Getting Out and Staying Out: Making Discharge Planning Work
What do you do with clients who do get into care but have heard horror stories about HIV meds?
I had a client who was really ambivalent about the meds and I wound up sharing with him that I had just started them myself. And he counseled me! He walked me through the process and that enabled him to eventually go on the meds himself, because of that trust factor. He realized that everyone is different, that this is not 15 years ago, and that there are a lot of new meds with fewer side effects. I think because we talked about those things and read so much, he was able to base his decision on factual information. He wasn't being "informed" by misinformed people. We went through this together, and that made him feel safe. Both of us are still on the same meds and neither one of us had any side effects! It was a trust thing: If you could do it, I can do it. If it doesn't work, we can talk about the options, but let's do this together. You need to almost make a pact with people. It's "each one, teach one."
How does disclosure affect the process?
Some clients hide their HIV status while in prison, but they feel safe here so they disclose. And they worry that if they have to go to the city's HIV/AIDS Services Administration, they might see somebody they know. That can be a problem if they haven't disclosed to anyone outside of our program. Luckily, now we have clinics that treat a broad range of illnesses, so we don't have to send them to an HIV clinic.
I had a client the other day who was concerned about the family cat. He said, "I haven't told my family that I'm positive. How do I not mess with the litter box? They're going to question me." We tried to give him some options, because it's not about us telling him when to disclose. It's about helping him take care of himself. If we get them to care for themselves, that will allow them to care for other people, too.
What about people who don't tell their sex partners?
Sometimes I just want to say, "Man, do the right thing!" One of my clients was a sex worker. On the inside, he was having a lot of sex, just to pass the time. When he came out, he was sleeping with his wife and with other women, but he would not disclose. When I asked if he used condoms, he said it "depended". I tried to engage him -- not just about the disclosing part, not what he did while he was in prison, but, "Hey, how about using a condom for your own safety?" And I want to believe that he's gotten better with that -- when I've asked again, he says, "I'm doing good." But "good" means a lot of different things. He may use a condom three times out of five, but that's better than no times out of five.
And the earlier that conversation happens, the better. If there are peer programs in prison where they feel comfortable enough to talk, that's great. In one of our programs, Project START, we do that from the very beginning. We talk about risk reduction and being safe. So when they come out, they've heard this idea, they know how to protect themselves and others. Because once they get out, they may have a whole other agenda. In prison, we have a captive audience. They don't mind coming down for the counseling. But once they're out, they're going to do what they want to do. So if the safer sex counseling can happen prior to release, I certainly think the outcome will be better.
Is it easier for clients to talk to a peer as opposed to service providers?
The power division in correctional institutions is very clear. The staff doesn't care about anything except keeping order. So I can't act like I'm a correctional officer -- I'm not your parole officer. I have to make it clear that we're in this together. It's not about you against me or me against you. It's an "us" thing. Then the client says, "Wow, you're inviting me in this process?" You know, I've actually seen care plans done without the client. How do you create a care plan without the client being there, and expect them to sign off on it? That's insane! So I engage them from the very beginning and let them know this is a partnership -- it's not about me being in control and you following my lead. It's about, "What steps will you take to address your needs and how can I assist you?"
In prison, it's all about being manipulative, about telling people what they want to hear. It's about trying to be safe: "I don't want you to be mad at me." It's the "bad parent, good parent" thing -- always trying to please the person in power, to be good. Surprisingly, it's often the person who acts out and has problems that makes progress. I'm more concerned about the people who always do what they're supposed to do. How do you not act out in the process of growth? It has to be uncomfortable -- it is uncomfortable.
People who are institutionalized get so conditioned to say the right things. I've had clients who've been to every program in the city, so they know exactly what providers are going to ask and they know the right answer -- the answers that are going to meet their needs at that moment. It becomes a game: Who's going to blink first? So I have to be very clear: "Hey, I've been there, I know what's up." And in the end, the reality is that I work for you. Your provider, your doctor -- they work for you. You're empowered here. We try to facilitate that understanding.
A lot of clients come in with a poker face, with the intent to play the game. But once they get here, they realize they don't have to. They can be real and vulnerable and still get their needs met, and they won't be looked at as "less than". They can't be vulnerable and fearful in jail. They have to either wash people's clothes and act like a doormat or fight back and maybe get cut. They don't believe there's a happy medium. So they come to places like Exponents and begin to see things differently.
I had a client who said, "Wow, you laugh a lot in here." I said, "We do. We do a lot of work, but we laugh a whole lot more than not." And he kept coming back. I think it made a difference. At other places, it was all about, "Where's your Medicaid card? You must be here on this day at this time." But we have fun here, and people aren't used to that. You don't have to pretend here, and people aren't used to that. And once they know that, we can't get rid of them!
If you were king of NYC, how would you improve transition services?
That's a tall order! Well, first, I would make sure that housing was available for everyone who needed it, along with job training and placement services. Support groups would be part of the transition for addicts, alcoholics, people with HIV or HCV, and any other serious problems. I would almost mandate that, but I don't feel anyone should be forced to do anything. If you want something to work, the person has to buy into it. So let's say I'd make it a strongly recommended "condition" of release.
I would make community-based organizations a part of the discharge planning once again. Condoms would be distributed freely inside prisons. And inmates would receive the same standard of medical care that is expected on the outside, from doctors who are experienced in HIV and HCV. I would immediately end the color-coding of medical charts and create private spaces for clinic visits, to protect confidentiality. And I would end the segregation and ghettoization of people with HIV and HCV. That doesn't work -- education does. Finally, medicines would not be withheld due to cost, and would be provided for at least 30 days after discharge.
If we really took discharge planning seriously -- beginning it as soon as people enter the system and continuing it as long as needed after they are out -- we would have a real chance to make sure they never have to go through it again.
Mark Milano is the Editor of Achieve.
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.
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