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Getting Out and Staying Out: Making Discharge Planning Work

Summer 2011

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Tracy Mack

Over 600,000 people are released from state and federal prisons every year. But unless they are prepared for life "on the outside" and get the support they need, chances are they will return to their former behaviors and possibly to prison. In addition, people with HIV have specific needs that must be addressed if they are going to make the transition successfully.

To try to understand this complex process, I interviewed Tracy Mack (pictured at right), Director of Transitional Services and HIV Testing at Exponents, a community-based organization in New York City.

When should discharge planning start?

If it starts when a person enters the system, the outcome will be better, since a lot of the process is based on trust. If I'm an inmate and I meet with a discharge planner, I have to believe that you care about me before I'm able to care about me. And even if I don't care about me, the fact that you care makes a difference. I might just be engaging in the process for you, but once I get involved in it, I'm going to stay.

Unfortunately, the system is now run by government agencies, and they don't have the staff to invest the time needed to facilitate that change. Behavior is one of the hardest things to change, and if you only give a person five to ten minutes, that's not enough. If there's a community-based organization working in the prison that calls them down twice a week, they can build a relationship. They can trust the process and we can give them the time they need to digest all the information, answer questions, address their fears, and distinguish what's factual from myths. Currently, the system is not set up to do that. They can't spend that quality time with people.

You have to take the time to get the person invested in the process.

Absolutely. They have to believe that their life is going to improve if they do things differently: "If I do this, then this may happen for me." Often you have to want things for them that they may not realize they want. It's often just about being there -- setting up another appointment, creating structure. Structure is needed. You don't want to act like a correctional officer, but you have to have boundaries in place. Let them know that there are certain things they have to do in order to receive services. You don't want to hit them in the head, though -- you have to be loose, but structured.

What role do former inmates play?

Sometimes we bring in former inmates to do discharge planning, and it makes a difference Some inmates think that unless you've been there, you can't possibly help them. If I say, "You can do this," they'll respond, "Yeah, right -- you tell everyone that." But once they know that the person they're sitting next to in a support group came from the same penitentiary, knew that same prison guard, lived in the same dorm, and once they got out they got their GED or even Masters degree and became a substance use counselor, they're like, "Wow -- I can do that too." And sometimes we're able to disclose, if it will help -- if you're HIV positive and I'm positive, I can share that.

You can't hit your head against a wall until a client is ready to take positive steps. You have to provide them with the support mechanisms that facilitate that change. And it's not going to happen overnight. Some people come out with a plan: "I'm sick and tired of this and I'm not going back in. I really want to get my act together and do the right thing." But others just aren't ready. And that's okay, as long as you let them know the consequences of not being ready.

For example, one of my first clients had a long history of incarceration and substance use. I was really green -- I wanted to save the world. I held his hand, I was present for him. But he just wasn't ready. He had other ideas. He stopped using drugs so he could fulfill his probation requirements, but as soon as he got off probation he went right back to using. I was crushed. I stuck with him, thought about it, and finally realized what the harm reduction process needs. I hadn't asked him what he wanted. Once I did, and found a way to fulfill the needs he articulated, he was able to make progress. Today, he has four years clean and hasn't been back to prison. But that took a good year and a half of work.

How long does follow-up need to continue?

It's open-ended. Some people know what they're going to do, they have things in mind, and they're insistent on attaining them. For others, it's a longer process. They may get sticky fingers -- they still don't get the concept of paying for things they want; they need instant gratification. Substance use is a major issue, as well as mental health. We've had people who've attended every one of the twelve programs we run. Others just want to use a few of our services. They may go in and out of our program, but we always invite them back. There's no close date.

So clients come to you with a range of issues -- not just their health.

Yes, and we know those issues. Of course, we believe that people with HIV should get into care as soon as possible. But if they're homeless, that might be the issue they need to address first. Or "I'm using drugs and I want to continue to use, so I can't commit to taking meds or going to a doctor regularly." Or "I live with my family and I can't start treatment because God knows they're going to find out somehow." Some of these problems are very delicate and take time to resolve. For example, the housing program in this city may send you to places that are not conducive to well-being. We try to find a place clients can feel good about.

You also have to work on a person's self-worth. If I don't feel good about myself, or if I have mental health issues, my HIV is irrelevant, especially if I'm not sick. Sometimes providers forget to ask clients, "What is it that you want?" I think if they did that more, rather than worrying about their agenda or their deliverables, they'd have better outcomes. If we engage them and invite them into the process, they'll be more apt to do what's needed. Now they can care about what they think and even if they say, "No, I don't want to see a doctor. I don't want to take meds. I still want to see you on a weekly basis, but right now I want adequate housing. I want the support groups and your training program, but I'm not ready to talk about being HIV positive." And I say, "That's okay. When you are ready to talk about your HIV, I'm here. And I may ask about it every time. And if you accept that, cool." I find if I take that approach, those walls will come down.

I recently went to a meeting with some bigwigs from the Department of Health. They wanted to change the whole process of how they deal with the mentally ill coming out of jail. All these wonderful, smart policymakers -- but not once did anyone say, "Let's ask the clients what they need."

I've had people who are eager for care when they're inside: "I want your services. I want to connect to a provider." But then they jump out of the transport van at a red light as they are being brought to me after release. That's probably because other issues were not addressed, and health care was not one of their priorities. "I want to get laid, I want to smoke, I want to shoot some dope." If they have issues other than their health, we have to address those other needs first.

But the current system is not set up for that. It doesn't provide that comfort level and that level of safety. There was a time when community-based organizations did the discharge planning, and I think that worked a whole lot better than the way it is today. Now you have Department of Health care coordinators. They make appointments for people, but they send them to random places. Why don't they ask the person where they want to go? They may have a provider or place they like. I think if community-based organizations were more involved in the discharge planning process, the rate of connection would be higher.

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This article was provided by ACRIA and GMHC. It is a part of the publication Achieve. Visit ACRIA's website and GMHC's website to find out more about their activities, publications and services.
See Also
More on the Incarcerated and HIV

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