Baseline Trauma Symptomatology Decreases Likelihood of
Drug Court Graduation of Female Offenders

Mara J. Richman, Kalamazoo College
University of South Florida

Kathleen Moore*, Blake Barrett*, Scott Young*
Kalamazoo College

Keywords: Drug court / female offenders / prescription drug abuse / trauma/ co-occurring


The purpose of this study was to assess mental health and trauma symptoms as predictors of drug court graduation among female offenders arrested and charged with prescription drug related offenses. Findings from a logistic regression demonstrated that, after controlling for baseline substance use, higher levels of trauma symptomatology significantly decreased likelihood of drug court graduation. Current results revealed female drug court offenders arrested and charged with prescription drug-related offenses with increased trauma symptomatology may need a more comprehensive baseline assessment and a greater level of trauma-informed clinical programming.


Co-occurring mental health and substance issues are a national concern and are exacerbated with criminal offenders. In both state and federal correctional facilities, mental health and substance abuse issues are prominent among offenders due to few treatment options (Hodgins & Cote, 1990; Peters, Greenbaum, Edens, Carter, & Ortiz, 1998). Specifically, research has shown 75 percent of offenders experiencing a substance abuse disorder also reported having a mental health disorder (i.e., trauma, depression, and anxiety) (Teplin, Abrams, & McClelland, 1996). Research in the past several years has shown a majority of these co-occurring offenders in the criminal justice system are female (Messina et al., 2004).

Female offenders have more mental health issues than males at a rate of 75 percent to 55 percent, respectively (Department of Justice, 2008). Furthermore, depression, anxiety, and suicide attempts are more prevalent among female than male offenders (Sacks, 2004; Staton-Tindall, Leukefeld, & Webster, 2003). In part, this is a result of higher levels of traumatic experiences reported by females (Sartor, McCutcheon, Callahan O'Leary, Van Buren, Allsworth, Jeffe, & Cottler, 2012). In a study with inmates in jails, a majority of female offenders met diagnostic criteria for lifetime levels of PTSD (DeHart, Lynch, Belkamp, & Green, 2012).

The drug court alternative, unlike traditional court systems, was created to provide offenders with both treatment and punitive measures. As a result, offenders are afforded the chance to improve their lives through methods of abstinence and prosocial behavior (Belenko, Fabrinkat, & Wolf, 2011; Wilson et al., 2006). With a collaborative effort by the Drug Court Judge and team (e.g., case managers, substance abuse treatment providers, state attorney, and public defender), clients are given options tailored to their situation that give them the best chance for success in remaining substance-free (Belenko, 2000; Gottfredson, Najaka, & Kearney, 2003).

Drug courts have been proven to be successful in helping offenders. Both meta-analyses and evaluation reports indicate that drug court has effectively reduced criminal recidivism and substance use (Belenko, 2000). In several outcome studies on drug court, results have demonstrated that drug court helped clients decrease narcotic substance usage and increase therapeutic alliance (Brewster, 2011).

The nationwide average graduation rate of drug court clients is 63 percent (Peters, Kremling, Bekman, & Caudy, 2012). Graduation from drug court is defined as successful completion of the drug court program (including treatment attendance, passing of drug tests, and compliance with drug court rules). Studies examining successful graduation have focused mainly on recidivism (Goldkamp et. al, 2001; Wolfe, Guydish, & Termondt, 2002), substance frequency/relapse, drug court judge interaction (Marlowe, Festinger, & Lee, 2004), as well as demographic characteristics like substance abuse, employment (Butzin, Saum, & Scarpitti, 2002), race, and education (Sechrest & Shicor, 2001; Schiff and Terri, 1997).

Previous literature examined mental health symptomatology as a predictor of graduation rates among non-specific populations (Peters, 2008). One study found drug court offenders with mental health issues (including trauma, depression and/or anxiety) were less likely to graduate (Gray & Saum, 2005). Another study found those with higher trauma at entry into drug court were less likely to graduate (Shaffer, Hartman, & Listwan, 2009). Despite this trend, there has been no study conducted that has assessed predictors of graduation in female drug court offenders with bothmental health and prescription drug issues.

Current Study                                                                                             

The current study focused on 210 female offenders from the Pinellas County Adult Drug Court that completed baseline assessment. Information collected at baseline included mental health symptomatology (e.g., self-reported general mental distress and depressive symptoms), trauma, and substance abuse frequency. Follow-up information included successful or unsuccessful client graduation. The study hypothesized that clients suffering from higher levels of mental health and trauma symptoms will be less successful in graduating from drug court as compared to clients exhibiting fewer mental health and trauma symptoms.


Pinellas County Adult Drug Court WeCan! Program

In 2008, the Pinellas County Adult Drug Court in Pinellas County, Florida received a Substance Abuse and Mental Health Services Administration (SAMHSA) grant, focusing on female offenders with prescription drug issues (SAMHSA, 2002). The program titled WeCan! (Women Empowered to Cope with Addiction to Narcotics) was part of drug court and included a judge, drug court case managers, substance abuse treatment providers, defense attorneys, and the State Office of the Attorney General. WeCan! clients were required to attend monthly judicial reviews and substance abuse treatment.  They were also mandated to do 1-2 random drug screens per week.

The drug court treatment was comprised of two evidenced-based programs: Seeking Safety (Najavits, 2002) and Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (MET/ CBT 12; Miller & Rollnick, 1995). Seeking Safety is a curriculum for clients with a history of trauma and substance abuse that focuses on coping skills and psychoeducation. MET/ CBT-12 is a program dedicated to helping clients cope with depressive and anxiety symptoms. These evidence based treatment models use an integrated approach to address both mental and substance use disorders (Osher, 2008).


Secondary data analysis was performed following the approval from the Institutional Review Board (IRB) at the University of South Florida. WeCan! participants (N= 210) provided baseline information, and graduation data were supplied by the case manager of the drug court.


WeCan! clients. The participants were females that were arrested and charged with prescription drug offenses. These participants were admitted into the drug court program based on the following criteria: (a) prescription drug charges, (b) no psychotic mental illness diagnosis, (c) history of being non-violent, (d) willingness to participate in the drug court program, and (e) no alleged sexual perpetration. Demographics are displayed in Table 1.

Table 1
Baseline demographic characteristics for the sample and comparison of differences between those who graduated and those were terminated from the program


Entire sample
(N = 210)
(n = 139)
(n = 71)
Characteristic n % or M (SD) n % or M (SD) n % or M (SD) Significance
     Age (years) - 29.59 (8.95)   30.26 (9.31) - 28.27 (8.11) NS
     Race             NS
          Caucasian 188 95.9% 126 96.9% 62 93.9%  
          African-American 3 1.5% 1 0.8% 2 3.0%  
          Multiracial 5 2.6% 3 2.3% 2 3.0%  
     Ethnicity             NS
          Hispanic/Latino 10 4.8% 7 5.0% 3 4.2%  
     Education (years) - 12.82 (2.21) - 12.69 (2.01) - 13.07 (2.55) NS
     Housing status             NS
          Own/rent apartment 81 40.7% 60 45.8% 21 30.9%  
          Someone else's apartment 100 50.3% 59 45.0% 41 60.3%  
          Institution 15 7.5% 9 6.9% 6 8.9%  
          Other housed 3 1.5% 3 2.3% 0 0.0%  
     Employment status             NS
          Full-time (35 + hours a week) 59 28.1% 43 30.9% 16 22.5%  
          Part-time 33 15.7% 24 17.3% 9 12.7%  
          Unemployed, looking for work 88 41.9% 54 38.8% 34 47.9%  
          Unemployed, disabled 9 4.3% 6 4.3% 3 4.2%  
          Unemployed, not looking for work 21 10.0% 12 8.6% 9 12.7%  
     Past 90 day Income (total) - $782 ($849) - $830 ($891) - $689 ($759) NS
          Wages - $447 ($703) - $500 ($732) - $341 ($634) NS
          Public assistance - $116 ($210) - $110 ($218) - $127 ($195) NS
          Disability - $30 ($156) - $31 ($152) - $27 ($165) NS
          Family/friends - $84 ($199) - $61 ($$139) - $128 ($277) NS
          Retirement - $13 ($148) - $20 ($183) - $0 ($0) NS
          Other - $65 ($389) - $66 ($380) - $65 ($409) NS
     Pregnant 6 2.9% 4 2.9% 2 2.8% NS
Mental Health Scales              
     Traumatic Stress Scale (TSS) - 3.03 (3.61) - 2.55 (3.47) - 3.99 (3.73) .007
     Depressive Symptoms Scale (DSS) - 3.76 (2.92) - 3.48 (2.97) - 4.31 (2.74) NS
     General Mental Distress Scale (GMDS) - 8.24 (6.40) - 7.60 (6.36) - 9.49 (6.33) .042
Substance Abuse Scales              
     Substance Frequency Scale (SFS) - 0.09 (0.13) - 0.08 (0.11) - 0.12 (0.16) .037
     Past 90 Day Alcohol Usage - 5.87 (13.64) - 5.23 (11.66) - 7.11 (16.86) NS
     Past 90 Day Marijuana Usage - 5.85 (15.83) - 5.49 (16.04) - 6.55 (15.51) NS
     Past 90 Day Crack Usage - 0.84 (5.47) - 0.65 (5.20) - 1.24 (6.01) NS
     Past 90 Day Cocaine Usage - 0.15 (0.92) - 0.19 (1.07) - 0.09 (0.45) NS
     Past 90 Day Heroin Usage - 0.23 (3.13) - 0.35 (3.84) - 0.00 (0.00) NS
     Past 90 Day Pain killers, Opiates  Usage - 12.23 (24.29) - 8.36 (18.34) - 19.77 (31.74) .006
     Past 90 Day Anti-Anxiety, Tranquilizer Usage - 3.74 (11.09) - 4.01 (11.96) - 3.19 (9.15) NS
     Past 90 Day Downers, Sedative Usage - 0.22 (1.80) - 0.15 (1.71) - 0.38 (1.97) NS
Some missing data; valid statistics displayed.  NS= Not statistically significant.  * p < .05; ** p < .01; *** p < .001


Graduation. Information concerning each participant's graduation or discharge status was obtained from the Pinellas County Adult Drug Court.

Global Appraisal of Individual Needs. (GAIN; Dennis, Titus, White, Unsicker, & Hodgkins,  2006). The GAIN is a bio-psychosocial review assessing participant clinic and demographic characteristics at intake. Four subscales were included:

Substance Frequency Scale (SFS). Aggregate average of percent of days reported of any alcohol/ or drug use (past 90 day use of heavy alcohol/ other drug use, marijuana, crack/ cocaine, opiate, and heroin use). Higher scores indicate more frequency of use.

Traumatic Stress Scale (TSS). Count of past year memories/ symptoms of trauma (e.g., PTSD) and current trauma as it is associated with exposure to traumatic events. This scale (13 total questions) is scored with higher scores indicating more traumatic symptoms.

Depressive Symptoms Scale (DSS).Symptoms of depression with higher levels indicate increased hopelessness and indecisiveness. The scale, made up of 9 questions, is scored with higher scores indicating more depressive symptoms.

General Mental Distress Scale (GMDS). Symptoms of depression, somatic, anxiety, and suicidal thoughts. The scale (26 total questions) is scored with higher scores indicating more general mental distress.


Simple descriptive statistics were used to depict participant demographic and clinical characteristics. Internal consistency reliability analyses were conducted on each scale, indicating the mental health and trauma scales produced scores with good to high levels of reliability (GMDS α = .904, TSS α = .891, DSS α= .822). SFS reliability could not be assessed due to the nature of the scale, which was an aggregate of several scales. Bivariate statistics were used to examine whether demographics and substance frequency (as well as subscales) differed between participants who graduated and those who did not. A series of stepwise logistic regressions was performed to determine whether any clinical or demographic variables could be used to predict drug court graduation. Participant baseline substance use was entered on the first step of each equation, with mental health variables entered on the second step to determine if they could predict graduation above and beyond the baseline substance use variable. Nagelkerke R2 statistics (Nagelkerke, 1991) were computed to gauge the percent of variance accounted for by each step of each regression model. All analyses were performed using SPSS version 21.


Graduation Outcome

Bivariate associations. Overall, bivariate associations indicated no statistically significant demographic differences between those who did and did not graduate; however, the Substance Frequency Scale (SFS) was directly related to graduation, t (111. 969) = 2.345, p = .037. Of the SFS subscales, only past 90 days of opiate usage was significant t (95.938) = 3.258, p = .006

Table 2
Descriptive statistics and correlations for study independent and dependent variables

Variable 1 2 3 4 5
1. Substance Abuse Frequency (SFS) 1.00 - - - -
2. General Mental Distress (GMDS) .131 1.00 - - -
3. Traumatic Stress Scale (TSS) .105 .643** 1.00 - -
4. Depressive Symptom Scale (DSS) .182** .914*** .582** 1.00 -
5. Graduation -.161* -.141* -.188** -.135 1.00
* p < .05; ** p < .01; *** p < .001

Multivariable associations. A series of multivariable, stepwise logistic regression models were used to examine the association between participant baseline scores on each of the mental health scales from the GAIN (GMDS, TSS, and DSS) and graduation status. Given the statistically significant differences in level of baseline SFS scores and graduation status, SFS was included as a covariate in the first step of all models. SFS was significantly associated with the likelihood of graduation, (X2 (1) = 6.402, p = .023) such that those with higher baseline scores on the substance frequency scale were less likely to graduate (OR = .081; p = .023, 95% CI [.009- .709]). Table 3 summarizes these results.

Model 1 explored the association between baseline GMDS scores and likelihood of graduation, after controlling for the association SFS. Results from Model 1 indicate no significant step (X 2 (2) = 11.439, p = .042) and no significant overall model chi-square after including GMDS, after controlling for SFS. Therefore, higher GMDS baseline scores were not associated with reduced likelihood of graduation (OR =. 960; p = .078, 95% CI [.917- 1.005]).

Model 2 explored the association between baseline TSS scores and likelihood of graduation after controlling for SFS. Results from Model 2 indicated that a significant step (X2 (2) =13.580, p < .001) or overall model chi-square after including TSS, after controlling for SFS.  Higher TSS baseline scores were associated with reduced likelihood of graduation (OR = 0.904; p = .014; 95% CI [0.834 - 0.979]). The overall model statistics obtained after Step 2 indicated that Model 2 achieved a Nagelkerke R2 of .079, meaning that the SFS and TSS collectively explained 7.9 percent of the variance in likelihood of graduating.

Model 3 explored the association between baseline DSS scores and likelihood of graduation after controlling for SFS. Results from Model 3 indicate no significant step (X2 (2) = 10.603, p < .005) and no significant overall model chi-square after including GMDS, after controlling for SFS.  Higher GMDS baseline scores were not associated with reduced likelihood of graduation (OR = 0.109, p = .117; 95% CI [.0.833-1.021]).

Table 3
Logistic regression stepwise models examining the associations between drug court graduation and baseline levels of substance use and mental health symptomatology

    Step 1 Step 2
Model Variable B OR 95% CI Sig Nag. R2 B OR 95% CI Sig Nag. R2
1 Substance Frequency Scale -2.513 0.081 0.009-0.709 .023 .034 -2.290 0.101 0.011-0.919 .042 .054
  General Mental Distress - - - - -0.041 0.960 0.917-1.005 .078
2 Substance Frequency Scale -2.746 0.064 0.007-0.586 .015 .040 -2.552 0.078 0.008-0.750 .027 .079
  Traumatic Stress Scale - - - - -0.101 0.904 0.834-0.979 .014
3 Substance Frequency Scale -2.513 0.081 0.009-0.709 .023 .034 -2.212 0.109 0.012-1.001 .050 .050
  Depressive Symptoms Scale - - - - -0.081 0.922 0.833-1.021 .117
Note: OR = odds ratio, CI = confidence interval, Sig = significance, Nag. R2 = Nagelkerke R2.

*Difference in Model 2 because of missingness

Model 1 – GMDS
             -Step 1, p=.022; Step 2, p = .077

Model 2 – TSS
             -Step 1, p = .014; Step 2, p = .013

Model 3 – DSS
             -Step 1, p=.022; Step 2, p = .115


This paper reports potential predictors of participant mental health on graduation in an adult drug court program with a uniquely at-risk and vulnerable population: female drug court offenders with prescription drug related offenses. The present findings indicated that participants with more trauma are less likely to graduate. These findings are consistent with our hypothesis in regard to trauma symptoms as predictors of graduation.

Our hypothesis that that higher levels of substance frequency was associated with trauma was supported by our results. In addition, our results are consistent with the substance abuse findings by Butzin and colleagues with trauma being associated with drug use (Butzin, Saum, & Scarpitt, 2002). Our results demonstrated that past 90 day opiate, prescription drug usage was significant which signifies the unique characteristics of our sample of female drug court offenders with prescription drug issues.

After finding that those with higher substance abuse frequency were less likely to graduate, we used substance abuse frequency as a covariate and first step in our logistic regression model. Results revealed higher levels of trauma were significantly associated with decreased likelihood of graduation. These results suggest that drug courts should do early assessment of traumatic stress before entry into treatment to help aid in drug court success. In addition, these conclusions reveal the importance of evidence-based assessment tools during intake of drug court.

Furthermore, the findings of our study recommend using more individualized specific treatment after early evidence-based assessment to reduce mental health issues. The WeCan! drug court program uses a specific evidence-based treatment model that address trauma (i.e., Seeking Safety). The author is currently developing a new treatment model titled "Creating Change," which includes new coping skills and representation of past memories to further address PTSD related issues (Najavits, in press). This new treatment curriculum may provide new coping skills that may be used to help deal with past, traumatic memories in conjunction with higher levels of graduation.

These findings are consistent with Gray and Saum (2005) who posited females with high levels of traumatic stress were less likely to graduate. However, this study did not focus on a gender or drug specific group but instead assessed the population as a whole. In contrast to Gray and Saum (2005), participants in our study were uniquely vulnerable in the criminal justice system. Prior research has suggested that females are more likely to have a co-occurring disorders and abuse prescription drugs as a method of coping as compared to men (Sacks, 2004; Staton-Tindall, Leukefeld, & Webster, 2003).


There were some limitations that arose in this study that need to be reported. First, the GAIN assessment was self-report and did not have a comparison group. Also, the current study only assessed drug court offenders in Florida, which may not be an accurate representation of the nation as a whole. Finally, the program was only comprised of females with prescription drug abuse issues and this leads to a potential lack of generalizability.


Despite some study limitations, these findings suggest that those who have traumatic stress symptoms at baseline are less likely to graduate. Furthermore, Pinellas County Adult Drug Court should consider trauma informed assessment early in intake/ treatment to increase successful graduation from the adult drug court. Future programs should address co-occurring mental health and substance abuse disorders at baseline, using a comprehensive assessment. Additionally, utilizing trauma informed programs may be helpful, particularly utilizing gender specific treatment.


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The authors would like to acknowledge the WeCan! drug court treatment team for their support and providing information for the analysis of the graduation of female offenders. The authors would also like to acknowledge Drug Court Judge De Anna Farnell for her dedication and treatment as well as Mr. Nick Bridenback for his assistance.


Funding for this project was supported by the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment grant #T120117-01.



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