Behavioral Health Interventions for Incarcerated Adults With Histories of Trauma: A Scoping Review

Abstract

Purpose: The majority of incarcerated individuals have experienced traumatic events in their lifetime, contributing to related behavioral health issues, including post-traumatic stress, mood, anxiety, and substance use disorders. The purpose of this article is to understand the existing state of the literature through a scoping review on correctional-based programs that address both trauma and behavioral health. Methods: Proquest and EBSCO databases were searched to identify studies focused on trauma and behavioral health that focused on incarcerated adults in the United States. Results: A total of 25 studies evaluating correctional-based programming on trauma and behavioral health problems. Most included studies reported improvement of behavioral health symptoms as a result of the intervention. Discussion: The findings indicated a need for additional research on behavioral health interventions for incarcerated adults with a history of trauma. Specifically, future research should focus on increasing the methodological rigor of intervention studies and expanding the diversity of included samples.

Keywords

corrections criminal justice mental health rehabilitation trauma psychosocial treatment scoping review

The number of individuals incarcerated in the United States accounts for approximately 20% of the total number of individuals incarcerated worldwide making it the country with the highest rate of incarceration of its citizens in the world (Alexander, 2020; Sawyer & Wagner, 2020). In the United States, 573 adults are incarcerated for every 100,000 adults (Kaeble & Cowhig, 2018; Sawyer & Wagner, 2022), leading to an annual total of approximately 1.9 million individuals who are detained within some type of correctional facility at any one time (Sawyer & Wagner, 2022).

These rates are even higher for individuals who are from disadvantaged populations, including racial minority groups, those who have lower socio-economic status, and those who have behavioral health (BH) disorders and/or substance abuse diagnoses (Behind Bars II, 2010; Bonczar, 2003; Steadman et al., 2009; Wheelock & Uggen, 2006). Individuals who are men, African American, and with low levels of formal schooling have the highest rates of incarceration in the United States (Pettit & Gutierrez, 2018). According to Kearney et al. (2014), “there is nearly a 70 percent chance that an African American man without a high school diploma will be imprisoned by his mid-thirties” and that “By their fourteenth birthday, African American children whose fathers do not have a high school diploma are more likely than not to see their fathers incarcerated.” Statistically, African American adults account for 33% of individuals incarcerated in prisons, which is almost triple their share of the adult population (Berg et al., 2021). In fact, “Among men between 20 and 40, the share of those with a felony conviction is over seven times greater for blacks and almost three times greater for Latinos, relative to the felony conviction rate among whites” (Pettit & Gutierrez, 2018, pp. 1158–119).

The Bureau of Justice estimates the costs of incarceration to be $80.7 billion a year (Economics of Incarceration, 2022; Wagner & Rabuy, 2017). However, others say this number significantly underestimates the total cost, as it does not account for the financial, social, and economic costs incurred by the families and individuals. Many families experience emotional and financial strain as they incur multiple costs navigating the court systems and often must travel and take time away from their jobs to maintain contact and support through visits and phone calls (Comfort et al., 2016; Wagner & Rabuy, 2017). These figures also do also not account for the long-term impact on individuals, families, and communities that experience high rates of incarceration. These include lower wages due to lower educational achievements, including high school graduations, the costs of postrelease services, and the losses associated with criminal activities within communities (Comfort et al., 2016; Kearney et al., 2014; Sawyer & Wagner, 2019; Wagner & Rabuy, 2017).

An additional cost is the impact of incarceration on individuals’ mental health, which can often exacerbate pre-existing mental health issues stemming from histories of adversity, including high rates of interpersonal and community trauma (Facer-Irwin et al., 2022; Morrison et al., 2019; Pettus-Davis et al., 2019a). Rates of post-traumatic stress disorder (PTSD) and other trauma-related outcomes are significantly higher among this population when compared to the general population (Morrison et al., 2019; Payne et al., 2008; Pettus-Davis et al., 2019a). These trauma reactions are often exacerbated through their experiences with the criminal justice system, which can remind individuals of past-traumas and/or create new ones (Gilbert & Postel, 2021; Knapp Garcia, 2020; Lee & Callahan, 2022). Such trauma histories can in turn contribute to greater challenges for individuals who experience incarceration both during their incarceration and postrelease, increasing the odds that they will return to prison. In fact, one in four individuals who have been incarcerated will be rearrested within the first year (Sawyer & Wagner, 2019), and within 5 years of release, approximately 76.6% of those who are released into the community are rearrested (Durose & Cooper, 2014). To break this cycle, it is critical that individuals who work within correctional facilities identify and employ evidence-driven behavioral-health interventions aimed at reducing incarceration rates across all communities (Sawyer & Wagner, 2019).

To that end, one profession in particular has taken this issue on as a major focus for the profession. The American Academy of Social Work and Social Welfare has identified addressing incarceration as one of its 12 Grand Challenges (Epperson et al., 2018; Grand Challenges for Social Work, 2020; Pettus-Davis & Epperson, 2015; Uehara et al., 2013). The Grand Challenge of Smart Decarceration Initiative (SDI) is grounded in social work's commitment to social justice and is an initiative aimed at reducing the number of people incarcerated, redressing racial, social, economic, and behavioral disparities within the correctional system; and maximizing public safety and wellbeing (Pettus-Davis & Epperson, 2015). To achieve these goals, the SDI advocates for policies that “use incarceration primarily for incapacitation of the most dangerous; make reduction of disparities a key outcome in decarceration efforts, remove civic and legal exclusions, and reallocate resources to community-based supports” (Epperson & Pettus-Davis, 2016, p. 1). Furthermore, the SDI seeks to change the narrative on incarceration and the incarcerated, make criminal justice system wide innovations, implement transdisciplinary policy and practice interventions, and employ evidence-driven strategies (Pettus-Davis et al., 2017, p. 2). Reducing the number of people incarcerated in jails and prisons throughout the United States alone does not make the SDI successful but must be done in a way that reduces racial, economic, and mental health disparities.

This final aim, of employing evidence-driven strategies is the focus of this article. Its purpose is to report the findings of a scoping review of interventions within correctional settings that address both BH outcomes (e.g., depression, anxiety, and substance use) and trauma-related symptoms simultaneously. A recent study reported that mental health practitioners who work within prisons lack the knowledge, resources, and access to empirically supported interventions (Grady et al., 2021). There are published research studies on prison-based interventions that target BH and trauma. This scoping review will provide a review of all existing studies that meet the eligibility criteria to help both researchers and practitioners understand what seems to be useful and with whom. The goal of this review is to provide social workers and other professionals who work in correctional settings with tools that can be used to break the cycle of incarceration and fulfill the aims of the SDI.

Connection Between Trauma and Involvement in the Criminal Justice System

Rates of Behavioral Health and Trauma-Related Disorders

To break the cycle of incarceration and reincarceration, it is necessary to identify potential contributing factors and then target interventions to address those factors. One such potential cause is the connection between childhood adversity, consequential BH conditions, and increased risk for incarceration. According to the American Psychological Association (“Trauma”, n.d.)

Trauma is an emotional response to a terrible event like an accident, rape, or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea.

Research continues to demonstrate that there is a strong association between trauma and BH disorders in both incarcerated populations and nonincarcerated populations. For example, among adults in a national survey, individuals who experienced trauma within the past year were more likely to have depressive episodes, PTSD, and anxiety disorders (McLaughlin et al., 2010). Childhood exposure to trauma is associated with higher rates of adult anxiety disorders, PTSD, and substance use disorders (Anda et al., 2006).

Unfortunately, these rates of BH issues are even higher among those who have experienced incarceration (Bronson et al., 2017; Bronson & Berzofsky, 2017; Steadman et al., 2009). According to Bronson and Berzofsky (2017), approximately 15% of people involved in the criminal justice system are currently experiencing great psychological distress, and just under 37% have ever had a mental health disorder. Specifically, 24% have ever had a major depressive disorder, 18% have had bipolar disorder, 13% had PTSD, 12% had an anxiety disorder, and 13% had a personality disorder. Moreover, approximately 51% of women in the criminal justice system, and 30% of men, meet the criteria for a substance use disorder (Fazel et al., 2017). More than three times as many incarcerated individuals meet the threshold for serious psychological distress (15%) than the U.S. general population (5%; Bronson & Berzofsky, 2017).

These higher rates of BH and trauma-related diagnoses among those who are incarcerated is likely because they have experienced more trauma across their lifespan than those of the general population. For example, in a study of incarcerated men, all of the 592 participants had exposure to at least one traumatic event, and up to 60% met the criteria for PTSD at some point in their life (Wolff et al., 2014). Other research indicates that between 37% and 68% of males who are incarcerated experienced childhood trauma, and 15% and 28% experienced severe traumatization (Altintas & Bilici, 2018).

These numbers are even more staggering for women. Almost all women who are incarcerated have experienced trauma (Kennedy et al., 2016; Tripodi et al., 2019b), with approximately 80% of these women reporting experiences of interpersonal violence across their lifespan (Komarovskaya et al., 2011). In addition, up to 75% of women who have been incarcerated report having experienced some form of interpersonal childhood trauma (Kennedy et al., 2016).

Among incarcerated populations, incarcerated men with exposure to trauma at any point in their lifespan had an increased likelihood of experiencing symptoms of depression and anxiety and were more likely to meet the criteria for substance use disorders (Wolff & Shi, 2012). Incarcerated women who experience childhood trauma were more likely to have mental health disorders and substance use disorders as adults (Tripodi & Pettus-Davis, 2013). Specifically, women who experienced childhood sexual trauma were more likely to have mental health problems and women who experienced childhood physical trauma were more likely to meet the criteria for substance use disorders. Women who experienced both childhood physical and sexual victimization were more likely to have both mental health problems and substance use disorders (Kennedy et al., 2016; Tripodi & Pettus-Davis, 2013).

Interventions to Break the Cycle

Considering the disproportionate number of incarcerated individuals who have experienced trauma and have related BH problems, it is important to understand how best to intervene and treat these BH problems during incarceration to increase the chances of success upon release from prison. According to the Risks-Needs-Responsivity model, it is vital to understand the criminogenic risk factors related to individuals’ incarceration, and then treat the dynamic criminogenic risk factors, such as substance use disorders and antisocial behavior (Andrews et al., 1990; Andrews & Bonta, 2010), to increase chances of success upon release. The eight primary dynamic risk factors to address are antisocial behavior, antisocial personality, criminal thinking, criminal associates, dysfunctional family, employment and education, leisure and recreation, and substance abuse (Wooditch et al., 2014). Additionally, according to the 5-Key Model of Reentry (Pettus-Davis et al., 2019b), the following constructs—all related to trauma and BH—are related to success and wellbeing in the process of releasing from prison and returning to their communities: promoting effective coping strategies, healthy thinking patterns, positive relationships, positive social engagement, and meaningful work trajectories.

Thus, in terms of treating trauma and related BH disorders, it is important to provide effective treatments to those who are identified as being in need of treatment, such as individuals who have experienced incarceration and trauma and who also meet the criteria for a BH disorder. To do this, it is vital to identify empirically supported interventions that simultaneously target trauma and BH disorders to understand how to provide effective treatments. Relatedly, practitioners need guidance as to how to address these issues within correctional settings (Grady et al., 2021), and policy advocates must understand which interventions are effective to advocate for funding to support treatment initiatives within correctional settings.

Prison-Based Therapeutic Interventions

BH is defined by the Substance Abuse and Mental Health Administration as, “the promotion of mental health, resilience, and wellbeing; the treatment of mental and substance use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families and communities” (Behavioral Health Integration, n.d., p. 1). Within correctional settings, these programs often have specific foci, depending on the specific BH issue being addressed. Substance use interventions are one of the most common types (Belenko et al., 2013; Rosen et al., 2004). Within this group of interventions, there are those that target both substance use and mental health disorders (Butler et al., 2011; de Andrade et al., 2018; Johnson & Zlotnick, 2012), while still others that are gender specific and aim to tailor their treatment to meet the unique needs of those groups (Doyle et al., 2019; Gunn et al., 2018; Johnson & Zlotnick, 2012; Pelissier, 2004).

Mental health specific interventions often target one diagnostic category, such as depression, attention deficit and hyperactivity disorder, or anxiety (Gussak & Beck, 2018; Johnson et al., 2019; Mattes, 2016; Maunder et al., 2009; Pardini et al., 2014). There are programs that indirectly target mental health issues by addressing specific areas of functioning, such as anger management and cognitive processes (Andersen & Sandberg, 2019; Dunne et al., 2018; Laursen & Henriksen, 2019). There are also specific treatments that target symptoms of trauma (Messina & Schepps, 2021; Petrillo, 2021; Rogers & Law, 2010), with the vast majority of these designed specifically for women (King, 2017; Tripodi et al., 2019b).

Unfortunately, at this time, the evidence that these programs are effective in improving BH issues, overall wellbeing, and/or reducing recidivism is limited or does not exist. In a recent systematic literature review on prison-based mental health interventions, the authors reported “mixed” results, stating that there is a “lack of depth and replication of research in this area” and more research is “needed to establish efficacy and best practices when treating mental health needs among this population” (Givens et al., 2021, p. 613). Another recent systematic review focused specifically on trauma-focused treatments within prisons and came to a similar but slightly more optimistic conclusion. The authors noted the “results suggest that trauma processing therapies, and individual modality trauma-focused interventions can be effective and delivered successfully in prison. However, inadequate comparison groups do not allow a firm conclusion to be drawn” (Malik et al., 2023, p. 844). Finally, one other recent systematic review that also included a meta-analysis on prison-based mental health treatment programs concluded that “Publication bias and small-study effects appear to have overestimated the reported modest effects of such interventions, which were no longer present when only larger studies were included in analyses” (Beaudry et al., 2021, p. 759). The authors, like the others who conducted similar systemic reviews, concluded that more research in this area should be a priority to not only improve the lives of the individuals themselves, but to also increase the safety of society by reducing risk factors associated with criminal justice involvement.

These systematic reviews were focused on examining the effectiveness of interventions focused on a mental health issue or trauma symptoms. While trauma and mental health often co-occur, individuals with both mental health and trauma-based symptoms present an even more complex clinical picture and may require additional types of treatments or interventions. To our knowledge, no review has been conducted examining treatments within correctional settings that target both BH and trauma-related issues. This scoping review was an attempt to address this critical gap in the literature and provide professionals working within those settings with information they can use to address the needs of their clients who present with these multiple needs.

Method

Scoping Review

Scoping reviews are conducted in general to “(1) examine the extent, range and nature of research activity, (2) to determine the value of undertaking a full systematic review, (3) to summarize and disseminate research findings, and/or (4) to identify research gaps in the existing literature” (Arksey & O’Malley, 2005, p. 21). The primary purpose of this review was to summarize and disseminate research findings as well as to identify any research gaps. In conducting the review, we followed the process as outlined by Arskey and O’Malley (2005), which follows a five-step process: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results. Accordingly, for step 1, this review was guided by the following research question: What is known from the existing literature on BH treatment programs for incarcerated individuals with BH needs and who have a history of trauma?

Identifying Relevant Studies

The research team searched the PROQUEST and EBSCO databases for peer-reviewed articles related to the research question. To identify studies focused on trauma and BH the following search terms were used: intervention, program, treatment, therapy, therapies, Seeking Safety, STAIR, EDMR, Prolonged Exposure Therapy, Cognitive Processing Therapy, Dialectical Behavior Therapy, Post Traumatic Stress Disorder, PTSD, and trauma. To identify studies focusing on individuals who are adults and incarcerated the following search terms were used: reentry, reintegration, returning citizen, prerelease, prison, jail, incarceration, imprisonment, correction facilities, prisoners, inmates, criminals, offenders, and incarcerated people. To ensure our search focused on adults and those still incarcerated, the following exclusion terms were used in the search: juvenile delinquency, juvenile offenders, youth offenders, formerly incarcerated, ex-convict, postincarceration, and previously incarcerated. Boolean operators and truncations were used for both database searches.

Search results were imported into a shared Zotero library for the next phase of review. Zotero was able to identify duplicate articles based on the article metadata provided by EBSCO and PROQUEST. From that point, two graduate research assistants (RA1 and RA2) conducted the initial review of article's title, publishing information, and abstracts based on the a priori inclusion and exclusion criteria. To be included in the study, articles must be peer-reviewed, published since 2002, and have been published in the United States. We decided to only focus on published research studies over the past 20 years in an attempt to capture the current landscape on correctional-based interventions that address BH and trauma. Additionally, we focused only on studies in the United States because of its unique policies regarding mass incarceration leading to the highest incarcerations rates in the world, longer incarceration sentences, and overcrowded prisons. Articles were also required to include participants over the age of 18 who are incarcerated at the time of intervention. Studies were also required to be focused on interventions that incorporated both BH outcomes and a participant’s trauma history in design and measurement. Studies that were excluded were those that did not include BH or trauma measures following the delivery of the intervention were excluded from consideration. In addition, studies that were focused on juvenile justice or community custody were excluded from review. Finally, this review does not include dissertations, government reports, or other forms of “grey” literature as the inclusion criteria only included sources that were peer-reviewed.

For round 1, RA1 reviewed the title and publication data of all articles and classified the articles as either “include”, “exclude”, or “further review”. In round 2, RA2 then reviewed using the same criteria and either confirmed the classification or the article was moved to the “further review” category. RA1 then compared this review's results against the citations from any scoping review, meta-analysis, or literature review that was included in the initial database search to ensure a comprehensive search strategy. No additional articles were added based on that comparison. For the third round of reviews, RA1 reviewed “include” and “further review” article abstracts against the eligibility criteria. All articles that were classified as either “include” or “further review” were then reviewed for round 4 in full by the study team. Each study team member fully read and analyzed the article for content and a final review of eligibility. For each article, the data charting was conducted using a standardized abstraction form that captured the following (if available): aims of the study, definition of treatment, geographic location of study, time period covered, study design, method of data collection, measurement tools and instruments, sample size, sample characteristics, comparison/control group characteristics, intervention design, evaluation of intervention, and findings relevant to BH or trauma outcomes. Following the completion of individual abstractions, the study team met to confirm inclusion/exclusion of the article within this review. An important aspect of scoping reviews is, unlike for systematic reviews, it is not typical for scoping reviews to include an assessment of the quality of the studies included within such a review (Nachman, 2023). Therefore, this review remains consistent with the aims of a scoping review, which is to provide a summary of the available literature. See Figure 1 for a visual depiction of the process (Nachman, 2023).

Figure 1.

Article inclusion decision tree. RCT: randomized controlled trial.

Results

Twenty-five articles met the eligibility criteria to be included in this review. These studies were charted based on the following categories: setting, intervention(s), research design, sample information, measurement tools, and relevant study outcomes. Table 1 is representative of the BH and trauma-related information for each study.

Table 1.

Data Charting of Included Studies.

Citation	Treatment	Research design	Sample	Measurement	Outcomes
Experimental studies
Bradley and Follingstad (2003)	Dialectical Behavior Therapy Southeastern State Prison	RCT Pre-test, Post-test Pilot Study	N = 49 (Tx = 24) (CG = 25) All female Pred. Black (62%) Ages ranged from 34 to 54 (M = 36.67, SD = 8.27)	Trauma Symptom Inventory Inventory of Interpersonal Problems Beck Depression Inventory	Treatment group participants reported a larger difference (moderate–large effect size) between pretest and posttest for depression, interpersonal problems, and most trauma symptom inventory subscales when compared to control group participants (small–medium effect size)
Kubiak et al. (2015)	Beyond Violence United States Prison	RCT Pre-test, Post-test TAU Control Group	N = 22 (Tx = 12) (CG = 10) All female Pred. Black/African American (63.6%) Average age (M = 34.18, SD = 9.12)	Patient Health Questionnaire (Depression) Patient Health Questionnaire (Anxiety) Short Screening Scale for DSM	All participants saw significant differences between pretest and post-test on depression, anxiety, and PTSD symptoms. Beyond Violence participants experience a significantly higher decrease in anxiety symptoms between pretest and post-test
Messina and Calhoun (2022)	Beyond Violence California Prison	RCT Pre-test, Post-test Waitlist Control Group	N = 145 (Tx = 78) (CG = 67) All female Pred. Black (27%) and White (27%) Average age (M = 39, SD = 14.0)	Patient Health Questionnaire (Depression) Patient Health Questionnaire (Anxiety) Short Screening Scale for DSM Conflict Tactics Scale and Abuse Behavior Inventory	Treatment group participants had significantly lower mean scores for depression, anxiety, and PTSD than the control group
Nidich et al. (2016)	Transcendental Meditation Oregon Prison	RCT Pre-test, Post-test	N = 181 (Tx = 90) (CG = 91) All male Pred. White Average age (M = 29)	Trauma Symptom Checklist Perceived Stress Scale	Significant reductions in total trauma symptoms, anxiety, depression, dissociation, and sleep disturbance subscales, and perceived stress in the TM group were found compared with controls. The high-trauma subgroup analysis further showed a higher magnitude of effects in the TM group compared with controls on all outcomes
Tripodi et al. (2019a , 2019b)	Seeking Safety North Carolina Prison	RCT Pre-test, Post-test, Follow-up	N = 40 (Tx = 20) (CG = 20) All female Pred. White (70%) Average age of treatment group (M = 43.07, SD = 8.63) Average age of control group (M = 37.33, SD = 8.94)	Center for Epidemiological Studies Depression Scale PTSD Checklist - 17	All participants improved depression scores from pretest to post-test, and from pretest to follow up. A higher percentage of treatment group participants saw improvements in PTSD and depression scores from pretest to follow up
Citation	Treatment	Research design	Sample	Measurement	Outcomes
Tripodi et al. (2022)	Seeking Safety & STAIR Florida Prison	Alt. Tx Design Pre-test and Post-test Random Assignment to Alt. Tx Groups	N = 85 (Seeking Safety = 43) (STAIR = 42) All female Pred. White (64.7%) Average age (M = 40.08, SD = 11.46)	Trauma History Questionnaire General Anxiety Disorder - 7 Coping Self-Efficacy Scale Center for Epidemiology Studies Depression Scale PTSD Checklist - DSM 5	Participants in both groups reported improvements in anxiety, coping self-efficacy, depression, and PTSD symptoms between pretest and post-test. Coping self-efficacy was the only score where there were significant differences between groups, with Seeking Safety participants reporting higher levels of significant differences at post-test
Wolff et al. (2015)	Seeking Safety & M-TREM Northeastern State Prison	RCT Pre-test and Post-test Two Tx Groups Waitlist Control Design	N = 230 (Seeking Safety = 117) (M-TREM = 113) All male Pred. Black (51.8%) Average age (M = 42.5, SD = 12.5)	PTSD Checklist for Civilians Clinician-Administered PTSD Scaled Global Severity Index of the Brief Symptom Inventory Rosenberg Self-Esteem Scale Proactive Coping Inventory Generalized Perceived Self-Efficacy	The Tx groups experienced a significant improvement on outcome variables when compared to baseline assessments. The participants experienced particularly large decreases on the Clinician Administered PTSD Scale and participants with a clinically significant score decreased by 19% on average between pretest and post-test. Waitlist participants also experienced a decrease, but it was significantly lower than the treatment participants
Zlotnick et al. (2009)	Seeking Safety United States Prison	RCT Pre-test, Post-test, Follow-up Pilot Study	N = 49 (Tx = 27) (CG = 22) All female Pred. White (46.9%) Average age (M = 34.6, SD = 7.4)	Clinician Administered PTSD Scale Trauma Symptom Checklist Trauma History Questionnaire Addiction Severity Index Timeline Follows Back Brief Symptom Inventory	Analysis showed that the number of Seeking Safety sessions attended was associated with better follow-up PTSD and Addiction Severity scores
Quasi-experimental studies
Ford et al. (2013)	TARGET & Supportive Group Therapy Connecticut Prison	Alt. Tx Design Pre-test, Post-test Crossover Design	N = 80 (N1 = 41) (N2 = 39) All female Pred. White (60%) Average age of TARGET participants (M = 34.6, SD = 8.6) Average age of SGT participants (M = 38, SD = 7.8)	Traumatic Events Screening Inventory Clinician Administered PTSD Scale Alcohol, Smoking & Substance Involvement Screen Clinical Outcomes in Routine Evaluation Trauma Symptom Inventory Generalized Expectancies for Negative Mood Regulation Hope Scale Expectancy of Therapeutic Outcome Working Alliance Inventory - Brief	Both interventions achieved statistically significant reductions in PTSD-related symptom severity and increased self-efficacy between pretest and post-test. TARGET participants showed a higher level of enhancing forgiveness and negative mood regulation. Participants in both groups showed a small effect size improvement on Trauma Symptom Inventory subscales
Citation	Treatment	Research design	Sample	Measurement	Outcomes
Holman et al. (2020a)	Canine-Assisted Therapy Seeking Safety Tennessee Prison	Single Subjects Design Repeated Measures Self-selection group assignment	N = 19 (N1 = 8) (N2 = 11) All female Pred. White Ages ranging between 24 and 48	Patient Health Questionnaire-9 Generalized Anxiety Disorder-7 PTSD Checklist	The results for both Canine-Assisted Therapy and Seeking Safety Participants indicated decreases in symptoms of anxiety, depression, and PTSD. Both percentage of nonoverlapping data and percentage of data exceeding the median analyses indicated strong effect sizes for both interventions
Jang et al. (2022)	Correctional Trauma Healing Program Virginia Jail	Quasi-Experimental Pre-test, Post-test, Follow-up Randomly selected no-contact comparison group	N = 349 (Tx = 210) (CG = 139) Male (51%) and Female (49%) Pred. Black (52%) Average age (M = 37.6, SD = 10.57)	Brief Trauma Questionnaire PTSD Rating Interview Center for Epidemiologic Studies Depression	Treatment group participants reported a significant reduction in symptoms of PTSD, state depression, state anger, suicidal ideation, and intended aggression. Treatment participation was also related to increases in religious variables, which the study proposed as a mediator for reduction of PTSD symptoms
Lynch et al. (2012)	Seeking Safety Northwestern State Prison	Quasi-Experimental Pre-test, Post-Test Waitlist Comparison Group	N = 114 (Tx = 59) (CG = 55) All female Pred. White (84%) Average age (M = 34.17, SD = 9.735)	Trauma History Questionnaire PTSD Checklist - Civilian Version Alcohol and Drug Use History Questionnaire Center for Epidemiologic Studies Depression Brief COPE Inventory of Interpersonal Problems	Treatment group participants experiences significant differences in depression scores over time. Treatment participants also indicated increased interpersonal function and decreased maladaptive coping mechanisms over time when compared to the waitlisted participants
Swopes et al. (2017)	HWR/BT Midwestern State Prison	Quasi-Experimental Pre-test, Post-test Matched Comparison Group	N = 95 (Tx = 55)(CG = 40) All female Pred. White (57.4%) Average age (M = 35.48, SD = 8.56)	Trauma Assessment for Adults – Modified PTSD Checklist-Civilian Version Posttraumatic Cognitions Inventory Drug-Taking Confidence Questionnaire Trauma Symptom Inventory Center for Epidemiological Studies Depression Scale	Results indicated a statistically significant main effect on Time, but not for the Time X Treatment interaction, for PTSD symptoms and substance use self-efficacy, suggesting overall pre–post improvement, but with no specific advantage for the treatment condition
Ward and Roe-Sepowitz (2009)	ESUBA Florida Prison Arizona Residential Facility	Quasi-Experimental Pre-test, Post-test Nonequivalent comparison group	N = 29 (Prison = 18) (Residential Facility = 11) All female Pred. White (75.8) Average age prison setting (M = 30.89, SD = 7.9) Average age residential facility (M = 36.73, SD = 5.61)	Trauma Symptom Inventory ESUBA Survey	All participants experienced decreases in Trauma Symptoms, with 6 subscales showing significant differences between pretest and post-test. The participants in prison saw significant differences postintervention for depression, intrusive experiences, defensive avoidance, dissociation, and impaired self-reference
Citation	Treatment	Research design	Sample	Measurement	Outcomes
Within-group studies
Fedock et al. (2019)	Beyond Violence Midwestern State Prison	Within-Group Pre-test, Post-test, Follow-up	N = 26 All female All Black (50%) and White (50%) Average age (M = 42, SD = 9.48)	Patient Health Questionnaire - Depression Patient Health Questionnaire - Anxiety Short Screen Scale for DSM-IV PTSD K6 Screening Tool State-Trait Expression Inventory	There were significant changes at both post-test and the 3-month follow-up-assessment for serious mental illness scores, post-traumatic stress disorder scores, and trait-based anger scores. The study also found that a significant interaction for the scores over time with the amount of time that a participant had served. Women who had served less than 10 years scored higher on anxiety, depression, and PTSD than women who served over 10 years. Women who served less than 10 years also saw a significantly different rate of change in these scores than women who had served over 10 years at the time of the study
Holman et al. (2020b)	Animal-Assisted Therapy Tennessee Prison	Within-Group Repeated Measures Pilot Study	N = 6 All female All White Ages range from 21 to 30 years	Generalized Anxiety Disorder-7	The study presented individual results due to small sample size. Intervention varied in effectiveness, but all three participants with clinically significant anxiety scores prior to the intervention were below clinical threshold at post-test
Jungersen et al. (2019)	STEP Southeastern State Jail	Within-Group Repeated Measures	N = 564 Pred. Female (89%) No Race/Ethnicity Information Average age of males (M = 40) Average age of females (M = 35)	Beck Anxiety Inventory Subjective Units of Distress Scale Trauma Symptom Inventory Detailed Assessment of Post-Traumatic Stress Substance Abuse Subtle Screening Inventory-3	Study found that participants anxiety decreased from session to session, with significant effects found for each session of participation. Subjective distress scores also decreased between the start and end of each session
Karlsson et al. (2014)	SHARE Arkansas Prison	Within-Group Pre-test, Post-test	N = 14 All female Pred. White (92.9%) No age information provided	Primary Care PTSD Screen Patient Health Questionnaire-9 Generalized Anxiety Disorder-2	Most participants with clinically significant PTSD, depression, and anxiety scores before the intervention were below the clinical threshold at post-test. Overall scores for all three areas significantly decreased between pretest and post-test
Karlsson et al. (2015)	SHARE Arkansas Prison	Within-Group Pre-test, Post-test	N = 52 All female Pred. White (82.7%) Average age (M = 33.8, SD = 9.24)	Primary Care PTSD Screen Patient Health Questionnaire-9 Generalized Anxiety Disorder-2	Most participants with clinically significant PTSD, depression, and anxiety scores before the intervention were below the clinical threshold at post-test. Overall scores for all three areas significantly decreased between pretest and post-test
Citation	Treatment	Research design	Sample	Measurement	Outcomes
Karlsson et al. (2020)	SHARE Kentucky Prison	Within-Group Pre-test, Post-test	N = 32 All female Pred. White (81.3%) Average age (M = 36.72, SD = 7.25)	PTSD Checklist for DSM-V Patient Health Questionnaire-9 Generalized Anxiety Disorder-2	PTSD, depression, and anxiety scores decreased significantly from pretest to post-test
Karlsson et al. (2022)	SHARE Arkansas Prison	Within-Group Pre-test, Post-test, Follow-up	N = 57 All female Pred. white (77.2%) Average age (M = 32.8, SD = 8.9)	Primary Care PTSD Screen (PC-PTSD) Patient Health Questionnaire (PHQ-9)	The number of participants who were above the clinically significant threshold for PTSD and depression significantly decreased between pretest, post-test, and follow-up assessments. Participants overall scores for PTSD and depression reduced significantly between all three time-points
Kubiak et al. (2012)	Beyond Violence Midwestern State Prison	Within-Group Pre-test, Post-test	N = 35 All female Pred. White (57.1%) Average age (M = 39, SD = 8.4)	Patient Health Questionnaire (Depression) Patient Health Questionnaire (Anxiety) Short Screening Scale for DSM K6 Screening Tool	There were significant changes between pretest and post-test for depression, anxiety, conduct problem, serious mental illness, and PTSD measurement tools among participants
Messina et al. (2016)	Beyond Violence California Prison	Within-Group Pre-test, Post-Test	N = 91 All female Pred. Latina/Hispanic (35%) Average Age of Peer Educators (M = 43, SD = 8.7) Average age of general participants (M = 36, SD = 7.3)	Patient Health Questionnaire (Depression) Patient Health Questionnaire (Anxiety) Short Screening Scale for DSM K6 Screening Tool	Peer educators had significant differences over time relating to anxiety, serious mental illness, and PTSD symptoms. Other participants had significant differences over time for depression, anxiety, serious mental illness, and PTSD symptoms
Roe-Sepowitz et al. (2014)	ESUBA Florida Prison Arizona Residential Facility	Within-Group Pre-test, Post-Test	N = 320 All female Pred. White (62%) Average age (M = 33.8, SD = 9.84)	Psychological Maltreatment Scale Trauma Symptom Inventory	There was a statistically significant difference between pretest and post-test for the trauma symptom inventory. Participants over the age of 25 experienced greater score reduction overall for all metrics when compared to participants between the ages of 18 and 24
Wolff et al. (2012)	Seeking Safety Northeastern State Prison	Within-Group Pre-test, Post-test	N = 74 All female Pred. Black (43.2%) Average age (M = 36, SD = 10)	Clinician Administered PTSD Scale Structured Clinical Interview for DSM-IV Non-Patient Version Trauma History Questionnaire Life Stressor Checklist-Revised	There was a significant difference from pretest to post-test for PTSD symptoms. This rate of change was higher for participants with the highest clinical threshold of symptoms

Pred.: predominately; PTSD: post-traumatic stress disorder; RCT: randomized controlled trial.

The articles reviewed included a wide variety of demographic and descriptive statistics based on the aims of the study and available administrative information. Race, gender identity, and age of participants were the most consistently reported demographic variables. Not all studies reported mean ages of their participants, but the mean ages of studies that did ranged between 32.8 and 43.07 years of age. Of the 25 studies, only 23 provided race or ethnicity information—a majority (n = 16) of which were comprised of a predominately White sample. While this is not representative of the racial make-up of the overall incarcerated population, it is possible that study location plays a role in the disproportionate representation of White participants. Gender was similarly disproportionate, with only four of the 25 studies including male participants. Of these four studies, only two had samples entirely comprised of incarcerated males. None of the included studies reported nonbinary or other alternative gender presentations in their demographic reports.

Research design is another way in which the included articles differed. All studies included the use of a voluntary convenience sampling strategy. However, the presence of and assignment approaches for comparison and control groups varied in rigidity throughout the included articles. The most prominent research design among included studies was a pretest and post-test design with no comparison group (n = 11). Of the 14 studies that did include a comparison or control group, only eight studies included random assignment. Measurement also varied, though a majority of articles reported data collected solely at pretest and post-test (n = 17). Some of these studies did attempt to collect follow-up data, but attrition between post-test and follow up prevented the data from being included their analyses. The measurement tools used also differed, with studies incorporating at least one of three approaches: specifically measuring post-traumatic stress disorder, measuring the presence of trauma symptoms, and measuring BH symptoms that are associated with increased exposure to traumatic experiences. Unfortunately, the measurement tools were not consistent across approaches, which make comparing effects across interventions difficult.

While 13 interventions were studied across the 25 articles, only four interventions were included in more than one study. The most prominent interventions were Seeking Safety (n = 7), Beyond Violence (n = 5), SHARE (n = 4), and ESUBA (n = 2). Among these four interventions, Seeking Safety is the only approach that was not specifically designed for female participants. Most of the interventions selected were specifically designed for group facilitation, it is important to note that all 25 studies utilized a group facilitation to implementation strategy. The range of study designs and measurement approaches mentioned above does make comparing effect sizes difficult. However, all included studies do indicate change in trauma-related and BH symptoms between pretest and post-test for participants. See Table 1 for a summary of the studies that were included in the scoping review.

Discussion and Application to Practice

As stated previously scoping reviews are conducted in general to “(1) examine the extent, range and nature of research activity, (2) to determine the value of undertaking a full systematic review, (3) to summarize and disseminate research findings, and/or (4) to identify research gaps in the existing literature” (Arksey & O’Malley, 2005, p. 21). Through this review, we sought to provide a summary of the available research and to identify any research gaps. This discussion sections provides readers with these summaries organized by practice, policy, and research.

The findings of this scoping review have many implications for practice. One of these is that compared to men, women are receiving services more frequently to address their trauma. Furthermore, there was no mention of other gender identities, which is likely an indication that there are no gender specific services for those who identify as nonbinary or trans. The issue here is not that women should be receiving less services, it is more than men and those with other gender identities should be receiving interventions that can simultaneously address their trauma histories as well as related BH issues. The lack of studies with men may stem from a belief that men experience less trauma than women (Affleck et al., 2018) or that men tend to under-report their trauma histories on self-report questionnaires (Peirce et al., 2009). However, it is clear from the literature that this belief is outdated and inaccurate, with many men who are incarcerated reporting significantly higher rates of trauma compared to the general population (DeHart & Iachini, 2019; Pettus-Davis et al., 2019a; Wolff et al., 2014). For a thorough review of this issue, readers are encouraged to review Pettus-Davis et al. (2019a, 2019b).

Although many of the studies included lacked scientific rigor, based on their reported findings, there does appear to be some evidence that providing individuals who are incarcerated with interventions that address their trauma and BH issues have a positive impact on their various symptoms. As such, it is important for administrators within correctional facilities to identify programs that they can use to support these individuals. An important first step in this process would be to screen all individuals newly placed within such facilities and then match them with the appropriate treatment intervention(s). It is highly likely, given the dearth of literature on this topic, that many behavioral/mental health staff are not familiar with or trained in trauma-based treatments. Therefore, administrators should provide training and resources to enhance the skills of their staff in these areas. At a minimum, administrators of facilities should seek to implement a trauma-informed care approach (Substance Abuse and Mental Health Administration; SAMHSA, 2014), which many argue should be adopted by correctional facilities (Branson et al., 2017; Hummer et al., 2010; Levenson, 2020; Levenson et al., 2017; Levenson & Willis, 2019). In addition, much more research needs to be done on the effectiveness of empirically supported interventions in these settings (Gannon & Ward, 2014).

From a policy perspective, the Center for Disease Control (Centers for Disease Control and Prevention, 2004) identifies three levels of prevention that should be considered to reduce public health issues, such as crime within our societies. Policies that support these efforts are critical in addressing the determinants of crime. Primary prevention focuses on universal approaches to prevention. These interventions focus on all members of society, regardless of their risk levels or any other distinguishing characteristic. In the case of preventing crime, primary prevention efforts should focus on supporting healthy communities and families with stronger gun control laws (Ngo et al., 2019), employment and educational opportunities for all, and equal access to community and government resources (Armstead et al., 2018). Secondary prevention focuses on those at risk for becoming involved with the criminal justice system (Centers for Disease Control and Prevention, 2004). Policy makers should provide on this level, more resources to at risk communities and families by providing such resources such as parent education, vocational training programs, gang prevention program, and other programs geared toward reducing risk and increasing protective factors (Coupland & Olver, 2020; Smokowski et al., 2004). Tertiary efforts target those individuals who have already been involved in the criminal justice system and these interventions are geared toward reducing their risk of recidivism and/or reinvolvement with the system (Centers for Disease Control and Prevention, 2004).

It is on this level that this scoping review has focused; interventions for those who have been incarcerated. As discussed previously in the literature review, a significant number of individuals involved in the criminal justice system have histories of trauma and adversity. While it would be impossible to state definitively that trauma causes criminal behavior, there is a strong association between traumatic experiences and subsequent risk factors associated with criminal activity and crime-related behavior itself (Pettus-Davis et al., 2019a; Wolff et al., 2014). Therefore, one of the most effective decisions policy makers can make is to provide the necessary resources and support needed within correctional facilities to address the risk factors associated with criminal behaviors. Such interventions should be provided within correctional facilities, as well as within communities for returning citizens to support their efforts to address trauma-related issues and BH needs upon release (Bunn, 2019; Pettus-Davis et al., 2019a).

Considering the extraordinary number of people who are incarcerated that have experienced trauma and related BH problems (Bronson & Berzofsky, 2017; McLaughlin et al., 2010), it is vital that more intervention research and program evaluations are conducted on correctional-based programs that address both trauma and BH. Specifically, to truly understand the effectiveness of these interventions and programs, there must be more randomized controlled trials that compare participation in the intervention under study to treatment-as-usual control groups. Only eight of the 25 studies reviewed for this scoping review were experimental studies. Most of the studies were either quasi-experimental studies with no randomized control group or single-group pretest–post-test designs with no comparison group whatsoever. Relatedly, many of the one-group pretest–post-test studies were pilot studies, but there were not any additional follow-up studies based on those results, such as quasi-experimental studies or even randomized controlled trials.

There appears to be promising evidence that trauma-informed programming helps improve incarcerated individuals’ BH problems, in some cases even compared to control groups that did not receive the intervention. Little is known, however, about the long-term effects of these correctional-based programs, especially as it pertains to postprison success in the community. Ideally, future research will assess these programs’ effectiveness on postrelease outcomes such as wellbeing, recidivism rates, and other important life indicators such as employment, education, housing, and BH outcomes. Moreover, there appears to be a dearth of qualitative studies on incarcerated individuals’ views of programs that address both trauma and BH problems. Future qualitative work has the potential to explore the experiences of participants and further understand what works about these programs and to whom. Participants should also have the opportunity to discuss aspects of the program that work compared to aspects of the program they recommend improving. Finally, diversity is a concern in the existing knowledge base. Most of the studies contained a sample that was predominantly White despite the disproportionate numbers of African American and Latinx people currently incarcerated. Men were significantly underserved in the studies reviewed for this scoping review, despite incarcerated men having experienced as much trauma as incarcerated women, and more trauma than men in nonincarcerated populations (Pettus-Davis et al., 2019a). Future research must include more men and minoritized populations.

The findings of this review should be considered along with its limitations. One potential limitation to this scoping review is that it is possible that the research team missed articles that meet the inclusion criteria despite the thorough process of searching databases. It is possible that the search terms may have been too narrow, and the research team limited the search to peer-reviewed publications. A second limitation is that since the gray literature was not included in the search, not all studies that have been conducted have been published or disseminated. It may be more likely that this is the case for nonsignificant results, which further limits the field's understanding of what does or does not work in this area of correctional services. Finally, although there were cross-reference checks at different parts of the review process, for the final review of the included studies it may have been stronger to have included a second member of the research team to review each article that met the inclusion criteria.

The results of this scoping review indicate that much more research is needed to understand how the criminal justice system is addressing the trauma and BH needs of the individuals for whom they are responsible during periods of incarceration. Given the limited literature including in this review, it is difficult to determine what is effective and for whom. As such, more rigorous research is needed regarding interventions focused on both trauma and BH needs with diverse samples that takes into account the multitude of needs of this population. By providing more specific and holistic care, correctional facilities can support efforts to reduce recidivism and promote smart decarceration.

Footnotes

Declaration of Conflicting Interests

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

Funding

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

ORCID iDs

Melissa D. Grady

Lauren Herod

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