Therapeutic interventions and animal assisted therapy with incarcerated females

The prison population in the United States is growing at an alarming rate. Incarcerated women manifest distinctly greater psychological distress than do their male counterparts. In addition, these women demonstrate higher rates of mood disorder, substance use disorders, and personality disorders. Ranging from individual and group therapy to vocational training, corrections facilities use various forms of therapeutic interventions in an attempt to provide inmates with the resources necessary to develop healthy coping skills and function successfully in society. For many years corrections facilities have used animals as rehabilitative or therapeutic tools. However, there have been few studies looking at the efficacy of programs using animals with incarcerated populations. This dissertation presents how I examined the impact of an animal assisted therapy group with female inmates at the Utah State Prison. I present three separate articles that I submitted for publication in peer-reviewed journals.

THERAPEUTIC INTERVENTIONS AND ANIMAL ASSISTED THERAPY WITH INCARCERATED FEMALES by Rachael Anne Jasperson A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Social Work The University of Utah May 2011 Copyright © Rachael Anne Jasperson 2011 All Rights Reserved The U niversity of U tah Gl'aduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Rar.hael Anne Jasperson has been approved by the following supelv isOlY committee members: Joanna Bettmann · Chair 03/14/2011 vate Appro\id Brad Lundahl · Member 03/14/2011 vaie Appro\:ed Moist's Prospho · Member 03/14/2011 Date ApproVM Caren Frost , Member 03/14/2011 Date ApproVM Larry Benr.h , Member 03/14/2011 vate Appro\id and by Jannah Mather . Chair of ----------------~==~~~~----------------- the Department of College of Social Work and by Charles A. Wight, Dean of The Graduate School. ABSTRACT The prison population in the United States is growing at an alarming rate. Incarcerated women manifest distinctly greater psychological distress than do their male counterparts. In addition, these women demonstrate higher rates of mood disorder, substance use disorders, and personality disorders. Ranging from individual and group therapy to vocational training, corrections facilities use various forms of therapeutic interventions in an attempt to provide inmates with the resources necessary to develop healthy coping skills and function successfully in society. For many years corrections facilities have used animals as rehabilitative or therapeutic tools. However, there have been few studies looking at the efficacy of programs using animals with incarcerated populations. This dissertation presents how I examined the impact of an animal assisted therapy group with female inmates at the Utah State Prison. I present three separate articles that I submitted for publication in peer-reviewed journals. I dedicate this dissertation to my understanding and patient husband, Kory, who has put up with these many years of education and research and who has been my emotional rock through not only the vagaries of graduate school, but my everyday life. I must also thank my beloved friend Rachel who has shared the many uncertainties, challenges and sacrifices for completing this dissertation. TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii LIST OF FIGURES ......................................................................................................... viii ACKNOWLEDGEMENTS ............................................................................................... ix Chapters 1 INTRODUCTION ...........................................................................................................1 Prison Population in the United States.............................................................................1 Female Inmate Population ...............................................................................................1 Female Inmates in Utah ...................................................................................................2 Personal Struggles and Coping Deficits ..........................................................................3 Attachment Theory ..........................................................................................................4 Animal Assisted Therapy .................................................................................................6 Research on Animal Assisted Therapy and Animal Assisted Activities .........................9 The Use of Animals in Corrections Facilities ................................................................11 Background ....................................................................................................................13 Methods.........................................................................................................................15 Design ............................................................................................................................16 References ......................................................................................................................18 2 INTERVENTIONS WITH INCARCERATED FEMALES: A SYSTEMATIC REVIEW ............................................................................................................................22 Abstract ...........................................................................................................................22 Characteristics of Female Inmates ..................................................................................22 Mental Health Needs of Female Inmates ........................................................................23 Research on Interventions Used with Prison Populations ..............................................25 Methods..........................................................................................................................26 Data Collection ..........................................................................................................26 Data Analysis .............................................................................................................29 Study Quality .............................................................................................................30 Results .............................................................................................................................30 Therapeutic Focus .......................................................................................................31 vi Theoretical Orientation ...............................................................................................31 Study Quality ..............................................................................................................47 Spiropoulos et al. (2005): Pathfinders and Problem Solving ......................................47 St. Lawrence et al. (1997): HIV Risk Reduction for Incarcerated Women ................49 Discussion .......................................................................................................................51 Policy Implications and Directions for Future Research ............................................52 Clinical Implications ...................................................................................................53 Study Limitations ........................................................................................................53 References .......................................................................................................................55 3 ANIMAL ASSISTED THERAPY WITH FEMALE INMATES WITH MENTAL ILLNESS: A CASE EXAMPLE FROM A PILOT PROGRAM .................................58 Abstract ...........................................................................................................................59 Mental Health in the Inmate Population .........................................................................59 Incarcerated Females and Their Mental Health Issues ...................................................60 Female Inmates in Utah ..................................................................................................60 Attachment Theory .........................................................................................................61 Animal Assisted Therapy ................................................................................................62 Research on AAT and AAA with Individuals with Mental Illness ................................63 The Use of Animals in Corrections Facilities .................................................................64 A Pilot AAT Program for Female Inmates with Mental Illness .....................................64 Background .....................................................................................................................64 Group Participants ..........................................................................................................65 Program Description .......................................................................................................66 Program Conclusion........................................................................................................66 AAT and Attachment Theory .........................................................................................67 Case Example..................................................................................................................67 Background .................................................................................................................67 Description of the Presenting Problem .......................................................................68 Intervention .................................................................................................................69 Clinical Implications .......................................................................................................69 Strengths and Limitations ...............................................................................................70 Discussion .......................................................................................................................70 References .......................................................................................................................71 4 AN ANIMAL ASSISTED THERAPY INTERVENTION WITH FEMALE INMATES ......................................................................................................................74 Abstract ...........................................................................................................................74 Female Inmate Population ..............................................................................................74 Female Inmates in Utah ..................................................................................................75 Interventions Used with Female Inmates ........................................................................77 Animal Assisted Therapy ................................................................................................78 vii The Use of Animals in Corrections ................................................................................79 Methods..........................................................................................................................81 Program Description ...................................................................................................81 Design .........................................................................................................................82 Participants ..................................................................................................................83 Measures .....................................................................................................................84 Data Collection ...........................................................................................................84 Results .............................................................................................................................85 Analysis.......................................................................................................................87 Discussion .......................................................................................................................90 Clinical Implications ...................................................................................................91 Directions for Future Research ...................................................................................93 Limitations ..................................................................................................................94 References .......................................................................................................................95 5 CONCLUSION ............................................................................................................100 Organization and MAP Connections ............................................................................101 Attachment Theory and Animal Assisted Therapy .......................................................102 Clinical Implications .....................................................................................................103 Policy Implications .......................................................................................................106 Directions for Future Research .....................................................................................107 References .....................................................................................................................108 Appendices A ANIMAL ASSISTED THERAPY GROUP CURRICULUM ...................................110 B SCREENING QUESTIONNAIRE .............................................................................118 C OUTCOME QUESTIONNAIRE 45.2 ........................................................................119 D RESEARCH QUESTIONNAIRE...............................................................................121 LIST OF TABLES Table 1.1 Difference Between AAT, AAA, and Service Animals ...............................................8 2.1 Primary Search Strategy .............................................................................................27 2.2 Search Results (A) ......................................................................................................32 2.3 Search Results (B).......................................................................................................39 2.4 Study Quality Scoring .................................................................................................45 2.5 Study Quality Results .................................................................................................48 4.1 Demographic Data ......................................................................................................86 4.2 Means and Standard Deviations..................................................................................89 ACKNOWLEDGEMENTS I would like to thank all of those people who helped make this dissertation possible. First, I wish to thank my chair, Dr. Joanna Bettmann for all her guidance, encouragement, support, and patience. Throughout my graduate education, she has been a great inspiration to me. In addition, I would like to thank my committee members Dr. Moisés Propero, Dr. Brad Lundahl, Dr. Caren Frost, and Dr. Larry Bench for their very helpful insights, comments and suggestions. Additionally, I would like to acknowledge all of those people who provided technical support and assistance: Michael Tanana for his statistical brilliance, Peter Fawson for his SPSS knowledge and database expertise, and Ammie Simpson for assisting in the data collection process. CHAPTER 1 INTRODUCTION Prison Population in the United States According to the U.S. Department of Justice, during 2006, the prison population grew at the fastest rate recorded since 2000. Specifically, the prison population increased by 2.8% compared to an average annual increase of 1.9% from 2000 through 2005 (Sabol, Couture, & Harrision, 2007). From 2000-2009 the number of state prisoners increased at an average rate of 1.3%. However, from yearend 2006 through 2009, the prison admittance (2.5% decline) and prison release numbers (2.2% increase) converged, resulting in the slowing of the growth of the nation‟s prison population (West, Sabol & Greenman, 2010). Female Inmate Population In 1999 the Bureau of Justice Statistics reported that the per capita number of women involved in corrections (incarceration, probation, and parole) had grown 48% since 1990, compared to their male counterparts who experienced a 27% increase in the per capita number (Greenfield & Snell, 1999). In 2006, the growth rate of the female inmate population was also greater than that of the male population. While the male growth rate was 2.7%, the number of women in prison increased by 4.5%. This growth 2 rate for female inmates exceeded that of the average annual growth rate of 2.9% from 2000 through 2005 (Sabol et al., 2007). Incarcerated women do not differ greatly from incarcerated men in terms of basic demographics such as race, ethnic background, and age. However the type and severity of crimes that women are involved in as well as their childhood upbringing, differ substantially (Snell & Morton, 1994). Women are more likely to be incarcerated on property or drug offense and have a much lower rate of violent offense than do men (Sabol et al., 2007). Female Inmates in Utah In 2004, the Utah Commission on Criminal and Juvenile Justice collected data on the characteristics of the female prison population in Utah. Three hundred fifty-eight female inmates, housed at the Utah State Prison or county jails in the state of Utah, completed this survey (Utah Commission on Criminal and Juvenile Justice, 2004). They found that nearly half, 44.7%, of the surveyed participants had not completed high school and that 54% reported a total household income of under $10,000 prior to incarceration. They stated that 62.5% of participants reported incarceration for drug related crimes and 77.6% reported they committed their crimes while under the influence of drugs or alcohol. In fact, 50.6% of all respondents reported that they committed their crimes in order to acquire money for drugs. In this survey, the authors found mental health issues to be of particular concern for this population. More than 28% of participants reported current mental health treatment, and 45.4% reported having had treatment at some point in the past while incarcerated. Fifty-six percent of respondents reported receiving some mental health 3 treatment in the past while not incarcerated. Most of the women previously attended a residential treatment program and outpatient treatment, while 15.2% reported prior mental health hospitalization (Utah Commission on Criminal and Juvenile Justice, 2004). Considering their reported lifetime prevalence of abuse, it is not surprising that mental health is a concern for this population. Eighty-five point eight percent of the women incarcerated in Utah report physical or sexual assault at some point during their lifetime. Sixty-nine point three percent reported victimization by sexual assault or rape and 79.1% reported physical assault. Overall, nationally more female inmates than male inmates report being raised in a single parent home and have family members with histories of incarceration and/or drug use (Snell & Morton, 1994). Further, most incarcerated women report a history of physical and/or sexual abuse (James & Glaze, 2006). For many of them, their histories and this trauma play a role in their pathway to their criminal involvement (Chesney-Lind, 2000). Personal Struggles and Coping Deficits It is likely that inmates, many of whom are struggling with mental health concerns, experience heightened emotional distress and therefore utilize less adaptive coping strategies. In a longitudinal study of 291 adults, Aldwin and Revenson (1987) found that people with poorer mental health and experiencing greater stress used less adaptive coping strategies. While the relationship between poor mental health and use of maladaptive coping skills appears bidirectional, Aldwin and Revenson argue that this relationship is best accounted for by a mutually reinforcing causal relationship. In other words, individuals in poorer mental health may experience more stressful life events. The 4 higher the initial degree of emotional distress, the more likely these individuals are to use maladaptive coping. This cycle increases the emotional distress and increases the likelihood of problems in the future (Aldwin & Revinson, 1987; Felton & Revinson, 1984). Incarcerated women manifest distinctly greater psychological distress than do their male counterparts. This is evident in higher reports of major depression and PTSD (Browne, Miller, & Maguin, 1999; Burnette & Newman, 2005; Warren et al., 2002). In addition, this population demonstrates higher rates of mood disorder, substance use disorders, and personality disorders, most notably borderline personality disorder (BPD; Chapman, Specht, & Cellucci, 2005; Jordan, Schlenger, Fairbank, & Caddell, 1996; Nee & Farman, 2005). Individuals with BPD, especially those engaging in suicidal gestures and self-harm, pose a particular concern for corrections staff. Key features of BPD are interpersonal hostility, recurrent suicidal behaviors or self-harm, impulsivity, severe reactivity, highly unstable interpersonal relationships, and persistently unstable self-image (American Psychiatric Association, 2000). Results of some studies indicate that interventions directed at helping inmates develop active, problem focused coping strategies may result in less frequent suicidal behavior among female inmates (Chapman et al., 2005). Attachment Theory Many factors contribute to an individual‟s use of maladaptive coping strategies. Attachment theory asserts that these strategies stem from our belief in the availability of others to provide a secure base (Bowlby, 1988). In response to a caregiver‟s availability 5 and consistency in responding to her needs, an infant will develop a subjective view of herself as capable and of others as available to provide a safe haven in times of distress. In this case, the infant usually develops a secure attachment. However, if her caregiver is inconsistent or unavailable in responding to her safety needs, the infant may develop alternative strategies such as tantrums or suppressing their emotional needs. In this case, she likely develops an insecure attachment. Attachment theory offers a framework for understanding how early relationships affect later psychological functioning (Shorey & Snyder, 2006). Internal representations developed in childhood affect how individuals interpret their abilities to cope and how they utilize relationships throughout their lives. While adaptive during infancy, if unchanged, the alternative strategies developed by the insecurely attached child become maladaptive during adolescents and adulthood. In cases where the child was subjected to abuse or neglect or parented by a psychologically disturbed parent, these strategies can result in the development of personality disorders or other forms of psychopathology (Fonagy, 2000). In fact, some researchers view personality disorders as disorders of attachment (Shaver & Clark, 1994). Attachment styles are relatively stable across the life span (Bowlby, 1988; Hamilton, 2000; Hazan & Shaver, 1987), but research has shown that they are not fixed (Bowlby, 1973; Rothbard & Shaver, 1994; Shorey & Snyder, 2006). Exposure to factors that challenge existing representations can act as corrective experiences for insecurely attached individuals (Shorey & Snyder, 2006). This concept, "earned security," describes the classification of individuals once "insecurely attached" who developed a "secure" attachment style over time. In many therapeutic modalities, it is the role of the therapist 6 to provide a secure base for the client (Bowlby, 1977);,therefore, making the therapeutic relationship one place for this corrective experience to take place. Animal Assisted Therapy In the past few decades, researchers have looked at the human-animal relationship to identify how this bond can be used as a corrective relational experience, improving the health, psychological well-being, and overall functioning of various populations (Barker, Knisely, McCain, & Best, 2005; Hines, 2003; Jalongo, Astorino, & Bomboy, 2004; Marr et al., 2000; Motomura, Yagi, & Ohyama, 2004; Parish-Plass, 2008; Prothmann, Bienert, & Ettrich, 2006; Souter & Miller, 2007). These researchers found a variety of methods through which people use animals for therapeutic purposes. The community service model, where animals are rehabilitated so that they are adoptable out to the community, and service animal socialization model, where people train animals to work with individual with various disabilities, are the most common models. However, animal-assisted therapy (AAT) is an intervention that practitioners are using with increased frequency. AAT is a goal-directed intervention in which an animal is a primary element of the treatment process (Delta Society, 2008). It is an interaction between patients and a trained animal and human handler, with a therapeutic objective (Barker & Dawson, 1998). AAT is not a style of therapy. Rather, this approach uses an animal as a tool while operating from the therapist‟s principle foundational method (Delta Society, 2008). For example, a therapist may utilize a dog to strengthen the therapeutic relationship or to ease communication difficulties. In addition to AAT, therapy animals help individuals through animal-assisted activities (AAA). AAAs provide social, educational, and recreational benefits for people 7 during interactions. AAAs do not need to be overseen by a therapist and they do not work toward particular therapeutic goals (Barker & Dawson, 1998). It is important to note that therapy animals are not service animals (see Table 1.1). A handler utilizes a therapy animal in AAAs or AAT with people who do not necessarily have disabilities. According to the Americans with Disabilities Act, a service animal is trained specifically and individually to assist a person with disabilities (Americans with Disabilities Act, 1996). Since therapy animals operate in various settings with a wide array of individuals that are not disabled, they do not meet the classification of service animals. AAT is an intervention that can be understood through the lens of attachment theory. AAT is an approach based on emotional connection and relationship. The therapist uses the animal as a tool to assist the client in emotional expression and insight development (Parish-Plass 2008). During the therapy process, the therapist may trigger feelings of uncertainty or perceived threat as she brings up difficult issues. For an insecurely attached client, these feelings typically trigger responses of avoidance or intense attempts to maintain proximity (Mikulincer & Shaver, 2005).The animal‟s presence during the therapy process can create alternative approaches that may circumvent difficulties that can arise (Parish-Plass 2008). Research looking at attachment behaviors in offenders has found that secure attachment styles in this population are under-represented compared to general population individuals (Frodi, Dernevik, Sepa, Philipson, & Bragesjö, 2001; T. Ross & Pfäfflin, 2007; van Ijzendoorn, Feldbrugge, Derks, de Ruiter, Verhagen, Philipse et al., 8 Table 1.1 Difference Between AAT, AAA, and Service Animals (Americans with Disabilities Act, 1996; Delta Society, 2008) Approach Goal Handler Characteristics AAT  Specific Clinical/Therapeutic Goal €  Health/Human Services Professional  Certified By a Human- Animal Services Organization AAA  Social, Emotional, Educational, Motivational, Recreational Benefits  No Specific Clinical Goal  No Professional Credentials Required  Certified By a Human- Animal Services Organization Service Animals  Perform Tasks for the Benefit of a Person With a Disability  A Person With a Physical or Mental Impairment That Substantially Limits One or More of the Major Life Activities of the Individual  No Required Certification 9 1997). Therefore, this population may benefit from the inclusion of this approach in current rehabilitative or therapeutic programs. Research on Animal Assisted Therapy and Animal Assisted Activities Various researchers examined the effects of AAT and AAA on different populations (Barak, Savorai, Mavashev, & Beni, 2001; Barker & Dawson, 1998; Fournier et al., 2007; Prothmann et al., 2006). Prothmann et al. (2006) investigated possible influences of AAT on the state of mind of children and adolescents who had participated in inpatient psychiatric treatment. They looked at 100 children and adolescents aged 11- 20 years. The treatment group consisted of 61 subjects that participated in five individual nondirective free-play therapy sessions with a therapy dog. The control group consisted of 39 wait list children that did not receive the AAT intervention. This study found that the presence of the dog increased alertness, attention, caused more openness and desire for social contact, promoted the perception of healthy and vital factors, and enabled the child to become more psychologically well balanced. In addition, these effects were stronger the worse the child felt before contact with the dog. The authors reported that the children whose state of mind was worse prior to the intervention were the patients whom the hospital was treating for psychosis. Therefore, they ascertained that the heightened improvement was due to the "relationship with reality that is created by an animal" (Prothemann et al., 2006, p.275). In another study, Barker and Dawson (1998) looked at whether a session of AAT reduced anxiety in hospitalized psychiatric patients and whether reductions were associated with patients' diagnoses. Participants were 230 adult patients. This study 10 utilized a pre- and posttreatment crossover design to compare the effects of a single AAT session with those of a single therapeutic recreation session. Results indicated significant reductions in anxiety after the AAT session for patients with diagnoses of psychotic disorders, mood disorders, and other disorders, whereas after the therapeutic recreation sessions only patients with mood disorders showed a significant decrease in anxiety. In addition, the reduction in anxiety following AAT for patients with psychotic disorders was twice as great as that of the recreation session. In another study, Barak et al. (2001) evaluated the effects of AAT on patients in a psychogeriatric ward. Subjects were 20 elderly individuals with schizophrenia. Ten subjects either were randomly assigned to the experimental or control group. The experimental group participated in 4-hour weekly AAT groups over 12 months. The focus of treatment was to encouraged mobility, interpersonal contact, communication and to reinforced activities of daily living. The control group members convened for reading and discussion of current news. These sessions occurred on the same days as the AAT groups and for a similar amount of time. They found improvement on two aspects of the assessment used. Both groups improved self-care and the experimental group demonstrated statistically significant improvement in social functioning where improvements were evident at 6 months of treatment and maintained through the end of the study at 12 months. A meta-analysis of studies reporting on the effectiveness of AAT as a therapeutic intervention further supports this belief. Nimer and Lundahl (2007) reviewed 250 studies. Their investigation identified 49 studies meeting the inclusion criteria of: 1) reported 11 specifically on AAT, 2) had a minimum of five participants in the treatment group, 3) written in English, and 4) provided sufficient data to compute an effect size. This analysis reported that AAT is generally an effective intervention. Specifically they found that AAT had a positive effect on medical well-being, behavioral outcomes and on reducing Autism spectrum symptoms. Further, they found that four studies that compared AAT with established interventions reported that AAT was as effective as or more effective than other interventions. These studies show that AAT can improve social functioning and can affect the psychological well-being of mentally ill individuals. In addition, this intervention can strengthen social skills, reduce anxiety and encourage interpersonal growth. The Use of Animals in Corrections Facilities Prisons use various forms of interventions for therapeutic purposes. Ranging from individual and group therapy to vocational training, corrections facilities attempt to provide inmates with the resources necessary to develop healthy coping skills and function successfully in society. One approach utilizes animals. For many years corrections facilities have used animals as rehabilitative or therapeutic tools (Fournier et al., 2007; Furst, 2006; Walsh, 1994). In an attempt to understand the extent of the use of prison-based animal programs (PAPs) in the U.S., Furst (2006) did a national survey of state correctional systems. At the time of this study, 36 states reported using PAPs. The community service model, where prisoners rehabilitate animals so that they are adoptable out to the community, was the most commonly reported program. 12 The next most frequently reported was service animal socialization programs. According to the survey respondents, the most commonly mentioned benefit was the sense of responsibility developed from caring for the animals. In addition, most respondents reported no negative elements of the program. Those that mentioned negative aspects commonly mentioned staff resistance. There have been few studies looking at the efficacy of these programs. However, in one study, using a between subject, pre- and posttest design, Fournier et al. (2007) evaluated the effects of a PAP, referred to as a human-animal interaction (HAI) program on prison inmates. The researchers utilized two groups with 48 inmates. The treatment group consisted of 24 inmates who were in the HAI program. The control group consisted of 24 inmates on the HAI wait list. Results indicated that participation in the HAI program had a beneficial effect. Participants in the HAI program, relative to the control group, demonstrated positive psychosocial changes as evidenced by increased treatment progress, decreased institutional infractions, and improvement in social sensitivity. Studies evaluating this approach with the female population are also limited and had small sample sizes. Based on the community service model, the Nova Institution for Women in Canada implemented the Pawsitive Directions Canine Program (Richardson- Taylor & Blanchette, 2001). Their unpublished comprehensive evaluation found that, by providing the inmates with the responsibility of caring for and training dogs, this program improved the women‟s self-esteem, generated positive institutional changes, and altered the community‟s opinion of these incarcerated women. However, important to note is that 13 of the 49 women who participated in this program, only three women actually completed. Most attrition was due to parole. In 1994, Walsh and Mertin looked at changes in self-esteem and depression in eight women participating in a Pets and Therapy (PAT) program. These women were responsible for caring for and training dogs rejected from a program for guide dog training to place in homes in the community. They found significant changes between pre- and posttest scores on both self-esteem and depression. However, similar to the Richardson-Taylor and Blanchette (2001) study, the sample size of this study was also small. Background Some prisons use animals as rehabilitative tools, however, the state of Utah was not one of them. In fall 2007, my MSW program placed me at the Utah State Prison in Draper, UT for my second year practicum. During the second half of this placement, I developed and piloted an AAT program with the incarcerated women. During my search for information on AAT, I discovered a local agency called Intermountain Therapy Animals (ITA). ITA is a nonprofit organization that provides AAT in a variety of settings with the goal of "enhancing quality of life through the human-animal bond" (Intermountain Therapy Animals, 2008). After meeting with the director of the agency and describing to her what I had in mind, I created an 8-week group curriculum to address coping skills, social skills and interpersonal relations using a dog as a therapy tool. I developed this intervention from the theoretical perspective of attachment theory (see Figure 1). The basis for having the dog present was to see if the participants would 14 Figure 1. Program Theory Model. Program Description Objectives Goals 15 use the relationship that developed between each participant and the dog as a corrective relational experience. The goal was not to change their attachment classification, as classifications are patterns of coping in many areas of life and, at times, varies depending on relationships. To change the overall attachment classification takes an extensive amount of time and therefore is not feasible in this case. Rather, the goal of this group experience was to use the dog as a secure base, helping manage distress, and allowing participants to be open and receptive to the therapeutic value of the group experience. The theory was that participants would use the human-animal relationship to challenge their maladaptive coping strategies developed through their negative internal representations of self. It was my experience during the process of researching and developing this program that guided the focus of my dissertation. My dissertation sought to answer several questions that I present here in the format of three separate publishable articles. Methods This dissertation investigated the use of animals as a therapeutic tool in a correctional setting. Professionals use animals therapeutically in an assortment of environments and with various populations. My focus was on the effect of this method on females currently incarcerated at the Utah State Prison in Draper, Utah. I approached this topic from the framework of attachment theory. It is my belief that animals provide an essential attachment related component that can strengthen the impact of a therapeutic intervention. Through my research, I have provided some support for this effect, contributing additional evidence of the benefits of human-animal interaction to the field of animal assisted therapy (Jasperson, 2010). 16 Design I present this dissertation in the Multiple Article Path (MAP) format. I developed three separate articles, represented as chapters in this dissertation, thematically linked by their focus on therapeutic interventions with the female inmate population. The intent is for each article to extend from the previous article, taking the focus in a slightly new and more specific direction. However, I tie them all together through their focus on the needs of female inmates. I will submit all three articles for publication in peer-reviewed journals. These articles attempted to answer the following questions: Article #1 (Chapter 2): 1. What therapeutic interventions do corrections facilities use with the incarcerated female population? 2. What is the quality of the research examining these interventions? Article #2 (Chapter 3): 1. What was the effect of an AAT group utilizing a dog as a therapeutic tool on a "particular" mentally ill female inmate at Utah State Prison? Article #3 (Chapter 4): 1. How does an AAT group utilizing a dog as a therapeutic tool affect the symptom distress, interpersonal relationships, and social role performance of female inmates at Utah State Prison? Starting broad, the first article, Chapter 2 of this dissertation, explored types of therapeutic interventions implemented with the female inmate population. I focused on 17 the various theories behind these interventions, identified their reported effectiveness, looked at study quality, and discussed the therapeutic focuses. Article two, Chapter 3 of this dissertation, addressed clinical theory and intervention by bringing together my main theoretical orientation of attachment theory with a specific AAT intervention for female inmates at the Utah State Prison. This chapter consists of a literature review identifying research that has focused on AAT, a discussion on how AAT can have a theoretical orientation of attachment theory, a description of a piloted AAT program, and a clinical case example from this program. The final article, Chapter 4, presents the findings from a study developed from an expansion of the AAT program discussed in the previous chapter, article two. This pretest-posttest control-group design examined whether an AAT group utilizing a dog as a therapeutic tool affected the symptom distress, interpersonal relationships, and social role performance of female inmates at Utah State Prison. 18 References Aldwin, C. M., & Revenson, T. A. (1987). Does coping help? 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CHAPTER 2 INTERVENTIONS WITH INCARCERATED FEMALES: A SYSTEMATIC REVIEW Abstract Women‟s trajectories into crime, economic circumstances, and histories of trauma contrast with those of their male counterparts. The rise in the number and the distinctive characteristics of women under criminal justice supervision has generated attention toward the status of women in this system. This systematic review examines therapeutic interventions corrections facilities have used with incarcerated females. Most studies examined interventions for substance abuse and most utilized a cognitive-behavioral theoretical orientation. In addition, high quality studies were sparse. I discuss practice implications and recommendations for future research. Characteristics of Female Inmates Research on women's pathways into crime and the nature of crimes that they typically commit suggests that gender matters in the forces that drive their criminal behavior (Chesney-Lind, 2000). Their trajectories into crime, economic circumstances, and histories of trauma contrast with those of their male counterparts (Bloom & Covington, 2009). They typically become involved in criminal behaviors as a result of involvement with drugs often due to emotional trauma, following a man into the criminal 23 lifestyle, or as a way of coping with poverty due to economic marginalization (Holtfreter & Morash, 2003). Most incarcerated women have histories of trauma are economically marginalized, and come from families where incarceration or substance use is common (Greenfield & Snell, 1999).According to a Bureau of Justice Statistics report released in 2000, about 37% of women reported monthly incomes of less than $600 in contrast to 28% of male inmates. In addition, 30% of female inmates, compared to just under 8% of male inmates, reported receiving welfare assistance just prior to the arrest that brought them to prison Greenfield & Snell, 1999). Forty-three percent of female inmates, compared to 12.2% of their male counterparts reported a history of physical or sexual abuse. An even greater distinction is the age that respondents reported the abuse occurred. For women, 31.7% occurred prior to age 18 and 24.5% after age 18 (Note: this is not an either/or. For some, they experienced the abuse both prior to age 18 and after age 18.) For men, 10.7% reported the abuse occurred prior to age 18 with only 3% after age 18 (Snell & Morton, 1994). This continued abuse into adulthood is a unique characteristic to the female incarcerated population is should be taken into consideration when planning programming needs (Chesney-Lind, 2000). Mental Health Needs of Female Inmates Incarceration rates for females have been steadily increasing. From 2000-2007, the average growth rate of incarcerated females was 3%. This was 1.1% higher than that of their male counterparts ( Sabol, West, & Cooper, 2009). With this increasing population comes a unique set of mental health concerns. At midyear 2005, 24 approximately 73% of females in state prisons had a mental health problem. Twenty-three percent of females incarcerated in state prisons indicated that a mental health professional had diagnosed them with a mental disorder in the past 12 months. In addition, women in state corrections custody reporting mental health concerns were more likely than those without mental health concerns to meet criteria for substance abuse or dependence, to be homeless in the year before arrest, and to report past physical or sexual abuse (James & Glaze, 2006). This rise in the number and the distinctive mental health concerns of women under criminal justice supervision has generated attention toward the status of women in this system and to the unique conditions they encounter (Bloom, Owen, & Covington, 2004). There mental health struggles, histories of trauma, and economic circumstances are often relevant determinants of their crimes. Therefore, programs addressing these components are necessary (Holtfreter & Morash, 2003). It is important to develop programs with theoretical approaches and therapeutic foci that are congruent with the lives of these women (Bloom, 1999). The high rates of victimization and poor economic circumstances highlight two important areas of therapeutic interest for this population. Further, mental health interventions with incarcerated women are mostly cognitive behavioral approaches. Researchers have identified this approach as effective for the male inmates. However, research identifying this effectiveness with women remains limited (Spiropoulos, Spruance, Van Voorhis, & Schmidtt, 2005). 25 Research on Interventions Used with Prison Populations Much research has evaluated the effectiveness of rehabilitative approaches with prisoners (Dowden & Andrews, 1999). In 1974, Robert Martinson‟s divisive publication, What works? Questions and answers about prison reform, reporting on the lack of success of rehabilitation attempts with this population, created controversy in the field of criminal justice research. Researchers refute these findings by providing scientific evaluations of various interventions (McGuire, 1995). Although there are studies examining the effectiveness of correctional programs, whether or not these studies represent quality research remains in question. The issue of quality is a relevant concern because reliable and valid information serves as the basis for beliefs and decisions. If we make a decision based on inaccurate information, the results can be detrimental. Research on interventions used with the female population is still in the early stages. With the relatively recent increase in the presence of this unique population, researchers continue familiarizing themselves with the needs of these women and create programs that address their distinctive concerns (Callhoun, 2010). This systematic review examines therapeutic interventions corrections facilities use with the female incarcerated population. The purpose of this study is to answer two questions: 1) What therapeutic interventions do corrections facilities use with incarcerated females? 2) What is the quality of the research examining these interventions? To address the first research question, this chapter will highlight each study‟s therapeutic focus and theoretical orientation, the intervention and its purpose, and the results of each study. While examining what therapeutic interventions corrections 26 facilities use with the incarcerated female population, this systematic review will explore theoretical orientation in order to ascertain what theoretical approaches are being used with this population and the reported effectiveness of these approaches. To address the second research question a description is given of we will describe the study design, rate the study quality based on specified criteria, and discuss these ratings. Methods Data Collection We conducted three searches between February 15, 2010 and May 31, 2010. We describe the processes and results of each search below. We conducted our primary search between February 15, 2010 and February 28, 2010 using internet databases to identify relevant articles. We used the following databases: EBSCO‟s ERIC, Psych Articles, Academic Search Premier, Psych INFO, Psychological and Behavioral Science Collection, Women's Studies International, Illumina Criminal Justice Abstracts, Illumina Sociological Abstracts, Illumina-Social Services Abstracts, and OVID Social Work Abstracts. We chose these databases because they cover a wide range of disciplines. The search terms used were as follows: corrections, prison, detention, female prisoners, female inmates, female offenders, incarcerated females, incarcerated women, interventions, therapeutic programs, rehabilitative programs, depression, and anxiety. See Table 2.1 for results of this search. We prescreened abstracts for the following criteria: (a) target population of the study identified as incarcerated adult females (b) therapeutic or rehabilitative program described and empirically evaluated, (c) treatment outcomes measured (d) published in a peer-reviewed journal (e.g., no dissertations or books), and (e) published in English. 27 Table 2.1 Primary Search Strategy Database Search Terms Number of Hits Secured for Review Illumina-Criminal Justice Abstracts correction*, prison*, detention*, female prisoner*, female inmate*, female offender*, incarcerated female*, incarcerated women, intervention*, therap* program*, rehab* program*, depression, and anxiety 4 1 Ebsco-ERIC, Psych Articles, Medline, Academic Search Premier, Psych INFO, Psychology and Behavioral Science Collection, Women's Studies International Abstract Search: woman or women or female, inmate* or convict* or prisoner* or offender*, corrections* or AB prison* or AB detention*, intervention* or therap* program or rehab* program, depression or anxiety 273 Limiters - Scholarly (Peer Reviewed) Journals; Gender: Female; Age Related: Adult: 19-44 years, Middle Aged: 45-64 years, Middle Aged + Aged: 45 + years; Age Groups: Adulthood (18 yrs & older); English; Language: English; Age Groups: Adulthood (18 yrs & older) 148 19 Ovid-Social Work Abstracts corrections or prison or detention AND female or woman or women AND inmate or prisoner or incarcerated AND therapeutic or rehabilitative or intervention AND depression or anxiety 1 1 corrections or prison or detention AND female or woman or women AND inmate or prisoner or incarcerated AND therapeutic or rehabilitative or intervention 1 1 Illumina-Social Services Abstract corrections or prison or detention AND female or woman or women AND inmate or prisoner or incarcerated AND therapeutic or rehabilitative or intervention AND depression or anxiety 40 3 corrections or prison or detention AND female or woman or women AND inmate or prisoner or incarcerated AND therapeutic or rehabilitative or intervention NOT Juven* or adolescent* 66 10 28 Peer-review is a method employed to maintain research standards and provide credibility. Because this systematic review was looking for high quality research, we required publication in a peer-reviewed. We included only articles written in English because the author‟s primary language is English and because of the possibility of losing content and context in translation. In cases where the target populations were both males and females, we included the article if the authors made the data from the results of the female population explicit. If we could not make this distinction, the study was not included. If the abstract of the article appeared potentially relevant, we secured the complete article for review. In cases where there was no abstract, we secured the article and reviewed for relevancy. After we secured all potential studies, we evaluated them for relevancy. We excluded articles if we found that they did not meet the specified inclusion criteria, if information was not included regarding the inclusion criteria, or if the articles themselves were not relevant to the topic. We classified studies as irrelevant and/or excluded them for the following reasons: 1) authors did not specify the sex/gender of intervention participants; 2) the study reported that inmates did not participate in a particular program but were merely under the care of a psychiatrist or mental health worker; 3) authors identified the study population as parolees/probationers with a treatment program that was community based; 4) article reported on a case study; 5) study did not present formally gathered data 6) authors provided a program description only; or 7) the analysis was qualitative only. While we excluded qualitative studies from this systematic review, we did include studies that used a mixed method design of qualitative and quantitative measures but only 29 examined the quantitative findings. In addition, we included studies that looked at both male and female offenders, but examined the findings only for female offenders. As a way of identifying possible articles that we may have missed in the initial search, we conducted a second database search on March 31, 2010. This search was of the Cochran Library and focused on identifying systematic reviews or meta-analyses that we could reviewed for relevant articles. We found two articles: a protocol for a review by Dowling and Gardner (2005) and a meta-analysis by Dowden and Andrews (1999). From the Dowling and Gardner (2005) manuscript, we found one relevant study and secured for this review. We found two additional studies through examination of the Dowden and Andrews (1999) references. Because of the specific focus on women and criminal justice, on May 31, 2010 we conducted a full review of all articles in the journal Women and Criminal Justice. This search yielded no additional studies. Data Analysis We organized the included studies into Tables 2.2 and 2.3 for ease of overview. Table 2.2 describes the targeted populations, intervention, intervention theory, and the study purpose. We included the category "target population" because, while the inclusion criteria states the target population must be incarcerated adult females, some studies specify specific additional characteristics that may be important distinctions and may give context to the intervention focus and results. "Intervention" describes the specific program and therapeutic focus identified by the authors of each study. "Theoretical orientation" describes the intervention theory. For some studies, the article authors explicitly stated this. For others, we deduced what the theoretical orientation was based 30 on the detailed description of the intervention. The "study purpose" describes what the author‟s of each article specify as the overall goal of the intervention. All three components directly relate to the research question of this study. Table 2.3 describes the study design, variables examined, and the study findings. We included study design because it is an important element of study quality. "Variables examined" provides context to the study purpose and findings. "Study findings" describe the interpreted results of the intervention implementation. All three components provide a means of examining the various differences between the studies and address the first research question. Study Quality We assessed study quality by identifying the presence of specific variables in each article. See Table 2.4 for specific quality criteria and ratings. We gave each variable a score. A lower score indicates either a weaker study design or a lack of information reported. Results The initial search generated 31 potential studies. A secondary brief review of secured studies yielded what appeared to be 19 relevant articles, six irrelevant articles, and five studies needing further review or a second opinion. The final review resulted in the exclusion of the five studies that were uncertain, leaving 19 articles that met all inclusion criteria. Publication dates of these articles ranged from 1974 to 2009 with median of 2001. 31 Therapeutic Focus Therapeutic focus among these studies varied greatly. Seven studies targeted substance abuse, albeit from different perspectives. For example, Sacks (2008) examined the effectiveness of a therapeutic community modified for female offenders and looked at substance abuse as one component of the efficiency of this intervention modality. Kubiak (2004) compared participants with co-occurring PTSD to those without PTSD on treatment fidelity, relapse, and recidivism, while Kubiak et al. (2004) examined social and psychological functional changes among pregnant and substance-dependent female. When not targeting substance abuse, studies addressed job related behaviors, smoking cessation, grieving, the impact of education achievements during incarceration, parenting training, mental health symptoms, emotional turmoil associated with caring for people living with HIV/AIDS, Correctional adjustment, criminal thinking, HIV risk reduction, and traumatic risk reduction. Theoretical Orientation For many studies, the theoretical orientation of each study was not explicitly identified (Burdon, Messina, & Prendergast, 2004; Johnson, Shearon, & Britton, 1974; Kubiak et al., 2004; Valentine & Smith, 2001; Wexler, Falkin, & Lipton, 1990). Through reading the intervention descriptions, we could usually deduce a Cognitive Behavioral (CBT) approach implicitly for a few of the studies (Calabrese & Hawkins, 1988; Ferszt, 2009; Moore & Clement, 1998). This finding is consistent with other research that has identified a trend in corrections of transferring CBT programs designed for men to the female population (Chesney-Lind, 2000; Spiropoulos et al., 2005). Table 2.2 Search Results (A) Source Population Intervention Theoretical Orientation Purpose Burdon et al., 2004  Inmates in California  Female inmates N=2520  TC substance abuse treatment program  10 prison-based TC treatment programs in California with Integrated Substance Abuse Programs  Not specified  Identify possible predictors of participation in aftercare and 12-month return to custody Calabrese & Hawkins, 1988 Study 1:  2 women (ages 21 and 22)  Office-based Training: 2 hour session identifying and rationalizing the need to change behaviors and rehearsing more effective behavior (specific to participant)  In Vivo (on site) Training: In class observation and training  CBT (deduced)  Evaluate whether rehabilitation is possible and whether job related social behaviors can be part of this rehabilitation Study 2:  3 women (ages 23, 22, and 23) Cropsey et al., 2008  Women in a state prison in the southern United States N=539 women  Treatment N=250  Control N=289  10-week mood management group intervention combined with nicotine replacement therapy.  CBT  Examine the efficacy of a combined pharmacological and behavioral smoking cessation intervention 32 Farrell, 2000  Women in a Delaware prison  Treatment N=41  Control N=38  Treatment: CREST TC  Control: Work release program  Social Disorgan-ization Theory  Control Theory  Measure the effect of social support on drug use and return to criminal activity by identifying variables indicative of either formal or informal social support  Examine whether participation in a TC serves as one factor of post-incarceration support system building Ferszt, 209  Women from a women‟s prison in the Northeast  Treatment N=21  Control N=15  12-week psychosocial group called "Houses of Healing: A Prisoner‟s Guide to Inner Power and Freedom"  CBT (deduced)  Restorative Justice  Examine the impact of the identified variables on grieving female inmates Hall et al., 2004  Women from a California prison  Treatment N=119  Comparison N=96  Treatment group:"Forever Free": 6-month intensive in prison followed by community based substance abuse treatment program  CBT  Seeks to determine which factors predicted better outcomes for study participants  Examines outcomes among participants in the "Forever Free Program" using a prospective, longitudinal design Table 2.2 (Continued) Source Population Intervention Theoretical Orientation Purpose 33 Table 2.2 (Continued) Source Population Intervention Theoretical Orientation Purpose  Comparison group: "Life Plan for Recovery" program-8-week, 3 hours/day substance abuse course Johnson et al., 1974  Women released from North Carolina Correctional Center for Women  Treatment N=100  Control N=100  Retrospective evaluation o January 1 1963 to March 31, 1969  Treatment: G.E.D. certificate received during incarceration  Control: No G.E.D. certificate received during incarceration  Not specified  Assess whether successful completion of an educational program helped reduce recidivism Kubiak, 2004  Inmates voluntarily in a residential substance abuse program  Female N=60  A residential substance abuse program located at the participant‟s respective institution  CBT  Compare study participants with co-occurring PTSD and those without  Examine treatment adherence, relapse, and recidivism Kubiak et al., 2004  Pregnant women with a history of drug/alcohol dependence, willing to actively parent  6-9 month community-based residential program  Not specified  Examine social and psychological functional changes among pregnant and substance-dependent female 34 their newborns  N=27 Moore & Clement, 1998  Mothers at the Virginia Correctional Center for Women  Treatment N=20  Control N=20  Mothers Inside Loving Kids (MILK) program  CBT (deduced)  Evaluate the effects of a parenting training program on parenting skills Mosher & Phillips, 2006  Women from the Washington State DOC  Treatment N=279  Control N=279  New Horizons Program: A holistic residential TC for substance abuse  CBT  Examine the effects of participation on reconviction Pomeroy et al., 1998  Women in a jail in Orange County, FL  Treatment N=13  Comparison N=9  Psychoeducational group  Reality therapy, behavior modification, cognitive theory, and empowerment theory  Reduce perceived stress, anxiety, depression, and trauma experienced by women inmates with the long-term goal of reducing recidivism Pomeroy et al., 1999  HIV/AIDS-infected/ affected women in Orange County, FL jail  Psychoeducational group  CBT  Task-centered approach  Alleviate the emotional turmoil associated with caring for people living with HIV/AIDS 35 Table 2.2 (Continued) Source Population Intervention Theoretical Orientation Purpose  Treatment group N=87  Comparison group N=52 Sacks, 2008  Women in a Colorado corrections facility  Treatment group N=163  Control group N=151  Treatment intervention: TC  Control intervention: Colorado DOC standard treatment known as the Intense Outpatient Program  Treatment group- Not specified  Control group-CBT  Examine the effectiveness of a TC on mental health (psychological symptoms and trauma), substance use, criminal behavior, and HIV-risk behavior Spiropoulos et al., 2005 Women in community diversion: o Treatment N=64 o Comparison N=93  Female‟s in prison o Treatment 1 N=51 o Treatment 2 N=54 o Comparison N=54  "Problem Solving" program (Taymans & Parese, 1998)  "Pathfinders" program (Hanson, 1993)  Problem Solving- CBT  Pathfinders-CBT with components of relationships and empowerment  Examine the effectiveness of 2 correctional treatment programs: The "Problem Solving" program by itself, the "Problem Solving" program augmented by the "Pathfinders" program, and utilized a no intervention comparison group Table 2.2 (Continued) Source Population Intervention Theoretical Orientation Purpose 36 St. Lawrence et al., 1997  Women from a state‟s women‟s facility near a southern city  Total N=90 (specific distribution not noted)  A group intervention based on Social Cognitive Theory  A group intervention based on Gender and Power Theory  Theory of gender and power  Compare a social cognitive theory intervention to a theory of gender and power intervention for effectiveness on HIV risk reduction Sultan, 1984  Women in a North Carolina Correctional Center for Women  Total N=61 (specific distribution not noted)  Psychodidactic Intervention support group  Support-only group  Psychodidactic theory  Investigate an intervention program designed to facilitate successful entry of women into prison Valentine & Smith, 2001  Women from a federal correctional facility in Florida  Treatment N=56  Control N=67  Traumatic Incident Reduction (TIR)  Empowerment theory (deduced)  Pyscho-dynamic (deduced) Examine the effectiveness of traumatic incident reduction 37 Table 2.2 (Continued) Source Population Intervention Theoretical Orientation Purpose DOC=Department of Corrections; TC=Therapeutic Community Wexler et al., 1990  Inmates who completed the program, on a wait list for the program, or participating in an alternative drug counseling program  Female treatment N=247  Female no treatment N=38  Female alternative treatment N=113  Stay‟n Out TC  Not specified  Examine whether prison-based TC treatment can significantly reduce recidivism Table 2.2 (Continued) Source Population Intervention Theoretical Orientation Purpose 38 Table 2.3 Search Results (B) Source Study Design Variable(s) Examined Outcome(s) Burdon et al., 2004  Single group design  Criminogenic needs and factors, retreatment/preincarceration socio-demographics, participation in aftercare, type of aftercare program, 12-month return to custody, lifetime years of incarceration, substance abuse/dependence related DSM-IV diagnoses, area (urban, suburban, rural) paroled to, motivation for treatment  Increased time spent in prison-based treatment were significantly more likely to participate in aftercare and significantly less likely to be returned to custody within 12-months  Increased time spent in aftercare predicted decreased 12-month return to custody  County of parole did not predict participation in aftercare Calabrese & Hawkins, 1988 Study 1:  Single subject design (multiple baseline across behaviors) Study 1: Subject 1:  Discourteous behaviors, seeking attention of work supervisor, seeking attention of others Subject 2:  Flirtatious behavior, non-work related interaction Study 1:  Individualized job-related training can produce functionally valid changes Study 2:  Same as study 1 Study 2:  Off task, talking, disruption  An intervention aimed at inappropriate classroom behaviors can be effective in a prison setting Cropsey et al., 2008  RCT with a 6-month waitlist control group  Abstinence vs. Smoking  The combined behavioral and pharmacological intervention was effective at promoting smoking cessation 38 39 Farrell, 2000  Nonequivalent control group design  RCT  Treatment group clients randomly selected  Selection of control group participants was not specified Independent Variables:  Current status in community, involvement in support/treatment networks, connection with friends/ family, drug usage-self and friends/family, work/education Dependent Variables:  Relapse, recidivism  Treatment program failed to significantly reduce recidivism or relapse  Treatment group participants were significantly more likely to attend drug treatment in the community  The program failed to reduce either recidivism or relapse significantly for female offenders.  No significant difference between groups in use or development of social support  Being responsible for childcare and having a significant other that does not use drugs decreased likelihood for relapse  Participants in the treatment group were significantly less likely to relapse on alcohol Ferszt, 2009  Quasi-experimental  Mixed methods evaluation  Nonequivalent control group design  Anxiety, depression, self-esteem, and spiritual well-being  While quantitative data indicated no significant difference between groups overtime qualitative data indicated participants had a more positive view of themselves and increased self-acceptance Hall et al., 2004  Nonequivalent control group design  Quasi-experimental  Crime or recidivism, drug use, employment  Treatment group had significantly fewer arrests and convictions but significance was not achieved for re-incarcerations  The greater number of lifetime arrests had an increased risk on re-incarcerations 40 Table 2.3 (Continued) Source Study Design Variable(s) Examined Outcome(s)  Treatment group participants engaged in significantly lower levels of drug use  Age predicted drug use (younger subjects more likely to engage in drug use) and heroin users were more likely to return to use than alcohol or methamphetamine users  Days of post-release residential treatment and education were predictors of employment Johnson et al., 1974  Quasi-experimental design: Incidental sample  Secondary data analysis Independent Variable  G.E.D. earned through the academic program provided by the NCCCW Dependent Variable  Recidivism  Recidivism rate was slightly higher for the control group. However, difference did not reach statistical significance.  80% of women who completed their GED while they were incarcerated did not recidivate Kubiak, 2004  Experimental exploratory design Independent Variable  PTSD Dependent Variables  Treatment adherence, drug relapse, and criminal recidivism  Women with substance abuse disorders and PTSD were significantly more likely to relapse than women with substance abuse disorders only  PTSD diagnosis accounted for 22% of the variance in relapse  Recidivism did not significantly differ by PTSD diagnosis Kubiak et al., 2004  Pre-experimental  One group pre-test/ post-test design  Life skills related to community living, employment-seeking skills, program completion status, mental health  Approximately one third of the women who entered did not attain completion goals  Over the course of the program, efficacy in employment-seeking behaviors and mastery 41 Table 2.3 (Continued) Source Study Design Variable(s) Examined Outcome(s) improved significantly, and depression symptoms declined Moore & Clement, 1998  Quasi-experimental with comparison groups  Nonequivalent control group design  Self-esteem, parenting and child rearing attitudes, knowledge of specific behavioral management techniques  Using Wilcoxen nonparametric statistics, improvement in parenting techniques reached statistical significance.  No other differences reached statistical significance between groups Mosher & Phillips, 2006  Nonequivalent control group design Independent Variable  Participation in the New Horizons Program Dependent Variable  Reconviction  Women in the treatment group were less likely to be reconvicted of a crime, net of other demographic variables, than were women from the control group Pomeroy et al., 1998  Nonequivalent control group design  Stress, anxiety, depression, trauma symptoms  The intervention had moderate to strong effects in reducing the depression, anxiety, stress, and trauma. Strongest effects were on reducing the depression and anxiety Pomeroy et al., 1999  Quasi-experimental pre/posttest design  Anxiety, depression, trauma symptoms  The group had a meaningful impact in reducing the depression, anxiety, and trauma symptoms Sacks, 2008  Experimental, prospective, longitudinal, repeated measures design  Mental health (psychological symptoms and trauma), substance use, criminal behavior, and HIV-risk behavior  Outcomes at 6-months showed significant improvements for both groups on all variables.  Treatment group showed significantly more improvement on mental health, trauma exposure, criminal behavior, and HIV risk behaviors but not substance abuse 42 Table 2.3 (Continued) Source Study Design Variable(s) Examined Outcome(s) Spiropoulos et al., 2005  Community diversion: Nonequivalent control group design  Women‟s prison: Experimental group design  Participant program evaluation  Depression  Correctional adjustment  The Problem Solving program significantly reduced reported misconduct depression scores  In the women‟s prison group, the Pathfinders program significantly reduced depression scores over a longer sustained period of time  The addition of the Pathfinders program to the Problem Solving program did not significantly affect any other variables St. Lawrence et al., 1997  Experimental group design: Alternative treatment groups with random assignment  Self-efficacy, self-esteem, attitude toward prevention, AIDS knowledge, communication skills, condom application skills, perceived vulnerability to HIV, commitment to prevention  Did not find significant differences in skills, knowledge, or attitudinal changes between the two groups  The social cognitive theory intervention showed greater improvement in condom application skills, and the theory of gender and power group showed greater commitment to change  All other variables changes were equivalent over time for the two intervention conditions Sultan, 1984  Experimental design with a treatment group, support only group, and no treatment group  Depressive symptoms, anxiety, prison adjustment (social/emotional factors), prison adjustment (somatic)  Subjects in the 2 experimental groups reported a significant decrease in psychosomatic complaints  There were no significant differences between the 2 treatment groups at post-test Table 2.3 (Continued) Source Study Design Variable(s) Examined Outcome(s) 43 Valentine & Smith, 2001  Experimental design with a pretest-posttest control condition and a 3- month follow-up  Depression, anxiety, PTSD symptoms, self-efficacy  TIR was effective at alleviating PTSD, depression, anxiety, and low expectancy of success  The control group‟s scores remained stable across all three testing periods, whereas the treatment condition‟s scores decreased steadily Wexler et al., 1990  Nonequivalent control group design with 2 control groups: o No treatment group o Alternative treatment group  Arrests, time until arrests, parole discharge/revocation  The treatment group was significantly more effective at reducing arrests in comparison to the alternative treatment group but not the no treatment group  The treatment group had a significantly higher percentage of positive discharge from parole than the no treatment group but not the alternative treatment group  No relationship was found between study group and time until arrest Table 2.3 (Continued) Source Study Design Variable(s) Examined Outcome(s) 44 45 Table 2.4 Study Quality Scoring 0 1 2 3 4 Group Assignment Violated randomization, nonequivalent Tested for pre-treatment equivalence Matched group or case control True randomization Control Group Not mentioned or no comparison/ control group Waitlist Treatment as usual - with an explicit program Control group Control group and a third comparis on group Sample size Not mentioned Less than twenty participants 21 to thirty participants 31 or more participants Treatment Standardized Not mentioned No specific training Manual used or specific training (credit given if mention of a specific curriculum) Fidelity No mention of fidelity or supervision Assessed: Moderate fidelity Assessed: High Fidelity or Supervision Dose: Frequency of sessions/ contacts indicated: Not mentioned less than three between four and seven sessions eight or more sessions Drop Outs No mention Enumerated or discussed or compared Indicators of population demographics Reported two or less Reported three or more 46 Some studies specified other theoretical orientations. For example, Farrell (2000) utilized social disorganization theory to examine whether social support would impact drug use and criminal activity recidivism while Sultan (1984) utilized psychodidactic theory to examine the effectiveness of an intervention aimed at easing the transition to incarceration. Some researchers have argued that empowerment based interventions are more appropriate for the female populations (van Wormer, 2010). Two studies utilized empowerment theory in their intervention development. In one study, the authors did not specify this theory but we were able to infer it from the description. Pomeroy, Kiam, and Abel (1998) employed a combination of reality therapy, Lazarus' model of behavior modification, cognitive theory, and empowerment theory and examined whether psycho-educational groups would reduce certain mental health symptoms and ultimately recidivism with female inmates. St. Lawrence et al. (1997) compared an intervention grounded in social cognitive theory with an intervention grounded in theory of gender and power for effectiveness on HIV risk reduction. Spiropoulos et al. (2005) specified the use CBT with an additional component focusing on relationships and empowerment with the Pathfinders program and CBT only with the Problem Solving Program. However, they do state that the Pathfinders program was not designed for women nor was it developed as a gender-responsive program. Valentine and Smith (2001) use an intervention called Traumatic Incident Reduction (TIR). The authors describe this as a "client-respectful technique… wherein the client‟s perception of the traumatic incident takes precedent over any other perception of the incident" (pp. 40-41). With the therapist providing structure, this approach gives 47 the client the authority, or power, to client and therefore we considered it one that utilizes empowerment theory. Researchers used a variety of theoretical approaches in the creation and implementation of interventions with this population. Most studies described some success in the outcomes of their research regardless of whether the programs were designed according to the principles of gender-responsive programming (Bloom, 1999). Study Quality Table 2.5 summarizes the overall study quality. The highest quality score that a study could receive was a 19. Scores ranged from 5-18 with a mean score of 11.32 or 60% of possible points. The top two studies received at least 84% of the possible points with the next highest only receiving 74%. Spiropoulos et al. (2005) had the highest score of quality at 18 points followed by St. Lawrence et al. (1997) at 16 points. Spiropoulos et al. (2005): Pathfinders and Problem Solving Spiropoulos et al. examined the effectiveness of two correctional treatment programs, the Problem Solving program, a program utilizing cognitive skills training to address impulsivity, and the Problem Solving program augmented by the Pathfinders program, which addresses issues such as self-image, trust, communication, relationships and empowerment. The aim of this study was to examine whether adding the additional element of the Pathfinders program would be more effective in changing criminal thinking patterns. One of the strong quality components of this study was their true randomization and utilization of a control group and a third comparison group to strengthen the design. In addition, they evaluated groups for equality based on demographics and criminal Table 2.5 Study Quality Results Source Group Assignment Control Group Sample Size Treatment Standardized Fidelity Dose Frequency Drop outs Demographics Total Burdon et al., 2004 0 0 3 0 0 0 1 1 5 Calabrese & Hawkins, 1988 0 0 1 0 1 3 0 0 5 Cropsey et al., 2008 3 3 3 0 0 3 1 1 14 Farrell, 2000 3 3 3 0 0 3 0 1 13 Ferszt, 2009 1 1 2 2 0 3 0 1 10 Hall et al., 2004 2 2 3 2 0 3 1 1 14 Johnson et al., 1974 2 3 3 0 0 0 0 1 9 Kubiak, 2004 0 0 3 0 0 3 0 1 7 Kubiak et al., 2004 0 0 2 0 0 3 1 1 7 Moore & Clement, 1998 1 1 3 2 0 3 0 1 11 Mosher & Phillips, 2006 2 3 3 0 1 3 1 1 14 Pomeroy et al., 1998 1 1 1 2 0 3 0 1 9 Pomeroy at al., 1999 1 1 3 2 2 3 0 1 13 Sacks, 2008 3 3 3 0 0 3 0 1 13 Spiropoulos et al., 2005 3 4 3 2 1 3 1 1 18 St. Lawrence et al., 1997 3 3 3 2 2 2 0 1 16 Sultan, 1984 3 4 3 0 0 0 0 1 11 Valentine & Smith, 2001 3 3 3 2 0 2 0 1 14 Wexler et al., 1990 1 4 3 0 0 3 0 1 12 48 49 history and reported they were statistically similar. They also received the maximum points for sample size stating that the women‟s prison participants started with a total number for all three groups of 159 and finished with 87. They thoroughly addressed attrition by identifying the reasons for incomplete data collection and statistically analyzing and differences between dropouts and completers, and therefore received the point for accounting for dropouts. While slightly ambiguously reported, this article did receive full points for treatment standardization. They did not mention whether the Problem Solving program used of a manual, specific training or curriculum. However, the authors described it as a program and identified it as a component of a widely used manualized program Thinking for a Change. In addition, the authors provided specific details of what was covered. The Pathfinders program description included the mention of a specific curriculum, exercises, surveys, games, and activities. Therefore, we assumed that these programs were manual and/or curriculum based. This study lost their only point for fidelity. The authors did not mention the use of supervision for facilitators to assure treatment fidelity. However, they did use an evaluation that addressed many facets of the program including feedback on the facilitator‟s adherence to the program design. St. Lawrence et al. (1997): HIV Risk Reduction for Incarcerated Women These authors compared a social cognitive theory intervention that provided specific skills training to a theory of gender and power intervention that used unstructured discussion and open-ended questions about gender and power issues related 50 to HIV. Their goal was to assess which approach was most effective at reducing HIV risk. Similar to Spiropoulos et al., these researchers utilized random assignment, strengthening the quality of this study. However, they used a comparison group only with no control group. The authors statistically evaluated their groups for equality and found no between group differences. This study reported a sample size of 90. However, the authors do not specify whether this was a starting number or the number that completed treatment. Unfortunately, there was no mention of attrition, weakening the overall study quality. This article also did not specifically mention the use of a manual. However, they described both interventions in detail. The article notes, "All intervention sessions were audiotaped and assessed for adherence to the interventions‟ protocol" (St. Lawrence et al., p. 505). This statement indicates that there were specific guidelines for each intervention. Because of this statement, we gave this study full points for treatment fidelity. Of the 19 studies from this review, most study designs were quasi-experimental. Only five utilized randomization (Farrell, 2000; Spiropoulos et al., 2005; St. Lawrence et al., 1997; Sultan, 1984; Valentine & Smith, 2001). Farrell (2000) randomly selected participants from a specific population for their treatment group. However, they made no mention of the selection process for the control group. The other four studies described random assignment to both or all research groups. This missing component in the study design of the remaining articles weakens their conclusions about the effectiveness of the intervention. 51 Three areas where most of the studies consistently lost points were fidelity, dropouts, and treatment standardization. Only 5 of the 19 studies received points for fidelity with only 2 of those receiving full points. The strongest areas were sample size and demographics reported. All studies receiving some points for sample size and all except four of the studies received full points. Only one study did not receive points for demographics. Discussion Most of the studies targeted substance abuse and utilized a cognitive behavioral theoretical orientation. Further, all reported successful treatment outcomes. This begs the question of whether the effectiveness of the cognitive behavioral model with women is as unsupported by research as some scholars assert (Bloom, 1999; Chesney-Lind, 2000). It is important to note that each study operationalized and measured success differently. Their reported success does not mean that gender-responsive programs would not be equally or even more beneficial. What it does mean is that a variety of approaches may be necessary depending on the specific needs of the inmate and the therapeutic focus. High quality studies evaluating the effectiveness of therapeutic interventions with the female incarcerated populations were sparse. One possible reason for this is that accessing prisoners for research purposes can be a cumbersome process. Research ethics review boards now consider prisoners a vulnerable population in terms of research ethics due to a history of exploitation in the name of research. Studies with incarcerated populations require researchers to navigate additional IRB restrictions as well as correctional institutional restrictions (U.S. Department of Health & Human Services, 2003). Further limits are often in place for security concerns that accompany operating 52 within the walls of a correctional facility. While navigating the IRB review process does not necessarily ensure that quality research is conducted, the additional requirements and cumbersome process may dissuade researchers from attempting to access this population leaving programs unevaluated by outside sources. Policy Implications and Directions for Future Research Even after navigating the review board systems, many of these studies still did not produce high quality research. It is essential that prison administrators base their program development considerations on quality research findings. Often, when an intervention in one setting appears successful, correctional facilities adopt the practice, thinking it will fit in their system (Henderson, Young, Farrell, & Taxman, 2009). Fortunately, we are seeing a shift in this practice as evidence-based treatment becomes more common within the correctional setting (Henderson et al., 2009). Quality studies often require resources that are not always readily available and result in hastily planned and executed research. These types of studies can generate findings based on faulty assumptions and ultimately reinforce ineffective responses to problems. High quality research can help prevent this wasted time, money and energy by ensuring that interventions used are relevant in design, focus, and implementation. One way to address the deficit of quality research in this field is to conduct more randomized control trials. Random assignment is a technique used in research that allows for the assumption of group equality. If researchers randomly assign two groups, the assumption is that between group differences are due to the treatment effect and not individual group characteristics. It addresses most of the basic assumptions of internal 53 validity. Therefore, without this component, we cannot exclude outside variables from the list of reasons for the treatment effect. Clinical Implications These findings can guide future therapy practice with this population. Practitioners have a responsibility to understand the importance of quality research and to learn how to be effective consumers of this research. These findings provide guidance for program components that practitioners should look for. Before implementing an intervention with female inmates, practitioners should conduct a needs assessment identifying the distinctive concerns of the group they are targeting. Next, they should consider the theoretical orientation of the intervention in order to ensure that they address needs properly. For example, if skill development from a CBT orientation is the focus of the intervention, this approach may only be effective if an additional component is included from an empowerment perspective addressing self-efficacy. We teach a client various skills, but if she does not believe she is capable of utilizing these skills, then teaching them becomes less practical. Study Limitations There are limitations to this systematic review. First, we included only studies accessible through electronic database searches. Even though a great deal of research is accessible through this search approach, we likely missed some quality studies that were not available through the electronic search or through the specific databases we used. Next, we assessed study quality using seven primary factors that we deemed relevant. We identified components of study rigor and chose those that we believed 54 indicated quality in research. There are components that we did not specifically address. For example, there are elements of internal and external validity that we did not include. These limitations do not take away from the importance of the findings. However, future research should include a more comprehensive review. This may include unpublished research, governmental studies, and should assess quality based on the full spectrum of valid constituents. With the growing rate of incarcerated females comes the need for empirically validated interventions addressing their specific and unique needs. 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Criminal Justice and Behavior, 17(1), 71-92. doi: 10.1177/0093854890017001006 CHAPTER 3 ANIMAL ASSISTED THERAPY WITH FEMALE INMATES WITH MENTAL ILLNESS: A CASE EXAMPLE FROM A PILOT PROGRAM ____________________ 1Reprinted with permission from Taylor and Francis 59 Downloaded By: [University of Illinois Chicago] At: 19:30 31 January 2011 Journal o f Offender Rehabilitation, 49:417-433, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 1050-9674 print=1540-8558 online DOI: 10.1080/10509674.2010.499056 Animal-Assisted Therapy with Female Inmates with Mental Illness: A Case Example from a Pilot Program RACHAEL A. JASPERSON College of Social Work, University of Utah, Salt Lake City, Utah, USA Female offenders‟ mental health needs have consistently been shown to exceed those of male offenders. Incarcerated women report higher rates of violent victimization, major depression, post- traumatic stress disorder, mood disorders, substance use disorders, and p e r s o n a l i t y disorders. For years, researchers have examined the human-animal relationship through t h e lens of attachment theory in order to understand the symbiosis that exists. The following article describes a pilot animal-assisted therapy program implemented at Utah State Prison for female inmates s t r u g g l i n g wi th mental i llness. Following this description, a clinical case example is used to illustrate the impact of this program on a particular group member. KEYWORDS AAT, animal-assisted therapy, female inmates, group intervention MENTAL HEALTH IN THE INMATE POPULATION In the wake of deinstitutionalization, our nation‟s prison system has replaced state hospitals as the primary purveyors of mental health services, by default becoming the new mental health institutions (American Psychiatric Association, 2004). According to the U.S. Department of Justice, at midyear 2005 more than half of all prison and jail inmates had a mental health problem, with state prisoners most likely to report a recent history of a mental health problem (James & Glaze, 2006). This criminalization of mental illness, as this shift is often referred to (Munetz, Grande, & Chambers, 2001), forces prison administration to consider the special needs of this growing population and how best to address these needs while maintaining adequate security (Magaletta, 2009). Inmates with mental illness struggle more than their counterparts with adjusting to prison life and are more susceptible to becoming caught in the „„revolving door‟‟ of the corrections system (MacKain & Messer, 2004). The lack of community services, difficulties in accessing services, and previous contact with the criminal justice system, are commonly cited as causes for this revolving door (American Psychiatric Association, 2004). INCARCERATED FEMALES AND THEIR MENTAL HEALTH ISSUES In 2006, the growth of the female inmate population was even greater than that of the male population. While the male growth rate was 2.7%, the number of women in 60 prison saw an increase of 4.5%. This growth rate for female inmates exceeded that of the average annual growth rate of 2.9% from 2000 through 2005 (Sabol, Couture, & Harrision, 2007). By the end of 2006, approximately one out of every eight adults on parole was a woman (Glaze & Bonczar, 2007). Female offenders‟ mental health needs have consistently been shown to exceed those of men (P. H. Ross & Lawrence, 2009). An estimated 73% of females in state prisons, compared to 55% of male inmates, have a mental health problem (James & Glaze, 2006). Incarcerated women report higher rates of violent victimization, major depression, and posttraumatic stress disorder (PTSD; Broner, Kopelovich, Mayrl, & Bernstein, 2009; Browne, Miller, & Maguin, 1999; Burnette & Newman, 2005; Warren et al., 2002). In addition, this population demonstrates higher rates of mood disorders, substance use disorders, and personality disorders, most notably borderline personality disorder (Chapman, Specht, & Cellucci, 2005; Jordan, Schlenger, Fairbank, & Caddell, 1996; Nee & Farman, 2005). Key features to borderline personality disorder are interpersonal hostility, recurrent suicidal behaviors or self-harm, impulsivity, severe reactivity, highly unstable interpersonal relationships, and persistently unstable self-image (American Psychiatric Association, 2000). Individuals with borderline personality disorder, especially those engaging in suicidal gestures and self-harm, pose a particular concern for corrections staff. However, results of some studies indicate that interventions directed at helping inmates develop active, problem focused coping strategies may result in less frequent suicidal behavior among female inmates (Chapman et al., 2005). FEMALE INMATES IN UTAH Recognizing the need to understand the special circumstances of the female inmate population, in 2004 the Utah Commission on Criminal and Juvenile Justice collected data on the characteristics of the female prison population in Utah (Utah Commission on Criminal and Juvenile Justice, 2004). They found that nearly half of the survey participants had not completed high school requirements (44.7%) and 54% reported a total household income of under $10,000 prior to being incarcerated. Most (62.5%) of the participants were there for drug related crimes and 77.6% of them reported that their crimes were committed while under the influence of drugs or alcohol. Half of all respondents (50.6%) reported that they committed their crime in order to acquire money for drugs. Particularly concerning were the mental health issues for this population. Of the participants, 28.2% reported current mental health treatment, and 45.4% reported having had treatment at some point in the past while incarcerated. Over half of respondents (56.0%) reported that they had received some mental health treatment in the past while not incarcerated. Most of the women reported that they had previously been in a residential treatment program and attended outpatient treatment, while 15.2% reported prior mental health hospitalization (Utah Commission on Criminal and Juvenile Justice, 2004). When looking at their reported lifetime prevalence of abuse, it is not surprising that mental health is a concern for this population. 85.8% of the women incarcerated in 61 Utah reported having experienced physical or sexual assault at some point during their lifetime. 69.3% reported a sexual assault or rape and 79.1% reported physical assault at some point in their lives. ATTACHMENT THEORY Attachment theory offers a framework for understanding normal and pathological relationship formation through learning how early relationships affect later psychological functioning (Shorey & Snyder, 2006). Internal representations developed in childhood effect how an individual interprets her ability to cope and how she utilizes relationships throughout her life. While adaptive during infancy, if unchanged, the alternative strategies developed by the insecurely attached child become maladaptive during adolescents and adulthood. In cases where the child was subjected to abuse or neglect, or parented by a psychologically disturbed parent, these strategies, if unchanged, can result in the development of personality disorders or other forms of psycho- pathology (Fonagy, 2000). In fact, some researchers view personality disorders as disorders of attachment (Shaver & Clark, 1994). Research has found that a chaotic childhood, including neglect and/or physical or sexual abuse is an important etiological factor for the development of borderline personality disorder (Zanarini, Williams, Lewis, & Reich, 1997). The vast majoring of female inmates have experienced trauma such as childhood physical and/or sexual abuse (Bloom & Covington, 2009). Research looking at the lifetime prevalence of traumatic experiences of female offenders has found their trauma exposure to be significantly higher than general population women or incarcerated men (McClellan, Farabee, & Crouch, 1997). Because of these chaotic and often traumatic childhoods, it is likely that these women demonstrate some form of disrupted attachment behaviors. Some studies have examined the nature of attachment behaviors in offenders with mental illness. Overall, these studies have found that secure attachment styles in this population are extremely underrepresented com- pared to general population individuals (Frodi, Dernevik, Sepa, Philipson, & Bragesjo¨, 2001; T. Ross & Pfa¨fflin, 2007; van Ijzendoorn et al., 1997). Further, while the relationship between personality disorders and attachment is often complicated by many variables, the more diagnosable signs of a personality disorder that are present the more insecurely attached criminal offenders tend to be (van Ijzendoorn et al., 1997). Attachment and Animals For years, researchers have been examining the human-animal relationship in order to understand the symbiosis that exists (Crawford, Worsham, & Swinehart, 2006; Endenburg, 1995; Woodward & Bauer, 2007). Some studies have found a great deal of support for the strength of the affectional bond between pet and owner (Palestrini, Previde, Spiezio, & Verga, 2005; Prato-Previde, Custance, Spiezio, & Sabatini, 2003; Topa´l, Miklo´si, Csa´nyi, & Do´ ka, 1998). Using traditional attachment measures to study the human-animal bond between pets and pet owners, Prato-Previde, Custance, Spiezio, and Sabatini (2003) replicated a 62 study by Topa´l et al. (1998) in which they used the Strange Situation test to measure the attachment relationship between dog owners and their dogs. Developed by Ainsworth and colleagues, the Strange Situation test was developed in order to understand and classify infant attachment based on environmental exploration behaviors and infant responses to short-term maternal separation (Ainsworth & Bell, 1970). They found some evidence of dogs using owners as a secure base for exploration and play, although not as strong as with human infant and caregivers. In addition, they found that once dogs became aware that their owners had left the room, they displayed distress and protest and engaged in behaviors that indicated they were actively searching for their missing owners. Further, similar to securely attached infants, the reunion of the owner and dog elicited proximity and contact-seeking behaviors. Only the dogs that had experienced abandonment at some point in their lives displayed insecure attachment behaviors such as avoidance or withdrawal in response to this reunion. In addition to dogs displaying attachment behaviors similar to infants, the attachment relationship between human and animal also serves a similar purpose for humans. Headey (1999) reported that most of the respondents to his study described an emotional security derived from their relationship animal, describing their pets as comforting during times of distress. Further, a number of studies show that companion animals have a positive influence on general physical health and mental health (Friedmann & Thomas, 1995; Headey, 1999; Siegel, Angulo, Detels, Wesch, & Mullen, 1999) and have been shown to decrease stress and anxiety in some populations (Fritz, Farver, Hart, & Kass, 1996). ANIMAL-ASSISTED THERAPY There are several ways that professionals use animals for therapeutic purposes. The community service model, where animals are rehabilitated in order to be adopted out to the community, and service animal socialization programs, where animals are trained to assist individuals with disabilities, are the most common. However, another form, animal-assisted therapy (AAT), is a goal-directed intervention in which an animal is a primary element of the treatment process (Delta Society, 2009a). It is an interaction between patients and a trained animal and human handler, with a therapeutic objective (Barker & Dawson, 1998). AAT is not a style of therapy. Rather, this approach uses an animal as a tool while operating from the therapist‟s principle foundational method. For example, a therapist may utilize cognitive-behavioral techniques to facilitate change in a client through interactions with an animal (Delta Society, 2009a). In addition to AAT, therapy animals help individuals through animal- assisted activities (AAA). AAAs provide social, educational, and recreational benefits for people during interactions. AAAs do not need to be overseen by a therapist and they do not work toward particular therapeutic goals (Barker & Dawson, 1998). It is important to note that therapy animals are not service animals. A handler utilizes a therapy animal in AAAs or AAT with people who do not necessarily have disabilities. According to the Americans with Disabilities Act, a service animal is trained 63 specifically and individually to assist an individual with disabilities (Americans with Disabilities Act, 1996). Since therapy animals operate in various settings with a wide array of individuals that are not disabled, they do not meet the classification of service animals. RESEARCH ON AAT AND AAA WITH INDIVIDUALS WITH MENTAL ILLNESS There are several studies looking at the effects of AAT and AAA on individuals with mental illness (Barak, Savorai, Mavashev, & Beni, 2001; Barker & Dawson, 1998; Prothmann, Bienert, & Ettrich, 2006). Prothmann et al. (2006) investigated possible influences of AAT on the state of mind of children and adolescents who had undergone inpatient psychiatric treatment. Following five individual therapeutic sessions with a therapy dog, compared to the control group, the treatment group demonstrated increased alertness, attention, openness and desire for social contact, perception of healthy and vital factors, and participants appeared psychologically more well balanced. In addition, these effects were stronger the worse the individual felt before the contact with the dog. In a study examining whether a session of AAT reduced the anxiety in adult patients at a psychiatric hospital and whether any reductions were associated with patients‟ diagnoses, Barker and Dawson (1998) compared the effects of a single AAT session with those of a single therapeutic recreation session. Results indicated significant reductions in anxiety after the AAT session for patients with diagnoses of psychotic disorders, mood disorders, and other disorders, whereas after the therapeutic recreation sessions only patients with mood disorders showed a significant decrease in anxiety. In addition, the reduction in anxiety following AAT for patients with psychotic disorders was twice as great as that of the recreation session. In another study, Barak et al. (2001) evaluated whether an AAT program would encouraged mobility, interpersonal contact, communication and rein- forced activities of daily living with elderly patients with schizophrenia in a psychogeriatric ward. Results indicated that AAT could have a significantly positive effect on this population. They found significant improvement on all aspects of the measure used. Most notable was the effect on social functioning where improvements were already evident at six months. These studies show that AAT can have a positive effect on the psychological well-being of individuals with mental illness. In addition, this intervention can strengthen social skills, reduce anxiety and encourage interpersonal growth. THE USE OF ANIMALS IN CORRECTIONS FACILITIES Corrections facilities have been using animals as rehabilitative or therapeutic tools for many years (Fournier, Geller, & Fortney, 2007; Furst, 2006). In an attempt to understand the extent of the use of prison-based animal programs (PAPs) in the United States, Furst (2006) did a national survey of state correctional systems. At the time of this study, 36 states were using PAPs. The community service model was the most commonly reported 64 Downloaded By: [University of Illinois Chicago] At: 19:30 31 January 2011 program, and the service animal socialization programs were the next most commonly reported program. The most frequently mentioned benefit was the sense of responsibility developed from caring for the animals. In addition, most respondents reported no negative elements of the program. Those that did, mentioned the negative aspect was staff resistance (Furst, 2006). There have been few studies done looking at the efficacy of these programs (Furst, 2006). However, in one study, Fournier et al. (2007) evaluated the effects of a human-animal interaction (HAI) program on prison inmates. Results of this study indicated that, compared to the control group, participation in the HAI program produced psychosocial changes in the inmates. This was evident by increased treatment progress, decreased institutional infractions, and improvement in social sensitivity. The number of prisons that are currently using animal programs seems to indicate a general acceptance of this model of rehabilitation. However, this author has been unable to find any publications attesting to the use of AAT in a group therapy format with the inmate population. In addition, there have been no studies to date evaluating the potential effectiveness of this type of intervention with the incarcerated population struggling with mental illness. A PILOT AAT PROGRAM FOR FEMALE INMATES WITH MENTAL ILLNESS The following sections describe a pilot AAT program developed for female inmates with mental illness implemented at Utah State Prison in spring 2008. Following this description will be a clinical case example used to illustrate the impact of this program on a particular group member. Important to note is that this case example is not intended to be a case study. Rather, the case example provides some clinical insight and is intended to generate direction for future research. An application was submitted to the Institutional Review Board (IRB) requesting approval for this manuscript. However, the IRB decided that oversight was not necessary, as this project did not meet the definition of human subject‟s research. Background Treatment team discussions were an essential part of the process of gauging group impact. Each week, all mental health staff working directly with the residents of the female inpatient mental health program engaged in in-depth discussion about current functioning and possible mental health needs. These discussions included social workers, whose experience ranged from intern to 20 years of working with this population, a psychiatric advanced practice registered nurse, and caseworkers. The wide range of expertise and professional input provided a rich perspective on possible group effects. Direct observations combined with reports from these various mental health workers whom interacted with the participant on a daily basis provided the information that was used to construct the clinical case example. It is important to note my role as the author and to explain my access to the group, the population, and the clinical information used in this case example. As a mental health therapist working directly with the female inpatient mental health unit, I had firsthand 65 knowledge of the group members and their therapeutic progress. I had access to group members on a daily basis, had opportunity to observe them in their daily environment, conducted individual and group therapy with several of the group members, had access to the therapeutic content of their treatment, and I was part of weekly treatment team discussions. In addition, I was the facilitator of the AAT group being described. Therefore, my knowledge of the group experiences, group content, and impact on group members was not merely observation but involved direct interaction with all group members. Group Participants The treatment team selected participants based on severity of the inmate‟s social and coping skills deficits. Their therapist asked the individuals selected if they would like to participate in the group, told them about the group content, and informed them that there would be a dog present during group sessions. All five inmates offered the opportunity to participate accepted. No group members were required to attend. Further, the group facilitator informed participants that if they opted not to participate in that group, that they would likely have an opportunity to participate in another group in the future. Group members were five women who, at the time, were residents in the mental health inpatient program. Ages ranged from 26 to 42. Inmate diagnoses included schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. All women had co-morbid substance abuse or dependence diagnoses. Time in the inpatient program ranged from two months to one-and-a-half years. Others present during groups were the group facilitator, the animal handler, and the dog. The animal handler had no prior mental health experience. Her presence in the group provided inmates with knowledge of the dog‟s history, boundaries, likes, dislikes, and daily life. This information was essential to the group process. It provided inmates with the data necessary to understand group topics in the context of the dog. The dog was a therapy animal certified by the Delta Society. The Delta Society is an international nonprofit organization. It was the first of its kind to offer comprehensive training and certification of animals and handlers in AAT and AAA (Delta Society, 2009a). The Delta Society certified the dog in June 2007. Previously, in July 2006, Therapy Dogs Incorporated had provided his certification. The reason for the change in certification organizations was that the dog‟s owner moved to a new state. PROGRAM DESCRIPTION In March 2008, the mental health department at the Utah State Prison in Draper,