Mental Health Treatment Engagement of Formerly Incarcerated People with Serious Mental Illnesses Living In Permanent Supportive Housing

Background and Purpose:

Formerly incarcerated people with serious mental illnesses (SMI) experience the criminal legal system unequally and have elevated rates of recidivism, homelessness, and substance use disorders. Permanent supportive housing (PSH) is often used during reentry despite limited resources for addressing community integration. PSH sites are often located in environments with both increased criminogenic risk and public spaces associated with positive outcomes. We examined the role of social environments in supporting mental health treatment engagement.

Methods:

The study used a QUAL + QUAN concurrent mixed-methods design to examine how individual, interpersonal, and environmental factors situated in the risk environments of permanent supportive housing interact with public and private spaces to inform reentry wellbeing. Methods included qualitative, quantitative, and participatory mapping methods interviews (n=67) and go-along interviews (n=20) with formerly incarcerated clients with SMI. We used linear regression analysis to examine how neighbor relationships and overall social support impacted mental health treatment engagement. Inductive grounded theory analysis of qualitative data was used for convergence and expansion.

Results:

A regression model with demographic covariates as well as social support and neighbor variables explained 47.2% of the variance in perceived coordination of mental health treatment, used as a proxy for treatment engagement, F (6, 52) = 7.74, p < .001. Higher rated neighbor relations (β = .316, p = .004), greater overall social support (β = .268, p = .010) as well as covariates younger age (β = -.282, p= .009) and fewer lifetime arrests (β = -.262, p = .015) were significantly associated with greater perceived coordination of mental health treatment, a proxy for treatment engagement. Mental health symptomatology, while trending (β = .203, p = .062) was meaningfully not significant. Findings from qualitative data indicated participants communicated three primary themes: 1) barriers to accessible, consistent, and appropriate healthcare and reentry support services, with many participants emphasizing little to no reentry support post release; 2) the importance of belonging and nonclinical supports and spaces, including pets, green spaces, and social connections in supporting their mental health. Participants emphasized how challenges around adapting to changing cultural norms across prisons and jails, homelessness, and PSH environments impacted their sense of belonging in each space; and 3) a mismatch between PSH and reentry because of increased exposure to substance use and death from overdose or unmet complex medical needs and heightened surveillance by both internal security guards and external police officers. These risks created different barriers to treatment, including reduced trust in service systems.

Conclusions and Implications:

Quantitative findings emphasized the significant role social and neighborhood environments play in supporting treatment engagement, even when controlling for mental health symptomatology. Qualitative analyses further expanded these findings demonstrating the importance of accessible, consistent, and appropriate healthcare against a backdrop of supportive nonclinical resources and environments. Obstacles to achieving a sense of belonging because the changing norms of their identities challenged their collective ability to integrate in their communities, which participants by and large communicated as essential to their mental health wellbeing.