Provider Perspectives on Barriers to and Facilitators of Implementation of Evidence Based Mental Health Treatment in Prison Settings

Adam Chuong, B.A, Marlanea E. Peabody, M.P.H., Shannon Wiltsey-Stirman, Ph.D., and Jennifer E. Johnson, Ph.D.

Rationale. In 2005, a Bureau of Justice Statistics survey found that of prisoners who indicated a need for mental health treatment, only 34% of state prisoners, 24% of federal prisoners, and 17% of jail inmates received treatment. There is a significant disparity between treatment provided and prisoner indicated need for mental health services. Moreover, of those who received treatment, taking a prescribed medication, compared to receiving professional therapy, was the most common type of treatment inmates received since incarceration.

Individuals with  psychiatric disorders have substantially increased risks of multiple incarcerations. Once outside of prison,  major depressive disorder (MDD) and other severe mental illnesses increase the risk for parole revocation. The lack of mental health treatment availability to prisoners has consequences  not only for prisoner health and well-being but for re-integration, recidivism, and associated costs to society.

There are several  EBTs for major psychiatric disorders that have been found to be effective within community settings, including Interpersonal Psychotherapy (IPT) for  MDD. However, consumers in the community often wait up to an estimated 15-20 years before EBTs are integrated into real-world practice. In prisons, additional barriers to implementation exist. Multiple stakeholders, including inmates, providers of care, and the prison system, contribute to the availability and quality of treatment in prison. Providers of care face an interesting dilemma as they must balance the societal goal of “security” with individual treatment. 

This poster examines  barriers and facilitators of implementation of empirically supported treatments in prisons identified by prison  treatment administrators and mental health and substance use providers from men’s and women’s minimum and medium security correctional facilities.

Method. Surveys were administered to 66 mental health staff, substance use counselors, MD/RNs who take part in mental health or substance use treatment, and their clinical supervisors at 7 prison facilities in 2 states. Of the 66 potential stakeholders identified, 46 participants completed the survey. Participant’s average age was 35 years old.  

Measures. The Evidence-Based Practice Attitude Scale (EBPAS-50) assessed potential hindering or facilitating factors to the adoption of evidence based treatments by providers. Provider attitudes towards rehabilitation and punishment were measured using the Attitudes Toward Rehabilitation and Punishment scale.  The Stakeholder Acceptability Survey (SAS) assessed the ease of delivery, perceived helpfulness, and level of enthusiasm for  a specific EBT for MDD, IPT.  

Analyses. Descriptive analyses were conducted to determine mean total scores for all questionnaires.  Independent samples t-tests were also conducted to examine whether barriers and facilitators varied by male vs. female prisons and between  a system that directly employed mental health providers and one that  contracted mental health services from a community agency.  

Summary and Conclusions. Prison treatment providers view rehabilitation as an important aspect of incarceration and value it more than the punitive aspects of incarceration (i.e., deterrence, incapacitation, etc.) (Table 2). Providers rated workload burden and potential inconvenience of new EBTs as the greatest obstacles to being willing to implement them during the regular prison clinical work.  Supervision and clinical fit were rated as the greatest facilitators of implementation (Table 3). Furthermore, the majority of stakeholders express a high interest in, awareness of, and concern about  evidence-based treatments of depression (Table 4).

With a few exceptions, barriers and facilitators were similar across institution type.  Specifically, providers from women’s facilities rated availability of organizational support as a  stronger facilitator of adopting evidence-based treatments (EBTs) than did providers from men’s facilities (Table 5). Providers from women’s facilities were also more aware of  various EBTs. Providers from the prison system with contracted mental health care were more likely than those in the system that directly employed mental health providers to cite organizational support as an important facilitator for adopting a new EBT; they were also more aware of available EBTs (Table 6).

Identifying  provider-perceived barriers and facilitators may give insight into successfully implementing EBTs in prisons, with the ultimate goal of providing effective treatments to prisoners. Future studies may seek to incorporate other perspectives on mental health treatment in prisons (such as inmates, legislators, and the public),  understanding that multiple stakeholders  define the availability, goals, and quality of treatment. Improved mental health  access and utilization in prisons may reduce disease burden  and recidivism for this vulnerable population.