Incarceration places people at high risk for substance use disorders and mental health concerns and vice versa. Yet, formerly incarcerated people face profound barriers in access to treatment. This study seeks to understand these experiences from the perspective of formerly incarcerated individuals themselves.
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There is a strong association between poorer mental health and imprisonment. Substance use disorders and other psychiatric conditions are common among people who are incarcerated, with an estimated 2 million people with mental illness and substance use disorder being booked into jails every year. Incarceration may exacerbate existing problems, as the conditions of confinement may lead to worsening mental illness and substance use disorder. Upon release from incarceration, formerly incarcerated people experience perceived and actual barriers to treatment engagement and entry. Barriers to such recovery capital interferes with successful and sustained recovery. Although these associations are well-documented through empirical research, less is known about the specific barriers formerly incarcerated people face. Qualitative research is one methodological approach informed by open ended conversations with key stakeholder groups (in this case, formerly incarcerated people) about treatment needs and barriers, which can be a useful tool for increasing access to care. This study seeks to understand these experiences from the perspective of formerly incarcerated individuals themselves.
The study was conducted using a community participatory research model seeking input from community stakeholders. 25 people (16 men, 9 women) over the age of 18 released from incarceration within the last five years and self-reporting engagement with mental health services were invited to complete private, 45–90-minute interviews in Providence, Rhode Island. Respondents were asked open-ended questions about their experiences navigating mental health care post-release. Themes emerging in interviews were used to guide future interviews. Interviews were independently coded by three researchers and then reconciled through discussion until intercoder agreement was achieved. Identification of themes were focused on the individual’s mental health conceptualization and barriers to service engagement identified through grounded theory approach to qualitative interviewing.
Over the course of the qualitative interviews, five themes emerged.
1) High Adjustment Burden, Low Support:
First, interviewees noted the overwhelming demand of life post-incarceration, such as juggling medical appointments, searching for employment and housing, and meeting parole requirements, while receiving very little practical support. Such responsibilities can interfere with mental health treatment engagement, either by necessity or due to feeling obligated to prioritize more basic need relative to mental health care.
2) Little Focus on Needed Recovery Resources Outside of Medication or Treatment:
Second, interviewees reported that the fragmentation of services represented a major barrier to care. Interviews shared disappointment in seeking services to find that the scope of services was narrower than what was necessary, focusing primarily on treatment or medication management but providing no assistance with housing or other case management services. Ultimately, this led to the perception that providers did not understand the individuals’ circumstances, another barrier to treatment engagement.
3) Lack of Focus on Basic Needs:
Third, interviewees noted homelessness, unemployment, and difficulties with insurance access as barriers to treatment engagement. Some interviewees reported being in survival mode and not having time for mental health. This led to frustration with being offered treatment, such as medication, as a solution to their mental health when they understand their problems as driven by housing insecurity. Further, interviewees reported difficulties with securing employment due to a history of incarceration. The authors reported that “double binds,” or using substances to help achieve financial stability needed to engage with care, which also undermined engagement with care—were common throughout the interviews.
4) Poor Discharge Planning Including the Types and Roles of Needed Providers:
Fourth, interviewees reported frustration with an “opaque” healthcare system that they found difficult to navigate. Interviewees reported limited discharge planning when leaving prison despite feeling the need for guidance. They also reported uncertainty about the type of provider they need, and in some cases, uncertainty about the roles of providers that are currently on their team.
5) The Role of Faith and Family:
Fifth, interviewees shared that faith and family buffered against negative mental health.
The study findings may be best conceptualized through the lens of research in recovery capital, which refers to the collection of resources that collectively enhance and bolster recovery and include the domains of social, physical, human, and cultural capital.
People with a history of incarceration likely face multiple barriers to physical capital, including housing, employment, and adequate mental health treatment, that interferes with successful engagement with mental health treatment for psychiatric disorders and substance use disorders. Although there may be mental health care resources available to formerly incarcerated people, deficits in physical recovery capital may need to be addressed alongside treatment to adequately address concerns. A failure to address such issues may interfere with treatment through multiple pathways, including through “double binds” and financial need or ruptures in the patient-therapist therapeutic relationship. Despite these barriers, High levels of other types of recovery capital, such as social capital, may buffer against deficits in physical capital, and bolstering all types of recovery capital may still confer benefits. However, it is also important to note that physical capital may be necessary, but not sufficient to facilitate successful recovery; providing resources to access physical capital while continuing to provide and enhance mental health treatment access may produce additive or multiplicative effects beyond the efficacy of either approach individually.
At a systems level, criminal justice systems may reduce recidivism through effective case planning upon discharge. Interviewees reported difficulties in coordinating access to mental health care in the midst of the challenging and overwhelming demands of life post-incarceration. Creating a concrete plan that incorporates the needs and wants of the individual may increase the likelihood that mental health treatment is accessed. Further, systems of care that carefully articulate levels of care and roles of providers and connect their patients with resources may have greater treatment success and engagement.
In addition to treatment and therapy, people who are formerly incarcerated and seeking treatment may benefit from additional services, such as a case manager or social worker to assist navigation of treatment and life post-incarceration. Addressing basic needs such as housing may increase the success of treatment and reduce the risk of future episodes of incarceration.
Nishar, S., Brumfield, E., Mandal, S., Vanjani, R., & Soske, J. (2023). “It’s a revolving door”: understanding the social determinants of mental health as experienced by formerly incarcerated people. Health and Justice, 11(1), 1-9. doi: 10.1186/s40352-023-00227-8
l
There is a strong association between poorer mental health and imprisonment. Substance use disorders and other psychiatric conditions are common among people who are incarcerated, with an estimated 2 million people with mental illness and substance use disorder being booked into jails every year. Incarceration may exacerbate existing problems, as the conditions of confinement may lead to worsening mental illness and substance use disorder. Upon release from incarceration, formerly incarcerated people experience perceived and actual barriers to treatment engagement and entry. Barriers to such recovery capital interferes with successful and sustained recovery. Although these associations are well-documented through empirical research, less is known about the specific barriers formerly incarcerated people face. Qualitative research is one methodological approach informed by open ended conversations with key stakeholder groups (in this case, formerly incarcerated people) about treatment needs and barriers, which can be a useful tool for increasing access to care. This study seeks to understand these experiences from the perspective of formerly incarcerated individuals themselves.
The study was conducted using a community participatory research model seeking input from community stakeholders. 25 people (16 men, 9 women) over the age of 18 released from incarceration within the last five years and self-reporting engagement with mental health services were invited to complete private, 45–90-minute interviews in Providence, Rhode Island. Respondents were asked open-ended questions about their experiences navigating mental health care post-release. Themes emerging in interviews were used to guide future interviews. Interviews were independently coded by three researchers and then reconciled through discussion until intercoder agreement was achieved. Identification of themes were focused on the individual’s mental health conceptualization and barriers to service engagement identified through grounded theory approach to qualitative interviewing.
Over the course of the qualitative interviews, five themes emerged.
1) High Adjustment Burden, Low Support:
First, interviewees noted the overwhelming demand of life post-incarceration, such as juggling medical appointments, searching for employment and housing, and meeting parole requirements, while receiving very little practical support. Such responsibilities can interfere with mental health treatment engagement, either by necessity or due to feeling obligated to prioritize more basic need relative to mental health care.
2) Little Focus on Needed Recovery Resources Outside of Medication or Treatment:
Second, interviewees reported that the fragmentation of services represented a major barrier to care. Interviews shared disappointment in seeking services to find that the scope of services was narrower than what was necessary, focusing primarily on treatment or medication management but providing no assistance with housing or other case management services. Ultimately, this led to the perception that providers did not understand the individuals’ circumstances, another barrier to treatment engagement.
3) Lack of Focus on Basic Needs:
Third, interviewees noted homelessness, unemployment, and difficulties with insurance access as barriers to treatment engagement. Some interviewees reported being in survival mode and not having time for mental health. This led to frustration with being offered treatment, such as medication, as a solution to their mental health when they understand their problems as driven by housing insecurity. Further, interviewees reported difficulties with securing employment due to a history of incarceration. The authors reported that “double binds,” or using substances to help achieve financial stability needed to engage with care, which also undermined engagement with care—were common throughout the interviews.
4) Poor Discharge Planning Including the Types and Roles of Needed Providers:
Fourth, interviewees reported frustration with an “opaque” healthcare system that they found difficult to navigate. Interviewees reported limited discharge planning when leaving prison despite feeling the need for guidance. They also reported uncertainty about the type of provider they need, and in some cases, uncertainty about the roles of providers that are currently on their team.
5) The Role of Faith and Family:
Fifth, interviewees shared that faith and family buffered against negative mental health.
The study findings may be best conceptualized through the lens of research in recovery capital, which refers to the collection of resources that collectively enhance and bolster recovery and include the domains of social, physical, human, and cultural capital.
People with a history of incarceration likely face multiple barriers to physical capital, including housing, employment, and adequate mental health treatment, that interferes with successful engagement with mental health treatment for psychiatric disorders and substance use disorders. Although there may be mental health care resources available to formerly incarcerated people, deficits in physical recovery capital may need to be addressed alongside treatment to adequately address concerns. A failure to address such issues may interfere with treatment through multiple pathways, including through “double binds” and financial need or ruptures in the patient-therapist therapeutic relationship. Despite these barriers, High levels of other types of recovery capital, such as social capital, may buffer against deficits in physical capital, and bolstering all types of recovery capital may still confer benefits. However, it is also important to note that physical capital may be necessary, but not sufficient to facilitate successful recovery; providing resources to access physical capital while continuing to provide and enhance mental health treatment access may produce additive or multiplicative effects beyond the efficacy of either approach individually.
At a systems level, criminal justice systems may reduce recidivism through effective case planning upon discharge. Interviewees reported difficulties in coordinating access to mental health care in the midst of the challenging and overwhelming demands of life post-incarceration. Creating a concrete plan that incorporates the needs and wants of the individual may increase the likelihood that mental health treatment is accessed. Further, systems of care that carefully articulate levels of care and roles of providers and connect their patients with resources may have greater treatment success and engagement.
In addition to treatment and therapy, people who are formerly incarcerated and seeking treatment may benefit from additional services, such as a case manager or social worker to assist navigation of treatment and life post-incarceration. Addressing basic needs such as housing may increase the success of treatment and reduce the risk of future episodes of incarceration.
Nishar, S., Brumfield, E., Mandal, S., Vanjani, R., & Soske, J. (2023). “It’s a revolving door”: understanding the social determinants of mental health as experienced by formerly incarcerated people. Health and Justice, 11(1), 1-9. doi: 10.1186/s40352-023-00227-8
l
There is a strong association between poorer mental health and imprisonment. Substance use disorders and other psychiatric conditions are common among people who are incarcerated, with an estimated 2 million people with mental illness and substance use disorder being booked into jails every year. Incarceration may exacerbate existing problems, as the conditions of confinement may lead to worsening mental illness and substance use disorder. Upon release from incarceration, formerly incarcerated people experience perceived and actual barriers to treatment engagement and entry. Barriers to such recovery capital interferes with successful and sustained recovery. Although these associations are well-documented through empirical research, less is known about the specific barriers formerly incarcerated people face. Qualitative research is one methodological approach informed by open ended conversations with key stakeholder groups (in this case, formerly incarcerated people) about treatment needs and barriers, which can be a useful tool for increasing access to care. This study seeks to understand these experiences from the perspective of formerly incarcerated individuals themselves.
The study was conducted using a community participatory research model seeking input from community stakeholders. 25 people (16 men, 9 women) over the age of 18 released from incarceration within the last five years and self-reporting engagement with mental health services were invited to complete private, 45–90-minute interviews in Providence, Rhode Island. Respondents were asked open-ended questions about their experiences navigating mental health care post-release. Themes emerging in interviews were used to guide future interviews. Interviews were independently coded by three researchers and then reconciled through discussion until intercoder agreement was achieved. Identification of themes were focused on the individual’s mental health conceptualization and barriers to service engagement identified through grounded theory approach to qualitative interviewing.
Over the course of the qualitative interviews, five themes emerged.
1) High Adjustment Burden, Low Support:
First, interviewees noted the overwhelming demand of life post-incarceration, such as juggling medical appointments, searching for employment and housing, and meeting parole requirements, while receiving very little practical support. Such responsibilities can interfere with mental health treatment engagement, either by necessity or due to feeling obligated to prioritize more basic need relative to mental health care.
2) Little Focus on Needed Recovery Resources Outside of Medication or Treatment:
Second, interviewees reported that the fragmentation of services represented a major barrier to care. Interviews shared disappointment in seeking services to find that the scope of services was narrower than what was necessary, focusing primarily on treatment or medication management but providing no assistance with housing or other case management services. Ultimately, this led to the perception that providers did not understand the individuals’ circumstances, another barrier to treatment engagement.
3) Lack of Focus on Basic Needs:
Third, interviewees noted homelessness, unemployment, and difficulties with insurance access as barriers to treatment engagement. Some interviewees reported being in survival mode and not having time for mental health. This led to frustration with being offered treatment, such as medication, as a solution to their mental health when they understand their problems as driven by housing insecurity. Further, interviewees reported difficulties with securing employment due to a history of incarceration. The authors reported that “double binds,” or using substances to help achieve financial stability needed to engage with care, which also undermined engagement with care—were common throughout the interviews.
4) Poor Discharge Planning Including the Types and Roles of Needed Providers:
Fourth, interviewees reported frustration with an “opaque” healthcare system that they found difficult to navigate. Interviewees reported limited discharge planning when leaving prison despite feeling the need for guidance. They also reported uncertainty about the type of provider they need, and in some cases, uncertainty about the roles of providers that are currently on their team.
5) The Role of Faith and Family:
Fifth, interviewees shared that faith and family buffered against negative mental health.
The study findings may be best conceptualized through the lens of research in recovery capital, which refers to the collection of resources that collectively enhance and bolster recovery and include the domains of social, physical, human, and cultural capital.
People with a history of incarceration likely face multiple barriers to physical capital, including housing, employment, and adequate mental health treatment, that interferes with successful engagement with mental health treatment for psychiatric disorders and substance use disorders. Although there may be mental health care resources available to formerly incarcerated people, deficits in physical recovery capital may need to be addressed alongside treatment to adequately address concerns. A failure to address such issues may interfere with treatment through multiple pathways, including through “double binds” and financial need or ruptures in the patient-therapist therapeutic relationship. Despite these barriers, High levels of other types of recovery capital, such as social capital, may buffer against deficits in physical capital, and bolstering all types of recovery capital may still confer benefits. However, it is also important to note that physical capital may be necessary, but not sufficient to facilitate successful recovery; providing resources to access physical capital while continuing to provide and enhance mental health treatment access may produce additive or multiplicative effects beyond the efficacy of either approach individually.
At a systems level, criminal justice systems may reduce recidivism through effective case planning upon discharge. Interviewees reported difficulties in coordinating access to mental health care in the midst of the challenging and overwhelming demands of life post-incarceration. Creating a concrete plan that incorporates the needs and wants of the individual may increase the likelihood that mental health treatment is accessed. Further, systems of care that carefully articulate levels of care and roles of providers and connect their patients with resources may have greater treatment success and engagement.
In addition to treatment and therapy, people who are formerly incarcerated and seeking treatment may benefit from additional services, such as a case manager or social worker to assist navigation of treatment and life post-incarceration. Addressing basic needs such as housing may increase the success of treatment and reduce the risk of future episodes of incarceration.
Nishar, S., Brumfield, E., Mandal, S., Vanjani, R., & Soske, J. (2023). “It’s a revolving door”: understanding the social determinants of mental health as experienced by formerly incarcerated people. Health and Justice, 11(1), 1-9. doi: 10.1186/s40352-023-00227-8
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