Experiences of women on release from custody and their engagement with general practice in the community: an interview with Dr Penny Abbott, Western Sydney University
The difficulty facing women upon release from prison cannot be understated. The pressures on them to integrate with the society they have been cut off from - no matter how long for – make for a difficult journey. However, there is no question that this journey is dependent on the support system around them. Families, friends, partners, living conditions and financial situations all have an immediate effect on how successfully women adjust to life outside of the prison system.
With these factors taken into account, Dr Penny Abbott, an academic general practitioner at Western Sydney University’s School of Medicine, has been researching the role of the GP in the effectiveness of women adjusting to life outside of prison.
Dr Abbott’s research - funded through the RACGP Foundation Family Medical Care Education and Research Grant - has been able to increase the awareness of what kind of service women leaving prison need, and also gain a better understanding of the health concerns they face immediately upon release.
This research enables GPs to ensure these women receive the right health care as well as provide them with support when it is most needed.
How does your research aim to ease the transition of women in custody back into society?
Dr Penny Abbott:
People in contact with the criminal justice system commonly have high medical and social needs, including high rates of mental health problems, experiences of life trauma, substance misuse, chronic disease and social isolation. However, they are also more likely to experience long-term fragmented health care which can contribute to cycling in and out of prison. Good health and social and emotional wellbeing are known to lower the rate of returning to prison.
On leaving prison people need to re-establish their life in the community and often face many demands on top of their health issues, such as homelessness, poverty and social disruption. The risk of death and hospitalisation in the year after release from prison is high1.
As a GP in both the prison and community sector, I was aware of the high health needs of women in prison and also of the importance of connections between prison health services and community-based general practice. I wanted to look into what the women viewed as their healthcare needs and their experiences related to community-based general practice care.
Additionally, I wanted to examine continuity of care across the interface between prison and community-based health services, with a focus on GP care. It seemed to me that this was not always easy or done well.
Given that half of the people leaving prison in Australia see a GP within a month of release, GPs are at the pointy end of health care delivery for people leaving prison.
GPs are in a great position to try to help at this time of opportunity and vulnerability and ease the transition of people leaving prison back into the community.
From your findings, how do you see the role of the GP helping patients improve their mental health?
I came to see women in contact with the criminal justice system as a group who experienced ‘medical homelessness’, in that they often had disrupted medical care and felt that they were not seen as legitimate patients compared to others who were ‘more deserving’.
This could mean that they fell between the health system cracks and their health needs went unmet. I recognised that GPs have an important role in helping these patients find a medical home in general practice.
My research highlighted that GPs need to have their antennas up and watch out for mental health problems and the difficult social situations which put people leaving prison at risk. The women leaving prison who participated in my research had a perception that GPs were not interested in their wellbeing beyond physical ailments, and were particularly unable to help them with their substance misuse problems.
In fact, it seemed most likely they would not even tell the GPs they had been in prison because they believed the linked stigmas of incarceration and substance misuse would lead to differential treatment.
This had a strong effect on continuity of care of course - they were unlikely to hand on discharge summaries from the prison even if they were half way through important investigations or needed treatment unless they knew the GP well. Furthermore, it seemed the women would not think to let the GP know more about their life, perhaps that they were homeless or in a situation involving family violence, even though these issues were really the background to their mental health problems.
The GP can provide care which improves their patients’ mental health and wellbeing if they identify the problems in the first place.
GPs are very important in helping people leaving prison with their substance misuse, which can be at the heart of why many people ended up in prison. Mental health problems and substance misuse often coexist, and people leaving prison are at great risk of relapse after release.
Another GP role is to ensure that mental health gains made in prison are maintained. Prison health services generally have a strong focus on mental health and substance misuse and many people receive treatment from mental health nurses, psychiatrists, GPs and drug and alcohol clinicians while they are in prison. There is a risk that this care will stop at release.
For example, people can come off their medication or stop receiving support which was valuable to them. On the other hand, not everyone in prison receives the help they need, for reasons including the challenges of healthcare delivery in a prison environment and long waiting lists, distrust of prison health services and the stress of being in prison.
On release, some people may be well overdue for much-needed health care.
In what ways are the findings of your research empowering GPs to manage and provide the specialised care that these patients may require?
I reflected throughout this research that it is certainly hard for GPs to help if they don't even know their patient’s story. Also, GPs may be worried that asking a woman who has just left prison about their mental health, substance misuse or social support needs would amount to stereotyping their patient and would be poorly received.
However, my research demonstrated that women considered such questions welcome and timely, and that GPs were well placed to intervene and assist in that vital post release period.
I was also struck that women leaving prison did not expect all their problems to be quickly solved by the GP, but wanted a welcoming reception and a skilled GP who was on their side.
GPs may find different approaches helpful such as mental health care plans, psychology referrals, drug and alcohol counselling, opioid replacement therapy, giving out the family violence hotline number or following up with the prison health service to ensure continuity of care.
Clearly in the long term we need to assist women in contact with the criminal justice system to know that we will approach their health care in a non-judgemental and skilled way, and allow the time for therapeutic relationships to build to enable the whole person care that is needed.
1. Kinner SA, Preen DB, Kariminia A, Butler T, Andrews JY, Stoové M, Law M. Counting the cost: estimating the number of deaths among recently released prisoners in Australia. Med J Aust. 2011 Jul 18;195(2):64-8.
Abbott P, Davison J, Magin PJ, Hu W. ‘If they’re your doctor, they should care about you’: Women on release from prison and general practitioners. Aust Fam Physician. 2016 Oct;45(10):728-732
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