Hoping against hope: The prison-to-community transition experience of men with co-occurring severe mental illness and substance use disorder

TLDR: In this paper, the authors explored the prison-to-community transition experience after short-term incarceration, from the perspective of men with co-occurring mental illness and substance use disorder in Queensland, Australia.

Abstract: This thesis explores the prison-to-community transition experience after short-term incarceration, from the perspective of men with co-occurring mental illness and substance use disorder in Queensland, Australia. A specific focus was to examine the impact of systems and structures on the individual experience of transition. Prior research has established that people with co-occurring mental illness and substance use are overrepresented in the Australian prisoner population. It is also known that transition from prison to community for the general custodial population is a time of vulnerability, with increased risk of substance use, homelessness, unemployment, reincarceration and post-release death. All of these risks are compounded for prisoners with co-occurring disorders who are also at risk of a range of poor criminal justice outcomes and losing contact with mental health services after release. Review of the literature indicates a tendency for research to focus on recidivism as an outcome and emphasise either individual risk behaviour or social and structural factors influencing prison-to-community transition. Interventions during transition for the current population have traditionally been based on the criminalisation hypothesis, with a focus on increased provision of mental health services in prison and an emphasis on continuity of care in the community. There is a growing recognition in the international literature that the issues are much broader than mental illness; however, there is a lack of clarity as to how to respond to the complex needs of this population. Research exploring the perspective of men with co-occurring severe mental illness and substance use disorder during their prison-to-community transition experience has rarely been undertaken. The conceptual framework developed for this study shifts the emphasis away from recidivism towards recovery and wellbeing through a lens of individual action, but only in the context of the potential for systems and structures to impact on the ability of individuals to exercise agency. A qualitative method was used comprising repeat in-depth interviews with 18 men: within 1 month prior to leaving prison, within 2 weeks post-release and at 3 months post-release. Three themes characterised the transition experience of participants: “hoping against hope”; “adrift in freedom”; and “the slippery slope”. Participants reported leaving the predictable and routine life in prison where they hoped for a better life after release, to an uncertain, unstable and isolated environment in the community, eventually sliding into drug use, chaos and despair. The risk environment framework (Rhodes, 2009) and structuration theory (Giddens, 1984) were employed to understand how participants were caught in a complex dynamic between their individual risk behaviour and broader structural risk environments. This thesis proposes that a web of interrelated factors contributed to participants in the study as “ambivalent agents” who were suspended between the two worlds of prison and community, with a sense of “non-belonging” in either world. They negotiated multiple and competing identities and were ultimately set up to fail in their hope for a normal life in the community by the “structuration” of risk during transition. The findings in this study support previous research that prison mental health services alone are inadequate to meet the needs of this population. There is a need for the review of parole practices for this population, with an emphasis on prevention of incarceration related to non-offending behaviour. In addition, a focus on the provision of comprehensive interventions during prison-to-community transition, such as supported accommodation, assisted employment and other individually tailored social supports, is indicated. These interventions, in combination with a focus on flow through integrated treatment services targeting the needs of short-term prisoners with co-occurring disorders may facilitate recovery and wellbeing in this population, improve continuity of mental health care on return to the community, as well as address criminal justice outcomes. These interventions should be planned as a whole of government response, framed by a mental health recovery approach that fosters belief in the individual for recovery, as well as utilising a collaborative focus on risk in terms of both “a risk” and “at risk” identities.

Figures

Figure 1: Historical and thematic diagram of literature and research exploring prison-to-community transition for people with severe mental illness.

Figure 6: Adrift in freedom.

Figure 3: The experience of prison-to-community transition.

Figure 4: Hoping against hope.

Table 2: Participant characteristics (n = 18)

Figure 5: Caught in a cycle.

Full text

Hoping Against Hope:
The Prison-to-Community Transition Experience of Men With
Co-Occurring Severe Mental Illness and Substance Use Disorder
Michelle Denton
Bachelor of Health Science (Nursing)
Master of Business Administration
A thesis submitted for the degree of Doctor of Philosophy at
The University of Queensland in 2014
School of Social Work and Human Services

ii
Abstract
This thesis explores the prison-to-community transition experience after short-term
incarceration, from the perspective of men with co-occurring mental illness and substance use
disorder in Queensland, Australia. A specific focus was to examine the impact of systems and
structures on the individual experience of transition. Prior research has established that
people with co-occurring mental illness and substance use are overrepresented in the
Australian prisoner population. It is also known that transition from prison to community for
the general custodial population is a time of vulnerability, with increased risk of substance
use, homelessness, unemployment, reincarceration and post-release death. All of these risks
are compounded for prisoners with co-occurring disorders who are also at risk of a range of
poor criminal justice outcomes and losing contact with mental health services after release.
Review of the literature indicates a tendency for research to focus on recidivism as an
outcome and emphasise either individual risk behaviour or social and structural factors
influencing prison-to-community transition. Interventions during transition for the current
population have traditionally been based on the criminalisation hypothesis, with a focus on
increased provision of mental health services in prison and an emphasis on continuity of care
in the community. There is a growing recognition in the international literature that the issues
are much broader than mental illness; however, there is a lack of clarity as to how to respond
to the complex needs of this population. Research exploring the perspective of men with co-
occurring severe mental illness and substance use disorder during their prison-to-community
transition experience has rarely been undertaken.
The conceptual framework developed for this study shifts the emphasis away from recidivism
towards recovery and wellbeing through a lens of individual action, but only in the context of
the potential for systems and structures to impact on the ability of individuals to exercise
agency. A qualitative method was used comprising repeat in-depth interviews with 18 men:
within 1 month prior to leaving prison, within 2 weeks post-release and at 3 months post-
release. Three themes characterised the transition experience of participants: “hoping against
hope”; “adrift in freedom”; and “the slippery slope”. Participants reported leaving the
predictable and routine life in prison where they hoped for a better life after release, to an
uncertain, unstable and isolated environment in the community, eventually sliding into drug
use, chaos and despair. The risk environment framework (Rhodes, 2009) and structuration
theory (Giddens, 1984) were employed to understand how participants were caught in a
complex dynamic between their individual risk behaviour and broader structural risk

iii
environments. This thesis proposes that a web of interrelated factors contributed to
participants in the study as “ambivalent agents” who were suspended between the two worlds
of prison and community, with a sense of “non-belonging” in either world. They negotiated
multiple and competing identities and were ultimately set up to fail in their hope for a normal
life in the community by the “structuration” of risk during transition. The findings in this
study support previous research that prison mental health services alone are inadequate to
meet the needs of this population. There is a need for the review of parole practices for this
population, with an emphasis on prevention of incarceration related to non-offending
behaviour. In addition, a focus on the provision of comprehensive interventions during
prison-to-community transition, such as supported accommodation, assisted employment and
other individually tailored social supports, is indicated. These interventions, in combination
with a focus on flow through integrated treatment services targeting the needs of short-term
prisoners with co-occurring disorders may facilitate recovery and wellbeing in this
population, improve continuity of mental health care on return to the community, as well as
address criminal justice outcomes. These interventions should be planned as a whole of
government response, framed by a mental health recovery approach that fosters belief in the
individual for recovery, as well as utilising a collaborative focus on risk in terms of both “a
risk” and “at risk” identities.

iv
Declaration by author
This thesis is composed of my original work, and contains no material previously
published or written by another person except where due reference has been made in the text.
I have clearly stated the contribution by others to jointly authored works that I have included
in my thesis.
I have clearly stated the contribution of others to my thesis as a whole, including statistical
assistance, survey design, data analysis, significant technical procedures, professional
editorial advice, and any other original research work used or reported in my thesis. The
content of my thesis is the result of work I have carried out since the commencement of my
research higher degree candidature and does not include a substantial part of work that has
been submitted to qualify for the award of any other degree or diploma in any university
or other tertiary institution. I have clearly stated which parts of my thesis, if any, have been
submitted to qualify for another award.
I acknowledge that an electronic copy of my thesis must be lodged with the University
Library and, subject to the General Award Rules of The University of Queensland,
immediately made available for research and study in accordance with the Copyright Act
1968.
I acknowledge that copyright of all material contained in my thesis resides with the copyright
holder(s) of that material. Where appropriate I have obtained copyright permission from the
copyright holder to reproduce material in this thesis.

v
Publications during candidature
No publications
Publications included in this thesis
No publications
Contributions by others to the thesis
No contributions by others
Statement of parts of the thesis submitted to qualify for the award of another degree
None

Frequently asked questions

Q1. What contributions have the authors mentioned in the paper "Hoping against hope: the prison-to-community transition experience of men with co-occurring severe mental illness and substance use disorder" ?

For example, Hartwell et al. this paper conducted a qualitative study focusing on the transition experience of prisoners with severe mental illness and co-occurring substance use disorder after repeated short-term imprisonment. 

Q2. What are the future works in "Hoping against hope: the prison-to-community transition experience of men with co-occurring severe mental illness and substance use disorder" ?

Kinner et al. ( 2013 ), for example, have combined longitudinal research with record linkage, and this method may prove useful in future research on prison-to-community transition. Hence a major challenge for future research is to investigate mechanisms to retain participants in research projects with this population, particularly post release, in order to gain further insight into the dynamics of social exclusion during the transition phase, that are potentially the same factors excluding them from the research. The direct impact on the target population of parole policy and practice, such as immediate revocation of parole and return to prison in response to minor drug use, or for breach of regulations such as failing to notify change of address or failing to attend appointments, requires further research. It has been hypothesised in this thesis and elsewhere that this may be occurring due to complex interrelated reasons including the broader impact of social exclusion, itinerant and chaotic lifestyle post release, lack of anchors in the community such as housing and employment and the desire to cut ties with anyone associated with the criminal justice system.