Introduction
The US criminal justice system is marked by large disparities in the health outcomes of the incarcerated population. Increasingly, due to overcrowding and biased institutional policies, imprisoned people receive fewer health interventions but encounter more barriers to health access, privacy, and quality than the general population. Improving care using new interventions based on evidence can help resolve this disparity and achieve better outcomes for this population.
Vulnerable Group, Social Determinant(s) of Health, and Health Disparity
Identification and Description
The vulnerable population used for this analysis is incarcerated individuals. Social determinants of health, including unemployment, poor housing, low socioeconomic status, prejudice, stigma, and gender-relevant violence, are strong predictors of poor mental health among minority populations that have been disproportionately incarcerated (Sugarman et al., 2020). Besides, the punitive nature of the prison setting, solitary confinement, and barriers to access to behavioral care aggravate their mental health status. They receive fewer diagnostic tests and interventions for mental health conditions and behavioral problems such as substance use disorder (SUD) than the general, representing a disparity in healthcare.
Local, National, and/or Global Incidence Statistics
The burden of mental health among incarcerated people differs widely by region and race. Overall, the burden of SUD and mental illness is higher in incarcerated individuals than in the general population (Sugarman et al., 2020). In Hennepin County, Minnesota, the rate of SUD and mental health disorders is 66.5% and 55.3% in incarcerated individuals compared to 8.1% and 14.4% in the general population, respectively (Olson et al., 2021). Racially, white adults under incarceration or probation were about 1.5 times more likely to be diagnosed with SUD or mental illness than blacks.
In comparison, in Minnesota, the number of incarcerated African Americans is about ten times that of whites (Olson et al., 2021). As a result, the burden of poor mental health is high in black inmates. The imprisonment rate in the US is among the highest globally, at 655 per 100,000 persons compared to Russia’s 328.1 per 100,000 inhabitants (Sugarman et al., 2020). Because of the high incarceration rate, the burden of poor mental health is higher among US inmates than the general population, representing a health disparity that needs to be resolved.
Concept of Social Justice
Social and economic disadvantages are inextricably linked to crime and health-related problems. Unemployment, low literacy levels, and substance abuse are disproportionately high in poor communities and minorities, contributing to increased offending rates. As a result, in the US, the number of African Americans and Latinos imprisoned is 5.1 and 1.4 times that of whites, respectively (Olson et al., 2021). This disparity represents a social justice issue, as the burden of disease is higher in the incarcerated group than in the general population.
Appropriate Theory for the Project
Good self-care is crucial to meeting physical and mental health needs, especially in prison settings. Dorsey’s Theory of Self-care Management is selected to guide this project, which aims to provide care to the incarcerated population vulnerable to SUD, depression, and anxiety. This theory posits that chronic conditions predispose patients to factors that aggravate their vulnerability (Gobeil-Lavoie et al., 2019). These factors may be modifiable, e.g., income, literacy level, and housing, or non-modifiable, e.g., age, ethnicity, and sex.
In nursing care, vulnerability is considered a consequence of limited community support and individual resources. Incarcerated patients with mental illness may face access barriers to mental health. They may feel distrusted and stigmatized by providers, reducing their willingness to seek help. This behavior impedes self-care management, aggravating mental health conditions.
Self-care management is reflected through therapeutic behaviors and initiating activities that promote personal well-being. According to the Self-care Management Theory, self-care is achieved by cultivating key skills and behaviors, such as self-efficacy and assertiveness, and exploiting available social supports to improve one’s health status (Gobeil-Lavoie et al., 2019). Incarceration can be a traumatic experience due to punitive rules and restricted freedoms. Thus, self-care while being imprisoned can help inmates cope with this corrective system. It will help build better support networks with fellow convicts, prison staff, and family. Therefore, an intervention utilizing Dorsey’s Theory of Self-care Management will enhance the self-care capacity and coping mechanisms of incarcerated individuals, improving their mental health.
Brief Literature Review
The prevalence of mental illness is high in the US incarcerated population. Canada et al. (2022) evaluated challenges to the utilization of mental health services in US prisons. They established that programs promoting better interactions with prison officers could protect against stressors and stigma in the US correctional systems. In this qualitative study, participants reported cumbersome procedures and staff shortages as key access barriers to mental health services. Access to self-help groups and appointments with psychologists and psychiatrists were considered to help reduce substance dependence. Overall, mental health care received in correctional facilities was not perceived to be patient-centered, accessible, safe, or adequate. Addressing access barriers, perceived limited staff, and safety during treatment will increase engagement in mental health services to achieve better mental health outcomes among inmates.
Psychosocial interventions have also been used with incarcerated patients with mental illness. A systematic review by Thekkumkara et al. (2022) found “motivational intervention, cognitive behavior therapy, positive psychology intervention, and music therapy” could ameliorate depressive symptoms, anxiety, and SUD in inmates (p. 214). Additional secondary outcome measures obtained using these interventions included increased motivation and reduced aggressiveness and reoffending. Thus, non-pharmacological interventions can improve the mental health outcomes of inmates with SUD, depression, or dual diagnoses.
Besides psychosocial programs, some correctional facilities offer medications for SUD. Krawczyk et al. (2022) interviewed prison officers in New Jersey’s incarceration system and measured current practices in the pharmacological management of SUD. They found that medications are widely used in this setting to treat opioid use disorder. Notably, linkage to community-based treatment was provided to inmates upon their release. However, barriers such as the suspension of Medicaid for incarcerated individuals limit the continuity of care (Krawczyk et al., 2022). In addition, limited resources and strict regulations affect the delivery of this intervention in community settings.
Project Intervention
The proposed intervention involves a mindfulness-based program for incarcerated patients with SUD and other mental illnesses. As a skill, mindfulness enables individuals to self-regulate their awareness uncritically, embracing current sensations, thoughts, and emotions. A structured mindfulness-based mediation project will be implemented with minority prisoners in two sessions, teaching them how to positively regulate their emotional states. In Session 1 (three weeks), participants will be taught loving and be kind to oneself before extending kindness to others. Mindfulness-based meditation will be used to build these values over several weeks. Session 2 (two weeks) will focus on discussions on how to create and maintain a healing environment. The goal of the training is to help each prisoner discover what works for him or her.
Good self-care leads to a better relationship with oneself and other people. The proposed intervention is related to the self-efficacy and assertiveness concepts of the self-care management theory (Gobeil-Lavoie et al., 2019). By training prisoners how to self-regulate their thoughts and emotions, they will learn to hold internal peace. The prison experience can be traumatic due to various stressors. Learning how to care for one’s mind and body is essential to coping. The mindfulness training project will improve the capacity to self-regulate mood and stress, reducing anxiety and worry among prisoners.
After the intervention, self-reported perception of self-care skills will be measured via a survey and be compared with the baseline. The primary outcomes of self-caring that will be evaluated include the capacity to treat oneself with love and kindness, practice self-care to meet personal needs, create a caring environment, and cherish one’s beliefs and values.
Differences from Past Interventions
The proposed mindfulness training differs from other psychosocial interventions implemented with incarcerated populations as it emphasizes self-care. Self-help groups and psychotherapy sessions were shown to alleviate substance dependence, but coping with stressors in the prison environment requires self-care and self-regulation skills (Canada et al., 2022). In contrast, mindfulness is a patient-centered approach to help inmates cope with life in prison. Compared to other psychosocial interventions, such as CBT and music therapy, which have been used with inmates to treat depression, mindfulness meditation training may produce lasting effects because it builds self-efficacy. By teaching minority inmates this technique, this project will reduce the disparity in mental health in this population, which is overrepresented in correctional facilities.
Conclusion
Incarcerated individuals have a disproportionately high burden of mental illness. In addition, minority populations are overrepresented in the US prison system, which is characterized by access barriers to psychiatric or psychological care. To address this disparity, mindfulness meditation training is proposed for prisoners with SUD and other mental illnesses. This project is designed to enhance their self-regulation skills to cope with prison stressors.
References
Canada, K., Barrenger, S., Bohrman, C., Banks, A., & Peketi, P. (2022). Multi-level barriers to prison mental health and physical health care for individuals with mental illnesses. Frontiers in Psychology, 13, 1-11. Web.
Gobeil-Lavoie, A., Chouinard, M., Danish, A., & Hudon, C. (2019). Characteristics of self-management among patients with complex health needs: A thematic analysis review. BMJ Open, 9(5), 1-5. Web.
Krawczyk, N., Bandara, S., Merritt, S., Shah, H., Duncan, A., McEntee, B., Schiff, M., Ahmad, N. J., Whaley, S., Latimore, A., & Saloner, B. (2022). Jail-based treatment for opioid use disorder in the era of bail reform: A qualitative study of barriers and facilitators to implementation of a state-wide medication treatment initiative. Addiction Science & Clinical Practice, 17(30), 1-12. Web.
Olson, M., Shlafer, R. J., Bodurtha, P., Watkins, J., Hougham, C., & Winkelman, T. N. A. (2021). Health profiles and racial disparities among individuals on probation in Hennepin County, Minnesota, 2016: A cross-sectional study. BMJ Open, 11(9), 1-9. Web.
Sugarman, O. K., Bachhuber, M. A., Wennerstrom, A., Bruno, T., & Springgate, B. F. (2020). Interventions for incarcerated adults with opioid use disorder in the United States: A systematic review with a focus on social determinants of health. PLoS ONE 15(1), 1-14. Web.
Thekkumkara, S. N., Jagannathan, A., Muliyala, K. P., & Murthy, P. (2022). Psychosocial interventions for prisoners with mental and substance use disorders: A systematic review. Indian Journal of Psychological Medicine, 44(3), 211-217. Web.