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Forever Free
Date of Review: December 2006

Forever Free is a drug treatment program for women who abuse drugs and are incarcerated. The intervention aims to reduce drug use and improve behaviors of women during incarceration and while they are on parole. While they are incarcerated, women participate in individual substance abuse counseling, special workshops, educational seminars, 12-step programs, parole planning, and urine testing. Counseling and educational topics include self-esteem, anger management, assertiveness training, information about healthy versus dysfunctional relationships, abuse, posttraumatic stress disorder, codependency, parenting, and sex and health. The program lasts 4-6 months. Women participate in 4 hours of program activities 5 days per week. After graduation and discharge to parole, women may voluntarily enter community residential treatment. Residential treatment services include individual and group counseling. Some women also participate in family counseling, vocational training/rehabilitation, and recreational or social activities.

Descriptive Info Outcomes Ratings Study Populations Studies/Materials Replications Contacts

Descriptive Information

Topics Substance abuse treatment
Areas of Interest Criminal/juvenile justice 
Outcomes Outcome 1: Drug use
Outcome 2: Parole outcomes
Outcome 3: Employment after incarceration
Study Populations Age: 26-55 (Adult)
Gender: Female
Race: Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified
(See Study Populations section below for percentages by study)
Settings Correctional 
Implementation History Forever Free has been implemented at the California Institution for Women, a female-only State prison in Riverside County, California, since 1991.  
ReplicationsThis intervention has been replicated. (See Replications section below)
Adaptations No population- or culture-specific adaptations were identified by the applicant.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the applicant.
Public or Proprietary Domain Mix of public and proprietary
Costs Training on relapse prevention costs between $395 and $695, including materials.  

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Outcomes

Outcome 1: Drug use

Description of Measures Drug use was measured using structured interviews. Interviewers asked respondents to report frequency of drug use over the past year and during the past 30 days. Respondents were asked about 13 categories of drugs as well as drugs not specified in the categories.
Key Findings

In a study of outcomes for 180 women 1 year after their release from prison, 8% of Forever Free participants reported drug use in the past 30 days, compared with 32% of the comparison group (p = .001). A total of 50.5% of Forever Free participants reported any drug use in the past year, compared with 76.5% of comparison group participants (p = .001).

In a study of outcomes for 64 women 1 year after their release from prison, a lower percentage of women who had participated in Forever Free and residential aftercare reported any heroin use in the past year (5.3%) than those who had not received aftercare (21.7%) and those in the no-treatment comparison group (40.9%). A total of 10.5% of Forever Free plus residential aftercare clients reported past-year amphetamine use, compared with 8.7% of those who did not participate in aftercare and 22.7% of the no-treatment comparison group. A total of 21.0% of Forever Free plus residential aftercare clients reported using cocaine or crack in the past year, compared with 69.5% of those who did not participate in residential care and 50.0% of the no-treatment comparison group.
Studies Measuring Outcome Study 1, Study 2
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)

Outcome 2: Parole outcomes

Description of Measures Parole outcome data were collected using a structured interview. "Discharged/active with no return" was considered success. "Discharged/active returned to custody" and "in prison" were considered failures. In one study, reincarceration data were obtained from the Offender-Based Information System (OBIS).
Key Findings In one study, 68.4% of Forever Free graduates who entered residential treatment had not returned to custody 1 year after release on parole; 52.2% of Forever Free graduates who did not enter residential treatment had not returned to custody, while only 27.2% of women in a no-treatment comparison group had not been returned to custody (p < .05). In a second study, 49.5% of Forever Free graduates compared with 74.7% of a no-treatment comparison group reported being arrested in the year following release from prison (p = .001).
Studies Measuring Outcome Study 1, Study 2
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs Quasi-experimental
Quality of Research Rating 3.2 (0.0-4.0 scale)

Outcome 3: Employment after incarceration

Description of Measures Postincarceration employment was assessed with structured interviews. Participants were asked if they were employed, how many hours they worked per week, and the amount of their weekly take-home pay.
Key Findings In a study of outcomes among 180 women 1 year after release from prison, 65.3% of Forever Free participants, compared with 44.7% of comparison group participants, were employed. The groups were equivalent in hours worked per week and weekly take-home pay.
Studies Measuring Outcome Study 2
(Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs Quasi-experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)

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Ratings

Quality of Research Ratings by Criteria (0.0-4.0 scale)

Outcome Reliability
of Measures		 Validity
of Measures		 Fidelity Missing
Data/Attrition		 Confounding
Variables		 Data
Analysis		 Overall
Rating
Outcome 1: Drug use 2.8 3.1 2.8 3.3 2.3 3.5 2.9
Outcome 2: Parole outcomes 3.1 3.1 2.8 3.3 2.8 4.0 3.2
Outcome 3: Employment after incarceration 3.0 2.5 2.5 3.0 2.5 3.5 2.8

Study Strengths: The interview tools used in both studies were developed from other instruments with established reliability and validity. The researchers demonstrated effort to match comparison groups. Data analysis was appropriate.

Study Weaknesses: The sample sizes were small, allowing limited comparisons.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

Implementation
Materials		 Training
and Support		 Quality
Assurance		 Overall
Rating
1.3 0.5 0.5 0.8

Dissemination Strengths: The program uses best-practice materials from a variety of expert resources targeted to this specific population. Some training materials are provided for topic areas relevant to the intervention. A client satisfaction survey and a standardized therapeutic community fidelity measure are provided to support quality assurance.

Dissemination Weaknesses: The program materials are specific to one implementation site and may not be easily adapted or transferred to other implementation sites. The relationship between the submitted program materials is unclear. While implementation, program goals, and recommendations for staffing are addressed in some of the materials, the guidance across these materials is inconsistent. No support resources specific to the program and its implementation are provided. The connection between the quality assurance measures provided and the program model is unclear. Materials state that one implementation site was engaged in external quality reviews, but no standards or protocols for evaluation or quality assessment are provided.

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Study Populations

The studies reviewed for this intervention included the following populations, as reported by the study authors.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult)
 100% Female
 38.6% White
37% Black or African American
22.8% Hispanic or Latino
1.6% Race/ethnicity unspecified
Study 2 26-55 (Adult)
 100% Female
 34.6% Black or African American
33.6% White
22% Hispanic or Latino
9.8% Race/ethnicity unspecified

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Studies and Materials Reviewed

The documents below were reviewed for Quality of Research and Readiness for Dissemination. Other materials may be available. For more information, contact the person(s) listed at the end of this summary.

Quality of Research Studies

Study 1

Prendergast, M. L., Wellisch, J., & Wong, M. M. (1996). Residential treatment for women parolees following prison-based drug treatment: Treatment experiences, needs and services, outcomes. Prison Journal, 76, 253-274.

Study 2

Hall, E. A., Prendergast, M. L., Wellisch, J., Patten, M., & Cao, Y. (2004). Treating drug-abusing women prisoners: An outcomes evaluation of the Forever Free program. Prison Journal, 76, 81-105.

Prendergast, M. P., Hall, E., & Wellisch, J. (2002). An outcome evaluation of the Forever Free Substance Abuse Treatment Program: One-year post-release outcomes. Final report to the National Institute of Justice. Los Angeles: UCLA Drug Abuse Research Center.

Quality of Research Supplementary Materials

Hall, E. A., Baldwin, D. M., & Prendergast, M. L. (2001). Women on parole: Barriers to success after substance abuse treatment. Human Organization, 60, 225-233.

Prendergast, M., Hall, E., Baldwin, D. M., & Wellisch, J. (1999). A qualitative study of participants in the Forever Free Substance Abuse Treatment Program. Report to the California Department of Corrections. Los Angeles: UCLA Drug Abuse Research Center.

Prendergast, M., Hall, E., Wellisch, J., & Baldwin, D. M. (1999). A process evaluation of the Forever Free Substance Abuse Treatment Program. Final report to the National Institute of Justice. Los Angeles: UCLA Drug Abuse Research Center.

Readiness for Dissemination Materials

Center for Substance Abuse Treatment. (2006). Therapeutic community curriculum: Participant's manual (DHHS Publication No. [SMA] 06-4122). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Center for Substance Abuse Treatment. (2006). Therapeutic community curriculum: Trainer's manual (DHHS Publication No. [SMA] 06-4121). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Covington, S. (1999). A woman's journal (participant workbook from Helping women recover: A program for treating substance abuse, criminal justice edition). San Francisco: Jossey-Bass.

Covington, S. (2000). A woman's way through the twelve steps. Center City, MN: Hazelden.

Covington, S. (2002). Women in recovery: Understanding addiction. Carson City, NV: The Change Companies.

Covington, S. (2003). A healing journey: A workbook for women (participant workbook from Beyond trauma: A healing journey for women). Center City, MN: Hazelden.

De Leon, G., Melnick, G., & Center for Therapeutic Community Research. (1993). Therapeutic community Survey of Essential Elements Questionnaire (SEEQ)--Short form. New York: Community Studies Institute.

Fry, R., Johnson, S., Melendez, P., & Morgan, R. (1998). A parent's guide to changing destructive adolescent behavior. Ontario, CA: Parent Project.

Gordon Graham and Company, Inc. (1993). A framework for recovery. Bellevue, WA: Authors.

Gordon Graham and Company, Inc. (1998). A framework for breaking barriers. Bellevue, WA: Authors.

Gorski, T. (1997). The GORSKI-CENAPS model: An overview. Homewood, IL: Author.

Gorski, T., & Trundy, A. (2000). Relapse prevention counseling workbook: Practical exercises for managing high-risk situations. Homewood, IL: Terence T. Gorski.

Handouts:

Hermes, S. (1998). Assertiveness: Practical skills for positive communication. Center City, MN: Hazelden Foundation.

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Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

* Hall, E. A., Prendergast, M. L., Wellisch, J., Patten, M., & Cao, Y. (2004). Treating drug-abusing women prisoners: An outcomes evaluation of the Forever Free program. Prison Journal, 76, 81-105.

Jarman, E. (1993). An evaluation of program effectiveness for the Forever Free Substance Abuse Program at the California Institution for Women, Frontera, California. Sacramento: California Department of Corrections, Office of Substance Abuse Programs.

* Prendergast, M. L., Wellisch, J., & Wong, M. M. (1996). Residential treatment for women parolees following prison-based drug treatment: Treatment experiences, needs and services, outcomes. Prison Journal, 76, 253-274.

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Contact Information

For information about implementation:

David Conn, Ph.D.
Vice President, Corrections and Rehabilitation Division
Mental Health Systems, Inc.
9465 Farnham Street
San Diego, CA 92123
Phone: (858) 573-2600
E-mail: dconn@mhsinc.org

For information about studies:

Elizabeth A. Hall, Ph.D.
Department of Psychiatry and Behavioral Sciences
University of California, Los Angeles
1640 South Sepulveda Boulevard, Suite 200
Los Angeles, CA 90025
Phone: (310) 267-5501
Fax: (310) 312-0559
E-mail: ehall@ucla.edu

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The NREPP review of this intervention was funded by the Center for Substance Abuse Treatment (CSAT).