Improving the Wellbeing of Female Prisoners via Psychological Skills Training: A Feasibility Study

Abstract

Prisoners display significantly higher rates of mental disorders and lower mental wellbeing than the general population. The integration of positive psychological interventions in offender supervision has received recent advocacy. The aim of the current pre-post pilot study was to determine the short-term effects of group-based resilience training on mental health outcomes for female offenders and explore intervention acceptability. Offenders (n = 24) self-selected to partake in a multi-component psychological skill program based on positive psychology, cognitive–behavioural therapy, and mindfulness-based activities. The training was taught in nine sessions of 1.5 hr each. Baseline and follow-up measurements of mental wellbeing and psychological distress were collected and focus groups conducted to investigate participants’ experiences, acceptability, and appropriateness of the training. Moderate to large effect sizes indicating significant improvements were observed for wellbeing, g = 0.75 and distress, g = 0.56. Training was well received by participants and staff and was delivered feasibly within the prison context. The results are encouraging, and a future well-powered study using a rigorous controlled design is warranted.

Keywords

female prisoners positive mental health positive psychology intervention psychological skills training resilience intervention wellbeing and resilience program

Introduction

At any given time, there are more than 10 million imprisoned individuals worldwide, with another 30 million who circulate in and out of prison each year (Fazel et al., 2016). Among the prison population across the world and in Australia, females are the fastest growing population (Casey et al., 2015; Jeffries & Newbold, 2016). In Australia alone, statistics show an average increase of 10% in female prisoners from the 2017–2018 period (Australian Bureau of Statistics, 2018), with increases as high as 46% in South Australia (Department of Correctional Services, 2017).

The prison population often shows high levels of psychological distress and high rates of psychiatric disorders, as well as low levels of mental and physical wellbeing (Fazel et al., 2016; Maxwell et al., 2013; Sharma, 2012; Williams et al., 2014). These high rates are fuelled by a complex combination of risk factors such as social disadvantage, domestic violence, substance abuse and discrimination (Keleher & Armstrong, 2005), and the negative aspects associated with being incarcerated, including fear, trauma, anxiety, and violence (Liebling & Maruna, 2013). A systematic review of more than 100 studies and 33,000 prisoners found the 6-month prevalence of psychotic illnesses to be 1 in 7 prisoners (Fazel & Seewald, 2012), although rates varied depending on the study. For instance, one Australian study found the 12-month prevalence of any psychiatric illness to be 80% for prisoners compared to 31% in the general population (T. Butler, Andrews, et al., 2006). In extreme cases, some countries have more individuals with mental illnesses in prison than there are in psychiatric hospitals (Fazel et al., 2016). In Australia, the impact of mental disorder is greatest for female prisoners and prisoners of Aboriginal and Torres Strait Islander descent, who are at higher risk of suffering from mental illnesses compared to the general (male) population (Bartels & Gaffney, 2011; Fazel et al., 2016; Mak & Chan, 2018; Maxwell et al., 2013). This trend has also been observed in other minority and indigenous populations around the world (Norris, 2019).

These high rates of psychiatric problems in the prison population are accompanied by low levels of mental wellbeing and reduced physical health (Liebling & Maruna, 2013). So much so, that by the age of 50–55 years, prisoners are often considered geriatric due to their complex health needs, which are either chronic in nature or long term (Williams et al., 2014). Even after release, prisoners with previously reported or current mental illness are more likely to experience poor health outcomes, crime, and substance abuse (Cutcher et al., 2014).

As most prison sentences are temporary, the poor health and mental wellbeing of prisoners will add to the existing health burden of the general population once reintegrated. In 2014, the median sentence period for prisoners was 1.8 years (Australian Bureau of Statistics, 2014; Australian Institute of Health and Welfare Canberra, 2015), and in 2017, 70% of female prisoners on remand in South Australia were released with an average custody period of 47 days (Department of Correctional Services, 2017). Although incapacitation, deterrence, punishment, and retribution are all goals of incarceration, it is vital to have effective prison practices in place to help rehabilitate prisoners as they eventually return to the community (Baillargeon et al., 2009). Improving the mental health and wellbeing of offenders, an evidently vulnerable group, is therefore a societal imperative.

The lack of resources within government departments is a common barrier to the provision of extensive rehabilitation services for prisoners, particularly related to mental health care (Borzycki, 2005). It is therefore important to find solutions which are cost-effective and deliver tangible benefits to offenders. The use of psychological group interventions that integrate positive psychological principles in offender supervision and recidivism prevention strategies have received recent advocacy (Gredecki & Turner, 2009; Tomar, 2013; Woldgabreal et al., 2014). The integration of strengths-focused techniques within psychological interventions are integral to influencing lasting improvements to mental wellbeing (Tomar, 2013) as simply focusing on addressing deficits and distress is insufficient. Strength-based interventions focus on the promotion of adaptive aspects of mental health such as positive affect, mindfulness, and resilience, resulting in increased subjective wellbeing and improved health outcomes (Howell et al., 2007).

The limited evidence on the application of psychological group interventions that use positive psychological principles and related constructs such as mindfulness within prison populations has shown promising results. A study integrating positive psychology interventions and cognitive behavioural therapy indicated a significant decrease in female prisoner’s psychological distress and increase in psychological wellbeing (Mak & Chan, 2018). A small-scale pilot study found promising results for mindfulness-based programs levels of stress for incarcerated women (Ferszt et al., 2015). These results complement an earlier systematic review that found that practicing mindfulness in a correctional setting leads to improvements in negative affect, substance use, hostility, relaxation capacity, self-esteem, and optimism (Shonin et al., 2013).

These early but positive findings point to the potential benefit of teaching basic psychological skills such as mindfulness and positive psychological principles to prisoners. As the number of female prisoners is rising, more research is required to investigate novel approaches that aid in rehabilitation and help prepare for reintegration into the community (Walmsley, 2006). While emerging research shows promise, implementing a positive psychological group training within the prison setting may face several challenges that are less apparent within the general population, including logistical constraints and potential issues in comprehension of the material. The current pilot study therefore aimed to add to the existing evidence by testing a group-based resilience training for female offenders in Australia. The primary focus of this study was to explore preliminary short-term effectiveness on mental health outcomes, specifically psychological distress and subjective wellbeing. A secondary focus was to explore the suitability and acceptability of the intervention in this unique population group.

Method

Participants and Setting

Participants were female prisoners within a women’s prison in Adelaide, South Australia. Participants self-selected and stemmed from three groups, which were designed by the correctional staff to be most appropriate for the setting. Groups were (a) offenders in the pre-release centre, (b) long-term sentenced offenders, and (c) offenders of Aboriginal or Torres Strait islander descent (hereafter: Aboriginal). The “pre-release” group comprised of offenders awaiting release back into the community. This unit is located in a separate area of the prison facility and comprised of offenders in the end stages of their sentence, who can participate in family leave, education, work release, and community work programs. For the purposes of this study, “long-term sentenced” offenders are defined as those serving a mandatory minimum sentence of 25 years, with or without the opportunity for parole. The offenders in the long-term sentenced and Aboriginal groups were all located in the mainstream area of the prison complex. The use of a separate, closed group of Aboriginal women from the mainstream area of the prison complex was deemed most appropriate and culturally sensitive following a comprehensive consultation with stakeholders prior to roll-out of the intervention.

A total of 24 participants (M_age = 37.68, SD = 9.04) completed training, with 54% (n = 13) having completed some high school. The lowest level of education was primary school (8% or n = 2) and highest level was a post-graduate qualification (4% or n = 1). There were six participants from the pre-release group (M_age = 38.41, SD = 9.46), 13 from the long-term sentence group (M_age = 38.11, SD = 9.49) and five from the Aboriginal group (M_age = 35.67, SD = 9.00). This study has ethics approval obtained from the Aboriginal Health Research Ethics Committee (AHREC; ethics approval code 04-17-743), which covers ethical approval for Aboriginal and non-Aboriginal participants. Prior to the study, participant consent was obtained to study the data.

Study and Intervention Design Procedure

An extensive consultation process was undertaken prior to the commencement of this study to ensure all study materials and training content were adapted in a way that would be appropriate for the prison population. Two stakeholder groups were formed, one of which consisted of prison staff who have daily contact with the women offenders, including correctional officers, activity coordinators, and offender development staff. This group met regularly during the initial study planning phase and assisted with the adaptation of training content and method of delivery to suit the prison setting. They provided critical insight into ways in which trauma informed practice methods could be incorporated into the training and facilitated the formulation of focus groups with selected women prior to the commencement of the study, for certain training activities to be trialled with the women offenders.

The second stakeholder group consisted of DCS staff, local Aboriginal elders, researchers, and community members identifying as Aboriginal or Torres Strait Islander. This group was specifically formed to guide the development of the training program to ensure it was culturally appropriate for Aboriginal participants. Based on this group’s recommendations regarding the importance of community and cultural connection, several decisions specific to the Aboriginal women program were made. Female offenders were invited to attend any of the scheduled sessions; however, a closed group of Aboriginal women was formed to provide an additional level of safety and support for Aboriginal women if they chose to attend these sessions. It was decided that this group would be trained by two female Aboriginal correctional staff members, one of whom had previously delivered the training material to other groups and one elder who had strong existing relationships with participants. This was different from the other groups of offenders, who were trained by members of correctional staff experienced in delivery of the program. Five correctional staff members were accredited as trainers and they shared the responsibility of facilitating the training. Generally, one trainer was involved in the delivery of all training sessions, and was assisted by one of the other trainers. For the Aboriginal-specific group, the training was delivered by an Aboriginal staff member and an Aboriginal Elder, who were supported by the central trainer.

Measures

Psychological distress was measured using the Kessler Psychological Distress Scale (K-10) (Kessler et al., 2002), which is a global measure of distress. The K-10 has 10 items which explore the presence of participants’ self-reported symptoms of anxiety and depression during the past 4 weeks. An example question was “During the last 30 days, about how often did you feel hopeless?” Participants answered on a 1 (none of the time) to 5 (all of the time) scale (α₁ = .94, α₂ = .90). K10 scores come with cut-offs indicating whether participants are likely to be well, to have a mild mental disorder, moderate mental disorder, or severe mental disorder (Andrews & Slade, 2001).

An adaptation of the 23-item PERMA Profiler (J. Butler & Kern, 2016) was used to measure mental wellbeing. The PERMA Profiler is based on the PERMA model which stresses that wellbeing consists of five domains: Positive emotion, Engagement, Relationships, Meaning, and Accomplishment (Seligman, 2011). Overall PERMA scores correlate .98 with other subjective wellbeing measures (Goodman et al., 2018). Participants answered questions on a 0 (never) to 10 (always) scale (α₁ = .93, α₂ = .92).

After consultation with the stakeholder groups and in light of evidence of measurement challenges in the correctional setting, the PERMA profiler was reduced to five items instead of 23. A recent study conducted with prisoners in the Netherlands indicated that incarceration tends to reduce prisoner’s attention spans (Meijers et al., 2018). Therefore, to reduce attention loss and ensure reliable results were produced for this study, a single question from each PERMA construct was selected in addition to the happiness item. The specific questions that were used in the current study were determined by the factor loading scores presented in the original paper, where the questions with the highest factor loading in each construct were selected (J. Butler & Kern, 2016).

Intervention

The training program was based on the TechWerks Resilience Training program (www.technologywerks.com and www.4-9-north.com), which combines content derived from positive psychology interventions (Bolier et al., 2013; Hone et al., 2015) and psychological treatment methods such as Cognitive Behavioural Therapy (A. C. Butler et al., 2006) and Mindfulness (Gu et al., 2015). The training is a multi-component program comprising of a set of techniques designed to increase one’s sense of wellbeing and resilience and has been tested in a range of populations including older aged carers, health services staff, and disadvantaged youth (Bartholomaeus et al., 2019; Raymond et al., 2018; van Agteren et al., 2018). See Table 1 for the exact wellbeing and resilience skills taught in this study.

Table 1.

Overview of 11 Skills Taught in the Resilience Training.

Resilience Training Skills
Growth Mindset	Participants are taught that basic abilities and personal characteristics are not set but can be developed through effort and practice.
Event-Thought-Reaction Connections	This skill increases individual awareness of how thoughts drive reactions to events and is used to determine whether thoughts and reactions are helping individuals work towards their goals, act upon their values, improve their performance, and strengthen their relationships
Meaning Making	Learn to cognitively appraise challenges and failures in a healthy and productive way through a focus on meaning.
What’s Most Important	This skill increases individual awareness of what influences unproductive reactions (emotional and/or physical) that may interfere with their performance, goals, or relationships.
Balance Your Thinking	This skill helps individuals cognitively appraise situations in an accurate manner that is based upon evidence.
Cultivating Gratitude	This skill seeks to build optimism, positive emotion, and resilience by bringing ongoing attention to gratitude as a cognitive process.
Mindfulness	This skill teaches individuals to regulate their attention in a focused, open, and non-judgemental manner.
Interpersonal Problem Solving	This skill teaches individuals the elements to address interpersonal problems in a respectful manner with healthy and productive emotional expression and use of compromise.
Active Constructive Responding	This skill increases awareness of communication patterns and responses that maintain, strengthen, and cultivate positive and important relationships.
Capitalising on Strengths	This skill increases individual awareness of their and others’ personal strengths and how to apply strengths across all life domains.
Value-Based Goals	This skill increases individual awareness of their values and how to translate these values into actions and goals.

The training was delivered using a train-the-trainer approach, where correctional staff were taught by professional trainers to deliver the training directly to participants. The resilience intervention for the pre-release and long-term sentence groups consisted of nine weekly training sessions lasting up to 1.5 hr each, delivered in groups between 5 and 10 participants facilitated by two trainers. Training for the Aboriginal group was delivered in bi-weekly sessions over 5 weeks.

Data Analysis

Paired samples t-tests were conducted to determine change between time 1 (baseline) and time 2 (post-intervention) for the overall group and split for each of the different offender groups. Analysis of normality and the presence of outliers was assessed, demonstrating that the assumption of normality was met. Five outliers for overall wellbeing and two outliers for overall K10 were revealed at baseline time 1. No differences in results were found when conducting the analyses with and without the outliers, and testing the results using parametric and non-parametric tests, causing the outliers to be retained for data analysis. A one-way analysis of variance (ANOVA) was also conducted to test for baseline group differences, showing no differences between the baseline means of the intervention groups. As this was a feasibility study and sample sizes were small, training effectiveness was examined using p values as well as effect sizes, specifically Hedges g (Hedges, 1981). Hedges g accounted for the within-subject design by using the correlation scores for pre and post scores. Hedges g of 0.2 demonstrates small changes, scores of 0.5 represent medium changes, and scores of 0.8 represent large changes (Lakens, 2013); 95% confidence intervals were also calculated for each group.

Three focus groups were held by two members of the research team after the final measurement to explore the acceptability, appropriateness, and participant experiences of the training. These focus group included participants from the Aboriginal group, the long-term sentenced group, and the trained trainers. Due to the study setting, focus groups could not be recorded; however, researchers took detailed notes and have produced a thematic description of the sessions.

Results

Figure 1 displays the comparison of overall wellbeing for all trained groups at pre- and post-training. Results for the total sample of 24 participants showed a significant, p = .00, mean increase in wellbeing of 1.64 (SD = 0.67) with a large effect size (g = 0.76). Overall psychological distress scores showed a significant, p = .01, mean reduction of 5.50 (SD = 2.78) between pre- and post-training with a moderate effect size (g = 0.56). Baseline measures of psychological distress showed a mean score of 25.58 (SD = 9.01), which borders the “likely to have a moderate mental illness” K10 cut point.

Figure 1.

Mean pre- and post-intervention scores in wellbeing (left) and psychological distress (right).

Table 2 shows the results by intervention group, showing that training had the largest effect on the long-term sentenced participants’ wellbeing, followed by the pre-release and Aboriginal groups. The long-term sentence group displayed statistically significant (p = .01) large effect sizes, whereas the other two groups displayed moderate effect sizes. For psychological distress, the effect size was again largest in the long-term sentenced group (large effect), followed by the Aboriginal group (large effect) and pre-release (moderate effect). While wellbeing and psychological distress effect sizes were within the moderate to large range for individual groups, the sample size did not provide sufficient power to determine statistical significance.

Table 2.

Outcome Data for Mental Health Parameters for Each Group at Pre and Post Intervention.

	n	Baseline		1-Month follow-up		p	Hedges g	95% Confidence intervals
Group		M	SD	M	SD			Lower	Upper
Wellbeing
Pre-release	6	5.86	2.05	6.83	1.22	.14	0.56	–0.59	1.72
Long-term sentence	13	6.13	2.03	7.67	1.07	.01	0.82	0.02	1.62
Aboriginal	5	6.83	2.48	7.97	1.93	.25	0.44	–0.81	1.70
Psychological distress
Pre-release	6	30.83	8.21	26	7.46	.36	0.30	–0.84	1.44
Long-term sentence	13	24.08	9.31	18.38	4.07	.08	0.51	–0.27	1.30
Aboriginal	5	23.20	8.20	17.40	5.73	.21	0.48	–0.78	1.73

Three narrative themes emerged from the focus group sessions, related to the group-based delivery, the unique “narrative” of the training, and the outcomes of the training. The women reported enjoying the group setting and being able to share personal stories and real-world examples to better understand the skills. Participants commented that the group setting allowed them to learn from each other and that hearing each other’s perspectives of shared experiences was particularly useful. Participants noticed that the training was being delivered for their own benefit, rather than the usual correctional setting mandated training. This sentiment was reinforced by the unusual combination of trainers, which included correctional staff who were able to relate on a personal level and discuss relevant examples. This was particularly evident in the Aboriginal group, where trainers could contextualise the skills with Aboriginal cultural values.

The participants commented on a range of benefits that they took away from the training, these included being less physically aggressive, being more considerate of others, learning to treat others as they want to be treated, paying more attention to people when they are talking, being able to stop and think in the moment, and being able to recognise their own strengths that they are proud of. Some participants mentioned that they would use the skills to help them back in the community to avoid negative influences, but the women expressed that it would be useful to have a transition pathway to continue learning about the skills after they leave the custodial setting.

From a feasibility perspective, trainers commented on the benefits of using in-house staff, who were able to draw upon contextually relevant examples and to deliver the weekly sessions flexibly around the unreliable scheduling in the prison. It was commented that the more common approach of using external trainers often results in programs being cancelled or missed due to unforeseeable events that occur within the prison. The nature of the relationship between prison staff and offenders was also commented on, as the open sharing that occurred in the sessions built trust and broke down the barriers that often separate these two groups.

Discussion

The current study aimed to investigate the short-term effects of a resilience training intervention on female prisoners’ mental health outcomes and to explore the overall acceptability of the intervention in this unique setting. Overall, increases in wellbeing and reductions in psychological distress were observed at the group level, with moderate to large effect sizes depending on the outcome and the offender type. However, these results need to be placed in the context of a small sample size. The focus groups highlighted positive and beneficial experiences from the participants towards the training and its implementation within the correctional setting.

Given that females are the fastest growing prisoner population and who also suffer from low wellbeing and high mental illness (Australian Institute of Health and Welfare Canberra, 2015; Casey et al., 2015; Fazel et al., 2016; Maxwell et al., 2013), the findings in this study are promising. This study complements positive results by the limited number of studies that have previously integrated group psychological interventions using positive psychological principles and related constructs in offender populations (Ferszt et al., 2015; Mak & Chan, 2018). Mak and Chan (2018) explored the effect of cognitive behavioural therapy, strengths, gratitude, hope, and mindful awareness on women offenders’ psychological distress and wellbeing. The results showed a significant decrease in psychological distress and increase in wellbeing. In another pilot study, Ferszt et al. (2015) examined the effect of a group mindfulness-based program on women offenders’ psychological distress which also showed a decrease in participant psychological distress; results which add the positive findings as reported by a systematic review on mindfulness-based interventions in the correctional setting (Shonin et al., 2013). This study therefore not only contributes to but also strengthens the limited literature that currently exists on the treatment and support for female prisoner’s wellbeing. Moreover, as suggested by previous studies (Ferszt et al., 2015; Shonin et al., 2013), the current study suggests that group-based delivery may be a potentially beneficial and cost-effective strategy for building positive mental health within a vulnerable but unique population. Cost-effective group-based mental health interventions are becoming more frequently delivered in correctional settings, including programs designed to provide clinical treatment (Hills et al., 2004; Leidenfrost et al., 2017).

The moderate to large effect sizes found in this study are higher than typically reported in the psychological skills literature, which tend to be small to moderate at best, even in clinical populations (Bolier et al., 2013; Chakhssi et al., 2018). A potential explanation for the positive results lies in a combination of baseline distress and wellbeing levels found in this population, which point to a group of participants with impaired mental health status and lower access to services in the prison setting (Borzycki, 2005). The ability for psychological interventions to improve mental health outcomes has been found to be larger for people with a more impaired mental health status (Driessen et al., 2010). For instance, the impact of positive psychological interventions is higher for people who have moderate or low wellbeing at baseline, compared to those with high baseline wellbeing (Proyer et al., 2015; van Agteren et al., 2018).

The improvements in wellbeing found in the group of participants with a long-term sentence were particularly striking, which might start giving insight into the utility of group-based interventions for different stages of incarceration. For example, the pre-release group (individuals with shorter sentences, some of which were about to be released) may be more anxious and concerned about their immediate future and their pending departure of the custodial setting (Shinkfield & Graffam, 2010). In contrast, participants in the long-term sentence group may be more likely to have accepted their long-term situation and use the program to prioritise their wellbeing, rather than trying to deal with the insecurity of returning to mainstream society. Although the nature of this study cannot confirm this, results here may suggest that group-based psychological services might be most suitable to be given at earlier stages of incarceration.

The intervention was well received by participants, was feasibly delivered by local, trained staff—despite the cultural and logistical complexities of the correctional setting—and the group-based delivery format was considered useful by participants. The train-the-trainer approach was successful as trainers brought cultural competence, appropriate worked examples, experience, and qualifications of working with the unique cohort. The use of train-the-trainer methodology to deliver psychological skills training has been successfully used in various Australian populations including older aged carers and disadvantaged youth (Bartholomaeus et al., 2019; Raymond et al., 2018) pointing to its utility as an efficient method of delivery of basic psychological skills training across society. This method may be particularly relevant for the Aboriginal context, as this approach enabled the intervention to align with proposed principles of Aboriginal Prisoner Health and Wellbeing models of care (Sivak et al., 2017). It also allowed for the training to be delivered in a culturally appropriate manner without the need for extensive cultural adaptation that is thought to be needed when applying Western psychological interventions to the Aboriginal setting (Pollok et al., 2018).

It is important to consider the limitations of the study and its design. The lack of a randomised controlled trial prevents causal relationships to be drawn between the intervention and mental health outcomes (Cartwright, 2010). Due to the small sample size, the results from this study cannot be generalised to the wider female prison population without further investigation, and caution should be exercised when interpreting the findings. Moreover, only short-term effects were studied, meaning that the impact of the intervention in the longer term still requires to be investigated, as intervention effects of psychological interventions diminish with time (Weiss et al., 2016).

Despite these methodological limitations, the positive results from this study strengthen the existing literature on the use of psychological skills training to service female prisoners’ mental health and wellbeing. It paves the way for a more rigorous study using controlled design to investigate the role of group-based psychological skills training targeting positive mental health building in addition to distress reduction for prisoners; an intervention which may ultimately help lead female prisoners onto a rehabilitative path of increased wellbeing and overall mental health.

Footnotes

Acknowledgments

We would like to acknowledge Monique Newberry for her work scoping, developing, and managing the project, Shannon Fewings-Hall and Rosalba Rivis for their ongoing project support; Faye Shone, Scott Willis, Patricia Waria-Read, Joanne Leonello, and the Department of Correctional Services staff who facilitated the training; and 49 North (TechWerks). Training participation was funded by the collaborative correctional organisation: Department of Correctional Services.

Authors' Note

Joseph van Agteren is also affiliated with College of Education, Psychology and Social Work, Flinders University, Adelaide Australia and Órama Institute for Mental Health and Wellbeing.

Data Availability

The dataset generated and analysed during the current study are available from the corresponding author on reasonable request.

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.

ORCID iD

Laura Lo

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