SOJ Nursing & Health Care

Data for this study were drawn from quantitative analyses derived from secondary statistics from the National Longitudinal Study of Adolescent to Adult Health [Add Health], which is a longitudinal study of a nationally representative sample of adolescents in grades 7-12 in the United States. The purpose of our study is to address multiple selfreported victimization among a sample of women who have reported using illicit substances, and the extent to which type of victimization affects psychological maladaptation. This study extends current investigations on patterns of victimization among high-risk women to examine the linkage between violent victimization and mental health status as risk factors. Our hypothesis is Women who report substance use that have experienced family- and community-level victimization during their lifetime will exhibit higher levels of mental health problems as emotional outcomes/psychological maladaptation over and above sociodemographic factors including race and those characteristic of reduced social class [extreme poverty]. In sum, results show that for mental health complications, select indicators of childhood victimization and community-level or weapon-related victimization explained variance over and above sociodemographic factors as measured by race and social class indicators. As these outcomes display, accounts of depression, sadness, and other forms of symptomatology are higher when substance-using women report childhood neglect, childhood sexual abuse, and environmental stressors, which is consistent with previous research. Policy implications and suggestions for future research are addressed.

Keywords: Illicit Substance Use; Emotional Outcomes; Victimization Experiences; Women;

Research regularly shows a distinct increase in the number of women incarcerated in the United States, many of whom are imprisoned for non-violent, first-time offenses [12]. Studies have also suggested that among those women incarcerated for low-level offenses, their increased rates of drug addiction are indicative of their need to escape domestic violence, economic hardship and childhood adversity, yet they are less likely to receive adequate substance abuse treatment, both while incarcerated and upon release. Further, a substantial number of criminal justice-involved women have been victims of intimate partner violence at some point in their lives, many of whom have been reared in poor and working-class families, placing them at an even greater risk for community violence. Conversely, problems surrounding multiple traumas are rarely addressed in discussions of counseling and treatment strategies among female offenders, particularly among those who suffer from repeated victimization [3]. The aforementioned issues point toward the multitude of difficulties that many women offenders face, as research continues to suggest that those with histories of substance abuse, in particular, present complex clinical profiles with a range of medical, psychological, and social problems [12, 15, 21]. Nonetheless, fewer programs have assessed the specific needs of these women and have focused more on the observations of clinicians.

Research has also shown that when many women enter the criminal justice system, they do so with higher amounts of childhood victimization, and have been involved in more high-risk activities including drug use [7, 13]. Further, they have increased physical and mental health difficulties, and are more likely to experience imminent victimization upon reentry. Regarding substance use problems in particular, studies have concentrated on the treatment needs of female inmates who report higher levels of childhood physical, sexual and emotional abuse that are specifically linked to mental health complications [2, 7, 17]. Scholars have noted that the repercussions of failing to diagnose and subsequently treat these women effectively can further lead to higher rates of joblessness, homelessness, and separation from children [12, 13]. Additionally, studies have shown that patterns and ensuing outcomes of treatment for drug/alcohol abuse and mental health difficulties differ significantly across a woman’s race and social class [11]. Despite extensive research on the emotional impact of violence against women, particularly in the area of singular occurrences such as sexual assault or domestic abuse, less is known about multiple victimizations across families and communities/neighborhoods that can impair women’s physical health and mental health functioning, and in some cases can lead to drug addiction and psychological pain. Additionally, fewer studies have examined the influence of these multiple victimizations or traumatic events on what are considered trajectories or pathways to prison and jail [6, 7, 18, 19]. This further indicates that many women enter the system with past distress and drugrelated problems, placing them at an even greater risk for recidivism as measured by re-arrests and re-incarceration [12].

Scholars have continued to illustrate an association between experiences with violence, mental health functioning, and adjustment outcomes [for example, drug use]. Becker et al., for example, observed intimate partner violence [IPV] and previous experiences with childhood exposure to violence as predictors of PTSD symptomatology [1]. Their research found that physical abuse, sexual abuse, and the witnessing of domestic violence as an indirect form of victimization each held an independent association with PTSD. Additionally, their results indicated that adult exposure to intimate partner violence [IPV] mediated the relationship between physical abuse during childhood and adult symptomatology. Similarly, Hughes et al., in an examination of victimization and substance use disorder, found a strong association between victimization experience and substance use within the past year [5]. Across sexual minority subgroups, they found evidence to suggest that childhood victimization, namely childhood neglect, had the strongest association with substance use. Further, the odds of substance use were higher regardless of sexual identity among those reporting two or more victimization experiences symptomatic of multiple victimization. Linares found a main effect of types of victimization and levels of social connection to neighbors on current measures of health including distress, PTSD, and illicit substance use [8]. Their results held constant even after considering ethnicity, immigration, and marital status.

Additional studies of the relationship between victimization and mental health functioning have addressed the specific experiences of women, particularly those who have been marginalized by an oppressive, patriarchal structure. As a result, many have been placed at a greater risk for engaging in activities such as drug abuse, illicit sexual behavior, and violent victimization. Fusco et al., in a study of victimized mothers and their children, examined the impact of maternal childhood and adult victimization on child trauma symptomatology [4]. Findings revealed that mother’s victimization status had an effect on outcome measures such as depression, anxiety, and hostility. In fact, mother’s adult victimization had a stronger effect on their child’s trauma symptomatology when compared to maternal childhood victimization. Additionally, maternal hostility was associated with both childhood and adulthood victimization. When examining “high-risk” women who were either pregnant or were parents, Kennedy et al. found that cumulative victimization, measured by such factors as lifetime of witnessing intimate partner violence [IPV], childhood physical abuse by an adult caregiver, and stigma predicted PTSD symptomology [6]. However, no statistical support was found for community violence exposure as a predictor of PTSD among this subgroup of women. McGee et al., in a study of the impact of maternal incarceration on adolescent symptomology, found that mother’s detainment explained variance in both emotional outcomes and behavioral risk influences over and above sociodemographic factors including gender, educational level, and family income [10]. Parks et al., found that among low-income urban women, childhood maltreatment predicted adult violent victimization [16]. Further analyses of their research pointed toward examinations of illicit drug use as a covariate in the childhood maltreatment and adult violent victimization relationship. Additionally, McGee & Gilbert in a study of female prisoners, found that ½ of them engaged in both drug and alcohol abuse at the time of their offense [11]. Although they were more likely to display significant substance abuse problems stemming from their exposure to multiple forms of violence during childhood and adulthood, they were less likely to receive substance abuse treatment while incarcerated. Instead, minimal treatment was presented to these women suffering from a range of other problems, addressing the need for increased group therapy, family counseling, reunification programs, and mental health treatment. Studies such as these are particularly relevant in discussions of women’s adjustment outcomes, including those relating to lifetime self-reported victimization, since drug abuse and addiction remain the primary reasons many of them enter prisons and jails.

Research has also shown that criminally involved women are more likely to report being exposed to violence in the home in childhood and adulthood, and are more likely to engage in substance abuse and experience poverty [10]. Because of the extended exposure, these women often face higher risks of developing symptomatology and have specific mental health needs that require broad treatment methods. However, Muraskin’s research suggests that certain characteristics relating to women’s victimization status are overlooked when developing effective treatment plans [14]. Here she argues that women bring a variety of unique health and relationship issues to the criminal justice experience. Moreover, without understanding the many characteristics of female offenders, treatment programs cannot be appropriately tailored to address their needs [14]. This poses a particular problem for women offenders since many of them are more likely to have been physically, sexually, and emotionally abused as children, and their mental health issues were not properly diagnosed and treated prior to incarceration [11].

Additional scholarship in the area of violent victimization and mental health outcomes has addressed the unique experiences of women in prison, and the extent to which impaired functioning leads to high rates of recidivism upon reentry. DeCou et al., for example, found that physical and sexual victimization predicted suicidality among women in prison, and that ethnicity moderated the significant positive association between trauma and suicidality [2]. Tripodi et al., also addressed the scarcity of research on victimization and suicidality among women inmates, and found that childhood victimization, childhood neglect, and childhood positive support all had significant associations with nonfatal suicide behavior with neglect having the largest effect size as a predictor [20]. Kennedy et al., in research examining childhood victimization and psychosis among incarcerated women, found that those women with multiple victimizations were 2.4 times more likely to report psychosis than those reporting only physical or sexual victimization during childhood [7]. Their research suggested the use of a dose-response model in prison-based mental health services. Similarly, Lynch found that mental health and substance use disorder mediated the association between childhood victimization and the number of convictions among female prisoners [9]. In an additional study of women inmates and substance abuse, Mejia et al., found that female offenders with substance abuse problems were more likely to report histories of sexual, physical, and emotional abuse [13]. Their findings highlighted the importance of examining revictimization in specific programs designed to treat the women inmates.

In summary, interventions addressing the impact of victimization on mental health, particularly among criminal justiceinvolved women, often do not employ an all-inclusive approach, and fewer programs address the impact of multiple victimization and trauma on substance abuse and mental health difficulties as outcomes. Situations for some of these women are often worsened by their poor educations, limited resources, and their location in high crime neighborhoods. While many of their crimes are non-violent, they are more likely to face harsher charges and sentencing, much of which is due to the impact of race, class, and gender oppression on addiction [11]. This is particularly problematic since it has been suggested that the children of incarcerated women may be the next generation of prisoners without access to successful intervention programs and the necessary financial resources to escape poverty and violence.

The intent of our study is to address multiple self-reported victimization among a sample of women who have reported using illicit substances, and the extent to which type of victimization affects psychological maladaptation. This study extends current investigations on patterns of victimization among high-risk women to examine the linkage between violent victimization and mental health status as risk factors. Our hypothesis is Women who report substance use that have experienced family- and community-level victimization during their lifetime will exhibit higher levels of mental health problems as emotional outcomes/psychological maladaptation over and above sociodemographic factors including race and those characteristic of reduced social class [extreme poverty]. This hypothesis will guide recommendations for strategies to reduce the negative adjustment outcomes experienced by female victims of violence with histories of illicit substance use.

When examining the “at-risk” population of women who have both used illicit substances and have been exposed to violence, studies have focused primarily on specific types of victimization, primarily childhood abuse and intimate partner violence [IPV]. Less is known about the impact of additional forms of victimization, including neighborhood or community violence, and the extent to which multiple forms of victimization may be divergent or interconnected risks to mental health outcomes. Sousa et al., for example, argue that most studies fail to address both child abuse and economic stressors, or in other instances, they may combine these two measures as one adjustment effect [18]. Their research found that both child abuse and neighborhood violence independently predicted higher levels of adult depressive symptoms. With regard to criminal justice-involved women in particular, Tripodi & Pettus-Davis posit that since fewer studies have emphasized trajectories, less is known about the impact of cumulative stressors on mental health and overall well-being [19]. Among a sample of women with a history of victimization on probation or parole, they used a gendered-pathways model to examine childhood victimization, current attachment, psychological distress, and levels of substance abuse. Their findings suggested that treatment strategies should be based more readily on women’s trajectories or pathways to prison and jail. Similarly, Renn et al., have highlighted the importance of developing and testing a model of pathways from childhood to adulthood in an effort to examine the linkages between high-risk behaviors, childhood victimization, and adult health outcomes among criminal justice-involved women [17]. Finally, Winham et al., emphasize an integrated evidence-based treatment approach to both prevent rearrests and reincarceration and to improve passageways for women with histories of victimization [22].

In this study, we test the effects of different forms of victimization [childhood abuse, intimate partner violence [IPV], and community level or weapon-related victimization] on risk factor [emotional] using wave 4 of data from the National Longitudinal Study of Adolescent to Adult Health [Add Health]. In particular, we examine whether part of the reason female substance users are at a risk of emotional problems is a result of multiple forms of victimization beyond broad demographic factors including race, educational level and family income. Specifically, we observe women who have reported illicit substance use to highlight the importance of examining routes to criminal justice-involvement since a disproportionate number of women engage in drug-related crimes and enter the system to escape current abuse and violent pasts [12]. In essence, their use is in response to the trauma, which will in effect impair their ability to function, forcing them to suffer mental health complications. Hence, the current study advances previous research by examining trauma, mental health concerns, and substance use among women by inspecting patterns across time using longitudinal data.

Data for this study were drawn from quantitative analyses derived from secondary statistics from the National Longitudinal Study of Adolescent to Adult Health [Add Health], which is a longitudinal study of a nationally representative sample of adolescents in grades 7-12 in the United States. The Add Health cohort has been followed into young adulthood, and the most recent was in 2008, when the sample was aged 24-32 years. Add Health combines longitudinal survey data on respondents’ social, economic, psychological, and physical well-being with contextual data on the family, neighborhood, community, school, friendships, peer groups, and romantic relationships, providing unique opportunities to study how social environments and behaviors in adolescence are linked to health and achievement outcomes in young adulthood. For this project, the survey data were analyzed on self-identified female participants reporting illicit drug use as measured through marijuana use, cocaine use, or other drug use [N = 1,399]. Usage was measured with the items, “I have used marijuana,” “I have used cocaine,” and “I have used other illegal drugs.” Responses were coded “0” for those women who reported not ever having used the specific drug and “1” for those women who confirmed they had used the specific drug. Cronbach’s alpha was equal to .727 for the three items of the create drug scale whereby a higher score denotes increased drug usage. Only women who reported the use of one or more of these drugs during their lifetime were selected for analyses, thus creating a composite of “high risk” women, namely those with greater possibility for criminal justice involvement. Measures of self-reported depression and sadness are also included to examine mental health outcomes. Analyses of the aforementioned variables are conducted across types of victimization, whereby respondents reported the extent to which they have experienced childhood abuse, intimate partner violence [IPV] and community-level or weapon-related violence. The intent is to highlight the mental health challenges for these women who have used illicit substances and have been exposed to multiple forms of victimization throughout their lifetime, while adding to the knowledge of how type of exposure to violence may distinctively vary in explaining emotional adjustment outcomes.

There were three childhood victimization variables incorporated into the analysis whereby each woman indicated the frequency with which she experienced neglect, physical abuse, and sexual abuse prior to the age of 18. Scores on each item were coded the same with “1=one time” to “5=more than 10 times”. Hence, the means of each item formed continuous measures of childhood neglect [M = 4.29, SD = 1.13], childhood physical abuse [M = 3.36, SD = 1.34], and childhood sexual abuse [M = 3.64, SD = 1.90]. Next, three community-level or weapon-related victimization associated measures were analyzed with the items: “I have seen someone shot or stabbed,” “Someone has pulled a knife or gun on me,” and “Someone has shot or stabbed me.” Answers were dichotomized to include “no” and “yes” responses to develop a direct and indirect victimization scale whereby a higher score denotes increased victimization suggestive of environmental stressors or neighborhood violence as opposed to victimization perpetrated through childhood abuse or intimate partner violence [IPV] [Cronbach’s alpha=.825]. Subsequently, intimate partner violence [IPV] was measured with the items, “My partner has been violent toward me,” “My partner has slapped or hit me,” “My partner has injured me,” and “My partner has forced sex on me.” Responses ranged from “0=never” “to “8=more than 20 times” in the last year. Items were scaled to create an intimate partner violence [IPV] score whereby a higher score denotes increased intimate partner violence [Cronbach’s alpha=.826]. The final outcome of interest for this study was a measure of symptomatology consisting of seven items whereby women reported the extent to which over the past 7 days they: [1] “felt bothered”, [2] had trouble “shaking off the blues,” [3] had trouble “concentrating,” [4] felt depressed, [5] “felt too tired”, [6] “felt sad”, and [7] “felt disliked”. Cronbach’s alpha was equal to .78 for the seven items to create a symptomatology scale whereby a higher score denotes increased mental health problems.

Descriptive analyses were conducted for the subset of women reporting illicit drug usage. Results showed that 77.9% were white, 36.7% had some college education, and a substantial number [23.5%] had family incomes ranging from $50,000 to $74, 999.

To examine the importance of victimization type for emotional adjustment outcomes, a hierarchical multiple regression was used. Race, educational level, and family income [as social class measures] were entered first as background sociodemographic factors, followed by different forms of victimization. Results in Table 1 show no effect of measures of race and social class as predictors of mental health outcomes for this group. When entered in the next steps, sociodemographic factors add no significant amount to the explained variance in mental health complications. However, specific types of victimization add a significant amount to the explained variance in symptomatology with substanceusing women being more likely to report higher rates of mental health complications if they had experienced childhood neglect, childhood sexual abuse, and community-level or weapon-related victimization.

In sum, results show that for mental health complications, select indicators of childhood victimization and community-level or weapon-related victimization explained variance over and above sociodemographic factors as measured by race and social class indicators. As these outcomes display, accounts of depression, sadness, and other forms of symptomatology are higher when substance-using women report childhood neglect, child sexual abuse, and environmental stressors, which is consistent with previous research. Indicators of intimate partner violence [IPV], however, did not add to amount of explained variation, suggesting greater support among this group for the impact of childhood experience and environmental stressors, but not adult domestic violence. [Table1]

Consistent with other studies, our findings indicate that women who have used illicit substances in their lifetime have experienced levels of childhood abuse and community-level victimization that place them at a greater risk of mental health difficulties [13, 9, 12, 16]. Hence, the co-occurrence of specific types of childhood and adult victimization can in effect convert into summative exposure to violence, making them more vulnerable to multiple stressors, ultimately placing them at heightened risk for criminal justice involvement. Our current study extends beyond the analyses of traditional forms of victimization including child abuse and intimate partner violence [IPV] to examine the distinct or interrelated impact of community-level exposure to violence as a different form of victimization. The analyses are consistent with previous research that has addressed the impact of multiple forms of victimization to explain emotional adjustment, particularly among women who have entered the criminal justice system [6, 7]. While earlier studies have identified associations among women’s experiences with childhood victimization and intimate partner violence [IPV], this research contributes to the literature by including an additional measure of victimization among women with a history of drug use to discover the broad range of symptoms symbolic of mental health difficulty. We found that childhood victimization and community-level exposure to violence was associated with distinct mental health symptoms over and above the effects of sociodemographic factors such as race, educational level, and family income.

Hence, this study addresses the policy implications relating to the collateral effects of multiple forms of victimization among women who use illicit drugs, further placing them at greater risks for emotional problems. Our findings indicate, these women may face greater hardships because of their illicit substance use compared to those women who may not engage in such activities. Additionally, the findings show the necessity of first identifying women who have used illicit drugs as immediate risks for hardship and instability, followed by the identification of their risk for increased exposure to multiple victimizations as predictors of impaired mental health. Our research highlights the need for greater mental health services at the community, state, and federal levels for the women who use illicit substances, many of whom have been exposed to repeated victimization. Findings also address the need for continued investigation of using the life-course perspective to guide this line of research, which has proven effective in enhancing our understanding of the trajectory or pathways that result from victimization experience [1, 18, 19].

As previously noted many women serve time for low-level drug offenses and are faced with punitive policies regarding probation, parole, and reentry. Further, a disproportionate number of them have minor children, and they are less likely to receive family reunification and other courses while incarcerated to assist them with effective parenting upon their release [11]. While we understand that the findings from this study cannot affect policy change across the full population of substance-using women affected by multiple victimization experience, we do anticipate that these results will illuminate the circumstances of many of these women, who frequently bear the burden of punitive policies within an oppressive, patriarchal structure. Additionally, when women are arrested and subsequently incarcerated, more programs that are effective can battle both their physical and psychological problems as they navigate through the prison system. Currently, many correctional institutions at a minimum offer legally assigned levels of medical resources and services that only address physical health concerns and not mental health concerns. Programs that are operative should include a combination of substance abuse programs, parenting classes, work release programs, comprehensive education and mental health care programs [11]. Women offenders also need a resilient system of supportive peers and programs that focus on the cumulative experiences of child sexual abuse and domestic violence. Hence, to successfully decrease recidivism and encourage healthy lifespan choices and surroundings among women in the prison systems upon release, it is imperative to address their historical experiences of victimization while addressing present behaviors involving drug and alcohol abuse. Additionally, this study emphasizes the impact of different forms of victimization on women’s emotional outcomes which should be of particular concern to communities and policy makers as the rates of incarcerated women with drug-related problems continue to increase. In many instances, the initial exposure to illicit substances is not recognized as a potentially traumatic event that can spiral into increased risk for multiple victimization and emotional difficulties. It is expected that our findings will shed light on the need for specific mental health treatment strategies to mitigate the impact of the childhood and adult victimization. Comprehensive trauma screening and addiction assessment remain dominant as do mental health service training to assist women impacted by victimization experiences, placing them at the highest threat for emotional challenges. Finally, we anticipate that these results will point toward the need to develop interventions appropriate for women’s stages in the life course, further suggesting the need for increasing programs that identify the multiple risks and issues of criminal justice-involved women, as well as those placed in danger of arrests and subsequent incarceration [17, 22]. Factors such as age during time of initial drug use and duration of victimization experiences are critical to understanding the outcomes of these women. Only then can we lay the groundwork for both early treatment of illicit substance use and rehabilitating those who are already involved in the criminal justice system in response to their perilous journey to escape violence and repeated victimizations in their lives.

We wish to thank Hampton University for support for the project through funds obtained from the Faculty Research Grant.

This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01- HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Healthwebsite [http://www.cpc.unc.edu/addhealth]. No direct support was received from grant P01-HD31921 for this analysis.

We wish to thank Hampton University Veterans Education Transition for Success [HUVETS] VBSN for support of co-authorship UF1HP26487.

The authors acknowledge that there are no conflicts of interest.

Approval was obtained by the Hampton University Institutional Review Board. It was determined that there were no risks involved and that informed consent was not required for the analyses of secondary, aggregate data.

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