Working with incarcerated clients in a prison setting presents several challenges. As with people in the community, those in prison settings with co-occurring AOD and mental health conditions often experience a range of complex, long-term problems and have likely come into contact with numerous services in the past. In general, people in contact with the justice system are more likely to be socially and economically disadvantaged, experience higher rates of homelessness and unemployment, have a history of imprisonment or previous criminal involvement, and have experienced childhood neglect and/or trauma compared to those in the general community [1851–1854]. There is evidence to suggest that incarceration can exacerbate previous traumatic experiences through environmental triggers (e.g., discipline from authority figures, strip searches), institutionalised racism, lack of connection to culture for Aboriginal and Torres Strait Islander people, separation from children or family, or further exposure to trauma in prison [389, 1855–1857].
The most recent Health of Australia’s Prisoners survey conducted in 2018, found high rates of AOD use and mental disorders compared to the general population [1851]. Two in five prisoners (40%) had been previously diagnosed with a mental health condition, including an AOD use disorder, and just under one in four (23%) were currently taking medication for their mental health, most commonly antidepressants. People entering prison were twice as likely to be experiencing high or very high levels of psychological distress compared to the general population (26% vs 13%), and 21% reported a history of self-harm. There is evidence that people in prison are 10 times more likely than the general population to have experienced suicidal ideation and previous attempts in the past year [1858]. Due to this elevated risk of suicide and self-harm, conducting risk assessments is especially important (see Chapter B4, Chapter B5).
Also common among people entering prison are smoking (75%) and poor physical health, with 30% reporting experiencing at least one chronic physical health condition (including arthritis, asthma, cancer, cardiovascular disease, diabetes), and 28% reporting that their physical health causes significant psychological distress [1851]. Rates of blood-borne viruses such as hepatitis B and C are higher than in the general community [1851], which is likely due to the lack of available sterile injecting equipment [1859, 1860]. Harm minimisation strategies for AOD use, such as only re-using personal injecting equipment to minimise the risk of blood borne viruses, should be encouraged [389].
As with clients who have been coerced into treatment, AOD treatment within the prison environment may present an opportunity which incarcerated clients had not previously considered. It is important for the AOD worker to positively frame the opportunity for treatment and maintain a positive attitude, hope and optimism. Many of the treatment principles for working with people who are incarcerated are similar to those for working with coerced clients. Importantly, any limits of confidentiality should be outlined clearly and early on, as they may differ to limits within community settings [389]. Due to the inherent power imbalances and structures of correctional settings, AOD workers may need to make additional efforts to engage an incarcerated client and build a trusting, therapeutic relationship, which are key to good outcomes [117–119]. Clients may experience difficulties establishing a trusting environment and may disclose information slowly to gauge worker reactions [1861]. As with coerced clients, the role of educational and motivational interventions may require more attention.
Given the high rates of trauma exposure among incarcerated clients, a trauma-informed approach should be adopted (see Chapter B2; [389]), bearing in mind that clients in prison settings may not feel safe to disclose the details of their trauma history. With regard to treating PTSD, the majority of research conducted among prisoners has focused on present-/non-trauma-focused therapies [1862]. As with community samples, past-/trauma-focused therapies appear to be more effective, but implementation is challenging in a setting that does not provide a safe and consistent environment within which trauma processing can occur [1862]. With regard to treating PTSD among prisoners with a history of co-occurring AOD use disorders, research to date has been limited to pilot studies of the present-/non-trauma-focused therapy Seeking Safety, conducted among female prisoners in the US [1863–1865] and male prisoners in Australia [1866], all of which have positive preliminary evidence supporting its acceptability.
There are also significant challenges associated with release from prison, including transitioning from a controlled environment with routine and stability, finding accommodation and employment, managing finances on a low income, returning to the same peer groups, risk of overdose, and returning to communities with few opportunities [1867, 1868]. The 2018 Health of Australia’s Prisoners survey found that one in three people were homeless in the month prior to incarceration, and less than half had stable accommodation arranged post discharge [1851]. It can also be difficult for some people who were able to access AOD and mental health care in prison to access the same care in a community setting [1851, 1868]. Linking in with post-release services and coordinating with community-based treatment, where appropriate, may help clients transition into the community. In fact, having access to effective interpersonal support, community-based resources, employment, secure housing, continuity of care throughout the release process, and enrolment in treatment programs are protective factors following release from prison [1869–1872], and many of these factors can be targeted or addressed prior to release [1873].