With the many issues associated with reentry delineated by the previous panel (see Chapter 5), the final topical panel of the workshop turned to practices and models that can contribute to successful reentry. Each of the panelists noted that such programs and supports have many other benefits, increasing their value as investments in individuals and communities.
APPLYING THE ANTICARCERAL MOVEMENT TO PHILADELPHIA
Alison Neff, clinical director of the Center for Carceral Communities, began by framing the conversation about reentry in Philadelphia. As in other large U.S. cities, crimes rates have been dropping, yet incarceration rates remain high. Philadelphia has 7,000 reentering people every year, and Pennsylvania has the second highest probation/parole population in the country, with 44,000 people on probation in Philadelphia alone. More than 40 percent of those 44,000 people will be reincarcerated within 3 years, Neff said. “Something isn’t working about what we’ve been doing to try to support people in reintegrating into communities.”
The highest rates, by far, of reincarceration are for probation/parole violations, often for positive drug screens, including marijuana, even though marijuana has been largely decriminalized in the city, Neff observed. Detentions for parole and probation account for one-third of state prison inmates and half of the county jail population. One in three adults in Philadelphia has a criminal record, which means that one in three Philadelphians faces the barriers in employment, housing, education, and other areas that come with a criminal record. “This is affecting a massive number of people in this city,” and it disproportionately affects people of color and people in poverty.
These grim statistics point to a “huge opportunity” in Philadelphia, said Neff. Philadelphia has a community need and is at the apex of a national epidemic. The anticarceral movement is proving to be effective, and Philadelphia offers an ideal laboratory to intervene meaningfully and to create practices that can be replicated in other parts of the country. “The hope is that, here in Philadelphia, we can work together, have these conversations, and become a national model.”
The Center for Carceral Communities uses an intervention known as GAINS. The G in GAINS is for groups, which is the center’s primary clinical modality. Bringing people together who share a marginalized experience and experience of oppression can be very powerful, said Neff. “It’s much more powerful than an individual practitioner providing a service to an individual person.”
The A in GAINS stands for advocacy, which focuses on the larger picture and political environment. “How can we take what we’ve learned from direct practice experiences and influence the people who have power in the city, in the state, and beyond?” Neff asked. Part of the answer is connecting with people who have influence and asking them to hear about the problem and understand it better, including judges, the district attorney’s office, the city council, the public defender’s office, parole/probation offices, community-based health organizations, and community groups. Clients can act as spokespeople in different settings, whether they use an empowerment and mastery narrative or an exploitation and trauma narrative.
The INS of GAINS stands for Integrated Network Services, which again embodies the idea that people are more effective collectively than individually. “There are all kinds of people in the city and outside the city who are doing this important work. What we need to do is to come together and create networks that create a safety net for people.” Partnerships and coalitions can support the work everyone is doing and build connections between services to provide a more seamless system of support.
The center works with a group cognitive behavioral therapy and motivational interviewing model known as CHATS. The CH in CHATS stands for challenges, which calls for everyone in a discussion to describe the challenges they have been dealing with recently. “It’s a way that people can check in and become more conscious of the things that they are dealing with and get some support from the group,” said Neff. The A stands for alternatives or avoid, figuring out what does not work and how to minimize that thing. The T stands for triumphs, which Neff said is “my favorite part of CHATS.” Sometimes answers are in the details of what works for people as much as what does not work. Neff said:
It also is important for all of us to get out of problem-infused narratives. One thing I’ve noticed since we’ve been using this model is that people become very tuned in to the things that are going well in their lives, just by virtue of knowing that they’ll be asked what’s going well. Sometimes people come to group and [ask], “Can we start with triumphs?” and I say, “Sure, let’s go ahead, let’s hear the triumphs.”
Finally, the S stands for solutions, where the discussants look ahead to the following week and ask, “What can we try? What are some ideas? What can we do differently?” People come together to solve problems collective and help each other overcome their problems.
The center has had about 250 clients since it opened. It identified about 45 of 125 recent clients as high need and provided them with intensive engagement, including one-on-one crisis management. Of the 45 high-need clients, it identified 15 as having a high risk of reincarceration. Of the 125 clients, 115 were able to maintain their education and employment trajectories, including 44 of the 45 high-need clients and 14 of the 15 high-risk clients.
In response to a question about gender, Neff pointed out that the center also works with sex workers, who are at high risk for incarceration. Their situation, too, is one of poverty, vulnerability, and marginalization.
Neff concluded by making some policy recommendations based on this work. First, people need real, tangible, and effective wraparound services as a standard model of care, she said. Instead of receiving piecemeal services of housing, employment, behavioral health care, and physical health care, people should be able to come to a one-stop shop where they
can receive holistic and comprehensive care. In addition, services should be collective rather than individualized. She said:
With these groups—people of color, people who are poor, people who are marginalized—they want to come together. We can create a space where we can make it supportive and safe and productive for them to come together and collectivize around their experiences.
Second, evidence-based practices and the evaluation-based services need to be expanded and further developed, she continued, and services need to be designed for and tailored to particular populations. Academic and community partnerships that bring together scholars from across disciplines, such as social work, nursing, and education, could sculpt a rigorous, evidence-based regime of practice. In turn, cities like Philadelphia could make data more available to academic research partners to generate evidence.
Third, the city needs to step up in its role as a provider of structural opportunities, she said, explaining:
The bottom line is nothing is going to work if people don’t have the basic things that they need. They need to have access to housing. They need to have employment. They need to have basic health care. Without those things, the most amazing services in the world are going to fall flat.
Many people responding to these issues are trained in different tracks, which creates silos of practice. In such a situation, interventions, whether collective or one on one, need to occur on multiple levels, she said. At the same time, people need to think about the systems that create these conditions in the first place and how to intervene on those levels.
She closed with a final, specific recommendation:
We have to stop testing people on probation and parole for marijuana. I can’t tell you how much time in our groups is devoted to just figuring out how to help people not smoke marijuana ever, even one time because their freedom is on the line. It’s a huge problem with reincarceration.
She also encouraged those who have been involved in the decriminalization of marijuana to turn their attention to other substances that negatively affect criminalization in vulnerable communities.
Harm reduction is important before incarceration, during incarceration, and after release, said Scott Burris, professor of law and public health at Temple University, where he directs the Center for Public Health Law Research. At all three points, access to medication-assisted treatment is key, said Burris, because this access helps determine whether people will
continue to suffer from a pathological substance use disorder or will be able to control their drug use.
Before incarceration, nonarrest strategies such as the Law Enforcement Assisted Diversion program used in Seattle can reduce the number of people in jail, as can the integration of medication-assisted treatment into drug court options. Drug decriminalization is also a major factor, whether that consists of not arresting people for marijuana use, changes in prosecutorial discretion, or change in the law.
Legal barriers to drug treatment in prisons, along with “folk law” in prison or jail systems, could be changed to help people deal with substance abuse issues. “We are doing it here in Philadelphia, and we should be doing it in every jail system in the country,” Burris explained.
After release, a major issue is that drug treatment is embedded within “a dangerous world of consumer fraud,” Burris said. “Huge amounts of money are being sucked out of the health system for non-evidence-based treatment, for referral networks, for all sorts of chicanery that is not helping people but is making life harder for them and for their families.” In addition, movements such as “ban the box,” which is seeking to persuade employers to remove from application forms the check box that asks whether applicants have a criminal record, could help releasees get employment. Other rules still make it difficult for people with drug convictions to get public housing. “There is so much we could do,” Burris said.
The key harm reduction interventions are syringe-access programs, naloxone training and distribution, Good Samaritan laws, safe injection facilities, and low-threshold medication-assisted treatment. Syringe exchange not only keeps people healthy from infections but is also a primary entry point into treatment. For example, in Philadelphia the syringe exchange program has been helping people with their housing and their warrants, helping to form a network of services that can keep people away from the police and out of scrutiny.
Naloxone training and distribution helps people understand their risks and gives them the ability to help themselves and others around them. Good Samaritan laws, which provide some level of immunity from arrest at an overdose site, are another way to keep people out of jail. Naloxone access has been universally adopted, but Good Samaritan laws have not. Syringe exchange programs are even less common. Many states have drug paraphernalia laws that include syringes, which is the biggest legal barrier to accessing sterile syringes, according to Burris. Some states have authorized syringe exchange programs, but many states in the South and Midwest have not. This “is crazy,” said Burris, “when you think of how effective they’ve been in places like Philadelphia, [where] we turned back major epidemics of HIV among drug users.” Also, syringe laws gen-
erally are passed at the state level, but the risk occurs at the local level, and programs may not exist in a given locality.
Safe injection sites—or as they are known in Philadelphia, comprehensive user engagement sites—give people an opportunity to not get infected and to not be rushing to avoid police scrutiny. It they overdose, someone will be there to monitor them. More than 30 years of strong, well-evaluated research shows that such harm reduction saves lives and helps people, he said. It is a tool that people can use to build capacity and stay out of jail. Safe injection sites have a long track record in other countries. They exist throughout Europe and are rapidly spreading across Canada. They have reduced overdose deaths, HIV risk behaviors, public drug use, and street needle litter and have increased access to HIV treatment and drug treatment access. “We know this works on all these dimensions,” said Burris. “It could be working here in Philadelphia and in cities across the country.”
Such programs also can save large amounts of money. For example, Burris cited a study of drug dependence–associated endocarditis, which in North Carolina alone cost more than $20 million in 2015 to treat, or $54,000 per case (Fleischauer et al., 2017). At that cost, which is probably low, said Burris, the 604 cases of infective endocarditis among people with a co-occurring opioid use diagnosis represented $32 million in treatment costs between 2008 and 2015. “This is entirely preventable,” he said. “You don’t get endocarditis coming out of safe injection sites. This is an area where we should be getting policy makers’ attention because of the amount of money that we could save.”
In response to a question about the numbers of used needles encountered in cities, Burris pointed out that needle distribution, as opposed to needle exchange, is typically seen as a beneficial step. “If somebody came in and they wanted a dozen, you’d want to give them a dozen because they probably needed a dozen.” Needle distribution also results in secondary distribution among people who do not have access to needle exchange programs. The downside is that needles then need to be disposed of in some way other than through returns. “It is a difficult problem,” Burris said. Increasing the number and availability of disposal bins for used needles is one option. Social marketing and promotion of sterile, safe disposal is another. But
this is going to be an imperfect solution. People with houses and jobs are going to inject in other places. But people who come out of prison and do not land on their feet, so that they are using in public places, are at higher risk of getting arrested and suffering incarceration.
All state and most local governments have the authority to authorize and fund reasonable public health measures. A comprehensive user engagement site is clearly a reasonable health measure, Burris pointed
out, which implies that states and cities can authorize such measures. A largely unknown factor is whether they can exercise this authority if it violates other laws, including federal laws. This is the same thing that happened with needle exchange laws, where the question was whether such laws would run afoul of paraphernalia and prescription laws. In Philadelphia, the interpretation is that needle exchange programs do not run afoul of such laws. “There’s a dialogue to be heard here, but more importantly there is action to be taken in the face of legal uncertainty.” Cities should not let “legal uncertainty get in the way of an intervention that would save lives, particularly when we are talking about people coming out of jail,” Burris said.
Burris concluded with a broader argument for harm reduction. Such an approach accepts the reality and ubiquity of drug use in our society. Some people use drugs and are not harmed by them, while others use them and have very bad consequences. As Burris noted, no model other than totalitarian regimes has been able to stop substance abuse. On the contrary, the idea that substance abuse can be stopped raises a large moral hazard, in that the effort to limit access to opioids has driven many people to buy street drugs. Some people may be fortunate enough to work their way to abstinence. But many people who use will not reach that place for a long time, and they are at risk of dying until they can find a solution that works for them. Burris said:
Our goal is not to somehow praise those who are lucky enough to be so situated and so genetically endowed that they don’t have a problem. Our job is to help and accept everybody at the level of their use and their needs.
Harm reduction reduces stigma in favor of full acceptance of the humanity of people who use drugs. It adopts a public health approach and a spectrum of tools to substance use. Drug use is a reflection of inequality, unaddressed trauma, and lack of services and opportunities, Burris said. “It’s not so much that we don’t know what to do. It’s that we don’t have the will to do it.” Getting rid of barriers to syringe access programs and safe consumption sites could be done in a few hours in legislatures across the country, said Burris. But the dominant narrative about drug use needs to change, he said. “I’m not mad at you because you are diabetic, and I’m not mad at you because you are an opioid-dependent person. My job is to try and figure out how we get you to a place where you can have the healthiest life that you can.”
In response to Burris’s presentation, Gail Scott, manager of the Substance Use Disorders Institute at the University of the Sciences, noted that those using medication-assisted treatment resist characterizing such treatment as harm reduction, because it can imply that they are not fully in recovery—which Burris acknowledged as an important clarification.
A SMARTPHONE-BASED INTERVENTION
“It’s impossible to over emphasize the impact that smartphones have had on all aspects of our lives,” said Naomi Sugie, assistant professor of criminology, law, and society at the University of California, Irvine. Why not use smartphones as tools to increase knowledge about reentry experiences and to better support and bring together resources at reentry?
Sugie described the Newark Smartphone Reentry Project, which recruited 135 participants from the Newark, New Jersey, parole office from April 2012 to April 2013. Participants were eligible if they were male, recently released from prison to parole in Newark searching for work, and neither gang identified nor convicted of a sex offense. More than 90 percent self-identified as non-Hispanic black. Nearly 90 percent of the people she asked to participate in the study agreed to do so, and 70 percent completed all parts of the project, which included an initial in-person interview, smartphone surveys sent to their phones at least twice daily for 3 months, and a final interview at the end of those 3 months. The project also collected GPS location estimates during daytime hours and limited information on phone and text logs.
The project focused on employment as one important dimension of health and well-being after prison. Employment is a basic necessity to meet daily needs and is important for social identity, self-esteem, and mental and physical health. However, people with criminal records encounter stigma, occupational restrictions, and legal liabilities related to their employment in addition to more general barriers, such as geographical mismatches between their homes and work, few resources for job search, lower educational attainment, and limited work history. The pressures to find good quality employment, combined with precarious and sometimes exploitative temporary work, can lead to frustration, stress, and relapse, she pointed out.
Smartphone-based studies can improve knowledge about reentry by answering two questions: (1) What is the daily experience of job search and work after prison, and (2) Does spending time in job-rich areas improve employment outcomes?
To understand people’s daily experiences of searching for work after prison, Sugie analyzed more than 8,000 daily measures collected from daily smartphone surveys (Sugie, 2018). She found that people do spend time searching for work when they are released, but within about 6 weeks their search time starts to diminish without a comparable time spent actually working. She also divided the responses into groups that she called the early exit group, the recurring work group, and the persistent search group.
The early exit group quits looking for work even earlier, after just the first few weeks. The recurring work group does find work soon after release from prison, but in fact they are cobbling together multiple types
of jobs over different industries and different occupations to put together a consistent work profile. The people in this group tend to have the lowest levels of educational attainment and the least previous work experience compared with people in the other groups. “They are finding work more consistently because they are willing to take on poor quality work.”
The persistent search group, which tends to be small, consistently looked for work over the entire 3 months with little success attaining paid work even for 1 day. The people in this group were on average about 10 years older than the people in the other groups. This is a particularly important group to support, said Sugie, because they are committed to their job search yet are not able to find work on their own. But in all three groups, work is so hard to get and so unstable that the experience is likely to cause heightened stress and anxiety, she added.
In a second study, Sugie and a colleague used GPS estimates to investigate whether spending time in job-rich areas improves employment outcomes. They found no relationship between living in a job-rich area and finding work (Sugie and Lens, 2017). But spending time during the day in areas with lots of jobs and employers is strongly related to the number of days they work and how quickly they find a job. If people could be “told about where these job clusters are,” said Sugie, “that might be a good way for reentry service providers to provide information about job searches that would improve employment outcomes.”
Sugie has also investigated whether peer-based online “job clubs” improve reentry experiences. Half of the people in her study were assigned to a group-based text messaging forum that connected them to each other to provide peer-based support for job searches. Every day, participants in the job search forum received job leads and real-time information about job openings. The other half of the participants got the same job information but only through individual text messages. At the end of 3 months, the differences between the two groups did not reach a significant level, but the direction of differences indicated that a larger sample size might show the groups to be benefiting job searches.
Most recently, Sugie has been developing smartphone applications that can link job searchers with service providers and employers. For job searchers, the application provides peer-to-peer resources for job search, job leads, and information on service providers; for service providers, it provides a central portal for services and linkages to job searchers. For employers, it provides a platform for recruitment and linkages to service providers; and for researchers, it provides an opportunity to examine how just-in-time adaptive interventions could be used to promote active and persistent job searches. The use of smartphones raises issues around privacy, confidentiality, and surveillance, Sugie acknowledged. Nevertheless, “Smartphones could be used to leverage what’s already going okay
in many of these communities, especially resources and supports that individuals may not know about or have access to,” she concluded.
When asked to comment on her recommendation concerning marijuana, Neff observed that the new district attorney in Philadelphia (see Chapter 7) has been making changes around the prosecution of marijuana charges, but probation and parole do not come through the district attorney’s office. Change will require a political process, she said, adding:
Put pressure on the situation and say, “We don’t think that this is an acceptable reason for people to be incarcerated.” People are sometimes shocked when they realize that it’s still happening. We’ve had clients recently sentenced up to 9 months for a positive drug screen for marijuana.
In addition, the decriminalization movement has affected the average person walking down the street and having a small amount of marijuana, but for people under probation or parole, marijuana is still a great threat. They may test positive, or they may be fearful of testing positive and avoid reporting in, which means that they enter absconder status and can be reincarcerated for that reason. In addition, marijuana stays in the system longer than any other drug, so people can do hard drugs and 2 days later test clean. Marijuana can stay in a person’s system for 1 month, so even if they smoke infrequently they can be at risk. The discretion of the probation officer is also a factor.
Community members need to become more informed, Neff insisted, and find opportunities to say, “This is not a community safety issue. This is about power and control…. We don’t find this acceptable.”
In response to a question, Sugie pointed to several of the broad issues associated with incarceration. People can try as hard as they can to stay the right course, find work, and commit to a job search, she said, adding:
But at the end of the day, if we don’t have jobs in place that are available, that are not dangerous and not predatory and that offer some sense of stability … it’s impossible. It’s such a huge battle for any one person to have to navigate in that environment.
She also pointed out that efforts such as “ban the box” are well intentioned but incomplete. They address one part of the hiring process, but they still ask employers, landlords, and institutions of higher education to consider people’s arrest and conviction records. Sugie suggested:
Maybe we should be looking to Europe and saying, “If someone has been arrest-free for 5 years since their conviction, we are going to seal that record completely.” We are not going to put it on landlords and employers and higher education institutions to screen those people and take on that risk.
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