Thoughts on Reentry and the Continuum of Care

By Elizabeth Lowenhaupt, MD, CCHP

As the psychiatrist and medical director of a juvenile correctional facility, I embrace the opportunity to develop and implement, alongside my team, state-of-the-art services for our incarcerated adolescent patients. They deserve every opportunity to grow and thrive, and it is our privilege to help them.

It has become increasingly clear, however, that our patients do not always have access to the services they need upon release to their communities.

John’s Story
Take John, for example, an 18-year-old first detained at age 13. For five years, he cycled in and out of our facility – most recently for a two-year sentence.

Over the years, John was diagnosed with schizophrenia and ADHD. While in our care, he would consistently take his prescribed medications, only to stop each time he left, resume illegal substance use and gang activity, and return to the facility.

John did very well during his recent two-year bid with us. He earned his GED, maintained stability in terms of his psychiatric illness and aggression, and ultimately stepped down to a group home to complete the last few months of his sentence.

During a recent visit at my outpatient clinic, John expressed pride in his accomplishments and the fact that he had done well during his first weeks in the group home. He shared his intention to continue taking his meds and abstain from illegal substances … “for now.”

But he wasn’t sure what he would do once the external motivators for following the rules – probation and court supervision – ended. He talked about possibly staying in the group home until he is 21, which he is eligible to do, but also said he didn’t like living with younger kids and having to follow rules like curfew. He did not yet have an identified primary care provider or therapist. He scheduled a medication management visit with me for a month later and asked me to give his regards to his clinical team back at the facility.

I’m not sure if John will return for his follow-up visit or if I will ever see him again. I certainly hope so. But I understand the enormous obstacles facing him and others like him: housing and employment challenges, the complexities of navigating the medical and mental health care systems, the pervasiveness of cannabis and stronger drugs, and the ever-present pull to return to gang-involved family and friends. Those forces far outweigh my influence as an outpatient psychiatrist.

Prioritizing Opportunities
I am fortunate to work at a facility that values rehabilitation, prioritizes access to clinical and educational services, and collaborates closely with other branches of the child welfare agency that create support upon release. John’s prolonged period of incarceration allowed his team time to develop a discharge plan and make sure his insurance was active.

However, at 18, John is largely on his own to make decisions about where he will live, what type of job or classes he will pursue, and whom he will rely on to provide guidance and support. I can offer referrals for a new therapist or intensive psychiatric treatment programs, but those aren’t his priority right now, nor are they necessarily what he needs as he sets out – currently stable from a psychiatric perspective – to make his way in the world.

Through the development of the HOPE for Justice Clinic (Hasbro Outpatient Psychiatric Evaluations for Justice-Involved and At-Risk Youth), which expands psychiatric treatment for youth involved in the juvenile legal system across a continuum of community-based and residential treatment settings, I can at least ensure that John has his medication and access to a health care professional he knows and trusts to help him make those decisions. And although I remain optimistic, it’s clear to me that our system needs to do more to give patients like John a chance to see and experience the world differently outside the walls.

NCCHC for many years has supported correctional health professionals in providing the high-quality health care that our incarcerated patients deserve. As we continue to work toward improving patient care and quality of life, we must prioritize – as individual providers, as facilities, and as an organization – access to services and opportunities for our patients upon reentry into the community.

Elizabeth Lowenhaupt, MD, CCHP, is the 2024 chair of NCCHC’s Governance Board and board liaison of the American Academy of Child and Adolescent Psychiatry.