Implementation of Peer-Led Seeking Safety for Women in Jail

Abstract

Women are the fastest-growing segment of the incarcerated population and experience high rates of cumulative trauma exposure, mental illness, and PTSD. The aim of this study is to assess the implementation of a peer-led Seeking Safety (an evidence-based intervention for addressing trauma and addiction) pilot program for women in jail. Guided by principles from community-based participatory research and cooperative inquiry, participant surveys were analyzed (secondary data) using descriptive methods (n = 60), and qualitative interviews with program facilitators were conducted and analyzed using a general inductive approach (n = 7). Peer-led Seeking Safety is feasible, acceptable, and appropriate for women in jail, with high levels of participant satisfaction. We describe several “lessons learned” related to the jail context, including structure and security processes and vicarious and retraumatization experiences among facilitators. Preventing facilitator burnout is necessary for the sustainability of the program. Future implementations of Seeking Safety in jails should consider the lessons learned in this study.

1. Introduction

Women are the fastest-growing segment of the incarcerated population, with rates climbing at double that of men (Dholakia 2021). On any given day, there are 1.2 million women under the supervision of the criminal legal system, including confinement and community supervision (The Sentencing Project 2020). About 200,000 women are incarcerated across 446 state prisons, 27 federal prisons, 3116 local jails, 1323 juvenile correctional facilities, 80 Indian country jails, and 80 immigration detention facilities (Kajstura and Sawyer 2024). Over half of incarcerated women are locked up in county jails, and 60% of women in jail have not been convicted of a crime. While overall incarceration rates have been decreasing in recent decades, women’s incarceration rates have grown exponentially, especially in local county jails (Sawyer 2018). Jails tend to offer less programming and services than prisons, and programming for women who are incarcerated is often not prioritized relative to programming for men (Harris 2022; Stuart and McCoy 2023; Agarwal and Draheim 2024). This makes jails a critical site for intervention with women.

Women’s pathway to incarceration is often characterized by the criminalization of women’s trauma (Sered and Horton-Hawk 2014; Lynch et al. 2013)—that is, criminalizing behaviors that follow gender-based violence and mental illness, such as survival crime, homelessness, drug use, and sex work (DeHart et al. 2014; Herring 2020; Noska et al. 2016). Cumulative trauma exposure, mental illness, and PTSD are high among women who are incarcerated (Karlsson and Zielinski 2020; Konecky and Lynch 2019), necessitating trauma-specific treatment (Saxena and Messina 2021). There is some evidence that providing trauma-informed care to women who are incarcerated lowers recidivism rates (Lehrer 2021), although activists warn that advocating for trauma-informed jails for women will contribute to continuing mass incarceration rather than addressing root causes of women’s incarceration (e.g., gender-based violence) (Mon M. 2022).

Nevertheless, programs such as Seeking Safety are evidence-based for addressing trauma and addiction (Najavits 1999, 2009, 2022) and have been deployed in a variety of settings. These include residential drug treatment (Ghee et al. 2009), recovery groups (Sperlich et al. 2021), Veteran’s Administration (Najavits et al. 2018), hospital and clinical settings (Shenai et al. 2019), and prisons (Lynch et al. 2012; Wolff et al. 2012; Zlotnick et al. 2003). Seeking Safety is flexible and present-focused on developing coping skills and can be delivered by anyone (e.g., it does not require a specific educational degree) (Treatment Innovations 2020). The modules are designed, such that they can be implemented in any order with different levels of dosing to fit the intervention setting.

Seeking Safety was originally designed to address co-occurring posttraumatic stress disorder (PTSD) and substance-use disorder (SUD) (Najavits 1999, 2009, 2022). The intervention has evolved to be applied more broadly to other populations, including people with just one or the other disorder, trauma-related problems (e.g., subclinical PTSD), and as a general model to increase stabilization. It is a present-focused cognitive behavioral therapy offering 25 topics. Present-focused refers to dealing with current issues rather than a detailed exploration of the past while honoring what participants have survived. Each topic is a practical, safe coping skill focused on psychosocial education and rehearsal of the new skill. The topics include Honesty, Asking for Help, Setting Boundaries in Relationships, Getting Others to Support Your Recovery, Healthy Relationships, Compassion, Creating Meaning, Discovery, Integrating the Split Self, Recovery Thinking, Taking Good Care of Yourself, Commitment, Respecting Your Time, Coping with Triggers, Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding), and Life Choices.

Peer-led interventions for SUD have long existed (e.g., Alcoholics Anonymous, Narcotics Anonymous) and are a primary component of many current SUD-related interventions (Bassuk et al. 2016; Eddie et al. 2019; Gormley et al. 2021). Similarly, peers have been integrated into prison education and reentry mentorship programs (Bagnall et al. 2015; Reingle Gonzalez et al. 2019; Sells et al. 2020). Peers participate as interventionists, given their experiential expertise, although peers can also have professional training and educational expertise. The use of peers in addiction services has been shown to reduce stigma empathically through shared emotional, physical, and traumatic pain and increase clients’ sense of empowerment through respect, shared responsibility, and mutual aid (Burke et al. 2019; Mead et al. 2001; Simoni et al. 2011). A previous study of peer-led Seeking Safety in a residential drug treatment facility allowed peers to serve as both a “peer guide” and a participant (Najavits et al. 2014). Participants who were trained in Seeking Safety rotated as peer guides for 4 weeks at a time. A clinical staff member was present and observed the sessions but did not participate. The study concluded that the professional Seeking Safety treatment manual can be successfully implemented by peers, with positive feedback on the use of peers by participants, clinical observers, and facility staff.

The goal of the current study is to assess the implementation of peer-led Seeking Safety for women in jail. Jails are unique correctional settings often operated at the county level. Most people in jails hold pre-adjudication (meaning they have not been convicted of a crime and are awaiting the disposition of their case). Nationally, 7.3 million people were admitted to jail in 2022, with an average daily population of 663,100 (Zeng 2023). There are high rates of population turnover. About 50% of people are released within 24–48 h. This environment often makes implementing evidence-based interventions and practices challenging, leading to limited adoption (Prendergast 2011; Berk et al. 2024). Rather than assessing the impact of Seeking Safety on clinical and other participant outcomes, we assess implementation outcomes (Proctor et al. 2023) and barriers and facilitators for successful implementation in a jail setting (Blackaby et al. 2023; Damschroder et al. 2022) from the perspective of the program participants (women in jail) and the facilitators implementing the program. Our goal is to provide “lessons learned” for future implementation of Seeking Safety in jails.

2. Materials and Methods

The purpose of this study is to identify the barriers and facilitators to implementing the evidence-based intervention, Seeking Safety, for women in an urban jail context using peer facilitators. A nonprofit women’s reentry organization piloted Seeking Safety in jail across five cohorts from December 2022 through September 2023. The data for this study come from two sources: secondary data analysis of limited de-identified organizational data and primary data collected through qualitative interviewing. Our study was guided by principles from community-based participatory research and cooperative inquiry (inquiring with people instead of about people) (Russ et al. 2024; Råheim et al. 2016), including the collaboration of researchers and community partners in the planning, research design, and dissemination of research findings.

2.1. Participant Surveys

As part of an internal evaluation conducted by the nonprofit, facilitators administered “exit” surveys to women on the last day of class to measure four implementation outcomes: satisfaction, acceptability, appropriateness, and feasibility (Proctor et al. 2023). Personal satisfaction with the program was assessed by asking: “How would you rate the quality of the programming you received?” and “If a friend were in need of similar help, would you recommend our program to her?” Open-ended questions on course feedback were also included. Three scales assessed implementation, in general, for women in jail: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) (Weiner et al. 2017). Each scale consists of four questions assessing the implementation outcome. Items were adapted for the current program (e.g., “The Seeking Safety Program seems easy to complete in jail”. “The Seeking Safety Program seems like a good match for the needs of women in jail”. “The Seeking Safety Program is appealing to me”.) and answer choices were a 5-point Likert scale from “completely disagree” to “completely agree”.

Limited de-identified data were provided to the lead author for secondary data analysis. Each item was re-coded to a binary score to calculate an overall percent approval rating. ‘Completely agree’ and ‘agree’ were combined to “positive”, and ‘neither agree nor disagree’, ‘disagree’, and ‘completely disagree’ were combined to “negative”. Coding was conducted in this manner to create conservative ratings. A total of 358 women attended at least one class session during the pilot phase. Each cohort included multiple classes led by unique facilitators, including ten class sessions in total, two class sessions per week, for 5 weeks. Class sessions were scheduled for 2 h. Exit surveys were not available for one (n = 98) out of the five cohorts because the jail did not provide them on the last day of class. A total of 60 women (60/260; 23.1% response rate) completed exit surveys. Survey non-completion was most commonly due to women not being present in class, either because they were discharged from jail or were unable to attend for another reason, or surveys were not available for the class. The classes were intended to be closed groups to build and maintain rapport. However, it was quickly determined that closed groups were not feasible due to the high levels of jail population turnover coupled with the uncertainty of release dates. The classes turned into open groups, meaning people could “drop in” and attend classes as they were able/interested. Therefore, the surveys represent women who attended the last day of class for whom surveys were available. There was also some missing data, with the number of responses per survey item ranging from 55 to 60. Given the small sample size, we did not perform any imputations. All data were analyzed in Microsoft Excel and presented as descriptive findings.

2.2. Facilitator Interviews

One-on-one semi-structured qualitative interviews were conducted by the lead author with seven facilitators via video chat. While the sample size for the facilitator interviews was small, participants had high-quality and specific experiential knowledge, and the interviews were narrowly focused, allowing for a smaller sample size (Malterud et al. 2016). The interview guide had two parts: the first part focused on the barriers/challenges and facilitators/successes to implement Seeking Safety at the jail, and the second part focused on the personal impact of this work on the facilitator. The first part of the interview guide addressed inner setting constructs from the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al. 2022), such as structural characteristics (e.g., infrastructure, physical layout of space), relational connections and communication (e.g., quality of relationships between the jail staff and facilitators), available resources (e.g., materials, equipment, and space), relative priorities (e.g., Seeking Safety prioritized against other initiatives), and compatibility with current workflows and processes at the jail.

The interviews were recorded and professionally transcribed verbatim. Interviews lasted between 30 and 60 min, and facilitators were provided with a $25 cash gift card. Five out of the seven facilitators were formerly incarcerated women who graduated from the nonprofit prison reentry program. They now work for the nonprofit and have received special permission from the jail, given their criminal convictions, to provide services to women detained in the jail. All facilitators completed extensive training in delivering Seeking Safety. The one-day, 7-h interactive webinar covered the 25 Seeking Safety topics focusing on cognitive, behavioral, interpersonal, and case management skills. Topics also included PTSD recovery, setting boundaries, coping with triggers, and fostering healthy relationships. Facilitators met regularly to discuss issues related to facilitation, and they had access to an experienced Seeking Safety facilitator with years of experience delivering the intervention to women in a local prison. Facilitators were assured that only the interviewer would have access to the data, that their name would not be linked to the interview transcript, that nobody at the nonprofit or jail would have access to the data, and that any findings would be presented in a way that could not identify them. Some of the quotes presented in this paper have been edited to change language to protect the identities of the facilitators. Some examples include changing language—wherein a non-native English speaker is not easily identified—or changing minor potentially identifying details or words that do not alter the meaning of the statement. All procedures for the facilitator interviews were approved by the University IRB [blinded for review]. Verbal informed consent was obtained and documented by the interviewer from all participants involved in the qualitative interviews.

A general inductive approach was used to analyze the transcripts and identify themes (Thomas 2006). This analytic approach uses data as a mechanism for revealing the main themes that are reflected in the respondent interviews by providing a straightforward approach for deriving findings in the context of focused research questions. Transcripts were inputted into NVivo 14 and were coded by the lead author using a pre-established codebook that closely followed the interview guide, including CFIR concepts while allowing for new themes to emerge. Once the findings were written and the quotes were anonymized, member checking—a type of reflexive participant collaboration in which participants review findings and provide feedback to the researcher on the resonance with their experiences (Motulsky et al. 2021)—was used to obtain critical feedback on the findings from facilitators (Birt et al. 2016), which is appropriate for collaborative research, especially to guarantee anonymity (Thomas 2016). The lead author was successful at anonymizing the quotes because facilitators could not attribute quotes to anyone other than themselves (they could identify only their own quotes).

3. Results

3.1. Satisfaction, Feasibility, Acceptability, and Appropriateness from Client Perspective

Women were overwhelmingly positive about the program. In total, 98.3% of women (59/60) positively endorsed the program quality, with 81.7% rating the program quality as excellent (49/60). All women (58/58) said that they would recommend the program to a friend. Appropriateness was most highly rated; 99.1% rated the program as appropriate for women in jail. Most women (94.8%) rated the program as acceptable for women in jail, while feasibility was rated the lowest (90.3%), yet still within acceptable standards (>80%).

Women were asked an open-ended question, “What did you like most about the programming?” and 35 provided comments. The patterns across the responses were speaking freely, relating to the facilitators, and skill-building. Women stated that they appreciated being able to “speak freely”, writing things like “I like the open space and confidentiality”, “They listen to us and talk about our issues”, and “I love the concept of having support and being able to have people relate to me, experience women being able to speak about their testimonies”. Women also mentioned that they liked the use of peers to facilitate the program. Women wrote, “I love that [the instructor] related with our addictions and incarceration” and “I feel open to sharing with the women that had also been incarcerated”. A couple of women suggested additional outside speakers that could share their testimonials. Finally, women mentioned the skills that they acquired, including grounding, coping skills, and breathing techniques, as positive outcomes of participation. When asked, “What did you think we can do to improve the programming?” many women responded with things like “nothing” or requests for additional services. However, some women commented on structural issues, such as being able to keep their handouts and needing a larger space for the group. Women also requested additional books and certificates, as well as “time off” incentives (reduction in sentence for program participation). Women noted the need for employment programming (e.g., CDL, cosmetology), parenting classes, anger management classes, English as a second language courses, GED classes, access to a law library, and additional one-on-one counseling and mental health support.

3.2. Barriers and Facilitators to Program Implementation from Facilitator Perspective

3.2.1. Security Measures Are a Major Barrier to Fidelity

Security measures employed by the jail were consistently mentioned as a barrier. To be sure, security is a top priority for correctional institutions, but program facilitators expressed how some jail policies hindered their ability to deliver services. First, guests at the jail are not permitted to move freely in secure spaces; they must be escorted by a correctional officer. One facilitator stated:

“It’s hard. But yeah, simply as a facilitator, it can be very frustrating because we’re scheduled to go in for two hours, but we arrive and then sometimes sit 30 min, sometimes an hour sitting in the lobby waiting for someone to escort us physically [to the unit], because we cannot go on our own”.

A consequence of this waiting is that the 2-h course period is drastically reduced, and lesson plans cannot be delivered with fidelity. When asked why it sometimes takes long to be escorted by a correctional officer to the unit, facilitators offered some ideas: “‘Medline’ [when women line up in the dorm to receive their medication] is one thing that they do not stop for anything… uniform exchange, if they were having a shakedown”. In other words, the unpredictability of jail administration can be an impediment to program delivery. But all facilitators noted that it has “gotten better” over time, with one person noting that waiting for an escort “was a big thing until one of the higher-ups got involved”.

Echoing clients, facilitators also mentioned the inability to provide handouts to group members as impeding their ability to fully implement the intervention. Handouts used during class are printed by the nonprofit and are delivered to the jail along with any additional materials one-to-two weeks prior to class start. The items are inspected and screened by “drug-sniffing dogs”. Yet, participants are not allowed to keep handouts for reference or to complete individual work between classes, a key component of the intervention. One facilitator explained that they have been told by the jail that the lesson content needs to be read and approved: “The actual words have not been read by anybody. They’re just checking to make sure the paper is I guess paper and not… I don’t know what else it would be, acid? I don’t know what else it would be”.

Facilitators were unanimous in their frustration with security procedures that seemed overly cautious while respecting the needs of the jail. Security procedures related to unexpected events (e.g., lockdown due to a fight) are unpredictable and necessitate flexibility. However, other procedures, such as allowing participants to keep course handouts or allowing registered volunteer instructors to move freely around the jail (while still under video surveillance), are potentially modifiable.

3.2.2. The Physical Structure of the Jail and the Ethics of Trauma-Informed Services

The physical structure of the jail could also create challenges. Women were housed in multistory open-bay dorms, meaning there was a large atrium-like space in the middle and cells lining the walls. One facilitator described it as “an open bay situation or shared dayroom situation, where they’re on top of each other all the time”. Everything is made of metal, and all activity takes place in the dorm: eating, sleeping, talking on the phone, watching TV, programming, medication distribution, showering, etc. It can be a loud space. Each unit has one private room where the classes are supposed to take place. But that does not always happen:

“It depends on the officer. A couple of facilitators are able to get in the back room because their officers are kind to them. But the officer that I have will not, absolutely not, and so I’m in the day room. We asked if we could use the private room and were told no because it was a security issue because men could not be in that back area with the women. But all the facilitators are women… It’s at their convenience that they’ll let us back there, honestly”.

Facilitators mentioned that having Seeking Safety classes in public spaces with other dorm residents around negatively impacts course delivery, such as lower attendance and women not feeling as comfortable talking. Another facilitator lamented, “I just feel like [the program] would be more meaningful if we had a dedicated space and those that wanted to attend were able to attend, instead of having a small room and you’re in there with all of these things going on”.

Major tenants of trauma-informed practices include ensuring participants feel safe and empowered to use their own voice and tell their stories in a way that is comfortable to them (Center for Health Care Strategies 2024). The physical structure of the jail and the denial of access to private meeting spaces created ethical dilemmas for facilitators and reduced participant engagement. Seeking Safety is designed to be present and focused on skill building rather than focusing on participants retelling their traumatic experiences. Nevertheless, participants’ safety cannot be ensured in public spaces, which greatly impacts course dynamics and, likely, the efficacy of Seeking Safety.

3.2.3. Correctional Officers and Other Potential Champions

Correctional officers have a huge impact on program implementation and could hinder or help the facilitation of classes, depending on the officer assigned to the unit. Officers also rotate units, making it difficult to establish trusting relationships. One facilitator summed it up when she said, “The attitude of the officer is all important. Whoever is manning that unit and how cooperative they are is huge… It’s really at their discretion how helpful they want to be”. Another facilitator noted:

“Sometimes it’s a captain manning the floor and doesn’t want to deal with us… and it gets a little stranger then. There were a lot more excuses as to why we couldn’t do the class. And some of our facilitators, myself as well, were turned away. That’s just the way it is”.

When asked by the interviewer, “Do you feel comfortable challenging the officer and being like, ‘Hey, so-and-so told me that this class is a priority and I’m allowed to be here?’”, the facilitator explained: “No. I mean… it’s not that I don’t feel like I have a right to do that, and it’s not that I haven’t tried it, but it doesn’t work I’ve found”. A different facilitator saw the floor officer assigned to their unit as a great source of support. She said, “The good thing was the officer that was in charge of the dorm that I would go to, she was amazing. But then she got transferred out”. Facilitators noted how, overall, relationships have improved over time: “Most of the facilitators, I believe, have good relationships with floor officers now, as long as the officers don’t change. But they do, they get rotated”. For example, “just last Monday, there was a new officer that said, ‘Oh, you’re not supposed to be here. You need to be outside’.” and the facilitator responded, “No, no, no. I am supposed to be here”. She went on, “I just said it that way and she kind of said, ‘Oh, okay’”.

Facilitators saw the time being escorted to or from security and the dorm as a chance to educate correctional officers about what they were doing and the importance of the program. “That’s really when most of the talking happens”, said one facilitator, “I even had an officer tell me that he was really interested in what we do”. Another facilitator reported that “an officer approached me as I was leaving and she goes, ‘Why are you not in my unit? I think you’re missing people’. And then the next cohort, we went in that unit. So, it was a good opportunity for us”.

Jails operate using a hierarchical military-like structure, like law enforcement. While correctional officers in this setting seem to have a high level of flexibility in running housing units, they are subject to a command chain. Having buy-in and support from higher-level administration, including a memorandum of understanding, has shown itself to be necessary. However, better communication between administration and floor officers, as well as obtaining buy-in from floor officers, might help with program implementation.

3.2.4. Responding to Chaos with Flexibility

While jail conditions and correctional officers were sometimes barriers for program facilitators, being flexible and spontaneous were perceived as ways to overcome these barriers. One facilitator succinctly stated, “I think the jail sits in a world and fitting into that, you have to be the flexible one, period”. In fact, the Seeking Safety intervention was specifically chosen by the nonprofit for its flexible nature:

“It’s a program that we decided to use in the jail particularly because of the chaotic nature of the jail, and because those lessons do not build upon each other. And even if you receive one lesson in Seeking Safety, you will have a benefit from it and do not have to take all of the lessons to receive a benefit”.

The interviewer followed up with, “What did you mean by ‘the jail’s chaotic’?” She responded:

“The jail’s chaotic simply because when someone’s arrested, they could be there one day, they could be there three days, they could be there a week, a month, or several years. And so, it’s very transient, and because of it being very transient, it’s hard for there to be ongoing programs there with repeat students. There’s situations where they have lockdowns, there’s situations where there’s quarantines and they’re not allowed out of their cells, and then there’s situations where their lockers get raided by the officers. And there’s a lot of emotional things that happen on a daily basis there, and there’s a lot of interruptions. So, it’s a very emotional place, and so those things have to be addressed before any kind of learning can happen”.

When speaking about arriving to class late due to waiting for an escort, one facilitator discussed how they altered the class programming: “They’re upset just as much as I am that class is happening late, because they look forward to it. And so sometimes we have to do breathing exercises first or we have to address the concerns and talk it out”.

Another facilitator explained how sometimes the bins with their class supplies would not be available: “Sometimes I would go in there and there’d be no bins, no pencils to sign in. The bins have our pencils, our papers, it’s got everything. I’d have to borrow a pen from the officer to do sign-ins”. This meant the facilitator would not be able to deliver Seeking Safety content and would have to improvise: “I’d have open class. I’d let them talk about whatever they wanted to talk about. I tried to find something empowering and motivating to talk to them about”. She went on to reflect, “If I had never been incarcerated myself, it would’ve been even worse, I feel like. But I had been in that space, and I could relate to what they were going through. If they came in and they were upset by whatever was happening in the dorm that day, I let them talk about it, get it out. You know what I mean? Because I can relate, I’ve been there”.

Flexibility was also talked about in the context of the nonprofit for which the facilitators worked. A facilitator explained, “It was helpful to have the freedom to choose when I would come [to the jail] as far as [the nonprofit] saying, ‘What days and times will work for you? When are you available to do this?’ So that was helpful to be able to work around my schedule and get me in there”. First-time facilitators worked with an experienced partner, which was also found to be helpful.

While flexibility was necessary given the unpredictable nature of the jail setting, abandoning intervention content raises serious fidelity concerns. This may be mitigated through additional training for facilitators, including standardization of responses to shortened class times and discussions of potential role conflict. Peer facilitators sometimes seemed conflicted about their role as interventionists and peer supporters. Having directed discussions about peer support roles may be beneficial for facilitators.

3.2.5. Secondary Trauma and the Emotional Toll of Working in Jail

All facilitators talked about how much they enjoyed their work but that facilitating these classes was traumatizing at times and took an emotional toll. In some instances, facilitators described secondary traumatic stress from hearing other women’s stories or witnessing their poor treatment in jail. As one facilitator said, “It’s a mixed bag. I mean, it’s very rewarding in some ways, and other ways it’s traumatizing for sure”. She went on to say:

“I remember the first couple of weeks that I went in [to the jail] and I went into kind of a depression. It gave me a feeling of relief to learn more about secondary trauma, because I didn’t know what was happening with myself. And then I totally knew what was happening, and then having compassion for myself and realizing I needed self-care if I was going to continue this kind of work. And you do need self-care. And it’s kind of weird because almost every time when it’s my day to go in the jail, in the morning I have a sense of dread. But when I leave, I’m so happy and thankful I did it…. Sometimes when it’s super quiet in the jail or something, I get this thing that comes over me, and I’m like, ‘Oh, no, I did not want to be back here’. But definitely the traumatizing part is hearing the women’s stories. To hear from a woman that she has a seventh-grade education and she’s been abused from the age of two to 24. I have to really hold back the tears. It’s very overwhelming. And you understand that person. And I always want to physically embrace them, which I can’t [touching is not permitted in correctional settings], because that to me feels like the natural thing. And I just want to hug you so you can understand that somebody cares about you”.

Similarly, another facilitator stated, “It was hard. I didn’t realize until I stopped [facilitating classes] how much it was affecting me, how much you do hear from them and their stories. We used to always joke about binge eating after class, but we were doing that because it was affecting us”. She depicted an instance where a woman stayed after class and disclosed being sex trafficked [it is common for victims of sex trafficking to experience incarceration while being trafficked (Polaris 2024)]: “So that was a really hard day. I cried on the way home. She was so young. I didn’t know what to do except tell her it’s going to be okay”. When asked what kept her motivated to keep going into the jail, she responded, “The connections with the women. I learn from them too”. Another facilitator reflected on the first time she was incarcerated in jail: “The first time I was incarcerated, the very first time I was incarcerated, I think I was 18 years old, and they had this rec space. And we went out and this lady came in and she told her story. I was so moved. And just the chance to go back in, I was like, yes, yes, yes. I want to go back in. I want to do this”.

The way women detained in the jail were treated by correctional officers was also mentioned. One facilitator recalled having conversations with officers to educate them about the purpose of the program and sometimes receiving responses like, “No, they don’t want to change. They prefer to sleep the whole day”. The facilitator went on to say:

“The ladies don’t sleep well, don’t eat well. Many times, participants told me that some guards are really… they do things that are not good for them. They go in the middle of the night and open the doors and turn on the lights. This kind of thing they are super stressed about… this stuff increases the anxiety and fear they are already feeling. It is shocking to hear because the guards are seeing these ladies every day, they are seeing that they are crying, they are suffering. I know they probably did something bad, but they are humans. It was so hard for me. I only listened to the guard, and I said, ‘Okay’. If you think that… ‘Okay’”.

Secondary trauma, vicarious trauma, and burnout are major issues among victim advocates, counselors, and others working with survivors of trauma (Baird and Jenkins 2003; Benuto et al. 2018). There exists a paradox where “victim service provision can be helpful to victims but harmful to providers” when providers experience symptoms of traumatic stress secondary to engaging with victims (Ellis and Knight 2021). Among this workforce, the current caseload and having a personal history of trauma exacerbates secondary trauma symptoms (Hensel et al. 2015), as women are reminded of their past trauma during advocacy and service work (Mihelicova et al. 2021). Women involved with the criminal legal system report high rates of physical and sexual violence during both childhood and adulthood, making the risk for secondary trauma heightened among peer facilitators working in jail settings (Karlsson and Zielinski 2020; Konecky and Lynch 2019; Saxena and Messina 2021).

3.2.6. The Use of Peers and Retraumatization Related to Incarceration

In addition to secondary trauma, peer facilitators described retraumatization related to their own history of incarceration. Formerly incarcerated facilitators were asked what it is like to enter jail as a “free” person. One facilitator said, “One thing I could tell you that got me every time I stepped in there was the smell. I couldn’t deal with the smell. It affected me. It really did affect me. I went back to therapy and everything because of it”. The interviewer asked her to explain, “What do you mean? What’s up with the smell?” The facilitator explained:

“Jail is not the same as prison. I am pretty sure most people know that, but when you go in there, the smell… It was the same smell. I don’t know how to explain the smell. It’s not a good smell and it’s not a bad smell, it’s just a constant stench that then it stays in your… It stayed in my nose like if I was still living in jail. I felt like every time I left there, I felt like I had that smell on me. It’s all closed up in there. You can’t open windows, you can’t… anything. It smelled like… it’s gross. It was gross”.

Another facilitator said, “Certain things would remind you [of your own incarceration]. You hear a door slam or when they bring in the [food] trays… And it makes you feel for [the women] even more. Some of them are there for a really long time. It’s crazy. And the food, they eat the same thing every day for lunch, every day. Bologna sandwich or peanut butter sandwich every day. And hygiene is so expensive for them. I even was like, can we give them hygiene kits as part of completing our class? Can we do something?” [The facilitator is referencing having to purchase basic hygiene products from the jail commissary at a higher markup than free world prices (Weill-Greenberg and Corey 2024)]. Similarly, one facilitator discussed the simple act of reminding herself that she does not have to walk behind the correctional officer but can walk beside them when being escorted:

“You’re used to walking behind the officer. You’re not supposed to walk beside them, you walk behind them and you walk to one side. I told myself: ‘You are not here as an inmate. You get to go home. You are an equal to the officer. You don’t have to walk behind them’. But I did it a couple times. I always catch myself… Your instinct was to walk behind them and then you’re like, ‘Oh, wait’. Like it’s instilled in you, and it was still there. That’s crazy. After so many years, it was still there”.

Formerly incarcerated peer facilitators were often “emotionally triggered” by seemingly banal aspects of the jail: hearing food trays, walking with correctional officers through hallways, etc. They often spoke of unique features of carceral life as being ingrained, even after long periods of time. Some advocates have described this phenomenon as “post-incarceration syndrome”, a syndrome similar to PTSD where people experience negative mental health effects associated with incarceration that continue long after their sentence is served (National Incarceration Association 2023; Quandt and Jones 2021). Having a supportive network of fellow peers wherein they could debrief and process was seen as a beneficial way to help allay retraumatization.

4. Discussion

In this study, Seeking Safety was delivered to five cohorts of women in jail across dozens of classes over a 10-month period. Our goal was to evaluate implementation outcomes as well as the barriers and facilitators to the implementation of the Seeking Safety program. From the participant’s perspective, the program was rated as acceptable, appropriate, and feasible for women in jail (all > 90%). Almost all women positively endorsed the program, and 100% would recommend the program to a friend. In open-ended questions, women noted that they liked being able to speak freely, being able to relate to the facilitators, and the skill-building they learned. While these findings are extremely positive, they are not representative of all 358 women who attended at least one class during the pilot period, and the small sample size limits our ability to draw conclusions. This is a limitation of the data but also an important implementation finding. It is not feasible to operate closed group classes in a jail with a low sentenced population. Therefore, flexible programming is required. Evaluation of clinical outcomes will be difficult and require complex research design with the ability to follow participants as they are assigned to new dorms, released to the community, or transferred to prison. Similar to the participants, program facilitators were positive about the program overall and enjoyed their work in the jail. However, they noted several implementation challenges related to the jail context as well as ways in which they attempted, sometimes successfully, to overcome these challenges. Below, we outline some “lessons learned” for future implementation of Seeking Safety in jail settings.

4.1. Implementation Strategies

4.1.1. #1: Obtain Buy-in and Identify Champions at All Levels of Jail Staffing

Increasing internal champion support is critical for the ethical delivery of Seeking Safety in jails. Despite having a formal memorandum of understanding in place, program facilitators described how correctional officers were hugely impactful on program implementation and could hinder or help the facilitation of classes. Floor officers appear to have a lot of power in how dorms are operated and in determining how the program fits within the dorm. Sometimes, indifferent or hostile correctional officers could derail classes by turning the facilitator away and cancelling classes or requiring the class to be held in loud, public spaces. On the other hand, correctional officers who were supportive helped to grow the program by expanding classes to new dorms and helping program facilitators. The mandatory rotation of officers across dorms meant that facilitators had to constantly reintroduce the program and work on building new relationships.

Having champions at higher levels of administration was clearly helpful. However, findings demonstrate the importance of better communication between administration and floor officers. In particular, reinforcing how programming is prioritized in the dorm relative to other activities would likely improve implementation. Conducting educational meetings with correctional officers is another potential strategy to ensure smooth implementation and a method for identifying additional champions. Finally, facilitators described that they did not always feel comfortable challenging correctional officers’ decisions when they interfered with program delivery. A communication policy involving jail administration as mediators may help in these instances.

4.1.2. #2: Co-Develop Implementation Processes with Impacted Jail Staff

Security processes at the jail were a major barrier to program implementation. Delays in being escorted to dorms by correctional officers often shortened class time. Not being able to hold class in private spaces damaged class cohesion and reduced attendance. The restriction on women from keeping class handouts likely limited the impact of the program. The lack of private meeting spaces for class also raises serious ethical concerns about the ability to implement Seeking Safety in this jail. Co-developing implementation processes with the staff who will be most impacted by the addition of Seeking Safety may help to address these barriers. This could be performed with identified correctional officer champions, such that programming better “fits into” current security processes. This was conducted to some extent in the current study (e.g., conducting security checks of course materials ahead of class start, scheduling classes around meal times and mandatory counts) but could also be improved (e.g., working with the jail to allow facilitators to walk from the security checkpoint to class unescorted).

4.1.3. #3: Provide Ongoing Training for Facilitators Specific to Seeking Safety and Jail Setting

Peer service providers are vital to a variety of recovery services (Gaiser et al. 2021). Stigma from other professionals, poorly defined roles and role confusion, and lack of professional support has historically hindered the successful integration of peers into service teams, while working in highly central recognized positions mitigates these barriers (Siantz et al. 2018). Organizational support for peers is necessary and can be achieved through the provision of regular supervision that is recovery-oriented and trauma-informed with reasonable accommodations (Gagne et al. 2018).

Interviews with peer facilitators suggest that additional training related to developing skills for using one’s life story and lived experience in the context of delivering Seeking Safety could reduce role conflict. The jail was described as “chaotic”, requiring adaptation to the unpredictability of daily life in jail, for which peer facilitators were well prepared given their lived experience. For example, program facilitators described instances when classes were cut short, class supplies were not available, or something “emotional” was occurring in the dorm that was distracting participants. Peer facilitators were able to be spontaneous, change the curriculum, or sometimes ditch the curriculum altogether to best serve participants that day. To be sure, peer facilitators are working in the best interest of participants, drawing upon their own experiences and ability to relate to the stressors of living in jail. The flexibility of peer facilitators should be viewed as an asset that contributes to building a safe space for participants to feel heard and supported, facilitating an openness to exploring change through the lessons. Peer facilitators often shared “messages of hope” with their lived experience, including journeys to regaining custody of children after incarceration and successes in employment and education. Having a space for peer facilitators to share their lived experiences in connection to the curriculum is impactful. Yet, these adaptations raise concerns about maintaining fidelity to the Seeking Safety intervention in jail settings. Research suggests that recurring workforce training along with peer-led supervision are essential to support the effective employment of peers (Byrne et al. 2022). Developing standardized responses to disruptions and defining the role of peers and peer support in program delivery are essential to implementing Seeking Safety in jail settings.

4.1.4. #4: Conduct Regular Screenings for Traumatic Stress and Provide Ongoing Support

All facilitators discussed experiencing traumatic stress from hearing participants talk about their lives or witnessing the conditions in which women lived and were treated. Retraumatization among formerly incarcerated facilitators was also common. Secondary traumatic stress among service providers is associated with burnout and compassion fatigue (Baird and Jenkins 2003; Benuto et al. 2018) and is compounded by feelings of “lack of control” and organizational bureaucracy (Hensel et al. 2015; Kulkarni et al. 2013). It is imperative that peer facilitators receive additional training in traumatic stress and healthy coping behaviors. It is the responsibility of supervisors to implement regular screenings for symptoms of traumatic stress, burnout, and compassion fatigue and have clear organizational protocols in place to mitigate burnout and support the mental health of facilitators (Hockaday 2017). Resiliency training and monitoring (e.g., regular reminders of facilitator motivation, physical movement/exercise prompts, rest and relaxation “clocks”) can reduce compassion fatigue and provider burnout (Wood et al. 2017). The facilitators in this study described both positive (e.g., debriefing with colleagues (Maier 2023)) and negative (e.g., binge eating) coping behaviors and education on secondary trauma while also expressing strong motivation and commitment to continuing to provide programming. Nevertheless, more comprehensive training, screening, and support are necessary for the well-being of facilitators and to ensure the sustainability of Seeking Safety programming.

4.2. Conclusions

Seeking Safety is a safe, low-cost intervention focused on developing coping skills and is designed to be delivered by anyone. Our findings suggest that peer-led Seeking Safety is feasible, acceptable, and appropriate for women in jail. The facilitators did not report any negative events related to the intervention, and women who responded to an exit survey rated the program highly. Future implementations of Seeking Safety in jails should consider the lessons learned in this study.

Author Contributions

Conceptualization, K.M.M.N., D.L.E., K.N.C. and Ladies Empowerment and Action Program; methodology, K.M.M.N.; formal analysis, K.M.M.N., D.L.E. and K.N.C.; investigation, K.M.M.N.; resources, K.M.M.N. and Ladies Empowerment and Action Program; data curation, K.M.M.N. and Ladies Empowerment and Action Program; writing—original draft preparation, K.M.M.N.; writing—review and editing, K.M.M.N., D.L.E. and K.N.C.; supervision, K.M.M.N. and Ladies Empowerment and Action Program; project administration, K.M.M.N. and Ladies Empowerment and Action Program; funding acquisition, K.M.M.N. and Ladies Empowerment and Action Program. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of University of Miami (protocol code 20240526, 10 June 2024).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the qualitative portion of the study.

Data Availability Statement

Data are not publicly available due to the sensitive nature of the study. Please email the corresponding author for any inquiries.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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