A decade ago, the Substance Abuse and Mental Health Services Administration determined that having two separate definitions of recovery—one for substance use disorder and one for mental illness—”complicate[d] the discussion.” To simplify things, it moved to a composite definition that doesn’t say anything about either of them.
On August 31, SAMHSA released a resource guide titled “Best Practices for Successful Reentry From Criminal Justice Settings for People Living With Mental Health Conditions and/or Substance Use Disorders.” The document is meant to identify the best-evidenced interventions for reducing recidivism, then describe how law enforcement, medical providers and community-based organizations can implement them.
The agency followed up with a September 7 webinar to discuss the three re-entry strategies in the guide: medications for opioid and alcohol use disorders (MOUD/MAUD); case management; and peer and patient navigation.
All were selected because studies support them as evidence-based, and discussed in the context of both substance use disorder (SUD) and mental illness, as well as the context of re-entry from both prisons and jails. But the guidance limited its effectiveness by characterizing abstinence as a part of successful re-entry and not centering people with lived experience. And, as with its definition of recovery, by deliberately avoiding anything too specific.
Medications shown to reduce fatal overdose, like methadone and buprenorphine, are a critical component of re-entry because it’s well-established that the period following release—generally defined as a few weeks or months—is when overdose risk is at its highest. The missed opportunity here was in talking about MOUD and MAUD as abstinence-based interventions, and presenting abstinence as a prerequisite for not going back to jail or prison.
Our health care and criminal-legal systems already conflate recidivism with “relapse,” so it makes sense for SAMHSA to not distinguish between re-entry and recovery. There’s no discussion about re-entry services for people who aren’t interested in abstinence; it’s just a foregone conclusion that everyone diagnosed with SUD needs abstinence-based recovery services. Harm reduction services are sprinkled in, but as afterthoughts or as line-items in a list.
Some harm reduction references are simply inaccurate. The authors encourage re-entry programs to facilitate access to naloxone and tell them it’s been available over-the-counter since March. One reason this is unhelpful is that naloxone only started becoming available in September. But mostly it’s unhelpful because not everyone recently released has access to naloxone, and they’re going to get get it by way of someone telling them they can pay $50 to order it online.
Equating successful re-entry with abstinence is harmful, but it’s how substance use is discussed all the time. Watching SAMHSA try to stretch the premise to cover abstinence from mental illness, however, is awkward.
The many people with co-occurring disorders are often excluded from studies, by researchers who don’t want to complicate their sample with more than one issue. We do need more resources that approach substance use disorder and mental illness together. But while the guide purports to cover both, mental illness is barely discussed at all.
A robust interdisciplinary team of social service navigators to help someone during re-entry is a fantastic approach, when it’s not missing the most important part. The guide contains obligatory acknowledgments that the person actually being released should be involved in their release plan, describing the role of corrections staff or medical providers or community groups before tacking on something like: “The client should also provide input on their case plan to establish their commitment to meeting its goals.”
Most corrections staff who have these discussions with people preparing for release aren’t seeking input; they’re seeking the biographical information needed to fill out the required fields on the paperwork. Even when a re-entry plan is spearheaded by outside providers, the experience of the person re-entering almost always amounts to being told what their goals are and how they’re expected to meet them.
If people were given authority over their own case plans and felt safe enough to express their actual needs, a case management team could help them create a re-entry plan that was more on-target.
A lot of people preparing for release would say that they don’t need help applying for public housing; they need corrections staff to approve the housing where their partner lives, which was deemed unsuitable because the officer sent to inspect it smelled marijuana.
They don’t need a ride to their treatment provider; they need help waiving the fines for their suspended driver’s license.
They don’t need the job downtown where they’ve been cleared to work; they need to be allowed to get a job near where they live. That one happens all the time, even when someone trying to maintain an abstinence-based recovery is asking to not have to work in the area where they used to buy drugs.
Patient navigation refers to a health care-specific version of case management, and those are the two approaches that make sense to group together. Peer navigation should have been the third category on its own.
Under SAMHSA’s definition, patient navigation is conducted by “trained health care workers” while peers have lived experience. Like MOUD/MAUD and case management, patient navigation was selected for a guide about evidence-based re-entry because a sufficient number of studies support it in that context.
Peer navigation in a re-entry context does not meet SAMHSA’s criteria for a best-evidenced practice, but the agency went out of its way to include it anyway. This was the right decision, but a missed opportunity—not just to discuss peer navigation on its own terms, but to represent it properly.
SAMHSA defines peers as people with lived experience “who have been successful in the recovery process who help others … stay engaged in the recovery process and reduce the likelihood of relapse.” Obviously this describes some peers, and will benefit some people navigating SUD and re-entry, but it will discourage people who don’t like abstinence-based environments from accessing re-entry services at all.
A peer-led guide might have avoided framings like “prisons and jails” in the first place.
One critical re-entry component that the guide got right, which is often overlooked or misrepresented in these discussions, is that re-entry planning should begin the first day of incarceration via “in-reach” by community-based organizations. But this was only discussed briefly, and the only evidence included was about re-entry from jails. In-reach to prisons wasn’t distinguished, as if it’s a minor detail that people being released after a few days need might need different services than people re-entering after decades.
The decision to not approach the two as separate scenarios, and instead stick to describing re-entry from “prisons and jails,” is a product of using academic studies to understand re-entry rather than lived experience.
More input from people with lived experience probably could have helped catch a lot of the little mischaracterizations that come from paraphrasing supporting citations without grasping what they actually mean, but a peer-led guide might have avoided framings like “prisons and jails” in the first place.
SAMHSA did not respond to Filter‘s request for comment about the role of people with lived experience in the guide’s creation.
The idea that every piece of guidance has to apply to every type of person precludes almost anything concrete enough to actually be helpful to anyone. SAMHSA refers to “treatment engagement” and “medication adherence” in contexts kept so deliberately broad that readers don’t know whether it’s talking about psychiatric medication or MOUD. Even the distinction between drug use and overdose is blurred at times, a casualty of the framework of approaching re-entry and recovery as the same thing.
Nobody navigates their way through the US health care and housing and criminal-legal systems with catch-all advice. Thinking that they do is the same perspective behind SAMHSA’s composite definition of recovery—two issues are related, so the experience of accessing their services must be similar. In the end, it’s the deliberate refusal to specify which issues it’s talking about at which points that complicates the discussion.
Top and inset graphics via Substance Abuse and Mental Health Services Administration