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Keywords:

  • Assessment;
  • forensic nursing;
  • impulsivity;
  • insecure attachment;
  • jail;
  • sexuality;
  • temperament;
  • women

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Method
  5. Results
  6. Discussion
  7. References

Background: Women constitute only a small proportion of inmates, but several studies have shown that they have higher rates of psychiatric disturbance than incarcerated men and community samples. Mental health treatment is necessary to prevent severe illness and suicide in these women. Methods: The convenience sample consisted of 40 female detainees and 40 controls who were administered self-report questionnaires to assess temperament (TEMPS-A), insecure attachment (ECR), impulsivity (BIS-11), and sexual behavior (SESAMO). Results: The incarcerated women had higher levels of affective temperament (except for hyperthymia), avoidance, anxiety, impulsivity, and psychosexual issues than the female community sample. Conclusions: Many interrelated emotional and affective disturbances affect the physical and psychological well-being of women in jail, and it is possible that these problems may lead to suicide. Health professionals need to develop gender-specific therapeutic interventions for women in jail.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Method
  5. Results
  6. Discussion
  7. References

Several studies have reported the prevalence of significant mental health problems in incarcerated women, with a high incidence of primary affective disorder (Good, 1978) and high levels of depression (Scott, Hannum, & Ghrist, 1982) and, in addition, a substantial number of women in prison with untreated mental illness (Turner & Tofler, 1986; Abdalla-Filho, De Souza, Tramontina, & Taborda, 2010).

Female detainees constitute only a small proportion of inmates in prisons. The proportion of the female prison population in Europe has a median of 4.4% (Bastick & Townhead, 2008). In Italy, they constituted only 4.36% of inmates during the first half of 2009 (Italian Department of Justice, 2010). Typically, incarcerated women have low levels of formal education and job experience, personal competencies, sense of responsibility to others and society, social skills, and self-management abilities (Tonkin, Dickie, Alemagno, & Grove, 2004). Many women are sentenced to serve short sentences for nonviolent offences. They often have alcohol and/or drug dependency and a history of physical and sexual abuse. High rates of severe psychological and psychiatric illness are present, such as depression, anxiety, impulsivity, and a tendency to self-harm and to engage in suicidal behavior (Singer, Bussey, Song, & Lunghofer, 1995; Lewis, 2006; Lukasiewicz, Neveu, Blecha, Falissard, Reynaud, & Gasquet, 2008; Pompili, Iliceto, Luciano, Innamorati, Serafini, Del Casale, Tatarelli, Girardi, & Lester, 2011). One study of suicide in female prisoners reported that 73% were located in a single-occupancy cell at the time of their suicide; all had histories of alcohol and drug abuse. The majority of suicidal deaths occurred in women who had mental health problems (Mackenzie, Oram, & Borrill, 2003).

Moreover, many women inmates are mothers, and staying in prison with their young children or being separated from them can result in emotional problems (Luke, 2002; van den Bergh, Gatherer, & Møller, 2009). In the United States, women in prison face the loss of their children, medical neglect, and sexual abuse (van Wormer & Kaplan, 2006). Parsons and Warner-Robbins (2002) collected data from women prisoners about their poverty, neglect, physical and emotional abuse, pain, drugs, and need for money and acceptance that led them into a cycle that they described as having ”no exit” and ”feeling helpless and hopeless.”

Access to physical and mental health care is a fundamental human right, and recently, the World Health Organization Regional Office for Europe and the United Nations Office on Drugs and Crime developed evidence-based guidance on women's health in detention (WHO/UNODC, 2009). As reported in Keaveny and Zauszniewski (1999), the psychological distress resulting from the prison environment can be appropriately understood and treated in the social context of the prison by modifying the personal, environmental, and situational variables that influence this distress. It is, therefore, important to identify and describe these variables. These women often experience anxiety, depression, suicidal tendencies, and a lack of trust in themselves and others (Shamai & Kochal, 2008). Progress has been made in the assessment and treatment of mental health problems in prisons, but knowledge concerning resources used to manage the psychological distress is limited (Gunter, 2004). Prison is a relevant setting in which to study the link between affective temperaments, insecure attachment, impulsivity, and sexual behaviors. The aim of the present study was to explore the differences between incarcerated and nonincarcerated women in order to quantify how much female jail detainees deviate from the norm, living as they do in a structured and restrictive environment, isolated from partners, children, and friends.

Method

  1. Top of page
  2. Abstract
  3. Background
  4. Method
  5. Results
  6. Discussion
  7. References

Participants

After obtaining the permission from the managers of the prison “Casa Circondariale di Reclusione Borgo San Nicola” in Lecce, Italy, we selected a convenience sample of 40 female prisoners between January and June 2007.

A convenience sample is a type of nonrandom sample widely used for quantitative studies of a preliminary and exploratory nature where it is the only feasible alternative, as in this case. In this jail, the females had sentences of less than 3 years (mean = 22.1 months, SD = 11.4), and this characteristic differentiated them from an ideal female sample of detainees that would be randomly selected. For a comparison group, we contacted by telephone households from a list of provincial residential telephone numbers in the district of Lecce, explaining the purpose and the procedures of the study. We selected randomly 40 women matched for age with the prisoners. All subjects voluntarily participated in this study and were administered four psychometric instruments. Their sociodemographic characteristics are listed in Table 1.

Table 1.  Sociodemographic characteristics of the two groups
CharacteristicDetainees (N = 40)Controls (N = 40)Statisticsp
  1. aValues shown as mean ± SD.

  2. bFisher's exact test.

Age (years)30.98 ± 7.44a31.80 ± 11.48at(78)= 0.3810.704
Education  χ2(3) 11.230.01
 ≤5 years (N) 4 0  
 ≤8 years (N)14 5  
 ≤13 years (N)1422  
 >13 years (N) 813  
Working status   0.05b
 Unemployed (N)3527  
 Employed (N) 513  
Married   0.07b
 No (N)2533  
 Yes (N)15 7  

No differences were found between the age of the female detainees and the age of the controls (30.98 vs. 31.80; t(78)= 0.38, p = 0.70), but the female detainees had fewer years of education (χ2(3) 11.23; p = 0.01), and they were more often unemployed and married than the controls.

Subjects participated voluntarily in the study, and each subject provided written informed consent. The study protocol received ethics approval from the local research ethics review board. One of the authors (IR) received formal authorization for collecting data by the above-mentioned jail.

Instruments

The first version of Temperament Evaluation of Memphis, Pisa, Paris, and San Diego contained 84 items (TEMPS-A) (Akiskal & Akiskal, 2005). Later, clinical and theoretical considerations led to the addition of 26 new items describing the anxious temperament, resulting in the 110-item-long version of the TEMPS-A (Akiskal, Placidi, Maremmani, Signoretta, Liguori, Gervasi, & Mallya, 1998). The scale is different from most other temperament scales in that it taps subaffective trait expressions as they were conceptualized in Greek psychological medicine and, in more modern times, German psychiatry. The TEMPS-A has been validated in Italian populations (Pompili, Girardi, Tatarelli, Iliceto, De Pisa, Tondo, Akiskal, & Akiskal, 2008). In that investigation, a principal component analysis with a varimax rotation resulted in a three-factor solution: the first (25.5% of the variance) represented dysthymic, cyclothymic, and anxious (Dys/Cyc/Anx) temperaments combined; the second represented the irritable temperament (7.5% of the variance); and the third the hyperthymic temperament (4.4% of the variance). Kuder-Richardson reliability coefficients ranged from 0.90 for the Dys/Cyc/Anx factor to 0.76 for the hyperthymic factor.

The insecure attachment scale (ECR: Brennan, Clark, & Shaver, 1998) includes 36 items, each scored on a five-point scale. The questionnaire yields scores on two dimensions, namely, Anxiety and Avoidance. People scoring high on the Avoidance scale tend to avoid emotional closeness and intimacy, do not feel comfortable opening up to, or depending on their partner, and are reluctant to ask their partner for comfort, advice, or help. People scoring high on the Anxiety scale tend to be preoccupied with their romantic relationships, worry about being abandoned, desire to be very close to their partner, and ask the partner for more feeling and commitment during the relationship. The validated Italian version of the questionnaire was used (Picardi, Vermigli, Toni, D’Amico, Bitetti, & Pasquini, 2002).

The Barratt Impulsiveness Scale, 11th version (BIS-11: Patton, Stanford, & Barrat, 1995), is the revised version of the BIS 10th version (Barratt & Patton, 1983). This instrument is a short questionnaire designed to measure impulsiveness. It contains 30 items, each of which is answered on a four-point Likert scale (rarely/never = 1, occasionally = 2, often = 3, almost always/always = 4), and a level of impulsiveness is calculated by summing up the scores for each item. The second-order factor analysis for the six primary factors identified three components as follows: (1) attentional impulsiveness (focusing on the task at hand); (2) motor impulsiveness (acting on the spur of the moment); and (3) nonplanning impulsiveness (lack of cognitive complexity). The Italian version of the questionnaire has demonstrated good reliability and validity (Fossati, Di Ceglie, Acquarini, & Barrat, 2001), replicating the original constructs.

The SESAMO scale (sex-relation evaluation schedule assessment monitoring scale) (Boccadoro & Perillo, 1996) provides a psychosexual profile with the main objective of defining and detecting causes of dysfunctional aspects of sexuality in individuals, and yields the following subscales: (1) psychosexual identity; (2) bodily experience; (3) desire; (4) areas of pleasure; (5) past history of masturbation; (6) past sexual experiences; (7) current masturbation; and (8) erotic imagination. The validation of Sesamo was conducted on a sample from the normal population of 648 subjects between 15 and 64 years, and the data obtained were compared with those from a clinical sample of 279 subjects treated for discomfort in sexual area relationships.

Statistical analyses

One-tailed t-tests, Pearson correlations, and multiple regression analyses (stepwise) were used for the continuous variables. Chi-square tests with Yates's correction, or Fisher's exact tests when appropriate, were used to identify differences in sociodemographic characteristics. The Bonferroni-correction procedure was used to control for type 1 errors. All analyses were carried out using SPSS for Windows 17.0 (SPSS, Inc., Chicago, IL).

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Method
  5. Results
  6. Discussion
  7. References

The significant differences in the psychological scores are shown in Table 2. Female detainees obtained higher scores on the TEMPS-A Dys/Cyc/Anx temperament (29.52 vs. 22.85; t(78)= 2.43, p = 0.01), Irritable temperament (6.40 vs. 4.27; t(78)= 2.45, p = 0.01), Avoidance (54.45 vs. 41.33; t(78)= 2.94, p = 0.004), Anxiety (74.83 vs. 61.80; t(78)= 2.62, p = 0.01), and Impulsivity (69.48 vs. 60.53; t(78)= 3.55, p = 0.001). No difference between the groups was found for the Hyperthymic temperament.

Table 2.  Comparisons between groups on the psychological dimensions
VariablesDetainees (N = 40)Controls (N = 40)t(78)p
  1. aValues shown as mean ± SD.

  2. bBonferroni's alpha = 0.05/6 = 0.008.

TEMPS-A Dys Cyc Anx29.52 ± 12.62a22.85 ± 11.90a2.430.01
TEMPS-A Irritable6.40 ± 3.88a4.27 ± 3.86a2.450.01
TEMPS-A Hyperthymic10.50 ± 2.75a9.87 ± 3.32a0.910.36
Avoidance54.45 ± 19.72a41.33 ± 19.61a2.94 0.004
Anxiety74.83 ± 18.47a61.80 ± 25.41a2.620.01
Impulsivity69.48 ± 11.84a60.53 ± 10.65a3.55 0.001

Significant differences for the psychosexual dimensions are shown in Table 3. Female detainees obtained higher scores on Psychosexual identity (53.63 vs. 44.00; t(78)= 2.87, p = 0.005), Bodily experience (32.48 vs. 14.28; t(78)= 3.24, p = 0.002), Past history of masturbation (65.43 vs. 39.50; t(78)= 5.58, p = 0.000), and Current masturbation (43.75 vs. 26.48; t(78)= 2.68, p = 0.009).

Table 3.  Comparisons between groups on the psychosexual dimensions
VariablesDetainees (N = 40)Controls (N = 40)t(78)p
  1. aValues shown as mean ± SD.

  2. bBonferroni's alpha = 0.05/8 = 0.006.

Psychosexual identity53.63 ± 2.16a44.00 ± 6.43a2.870.005
Bodily experience32.48 ± 3.08a14.28 ± 4.77a3.240.002
Desire39.95 ± 2.60a37.07 ± 2.96a0.420.67 
Areas of pleasure31.75 ± 2.24a29.03 ± 3.25a0.490.62 
Remote masturbation65.43 ± 2.02a39.50 ± 2.10a5.580.000
Past sexual experiences42.05 ± 3.11a53.95 ± 3.55a1.660.09 
Current masturbation43.75 ± 3.23a26.48 ± 3.65a2.680.009
Erotic imagination65.88 ± 3.50a52.43 ± 3.09a1.720.08 

In both the groups, the dysthymic/cyclothymic/anxious temperament was associated with irritable temperament, avoidance, anxiety, and impulsivity, and the correlation coefficients were high and positive (Table 4).

Table 4.  Correlation matrix
ControlsDys Cyc AnxIrritableHyperthymicAvoidanceAnxietyImpulsivity
  1. *p < 0.05; **p < 0.01.

Dys Cyc Anx1     
 Irritable0.738**1    
 Hyperthymic−0.131−0.1831   
 Avoidance0.672**0.401*−0.1671  
 Anxiety0.499**0.129−0.0050.425**1 
 Impulsivity0.601**0.588**−0.076−2920.3061
 Detainees      
Dys Cyc Anx1     
 Irritable0.675**1    
 Hyperthymic−0.270−0.0671   
 Avoidance0.660**0.462**−0.4191  
 Anxiety0.439**0.476**0.0780.2981 
 Impulsivity0.415**0.387*0.0580.2400.1291

On the basis of the results of the correlations, TEMPS-A Irritable temperament, ECR Avoidance and Anxiety, BIS-11 Impulsivity scores, and a group variable that was coded as Detainees/Controls were entered as predictors of the Dys/Cyc/Anx temperament in a stepwise multiple regression model. BIS-11 Impulsivity scores and the group variable did not enter in the equation. In the first step, the best predictor was Irritable temperament (R2= 0.527: 52% explained variance; F = 86.98; p = 0.000). The second step added Avoidance (R2 change = 0.154: 15% explained variance; F = 82.22; p = 0.000). The third step added Anxiety (R2 change = 0.027: only 2% explained variance; F = 61.57; p = 0.000). These variables explained about 71% of the variance (Table 5).

Table 5.  Multiple regression analysis (stepwise) with temperament dysthymic/cyclothymic/anxious as the criterion
ModelRR2R2 changeModelANOVA Fp
10.7260.5270.527186.980.000
20.8250.6810.154282.220.000
30.8420.7080.027361.570.000
Model  Beta stdtpPart correlations
1Irritable 0.7268.480.0000.726
2Irritable 0.5126.970.0000.449
 Avoidance 0.4476.090.0000.392
3Irritable 0.4826,740.0000.418
 Avoidance 0.3835.130.0000.318
 Anxiety 0.1852.670.0090.165

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Method
  5. Results
  6. Discussion
  7. References

This investigation highlighted the fact that women in prison have a higher incidence of mental disorders than women in the community, and they experience significant difficulties (Teplin, Abram, & McClelland, 1996). There are many complex and interrelated issues for women in jail and prison. The findings of this study indicate the need to provide services for women in jail that address their psychological and emotional problems. The comparisons with nonincarcerated women indicate that women detainees have experienced multiple life events that affect their psychological well-being. The findings show that it is possible that these women have a dysthymic, cyclothymic, anxious, and irritable temperament (but not a hyperthymic temperament), insecure attachment in the form of avoidance and anxiety, impulsivity and important psychosexual issues regarding identity, bodily experience, and masturbation. Nevertheless, an unexpected but interesting result is that irritability and insecure attachment dimensions predicted the affective dysthymic/cyclothymic/anxious temperament, and this result was shared by incarcerated and nonincarcerated women.

It has been well known for many years that rates of depression, anxiety, and suicidal risk are higher in incarcerated women than in community samples (Gunter, 2004; Lukasiewicz et al., 2008), and our findings indicate the presence of higher rates of other psychosocial disturbances. In order to fully address inmate health and mental health needs, there is need for links with community-based programs, and this means that criminal justice, mental health, and health systems must be linked for the task of suicide prevention in prisons (Pompili, Lester, Innamorati, Del Casale, Girardi, Ferracuti, & Tatarelli, 2009).

Health professionals are challenged in implementing therapeutic processes, strategies, and interventions because gender-specific mental health is critical for women in prison who may experience repeated exposure to trauma ranging from stigma, and powerlessness to sexual, emotional, and physical abuse. Without effective mental health treatment, these women will experience an increased likelihood of repeated incarceration (Heney & Kristiansen, 1997).

Mental health is a critical area, with interrelated issues in the lives of women offenders. These issues have a major impact on a female detainee's experience of incarceration and on the transition to the community in terms of both programming needs and successful reentry (Bloom, Owen, & Covington, 2003). Particular attention should be devoted to the personnel working in prisons and jails as the staff face difficult and critical situations that may undermine their own psychological well-being (Pompili, Rinaldi, Lester, Girardi, Ruberto, & Tatarelli, 2006) and, in turn, their ability to detect suicide risk and emotional disturbances in the inmates (Pompili, Mancinelli, & Tatarelli, 2003; Pompili, Girardi, Ruberto, Kotzalidis, & Tatarelli, 2005). Nurses have a crucial role in the delivery of proper care for people staying in jails. They also can play a central role in the assessment of specific features by administering psychometric instruments, and through the management of difficult and demanding patients.

Nurses should be regularly trained in recognizing difficult cases; that is, some individuals, particularly those with recurrent-specific temperament may be perceived by staff as manipulative, provocative, unreasonable, overdependent, and feigning disability. Many interrelated emotional and affective disturbances affect the physical and psychological well-being of women in jail, and it is possible that these problems may lead to suicide. Health professionals need to develop gender-specific therapeutic interventions for women in jail. Patients with fluctuating suicidal ideation are particularly likely to fall into these categories, which may lead to under-reporting of suicidal ideation by the nursing staff. The combination of such alienation and fluctuating suicidal ideation can lead to a failure to recognize the seriousness of suicidal risk. For instance, the so-called “dependent-dissatisfied” patient complains incessantly, makes demands, and tries to control others. These individuals show inflexibility and lack of adaptability, reiterating their complaints to others regardless of whether the others can do anything to remedy the situation. These subjects turn to the staff for support, but continually succeed in alienating them with their insatiable demands for special attention. Future research should be devoted to the role of nurses in the development of a therapeutic relationship with clients: how they can listen attentively, give reassurance, and offer support and empathy. The establishment of protocols aimed at early recognition of negative feelings toward suicidal patients as well as warning signs for further suicide risk are of paramount importance.

There are some limitations to the present study. The sample was a small convenience sample selected from one jail, and this may limit generalization of the results. Further research should be replicated across a number of jails, with a larger sample, in order to identify other important factors influencing psychological well-being in female prisoners. Furthermore, information regarding the number of times the participants were incarcerated and ever arrested; as well as existing psychological and other major diagnoses, and whether they were receiving current treatment for any mental disorder was not collected. Finally, studies are needed that can provide a classification of women with and without suicidal risk.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Method
  5. Results
  6. Discussion
  7. References
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