The objective of this qualitative study was to examine extrinsic barriers to substance abuse treatment among pregnant and parenting women enrolled in residential perinatal substance abuse treatment programs in Northern California. Life history interviews were conducted with 36 women to examine help-seeking behaviors before treatment enrollment. Data analysis used the analytic framework of Mandelbaum (1973) to describe dimensions, turnings, and adaptations of participants. Results indicated that the majority (n = 34) of participants sought prenatal care but identified fear of punitive actions from helping institutions and individuals as a major barrier. Other extrinsic barriers included substance abuse treatment program barriers, partners, the status of opiate dependency, and the status of pregnancy. Biological, socio-cultural, and psychosocial dimensions of participants' care-seeking experiences were identified. The turning was pregnancy and adaptations included preserving the family, managing fear and manifesting faith. Findings describe the transformation of the therapeutic alliance and the gendered impact of two decades of the War on Drugs in the United States. Participants' coping strategies suggest that the desire for child custody and concern for fetal and child well-being was a priority and motivated care seeking despite extrinsic barriers perceived to be threatening to the woman's safety and autonomy.

This paper reports findings from a clinical trial of a probation case management (PCM) intervention for drug-involved women offenders. Participants were randomly assigned to either PCM (n=92) or standard probation (n=91), and followed for 12 months using measures of substance abuse, psychiatric symptoms, social support and service utilization. Arrest data were collected from administrative datasets. The sample (N=183) included mostly African American (57%) and White (20%) women, with a mean age of 34.7 (SD = 9.2) and mean education of 11.6 years (SD = 2.1). Cocaine and heroin were the most frequently reported drugs of abuse, 86% reported prior history of incarceration, and 74% had children. Women assigned to both PCM and standard probation showed change over time in the direction of clinical improvement on 7 of 10 outcomes measured. However, changes observed for the PCM group were no different than those observed for the standard probation group. Higher levels of case management, drug abuse treatment, and probationary supervision may be required to achieve improved outcomes in this population. KeywordsSubstance Abuse; Drug Abuse; Women; Probation; Case Management; Criminal Justice Many women in the criminal justice system are drug-involved (Mosher & Phillips, 2006) and substance abuse, in concert with changes in drug laws and sentencing procedures, has led to increases in arrest and incarceration of women offenders (Grella & Greenwell, 2006;Prendergast, Wellisch, & Wong, 1996;Strauss & Falkin, 2001). At the end of 2005, there were 4.9 million adults on probation or parole nationally and, among probationers, 23% were women (United States Department of Justice, 2006; Glaze & Palla, 2004). In one survey of probationers, many women reported past drug (68%) or alcohol (25%) use, and 12% reported drug use at the time of the offense (United States Department of Justice, 1998). Compared to non-users, women reporting drug use were more likely to have been involved in criminal activity and to have been arrested in the past year (Substance Abuse and Mental Health Services Administration, 1997). NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptIn addition to substance abuse, many women offenders have mental health disorders including depression, posttraumatic stress disorder, cognitive impairments and problems controlling violent behavior (Oser et al. 2005;Henderson, Schaeffer, & Brown, 1998;Jordan et al., 2002;Teplin, Abram, & McClelland, 1996). Incarcerated women report high rates of victimization (Lake, 1993), sexual and physical abuse (Henderson, 1998;Snell & Morton, 1994), intimate partner violence (Staton, Leukefeld, & Logan, 2001), and specialized service needs upon release including family support, parenting assistance, and legal help (Alemagna, 2001). Health problems in this population include HIV infection, Hepatitis B and C, sexually transmitted diseases, and tuberculosis (Golembeski & Fullilove 2005;Hammett, Gaiter, & Crawford, 1998;Marquart, Brewer, & Mullings, 1999;Young, 1998...

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Based on availability of case management services, drug-involved women offenders entered either a probation case management (PCM) intervention (n = 65) or standard probation (n = 44). Participants were placed in the case management condition until all slots were filled, then placed in standard probation until case management slots opened. Participants were interviewed at program entry and at 6 and 12 month follow-up using measures of substance abuse, psychiatric symptoms, and social support. Results showed modest change over time in both conditions, but PCM did not result in more services or treatment, or in better outcomes, than standard probation. These findings are discussed in the context of study limitations, and in the context of state initiatives like those in Arizona and California designed to apply treatment as an alternative to incarceration.

The goals of the National Institute on Drug Abuse Clinical Trials Network (CTN) are to test promising drug abuse treatment models in multisite clinical trials and to support the adoption of new interventions into clinical practice. Using qualitative research methods, we studied adoption in the context of two multisite trials, one outside the CTN and another within the CTN. Seventy-one participants representing eight organizational roles ranging from clinic staff to clinical trial leaders were interviewed about their role in the clinical trial, the trial's interactions with clinics, and intervention adoption. Drawing on the conceptual themes identified in these interviews, we report on strategies that could be applied in the planning, development, and implementation of multisite studies to better support the adoption of tested interventions in study clinics after trials had ended. Planning for adoption in the early stages of protocol development will enhance the integration of new interventions into practice.