Effectiveness of Choice Theory Connections

Abstract

In the past 30 years, the rates of incarceration and recidivism for women in the United States have increased dramatically. Choice Theory® Connections (CTC) is a gender-tailored pre-release intervention program based on Choice Theory® (Glasser, 1999), and designed to achieve meaningful and sustainable cognitive and behavioral change. This evaluation examines CTC among 96 female participants in a California state prison enrolled in an introductory (n = 58) or advanced (n = 38) course. CTC significantly improved perceived stress, mindfulness, emotion regulation, impulsivity, and well-being on completion; effects were stronger for the introductory cohort, but significant effects also emerged for the advanced cohort. In addition, participants in the advanced cohort reported better scores at baseline, demonstrating the effects of prolonged engagement with the intervention. Results suggest that CTC can improve incarcerated women’s well-being pre-release, a strong predictor of recidivism post-release. Further study and wider use of CTC are encouraged.

Keywords

offenders behavior program psychometric evaluation women

Since the 1980s, incarceration of women in the United States has increased by 500% (Thompson, 2008). This alarming rise in female incarceration is matched by staggering recidivism; 57% of women released from prison in California are re-arrested within 3 years of their release (Strategic Offender Management System [SOMS], 2011), and the average per-year cost of incarceration is US$47,102 (California Legislative Analyst’s Office, 2009). These data, combined with drastic decreases in rehabilitation funding, spur a compelling need for effective pre-release strategies. Currently implemented within the California Institution for Women (CIW), Choice Theory® Connections (CTC) teaches individuals about the urges underlying their behaviors and presents new skills for creating sustainable, healthy relationships. Its framework is simple and provides relevant, self-generated rehabilitation to the unique challenges that incarcerated women face. CTC helps women make more effective choices that lead to more productive lives—both in prison and post-release. The current article briefly describes the development and effectiveness of CTC among a population of women across introductory and advanced phases of the intervention.

Women and Incarceration

Gender matters in criminality, and the circumstances and effects of imprisonment differ between men and women (Bloom, Owen, & Covington, 2003; Grella & Rodriguez, 2011). Women often suffer from triple jeopardy challenges, including gender, race, and class (Bloom, 1996). Pathways to incarceration for women include fragmented family histories, domestic violence, childhood and adult sexual abuse, trauma, substance abuse and substance abusing partners, difficulty meeting familial responsibilities, poverty, HIV/STD risk, and race (Belknap & Holsinger, 2003; Browne, Miller, & Maguin, 1999; Hardyman & Van Voorhis, 2004; Salisbury & Van Voorhis, 2009). More than 75% of incarcerated women have a history of intimate partner violence (Browne et al., 1999) and suffer a culture of domination both inside and outside prison (Haney, 2006). These experiences can contribute to chronic emotional stress with enduring effects on women’s self-esteem, depression, and sense of hopelessness (Zlotnick, Johnson, & Kohn, 2006; Zust, 2009). Further, their inadequate ability to effectively cope with severe stress, deprivation, low self-esteem, and peer pressure predicts individual criminality (Samuelson, Carmody, Kabat-Zinn, & Bratt, 2007).

These interpersonal and intrapersonal stressors continue during incarceration. Many incarcerated women suffer deeply from the forced separation from their families and children. Immense feelings of shame, guilt, and grief are common (Zust, 2009), and the resulting familial and social network isolation leads to greater perceived stress during incarceration than that found among their male counterparts (Fogel, 1993; Henriques & Manatu-Rupert, 2001; Poehlmann, 2005). This increased stress has also been correlated with impulsivity and risk-taking behavior post-release (Kim, 2003; Lindquist & Lindquist, 1997; Mooney et al., 2008). Other factors sustaining female criminality and recidivism include histories of personal abuse, mental illness, and substance abuse (Bloom & Covington, 2009), thus continuing the emotional and behavioral cycle of incarceration (Fogel, 1993; Perkins, 1998). In California prisons, more than 75% of incarcerated women are re-offenders (California Department of Corrections and Rehabilitation, 2012). The California Rehabilitation Strike Team, which focused on developing and implementing prison and parole programs, describes this phenomenon as “serving a life sentence on the installment plan” (Petersilia, 2007, p. 15).

The unique experience of female offenders can, and should, be used to inform pre-release intervention strategies to affect baseline and follow-up well-being, resilience, and a sense of personal control, thus reducing recidivism. Pre-release interventions provide an opportunity during incarceration to change lifelong patterns of violence, addiction, and unsatisfying relationships, and build productive lives with greater emotional literacy and increased pro-social behavior. Unfortunately, re-entry standards to aid women’s transition back into the community (The Council of State Governments, 2003) can be difficult to implement comprehensively due to complexity and a lack of funding. Nonetheless, building skills, healing emotional wounds, and increasing self-awareness can be accomplished along with easing the stress of incarceration and establishing a solid foundation for re-entry.

Choice Theory® (CT)

The theory and practice of CT provides a cognitive framework and behavioral procedures to achieve meaningful and sustainable personal change for women pre-release. CT is a non-coercive, behaviorally based theory of psychological processes driving behavior, while emphasizing the essentiality of good relationships with others (Glasser, 1999). It conveys information in simple terms to help people self-evaluate their current behavior choices and better understand themselves, others, and general human behavior. This approach promotes behavior modification by clarifying internal motivations and alternative choices (Smith, Kenney, Sessoms, & LaBrie, 2011). CT emphasizes developing quality emotional relationships with self and others to (a) gain more effective internal control and avoid detrimental external control by others; (b) possess more accurate self-concepts; (c) more effectively manage perceptions, actions, and emotions; and (d) create and sustain connections with others to establish meaning and quality relationships. These four dimensions are centerpieces of CT’s capacity to positively affect perceived stress, mindfulness, emotion regulation and impulsivity, and well-being.

Stress

Stress is the experience of coping with “stressors,” or events perceived as threatening or challenging. Although short-term stress can improve cognitive function and physical response, long-term stress is associated with negative psychological and physical reactions including depression and a weakened immune system (Cohen, Janicki-Deverts, & Miller, 2007). Incarcerated women perceive their lives to be unpredictable, uncontrollable, and overloaded, factors common to stress and stressors. Furthermore, these perceptions undermine their preparedness for re-entry into the community, thus increasing their risk of recidivism.

Mindfulness

Mindfulness is the awareness of thoughts, sensations, and emotions, as well as acceptance of unpleasant thoughts and emotions, and is a way to manage stress and impulsivity (Samuelson et al., 2007). Cultivating greater attention, awareness, and acceptance is associated with lower levels of psychological distress, including less anxiety, depression, anger, and worry (Brown, Ryan, & Creswell, 2007; Grossman, Niemann, Schmidt, & Walach, 2004), and can result in improved health, positive cognitions, awareness, and behavioral changes (Kabat-Zinn, Lipworth, & Burney, 1985; Lau & Yu, 2009; Singh, Lancioni, Wahler, Winton, & Singh, 2008; Teasdale et al., 2000). Mindfulness interventions can help women become less reactive to intense emotional states (Hawkins et al., 2003; Kabat-Zinn et al., 1985) and have been found to improve inmate hostility, self-esteem, and mood when applied in correctional settings (Samuelson et al., 2007).

Emotion Regulation and Impulsivity

Emotion regulation is the ability to monitor and manage one’s experience, expression, and response to emotion, and impulsivity is the inability to regulate emotions and subsequent behavior, often with diminished regard to consequences. Taken together, the research in these areas demonstrates a relationship between intrapersonal regulation and re-offending. The ability to inhibit one’s behavior is a robust correlate of offending (Jones & Lynam, 2009) and can serve as a predictor of violent and aggressive behavior and poor institutional adjustment (Komarovskaya, Loper, & Warren, 2007; Mooney et al., 2008). Day (2009) argues that interventions that assist inmates to better regulate their emotions may have an important role in improving rehabilitation outcomes.

Well-Being

It is important to note that all of the above-mentioned characteristics are directly related to perceived well-being or the contented state of being happy and satisfied with life (Diener, Suh, Lucas, & Smith, 1999). Well-being is negatively correlated with perceived stress (Cohen et al., 2007) and positively correlated with mindfulness (Kabat-Zinn, 1993; Samuelson et al., 2007) and emotion regulation (Gross, 2002; Gross & John, 2003). Overall, well-being is the ultimate goal of robust pre-release interventions to provide women the psychological tools to cope with the stresses both inside and outside prison.

The current assessment evaluates the effectiveness of CTC, a training intervention administered to women in a California correctional facility. It is hypothesized that participants will show improvements from baseline to follow-up in perceived stress, mindfulness, emotion regulation, and well-being after engaging in CTC training (Hypothesis 1 [H1]). Furthermore, the Phase 4 cohort will report more healthful baseline scores (Hypothesis 2 [H2]), demonstrating stronger effects from prolonged engagement with CTC. When available, participant means are compared with established means.

Method

Participants

Evaluation participants included 96 female offenders at the CIW in Corona, California, in spring 2011. All participants voluntarily enrolled in either an Introductory Course (Phase 1), which included 58 self-referred volunteers who had no prior exposure to CTC training, or an Advanced Practicum (Phase 4), which included 38 participants who successfully completed Phases 1 through 3 of the CTC curriculum and were invited to continue in the program. The Phase 1 cohort was significantly younger (M_AGE = 39.55) than the Phase 4 cohort (M_AGE = 46.66); χ²(4, 96) = 16.86, p = .003. Both cohorts were racially diverse (see Table 1 for complete demographic information) and included a wide range of women offenders, from parole violators to “lifers” and many shared histories of psychosocial problems (e.g., depression, sexual physical abuse).

Table 1.

Demographic Summary by Cohort.

Characteristics	Phase 1 cohort (n = 58)	Phase 4 cohort (n = 38)
M age	39.55 (10.95)	46.66 (10.18)
18-29	22% (13)	8% (3)
30-39	34% (20)	11% (4)
40-49	24% (14)	40% (15)
50-59	14% (8)	34% (13)
60 and above	5% (3)	8% (3)
White	41% (24)	34% (13)
African American	31% (18)	31% (12)
Latino	14% (8)	24% (9)
Other race/ethnicity	14% (8)	11% (4)
% completed	100%	100%

CTC

CTC is a program designed to restore personal choice and control. Participants are taught to behaviorally actualize five basic needs: (a) survival, (b) love and belonging, (c) power, (d) freedom, and (e) fun (Glasser, 1999). Certified CT trainers help women define and acknowledge their former lives (“What are you doing now to meet your needs?”), describe possible future selves (“What do you want?”), and establish the steps to achieve this future self (“How effective have your old strategies been and what can you do differently?”). Participants come to recognize that their lives need not be determined solely by past choices (“CT emphasizes the present moment”). CT training uses a variety of instructional methods and teaches essential CT principles: (a) human behavior is teleological, purposeful, and goal-directed; (b) all pleasure and pain are derived from our efforts to satisfy five basic needs; and, (c) acting from current internal motivations, people attempt to resolve the difference between what they want and what they have (Wubbolding, 2011). Furthermore, CTC emphasizes improved social relationships to decrease persistence in offending behavior through the social capital benefits obtained via membership in social networks (Portes, 1998). In CT, participants learn the relationship between acting, thinking, feeling and physiology for increased self-awareness, and an expanded repertoire of personal choices to meet basic needs and achieve quality relationships.

CTC is a progressive and sequential skill-based program consisting of five phases for a total of 140 instructional hours. Phase 1: Introduction to Choice Theory (CT) includes 20 hr of didactic instruction using reflection, discussion, and interactive exercises focused on fundamental CT principles, how CT works within a correctional setting, and how to apply CT to personal experience. Phase 2: Intermediate Training includes 20 hr of interactive classroom engagement and focuses on self-assessment and the connections between external stimuli, perceptions, values, and behaviors. Phase 3: Basic Practicum includes 30 hr of classroom participation that introduces mentorship, uses role-play to demonstrate understanding, and reinforces new behaviors, relationships, and choices learned in earlier phases. Phase 4: Advanced Practicum includes 30 classroom hours focused on training participants to become peer-mentors for Phases 1 to 3 participants. They demonstrate mastery of, and ability to apply, CT principles, skills, and tools. Phase 5: Choice Theory Connections (CTC) Certification includes 30 hr of classroom participation and 10 hr of self-directed application of CT outside the classroom. Students publicly demonstrate their understanding and utilization of CT to personal trainers. The current evaluation follows participants in Phase 1 and Phase 4.

Design/Procedures

The CIW approved the evaluation of a trial implementation of CTC within their education department. CTC procedures were consistent with other interventions conducted in a prison setting (Gobbett & Sellen, 2013; Heilbrun et al., 2008). As a routine, time limited evaluation and because of administrative constraints, only two of the five phases (Phases 1 and 4) were accessible for evaluation. A single-group design with self-reported data was collected before the first class (baseline) and again at the end of the last class (follow-up). Participants reported their age and ethnicity at baseline only. Reason for incarceration was not recorded to avoid stigma.

Measures

Perceived Stress Scale (PSS-10)

This widely used and well-validated 10-item scale measures how unpredictable, uncontrollable, and overloaded individuals perceive their lives to be in the past month. Items are rated on a 5-point scale from 0 (never) to 4 (almost always); higher scores indicate greater perceptions of life stress. Scores on the PSS-10 have been correlated with health behaviors and perceived health (Cohen, Kamarck, & Mermelstein, 1983), stressful life events, and negative affect (Cohen et al., 2007). Internal consistency was good in the current sample (α = .75).

Philadelphia Mindfulness Scale (PHLMS)

This 20-item measure assesses present moment awareness and acceptance over the past week on two dimensions (i.e., subscales): (a) awareness, or the extent to which participants are cognizant of their emotions and the emotions of others, which is associated with higher levels of reflection and attention; (b) acceptance, or the participant’s ability to accept events and persevere, which is negatively associated with depression and anxiety. Items are rated on a 5-point scale from 1 (never) to 5 (very often); higher scores indicate a greater mindfulness. The PHLMS shows good internal consistency across subscales (α = .72-.75) and predicts other measures of mindfulness and related constructs (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008). Internal consistency for both subscales were good in the current sample (α_Awareness = .77; α_Acceptance = .87).

Difficulties in Emotion Regulation Scale (DERS)

This 36-item, multidimensional self-report measure assesses the degree of emotion regulation across six dimensions (i.e., subscales): (a) non-acceptance of emotional responses, (b) goal-directed behavioral difficulties, (c) impulse control difficulties, (d) lack of emotional awareness, (e) lack of emotional regulation strategies, (f) lack of emotional clarity. Items are rated on a 5-point scale from 1 (never) to 5 (always); higher scores indicate greater difficulties in emotion regulation (i.e., emotion dysregulation) and predict other constructs related to impulsivity and emotion regulation (Gratz & Roemer, 2004). The total DERS (α = .93) and the individual subscales (α ≥ .80) demonstrate good internal consistency. In the current sample, internal consistency was strong for the total scale (α = .95) and each subscale (α ≥ .77).

Multidimensional Well-Being Assessment (MWA)

This 125-item scale, which is currently under development, assesses personal, relational, collective, physical, and transcendent well-being in the past month. Participants completed modified versions of two MWA subscales, consisting of 13 total items: (a) personal emotional-experiential (PE) addresses the extent of an individual’s positive emotional well-being (e.g., happy, hopeful, strong); (b) relational pro-social behavior (RP) addresses the extent of an individual’s positive engagement with others (e.g., listen, compliment, patience). Items are rated on a 5-point scale ranging from 0 (never true for me) to 4 (always true for me); higher scores indicate greater well-being. The current sample demonstrated strong internal consistency on both subscales (α_PE = .86; α_RP = .88).

Depression/Happiness Scale (D-HS)

This 25-item scale assesses the degree and frequency of depressed and happy thoughts over the past week and is considered a measure of well-being; 13 items ask about negative feelings, thoughts, and sensations, and 12 items ask about positive thoughts, feelings, and sensations. Items are rated on a 4-point scale from 0 (rarely) to 3 (often); higher scores indicate more frequent positive thoughts and less frequent negative thoughts. The D-HS demonstrates good internal consistency (α = .93) and predicts other constructs related to depression and happiness (McGreal & Joseph, 1993). Internal consistency was strong in the current sample (α = .94).

Analyses

Paired-samples t-tests were used to assess the effect of CTC from baseline to follow-up. Independent-samples t-tests were used to assess the long-term effect of CTC when comparing the baseline scores between the Phase 1 and Phase 4 cohorts. Statistical significance for all measures was calculated using a family wise alpha of .20 for three tests using across the 14 scales and subscales, resulting in a significance level of p ≤ .005 for each scale.

Results

Cohort means at baseline and follow-up are reported in Table 2.

Table 2.

Group Means.

		Baseline	Follow-up	Change scores
Perceived Stress Scale (PSS)
Phase 1 Cohort		19.86 (6.29)**	14.19 (6.05)*	−5.67 (6.29)^a*,^b
Phase 4 Cohort		15.61 (4.49)^b**	12.76 (4.22)^b*	−2.84 (4.91)^a*,^b
Philadelphia Mindfulness Scale (PHLMS)–Awareness
Phase 1 Cohort		38.24 (5.68)	41.16 (5.66)	2.91 (6.84)^a**
Phase 4 Cohort		40.13 (5.51)	41.50 (5.51)	1.37 (4.40)
Philadelphia Mindfulness Scale (PHLMS)–Acceptance
Phase 1 Cohort		24.48 (7.63)^b**	30.12 (8.22)^b*	5.64 (7.23)^a**
Phase 4 Cohort		30.74 (8.25)^b**	34.18 (7.92)^b*	3.45 (7.60)^a*
Difficulties in Emotion Regulation Scale (DERS)–Total
Phase 1 Cohort		90.33 (25.60)^b**	68.60 (20.35)^b*	−21.72 (24.98)^a*,^b
Phase 4 Cohort		70.11 (17.50)^b**	57.24 (16.35)^b*	−12.87 (17.15)^a*,^b
Difficulties in Emotion Regulation Scale (DERS)—DERS Subscales
Phase 1	Non-acceptance	14.40 (5.65)^b*	11.84 (5.39)	−2.55 (7.16)^a*
	Goal	14.86 (4.82)^b*	11.21 (4.20)^b*	−3.66 (4.62)^a*
	Impulse	14.07 (14.07)^b**	10.53 (4.54)^b**	−3.53 (4.68)^a**
	Awareness	17.07 (5.37)^b**	12.50 (4.01)	−4.57 (5.77)^a**
	Strategies	17.17 (5.94)^b*	13.33 (4.85)^b*	−3.84 (5.72)^a**
	Clarity	12.76 (3.94)^b**	9.19 (2.57)^b*	−3.57 (4.20)^a**
Phase 4	Non-acceptance	11.95 (4.29)^b*	10.13 (4.54)	1.82 (4.58)^a*
	Goals	11.89 (4.72)^b*	9.34 (4.35)^b*	−2.55 (4.35)^a**
	Impulse	11.08 (5.00)^b**	8.47 (3.08)^b**	2.71 (4.73)^a*
	Awareness	12.82 (4.70)^b**	11.29 (4.22)	−1.53 (3.83)^a^b
	Strategies	13.29 (5.73)^b*	10.61 (3.34)^b*	−2.68 (5.13)^a*
	Clarity	9.18 (3.10)^b**	7.39 (2.49)^b*	−1.68 (3.08)^a^b
Multidimensional Well-Being Assessment (MWA), Personal: Emotional-Experiential (PE)
Phase 1 Cohort		13.88 (4.18)^b*	16.50 (3.42)	2.62 (3.90)^a*
Phase 4 Cohort		16.18 (3.32)^b*	17.50 (2.13)	1.32 (2.87)^a**
Multidimensional Well-Being Assessment (MWA), Relational: Pro-social Behavior (RP)
Phase 1 Cohort		25.14 (4.90)	27.38 (4.06)	2.24 (4.04)^a*
Phase 4 Cohort		25.82 (4.84)	27.26 (4.00)	1.45 (4.88)
Depression/Happiness Scale (D-HS)
Phase 1 Cohort		45.62 (14.57)^b**	58.60 (12.58)	12.98 (13.42)^a,^b
Phase 4 Cohort		57.76 (13.42)^b**	59.87 (9.16)	2.11 (11.40)^b**

Within group.

Between group.

p ≤ .005. **p ≤ .001.

CTC reduced perceived stress for both Phase 1, t(57) = 6.87, p < .001; d = .90, and Phase 4, t(37) = 3.60, p = .001; d = .58, cohorts according to the PSS (H1). The Phase 4 cohort reported significantly lower perceived stress at baseline, t(95) = 3.61, p < .001, d = .75, (H2; see Table 2), indicating long-term effects of prolonged engagement with CTC. Furthermore, follow-up scores were not significantly different between cohorts; indicating that both cohorts reported similar perceived stress immediately after completing their current CTC training course. Compared with PSS gender and age matched norms (M_Female = 16.14 [7.56]; M_35-44 = 16.38 [7.07]; Cohen & Janicki-Deverts, 2012), Phase 1 participants achieved average levels at follow-up, whereas Phase 4 participants reported levels below average at both baseline and follow-up.

CTC appeared to improve mindfulness according to the PHLMS. CTC improved awareness for Phase 1 cohort only, t(57) = −3.25, p < .001; d = −.43, and acceptance for both Phase 1, t(57) = −5.94, p = .002; d = −.78, and Phase 4, t(37) = −2.80, p = .008; d = .03, cohorts (H1). Interestingly, there was no significant difference between phases at baseline for awareness, but there was a significant difference at baseline for acceptance, t(94) = −3.803, p < .001; d = .76, indicating that CTC may have a different effect on acceptance associated with amount of CTC exposure (H2).

CTC reduced emotion dysregulation (i.e., inability to regulate emotions and behaviors) for both Phase 1, t(57) = 6.62, p < .001; d = .93, and Phase 4, t(37) = 4.63, p < .001; d = .68, cohorts according to the DERS (H1). The Phase 4 cohort consistently reported less emotion dysregulation at baseline, t(95) = 4.26, p < .001, d = .88, and follow-up, t(95) = 2.89, p = .005, d = .60, demonstrating lasting effects of prolonged engagement in CTC on emotion regulation and impulsivity (H2).

When investigated separately, CTC reduced all subscales of the DERS for Phase 1 participants (ps < .05; H1) and reduced all but the non-acceptance and awareness subscales for Phase 4 participants (ps < .05). Interestingly, participants in Phase 1 reported significantly greater change in the awareness subscale, t(94) = −3.11, p = .002; d = −.63. Phase 4 cohort reported lower levels on all subscales of the DERS at baseline (H2), although non-acceptance and impulse did not achieve significance. There were very few cohort effects at follow-up; Phase 4 cohort and the Phase 1 cohort reported equivalent levels of non-acceptance, goals, impulse, and awareness. The DERS means for Phases 1 and 4, follow-up scores were slightly lower than those reported by women during validation of the DERS with an undergraduate college sample (M_TOTAL = 77.99 [20.72]; M_NONACC = 11.65 [4.72]; M_GOALS = 14.41 [4.95]; M_IMPULSE = 10.82 [4.41]; M_AWARENESS = 14.34 [4.60]; M_STRATEGIES = 16.16 [6.19]; M_CLARITY = 10.61 [3.80]; Gratz & Roemer, 2004)

CTC improved well-being according to the MWA and the D-HS. CTC resulted in improved emotional-experiential well-being, t(57) = −5.12, p < .001; d = −.68, greater pro-social behavior, t(57) = −4.23, p < .001; d = −.56, and improved depressive thoughts for Phase 1 cohort only, t(57) = −7.37, p < .001; d = −1.00 (H1). Change on the D-HS among Phase 1 participants was significantly greater than that of Phase 4 participants, t(94) = 4.12, p < .001; d = .88. The Phase 4 cohort reported greater emotional-experiential well-being, t(95) = 2.86, p = .005, d = −.59, and lower depression, t(95) = −4.21, p < .001, d = −.87, at baseline (H2), demonstrating lasting effects of prolonged engagement with CTC (H2). Furthermore, there were no significant differences between cohorts at follow-up; indicating that both Phase 1 and Phase 4 cohorts reported similar well-being and depression immediately after completing their respective CTC training phase. A score of 42 on the D-HS has been suggested as a cutoff for identifying mild but clinically relevant depression (Lewis, Joseph, & Shevlin, 1999). Given their proximity to the cutoff score, the Phase 1 cohort approached clinical levels of depression at baseline but not at follow-up.

Discussion

The results provide some initial support for the effectiveness of CTC as a pre-release intervention to address critical factors that sustain female criminality and recidivism. Overall, CTC resulted in improvements in stress, mindfulness, emotion regulation, impulsivity, and well-being for both cohorts (H1), and many of the effects appeared to be sustained over time in the baseline scores of the Phase 4 cohort (H2).

Phase 1 participants reported significant improvements on all measures, indicating an immediate effect of CTC. Phase 4 participants reported significantly better scores at baseline, indicating prolonged effects of CTC, and continued to make improvements on a majority of mental health markers during the evaluation period. Although the degree of change was not significantly different between groups on most measures, Phase 1 participants reported improvement on more dimensions of mental health; this effect may be due to the initial novelty of CTC. Phase 1 and Phase 4 participants reported no difference on several follow-up scores, indicating that CTC helped Phase 1 participants obtain equivalent levels of mental health markers as found in the Phase 4 participants. These dynamic effects speak to the nature of CTC over time; Phase 1 participants experience an improvement on all mental health markers, whereas Phase 4 participants begin their training with stronger psychological and behavioral strategies.

Affective and cognitive states of incarcerated women can be improved by CTC, a major accomplishment for incarcerated women. Particularly important is the significant improvements found on widely accepted measures of perceived stress, mindfulness, emotional regulation, and well-being (PSS, PHLMS, DERS, D-HS), as well as a newer measure (MWA). The unique experiences of imprisonment for women as described in the prior literature are considerable, and CTC appears effective in reducing stress for female offenders at various training phases and over time. Those in earlier phases experienced sharp decreases in stress and, after training, reported equivalent scores to participants in more advanced stages whose decreased stress is maintained over time. Even in a prison setting, women who participate in CTC report stress levels similar to the general population (Cohen & Janicki-Deverts, 2012).

Limitations and Future Research

There are relevant limitations warranting consideration. These include the lack of randomized controlled design and the inability to gather certain demographic information such as length and reason for incarceration that would allow for additional explanations of our findings (i.e., differences between cohorts’ due length of incarceration, type of sentence, etc.). These data emerged from a program evaluation that was not originally designed as an empirical study, and it was vitally important to staff, prison officials, and the project principals that all interested inmates access CTC. To date, 476 incarcerated women at CIW have engaged in formal CT classes, and 219 women are currently on the wait-list to begin the CTC program. While the absence of a randomized design limits our ability to demonstrate conclusively the effectiveness of CTC, random assignment would have denied access to incarcerated women who would benefit from the program, especially without a viable alternative.

In addition, the authors were unable to formally assess recidivism rates specifically for the women in this evaluation. However, since the inception of CTC program at the prison, all women who received any CTC training and were subsequently released (n = 175) were tracked post-release over a 2-year period. These data revealed that only 2.9% recidivated post-release, compared with the general recidivism rate for women in the state of 57% (SOMS, 2011).

Other important limitations of the design are that (a) cause of incarceration was not recorded, (b) participants were not tracked across CTC phases, (c) the sample size was small and derived from one correctional facility, and (d) all measures represent self-reported data. Given these factors, the results cannot be generalized to other female prison environments. In addition, even though treatment adherence and outcomes have been found to be the same among prisoners who enter treatment voluntarily versus involuntarily (Miller & Flaherty, 2000), time spent in the program and engagement in the program are critical success factors that were not included in the design.

To properly determine the effect of CTC, future studies should (a) utilize a randomized, wait-list control group study design; (b) assess level of responsiveness to the CTC intervention between inmates on key factors such as voluntary/involuntary participation, level of program engagement, offending histories, risk factors, characteristics of mental health, and life circumstances; (c) assess an inmate’s behavior and status changes (e.g., participation in education, treatment, and work programs; disciplinary actions; level of supervision; changes in classification levels—inmate risks/needs); (d) assess one cohort of participants across all five CTC phases and at post-release to track recidivism rates; and (e) include a larger number of participants in multiple correctional facilities. Finally, future studies should examine CTC’s contribution to successful transition from prison to community.

Conclusion

The CTC pre-release intervention is effective in improving incarcerated women’s perceived stress, mindfulness, emotion regulation, and well-being while incarcerated, and offers great promise for reducing recidivism post-release. CTC teaches how to evaluate behaviors, increase self-awareness, and distinguish between effective and ineffective behaviors, leading to personal change and better relationships with others. These are essential components of gender responsive approaches for incarcerated women (Salisbury & Van Voorhis, 2009). A key value of CTC lies in its flexibility. It can be used by a variety of specialists, including licensed mental health professionals and others affiliated with the criminal justice system. It allows participants to apply skills learned during the program to perennial challenges, including alcoholism and drug abuse, intimate partner violence, the workplace, and other stressors in their communities of origin (Glasser, 1999; Wubbolding, 2000). These results encourage wider implementation and examination of CTC with women in correctional facilities, and provide a rationale for funding CTC intervention programs.

Footnotes

Acknowledgements

The authors would like to acknowledge Brandon Farmer, Brittani Hudson, Rachael Martinez, Mary Talbot, and Monica Zandi for their efforts on this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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