“He just came out of prison, and he is now on parole. I would not know how to even start working with him. We should refer him somewhere else.” Roberto articulated these words about a new patient and client, Abi, to Karen, his supervisor, who paused, looked at him and said, “It can be very anxiety provoking when doing something for the first time. Furthermore, working with justice-involved individuals has its set of challenges and it requires a set of skills, but it can be very rewarding. Let us talk about how you could successfully work with Abi.”
In the United States, 2.3 million individuals are involved in the criminal justice system, and one fourth of them are mentally ill.
Conversely, individuals with mental illness are three times more likely to be incarcerated than hospitalized; they are more likely to be incarcerated when compared with individuals with no mental illness, and at least forty percent of individuals with mental illness will have been incarcerated at least once in their lifetime. Nonetheless, as Karen told Roberto, working with justice-involved individuals has its set of challenges, requiring a set of skills, and, yes, it can be rather rewarding. There are, in fact, new strategies that we all can learn for effective work with justice-involved individuals with mental illness. But, prior to delving into these new strategies, let us first explore why it is crucial for all of us to learn them. Below are five reasons why.
1. Cultural appropriateness
I speak a lot about cultural appropriateness, which goes beyond how we have been taught to think about culture, because it often neglects the importance and power of subcultures. The subcultures to which I refer include individuals who use illicit substances, those who have been incarcerated, and those who have been part of gangs, or grew up in certain neighborhoods – they all may have their own subculture. This insight should be used to better understand our patients and clients. The main point here, for us to serve and make meaningful changes, we need to be culturally appropriate. The caveat, however, is that being culturally appropriate when working with justice-involved individuals may not come naturally, but it can be learned.
2. Meaningful change
For meaningful change to take place, a therapeutic relationship is required to first establish trust. Trust from the patient and client, but also from the clinician, advocate, or the social service worker. Additionally, for trust to be established, both parties need to feel safe, although establishing safety may not come naturally to many. When feeling safe is lacking, it is important to make an effort to understand why, so that the therapeutic relationship can be established. “He just came out of prison, and he is now on parole…” said Roberto, with fear in his voice. He did not feel safe, a required condition for meaningful change to take place.
3. Overcoming barriers
Roberto had his preconceived notions about Abi, a justice-involved individual with mental illness. We just do, and so do they. They think we are more likely to judge them, that we will perceive them as “bad,” “immoral,” “weak,” or simply “dangerous.” They also think that we are likely to think very lowly of them, that they will not amount to much, and that they are simply a waste of time. These are only some of the preconceived notions of the justice-involved individuals with mental illness, especially when they come to our agencies, willingly or unwillingly. And these are barriers to overcome, if we are to work with them in a meaningful way.
4. Recidivism risk
As I mentioned above, individuals with mental illness are three times more likely to be incarcerated than to be hospitalized; they are more likely to be incarcerated than are individuals with no mental illness, and almost half of them are expected to be incarcerated at least once in their lifetime. Recidivism risk is the likelihood of committing a crime after already committing one previously. While the more serious the crime, the less likely it is to be repeated, it has been shown that individuals do tend to recidivate, committing a different crime, though often less serious. The sad and crucial aspect of all this is the fact that recidivism risk is highly associated with undiagnosed or poorly treated mental illness, which in turn can be associated with clinician’s (and some organizations) limited skills in engaging and successfully working with this patient population. Learning new strategies to working with justice-involved individuals with mental illness will ultimately allow us to decrease the risk of recidivism for our justice-involved patients and clients.
5. Public safety
Related to recidivism risk is public safety, which is equally relevant to all of us, if not more. A general violence risk assessment takes skill, but additional skills are required for a violence risk assessment for the justice-involved population. Part of the reason for this relates to biases on the part of the clinician, which can lead to reactive in lieu of responsive interventions. Additional reasons, when working with this population, it takes some specialized skills in assessment, in question framing, and in engagement.
“He just came out of prison, and he is now on parole. I would not know how to even start working with him. We should refer him somewhere else.” Roberto articulated these words about a new patient and client, Abi, to Karen, his supervisor, who paused, looked at him and said, “It can be very anxiety provoking when doing something for the first time. Furthermore, working with justice-involved individuals has its set of challenges and it requires a set of skills, but it can be very rewarding. Let us talk about how you could successfully work with Abi.”
Whether you are seeing your first justice-involved patient and client or your one-hundredth, a specific set of skills and essential strategies are required for effective work. Here are five reasons why:
1. Cultural appropriateness
2. Meaningful change
3. Overcoming barriers
4. Recidivism risk
5. Public safety
This is a population that carries many challenges, but effectively working with them can be very rewarding, if we learn and master the new strategies to working with justice involved individuals.
May your work continue to be rewarding and meaningful.
References:
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Wang, E.A., White, M.C., Jamison, R., Goldenson, J., Estes, M. and Tulsky, J.P. Discharge planning and continuity of health care: findings from the San Francisco County Jail. American Journal of Public Health. 2008;98(12):2182-2184.
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Bureau of Justice Statistics, US Department of Justice. Correctional Populations in the United States, 2014. December 2015.
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Drucker E. A plague of prisons: the epidemiology of mass incarceration in America. New York (NY): The New Press; 2011.
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Institute of Medicine, National Research Council. Health and incarceration: a workshop summary, Washington (DC): National Academies Press; 2013.
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Spaulding AC, Seals RM, McCallum VA, Perez SD, Brzozowski AK, Steenland NK. Prisoner survival inside and outside of the institution: implications for health-care planning. Am J Epidemiol. 2011;173(5):479–487.