commun icated to them (or even connected for myself) what I expected to change about in my time down. Now, I know I have much work to do to be different. In daily life, this process of self - directed rehabilitation was a way to maintain a sense of self despite th e prison environment. Felicia described: - you have to push for it. I got my GED in the first 6 weeks of being here. I got my associates in four years. I do things for me - it has to better me not just for the purpose of the m. Ultimately, if an opportunity does arise for women to be released, they still have to demonstrate change - however, without structured ways to be rehabilitated through the prison, 179 we get thrown in here and ar e told to rehabilitate The lack of treatment opportunities and constant deprivation were described by Kathy as feels like to walk around in these he avy shoes. including being deprived of the opportunity to be rehabilitated and released. Treatment by prison s taff . A life sentence was reinforced as an actual life duration sentence by some prison staff. For example, Denise described correctional officers telling her role in shaping prison culture, inmate expectatio ns, and environment, two women stated that they explicitly feel as though the prison staff actually want them to feel suicidal. They perceived staff viewing and reinforcing their lives as worthless. Also, their sense of hopeless was not taken as a serious concern by the prison, which was expressed as an area for needed intervention development. Kathy shared: The officers here act like they are above us. They had their Staff Appreciation Day meal one day after a woman killed herself. Sometimes I feel like they want us to kill and tell them if we are having a problem or if we know of someone who is having a problem and be heard about it, taken seriously. It is no joke in here . 180 Ursula expressed that more could be done year - round to addre ss suicide risk: There are certain times of the year where they do rounds every 15 minutes, like the holidays, instead of every 30 minutes because they are worried about it [suicide]. It seriously. people go home even though they had reinforced by decisions made by the parole board, statements by correctional officers, with othe r inmates, and simply the attitudes and ramifications of prison policies and practices as evident through the lack of treatment opportunities. Self - Improvement for p rison . Overall as suggested previously, the continuum of ways to cope in prison with a life sentence could be described as ranging from a non - rehabilitative to a I want to be better myself Even if you are a lifer, you want to make something of yourself en shared an investment in rehabilitation for the sake of improving the prison environment, such as Denise who said: We need groups that build our motivation and care for ourselves. We need a venting group to care about the units we live in we iron, we 181 Likewise, the women expressed wanting prison staff to affirm that even women with life sentences can make a difference within prison and t o offer structured support for this to occur. Ursula suggested that There should be someone in an advisor role, like when you go to school, someone who plans for you. When you are first here, they sit down with you and you set goals and have u need to be able to set - up a plan and see that you are not wasting away a counselor, a therapist to feel like you can be successful because you have a group of people rooting for you. Overall , women described multiple deprivation factors as shaping both their present experiences and future aspirations. Discussion While other studies have looked at coping in prison, this study specifically explored the coping strategies of incarcerated women with life sentences. The main finding was the pivotal role of how women perceived their life sentence in terms of its duration . This perception ranged from a view of never leaving prison to definitely being released from prison. Distinct coping strategies were linked to each type of the perception of a life sentence. Of note, the most concerning coping strategy suicide ideation w as most common for women viewing their life sentence as a truly life sentence, especially for women new to prison and early in their sentence. Other studies have looked at the coping strategies of women who expect to be released (e.g. Greer, 2002; Negy, W oods, & Carlson, 1997). For women with life sentences, the expectation to be released from prison is not necessarily unrealistic, but is also not a guaranteed outcome. With release rates of those with life sentences ranging from 9 to 18 percent (Nellis, 182 20 13), release is a small possibility. A sentiment of ambiguity and uncertainty as well as an amount of variability about the length and meaning of a life sentence was found in this relatively small sample of women with life sentence. This ambiguity is the r eflection of a historical ideology of prison as a site of rehabilitation and the conflicting current status of permanent punishment with a life sentence. This dynamic is eloquently described by Nellis and King (2009): Historically, life sentences were seen as indeterminate, with the possibility of parole as a catalyst for seeking personal redemption and growth. The widespread decline in granting parole, even in cases of clearly demonstrated personal change, undermines the incentive for reform and sends an i nconsistent message to persons in prison regarding how to spend their years behind bars. (p. 35) Thus, with the overwhelming trend of life sentences literally equating to life in prison, what does s evident in this study, women who perceptive is to push aga inst the over - riding penal discourse of life sentences, yet this perspective offers coping strategies that prevent suicide within prison and allow for some self - growth and improvement within prison. The complexity of the lives of incarcerated women with li fe sentences offers insight and implications for social work theory, practice, policy, and research. Implications for Social Work T heory on rehabilitation as a mainly individual - sentencing policy, penal regimes, and individual accountability discourses. Life sentences vary 183 by state in terms of how they are enacted and perceived politically (Nellis, 2013). Given women factor for consideration, as well as the particular culture of their prison. This study re - affirms existing work that posits that coping is situation driven and b ounded within a context, as well as spans beyond a dichotomy of active/passing coping strategies. Thus, continued theory building, micro, mezzo, and macro factors influencing their daily lived experiences and perceptions of the future. The future of a woman in prison with a life sentence is uncertain and subject to changes in perceptions of life sentences. Recently, life sentences for juveniles were debated and dec ided Miller v. Alabama, 2012 ). Some states are re - sentencing those given a life sentence as a juvenile, providing hope to those with life sentences of the possibility of being released from prison. However, the implication of this case is not straightforward nor has it gathered a unified state response. For example, Iowa is resentencing those with life without parole to at least 60 years in prison, the state of Washington is retroactively resentenci ng prisoners, and Michigan has decided not to retroactively resentence prisoners. Given the reality of uncertainty, accommodative coping may be a particularly useful construct for understanding how women serve time in prison, especially with a life sentenc e. This involves adjusting goals to respond to a constant stressor (Brandstadter & Renner, 1990). Thus, future research may examine how women live with ambiguity within a penal setting and how they experience changes in factors such as sentencing reforms, political discourses about life sentences, and parole board decisions. 184 Within deprivation theory literature, inmates who perceive the incarceration environment as not putting them in a state of deprivation have shown better rates of positive psychological adjustment ( Gibbs, 1991 ; Wright, 1991 ) . This study also provides insight into how p owerful the lives in prison. Thus, social work research is needed that broadens how the deprivations of prison settings. Further investigation may benefit from an exploration of deprivations through a human r ights perspective (e.g. Ife, 2012) in order to examine how just and ethical penal practices are in terms of the eff ects on the daily experiences of prisoners. Implications for Social Work Practice This study offers insight into practice with this under - served population of women. Opportunities for purposeful and meaningful daily activities were desired by women in orde r to prevent suicide ideation and to move beyond just functioning within prison. Thus, practice requires an incorporation of not only behavioral strategies feasible for the prison environment, but as connected to larger rehabilitation - focused goals. The im pact of such behaviors may be - board interaction), but also in regards to changes women experience within the prison. Future research may benefit from exploring cop ing that allows for meaning - making interventions ( e.g. Henry et al, 2010 ) within prison and through long - term goals within the intervention framework. Incorporating and improving outside and inside relationships may be a specific area for inte rvention development, . Women rely on outside relationships for motivation to 185 keep growing and improving, as well as to combat the stress of daily prison life. However, it is concerning given that the longer a woman is inside, often the fewer contacts she has. Thus, strategies for ways to grieve and handle loss are also needed components of practice with this population. Similarly, while women rely on legal involvement as a way to cope, practice components should addr research is needed that examines precise changes in outside and legal involvement, as well as successful strategies for handling these changes. Lastly, a focus on healthy relationships wi thin prison was a frequently expressed need by women. Thus, these relationships should also be addressed within intervention development efforts. Likewise, social workers may gain insight into how to work with women in prison experiencing abusive relations hips through existing practice tools (e.g. Kubiak, Sullivan, Fries, Nnawulezi, & Fedock, 2011). Also, social work advocacy is needed in terms of evaluating and expanding existing programs and services within ersections of importation and deprivation factors (such as child visitation programs for women who are mothers in prison and educational opportunities for women with a range of educational backgrounds.) Overall, for social work practice, there is tension a women with life sentences. Social workers have to be aware of the context of a life sentence (e.g. the prison environment, the political meaning, and the possibility of parole on an individual and state - level). This i s a dilemma for practice in terms of what to promote as a healthy goal for women with life sentences there is no indication of such a release? Or do social workers encourage women to only make meaning and goals related to prison life within the framework of prison as a permanent location? Given the suicide - 186 how social workers respond to such risk without giving women false hope of release. Moreover, as influenced by the larger discourse about life sentences and prisoners with life sentences. Social work advocacy and practice models are needed that illuminate the core values of the dignity of the person for those in prison (National Association of Social Workers, 2008). Implications for Social Work Policy In the past four years, there has been a 22 percent increase in the numbe r of individuals incarcerated with a sentence of life without parole (Nellis, 2013). Thus, not only is the number of women with life sentences increasing, but more specifically, the number of women without the possibility of parole is also growing. Therefo contributing to a potential rise in the number of women experiencing suicide ideation on a daily basis in prison. Social work policy is needed with an ethical framework in regards to life sentences and the mental hea lth effects of such a sentence. The United States is the country with the highest rate of life sentences in the world (Nellis, 2013). For example, in England and Wales, in 2013, less than 1 percent of all prisoners were serving whole life sentences ( van Zyl Smit, Weatherby, & Creighton, 2014 ) versus 11 percent of those incarcerated in the United States (Nellis, 2013). The percent for the U.S. does not reflect life sentences that are indirect, meaning very long sentences that are the equivalent to life (e.g. 75 years in prison is not technically a life sentence), whereas in England and Wales, 20 years in prison is viewed as excessive and also rare (van Zyl Smit, Weatherby, & Creighton, 2014). Recently, the European Court of Human Rights declared that all prisoners with life sentences have a right to a potential release from prison and a review by the parole board ( Vinter and Others v. United Kingdom, 2012 ). This case questions the 187 potential right to reh abilitation (van Zyl Smit, Weatherby, & Creighton, 2014) , the need for international intervention with the U.S. prison system ( Bernaz, 2013 ) , and glaring issue of the U.S. as out of sync with and lacking congruency with international prisoner - based human rights (Nellis, 2013). Social work policy advocacy in the area of reforming sentencing practices is greatly needed, as both a human rights concern and a suicide - prevention str ategy. Human rights focused social work may guide this advocacy, especially within the perspective of global sentencing practices. Limitations This study has multiple limitations. First, all the women interviewed were living within experiences in prisons with a range of deprivation levels both within (e.g . a variety of security levels) and across prisons. Second, this study did not look at differences and similarities across the intersections of race and gender. In particular, research is needed that explores the role of race in how women are perceived in prison in terms of staff and other inmates, and how For example, given the over - representation of Black women within the women with life sentences national pop ulation (Nellis, 2013), how does racism manifest within prison? How are system of disenfranchising and punishing Black women (Bush - Baskette, 2010; Richie, 2012)? T perceptions of their life sentence change or are able to be changed, their coping strategies also change. Time and life events play a role for example, appeals be ing denied, losing external 188 prison would be beneficial in better understanding the influence of time, events, and perhaps changes in prison deprivations. Despite these limitations, this research contributes to the preliminary understanding of how women cope in prison with a life sentence and point to areas of future res earch, as well as practice and policy implications. Conclusion Incarcerated women with life sentences are a growing population within prisons that face an uncertain future of either death in prison or a potential release from prison. Their perceptions of their futures shape their distinct coping strategies. Ultimately, both their perceptions and strategies are shaped not only by their individual life histories, but more so, by the ways in which the deprivations of a life sentence are enacted within the spe cific prison and by the ramifications of state and national sentencing trends and practices. Social work theory expansion, practice, policy advocacy, and future research are needed to guide ethical change for the lives of this under - served group of women. 189 REFERENCES 190 REFERENCES Aday, R. H., & Krabrill, J. J. (2011). Women aging in prison: A neglected population in the correctional system . Boulder, CO: Lunne Reinner Publishers. Asberg, K., & Renk, K. (2014). 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(1990). Coping, imprisonment, and rehabilit ation some data and their implications. Criminal Justice and Behavior, 17 (1), 53 - 70. 196 C HAPTER FIVE : DISCUSSION, IMPLICATIONS, AND CONCLUSION came and . . . he asked me, "Do you realize that you're gonna be in prison for the rest of your life?" And I said, "Do you really think that?" You know. . . and I was like, "For the rest of my life? Do you think that God will leave me in prison for the rest of my life? " - A 29 - year o ld incarcerated woman who receive d a life sentence at age 16 ( Human Rights Watch and Amnesty International, 2005) The older women take the younger w Then you got to let it sink in. When some women come it, they are unable to comprehend - how do you do 30 years in prison and still be happy, smiling, hold conversation, and going on every day? - Study Participant As the number of women in prison has inc reased over the past decades mental health in prison has been of interest to professionals in multiple fields, including criminal justice, social work, and public health . Some of the reasons for this self - harm and /or harm of others, coordinating treatment for their mental and physical health while incarcerated, creating and modifying policies around psychological health treatment, and promoting rehabilitation. As a growing population (especially as women aging in p rison), i ncarcerated women with life sentences often present with multiple physical and mental health needs in prison yet are often denied treatment based on their type of sentence in other words, services are often reserved only for women preparing to re - enter the community, which excludes women with life sentences. For this dissertation, t his mixed - methods study seeks to provide insight into improving the mental health of incarcerated women with life sentences. It is shaped by deprivation theory, which i mental health in prison, and importation theory, which focus es on how individuals import specific factors into prison which 197 influence their mental health in prison. T hree key questions are examined through the format of three manuscripts : (1) What are the pre - prison life experiences of incarcerated women with life sentenc es?; (2) What are the changes in mental health and forms of anger expression for women who complete the Beyond Violence interventio n ?; and (3) How d o women with a life sentence cope in prison? A sample of 26 incarcerated women with life sentences in a state prison was utilized , and analyses of their corresponding data from clinical interviews, pre/post/and fo llow - up surveys, and semi - structured interviews to answer these key questions. The three manuscripts presented in this dissert ation are intended to expand the knowledge about the experiences of incarcerated women with life sentences, and in particular, s pan an - prison lives, current experiences, and perceptions of their future . A specific goal was to examine both importation and deprivation factors and how they intersect and Given the lack of rese arch specifically focused on th is population of women, these manuscripts provide distinct contributions to the field of social work. In this chapter, results from the three manuscripts are briefly summarized, followed by a discussion of the strengths and l imitations of this research, implications for social work theory, practice and policy, and recommendations for future social work research. An Overview of the Major Findings - prison life experiences in order to un derstand relationships and dynamics between and across importation factors. Through a stories of persistent and cumulative adversity were visible. these experiences included coping behaviors of subs tance use, suicide at introduction to substance use. Lastly, a majority of women are serving their first prison sentence 19 8 for crimes committed under the influence of sub stances as well as in the context of relationships with histories of victimization. The key finding of this particular study was that a majority of women had no substance use or mental health based treatment prior to prison, even though a majority also rep orted frequent substance use and mental health concerns (e.g. depression and suicide attempts). Thus, this study offers two major insights. First, women who entered prison with a life sentence reported multiple importation factors that were interconnected in their occurrence (e.g. suicide attempts as a response to interpersonal violence victimization). Based during pri importa tion fa ctors of concern provide a rationale for the provision of treatment to this population of women in prison. Second, from a prevention perspective, social work effort s are needed in the community for women at risk of interacting with the criminal justice sys tem, and such efforts may benefit from addressing several, often interconnected concerns, including substance use, mental health, safety within relationships, and recidivism prevention. The second manuscript examined changes in ental health and forms of anger after completing a new gender - responsive, trauma - informed intervention entitled Beyond Violence. Two treatment groups of exclusively incarcerated women with life sentences went through Beyond Violence and completed pre, post, and 3 month fo llow - up surveys with measures of mental health disorders and forms of anger. In summary, women who had served less than 10 years started with higher scores on most of the mental health measures and show ed significant decreases on several of these measures over time. Significant changes were also found for women in regards to anger and forms of anger expression. While these positive results indicate a potential efficacy for Beyond Violence with women with life sentences, more research 199 is needed within the i ntervention development trajectory. Given the role of time, women may benefit from multiple interventions. with a life sentence. Based on semi - structured interviews with twenty - three of the twenty - six women with life sentences, women described coping strategies as distinctly based on how they perceive their life sentence. In particular, their coping strategies are shaped by their perception of the likelihood of being relea sed from prison. Of concern, women who view their life sentences as truly life sentences expressed suicide ideation and attempts as corresponding coping strategies. w - key deprivation factors related to a life sentence that shape their perspective of a life sentence and their ways of coping. This manuscript draws attention to the larger issue of life sentences within the context of a human rights framework. Overarching Themes Across these manuscripts, time - based insight s are - prison life experiences, current experiences , and perceptions of the future. Likewise, for this population of women, the role of the prison context and trends in sentencing practices are relevant and central aspects of their daily lives perhaps more so than incarcerated women without life sentences. In many ways, women with life sentences have similar pre - prison and prison - based experiences to women without life sentences such as high rates of trauma experiences and substance use and having a goal of gaining education during incarceration. However, t his research also shows how this population is distinct or in better words, has distinct experiences of a deprivation - level. For example, 200 status and are specifically d enied rehabilitation . Looking at these three manuscripts together, a cumulative neglect in the community, prison, and even an expected future neglect is present as a constant thread. A broad question is where is the advocacy and care for this population of women? Social work is primed to provide this type of justice - focused work. Thus, research regarding women with life sentences sheds insight into community - based work for prevention efforts, prison - based work to improve current conditions, and policy focu sed work to consider addressing human rights concern for this population. An overarching framework for this body of work is exploring how it fits into the two - tiered focus of human - rights based social work of examining discourses and practices that perpet uate social problems (Ife, 2012). In terms of discourse, and discourse for those wit h life sentences (Nellis, 2010). It appears that this discourse is somewhat present throughout these wome n lives as there is an absence of adequate intervention the neglect appears to have started prior to prison, continue within prison, and shape their expected futures in prison. Thus, to begin to conceptualize this population of women as underserved within a life course perspective may be beneficial. Additionally, t his dissertation pushes beyond the framing of this population of women as ives, before and during prison , and to add dimension beyond their conviction lives so, it begins to illuminate the multiple points of possible social work intervention (e.g. improving community safety, preventing and addressing sexual abuse within families , and preventing self - harm in prison ) including but also beyond the individual - leve l . 201 In regards to practice, t h e recurring theme across these manuscripts is the need for theme is also reflection of the influence of both importation and depri Within this small sample of women with life sentences, there is heterogeneity to their coping and responses to an intervention, with a commonality of the pains of imprisonment, histories of trauma and adversity, and the uncertainty of a life sente nce. mental health was influenced by deprivation - level factors. By shifting the discourse around women in prison to consider context, a practice spotlight can be placed on the prison and the larger criminal justice system as a site of intervention. Strengths and Limitations of the Study While each manuscript provides specific details about the unique contribution s and limitations of the research , there are overarch ing strengths and limitations. Given the neglect of incarcerated women with life sentences in research and practice, this study provides several novel investigations. An overarching strength of this study is the use of mixed methods in order sentence in prison. Through several forms of data collection that occurred over time, this study was able to explore a variety of impor tation and deprivation factors. This allowed for the collection of data in the form of both validated measures (such as for depression) and qualitative data. The sample of women, while a small sample, still provided variance, in regards to demographic factors, inclu ding race, motherhood status, current age, life with and without parole, and length of time served. while within prison in order to improve their mental health. A vast bod y of literature examining 202 the experiences of women (and men) while incarcerated focuses specifically or even exclusively on behavioral concerns , particularly in terms of misconducts ( e.g. Steiner & Wooldrege, 2009; Wright, Salisbury, & Van Voorhis, 2007 ). Thus, as this study did not dwell on offense s or other deviant behavior such as misconducts, it seeks to humanize this population of women principle o W hile not without limitations (as discussed below), this work extends the knowledge base about incarcerated women with life sentences in a way that promotes a core belief t hat this is a population worth the investment of research and practice resources. Furthermore, this is the first empirical study to examine treatment outcomes specifically and exclusively with incarcerated women with life sentences. This novelty is a refl ection of how under - limitations of not having comparison treatment - as - usual groups, t hese treatments groups are more ap propriately deemed pilot groups. As a result, th is study promotes a future research trajectory of intervention research inclusive of this population. The mixed - methods approach of surveys and interviews allowed for preliminary insight into treatment adaptations and directions specifically for this popul ation of women. In addition , t his study in particular, highlighting the role of context, the specific deprivation of a life sentence, and the corresponding uncertainty and hopelessness of this sentence. This s tudy is unique in that it highlights coping specifically in relation to women with life sentences. Due to the direct role of deprivation and the perception of a life sentence, the women in this study describe an embodiment of the realities of sentencing pr actices. Of particular concern is the link between viewing a life sentence as death in 203 prison which promotes suicide ideation. This finding highlights the ramifications of sentencing practices in the everyday experiences of incarcerated women . Given how th sentencing practices with life sentences are considered incompatible with international human rights, this research projects a larger focus on the role of a human rights focus specifically for women with life sentences. Lastly, this resea rch should be viewed within the context of prison - based research and histories of involvement in criminal behavior or to display them as only victims, it seeks to illuminate the under - studied deprivations of prison and push social work to evaluate the ethical ramifications of these deprivations and other functions of the penal system. It tries to address what Liebling (1999) has questioned and stressed as needed in prison - based research: The pains of imprisonment are tragically under - estimated by conventional methodological approaches to prison life. Prison is all about pain - the pain of separation and loss, the wrench of restricted contact in the context of often fragile relations hips, of human failings and str (to me, obvious) emotional function of , p. 165 ). This research started from an exploration of the literature on wom this study, another recurring que stion emerged --- 204 lives st ill have worth, to display the pains of prison, and question the ethical bounds of punishment. Study Limitations This study had several imitations. First, the sample of twenty - six women with life were incarcerated in a prison with relatively the same level of deprivations; a larger sample of women incarcerated in a variety of prisons would allow for a more in - depth study of the nuanced influences of deprivation factors. Future research may address how women with life sentences are treated differently across prisons in terms of treatment opportunities. Second, all of the women in the sample were in the Beyond Violence treatment groups. Without a comparison group, it is unclear if Beyond Violence wa s the cause of changes in understand the role and impact of a treatment - strategies were conducted post - intervention. Fut ure research may benefit from comparing the coping strategies for women with life sentences who have and have not received any treatment opportunities. based on their raci complexities of the intersections of race, class, and gender (e.g. Richie, 2012). However, a critical perspective incorporating intersectionality is limited within the research on wo well as from prison staff? What is the hierarchy of socia l position amongst women with life 205 sentences? Given the role of social organizational neglect in the community for women of color, how does the prison system treat women of color once they are incarcerated, especially those with life sentences? Given the d isproportionality of women of color being given life sentences, within their racial identities. For incarcerated women with life sentences, it is not known how r study, differences in treatment outcomes based on race could not be examined because of the limited understanding of the meaning of race for the women who par ticipated. Fourth, this study utilized a sample of women who were selected based on study criteria as well as prison administrative approval. One restriction was that women who had committed major misconducts and/or were in segregation or a high security l evel were not allowed to participate. Thus, this sample of 26 women represent women who, by prison standards, are doing well in prison are managing to do time without major tickets and are not under intensive supervision due to behavioral or mental health concerns. Future research may benefit from a sample of women that includes women who are not faring as well in prison. Implications for Theory and Social Work While both importation theory and deprivation theory were the foundation for this study, a cru cial theoretical component of this study is the need to expand the understanding of the range of deprivations in prison and how these deprivations may differ in application across prisoners . , 1958 ) and has also expanded to include conceptualized gender - specific pains, such as the role of motherhood (e.g. Celinska & Siegel, 2010 ) , there is a lack of theory incorporating the deprivations specific to a life sentence. As seen in the t hird manuscript, women with life sentences experience a distinct 206 deprivation not only from outside - of - , but also from rehabilitation within the prison. While prisoners are assumed to los e a wide variety of freedoms and certain rights (e.g. not being able vote) , rehabilitat ion is still considered by some scholars a remaining right that prisoners can access during incarceration (Ward & Birgden, 2006). Rehabilitation is understood as clinical services, life skills development, str uctured interventions, and work and educational opportunities, yet debates exist over the nature and implementation of rehabilitation (McNeil, 2012). Indeed the idea of rehabilitation is a contested notion within the new penology; in European countries, it is viewed as a constitutional right and in the United State s it is not (Rotman, 198 6 ). This difference is posited to be part of the reason the U nited S tates in behind in (Ploch, 2012). Likewise, the lack of implementation of rehabilitation focused activities within security of prisoners (Lewis, 2005). Thus, future work is needed that explore s ethical and human - rights centered frameworks of the deprivation of rehabilitation for incarcerated women with life sentences. Human rights focused social work examines both the discourses and practices that allow human rights concerns to exist and be perpetuated (Ife, 2012). Examining both the rhetoric of life sentences and the practices associated with a life sentence would provide insight into areas of change. Likewise, this work may benefit from a global comparative nature in order to understand varying perspectives on prisoners, punishment, and models of prisons in order to create alternative, human - rights centered models of criminal justice. 207 Implications for Social Work Practice First and foremost, this research promotes incarcera ted women with life sentences as a viable population for treatment and intervention pre - prison life histories, importation factors may be appropriate targets in interventions, in particular as interconnected concerns. Given the pivotal role of trauma, this study provides further suggestion for the need for trauma - informed interventions for women in prison. Likewise, for this specific population, interventions within prison are needed that address life within prison, such as healthy relationships with other inmates and how to parent over the long - te rm. Future intervention research may study the influence of multiple interventions and how interventions are - support interventions may be especially powerful for women. Likewise, Beyo nd Violence as an intervention may be of further benefit to women if it incorporates a stronger focus on preventing self - harm and coping with the challenges of life in prison. In order to promote practice with this population on a micro or clinical level, future work is needed to define a framework for this practice. In an environment of punish ment , how do social workers offer non - punitive practice? The power dynamic between a social worker and a Pollack, 2004) that is so fundamental, complex, challenging and striking in social work. A strengths - based perspective to practice has been encouraged, especially within the framework of an ever - increasingly management (ve rsus rehabilitation) based penal model (van Wormer, 2001 ). An anti - 208 both anti - oppressive social work practice (Pollack, 2004) and a feminist model of me ntal health care (Pollack, 2005), peer support models have been suggested. Given that promoting empowerment within prison as a practice strategy has been challenged (Kendall, 1994), social work practice models are needed that address the complexities of bo th a punitive context with deprivations and the possibility of individual - level agency and personal change. Human - rights focused s cholars have promoted the idea that ethical clinical practice is possible (albeit difficult) within correctional settings (War d & Salmon, 2009). Social workers are poised to address this complexity and advance models of ethical, just clinical practice within prison settings. Implications for Social Work Policy In conjunction to micro or clinical level practice implications, macro - level practice implications are needed. First, social work should evaluate prison, state, and federal policies about the treatment of prisoners. In particular, this evaluation is needed within a human - rights framework and should include assessing the qual ity of treatment as well as how treatment differs across prisoners and prisons. Also, as further work is done in regards to intervention development for this population, translational and implementation research are also needed to ensure that interventions are utilized within prisons and allow for inclusivity of women with life sentences. A larger policy issue is the human rights concerns regarding sentencing policy and practices, especially within a global perspective. From an ethical perspective for socia l work , what does it mean for women to experience suicide ideation as a reaction to the penal system and to a life sentence? Likewise, as current debates exist over the justness of life sentences, especially for juveniles, social workers have the potential to infuse social justice, an ethical 209 framework, a preventative perspective and an innovative approach to sentencing practices and from i nternational comparative w ork to promote a human rights focused policy advocacy to address life sentences , as well as to promote other models of correctional responses. Implications for Future Research Multiple points for future research have been suggested throughout this disserta tion. To bring together the varied points raises in this research, the following are specific future research goals. Mainly, lo ngitudinal research is needed that investigates health over tim e, as they serve time in prison with an examination the role of prison - events, changes in prison policy, and single and multiple opportunities for treatment engagement . Likewise, such research may benefit from a multi - site design in order to assess for how prison - experiences and mental health. Also, future research with a and may allow an investigation of how these factors also shape their mental health in prison. Moreover, prevention - focused research is needed to address how to prevent women from entering prison with a life sentence, and multi - level research (from individual - level interventions to examinations of sentencing practices) may be especially efficacious within a prevention framework. Conclusion - prison life g with their perceptions of their life sentence. 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