Theme: Mental Health
SECTION CONTENTS:
During the facilitated group discussions, we focused on mental health issues that the participants may have experienced during or after their incarceration. We asked about helpful resources in addressing mental health issues. We explored the role of peer mentors and learned about experiences that each individual had with various forms of peer support. Finally, we examined how it worked if they required prescribed medications to address their mental health issues. Here we present a series of themes that emerged from the participants’ collective responses. Each theme (a bulleted statement in boldface) is supported by direct quotes from the participants.
From the Facilitated Group Discussions: Mental Health
And I’m currently in therapy right now. I’m seeing a therapist . . . who understands the background that I come from, and who is able to help me, coach me through some of the complications I’m experiencing, the long-term effects of incarceration. And it gives me the space to walk through a plan to develop how I’m going to approach my mental health issues. So I want to say that and be very transparent that this is a subject that we have to talk about because . . . some of us, not all of us, have been impacted by our mental health.
- Many individuals described a variety of feelings—reluctance, disinterest, opposition—that kept them from seeking counseling or therapy while incarcerated. The participants described a general lack of engagement with mental health treatment services while incarcerated, partially due to a reluctance to seek out treatment support. As one person noted, “I didn’t seek mental health [services] in there. Kicking myself that I didn’t. I had such a skewed vision of those people.” Another person indicated that having counseling after getting out was quite helpful, but while incarcerated “I kind of went against it a lot.” Still another person expressed:
Before I came home, I didn’t trust any of the staff psychologists, psychiatrists. There was absolutely no trust there as far as I was concerned. They were simply another arm of the DOC [Department of Corrections] and therefore they were not to be trusted.
- If they desired counseling or therapy while incarcerated, most individuals reported on the barriers to availability. We heard from many participants that there seemingly was a lack of availability of treatment resources. The participants described feeling as if the prison did not prioritize access to mental health treatment. One person remarked:
As long as you’re getting up every day, doing your detail and doing what you got to do, they don’t care nothing about your mental health. . . . They’d send you back out in the street crazy as a box of rocks.
Even when they tried to arrange for treatment services while incarcerated, it was not clear how to demonstrate enough need to receive the services. “You would have to have real signs. And even if we had post-traumatic stress disorder [PTSD] and our symptoms weren’t like every day, they wouldn’t see us.” As one person described, “There was no such thing as going to see a therapist once a week or to talk to a counselor. If you were already prescribed mental health meds upon arrest and/or conviction, then the doctor there would continue the prescriptions.”
- Yet some were able to find support outside traditional, clinical forms of mental health treatment. Among those responding to the poll questions, only 22% said that resources were arranged to address their mental health concerns. To the extent that some individuals experienced support to cope with mental health issues, it came from nonclinical sources. For instance, we heard from one participant that “when I was incarcerated, the only thing that was available that helped my mental health were the twelve-step meetings that they were allowing to come in and the Bible study.” Another major source of support that was instrumental in helping individuals cope while incarcerated was in the form of peer mentoring and other self-initiated support groups. For example, “When I couldn’t find anyone to talk to, I created a support group. And so, we started our own support group of women who were being released so that we could have someone to talk to.” These support networks often began in prisons and jails and continued after release. One participant noted, “I still talk to my peer support people that are in prison. I still write to them. They call me . . . and we talk about . . . what it’s like for me out here now.” Finally, one participant described, “And it’s interesting; the people that actually helped me were people that were actually researchers, and they were people doing research who were able to ask me questions that made me think and helped me to find some help.”
- Incarceration is traumatic and can affect the mental health of individuals even after their release. Many of the men and women who participated in the group discussions described having mental health issues that predated their period of incarceration. They also made clear, though, that the experience of incarceration itself was traumatic. The internalization of being in such an institution was described by one participant as follows:
And it took about a year for me to recognize postincarceration syndrome . . . and it took me longer than that to recognize the symptoms in me and the hypervigilance. And what became normal inside, we bring home, and we think it’s normal.
As another participant noted, “You’re coming out of a forest of trauma.” Others described some of the horrific incidents that are hard to leave behind when released from incarceration. Among those responding to the poll questions, 86% said they never received assistance to address mental health issues related to incarceration. One of the women in one group discussion related her experiences about being pregnant while incarcerated:
I ended up going to segregation and still did not receive prenatal care. When I did go to have my baby, I was chained and shackled and . . . I think nine, 10 hours after I gave birth, they took me back to the prison.
Another female participant described, “I watched a number of women attempt to take their lives over the time that I was incarcerated in some really gruesome ways, and that affected my mental health.”
Connecting with others while incarcerated could be an important protective factor. One participant noted, “Human interaction with people that are compassionate and have empathy for your situation . . . goes a long way for people that are locked up.” Yet, prison can be isolating and can undermine the ability to connect with others in healthy ways after release. Some participants reported having spent substantial periods in solitary confinement. As one described, “In itself, just the effects of solitary confinement on mental health is unparalleled.”
- The adjustment process in the transition from incarceration to the community is stressful and anxiety inducing. The experience of leaving prison also was frequently traumatic. As one participant put it, “The process of being incarcerated is traumatic. And the process of coming home is twice as traumatic.” Another participant noted, “What a lot of people don’t understand is that especially when you’ve done a lot of time, getting out is a traumatic event.” The disorientation that many felt when released is captured in the following quote from one participant:
I was a mess. When I first got out, I was so confused, and I didn’t know really what I wanted to do with myself, and I didn’t really have the means to do anything. I was also scared. I was being shipped back out there with, and I started having anxiety really bad, and being around people was hard for me because I just was secluded in this little box for so long.
- Receptiveness to seeking treatment or taking the initiative to ask for help is a sign of growth that happens across time, typically after incarceration. Therapeutic support services made a difference in many instances. As one participant indicated:
Over the years, I figured out that if I’m going to get anything done, I’m just going to have to show up somewhere and be like look, I’m crazy as hell, I need help. But back then, 20 years ago, I didn’t know how to do that.
Another participant explained, “I didn’t seek mental health in there. Kicking myself that I didn’t. I had such a skewed vision of those people.” Getting to the point where they could recognize they needed help and seeking out resources was often a turning point, and we heard time and again how helpful the results were. One man described taking advantage of no-cost services in conjunction with his job: “When I joined the union, part of the health package is the EAP, employee assistance package. So, I went and got five free sessions or whatever, and it was amazing how much I learned just in those five sessions.” Another participant described the benefit of having access to a therapist at the right time: “In the end, it was probably a good thing and a very good thing for me for that time period because once I started, I stopped bucking it and just went with it. She was very helpful.”
- Finding a therapist who was a good fit for the individual client often was the reason for positive change. For instance, one participant explained:
I’m seeing a therapist who understands the background that I come from, and who is able to help me, coach me through some of the complications I’m experiencing, the long-term effects of incarceration. And it gives me the space to walk through a plan to develop how I’m going to approach my mental health issues.
Finding the right fit can take some time. One participant shared:
When I came home, I sought mental health treatment. I finally found a former correctional officer, who’s now a therapist, who married a formerly incarcerated person, so it was a perfect mix, but it took me over a year to find it.
Others stressed how important it was to find a therapist who was “culturally sensitive” and “trauma informed.” In our group discussions, we heard about the positive experiences when Native Americans were connected with the American Indian Prison Project and the Native Specific Outpatient Treatment Program, as well as the good fortune when one Black participant was connected to “one of the most renowned family therapists at the church that I was attending. And she specialized in the African American family and the reunification after prison.”
- The participants rarely described treatment services that exemplified continuity of care spanning the period from prelease to postrelease; instead, we heard more about the role of community-based organizations, including reentry programs, in connecting the participants with mental health treatment providers. As described by the participants, finding the right match for treatment options often was a function of the availability of culturally responsive options and support from community-based organizations. Some community-based providers were providers of housing and other reentry supports. One female participant pointed to the good fortune of finding effective treatment when she arrived at a:
sober living home . . . they’re very resourceful. The case manager had advised me about therapy there, and I’ve been doing therapy ever since I got out, and I never used to believe in psych meds and stuff. And I’ve started those.
Sometimes access to mental health treatment was facilitated by employment, as described earlier. We also heard from some participants who made connections to treatment providers through their informal networks. For instance, one participant relayed that:
my faith-based community and support system being in place really helped with mental challenges like anxiety and starting over and being able to deal with rejection of certain people who say they are welcoming for those returning back into the community.
- Peer mentoring support, when available, was highly valued and effective. Having the support of a person with lived experience was strongly praised by those who have participated in such support, either as the mentor or the mentee. Here is the perspective from one participant:
I have a mentor that I meet with . . . I just need someone that I can feel safe and confiding in and talking to about what I’m really feeling and going through. And it’s been a great help for me to be able to call her up, email, text her, and tell her, “Look, I need to talk.”
This is the perspective from another participant:
I still meet with a peer counselor to this day. . . . It helped navigate the stresses of postrelease and acclimating back in society . . . it has helped tremendously as far as seeing someone that’s been there in my situation, who I view as successful and who has made it.
- In the absence of formal peer mentoring programs, many took the initiative to develop programs or establish connections with informal mentors in their community. As impressive as peer mentoring programs appear to be, we heard from many participants that these programs are not widely available in all jurisdictions. As one participant noted:
All the programs that I was in promised, basically, that you would have a peer coach and a mentor when you got out. And they all failed to deliver on that. But that’s something that I really want. I think I have an informal mentor, so I’m really lucky about that. Just somebody that I met when I was in the work program when I was inside that worked for the actual company I was working for.
Others reported developing support groups with others prior to their release. As one man described:
There was a bunch of us guys who all had around 20 years, all of us transitioning out at the same time, and then we stayed in touch as we were released, and we all, basically, were having these issues. Everything’s a crisis as you experience it. And we formed a group together to basically support one another.
In another instance, one of the women in another group discussion described a women’s support group she helped to organize: “We just started asking professional women who were clinicians, practitioners, academics, entrepreneurs. We asked them to come in and talk to us.” Finally, as another participant noted, having positive peer support was a potential buffer against the inevitable influence of negative peers:
I’m a big proponent of peer support, and I’m impartial because I started an organization that does that. But to have someone that walked in my shoes and be able to have that connection when I come home, someone that understands, because our families don’t understand. No one understands what we’re going through. And if we don’t have that positive peer support, we’re going to go to the negative peer support because we have that mutuality.
- Access to prescription medication for mental health issues while incarcerated was characterized by difficulties due to lengthy waiting periods to see a doctor and misalignment of care to previous diagnoses and prescriptions. There were many challenges or complaints about the provision of medications for mental health issues while incarcerated. One participant noted as follows:
It’s like a one pill fits all type policy they have in there. They just give older, cheaper drugs to everyone. And we meet with the mental health doctor, you have three to five minutes and then he diagnoses you and throws you to the wolves.
Others struggled to get any mental health care at all. One person described, “Mental health is not one of their specialties. I was not able to be prescribed my mental health medication while I was incarcerated. I wasn’t even able to see a doctor until a month and a half later.” One complicating factor is that many people, while incarcerated, are looking to receive psychotropic medications without a diagnosable mental health disorder. This makes it harder for those with a true need to receive the appropriate care. As one person indicated, “If you’re legitimately trying to find medication that you need while you’re in there, good luck to you.” Finally, when some participants reported that they were able to receive prescription medications while incarcerated, one person shared, “They were not the correct mental health medications that I needed. It wasn’t until after I was released then I met with a private psychologist that I actually found medicine I needed.”
- It was common to have a 30-day supply of prescribed medications at the time of release, but this was not always coupled with referrals and connections to ensure no gaps in supply once they were back in the community. We heard about a range of experiences across the different jurisdictions and systems in which individuals had been under correctional supervision. At one end of the spectrum, one participant described that “we got a 30-day supply that they had something that paid for through the government or whatever. But then, yeah, she made a really big point to make sure that I did my Medicaid application right away.” At the other end of the continuum, another participant explained as follows:
If you were already prescribed some meds, you get the remainder of the month of your blister pack of meds, and then it’s good luck. There were no appointments set up . . . It’s total like you have to navigate this really complex system on your own after you’ve experienced new trauma right from your experience being incarcerated.
- Access to correct medications for mental health conditions may be difficult to arrange, may not be easy to sustain over time, and appears to depend on where the individual is living after their release. Some of the immediate challenges involve lining up the resources, including funding and prescriptions, to ensure the ability to maintain the necessary dose of medication, which were complicated by how much of a supply of medication was provided, and how easy it is to find a doctor or therapist to issue a new prescription that is accepted by local pharmacies that accept Medicaid. One participant described:
getting ahold of medication once out, I would say in my state is fairly easy if there is not a wait-list, and there’s a provider available that accepts your insurance. For a long time, a lot of providers didn’t because the state owed them so much money. But things are getting better now.
In other cases, we heard about some short-term arrangements that can end before alternative or permanent arrangements are in place. One participant explained, “Yes, it needs to be longer than what they give it to you. They give it to you for a month, three months, maybe, and then you got to re-up and re-up and re-up. It’s just a hassle.” There is not always careful coordination between the corrections facility and the available resources in the community. In one instance, we heard that “The prescription that come[s] from Department of Correction, the street doctors will not accept it. And they want full payment if you don’t have Medicaid.” Yet, some individuals were fortunate to be connected to reentry programs with their own resources. As one participant described:
I actually have been put on psych meds since I’ve been out, and it was very easy to get. My therapist is the one that referred me to this place, and it doesn’t matter if you have insurance or not; they will help you. They’re funded by grants, this place.
Recommendations
In their descriptions about how reentry works or how to improve conditions so that reentry success is possible, individuals in the group discussions provided numerous recommendations related to mental health.
- There is not enough attention to helping individuals heal from trauma while incarcerated. Many individuals experience trauma prior to incarceration, and most will have traumatic experiences while incarcerated. It is critical to offer effective services that bring about healing and improvement to well-being.
- There is a need to expand the availability of peer support services both prior to and after release to the community. People who have been incarcerated are influenced by their peers, and it makes sense that resources are in place so that peer support is positive, effective, and accessible.
- The transition from a very controlled setting to an unstructured environment can be disorienting, stressful, and even overwhelming. Ideally, everyone would have holistic support so that they have resources to address mental health and well-being issues.
- It is usually not a surprise when a person will be released from incarceration, so there should be a lot more integrated planning to make the transition from incarceration to the community potentially seamless, in terms of the continuity of mental health treatment services.
- Expand the availability of culturally relevant and competent services. Resources should be provided to ensure that these services are responsive and accessible.
- Participants were specific that it would be helpful if treatment and reentry providers used more trauma-informed approaches in their care.
Reentry should be about authentic second chances. Some suggested extending “ban the box” campaigns to include applications for treatment programs.
Implications for Stakeholders
Based on what we heard from participants, we present potential implications of our takeaways for reentry providers, correctional administrators, policymakers, and funders.
Based on what we learned from these group discussions, there are several takeaways for reentry providers. Most importantly, comprehensive initiatives are vital. Those in reentry need support in multiple ways:
- A continuum of care for mental health issues, including substance use disorders and treatment to address incarceration-affected post-traumatic stress disorder.
- Equity of access for all gender, racial, and ethnic subgroups for all services.
- Seamless continuity of care for those on medication.
- Engagement of individuals in peer mentoring (as both mentors and mentees).
- Effective strategies to support the adjustment process as individuals transition from incarceration back to the community.
The group discussions also produced several takeaways for correctional administrators, including offering better access to mental health treatment for those who are incarcerated and ensuring access to health records for everyone.
The themes and recommendations from these conversations also point to ways that legislators and policymakers might improve the reentry experiences for those who were previously incarcerated. Further consideration of ban the box initiatives for access to treatment services might have an important impact.
Based on the conversations with men and women who were previously incarcerated, funders interested in building the capacity for effective reentry might consider investments for peer support programs.
Download the Mental Health Discussion PDF
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