Journal of Substance Abuse Treatment 41 (2011) 215 224

Regular article

Childhood sexual abuse and substance abuse treatment utilization among

substance-dependent incarcerated women
Jessica R. Peltan, (M.S.), Tony Cellucci, (Ph.D.)
Idaho State University Pocatello, ID 83209, and East Carolina University, Greenville, NC 27858, USA

Received 8 July 2010; received in revised form 8 March 2011; accepted 28 March 2011

Abstract

Incarcerated women have high rates of substance abuse problems and trauma. A variety of variables may influence whether these women
seek help or are referred for substance abuse problems. This study reports an exploratory project on service utilization among incarcerated
substance-dependent women (N = 40) in southeastern Idaho. Using self-report and interview tools, most participants reported some substance
abuse treatment history, although extent and types of treatment varied. Most of the women also reported some type of childhood abuse. Age,
income, and consequences of alcohol and other drug use related positively to substance abuse treatment. However, severity of childhood
sexual abuse and current trauma symptoms were negatively correlated with substance abuse treatment episodes. These women may use
substances to cope with childhood trauma or may not perceive the substance abuse system as responsive to their co-occurring trauma
symptoms. 2011 Elsevier Inc. All rights reserved.
Keywords: Treatment utilization; Childhood sexual abuse; Incarcerated women

Incarcerated women have a high prevalence rate of
substance abuse and mental health problems. In a 2006
report by the Bureau of Justice, approximately two thirds of
incarcerated women had a substance abuse problem, with
this number increasing to approximately 75% when the
women reported experiencing symptoms of a mental health
problem (James & Glaze, 2006). The population of women
inmates has greatly increased in the past few decades. This
increase has been related to mandatory drug sentencing laws,
which have adversely impacted low-income women (Hen-
derson, 1998; Rathbone, 2005). Among incarcerated
women, the rate of trauma exposure is particularly high.
Green, Miranda, Daroowalla, and Siddique (2005) found
childhood trauma and other interpersonal traumas overly
represented in a sample of female inmates, with 62%
reporting exposure to childhood trauma and 90% reporting
experiencing at least one interpersonal trauma. Chapman,
Corresponding author. Psychology Department, 104 Rawl Building,
East Carolina University, East Fifth Street, Greenville, NC 27858-4353, USA.
E-mail address: celluccia@ecu.edu (T. Cellucci).
Specht, and Cellucci (2005) reported that of 105 female
inmates sampled from a multilevel women's prison, 78%
reported childhood physical/emotional abuse, 59% reported
sexual abuse, and 38% reported neglect.
Among women, childhood trauma and especially sexual
abuse have been strongly linked to substance abuse problems
(Kendler et al., 2000; Medrano & Hatch, 2005; Widom,
Marmorstein, & White, 2006). Moreover, substance abuse
and trauma-related mental health problems frequently co-
occur among incarcerated women (Battle, Zlotnick, Najavits,
Gutierrez, & Winsor, 2003; Najavits, Sullivan, Schmitz,
Weiss, & Lee, 2004; Sacks, 2004; Staton, Leukefeld, &
Webster, 2003).
Given the documented needs of incarcerated women with
substance abuse problems, it is important to examine the
degree to which this special population receives treatment
and factors related to substance abuse treatment utilization.
Rosen, Tolman, and Warner (2004) examined treatment
utilization among low-income women with mental health
and substance abuse problems. A greater percentage of
women with substance dependence (44%) versus those with
trauma experiences or depression (20%26%) received

0740-5472/11/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2011.03.004
216 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224
treatment, but overall, fewer than one in five (19.3%) with
current problems received treatment in the past 12 months. In
their sample of incarcerated women in Idaho, Vik and Ross
(2003) reported that one third of women methamphetamine
users and approximately half (43.8%) of women abusing
alcohol and other drugs never received treatment. However,
Najavits et al. (2004) reported relatively high lifetime
utilization rates for their sample of 77 women meeting
criteria for substance dependence and posttraumatic stress
disorder (PTSD).
A variety of variables influence whether individuals seek
help for substance abuse problems (Grant, 1997; Orford et
al., 2006; Tsogia, Copello, & Orford, 2001; Tucker & King,
1999). First, there may be differences in availability and
access to treatment due to geographical differences and
personal resources (e.g., insurance, income). Rural areas in
particular may not have as many treatment programs or
specialty programs for women (Warner & Leukefeld, 2001).
Green-Hennessy (2002) reported that income was related to
treatment utilization among persons with substance depen-
dence. Problem recognition and associated negative conse-
quences are the most frequently related variables to help-
seeking in clinical samples (Carroll & Rounsaville, 1992;
Hajema, Knibbe, & Drop, 1997; Tsogia et al., 2001). In an
early study, Grant (1997) reported that the most frequent
reason for not seeking treatment was the belief that it was not
necessary. Carroll and Rounsaville (1992) compared demo-
graphically matched treatment seeking versus non-treatment-
seeking drug-abusing persons and reported that those in
treatment had experienced more negative consequences and
distress. It is also known that individuals with co-occurring
disorders and thus perhaps greater problem severity are more
likely to engage in treatment services (Najavits et al., 2004;
Rosen et al., 2004). In addition, entering substance abuse
treatment is influenced by perceived social norms and social
support for help-seeking (Hajema et al., 1997; Tucker &
King, 1999). In the Rosen et al. (2004) study of low-income
women, a simple barrier index (i.e., no insurance, no car or
license, no childcare, and less than GED education)
predicted service utilization. Orford et al. (2006) formulated
a parsimonious model of help-seeking for alcohol problems
in which growing problem recognition based on accumulat-
ing life/health problems combines with an acute triggering
event or circumstance and/or external social influences.
A significant amount of research supports a positive
relationship between trauma and health care utilization
(Lewis et al., 2005; Young & Boyd, 2000). For example,
Young and Boyd (2000) examined the relationship among
sexual trauma, severity of substance use, and treatment
among a sample of 208 African American women who
smoked crack cocaine. The authors found that when
comparing women with a history of sexual trauma (n =
134) and women without a sexual trauma history (n = 74),
those with a history of sexual trauma were admitted to the
hospital or emergency room more often for health issues
related to their substance use. Ullman and Brecklin (2002)
reported that victims of sexual assault in both childhood and
adulthood (i.e., more severe trauma histories) were more
likely to report both PTSD symptoms and alcohol depen-
dence symptoms and were more likely to have sought
treatment, although unfortunately, this study did not
distinguish between mental health and substance abuse
treatment utilization.
Nevertheless, some evidence suggests a reexamination of
the relationship between trauma history and treatment
utilization (Simpson, 2002). Specifically, research has
suggested the possibility that increased treatment utilization
by those with trauma experiences is more linked to increased
mental health and physical health treatment utilization but
not substance abuse treatment utilization. Killeen, Brady,
and Thevos (1995) examined differences in treatment
outcomes among 30 pregnant and postpartum cocaine-
dependent women during inpatient treatment. The partici-
pants were divided into aftercare treatment compliers and
noncompliers. Treatment noncompliers were significantly
more likely to have experienced childhood abuse.
In an interesting study by Simpson (2002), the author
found that with greater severity of childhood sexual abuse
(CSA), the number of mental health episodes reported
increased, yet the number of substance abuse treatment
episodes decreased. She suggested that there may not be a
consistent relationship between CSA and substance abuse
treatment utilization because of the relationship between
CSA and utilization of other services. Specifically, she
hypothesized that individuals with more severe CSA
histories were more likely to be referred to or seek treatment
for trauma-related symptoms.
Of note, many individuals with substance abuse
problems are mandated into treatment settings or programs
(see Clark & Young, 2009; Klag, O'Callaghan, & Creed,
2005). This is certainly a complex issue and a consideration
for utilization studies. There is some evidence that court-
ordered patients actually might gain motivation and are
likely to have similar treatment outcomes as those who
were not mandated to treatment (Kelly, Finney, & Moos,
2005). However, Klag et al. (2005) indicate methodological
and conceptual concerns and many conflicting findings as
to how such patients might differ from nonmandated
patients. There are clearly multiple and overlapping sources
of influence on treatment seeking. A particular concern is
how such policies affect substance-dependent women with
co-occurring problems and how coercion and referral
policies interact with treatment processes.
The primary purpose of this study was to extend prior
research to better understand some possible influences (e.g.,
demographics, negative consequences, clinical variables) on
substance abuse treatment utilization, including the impact of
CSA, within a sample of incarcerated substance-dependent
women. Such research might better inform efforts to increase
help-seeking within this population of women, to provide
services that are more responsive to the needs of women, and
to plan community reentry interventions.
 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224
1. Method
1.1. Participants
Participants were 40 incarcerated women (20 interviewed
within a county jail and 20 at a state correctional facility) in
the rural state of Idaho. Their mean age was 31.10 years (SD =
10.76). The participants were predominantly European
American (72.5%), with the remainder consisting of Native
American (7.5%), Hispanic (7.5%), African American
(2.5%), and other/biracial (10.0%). Most of the women
(55.0%) were separated/divorced, with 27.5% single/never
married, 12.5% still married, and 5% widowed. Approxi-
mately one third (32.5%) reported living in a rural area prior
to incarceration. Average years of education was 11.9
(SD = 2.6), with 70% completing high school or earning a
GED certificate. The women were also asked to identify their
income prior to incarceration. Thirty-five percent reported
earning less than $4,999, with another 20% having an
income from $5,000 to $9,999. The remainder indicated
earnings in the following ranges: $10,000$14,999 (15.0%),
$15,000$19,999 (7.5%), $20,00024,999 (5.0%),
$25,000$29,999 (5.0%), $30,000$34,999 (2.5%),
$35,000$49,999 (2.5%), and greater than $50,000 (7.5%).
Interestingly, 67% of the women indicated that they had
some type of insurance in the 12 months prior to
incarceration. Thirty-seven percent indicated that they were
using Medicaid or Medicare.
Women were recruited via a study flyer/announcement
and were required to submit their interest in participating to
unit correctional officer. The only inclusion criterion for
participation in the study was having a substance use
problem. The only exclusion criteria were frank confusion
and/or inability to read and understand the questionnaire
measures with the interviewer's help, but no women were
excluded. In regard to incomplete data, two packets had one
item missing from a questionnaire, so these scales were not
used in analyses. In addition, treatment utilization data from
one woman were excluded from these analyses because her
treatment utilization report was two standard deviations
above the mean on the treatment utilization indices and may
have biased the findings. There were few differences
observed between the women recruited from the county jail
versus correctional center. The former were somewhat
younger, 33 vs. 41 years, t(38) = 2.62, p b .01, and more
likely to be single, (4) = 15.16, p b .01. However, there were
no differences on reported study measures or utilization, so
the two samples were combined for these analyses.
All participants met lifetime criteria for substance
dependence with 83% dependent in the 12 months prior to
their incarceration. These women reported using a wide
range of substances, although most frequently, they met the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition diagnostic criteria for being dependent on
methamphetamine (75%), alcohol (60%), and cannabis
(42.5%). Fifty-five percent of the current sample reported
217
that they had co-occurring alcohol and drug problems. The
average age of onset for substance abuse problem among the
current population was 18.52 (SD = 7.24), and the average
duration of the substance abuse problem was 16.95 years
(SD = 9.71). Fifty-five percent of the sample indicated that
they had used drugs intravenously.
The women also reported their legal arrest history. These
participants reported an average of being incarcerated 9.52
times (SD = 7.45), with a range of 125 times. Participants
interviewed in the county jail had been incarcerated more
often than those incarcerate in a state prison (11.9 vs. 7.2),
t(38) = 2.10, p b .05. The mean age reported for a first
arrest was 21.60 years (SD = 8.29 years). The mean
number of times convicted of a crime after the age of 18
was 6.05 (SD = 5.82), with a range of 121. The most
frequent types of offenses included drug possession or
selling (37.5%), parole violations (22.5%), DUI (7.5%),
forgery (5%), and theft or burglary (5%).
1.2. Procedure
The research was conducted with the approval of both the
university's human subjects committee and the facilities
where it was conducted. After participants received the
description of the project with informed consent, they
completed a brief substance abuse screen based on self-
report as part of the demographic/background form. Because
all participants answered the screen positively, they all went
on to complete a formal substance dependence diagnostic
interview. All data were collected in separate individual
interviews. In addition, several questionnaire measures
including negative consequences of substance abuse and
childhood abuse history were included. The participant's
history of treatment utilization was assessed last via a
structured interview including separate queries (using a cue
card) of treatments received for either substance use or
mental health problems.
Doctoral-level students and the clinical psychologist
supervising the project administered the interview and
questionnaires in one study session that lasted approxi-
mately 2 hours, with a break between major interview
measures. The assessment data, including self-report
questionnaires and diagnostic interviews, were coded with
an identification number to protect confidentiality. Partic-
ipants' names only recorded on the informed consent form,
which was kept separate from the self-report and diagnostic
interview information.
1.3. Study measures
1.3.1. Demographic and background form
This demographic sheet asked participants to provide
demographic information (e.g., age, ethnicity, marital status,
income). It also included background information regarding
their legal history (e.g., age at first arrest, prior incarcera-
tions) and a substance abuse screen.
218 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224
1.3.2. Psychiatric Research Interview for Substance and
Mental Disorders
The Psychiatric Research Interview for Substance and
Mental Disorders (PRISM) is a semistructured interview,
which was actually developed to provide differentiation
between substance-induced disorders and primary psychiat-
ric disorders (Hasin et al., 2006). Only the substance abuse
module was used in this study to diagnose and describe this
sample of incarcerated women in terms of substance
dependence. The PRISM has been shown to have good
interrater reliabilities (Kappa coefficients ranging from .66 to
.75; Hasin et al.). Diagnostic criteria for substance
dependence were assessed for both lifetime and the 12
months prior to incarceration.
1.3.3. Inventory of Drug Use Consequences (Miller,
Tonigan, & Longabaugh, 1995)
The Inventory of Drug Use Consequences (InDUC) is a
45-item questionnaire that assesses adverse consequences
associated with alcohol and other drug use. Participants
indicated whether they have ever experienced (lifetime) each
negative consequence listed on the measure. The conse-
quences fall into five categories: interpersonal, physical,
social responsibility, impulsive control, and intrapersonal,
which can be examined individually or can be combined to
create a total adverse consequences score. In this study, the
total score was used, and the alpha was .87.
1.3.4. Child Trauma Questionnaire (Bernstein & Fink,
1998)
The Child Trauma Questionnaire (CTQ) is a 25-item self-
report questionnaire that assesses several forms of childhood
maltreatment. This measure is composed of five subscales
including childhood physical abuse (CPA), CSA, childhood
emotional abuse (CEA), childhood emotional neglect
(CEN), and childhood physical neglect (CPN). On this
questionnaire, participants respond to the statements using a
5-point, Likert-type scale (1 = never true to 5 = very often
true) describing how true each statement is of their childhood
experiences. Scores for each subscale range from 5 to 25,
with higher scores representing greater severity of childhood
maltreatment. The CTQ has been shown to have good test
retest reliabilities (from .79 to .81; Bernstein, Fink, Handels-
man, & Foote, 1994) and good internal consistency (alphas
ranging from .66 to .95; Bernstein & Fink, 1998). Scores
were computed for all five subscales and the total score.
Alphas for the various subscales were generally high (CPA =
.94, CSA = .94, CEA = .93, and CEN = .93) with the
exception of physical neglect (CPN = .73).
1.3.5. PTSD Symptom ChecklistCivilian (Weathers, Litz,
Huska, & Keane, 1994)
The PTSD Symptom ChecklistCivilian (PCL-C) is a
17-item measure of distress that assesses the presence and
severity of PTSD symptoms in a civilian population. For each
of the items, respondents specify the degree to which a
symptom has bothered them in the past 30 days using a 5-
point Likert scale (1 = not at all, 5 = extremely). The PCL-C
has good internal consistency (Ruggiero, Del Ben, Scotti, &
Rabalais 2003); in this study, the alpha for total score was .93.
1.3.6. Service utilization interview
This measure was an adaptation of the treatment utilization
portion of the interview developed for use in the National
Epidemiological Survey on Alcohol and Related Conditions
(NESARC; Grant, Moore, Shepard, & Kaplan, 2004) and the
Miami Health Services Utilization Questionnaire (Chitwood,
McBride, French, & Comerford, 1999). Both substance abuse
and mental health treatment services utilized were systemat-
ically queried. Using the NESARC items, prior service
utilization for alcohol and other drug-related problems was
assessed. In addition, any substance abuse service mandated
by a court or probation was identified. Mental health service
utilization was assessed using the mental health service
utilization section of the Miami Health Services Utilization
Questionnaire. It is acknowledged that the differentiation of
substance abuse and mental health treatment episodes was not
precise. If a participant indicated that a particular treatment
experience was directed at both substance abuse and mental
health problems, it was coded for both, although such
instances were not frequent.
Similar to recent utilization studies (Elhai & Simons,
2007), treatment indices were developed from these data
including episodes of care (defined as any single occasion of
treatment provision irrespective of duration) and types of
care (defined as the sum of whether a person ever utilized
any of the specific treatments listed such as inpatient,
intensive outpatient program, psychologist, counselor,
Alcoholic Anonymous/Narcotics Anonymous [AA/NA],
etc.). Both substance abuse and mental health utilization
indices were computed resulting in four indices. For
substance abuse, professional treatment utilization was
defined as receiving treatment from a professional with
specific training to treat the problem at hand (e.g.,
psychologist, substance abuse program) versus use of only
recovery support treatment services (e.g., AA/NA). Howev-
er, the overall substance abuse treatment utilization indices
(i.e., episodes and types) included both professional and
recovery-based treatment. In addition, these included
mandated and voluntary substance abuse treatment; because
voluntary treatment was significantly correlated with total
treatment episodes (0.95), there was no benefit in examining
voluntary treatment separately from total treatment.
2. Results
2.1. Treatment utilization
The utilization indices were checked for skewness and
kurtosis. Although the substance abuse treatment episode
index was somewhat positively skewed (1.55), this was an
 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224 219

expected finding; that is, a small percentage of participants
(i.e., the tail of the distribution) received a large number of
treatment episodes. It was thought that transformations might
change the meaning of the underlying construct (Field,
2009), and so, untransformed data were used for analyses.
Moreover, transformations did not appear to impact the
findings when transformed indices were correlated with the
study predictor variables. The means and standard deviations
for the utilization indices and all other study measures are
provided in Table 1.
In regard to statistical analyses, first, we provided
descriptive information as to the type or treatment setting
and extent of treatment utilization reported by the women.
Second, significant correlations were reported between the
utilization indices and demographic and clinical factors
including childhood abuse subscale scores. We also
compared women having received professional treatment
(75%) versus no professional treatment (25%) using an
independent t test. Finally, several simultaneous regression
analyses were conducted using the utilization indices with
the criteria and childhood abuse scales as the predictors.
this also accounted for 30% of all episodes reported.
Approximately 58% reported that they had participated in a
residential treatment program for substance abuse problems,
which accounted for 8% of episodes. Forty-five percent of the
sample reported participating in some type of jail/prison
facility program for substance abuse treatment (7.4% of
episodes), and 40% of the sample indicated that they were
treated at an alcohol or drug detoxification unit (6.7% of
episodes). In addition, 40% reported receiving services
through an intensive outpatient program (5.1% of episodes).
2.1.2. Mental health
Most of the women also reported receiving mental health
services at some point during their lifetime (90%). Similarly
to substance abuse treatment, the extent and types of
treatment received varied. Mean treatment episodes for
mental health problems reported by women in their lifetime
was 10.51 (SD = 13.89), and the mean number of types of
treatment was 3.00 (SD = 2.29). Treatment utilization
episodes for substance abuse and mental health were not
significantly related (0.18, p = .26).

2.1.1. Substance abuse 2.2. Demographic correlates

The reported treatment utilization of the sample was
examined to determine whether participants had sought help As might be expected, there was a significant positive
for substance abuse and mental health problems. Most of relationship between participant age and lifetime substance
these incarcerated women actually reported some treatment abuse treatment episodes (0.36, p = .04) and substance abuse
history (75% professional treatment and 97.5% including treatment types (0.39, p = .01). Differences between
AA/NA). The mean number of episodes of treatment individuals who made $10,000 or more prior to incarceration
(broadly defined) for substance abuse problems received and individuals who reported making less than $10,000 was
by the women in their lifetime was 13.54 (SD = 14.71). assessed using independent sample t tests. Individuals whose
Thirty-three (32.6) percent of these episodes were reportedly income prior to incarceration was more than $10,000 reported
mandated by a court or probation. The mean number of types significantly more substance abuse treatment episodes (M =
of treatment received over lifetime was 4.72 (SD = 2.84). 20.39, SD = 18.54) in their lifetime than did individuals who
The extent and types of treatment received varied (see reported earning less than $10,000 (M = 7.67, SD = 6.37),
Table 2). The most frequently reported type of treatment t(37) = 2.954, p = .005. Individuals who earned more than
for substance abuse problems was through AA/NA or other $10,000 also reported receiving significantly more types
12-step recovery support groups. Ninety percent of the (M = 5.83, SD = 3.31) of substance abuse treatment than
current sample reported participating in this type of treatment; individuals who earned less than $10,000 (M = 3.76, SD =
1.97), t(37) = 2.413, p = .021.
Table 1
Descriptive statistics for study measures 2.3. Substance abuse consequences
Measures M SD Range
Child abuse (CTQ) 53.00 22.64 20.0087.00 Negative consequences due to substance abuse (InDUC)
Emotional abuse (CTQ) 14.85 7.19 5.0025.00 was significantly related to types of substance abuse
Physical abuse (CTQ) 12.90 7.19 5.0025.00 treatment experienced (0.41, p = .008), although its
Sexual abuse (CTQ) 13.23 7.09 5.0025.00
relationship to lifetime number of substance abuse treatment
Emotional neglect (CTQ) 14.40 6.59 5.0025.00
Physical neglect (CTQ) 10.38 4.41 5.0025.00 episodes (0.22, p = .175) was not significant. Moreover,
Trauma symptoms (PCL-C) 48.87 16.26 18.0080.00 women who reported receiving professional treatment for a
Negative consequenceslifetime 39.05 5.59 22.0045.00 substance abuse problem reported significantly more lifetime
(InDUC-2) consequences from their alcohol/drug use (InDUC; 40.63 vs.
Substance abuse treatment utilization
34.30) than participants who never received professional
Episodes 13.54 14.71 053
Types 4.72 2.84 012 treatment, t(38) = 217, p b .05. Duration of substance use
Mental health treatment utilization problems was also related to number of lifetime treatment
Episodes 10.51 13.89 062 types (0.44, p = .004) with the expected trend for number of
Types 3.00 2.29 09 episodes (0.30, p = .06).
220 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224

Table 2
Frequency of treatment episodes: substance abuse and mental health
Treatment utilization % received type of treatment % episodes
Substance abuse
AA, NA, or any 12-step meeting 90.0 29.6
Drug or alcohol rehabilitation program (residential) 57.5 8.2
Jail or prison facility program 45.0 7.4
Drug or alcohol detoxification unit 40.0 6.7
Intensive outpatient or day treatment program 40.0 5.1
Halfway house 30.0 3.4
Outpatient clinic or substance abuse program 27.5 4.0
Outpatient psychologist or counselor 25.0 7.3
Hospital inpatient (hospitalization) 22.5 2.5
Hospital emergency room 20.0 6.2
Psychiatrist 17.5 5.6
Private physician 17.5 3.3
Clergyman, priest, or rabbi 12.5 7.8
Methadone maintenance program 10.0 1.5
Family service or other social service agency 7.5 0.9
Employee assistance program 2.5 0.2
Other (e.g., probation and parole) 5.0 0.4
Mental health
Private physician 42.5 19.5
Psychiatrist 37.5 18.5
Outpatient psychologist or counselor 37.5 12.4
Community mental health (health and welfare) 30.0 8.5
Hospital inpatient 25.0 6.8
Jail or prison facility program 22.5 6.3
Outpatient clinic or substance abuse program 22.5 3.7
Community/migrant/rural clinic or health center 22.5 2.4
Clergyman, priest, or rabbi 17.5 12.9
Hospital emergency room 15.0 2.9
Intensive outpatient or day treatment program 15.0 2.9
Family service or other social service agency 10.0 1.7
Employee assistance program 5.0 0.5
Halfway house 2.5 0.7
Note. Substance abuse utilization indices included all listed types of treatment unless otherwise specified as professional treatment, which excluded episodes of
recovery support (AA/NA) and clergy.

2.4. Childhood trauma (CTQ)
To examine the relationship between childhood trauma
and substance abuse utilization, we first examined zero-order
correlations between CTQ scores and utilization. Sexual
abuse was negatively correlated with lifetime episodes of
substance abuse treatment (052, p = .001) and types of
substance abuse treatment (0.37, p = .019). The zero-order
correlations also indicated a negative correlation between
physical abuse and lifetime types of substance abuse
treatment (0.32, p = .048).
Childhood abuse variables were used to predict treatment
utilization indices using simultaneous regressions. When
significantly related to a specific utilization index, age and/or
income were controlled by using a hierarchical model. Only
models in which childhood abuse variables were significant
are reported (see Table 3). The regression for lifetime
episodes of substance abuse treatment resulted in a
significant model accounting for approximately 43% of the
variance in the criterion (R2 = .43, p = .01). Sexual abuse
history, = .34, t(37) = 2.07, p = .05, was the only unique
predictor when controlling for age, income, and other forms
of abuse. Thus, individuals reporting more severe sexual
abuse histories were less likely to receive treatment for
substance abuse problems.
There were fewer associations observed between predic-
tor variables and mental health utilization. The regression of
lifetime types of mental health treatment on childhood
trauma scales resulted in an overall model (R2 = .23) that
failed to reach significance (p = .13). However, sexual abuse
history, = .38, t(37) = 2.21, p = .04, was again the
significant unique predictor in this regression when control-
ling for other forms of abuse. In contrast to substance abuse
utilization, women having a history of sexual abuse reported
receiving more types of mental health treatment.
2.5. Trauma symptoms (PCL-C)
Finally, we examined the relationship between present
trauma symptoms, severity of childhood trauma, and
substance abuse treatment utilization. The PCL-C symptom
scale was positively related to the severity of sexual abuse
(0.46, p = .003) and reported emotional abuse (0.41, p =
.009). Moreover, present trauma symptoms were also
 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224 221

Table 3 receiving professional treatment. Some women received a

Summary of multiple regressions with child abuse variables (CTQ) large number of different episodes of care and different types
Variable B SE of B t Significance of treatment, whereas others reported fewer episodes and
Lifetime episodes of substance abuse treatment only a few types of treatment. Similar to this study, Staton et
Constant 3.64 7.92 0.46 .65 al. (2003) reported that 80% of their incarcerated women in
Age 0.33 0.21 .24 1.56 .13 Kentucky had received alcohol or other drug treatment, but
Income 10.41 4.55 .36 2.29 .03
they reported far fewer episodes than the current sample. It is
Emotional abuse 0.31 0.58 .15 0.53 .59
Physical abuse 0.05 0.54 .02 0.09 .93 likely that the women in our sample, especially those
Sexual abuse 0.71 0.34 .34 2.07 .05 participants interviewed in the jail versus prison setting, had
Emotional neglect 0.18 0.73 .08 0.25 .81 frequent contact with court and probation systems due to the
Physical neglect 0.37 1.01 .11 0.36 .72 nature of their problems. This is also highlighted by an
Note: full model R2 = .426, p = .01
earlier study that found that approximately 8 of 10
Lifetime types of mental health treatment incarcerated women in Idaho are in prison for drug-related
Constant 2.03 1.02 1.99 .06 crimes (Vik & Ross, 2003).
Emotional abuse 0.08 0.10 .24 0.77 .45 We asked participants which treatment episodes were
Physical abuse 0.08 0.09 .23 0.82 .42 legally mandated; 33% of the substance abuse treatment
Sexual abuse 0.12 0.06 .38 2.21 .04
episodes were mandated, with 70% of the women reporting
Emotional neglect 0.22 0.12 .62 1.77 .09
Physical neglect 0.16 0.17 .32 0.94 .35 at least one mandated substance abuse treatment episode.
Note: full model R2 = .227, p = .125 However, most of the women had both nonmandated and
Note. Income = individuals who earned more than $10,000 versus individuals mandated treatment episodes over lifetime use of alcohol and
who earned less than $10,000 in 12 months prior to incarceration. other drugs, and voluntary treatment was highly correlated
with total treatment episodes. Moreover, we are in agreement
with others (Klag et al., 2005; Wild, Newton-Taylor, &
negatively related to lifetime episodes of substance abuse
Alleto, 1998) that separating mandated versus nonmandated
treatment (0.44, p = .005) but not mental health utilization.
treatment episodes may not be as easy or informative as this
We also examined if current trauma symptoms might
implies. Wild et al. (1998) reported that patients mandated to
statistically account for the negative relationship found
treatment did not necessarily feel coerced, and a significant
between sexual abuse and substance abuse treatment
percentage of voluntary referrals did feel coercion from
utilization by using regression. When simultaneously
family or employers.
regressing lifetime episodes of substance abuse treatment
The demographic and clinical predictors of utilization
on both sexual abuse history and trauma symptoms, the
found in this study largely replicated prior research
overall model remained significant (R2 = .32, p = .001), but
(Greenfield et al., 2007; Green-Hennessy, 2002; Orford et
only sexual abuse history, = .41, t(38) = 2.61, p = .013,
al., 2006; Tsogia et al., 2001). Age was a significant
was a significant predictor. CSA severity apparently
predictor of substance abuse episodes and types but is
explained both present trauma symptoms and less substance
necessarily confounded with duration of substance abuse
abuse treatment utilization.
problems. Income was also a significant predictor, repeating
a well-replicated finding in health disparity research (Adler
3. Discussion & Newman, 2002). Individuals reporting that they earned
more than $10,000 in the 12 months prior to incarceration
This study examined treatment utilization within a sample reported more episodes and types of treatment for substance
of substance-dependent incarcerated women. The study abuse than poorer individuals. It is possible that a difference
findings most highlighted the differential impact of CSA on in economic resources leads directly to greater access to
substance abuse versus mental health treatment utilization. treatment services; however, having more economic re-
sources may be associated with other factors that make a
3.1. Treatment utilization person more likely to seek treatment, such as access to
childcare or greater knowledge about professional providers.
Among the sample, there were very high rates of Poorer individuals theoretically have access to substance
utilization reported for both substance use and mental health abuse treatment through the state system but may lack
problems. Most of the women had early-onset and severe knowledge regarding their eligibility to access this system, or
substance dependence, considerable trauma, and multiple the system could be less effective in serving poorer
life problems, as compared with general population samples individuals. Such health disparities are complex.
(Green-Hennessy, 2002; Grella, Karno, Warda, Moore, & There was also evidence in this study that duration and
Niv, 2009). Ninety-seven percent of the women had received severity of substance problems were related to utilization, at
some type of treatment for a substance abuse problem; least to experiencing more types of treatment. Lifetime
however, the type and extent of treatment varied. A negative consequences on the InDUC and duration of
significant portion (25%) of the women reported never substance abuse problems were both related to the types of
222 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224
substance abuse treatment index. In addition, women
reporting more lifetime negative consequences were more
likely to report receiving professional treatment. These
findings confirm the importance of negative consequences
for substance abuse help seeking and utilization among
clinical samples. In a recent prospective study of rural
stimulant users, Carlson et al. (2010) reported that greater
perceived need for treatment; greater legal problems, prior
treatment experience, and tranquilizer use were all associated
with treatment entry.
3.2. Childhood trauma and sexual abuse severity
In this study sample, childhood trauma, particularly CSA
severity, was negatively correlated with substance abuse
treatment utilization. Physical abuse was also negatively
correlated with substance abuse treatment utilization but did
not emerge as a unique predictor. This negative relationship
to substance abuse treatment utilization was consistent with
the study of Simpson (2002) and is perhaps the most
intriguing aspect of the study findings. Similar to her
findings, we observed a differential effect of CSA on
substance abuse versus mental health treatment. Childhood
abuse overall was not directly related to mental health
treatment utilization; however, controlling for other forms of
abuse, sexual abuse emerged as a unique positive predictor
of mental health treatment types. However, unlike Simpson
(2002), we also found a negative relationship between our
measure of PTSD symptoms and substance abuse treatment
utilization but not the expected positive relationship with
mental health utilization. There were many differences
between the studies in terms of participants, measures, and
so on. Hence, the similar pattern of findings is perhaps most
significant. Interestingly, present trauma symptoms did not
explain the negative relationship between severity of CSA
and substance abuse utilization.
Similar to Simpson's (2002) discussion, it could be that
there is an inconsistent relationship between sexual abuse
and substance abuse treatment utilization because of the
relationship between abuse and increased utilization of
mental health services. These women and/or referral sources
may see the mental health system as more relevant to the
sequelae of sexual victimization and the problems they are
experiencing. It is also possible that the negative relationship
is related to coping or other individual difference variables.
Abused women may use substances to cope with their
trauma and consequently may not wish to stop using by
entering substance abuse treatment. In keeping with this
idea, Min, Farkas, Minnes, and Singer (2007) reported that
childhood trauma was related to greater adult substance
abuse in part through avoidant coping. In other relevant
research, Ullman and Najdowski (2010) studied 526 women
problem drinkers with a history of sexual assault. Profes-
sional help seeking for alcohol problems was related
positively to age and use of planning coping strategies and
negatively to heavy alcohol consumption. Characterological
self-blame was associated with more alcohol-related arrests
and hospitalizations and greater likelihood of general
seeking help. It is possible that variables like trauma
symptoms or shame/self-stigma (Saunders, Zygowicz, &
D'Angelo, 2006) might have differential associations with
substance abuse versus mental health utilization.
The literature is mixed as to whether a history of sexual
abuse has negative effects on substance abuse treatment
effectiveness (Sacks, McKendrick, & Banks, 2008; Simp-
son, 2002). Given active substance dependence with all its
attendant difficulties, it is unfortunate if these women do
not perceive substance abuse treatment as responsive to the
complicated nature of their problems. If this negative
perception exists, then it is particularly important to provide
better access to gender-specific treatment for co-occurring
disorders. Najavits et al. (2004) reported that women with
comorbid substance dependence and PTSD preferred
integrated or PTSD treatment alone. A recent qualitative
study by Sered and Norton-Hawk (2008) suggests that
health care for incarcerated women (including behavioral
health) is fragmented and often interrupted by the patient's
multiple problems. These authors found that incarcerated
women often had to beg for treatment, hide information,
and depend on the authority of others to obtain proper
treatment. Treatment was often not long enough and did not
address individual needs. Sered and Norton-Hawk's (2008)
participants reported a procession of interactions with
treatment providers with little relief from symptoms.
Thus, although substance-dependent women with legal
problems due to alcohol and other drug use may be making
contact with the treatment system, there is a need to know
more about the nature and quality of that treatment (i.e.,
number of visits and duration, evidence based, coordination
with medical care).
Within this broader context, this study findings and
participant descriptors support the need to provide increased
access to integrated and gender-specific treatment programs,
which may be better suited than traditional programs to meet
the complicated needs of this population (Becker & Gatz,
2005; Clark & Young, 2009).
3.3. Study limitations
Several study limitations should be noted. First, we
necessarily relied on a self-report interview measure of
treatment utilization. The indices were all based on
retrospective recall, and there was no way to verify their
accuracy. Although other investigators have necessarily used
similar indices, more work needs to be done in this literature
to determine uniform and valid measures of utilization
(Henshaw & Freedman-Doan, 2009). Work also needs to be
done to begin to look at how best to capture both extent and
quality of treatment. Relatedly, in asking about prior
treatment utilization, the study described treatments very
generally in terms of setting type (e.g., jail-based program,
residential, intensive outpatient program), and a legitimate
 J.R. Peltan, T. Cellucci / Journal of Substance Abuse Treatment 41 (2011) 215224
criticism is that it would be helpful to have had more specific
descriptions of the treatment contents (e.g., early recovery
group, 12-step facilitation, relapse prevention). Most of the
substance abuse treatment provided to participants was in
traditional substance abuse agencies along with heavy use of
recovery support services. Second, findings for this study
were based on correlational analyses; therefore, no assertions
can be made about causality. For example, receiving
effective substance abuse treatment may very well decrease
emotional distress resulting in a negative correlation between
substance abuse treatment utilization and distress symptoms.
Moreover, in this exploratory study, we conducted a number
of correlation analyses such that some of the significant
relationships reported here may have been due to chance
sampling. Third, the sample was small and may be specific to
southeast Idaho. Results may not generalize to other incarce-
rated women in more ethnically and culturally diverse areas.
3.4. Conclusions and future directions
This study extends our understanding of treatment
utilization among a population of substance-dependent
women. Significantly, we replicated Simpson's (2002)
finding that CSA may be related to decreased utilization of
substance abuse treatment. It is important to better
understand why this might occur and any potential
differential mediators like avoidant coping or self-stigma
that might contribute to a relative lack of help-seeking for
substance abuse among those substance-dependent women
with severe sexual abuse histories.
Incarcerated women are a population that has significant
treatment needs, and thus, understanding the predictors of
treatment utilization for these women and any barriers to
seeking help for substance abuse may help providers design
interventions to encourage them to seek treatment and also
treatments that better meet their needs. We also must go beyond
measuring contact with the substance abuse system to look at
the content and quality of treatments provided and how to avoid
fragmentation in providing health care to this population.
Acknowledgments
We would like to thank Brian Konecky for his help in
collecting the data. A portion of this project was presented at
the 2010 annual American Psychological Association
convention in San Diego.
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