Continuity of mental health care: If the ties with community treatment are not cut, they don’t have to be reconnected.

From numerous studies, we know that people who are imprisoned consistently present poorer (mental) health compared to the general population (Vander Laenen & Audenaert, 2017; Kinner et al., 2018). These (mental) health problems are often already present before incarceration, and due to the deprivations in prison these problems increase. Still, an inclusive and qualitative treatment offer for people in detention is lacking. Treatment interventions in prisons in EU member states still do not adhere to the principle of equivalence as described in international recommendations by the United Nations General Assembly, UNAIDS/WHO and UNODC (Enggist et al., 2014).

The central issue is that, even if people get medical treatment and psychosocial support before their imprisonment, entry into prison often leads to a discontinuation of that support/treatment (worst case scenario) or they must start over support/treatment with a new professional (‘best’ case scenario). Knowing the importance of building trust and the impact of the therapeutic relationship, even the best care scenario is far from ideal. Moreover, most (mental) health care professionals in prison are not working in community treatment services, and even if they do, the chances of being able to receive support/treatment by the same professional after detention are slim. After several months/years of imprisonment, the person who is incarcerated, transitions to the community, and often, again, there is a cut in the continuity of care.

The recommendations of The Lancet Commission on global mental health and sustainable development (Patel et al., 2018) explicitly suggest that special consideration should be given to strengthening and expanding high-quality care and continuity of care in prisons.

Still, fundamentally, prison is no therapeutic environment and nor will it ever be (Beaudry et al., 2021). Moreover, substance use and mental health problems particularly challenge the re-integration of people after imprisonment, despite (fragmented) efforts to implement through- and aftercare initiatives in several European prisons (McDonald et al., 2012; Vandevelde et al., 2020). Many obstacles in realizing continuity of care for detained persons with substance use and mental problems are reported in the literature due to the specificity of the prison context (Fazel et al., 2016; Vandevelde et al., 2020). Moreover, we know that particularly people with complex mental health needs are strong advocates for continuity of care givers, more so then for continuity of care (De Ruysscher, 2019).

The ‘solution’ to this problem is surprisingly simple. For people with mental health and substance use problems, if we don’t discontinue the support and treatment in the community, we don’t have to reconnect it.  If small-scale forms of incarceration are integrated in the community, people can continue their support in that community, with the care giver they know and trust. Of course, this does require that sufficient geographically spread community-integrated forms of incarceration exist, to avoid discontinuity of support and treatment by a trusted counsellor/treatment service.  

Yet, one might reproach these arguments by stating that studies have found that some people are diagnosed for the first time in prison and that prison is the first location where they receive any type of support/treatment (Fazel & Baillargeon, 2011). For instance,  in a Belgian study on drug treatment in prison, we found that one in three people with substance use problems came into contact with drug treatment for the first time while in prison (Vandevelde et al., 2016). Again, there is no reason why these unmet (mental) health needs would not surface in small-scale forms of incarceration, especially in view of their tailored, holistic focus on the person’s different life domains.

References

• Beaudry, G., Yu, R., Perry, A., & Fazel, S. (2021). Effectiveness of psychological interventions in prison to reduce recidivism: a systematic review and meta-analysis of randomised controlled trials. The Lancet Psychiatry, 8, 759-773.
• De Ruysscher, C. (2019). Unravelling recovery : a qualitative study rooted in the lived experiences of persons with complex mental health needs, PhD Thesis. Gent: Ghent University, Faculty of Psychology and Educational Sciences.
• Enggist, S., Møller, L., Galea, G., & Udesen, C. (2014), Prisons and Health. Copenhagen: WHO Regional Office for Europe.
• Favril, L., Vander Laenen, F., & Audenaert, K. (2017). Psychiatrische morbiditeit bij gedetineerden in Vlaanderen. Panopticon, 38(4), 231-245.
• Fazel, S., & Baillargeon, J. (2011). The health of prisoners. Review. The Lancet, 377(9769), 956-965.
• Fazel, S., Hayes, A.J., Bartellas, K., Clerici, M., &Trestman, R. (2016), Mental health of prisoners: prevalence, adverse outcomes, and interventions, The Lancet Psychiatry, 3(9), 871-881.
• Kinner, S., & Young, J. (2018). Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis. Epidemiologic Review, 40(1), 4-11.
• MacDonald, M., Williams, J., & Kane, D. (2012). Barriers to implementing throughcare for problematic drug users in European prisons. International Journal of Prisoner Health,8(2),  68-84.
• Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., Chisholm, D., Collins, P.Y., Cooper, J.L., Eaton, J., Herrman, H., Herzallah, M.M., Huang, Y.Q., Jordans, M.J.D., Kleinman, A., Medina-Mora, M.E., Morgan, E., Niaz, U., Omigbodun, O., Prince, M., Rahman, A., Saraceno, B., Sarkar, B.K., De Silva, M., Singh, I., Stein, D.J., Sunkel, C. & Unutzer, J. (2018). The lancet commission on global mental health and sustainable development. The Lancet, 392(10157),  1553-1598.
• Vandevelde, S., Vander Laenen, F., Vanderplasschen, W., et al. (2016). PRocess and Outcome Study of Prison-basEd Registration points (PROSPER): report. Brussels: Belgian Scientific Policy.
• Vandevelde, S., Vander Laenen, F., Mine, B., Maes, E., De Clercq, L., Deckers, L., & Vanderplasschen, W. (2020). Linkage and continuity of care after release from prison: An evaluation of Central Registration Points for drug users in Belgium. International Journal of Prisoner Health,17(1), 19-30.