Dawn Ruzich of Gateway Foundation and Michael Oscher, ICJIA research intern, contributed to this article.

Introduction

Research indicates traumatic event exposure is a near universal experience among prisoners.[1] Research also suggests exposure to traumatic events is related to future criminal activity.[2] Illinois Criminal Justice Information Authority (ICJIA) researchers collaborated with the WestCare Foundation (Illinois) to survey men housed in Illinois correctional facilities to explore the impact of traumatic life events and posttraumatic stress disorder (PTSD). Through the survey, researchers sought to understand trauma experienced by those incarcerated and its intersection with substance misuse.

Most Americans experience a traumatic event in their lives, and a small percentage develop PTSD.[3] The proportion of individuals experiencing trauma and PTSD symptoms is higher among incarcerated individuals. Prior ICJIA studies found 60 percent of women prisoners and 20 percent of male jail detainees were PTSD symptomatic and almost all individuals in both samples had experienced a traumatic life event.[4] These findings were consistent with other research indicating that frequent trauma exposure and PTSD severity are risk factors for criminal justice involvement.[5] Increased PTSD symptom severity, for instance, is associated with increased adjustment problems, such as interpersonal hostility, substance abuse, and violent behavior,[6] conduct that increases the likelihood of criminal justice contact.

Along with high exposure to trauma and PTSD, research indicates that substance use disorders are highly prevalent among incarcerated persons.[7] Research estimates as many as 75 percent of individuals who are incarcerated have substance use disorders.[8] Prisoners with substance use disorders are more likely to have experienced physical and sexual abuse, parental substance misuse, parental incarceration, and homelessness compared to prisoners without substance use disorders.[9] Moreover, substance use disorders and PTSD commonly co-occur among samples of incarcerated people.[10]

Individuals suffering from a substance use disorder and PTSD are at an elevated risk of cycling in and out of the criminal justice system.[11] Research shows incarcerated men who have substance use disorders and PTSD have higher recidivism rates than those with only substance use disorders.[12] Similarly, the likelihood of relapse is higher among incarcerated women with co-occurring PTSD and substance use disorders than those who only have substance use disorders.[13]

Current Study

The purpose of this study was to understand trauma experienced by those incarcerated and its intersection with substance misuse. To learn about this issue, Authority researchers administered a paper survey to men incarcerated in April 2016 in two Illinois correctional facilities: Sheridan Correctional Center and the Adult Transition Center-Crossroads. All individuals surveyed were participating in substance abuse treatment with WestCare Foundation (Illinois). Traumatic life events and PTSD symptoms were cataloged using questions from the Life Events Checklist (LEC) and the PTSD Checklist-Civilian version (PCL-C).[14] Individuals also were asked questions regarding prescription and synthetic drug use.[15]

The sample totaled 573 individuals.[16] Among them, 25 percent were White, 48 percent were Black, and 11 percent were Hispanic (16 percent unknown). The average age among the sample was 35 years old, with a median age of 33 years. On average, individuals in the sample had 16 total prior arrests, with an average of six prior property arrests, five prior drug arrests, and three prior violent arrests. There was a median of 14 prior arrests, with a median of four prior property crimes, four prior drug arrests, and two prior violent arrests.

In addition to survey data, researchers examined the sample’s data collected by WestCare clinicians that included their demographics and Addiction Severity Index (ASI) assessments. The ASI was completed during one-on-one interviews with WestCare clinicians to create a diagnostic impression of client’s severity of substance use, potential issues during treatment and life areas impacted by substance use. These other areas include: health, employment, legal, family/social, and psychiatric. Authority researchers also matched survey participants to their criminal history information using the Illinois State Police, Criminal History Record Information database. The study was approved by the Authority’s Institutional Review Board, its oversight body for all research involving human subjects.

The PTSD Checklist-Civilian version (PCL-C) is a standardized, self-reporting tool. It consists of 17 questions using a Likert scale rating how much an individual has been bothered by certain concerns/issues in the last month (1= not at all, 5= extremely), resulting in a severity score ranging from 17 to 85. For the purpose of this report, a conservative cut-off score of 50 was used to classify individuals as having probable PTSD, using DSM-IV symptom criteria (Table 1).[17] The term “probable” is used because only clinicians, not researchers, are able to make diagnoses.

Table 1

DSM-IV criteria for PTSD diagnosis

Criteria DSM-IV (309.81 PTSD)
Criterion A : Defining a traumatic event Experienced, witnessed, or was confronted with an event(s) involved actual or threatened death or serious injury, or threat to physical integrity of self or others; Person’s response included intense fear, helplessness, or horror
Criterion B: Exposure-recurrent and persistence re-experiences of a traumatic event Intrusive distressing recollections; Distressing dreams; Acting/feeling as if event were recurring; Intense psychological stress at exposure (internal/external cues); Physiological reactivity (internal/external cues)
Criterion C: Persistent avoidance of stimuli associated with trauma & numbing of general responsiveness (prior to event), indicated by 3 or more of the criteria (that invoke or associated with trauma) Avoid thoughts, feelings, conversations; Avoid activities, places, or people; Inability to recall important aspects of trauma; Markedly diminished interest/participation in significant activities; Restricted range of affect; Sense of shortened future
Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-IV)

Limitations

All research studies have limitations and this study was no exception. First, individuals surveyed may have had difficulty recalling traumatic events prior to incarceration. Second, participants may have been hesitant to provide truthful information because they were surveyed while residing in prison. Although participants were informed of their rights as research subjects, including their rights to confidentiality, some participants may still have had concerns over disclosing past illegal drug behaviors. Third, the sample obtained was a convenience sample of individuals at two correctional facilities enrolled in substance abuse treatment with the WestCare Foundation (Illinois); therefore, the findings are not generalizable to other populations, even those residing in other Illinois Department of Corrections facilities.

Main Findings

Trauma Experiences and PTSD Scores of All Respondents

Researchers used a conservative cutoff score of 50 or more on the PTSD Checklist-Civilian Version (PCL-C) to identify respondents as having probable PTSD. Using this criteria, 136 respondents, or 24 percent, were identified as having probable PTSD.

Trauma Events

Eighty-nine percent of those surveyed had both experienced and witnessed more than one traumatic event during their lifetime. Ninety percent of all respondents indicated that they had experienced at least one traumatic event and 64 percent indicated they had witnessed at least one traumatic event.

PTSD Symptoms

Of all respondents:

  • 56 percent experienced symptoms for Criterion B; they experienced recurring and persistent re-experiences of traumatic event.
  • 39 percent experienced symptoms for Criterion C; they avoided certain thoughts, feelings, activities, places, or people; experienced difficulty recalling aspects of their trauma.
  • 46 percent experienced symptoms for Criterion D; they experienced difficulty sleeping or concentrating, irritability or anger, and hypervigilance.

A total symptom severity score ranges from 17 to 85 and is the sum the scores in each of the 17 items from 1= (Not at all) to 5 (Extremely). The average PTSD severity score of all respondents was 36.98, with a median score of 33 and a most frequently reported score of 17.[18] Figure 1 offers a box-whisker plot, which graphically displays the high and low ends of the distribution of PTSD severity scores (using horizontal brackets).

Figure 1

PTSD severity score distribution (N=573)

Figure 1
Data source: ICJIA survey of prisoners with substance use disorders in WestCare treatment

Trauma Experiences and Symptoms of Respondents Having Probable PTSD

Traumatic events

Nearly all of the 136 respondents with probable PTSD had experienced and/or witnessed more than one traumatic event during their lifetime (97 percent) with an average of 10 events being experienced and/or witnessed. Ninety-six percent indicated that they had personally experienced (not witnessed) at least one traumatic event from the Life Events Checklist with an average of seven events experienced. Seventy-three percent indicated they had witnessed at least one traumatic event, with an average of three events witnessed.

PTSD Symptoms

Of those having probable PTSD (n=136):

  • 54 percent had all five symptoms of Criterion B; they experienced recurring and persistent re-experiences of a traumatic event.
  • 75 percent five to seven symptoms of Criterion C; they avoided certain thoughts, feelings, activities, places, or people, or experienced difficulty recalling aspects of their trauma.
  • 42 percent experienced all five symptoms of Criterion D; they experienced difficulty sleeping or concentrating, irritability or anger, and hypervigilance.

More than half of those having probable PTSD reported experiencing 13 of the 17 problems or complaints from the PTSD Checklist–Civilian version. Of those in the sample who reported being bothered quite a bit or extremely by symptoms within the previous 30 days, 70 percent reported experiencing the symptoms of repeated, disturbing memories, thoughts or images of a stressful experience from the past and being “super alert” or watchful or on guard. Less than half reported having trouble remembering important parts of a stressful experience, being emotionally numb or unable to have loving feelings, acting or feeling as if a stressful experience were happening again, or feeling jumpy or easily startled (Figure 2).

Figure 2

PTSD symptoms reported by respondents having probable PTSD (n=136)

Figure 2
Data source: ICJIA survey of prisoners with substance use disorders in WestCare treatment
Note: Listed are all PTSD symptoms respondents reported being bothered by “quite a bit” or “extremely” within the previous 30 days.

Substance Use of Respondents Having Probable PTSD

The sample was in in-prison, substance use disorder treatment at the time they were surveyed, so the data found co-morbidity of those in the sample with probable PTSD. Twenty-three percent reported daily alcohol problems and 42 percent reported daily drug problems within the 30 days prior to incarceration. Sixty-three percent of those having probable PTSD reported using prescription drugs during their lifetimes to get high or alter their states of mind.

The ASI alcohol severity scores indicated that, on average, those who were identified as having probable PTSD had a moderate problem with drugs and a slight to moderate problem with alcohol.[19] Nearly half of the respondents with probable PTSD reported a considerable to extreme problem with drugs (48 percent) and 31 percent had a considerable to extreme problem with alcohol (Figure 3).

Figure 3

Percentage of sample with probable PTSD and troubled by alcohol or drug problems (n=111)

Figure 3
Data source: ICJIA survey of prisoners with substance use disorders in WestCare treatment

Differences Among Those With and Without Probable PTSD

Demographics of those having probable PTSD were similar to those without PTSD including race, age, and prior arrests. Researchers found a relationship between race and probable PTSD—a greater proportion of non-Whites identified as probable PTSD compared to Whites.[20] Researchers found individuals identified with probable PTSD experienced a higher number of traumatic events.[21]

Respondents reporting more PTSD symptoms also reported more drug use.[22] Higher PTSD severity was associated with reporting a higher number of days experiencing a drug problem (in the 30 days prior to incarceration); individual ASI scores indicate an average of 10 days experiencing a drug problem prior to incarceration, with a median of 0 days, and a range between 0 days (n=293) and 30 days (n=154). These scores were most frequent at 0 and 30 days.[23] Researchers found a greater proportion of those identified with probable PTSD previously used prescription drugs and/or synthetic marijuana.[24] The survey focused on prescription drugs and synthetic marijuana, so association with other drug use was unknown.

Implications for Policy and Practice

This research found that those in the sample of prisoners experienced a traumatic event and a high number of those individuals are PTSD symptomatic, which is consistent with previous studies. As seen in other studies, the data indicated that more traumatic events were associated with an increased number of PTSD symptoms. This research found a slight relationship between PTSD and substance use. A higher proportion of those identified as PTSD probable used drugs prior to incarceration. The data also revealed that a higher proportion of non-White respondents reported having probable PTSD than White respondents. The following are implications based on this research and the literature on trauma and PTSD of prisoners.

Consider Comorbidity

Anxiety disorders, like PTSD, and substance use disorders are among the most common mental health conditions.[25] This study found a relationship between probable PTSD and drug use—respondents who previously users were more likely to report symptoms indicative of a PTSD diagnosis. In addition, a correlation was noted between PTSD severity score and number of days experiencing a drug problem in the 30 days prior to incarceration. This supports research that has shown PTSD and substance use disorders to be comorbid and that substance use is commonly employed to cope with trauma.[26] Research has found comorbidity to be associated with greater symptom severity, greater functional impairment, and poorer outcomes than for either disorder alone.[27] Prisoners receiving substance use disorder treatment might also benefit from treatment for PTSD.

Minimize Re-Traumatization in Correctional Settings

Corrections personnel can avoid exacerbating PTSD symptoms suffered by individuals within the prison population by minimizing procedures that may inadvertently re-traumatize them. Policies, practices, and procedures found in prison settings, such as strip searches/pat downs, loud noises/voices, doors slamming, and segregation may trigger PTSD symptoms. Prison staff may work to minimize re-traumatization and address trauma in the prison population by screening and treating PTSD within the environment. According to the Substance Abuse and Mental Health Service Administration, trauma-informed correctional settings include:

  • “Do no harm” approach.
  • Minimization of re-traumatization.
  • Highly structured, predictable, consistent limits.
  • Staff training to include techniques in responding to trauma/trauma symptoms.[28]

Apply Trauma-Informed Practices and Evidence-Based Trauma Programming

Research suggests that patients diagnosed with PTSD and related disorders experience considerable symptom reductions when evidence-based practices (EBP) are implemented in routine care settings.[29] The need for implementation of EBPs for treating PTSD cuts across a variety of service agencies.[30] Individual or group cognitive behavioral therapy and adherence to an integrated treatment model in cases of co-occurring substance abuse and PTSD have been identified as best practices for treating PTSD.[31] In addition to clinical behavioral therapy, EBPs that can be used in correctional settings include Seeking Safety and Trauma Affect Regulation: Guide for Education and Treatment (TARGET). Seeking Safety is designed to treat those with co-occurring PTSD and substance use disorders. TARGET uses a seven-step process to help trauma survivors gain control of PTSD reactions and understand how trauma changes brain responses.[32] More research is needed to better understand how trauma treatment outside of the prison environment might be adapted to meet the needs of people who are incarcerated.

  1. Carlson, B. E., & Shafer, M. S. (2010). Traumatic histories and stressful life events and incarcerated parents: Childhood and adult trauma histories. The Prison Journal, 90(4).; Gibson, L.E., Holt, J. C., Fondacaro, K. M., Tang, T. S., Powell, T.A., & Turbitt, E. L. (1999). An examination of antecedent traumas and psychiatric comorbidity among male inmates with PTSD. Journal of Traumatic Stress, 12(3), 473-484.; Harlow, C. W. (1999). Prior abuse reported by inmates and probationers. Washington, DC: U.S. Department of Justice, Office of Justice Programs.; Maschi, T., Viola, D., Morgen, K., & Koskinen, L. (2013). Trauma, stress, grief, loss, and separation among older adults in prison: The protective role of coping resources on physical and mental well-being. Journal of Crime and Justice, 1-22.; Teplin, LA. (1990). The prevalence of severe mental disorder among male urban jail detainees: Comparison with the epidemiologic catchment area program. American Journal of Public Health 80, 663-669.; Wolff, N., Huenning, J., Shi, J., & Frueh, C. (2014). Trauma exposure and posttraumatic stress disorder among incarcerated men, Journal of Urban Health, 91 707-719. ↩︎

  2. Scott, C.L. (Ed.) (2010). Handbook of Correctional Mental Health. Washington, DC: American Psychiatric Publishing. ↩︎

  3. Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of Traumatic Stress, 26(5), 537-547. ↩︎

  4. Reichert, J., & Bostwick, L. (2010). Posttraumatic stress disorder and victimization among female prisoners in Illinois. Chicago, IL: Illinois Criminal Justice Information Authority; Ruzich, D., Reichert, J., & Lurigio, A. J. (2014). Probable posttraumatic stress disorder in a sample of urban jail detainees. International Journal of Law and Psychiatry, 37(5), 455. ↩︎

  5. Calhoun, P. S., Malesky, L. A., Bosworth, H. B., & Beckham, J. C. (2004). Severity of posttraumatic stress disorder and involvement with the criminal justice system. Journal of Trauma Practice, 3(3), 1-16.; Donley, S., Habib, L., Jovanovic, T., Kamkwalala, A., Evces, M., Egan, G., Bradley, B., & Ressler, K.J. (2012). Civilian PTSD symptoms and risk for involvement in the criminal justice system. Journal of American Academy of Psychiatry Law, 40, 522–529.; Sadeh, N., Binder, R. L., & McNiel, D. E. (2014). Recent victimization increases risk for violence in justice-involved persons with mental illness. Law and Human Behavior, 38,(2), 119-125. ↩︎

  6. Sadeh, N., Binder, R. L., & McNiel, D. E. (2014). Recent victimization increases risk for violence in justice-involved persons with mental illness. Law and Human Behavior, 38,(2), 119-125. ↩︎

  7. Carlson, B. E., & Shafer, M. S. (2010). Traumatic histories and stressful life events and incarcerated parents: Childhood and adult trauma histories. The Prison Journal, 90(4). ↩︎

  8. Carlson, B. E., & Shafer, M. S. (2010). Traumatic histories and stressful life events and incarcerated parents: Childhood and adult trauma histories. The Prison Journal, 90(4). ↩︎

  9. Mumola, C. J., & Karberg, J. C. (2006). Drug use and dependence, state and federal prisoners, 2004. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. ↩︎

  10. Gibson, L. E., Holt, J.C., Fondacaro, K. M., Tang, T. S., Powell, T. A., & Turbitt, E. L. (1999). An examination of antecedent traumas and psychiatric comorbidity among male inmates with PTSD. Journal of Traumatic Stress, 12(3), 473-484.; Wolff, N., Huening, J., Shi, J., & Frueh, C. (2014). Trauma exposure and posttraumatic stress disorder among incarcerated men. Journal of Urban Health, 91, 707-719. ↩︎

  11. Ardino, V. (2012). Offending behavior: The role of trauma and PTSD. Eruopean Journal of Psychotraumatology, 3(1).; Barrett, E. L., Mills, K. L., & Teesson, M. (2011). Hurt people who hurt people: violence amongst individuals with comorbid substance use disorder and post traumatic stress disorder. Addiction Behavior, 36(7), 721-728.; Cottler, L. B., Compton, W. M., Mager, D., Spitznagel, E. L. and Janca, A. 1992. Posttraumatic stress disorder among substance users from the general population. American Journal of Psychiatry, 149(5): 664–670.; Kubiak, S.P. (2004). The effects of PTSD on treatment adherence, drug relapse, and criminal Recidivism in a sample of incarcerated men and women, Research on Social Work Practice, 14 (6), 424-433.; Ouimette, P. C., Finney, J. W., & Moos, R. H. (1999). Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychology of Addictive Behaviors, 13, 105-114. ↩︎

  12. Kubiak, S.P. (2004). The effects of PTSD on treatment adherence, drug relapse, and criminal Recidivism in a sample of incarcerated men and women, Research on Social Work Practice, 14 (6), 424-433. ↩︎

  13. Kubiak, S.P. (2004). The effects of PTSD on treatment adherence, drug relapse, and criminal Recidivism in a sample of incarcerated men and women, Research on Social Work Practice, 14 (6), 424-433. ↩︎

  14. Researchers used the versions of the PTSD Checklist-Civilian Version and Life Events Checklist that corresponds to the DSM-IV. Those instruments have since been revised slightly to match the contents of the DSM-V. Instruments available from the National Center for PTSD at http://bit.ly/PtAse5.; See Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The Life Events Checklist for DSM-5 (LEC-5). Washington, DC: U.S. Department of Veteran Affairs, National Center for PTSD; Gray, M., Litz, B., Hsu, J., & Lombardo, T. (2004). Psychometric properties of the Life Events Checklist. (PDF) Assessment, 11, 330-341. ↩︎

  15. See full article on synthetic drug use: Gleicher, L., Reichert, J., & Cantrell, W. D. (2017). Study of self-reported synthetic drug use among a sample of Illinois prisoners. Chicago, IL: Illinois Criminal Justice Information Authority. ↩︎

  16. In addition, questions regarding demographics and drug availability, prevalence/use, effects, and treatment were asked. Survey questions were adapted from the synthetic drug survey conducted by Dr. Patrick S. Johnson at Johns Hopkins University.; See Johnson, P. S., & Johnson, M. W. (2014). Investigation of “bath salts” use patterns within an online sample of users in the United States. Journal of Psychoactive Drugs, 46(5), 369-348. ↩︎

  17. The PCL-C was revised in 2013 and tested in subsequent years to update it to reflect DSM-5 rather than DSM-IV criteria. See Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5). Washington, D.C.: U.S. Department of Veteran’s Affairs, National Center for PTSD. ↩︎

  18. Although no PCL-C score cutoff scores indicating probable PTSD for prison populations exits, the researchers believe an appropriate, but conservative cut off score is approximately 45-50. ↩︎

  19. On a scale of 0 (no treatment necessary) to 9 (immediate treatment to intervene in a life-threatening situation), respondents had an average ASI alcohol severity score of 3.46, a median score of 5, and the most frequent score was 5. Also, respondents had an average ASI drug severity score of 4.57 and a median score of 5, with 5 as the most frequent score reported.; Treatment Research Institute. (1990). Addiction severity index: Manual and question by question guide. Philadelphia, PA: University of Pennsylvania-Philadelphia, Veterans Administration Center for Studies of Addiction. ↩︎

  20. Researchers performed a chi square and found a weak, positive association between race and probable PTSD, χ2 (1, N = 573) = 6.91, p < .01. ↩︎

  21. Researchers computed a Pearson correlation coefficient and found a weak, positive correlation between traumatic life events and probable PTSD, r(573) = .29, p < .001. ↩︎

  22. Researchers computed a Pearson correlation coefficient and found a weak, positive correlation between PTSD severity score and the ASI drug severity score, r(482) = .25, p < .001. ↩︎

  23. Researchers computed a Pearson correlation coefficient and found a positive correlation between PTSD severity score and number of days experiencing a drug problem within 30 days prior to incarceration, r(482) = .19, p < .001. No relationship between prior drug arrests and probable PTSD was found. ↩︎

  24. Researchers ran a phi correlation test and found an association between probable PTSD and prescription drug use, ϕ (473) = .19, p < .001. Researchers ran a phi correlation test and found a weak, positive correlation between probable PTSD and synthetic marijuana use, ϕ (426) = .22, p < .001. ↩︎

  25. McHuch, K. R. (2015). Treatment of co-occuring anxiety disorders and substance use disorders. Harvard Review of Psychiatry, 23(2), 99-111. ↩︎

  26. Ouimette, P. C., Finney, J. W., & Moos, R. H. (1999). Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychology of Addictive Behaviors, 13, 105-114. ↩︎

  27. McHuch, K. R. (2015). Treatment of co-occuring anxiety disorders and substance use disorders. Harvard Review of Psychiatry, 23(2), 99-111. ↩︎

  28. Benedict, A. (2010). Using trauma-informed practices to enhance safety and security in women’s correctional facilities. National Resource Center on Justice Involved Women.; Miller, N. A., & Najavits, L. M. (2012). Creating trauma-informed correctional care: A balance of goals and environment. European Journal of Psychotramatology, 3. ↩︎

  29. Cook, J. M., & Stirman, S. W. (2015). Implementation of evidenced-based treatment for PTSD, PTSD Research Quarterly, 26(4), 1-3. ↩︎

  30. Cook, J. M., & Stirman, S. W. (2015). Implementation of evidenced-based treatment for PTSD, PTSD Research Quarterly, 26(4), 1-3. ↩︎

  31. Beck, J. G., & Coffey, S. F. (2005). Group cognitive behavioral treatment for PTSD: Treatment of motor vehicle accident survivors. Cognitive and Behavioral Practice, 12(3), 267-277. ↩︎

  32. Substance Abuse and Mental Health Services Administration. (2014). Treatment Improvement Protocol, Trauma-Informed Care in Behavioral Health Services (TIP) Series 57. Rockville, MD: Author. ↩︎