Looking Out from the Inside: Incarcerated Women's Perceived Barriers to Treatment of Substance Use

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Looking Out from the Inside:Incarcerated Women's Perceived Barriersto Treatment of Substance UseSusan J. Rose a , Thomas P. Lebel a , Audrey L. Begun b & DanielFuhrmann aa University of Wisconsin-Milwaukee , Milwaukee , Wisconsin , USAb The Ohio State University , Columbus , Ohio , USAPublished online: 05 May 2014.

To cite this article: Susan J. Rose , Thomas P. Lebel , Audrey L. Begun & Daniel Fuhrmann (2014)Looking Out from the Inside: Incarcerated Women's Perceived Barriers to Treatment of Substance Use,Journal of Offender Rehabilitation, 53:4, 300-316, DOI: 10.1080/10509674.2014.902006

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Looking Out from the Inside: IncarceratedWomen’s Perceived Barriers toTreatment of Substance Use

SUSAN J. ROSE and THOMAS P. LEBELUniversity of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA

AUDREY L. BEGUNThe Ohio State University, Columbus, Ohio, USA

DANIEL FUHRMANNUniversity of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA

Using the Allen Barriers to Treatment Instrument (ABTI), 299women incarcerated in a local jail were asked about the barriersthey believed they would face in seeking treatment after theirrelease. The top reported barriers were the inability to pay fortreatment, the lack of health insurance, and long waiting listsfor publicly funded care. An exploratory factor analysis was usedto categorize the ABTI barriers into seven factors these womenbelieved would stand in their way: Program Characteristics,Non-Gender Specific Programming, Treatment Site Access, Finan-cial Access, Personal Beliefs About Use & Recovery, Community &Social Environment, and Children & Work Obligations.

KEYWORDS ABTI, barriers, jails, substance use, women

INTRODUCTION

Of the 744,524 adults incarcerated in local U.S. jails by midyear 2012 (Minton,2013), 13.2% were women. Many women, especially women of color(Bloom, Owen, & Covington, 2003), are incarcerated in jails for crimesrelated to substance use (West & Sabol, 2008). Even if they recognize theseriousness of their use and are ready to make steps toward change, for many

Address correspondence to Susan J. Rose, Ph.D., Helen Bader School of Social Welfare,University of Wisconsin-Milwaukee, P.O. Box 786, Milwaukee, WI 53201, USA. E-mail:[email protected].

Journal of Offender Rehabilitation, 53:300–316, 2014Copyright # Taylor & Francis Group, LLCISSN: 1050-9674 print=1540-8558 onlineDOI: 10.1080/10509674.2014.902006

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jailed women treatment for substance use problems must wait until they arereleased, a result of the relatively short stays in jails and limited treatmentresources offered (CSAT, 1998; Wilson, 2000). Over 70% of jail inmates arereleased within one week (Glaze & Parks, 2012). In addition, only 55% ofjails provide any substance use treatment programs, and only 17% of jailedinmates actually participate in any program related to their substance use(Freudenberg, Daniels, Crum, Perkins, & Richie, 2005).

The lack of programs to address substance use related problems whileincarcerated in jail intersects with the many challenges women face whenthey reenter the community from jail, including reintegrating into familiesand neighborhoods, locating stable housing, and finding employment(Richie, Freudenberg, & Page, 2001). Substance abuse treatment can havepositive outcomes for both lower recidivism and reduced substance use(Kubiak et al., 2011), but women need to be able to access and remain intreatment to experience these benefits. Despite the acknowledgement ofsubstance use as a common problem for incarcerated women, little is knownabout the difficulties they experience in seeking treatment for their substanceuse problems or about their perceptions of the barriers that stand in theirway.

Barriers to Treatment

Those who use illegal substances or legal substances in illegal ways, do notalways enter treatment when treatment is needed. In the most recent study oftreatment need and utilization conducted by the Substance Abuse and MentalHealth Services Administration (SAMHSA, 2011) the most common reasonsfor not receiving treatment reported by persons 12 and over who used illicitsubstances included a lack of health care coverage and inability to pay(41.8%), not feeling ready to quit use (30.7%), fear of negative opinions byneighbors and other community members (14.6%), the potential negativeeffects of seeking treatment on employment (12.4%), not knowing whereto obtain treatment (12.1%), and the belief that they could handle their usewithout treatment (9.6%).

A better understanding of the barriers that may stand in the way ofseeking and staying in treatment by those who need treatment seemswarranted. Many studies investigating barriers to treatment for substanceuse have utilized the constructs of internal and external barriers to describethe challenges faced by those seeking treatment (Rapp et al., 2006; Xu, Wang,Rapp, & Carlson, 2007), and some studies have also noted the importance ofcommunity characteristics as a barrier (Allen, 1995).

Internal barriers are conceptualized as factors that are a component ofan individual’s thinking or belief system. These have variously been ident-ified as personal barriers (Allen, 1995), client characteristics (Schober &Annis, 1996), or perceptual barriers (Owens, Rogers, & Whitesell, 2011).

Incarcerated Women and Barriers to Treatment 301

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These include failure to acknowledge substance use as a primary problem(Thom, 1986), denial of problem use of substances (SAMHSA, 2011), andthe lack of motivation to pursue treatment (Allen & Dixon, 1994; K. E. Green,2011; Kenny, Harney, Lee, & Pennay, 2011; Taylor, 2010; Xu et al., 2007;Zenmore, Mulla, Ye, Borges, & Greenfield, 2009). Fears about social stigma(Copeland, 1997; Semple, Grant, & Patterson, 2005), guilt and shame aboutdrinking (Richie et al., 2001), and concerns about losing custody of minorchildren (Konrad & Morton, 2012) have all been cited as internal barriersfor mothers in particular.

External barriers have been conceptualized as factors in the social andcommunity environment as well as in the treatment system itself. Externalbarriers have variously been identified as systemic (Allen, 1995), environ-mental, structural (Owens et al., 2011), or as treatment program characteris-tics (Schober & Annis, 1996). These barriers include a lack of financialresources or insurance to pay for treatment (SAMHSA, 2011; Sung, Mahoney,& Mellow, 2011; Taylor, 2010), lack of transportation to access treatment(Jones-Saumty, Thomas, Phillips, Tivis, & Nixon, 2003), long waiting listsfor treatment, complicated referrals and intake procedures (Notley, Maskrey& Holland, 2012; Quanbeck et al., 2013; Rapp et al., 2006), and a lack ofgender sensitive treatment offered in facilities (Allen, 1995; Taylor, 2010).

As compared to men, internal barriers for women include more psycho-social risk factors (depression anxiety, victimization), the increased socialstigma of female addiction, and a lack of social and financial resourcesresulting from chronic underemployment experienced by poor women(C. A. Green, 2006; Richie, 2001; Schober & Annis, 1996). External barriersencountered by women include long waiting lists, failure of programs toprovide consistent therapists, strict abstinence requirements, difficulty inscheduling time to attend treatment due to family responsibilities, lack of infor-mation about treatment options, a lack of childcare facilities while mothersengage in treatment, social disapproval, a lack of support or even oppositionby family and friends, and the placement of addiction services in evenmore distant and stigmatizing psychiatric environments (Fendrich, Hubbell,& Lurigio, 2006; Finkelstein, 1994; C. A. Green, 2006; Schober & Annis,1996; Taylor, 2010; Tuten & Jones, 2003; van Olphen & Freudenberg, 2004).

Allen and Dixon (1994) specifically identified barriers commonlyencountered by African American women. These barriers included responsi-bilities at home, inability to pay for treatment, lack of health insurance to payfor treatment, believing they need to use drugs or alcohol to deal with stress,and fear that admitting a problem with alcohol or drugs could be used to takeaway their children.

For women recently released from local jails who have substance useproblems, inadequate child care and a lack of protection from sexual harass-ment are additional barriers to their seeking and remaining in treatment(Richie, 2001). For those returning to the community from state prisons, lack

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of financial resources or health care coverage were cited as the most signifi-cant barriers to obtaining treatment for their substance-related problems(Sung et al., 2011).

Measuring Treatment Barriers

One of the first measures to attempt to identify barriers to treatment forwomen seeking substance abuse treatment was the Allen Barriers to Treat-ment Instrument (ABTI). In developing the ABTI, Allen (1995), concernedwith the increasing numbers of African American women identified as sub-stance abusing by criminal justice and child welfare organizations, reviewedthe existing literature on barriers encountered by these women. In additionto personal (internal) barriers she identified barriers in both the treatmentsystem and in the communities of these women (external barriers) that stoodin the way of their accessing and staying in treatment. The ABTI was initiallytheorized as a three-factor model covering (a) treatment program character-istics, (b) personal beliefs, and (c) socioenvironmental issues (Allen, 1995).

Several subsequent studies (Rapp et al., 2006; Xu et al., 2007 Rinker,Lindsay, Schmitz, & Green, 2009) have reviewed the proposed factor struc-ture of various versions of the ABTI with differing results. Rapp and collea-gues administered an expanded BTI to 312 persons seeking outpatientsubstance abuse treatment (Rapp et al., 2006). Utilizing an exploratory factoranalysis they proposed a seven-factor solution: Absence of Problem,Negative Social Support, Fear of Treatment, Privacy Concerns, TimeConflicts, Poor Treatment Availability, and Admission Difficulty. Xu and col-leagues (2007) administered a 20-item version of the BTI to 518 clientsrequesting a substance abuse assessment from a public central intake unit.Using both exploratory and confirmatory factor analyses, they suggested afive-factor model as the best fit to the data: Absence of Problem, NegativeSocial Support, Fear of Treatment, Privacy Concerns, and CommittedLifestyle. Rinker and colleagues (2009) administered the ABTI to 77 womencompleting an intake interview at an outpatient substance abuse treatmentfacility. Using both exploratory and confirmatory factor analysis their itemlevel analysis suggested three different factors which they labeled FunctionalBarriers, Relational Barriers, and Affective Barriers. These differing factorstructures may have reflected the different populations (diverse gender,ethnic group identity, income, age, type of treatment sought). None of thesestudies specifically focused on incarcerated women, a population whoseanticipated and experienced barriers may differ from those of women intreatment and living in the community.

While little is known about the barriers faced by women as they seektreatment for substance use, even less attention has been focused on barriersfaced by incarcerated women as they return to their communities. Greaterclarity in understanding the barriers incarcerated women anticipate as they


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attempt to seek treatment upon reentry can only help in developing moreeffective prerelease interventions and intervention strategies after their returnto the community. Thus, the primary aim of this report is to understand thebarriers perceived by incarcerated women anticipating their release from jailand their early reentry experiences through a description of the factor struc-ture of the ABTI and to further instrument development for quantitativeassessment of women’s anticipated barriers to substance use treatment.

METHODS

Participants

The women participating in this study were recruited during their incarcer-ation in Milwaukee County Jails. These women were participants in a larger,longitudinal, randomized-control study about substance use problemsamong women in jail and during the first 2 months after reentry to the com-munity (Begun, Rose, & LeBel, 2010, 2011; Begun, Rose, LeBel, & Teske-Young, 2009). The current report presents data from a subset of 299 womenwho received a positive score on a brief screening measure for substance useproblems and were randomly assigned to the intervention condition. Theintervention condition included additional screening, feedback about theirsubstance use, and a motivational enhancement intervention. All studymeasures in this report were administered through individual, face-to-faceinterviews before the application of the intervention to avoid potential biason baseline data.

The self-reported race=ethnicity of these women was 58% AfricanAmerican, 28% White, 7% Hispanic, and 7% ‘‘other.’’ Over half (51%) of thesewomen reported education levels with less than a high school degree, with5.4% having less than an eighth-grade education, 45.5% having 9–12 yearsof education but no high school diploma, 7.4% earning a GED, and 18.4%achieving high school graduation. Their mean age was 34.9 years (SD¼9.2). Before coming to jail, 70% of the women had annual household incomesof less than $10,000. The vast majority of the women (80%) were mothers, and60% had minor children living with them before their incarceration. On aver-age, participants had been in jail eight times (M¼ 8.3), with a median numberof four times, and 25% reported having served time in prison, as well. Twothirds (67%) of the women reported attending at least one drug treatment pro-gram at some time prior to this period of incarceration, while 14% indicatedhaving been in a drug treatment program four or more times.

Measures

The initial substance use screening measure utilized was the Alcohol UseDisorders Identification Test-12, (AUDIT-12; Campbell, Barrett, Cisler,

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Solliday-McRoy, & Melchert, 2001). This is a 12-item measure based on theAlcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor,de la Fuente, & Grant, 1993) in which respondents are asked about theirsubstance use in the year before their incarceration. The AUDIT-12 usesa single cut-point whereby any score of eight or higher is considered to bea ‘‘positive’’ result.

As a part of the intervention condition, the ABTI (Allen, 1995) was admi-nistered. The ABTI is a 30-item inventory to which women are asked torespond to each item in relation to ‘‘how much do each of the following keepyou from getting treatment for alcohol or other drug problems?’’ The respon-dent uses a 4-point ordinal scale reflecting the magnitude of each as a barrier(1¼not at all, 2¼a little, 3¼an average amount, and 4¼a lot).

While measures were checked with the Fleisch-Kincaid reading score toinsure a fifth-grade reading level, all measures were read to respondents.Interviewers were also trained to ask women about potentially difficultwords and provide an explanation or definition to women if they believedsuch words or phrases were not well understood.

RESULTS

Descriptive and scale reliability analyses were completed using SPSS v. 21.0.The factor analysis results were obtained using MPLUS version 6.12 due toits superior handling of the response patterns observed in the barriersinstrument data.

The mean AUDIT-12 score among the 299 women was 26.3 (SD¼ 9.7),with a median score of 26. To be included in the study phase women musthave obtained a positive score of eight or more. Nearly three fourths (73%) ofthe women had scores of over 20, considered to be in the high positiverange, suggesting the need for further diagnostic evaluation for dependence(Babor, Higgins-Biddle, Saunders, & Monteiro, 2001).

The vast majority (82.6%) of the women reported at least one of the 30items of the ABTI as having ‘‘a lot’’ of significance as a perceived barrier. Onaverage, the women rated 5.2 of the 30 barrier items as ‘‘a lot’’ of a treatmentbarrier, with a median of 4.0 barriers receiving this highest possible score.Additionally, the women reported a mean of 10.6 perceived barriers as beingpresent to some extent: either ‘‘a lot,’’ ‘‘an average amount,’’ or ‘‘a little.’’ Only16 (5.4%) of the participants did not indicate the presence of any of the 30perceived barriers to getting help for their substance use problems.

Table 1 lists the top ten perceived barriers to getting help for substanceuse problems reported by study participants.

Notably, the top three barriers deal with access to treatment; threeadditional barriers (i.e., two transportation issues and lack of information) alsoappear related to accessing care. The top reasons reported by participants as ‘‘a


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lot’’ of a perceived barrier were: ‘‘I cannot pay for treatment of this problem’’(42.8%) and ‘‘I do not have health insurance’’ (40.8%). Incarcerated womenmost often identified ‘‘having to wait for an opening because the program isfull’’ (58.9%) as a potential barrier to substance use treatment. The perceivedbarriers following close behind include: ‘‘needing alcohol and=or drugs todeal with the stress of daily life in my community’’ (57.5%), and the inabilityto pay for treatment (57.2%). Another of the top ten perceived barriers focuseson the women’s social context concerns: ‘‘Living in a community whereeveryone is expected to party using alcohol and drugs.’’ About a quarter ofthe women (24.8%) identified this concern about alcohol and=or drugs intheir community as ‘‘a lot’’ of a barrier to getting help.

Exploratory Factor Analysis

Exploratory factor analysis (EFA) using MPLUS was used to determine thenumber of continuous latent variables needed to explain the pattern of correla-tions among the set of indicators (i.e., responses to the 30 barrier items).MPLUS was used because of its ability to specify the categorical nature ofthe indicators (i.e., the mode for 29 of the 30 items was the response of ‘‘notat all’’) and utilize an appropriate estimator. The robustWeighted Least SquaresMeans and Variances (WLSMV) approach was applied as the parameter

TABLE 1 Top 10 Perceived Barriers From the ABTI

Variable M (SD)

Response of ‘‘a lot,an average amount,

or a little’’ (%)Response of‘‘a lot’’ (%)

I cannot pay for treatment of this problem 2.48 (1.40) 57.2 42.8I do not have health insurance for thisproblem

2.37 (1.43) 50.8 40.8

Having to wait for an opening because theprogram is full

2.31 (1.30) 58.9 32.8

Needing alcohol and=or drugs to deal withthe stress of daily life in my community

2.22 (1.25) 57.5 26.8

Lack of information about and not knowingthe location of treatment programs

2.19 (1.28) 54.2 27.8

No available transportation to thetreatment program

2.15 (1.29) 51.5 28.4

In the past I have been unable to stayalcohol-free and=or drug-free after treatment

2.12 (1.28) 50.2 25.9

Living in a community where everyoneis expected to party using alcohol and drugs

2.02 (1.27) 45.8 24.8

The far distance of treatment programs frommy home

1.89 (1.17) 43.5 18.1

I feel ashamed when I admit to havingthis problem

1.84 (1.14) 43.1 17.4

Note. ABTI¼Allen Barriers to Treatment Instrument. Items scored using a 4-point Likert-type scale

(1¼not at all; 4¼a lot).

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estimator. Missing data were exceedingly rare, and were treated throughpairwise deletion in correlation matrices used in the factor analysis; no attemptwas made to replace missing data. In this case, a Geomin (oblique) rotationwas employed to obtain the factor solution because it was presumed thatthe resulting factors would be at least somewhat correlated with each other.

While exploratory factor analysis is a well-regarded statistical technique,deciding the number of factors that best represent the inventory of items‘‘falls in the realm of subjective judgment’’ (Spector, 1992, p. 54). The princi-ples applied in this report included: (a) factors with item loading scoresexceeding .50; (b) the Kaiser-Guttman Rule, where eigenvalues that aregreater than one are cross-checked with scree-plot analysis (examining theeigenvalue graphs for noticeable breaking points); and, (c) the interpret-ability of the factors (see Costello & Osborne, 2005; Floyd & Widaman,1995; Loehlin, 1992). Importantly, no single rule of thumb is thought to besufficient in determining the number of factors underlying a set of items.

The Kaiser-Meyer-Olkin Measure of Sampling Adequacy (obtainedusing SPSS v.21.0) was .850, with values of .80 or greater indicating thatthe 30 items in the ABTI were appropriate for factor analysis. Also, there isa meaningful association among the items being analyzed as shown by thesignificance (p< .001) of the Bartlett Test of Sphericity: chi-square (435)¼3151.43).

The initial exploratory factor analysis yielded eight factors with eigenva-lues greater than 1.00. However, only seven factors were retained based onan inspection of the factor loadings, the scree plot analysis, and the interpret-ability of the yielded factors. Table 2 presents the retained items along withtheir factor loadings for a seven factor solution.

Table 2 displays only the 24 items with loadings greater than 0.50, whichwas applied as a stringent criterion. Six of the 30 items did not load on any ofthe seven factors at levels �.50. Table 3 presents the matrix of correlationsamong the observed factors.

As expected, several factors were moderately correlated with oneanother, because each of the items measures a perceived barrier to receivinghelp for a problem with substance use.

Results of the factor analysis were complemented by internal consist-ency statistics for the latent scales (i.e., Cronbach’s alpha coefficient). Theindividual items in each factor and the reliability of each scale are also dis-played in Table 2. The first factor (a¼ .741) contains content reflecting a lackof confidence in the treatment programs and the behavior of treatment stafftoward patients. Combining this information with the other three itemsincluded for this scale, such as having to wait for an opening, no ‘‘aftercare’’or maintenance programs, and lacking information about programs, suggestsProgram Characteristics as the unifying theme.

Factor 2 (a¼ .874), labeled Nongender-Specific Programming, includesthree items, all of which reflect gender-specific aspects of treatment


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TABLE2

FactorLo

adingforaSeven-FactorSo

lution

ABTIitem

Factors

1a¼.741

2a¼.874

3a¼.812

4a¼.843

5a¼.546

6a¼.752

7a¼.624

Noco

nfidence

intheab

ilityoftreatmentprogramsto

teachmewhat

Ineedto

know

asan

alco

holordrugab

usingwoman

.687

Havingto

waitforan

openingbecause

theprogram

isfull

.681

Thebehavioroftreatmentstafftowardpatients

.673

Lack

ofinform

ationab

outan

dnotknowingthelocationoftreatmentprograms

.648

Nohelp

from

treatmentprogramsforstayingalco

hol=drugfreeafterw

ards

.576

Thepossibilityofhavingto

speak

inagroupwhere

menarepresent

.950

Treatmentprogramsthat

includemenas

wellas

womenpatients.

.877

Thepossibilityofhavingto

speak

ofmyproblemswithamaleco

unselor

.820

Thefardistance

oftreatmentprogramsfrom

myhome

.635

Noavailable

tran

sportationto

thetreatmentprogram

.542

Icannotpay

fortreatmentofthisproblem

.970

Idonothavehealth

insurance

forthisproblem

.828

Idonotlethealth

problemsinterruptmylife.

.681

Iwas

raisedto

believeIshould

takecare

ofmyownhealth

problems

.522

Ihavereligiousbeliefs

aboutthisproblem

.518

Idonotfeelthat

drinkingan

ddruguse

isaproblem

forme

.502

Livingin

aco

mmunitywhere

everyoneisexpectedto

party

.769

Protectedfrom

bad

resultsofalco

hol=drugproblem

byfriends,family,or

coworkers

.612

Needingalco

holan

d=ordrugsto

deal

withstress

ofdaily

life

.608

Angerfrom

boyfriend,husban

d,orloverforbeingalco

holordrugfree

.604

Notbeingacceptedbyfriendsifalco

holordrugfree

.521

Havingnoonein

myfamilyorco

mmunityto

takecare

ofmych

ildren.

.825

Thefear

that

myad

missionofthisproblem

could

beusedbysomeoneto

takemy

childrenaw

ay.

.782

Notbeingab

leto

gettimeofffrom

work.

.528

Notes.Factornam

es:1¼Program

Characteristics;2¼Nongender-Sp

ecificProgramming;3¼TreatmentSite

Access;4¼Finan

cial

Access;5¼Personal

Beliefs

AboutUse

and

Reco

very;6¼Communityan

dSo

cial

Environment;7¼Childrenan

dWork

Obligations.

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programs, rather than the women themselves. Factor 3 (a¼ .812), TreatmentSite Access, and Factor 4 (a¼ .843), Financial Access, contain just two itemseach. While this is recognized as a factor instability concern, the pairs ofitems fit well together and are distinct from the other factors, bolstering con-fidence in their adequacy. The two items in Factor 3 both reflect access issuesrelated to transportation and the two in Factor 4 both reflect access issuesrelated to the ability to pay for treatment.

The fifth factor (a¼ .546), Personal Beliefs About Use and Recovery,contains four items that all reflect aspects of a person’s belief system: beliefsabout not letting health problems affect one’s life, taking care of one’s ownhealth problems, religious beliefs, and beliefs concerning whether or notdrinking=drug use is problematic. Factor 6 (a¼ .752), Community and SocialEnvironment, includes items related to the social context of substance use.These items reflect a social environment where ‘‘everyone is expected toparty using alcohol and drugs,’’ as well as friends’ and intimate partners’likely responses to changing substance-using behavior and the lack of signifi-cant others who will support sobriety. The seventh factor (a¼ .624), Childrenand Work Obligations, contains three items. Two of the items, one aboutchildren and one about a woman’s job, reflect practical concerns related toparticipating in treatment; the remaining child-related item reflects a concernabout treatment being used as leverage to take custody of children.

DISCUSSION

This study was designed to further an understanding of the perceivedbarriers to substance abuse treatment anticipated by women incarceratedin jail and preparing for community reentry, through an exploratory factoranalysis of the ABTI. The proposed factors resulting from this exploratoryfactor analysis support previous research and suggest areas for further study.

The present study supports the findings of earlier studies identifyingbarriers that are a function of the treatment system itself (Haller, Miles, &Dawson, 2003; Jessup, Humphrey, Brindis, & Lee, 2003; Kenny et al., 2011;

TABLE 3 Correlations Among Seven-Factor Solution

Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7

Factor 1Factor 2 .337��

Factor 3 530�� .291��

Factor 4 .407�� .213�� .370��

Factor 5 .300�� .248�� .261�� .178��

Factor 6 .414�� .351�� .287�� .405�� .463��

Factor 7 .374�� .251�� .375�� .264�� .319�� .434��

�p� .05. ��p� .01. ��p� .001.


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Quanbeck et al., 2013), and those that are more idiosyncratic (K. E. Green,2011; Mojtabi et al., 2011; Rapp et al., 2006; Taylor, 2010; Xu et al., 2007).The current study does not support Allen’s (1995) original triadic categoriza-tion into (a) Personal Beliefs, Feelings, and Thoughts, (b) Treatment ProgramCharacteristics, and (c) Socio-environmental Issues. It does however supportthe conclusion of the exploratory factor analyses of Rinker and colleagues(2009) that Allen’s three-factor model could not be replicated in an outpatientpopulation. Rinker notes that the response options to Allen’s statements areconfusing and in some instances may not have been appropriate for specificitems. We found similar problems with this measure in administering itto incarcerated women, which may have influenced their responses andaffected the factor analysis.

The current study uses a quantitative approach to understanding barriersto substance use treatment perceived by women in jail, a relatively uncom-mon approach. A majority of studies that have attempted to identify barriersto treatment entry and retention have primarily used qualitative methods andlife history interviews to explore the nature of perceived barriers (Jessup et al.,2003; Kenny et al., 2011; Notley et al., 2012; van Olphen, Freudenberg, Fortin,& Galea, 2006; Redko, Rapp, & Carlson, 2006; Richie, 2001; Roberts &Nishimoto, 2006). Some have used interviewer administered surveys, or aself-administered questionnaire along with qualitative interviews (Massonet al., 2013; Venner et al., 2012). Studies which have used quantitative meth-ods have generally involved persons seeking outpatient treatment (Rappet al., 2006; Rinker et al., 2009; Xu et al., 2007) or those who are nothelp-seeking but have an identified disorder and would be appropriate fortreatment, either because of their history (K. E. Green, 2011; Kenny et al.,2011) or a diagnosed substance use disorder (Mojtabi et al., 2011). Fewstudies (van Olphen et al., 2006; Richie, 2001) have explored barriers totreatment for substance use disorders of men or women returning from jail.

Limitations

A limitation of this study is that the results describe barriers incarceratedwomen perceive they will face in seeking treatment, not those they actuallydo face. While many of the women in the study did seek treatmentpreviously, and their responses here may have been based on their priorexperiences, some other women may have been biased by the experiencesof friends or family members who had sought treatment in the past.

The study is further limited by some aspects of the measure itself. Theresponse options of the ABTI have been reported by Rinker and colleagues(2009) as potentially ambiguous and confusing. Women may not haveresponded consistently across items to the scale responses such as ‘‘a little,an average amount, a lot,’’ and individual women may have applied the scaledifferently compared to one another.

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Finally, due to the mobile nature of the jail population and the limita-tions of obtaining access to women every hour of the day, not all womenincarcerated in the jails were given an opportunity to participate. Thus, thissample may not be representative of all women in jails.

Implications

PRACTICE

Most of the women in this study reported that they perceive they will facemultiple barriers when they try to get treatment after their release. Inter-vention while women are still in jail should focus on identifying thesebarriers and helping women problem-solve ways to address them in orderto maximize the likelihood that they will be successful in accessing care.Such problem solving interventions should include how to pay for treatment,where treatment sites are located and how to get there, what is required toenter treatment, what format or method of treatment they will use, how tofunction in a home or community environment that may not be conduciveto sobriety, addressing personal beliefs about the need to change withoutany ‘‘outside help,’’ dealing with shame for their previous use and the prob-lems it may have created in their families, planning for the care of childrenduring treatment, balancing the time demands of work with treatmentappointments, and what is needed to stay in treatment for the duration ofcare.

The new health care legislation, the Affordable Care Act, may helpreduce the lack of affordability barrier that was so commonly cited bywomen in this study. Correct, up to date, and usable information abouthow to access new federal and state programs will be critical in addressingthis barrier, including the challenges of enrolling women returning from jailwho may have no permanent or stable address.

POLICY

Addressing long waiting lists and other barriers to public substance use treat-ment is directly related to financial access and should be a policy priority.Streamlining the intake process and creating multiple entry points to treat-ment sites should be encouraged. Some of these entry points should be inneighborhoods into which women are being released, and in jail facilitieswhere women could begin the intake process before their release.

Many women with substance use related problems have co-occurringhistories of physical and=or sexual trauma and some express preference fornon-mixed gender groups in treatment. Gender-specific and trauma sensitivesubstance use treatment programs have been strongly recommended forwomen in the criminal justice system (Bloom et al., 2003) and should be


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encouraged to address the risk women may perceive in mixed gendergroups. Finally, the obligations women have as family caretakers and primarywage earners should be addressed through more flexible scheduling andco-location of services in child friendly settings (e.g., schools, day carecenters).

RESEARCH

This factor analysis of the ABTI points to a research agenda regarding thebarriers experienced by incarcerated women as they contemplate seekingtreatment for substance use problems after their release. First, the importanceof particular barriers may not be similar across all populations and should befurther explored. The ABTI was originally constructed to explore the strengthof barriers faced by African American women seeking substance use treat-ment. While a majority of the women in this study were African American,not all were.

Second, Gerend, Shepherd, and Shepherd (2013) reported that thosewho really intend to engage in a ‘‘particular health behavior’’ are more likelyto perceive global barriers (lack of motivation, potential effectiveness of atreatment, etc.) standing in their way, while those who do intend to engagein a particular behavior, are more likely to perceive practical barriers (cost,transportation, difficulties in intake procedures, etc.). It would be importantto understand the role of internal or external barriers in relation to motiva-tion to enter substance use treatment in order to develop more targetedinterventions.

Third, we do not know the impact of a cumulative effect of multiple bar-riers or the impact of the interaction of specific barriers and should furtherexplore this area. Is there a tipping point in the number of barriers thathas a greater influence than any one specific barrier or set of barriers? Docertain barriers interact with incarcerated women to influence the desire orability to seek and=or remain in substance use treatment?

Finally, entering and remaining in treatment are not necessarilygoverned by the same processes, and may require different skill sets toaccomplish. Specific research should investigate whether barriers to treat-ment entry differ from those impacting treatment retention.

Conclusion

This research explored incarcerated women’s perceptions of barriers to treat-ment for substance use disorders. The investigators used an exploratoryfactor analysis of the ABTI to categorize the barriers these women believedthey would face in seeking substance use treatment after their release. Theperceived difficulty of accessing treatment was important to these women,with the top reported barriers being the inability to pay for treatment, the

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lack of health insurance, and long waiting lists for publicly funded care. Anexploratory factor analysis suggests that the characteristics of substance usetreatment programs themselves (i.e., waiting lists, a lack of confidence inthe ability of staff to understand them, as well as the lack of gender-specificprogramming and access to treatment), are all barriers women in jail perceivewill stand in their way. Specific in-jail programming to address these con-cerns should be implemented while women are still in jail and followedup after their release. Such interventions may enhance reentry services andhelp women struggling with substance use problems make the connectionwith treatment programs that will help them with the difficult tasks of reinte-grating with their families and communities.

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Documents

Looking Out from the Inside: Incarcerated Women's Perceived Barriers to Treatment of Substance Use