Aging in Prison

BE THE EVIDENCE PROJECT WHITE PAPER AGING PRISONERS A Crisis In Need of Intervention BE THE EVIDENCE PROJECT Be the Evidence You Want to See in the World†¦ What is Our Mission: The mission of the Be the Evidence Project is to create awareness of human rights and social justice issues through research, advocacy, and education. Be The Evidence Project activities foster dialogue and action on how human rights and social justice can be realized in everyday and professional practice. Who We Are: The Be the Evidence Project is a collective of globally conscious researchers, practitioners, educators, policy- ­? makers and advocates, and concerned itizens whose non- ­? profit independent scholarly and creative ventures are designed to disseminate knowledge, values, and skills that will help improve the individual and community response to critical social issues and improve well- ­? being using ‘any media means necessary’. What We Do: Be the Evidence Project activities that involve research, education, and advocacy provide a vehicle to disseminate information to raise critical consciousness and the recognition of psychological sociopolitical contexts in which injustices can occur. Transforming society first entails transforming ourselves to become â€Å"be the evidence we want to see in he world†. Through participation in self or project- ­? sponsored activities, we can help promote the achievement of a socially just world in which human rights, social justice, and well- ­? being are realized for all. On a daily basis, the lived reality of â€Å"being the evidence† challenges individuals everywhere to look inside themselves to identify and eradicate oppressive attitudes, thoughts, and practices towards self and others. Founder and Executive Director: Tina Maschi, PhD, LCSW, ACSW Coordinator of Projects: Samantha L. Sutfin, MSW Current Active Projects: †¢ Aging and Criminal Justice Project (ACJP) †¢ Arts for Change Proj ect (ACP) Qualitative and Mixed Methods Collective (QMMC) †¢ Moving Stories Project (MSP) For more information or to get involved in any projects visit our Be The Evidence Website CONTACT INFORMATION Be the Evidence Project 113 West 60th Street, 7th Floor New York, New York 10023 Email: [email  protected] edu Phone: (914) 367- ­? 3105/201- ­? 218- ­? 5064 2 About the White Paper On Saturday, October 8, 2011, Fordham University Graduate School of Social Service, Be the Evidence Project hosted a forum to ‘put a face and a name’ to this rapidly growing human rights and social justice issue: the aging prisoner crisis. For example, prisoners, aged 50 and older, omprise approximately ten percent of the overall prison population and had increased tenfold since 1990. Similar situations are noted internationally, including Canada and England. The national and international correctional care system, which was not designed to function as long- ­? term health care fa cility, is ill prepared to address older prisoners’ complex physical and mental health needs, while in prison and post prison re- ­? entry and community reintegration. This situation clearly needs a concerted and collaborative effort among researchers, practitioners, policymakers, and community members to craft and implement an effective esponse. International experts came to join us in speaking out about the crisis of aging prisoners for this historic event at Fordham University! The purpose of this follow- ­? up White Paper was to bring together a group of scholars and practitioners (who gave generously of their time) to contribute their work so that keystakeholders and the general public can become more aware of the crisis that is occurring in prisons around the world. Edited by Maschi, Morrissey, Immarigeon, and Sutfin, the White Paper includes nationally and internationally known experts presented research and best practices on topics related to older adults involved n the criminal justice system (especially prison), age specific correctional programming, elder and family justice, and criminal justice policy reform. This white paper was purposely made available as a free and public document so that any professional, organization, or concerned citizen can use this information to help advance public awareness of the crisis related to aging prisoners. It also provides recommendation on what we all can do about it, which includes to improve policy and practice with older adults in the criminal justice system. Please feel free to contact the Be the Evidence Project if you would like to become more involved n this project at [email  protected] edu or [email  protected] edu. We also invite your feedback about the White Paper and our ongoing projects. Edited by: Tina Maschi, PhD, LCSW Mary Beth Morrissey, PhD, MPH, JD Russ Immarigeon, MSW Samantha L. Sutfin, MSW Published February 8, 2012 Suggested APA citation: Maschi, T. , Morrissey, M. B. , Imma rigeon, R. , & Sutfin, S. (2012). Aging Prisoners: A Crisis in Need of Intervention. New York: Fordham University Be the Evidence Project. Retrieved from: https://sites. google. com/site/betheevidenceproject/white- ­? paper- ­? aging- ­? prisoner- ­? forum 3 BE THE EVIDENCE PROJECT AGING PRISONERS: A Crisis InNeed of Intervention TABLE OF CONTENTS PART I: INTRODUCTION AND OVERVIEW Chapter # 1 2 Chapter Titles and Authors Introduction†¦Tina Maschi, Mary Beth Morrissey Russ Immarigeon, & Samantha Sutfin Visualizing the Aging Prisoner Crisis: A Conceptual Model for Policy and Practice Decision Making and Action†¦Tina Maschi & Mary Beth Morrissey Executive Summary and Recommendations†¦Russ Immarigeon Page # 5 13 3 21 29 30 PART II: PUBLIC HEALTH, MENTAL HEALTH, PALLIATIVE AND END- ­? OF- ­? LIFE CARE ISSUES 4 Developing Ethical and Palliative Responses to Suffering Among Seriously Ill Aging Prisoners: Content Analysis Implications and Action Steps†¦MaryBe th Morrissey, Tina Maschi, and Junghee Han Forget Me Not: Dementia in Prisons†¦ Tina Maschi, Jung Kwak, Eujung Ko & Mary Beth Morrissey Trauma and Stress among Older Adults in the Criminal Justice System: A Review of the Literature with Implications for Social Work†¦Tina Maschi Age, Cumulative Trauma, Stressful Life Events, and Post-traumatic Stress Symptoms among Older Adults in Prison†¦ Tina Maschi and Deborah Courtney Substance Use and Older Adults in the Criminal Justice System†¦Keith Morgen True Grit: A Structured Living Program for Older Adults in Prison†¦Mary T. Harrison, 4 5 6 38 39 7 8 9 44 49 57 Karen Kopera-Frye and William O.Harrison PART III: CRIMINAL JUSTICE POLICIES AND PRACTICES 10 11 Criminal Sentencing Policy Reform and Aging Prison Populations†¦Kathleen Auerhahn Doing Hard Time: Issues and Challenges Facing Older Women in Prison†¦Azrini Wahidin Another Forgotten Population: Community Reintegration for Older Adults Leaving Prisonà ¢â‚¬ ¦Margaret E. Leigey Disproportionate Minority Contact in the American Juvenile Justice System: Implications for Older Adults in Prisons? †¦Susan McCarter Advocacy, Elderly Prisoners, and Mass Imprisonment†¦Russ Immarigeon It’s Still About Time: Aging Prisoners, Increasing Costs, & Geriatric Release†¦Tina Chiu 0 71 83 12 100 13 113 14 15 117 123 125 126 129 PART IV: INTERDISCIPLINARY COLLABORATION AND COMMUNITY PARTNERSHIPS 16 17 Social Work and Older Inmates: NASW Position Paper†¦Melvin Wilson Personal & Professional Contact Patterns among Older Adults in Prison: Interdisciplinary Practice Implications†¦Mary Beth Morrissey, Samantha Sutfin, and Tina Maschi Interdisciplinary Collaboration Practices with Older Adults in the Community: Implications for Prison and Community Corrections†¦Tina Maschi, Mary Beth Morrissey, Samantha Sutfin, and Manoj Pardasani The Viewing Room: Films about Older Adults in Prison†¦Rebecca Ackerman 8 134 Appendix 143 ABOUT THE BE THE EVIDENCE PROJECT: Be the Evidence Project is a non-profit independent scholarly and creative venture designed to disseminate knowledge, values, and skills that will help improve the individual and community response to critical social issues and improve well-being using ‘any media means necessary’. For more information or to get involved in any projects, please contact [email  protected] com or [email  protected] edu or visit: https://sites. google. om/site/betheevidenceproject/ Be the Evidence You Want to See in the World†¦ 5 6 PART I Introduction and Overview 7 CHAPTER 1 Aging Prisoners: A Crisis in Need of Intervention INTRODUCTION By Tina Maschi, Mary Beth Morrissey, Russ Immarigeon, and Samantha L. Sutfin Introduction: The Aging Prisoners Forum On October 8, 2011, Fordham University’s Graduate School of Social Service’s Be the Evidence Project hosted an academic-activist-practitioner forum entitled Aging Prisoners: A Cri sis in Need of Intervention.As a host for this forum, the Fordham University Graduate School of Social Service is distinguished by its mission to promote human rights and social justice globally through the advancement of economic, political, social, physical, mental, spiritual, and educational well-being. The Be the Evidence Project, which fosters public awareness through educational programs and campaigns, is designed to help achieve this mission.Consistent with the mission of the Fordham University Graduate School of Social Service, the purpose of the forum was to: †¢ †¢ †¢ †¢ Promote human rights and social justice and well-being for aging prisoners; Increase public awareness of the aging prisoner crisis; Help foster an international and interdisciplinary response to aging prisoners; Unveil an interdisciplinary model for describing and responding to public health-social problems such as aging prisoners for use in interdisciplinary prevention and intervention (Maschi & Morrissey, 2011). The event, organized by Drs.Tina Maschi and Mary Beth Morrissey of the Fordham University Graduate School of Social Service, gave internationally-known scholars and practitioners time to present their work to an audience of over 150 national, local, community, 8 and university members. Program co-sponsors and community partners were the Collaborative for Palliative Care for Westchester and NYS Southern Region, the Public Health Association of New York City, and the National Organization of Forensic Social Workers. Special thanks are extended to our expert presenters and discussants, which included Drs.Azrini Wahidin and Ronald Aday. Fordham University students, including Maryann Hom, Samantha Sutfin, Tanneh Wreh, Rebecca Ackerman, as well as many other Fordham students and community volunteers, particularly from the Public Health Association of New York City, volunteered in the planning and implementation of this event which was staged seamlessly. The Whi te Paper- Aging Prisoners: A Crisis in Need of Intervention This follow-up White Paper, Aging Prisoners: A Crisis in Need of Intervention is a tribute to and outcome of the October 8th forum.Its publication is well-timed in light of the recently released Human Rights Watch (2012) report, Old Behind Bars. We chose to self-publish this White Paper in order to make it readily available to key stakeholders and the general public. As the White Paper editors, we hope that these contributions of top scholars and practitioners across the globe will provide readers with many of the necessary tools and information that can be used to begin to address this growing crisis in both local and international arenas.Its purpose is to increase public awareness and provide information that can be used to foster the development and improvement of services for older adult offenders at each stage of the criminal justice process, including in prison and upon community reentry. Background to the Problem Ame rica’s prison system is rapidly graying. Behind the walls are prisoners with long sentences who will reach old age in prison. The population of older prisoners aged 50 and above is now five times as large as it was in 1990 and represents about 12% of the 2. 3 million prisoners 9 (Sabol & Couture, 2008).This increase in older adult prisoners is not due to a crime surge among older adult offenders, but rather is the result of the passage of stricter sentencing laws, such as â€Å"Three Strikes, You’re Out† and â€Å"Truth-In-Sentencing† laws (Aday, 2003). Thus, the adult correctional system is attempting to grapple with this rapidly growing older adult prison population in need of specialized long-term care. Most older adults in prison are men (93%) of whom half (50%) are Caucasian. However, a disproportionate number of these aging prisoners are minorities, such as African Americans (32%) and Hispanics (14%) (Sabol & Couture, 2008).As stated throughout the chapters in this volume, older adults in prison have documented physical and mental health problems, including dementia, and histories of trauma and chronic stress. Over 3,000 of these men and women will die each year in prison (James & Glaze, 2006; Maruschak, 2008; Maschi, Kwak, Ko, & Morrissey, 2012). The correctional system, which was not designed as a healthcare facility, is ill-prepared to address the complex bio-psychosocial and long-term health care needs of older adults. Neither is it able to bear the costs, which are three times higher for older than for younger prisoners (Chiu, 2010; Kinsella, 2004).Many older adults released to the community are disadvantaged by stigma and lack of access to community resources such as Social Security Income (SSI), housing, and medical care (Maschi & Morrissey, 2012). They also vary in their patterns of persistence and desistance from crime and their pathways to prison (Sampson & Laub, 2003). Older adults involved in the criminal justice s ystem are a highly vulnerable and neglected population. Currently, there are few professions and communities that can solely and adequately address the needs of this population.Despite the fact that these older adults have committed crimes, some of them heinous, an essential ethical human rights and social justice principle is to 10 â€Å"respect the inherent dignity and worth of the person† (UN, 1948), while at the same time attending to societal concerns about public safety and accountability. In the following section, older adults in prison describe the common themes of their differing pathways to prison, the stress related to conditions of confinement, and their concerns over prison reentry/community reintegration.These narratives were gathered from a variety of sources, including over 200 open-ended survey responses and letters from a regional research study of older adults in prison. Pathways to Prison Many older adults identified one or more factors that influence thei r pathways to prison. These pathways include the influence of interpersonal trauma and/or family violence, neighborhood effects, structural level oppression (especially as it relates to racial discrimination), a history of mental illness and homelessness, and tragic later life incidents †¢ History of Interpersonal Trauma: A 57-year old risoner wrote that he perceived that his history of interpersonal trauma influenced why he was in prison. He said, â€Å"I was sexually assaulted when I was thirteen, I never really trusted anyone after that, tried to ‘get even’ when I was a Marine, but it was pyrrhic victory at a devastating cost to me†. †¢ Family Violence: A 50-year old prisoner described his history of family violence: â€Å"I was crippled when I was younger, my family member beat and molested me. I was tied to the basement poles beaten always told over and over again you’re a jail bird just like your father. This was so tightly put into my hea d it blurred everything I saw†. Neighborhood Effects: A 50-year old prisoner described his neighborhood environment during childhood: He said, â€Å"From the sixth grade to the tenth grade I was forced to survive in the madness of the concrete jungle†. 11 †¢ Structural Level Oppression: A 63-year old prisoner wrote about his experience with structural level oppression that placed him at-risk and at odds with the system: â€Å"The education I received in the black community was different in content and context than that of whites. What I learned after 12 years of public education was that I was a problem, inferior, uneducatable, and a victim.We (black men) are on the endangered species list. † †¢ Mental Health and Homelessness: A 52-year old prisoner described his mental health and homelessness as related to his criminal justice involvement. He stated, â€Å"I believe my situation is unique for I committed a crime with the intention of getting caught be cause I was homeless (I suffer from Schizoid Affective Disorder due to a nervous breakdown, loss of job, apartment, car everything†¦I didn’t want to seek shelter at a homeless shelter or church. I was too ashamed and embarrassed to ask for help from my sister and the three friends I have left in the world.In prison, now I am somewhat stable (off meds and mental health roster) and healthy and strong again, and getting better. † †¢ Later Life Tragic Incident: A 62-year old prisoner shared his story of a later life tragic incident that led to his incarceration: He disclosed, â€Å"I was a very successful father of 3 kids with a wife to this day I absolutely adore. She is still waiting for me when I get out. I was a Chief Compliance Officer for a brokerage making over $300,000 a year. One night after a night at the racetrack, I got into an accident going the wrong way on the highway. I hit a van head on with four passengers.I was hurt bad all the passengers and t he driver lived but one was pregnant and she lost the baby†¦so I was charged with manslaughter and sentenced to prison. † 12 Stress and Conditions of Confinement In the sample of over 200 letters, many older prisoners described stress related to the adverse conditions of confinement. Two direct quotes state: †¢ â€Å"It’s very tough surviving prison. The provoking, the unnecessary treatment, verbal abuse, and violence only add to the original sentence term to be served. Little things begin to add by therefore causing inmates to react in ways with custody staff or fellow prisoners.Overcrowded conditions, poor medical service, lack of interaction with Administrative Staff is stammering. † †¢ â€Å"It was my first week of incarceration in 1979. I was standing in line in the mess hall along with about 150 other prisoners†¦when all of a sudden a man gets stabbed from behind with a sword†¦a 7? foot sword. The man must have been standing becaus e he was slumped over as if he was touching his toes†¦with the blade through him and the point of the sword stuck in the floor leaving the handle sticking out his back. â€Å"The kicker was what the officer said†¦ I thought the esponse would be†¦ Everyone on the floor†¦Everyone up against the wall. Instead he yelled for a bed sheet and draped it over the slumped body with the impression of the handle topping the sheet to a point. Bewilderment was all over my face as I looked at the dead body 3 feet away from me. I couldn’t remember if I thought or blurted out the words†¦Ã¢â‚¬Å"What kind of world is this? † The officer looked me right in the eye and said †¦ â€Å"Keep the line moving! † Again†¦my rationality kicked in†¦maybe I’m in a different time†¦I’m definitely in different world. I just wish I wasn’t. 13 Community Reintegration (Prison Reentry) The promise of community reintegration was often d escribed as a double-edged sword. Many older adults poised to exit prison and return to the community are not well prepared. One prisoner responded: †¢ â€Å"You don’t need a survey to know you have a lot of men over 50 getting ready to go home, with no money. No place to stay. And no one trying to understand this part of the problem. I earn $15 a month. I go home in 9 months. I have no family to turn to. I don’t want to come back to prison, after doing 7 years.I am trying to stay positive. I pray. I go to see the psych. For one on one and I try to look on the bright side. But the reality is, when I hit the street I am on my own. Tell me what good your survey will do me or people like me? † White Paper Overview In order to address the issues we have noted, this White Paper contains over 15 research briefs and full-length articles that are contributions from interdisciplinary scholars and practitioners from across the globe that define the problems and offer recommendations and problem-solving strategies.The major topics addressed about aging prisoners are related to health, trauma/mental health, criminal justice, and interdisciplinary collaboration. The briefs and articles included also help to provide a richer description of the lived experiences of aging prisoners in their social ecological contexts. This collection offers readers the opportunity to access a broad-based understanding of how psychosocial and structural issues have influenced the creation of and growth of the aging prisoner population.It also provides practical recommendations for policy and legal reform, program and policy development and improvement, and interdisciplinary practice. 14 Final Note As the editors of this White Paper, we welcome your comments. These comments can be provided via email at [email  protected] edu or by joining our Linked-In, Aging Prisoner and Action Forum at: http://www. linkedin. com/groups? gid=3892778&home Editors: Tina Maschi, PhD, L CSW, ACSW Mary Beth Morrissey, PhD, MPH, JD Russ Immarigeon, MSW Samantha L. Sutfin, MSW References Aday, R. H. (2003). Aging prisoners: Crisis in American corrections.Westport, CT: Praeger. Chiu, T. , (2010). It’s about time: Aging prisoners, increasing costs, and geriatric release. New York: Vera Institute of Justice. James, D. J. , & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. (NCJ Publication No. 213600). Rockville, MD: U. S. Department of Justice. Human Rights Watch (2012). Old behind bars. Retrieved January 30, 2012 from http://www. hrw. org/reports/2012/01/27/old-behind-bars Kinsella, C. (2004). Correctional health care costs. Lexington, KY: Council of State Governments. Maruschak, L. M. (2008).Medical problems of prisoners (NCJ Publication No. 221740). Rockville, MD: US Department of Justice. London, England: Author. Maschi, T. , Kwak, J. , Ko, E. J. , & Morrissey, M. (2012). Forget me not: Dementia in prisons. The Gerontologist. doi: 10. 1 093/geront/gnr131 Maschi, T. & Morrissey (2011). A social ecology of health and well-being for incarcerated older adults: An international process and practice model for recovery and reintegration (unpublished manuscript). Sabol, W. J. , & Couture, H. (2008). Prison inmates at midyear 2007. (NCJ Publication No. 221944, pp. 1–24. ) Rockville, MD: U.S. Department of Justice. United Nations. (1948). The Universal Declaration of Human Rights. Retrieved from September 1, 2011 from http://www. un. org/en/documents/udhr/ 15 CHAPTER 2 Visualizing the Aging Prisoner Crisis: A Conceptual Model for Policy and Practice Decision Making and Action By Tina Maschi and Mary Beth Morrissey Introduction Aging prisoner narratives, as well as the existing literature in criminology, gerontology, and social work, reveal that older adults involved with the criminal justice system have complex biological, psychological, emotional, social, and legal concerns.In the absence of holistic approaches that address these multidimensional needs, the health and well-being of older prisoners may be compromised and their risk of recidivism may be heightened (Human Rights Watch, 2012; James & Glaze, 2006; Kinsella, 2004; Maruschak, 2008; Nunez-Neto, 2008). In this context, individual, social, and structural factors that affect aging prisoners and their life course agency must be targeted in order to provide effective life course prevention and intervention efforts.Currently, there is a theoretical gap in understanding the complexity of the multi-level factors that contribute to this aging prisoner crisis. Interdisciplinary professionals lack a holistic and integrated model that will permit them to deepen their understanding about the psychological, social, and structural issues that inform appropriate interdisciplinary responses to this vulnerable population. In order to address this gap, we have developed a new intervention model Social Ecology of Health and Well-Being (SEHW): A Process Mo del for Human Agency and Development (Maschi & Morrissey, 2011).Model Overview As shown in Figure 1, this model conceptualizes life course human agency (in the direct center of the model). Life course human agency is a key human rights and social justice 16 construct that spans individual self-determination and social structure. Structural approaches to social problems such as the aging prisoner crisis should be designed in a functional way to help foster health and well-being across the life course. We will describe and apply this model that is well-suited for designing multidimensional assessment, prevention, and ntervention efforts, including those occurring within the context of the current aging prisoner crisis. Figure 1: Social Ecology of Health and Well-Being: A Process Model For Human Agency and Development Social Structures and Human Agency In our model, social structures are conceptualized as influencing human agency, including life course criminal justice involvement and overall health and well-being. When social structures, including relevant social policies, have the goals of fair and just societal conditions and the full recognition of human rights, individuals can exercise their freedoms in an 17 nimpeded environment. When social policies, such as punitive criminal justice policies, result in unfair consequences such as warehousing prisoners until they reach old age or die in prison, they impede individual prisoners’ right to self-determination. Fostering personal empowerment and development over the life course may enhance capacities for self-actualization and fulfillment, even in the presence of disadvantaging social structures.Older adults in prison, who suffer the loss of personal autonomy as well as multiple other losses and traumas over the life course, may find new pathways to personal growth and resilience, especially as they re-enter society and are integrated as members of their communities (Morrissey, 2011b; Maschi & Morrissey, 2011). Historical Time Additional factors that can impede the realization of individuals’ full potential across the life course include historical time at the individual and collective level.A person’s historical time, for example, may include being a victim of trauma (Maschi et al. , 2011; Stojkovic, 2007). Collective historical time may include being part of a generation in which many individuals became victims of detrimental policies such as the 1980s when stricter sentencing policies mandated longer prison sentences and resulted in many individuals suffering, growing old, and possibly dying in prison. On the more productive side, collective historical time may also facilitate human agency and development.An example includes the wide-scale adoption of public health and treatment approaches, such as the growing mental health recovery movement (Maschi & Morrissey, 2011). The implication of using a proactive approach with aging prisoners is that it can lead to the imp rovement of the overall health and well-being of older adult offenders in prison and in the community. 18 Practice and Stakeholder Contexts Practice and stakeholder contexts also influence individuals’ life course human agency. These contexts may be found when individuals encounter barriers to needed services, such as mental health or housing.These barriers might place an individual, such as an older adult reentering prison from the community, at risk of ongoing homelessness, decompensation, and/or recidivism (Snyder et al. , 2009; Nunez-Neto, 2008). Power Dynamics Power dynamics are perhaps the most critical component of our model. Power dynamics manifest themselves at individual and societal levels in the form of intentional or unintentional oppression, lack of awareness, and/or human rights violations, such as in the domains of equal access to employment, social security, housing, and/ or fair treatment in the criminal justice system.Additionally, structural barriers based on personal characteristics, such as age and race , may subjugate some groups more than others. This status disadvantage may have a cumulative effect over the life course. In the case of aging prisoners, evidence suggests that the disproportionate confinement of minorities may increase with age (Maschi & Morrissey. 2011). These structural barriers result in disadvantaging subordinate groups when it comes to fairness in the criminal justice system.These subordinate groups may be most at risk of receiving longer sentences that necessitates they grow old in prison. Disadvantaged groups, such as individuals living in poverty or racial minorities who are at a higher risk of long-term incarceration, may be impeded from achieving their full potential and well-being. They also would be more at risk of health-related decline associated with the long-term poor conditions of confinement (Human Rights Watch, 2012; Maschi, Kwak, Ko, & Morrissey, 2012). 19Interdisciplinary Perspectives Our SEHW model describes co-constructed interdisciplinary perspectives (e. g. , medical, social work, criminal justice, and public health) that help conceptualize and translate into practice more holistic, global responses, including to the international aging prisoner crisis. Multiple perspectives that can inform an effective response to complex social problems, such as aging prisoners, are guided by the following perspectives: human rights, social justice and critical conflict theories as well as life course, social ecology, and public health perspectives.Human rights, social justice and critical conflict theories are used to help inform issues of human rights and social justice (Mullaly, 2010; Wronka, 2008), especially as they relate to human rights violations and social injustices that have resulted in social problems, such as the neglect and mistreatment of aging prisoners (Maschi et al. , 2011; Snyder et al. , 2007; Stojkovic, 2007; UN, 1948). The social ecology perspective enables a m ore holistic view of social problems and recognition of interlocking service systems.In the case of aging prisoners, this perspective allows for the assessment of sequential and/or concurrent service use patterns of individuals throughout the life course. In the case of sequential service use patterns of older adults in prison, the lack of access to mental health or housing services may have put them at risk for criminal justice involvement. Additionally, an assessment of access to current service use may identify gaps in needed services, such as substance abuse treatment while in prison.The life course perspective is another key component of the model because it can be used to illuminate the complexities of human agency and how social and structural factors can facilitate or hinder development over the life course, (Elder, 2003). The life course perspective can be integrated with social science theories from criminology, sociology, and psychology and used to 20 explain psychologica l, social, and criminogenic factors that influence an individual’s life course health and well-being and criminal justice involvement (e. . , Sampson & Laub, 2003). The public health perspective complements and builds upon the aforementioned perspectives by adding a population-based approach for prevention and intervention that focuses on older adults’ health and well-being and criminal justice involvement (Maschi & Morrissey, 2011). Evidence-Based Practices and Policies Evidence-based practice and policies provide a framework that houses these multiple perspectives, and methods to evaluate the effectiveness of practice and policies.Evidence-based practice and policy strategies allow professionals to plan and monitor process and outcomes of interventions, including older adults’ health and well-being and risk of and/or involvement in the criminal justice system. Values and Ethics Personal and professional values and ethics inform all aspects of the model. Values and ethics are essential to any discussion of social problems because appropriate assessment and treatment responses to problems are not value-free.Instead, a process of valuing that is multidimensional involving cognitive, emotional, social, cultural and other dimensions is embedded in both personal and professional practices and policies, and in the decision processes of the vulnerable older adults whom we serve (Morrissey, 2011a). Making discussion of values and ethics explicit helps to ensure humane treatment for all persons, in this case aging prisoners, while also balancing societal concerns including public health and safety and offender accountability. Applying the Model In applying the SEHW model to an aging prisoner population, it is important to recognize that 21 risons and communities constitute social environments that have their own unique social ecology that can foster or inhibit the health and well-being of its inhabitants. For example, poor conditions of confinemen t may inhibit health and well-being of aging prisoners. Adopting evidence-based treatments as an approach or intervention may help to foster change in the ecological environment and promote well-being (Maschi et al. , 2011). As seen in the case of aging prisoners, both the prison and community environments are often lacking in initiatives that promote health and well-being or older ex-offenders are denied access to them.Moreover, for community reintegration or prison reentry programs that serve older ex-offenders must take into account all of these social structural factors in order to be successful. Designing and assessing existing interventions that target the personal, cultural and structural levels factors that contribute to social problems, such as the aging prisoner population should be key components of program design (Maschi & Morrissey 2011; Mullaly, 2010; Nunez-Neto, 2008). This model may be used to understand the larger conceptual picture undergirding the aging of prisone rs. References Elder, G. 2003). The emergence and development of life course theory. In J. T. Mortimer & M. J. Shanahan (Eds. ), Handbook of the life course (pp. 3-21). New York: Kluwer Academic/Plenum Publishers. Human Rights Watch (2012). Old behind bars. Retrieved January 30, 2012 from http://www. hrw. org/reports/2012/01/27/old-behind-bars James, D. J. , & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. (NCJ Publication No. 213600). Rockville, MD: U. S. Department of Justice. Kinsella, C. (2004). Correctional health care costs. Lexington, KY: Council of State Governments. Maruschak, L.M. (2008). Medical problems of prisoners (NCJ Publication No. 221740). Rockville, MD: US Department of Justice. London, England: Author. 22 Maschi, T. , Dennis, K. , Gibson, S. , MacMillan, T. , Sternberg, S. , & Hom, M. (2011). Trauma and stress among older adults in the criminal justice system: A review of the literature with implications for social work. Journal of Geront ological Social Work, 54, 347-360. Maschi, T. , Kwak, J. , Ko, E. J. , & Morrissey, M. (2012). Forget me not: Dementia in prisons. The Gerontologist. doi: 10. 1093/geront/gnr131 Maschi, T. & Morrissey (2011).A social ecology of health and well-being for incarcerated older adults: An international process and practice model for recovery and reintegration (unpublished manuscript). Morrissey, M. B. (2011a). Phenomenology of pain and suffering at the end of life: A humanistic perspective in gerontological health and social work. Journal of Social Work in End-ofLife and Palliative Care, 7(1), 14-38. Morrissey, M. B. (2011b). Suffering and decision making among seriously ill elderly women. Doctoral dissertation, Fordham University, New York, NY. Retrieved December 7, 2011 from http://avoserv. ibrary. fordham. edu/login? url=http://search. proquest. com. avoserv. library. f ordham. edu/docview/875564465? accountid=10932 Mullaly, B. (2010). Challenging oppression and confronting privilege ( 2nd ed. ). New York: Oxford University Press. Nunez-Neto, B. (2008). Offender reentry: Correctional statistics, reintegration into the community, and recidivism: A CRS report for congress. Retrieved fromhttp://lieberman. senate. gov/assets/pdf/crs/offenderreentry. pdf Sampson, R. J. , & Laub, J. H. (2003). Life-course desisters? Trajectories of crime among delinquent boys followed to age 70.Criminology, 41, 555-592. Snyder, C. , van Wormer, K. , Chada, J. , & Jaggers, J. (2009). Older adult inmates: The challenges for social work. Social Work, 54, 117–124. Stojkovic, S. (2007) ‘Elderly prisoners: A growing and forgotten group within correctional systems vulnerable to elder abuse’, Journal of Elder Abuse and Neglect, 19(3): 97-117. United Nations. (1948). The Universal Declaration of Human Rights. Retrieved from September 1, 2011 from http://www. un. org/en/documents/udhr/ Wronka, J. (2008). Human rights and social justice: Social action and service for the helpin g and health professions.Thousand Oaks, CA: Sage Publications. 23 CHAPTER 3 White Paper Overview and Recommendations By Russ Immarigeon, MSW* Part I: Introduction and Overview The articles and briefs in this White Paper on aging prisoners focus on different aspects of older offenders’ involvement with the corrections process, jail and prison confinement in particular, as well as their overall health and well-being. This White Paper builds on prior works on aging prisoners by using an interdisciplinary perspective in addressing public health, human rights and social justice issues associated with aging prisoners.Selected topics are covered in the White Paper that address gaps in the literature or build knowledge and delve more deeply into relatively uncharted areas such as trauma, mental health, palliative care, and interdisciplinary practice with older adults in prison. This white paper compliments the existing literature that focuses solely on the criminal justice aspects of aging prisoners. As has been noted in the introduction, most of these articles and briefs were originally delivered at a Fordham University Aging Prisoner Forum on October 8, 2011.Many of them were presented to an invited roundtable of leading academics, researchers, and practitioners. A number of these academics and practitioners agreed to have their work published in this free and available white paper. In releasing these papers to a broader constituency, we hope that they will be able to use the information provided in this volume to foster constructive dialogue about aging prisoners among scholars and practitioners as well as to develop or improve research, practice, and policy with older adults in prison. In our introduction to this collection, Tina Maschi, Mary Beth Morrissey, Russ Immarigeon, and Samantha L.Sutfin highlight the growing crisis of aging prisoners in the 24 United States. Reviewing more than 200 letters from elderly offenders, we describe their pathways to pris on, stressful prison conditions, and community reentry experiences. In addition, we note, â€Å"This collection will provide readers with a broad-based understanding of how psychosocial and structural issues have influenced the creation of and growth of the aging prisoner population. It also provides practical recommendations for policy and legal reform, program and policy development and improvement, and interdisciplinary practice strategies. Conceptual Model In the opening article, social work faculty member and researcher and president-elect of the National Organization of Forensic Social Workers (NOFSW) Tina Maschi, and public health law and social work researcher Mary Beth Morrissey of the Fordham University Graduate School of Social Service offer Social Ecology of Health and Well-Being (SEHW) as a process model for â€Å"deepening our understanding of the psychological, social, and structural issues that inform appropriate interdisciplinary responses† to aging offender s.Part II: Public Health, Mental Health, and Palliative and End-of-Life Care Issues Seven articles and briefs in this section address the physical and mental health care and end-oflife needs of aging prisoners. Mary Beth Morrissey, Tina Maschi and Junghee Han describe ethical and palliative responses to seriously ill elderly prisoners, stressing the importance of defining the conditions of these prisoners as a public health crisis. Moreover, â€Å"action steps† are necessary that establish an â€Å"infusion of palliative care philosophies, therapeutic models of care, training, and practices in settings across the care continuum for aging prisoners. Tina Maschi, Jung Kwak, Eujung Ko, and Mary Beth Morrissey follow with an apt discussion of dementia among older prisoners based on their article published in The Gerontologist. 25 The white paper also addresses the often overlooked issue of trauma among older adults in prison. In a series of short synopses, Tina Maschi and collea gues report on their review 19 journal articles for the Journal of Gerontological Social Work, and findings from their study for The Gerontologist on the relationship between age, trauma, and stressful life events.In the latter, the authors discovered a history of distress- and trauma-related events in the lives of prisoners, many of whom were likely to be released from prison in due time. It is clear based on these papers that older adults have a high frequency of being victims and/or witnesses to violence. In addition, they have unique stressors related to aging including stress over declining health and being victimized or dying while in prison. Additionally, research results provide preliminary evidence of connections between a history of earlier life trauma and later life mental health symptoms among older adults in prison.In another article, New Jersey psychologist Keith Morgen, currently the Secretary for the International Association of Addictions and Offender Counselors, ar gues for more research related to substance abuse disorders in older prisoners. According to Morgen, the lack of such research impedes â€Å"effective treatment and support services† for older offenders in prison, on parole, or in reentry. Importantly, Mary T. Harrison, Karen Kopera-Frye, and William O.Harrison offer a lengthy description of True Grit, a Nevada prison-based structured living program that has been in operation successfully for nearly a decade. As the authors note, â€Å"An important indicator of success is that there has been a zero-percent recidivism rate among the parolees from the True Grit program this far. The sense of community and of working together toward a common goal, coupled with the rehabilitative and bio-psychological aspects of the program have enabled these men to reenter the free world. The collaboration between this Senior 26Structured Living Program, its volunteers, and outside agencies has increased the possibility of difficult placements. † Part III: Criminal Justice Policies and Practices This next section of the white paper addresses head on criminal justice policies and practices from sentencing to prisoner reentry. The six articles and briefs in this section cover the costs of incarceration, the impact of disproportionate sanctioning, the challenges older prisoners confront in prison as well as during community reintegration, and the context of advocating for aging prisoners.Azrini Wahidin of Queen’s University in Belfast highlights challenges confronting the management of aging women prisoners’ health and social care needs, including the need for elder-oriented gender-specific practice guidelines and for increased training of criminal justice personnel. She also recommends the collection of relevant age-specific data, the expansion of programs for older prisoners, and study of the cost of incarcerating older offenders. Kathleen Auerhahn of Temple University assesses the impact of sentencing practices, including mandatory â€Å"three strikes† legislation, on the production of elder prison populations.She notes, â€Å"Devoting an increasing proportion of scarce carceral resources to housing an ever-growing population of lowrisk individuals undermines the ability to provide protection from those offenders who do threaten public safety. † Margaret E. Leigey of The College of New Jersey examines the biological, psychological, and social factors associated with older prisoners reintegrating into communitybased settings. In particular, she reviews the literature on post-release adjustment,, reunification with community networks, access to medical care, securing housing, obtaining employment, recidivism, and programs for older offenders. 7 Tina Chiu of the Vera Institute of Justice reports four factors related to the intent and impact of geriatric release laws: political considerations and public opinion; narrow eligibility criteria; procedures that discourage pr isoners from applying for release; and complicated, lengthy referral and review processes. Susan McCarter describes the rippled implications of disproportionate minority contact in the juvenile justice system for older prisoners. Russ Immarigeon, an editor of Offender Programs Report, provides a historical overview of advocacy efforts affecting older prisoners.He notes, â€Å"The critical point, in terms of advocating on behalf of elderly offenders or prisoners, including diversion and deinstitutionalization efforts, is more a matter of clear focus than of creating â€Å"new† options. Opportunities exist within current criminal justice and corrections structures to divert and deinstitutionalize elderly offenders. We need to focus our attention on this objective. † Part IV: Interdisciplinary Collaboration and Community Partnerships The final section addresses the often overlooked issue of interdisciplinary collaboration and community partnerships when it comes to addres sing the issue of aging prisoners.Three articles and briefs in the final section of this collection address social work and older prisoners, interdisciplinary and collaborative practices, and practice implications that emerge from personal and professional contact patterns within prisons. Melvin Wilson of the National Association of Social Workers (NASW) describes service coordination and other challenges facing those who work with older offenders in American jails and prisons. Filling a gap in the literature on personal and professional contacts of aging prisoners, Mary Beth Morrissey, Samantha L.Sutfin, and Tina Maschi review data collected from elderly New Jersey prisoners, finding that medical services, not psychological or social services, were most frequently used, although not always with satisfaction. These authors report, â€Å"Perhaps the 28 most troubling of findings is that older adults had minimal contact with family members from the community. Given that evidence that family social support is an important aspect of successful coping for older adults in prison, those older adults that do not have the opportunity to have visits or phone contact may place their well-being at risk. Lastly, Tina Maschi, Mary Beth Morrissey, Samantha L. Sutfin, and Manoj Pardasani explore the implications of interdisciplinary collaboration for practice with community-based older offenders. Analyzing secondary data from NASW’s 2004 National Study of Licensed Social Workers, these authors report that offenders frequently had multiple presenting problems, including chronic disease, grief and bereavement issues, end-of-life and palliative concerns, dementia issues, and caregiver concerns. Interdisciplinary work was common, especially between social workers and health care professionals.Issues and Recommendations In the course of their work, the multiple authors of these articles and briefs make a host of policy, practice, and research recommendations. Key items amo ng them are the following: †¢ Past and current trauma and stress are highly prevalent among aging prisoner populations. Older adults in prison with past and current trauma are at risk for adverse mental health problems which may be exacerbated by the prison environment. A variety of age-related mental health problems, such as dementia, are higher among older prisoner populations compared to their community counterparts.There clearly is a need for a more gero-sensitive, trauma-informed mental health treatment that addresses trauma and stress, and age-related mental health issues, such as dementia. †¢ Older male and female prisoners should be dealt with differently. More gender sensitive approaches for male and female incarcerated older adults are warranted. 29 †¢ The aging prison population has resulted in mass incarceration. Legal reforms should be considered that abate the production of elderly prisoner populations; †¢With the increase of aging prisoners, there is a reality that a sizable number will die in prison. Integration of palliative care approaches into prisons and community reentry programs including advance care planning and pain care and management can improve elderly prisoners’ quality of life and help to prevent and relieve suffering among seriously ill prisoners. Additionally, the introduction and promotion of shared informed decision making models can improve communication and holistic, coordinated care services in corrections; Older adults in prison often have minimal contact with their family members. Family involvement can improve the well-being of often isolated older prisoners. Therefore, more family programming is needed in corrections for older adults in prison; †¢ Older adult prisoner have different developmental needs than younger prisoners. More age-specific programming is needed across the United States, such as geriatric care units, including palliative and hospice services; †¢ Housing older adul ts in prison is costly.Monitoring, reporting, and evaluation strategies can enhance the safety and sensibility of geriatric release practices; and †¢ Many elderly male and female prisoners can be diverted or released from prison without undue risk to public safety. Policies such as compassionate release should be adopted and used. Social workers, the authors of many of these articles and briefs agree, have the skills and values necessary for linking the diverse service needs of aging prisoners. 30As a collective, these authors offer a forum to further the dialogue concerning aging prisoners’ health, mental health, and criminal justice issues. A major objective of this volume was to put a name to the face of aging prisoners and underscore the human rights and social justice issues evident in the aging prisoner crisis. The chapters written by well-respected academics and practitioners included in this volume clearly demonstrate that this objective was achieved. *Russ Immar igeon is Editor of Offender Programs Report. 31 PART II PUBLIC HEALTH, MENTAL HEALTH AND PALLIATIVE AND END-OF-LIFE CARE ISSUES 2 CHAPTER 4 Developing Ethical and Palliative Responses to Suffering Among Seriously Ill Aging Prisoners: Content Analysis Implications and Action Steps Mary Beth Morrissey, Tina Maschi, and Junghee Han Defining Public Health Problem and its Magnitude: Prison heightens the pain and suffering of prisoners aging into their later years absent the social and relational supports of community-dwelling older adults. Overcrowding and marginalized access to appropriate diagnosis, treatment, preventive care, and mental health services, severely limit the health and well-being of aging prisoners.The magnitude and severity of these unacceptable conditions are amply evident in the nation's prison systems and oftentimes rise to the level of constitutional violations of prisoners' rights, as demonstrated by the recent holding of the US Supreme Court in Brown v Plata (2011 ) affirming a lower court decision ordering California to release over 40,000 prisoners because of findings of dangerous overcrowding and â€Å"grossly inadequate provision of medical and mental health care† (p. ) that caused â€Å"needless suffering and death† (p. 3) in the state's prisons. Older adults in prison are at high risk for co-occurring (substance abuse and mental health) disorders and dementia (Maschi, Kwak, Ko & Morrissey, 2012). About 52% will die of a chronic illness, such as HIV/AIDS, heart and lung disease, and dementia (Maschi, Kwak, Ko, & Morrissey, 2012; Carson & Noonan, 2011). The seriousness of such public health problems among aging prisoners is reaching crisis proportions.The population of adults aged 50 and older is a rapidly growing subgroup of the prison population with complex medical needs, chronic illnesses, and disabilities. This public health crisis calls for comprehensive population–based strategies that focus on prevention, care , 33 education, and research (Institute of Medicine, 2011; Morrissey, Brown-Borg, de Cabo & Silverstein, 2011). The urgency of the care needs of older adults in prison requires interdisciplinary collaborative action to bring relief to their experiences of pain and suffering.The prison system all too often creates social and health care injustices for vulnerable human beings at the end-oflife, imposing an ethical and moral obligation upon interdisciplinary professionals, scholars, and advocates in the criminal justice system and larger community to cooperate and collaborate in building a movement that will deliver more humane and empathic care to suffering older prisoners.The foundation for such a movement draws on the values and practice of community reintegration, restorative justice and human rights, including affirming the dignity of and respect for every human person, promoting the well-being of all members of the community based upon shared responsibility and accountability, an d working toward peace (Maschi & Morrissey, 2011). Content Analysis This content analysis of the theoretical and empirical literature evaluates available research evidence on public health and health care prevention strategies and interventions that address the aging prisoner crisis.In the past decade, the number of hospice programs in the United States has grown to about 75, such as those at state prisons in Iowa and Louisiana (Maschi et al. , 2012). What is unique about these programs is that in some cases they have introduced and adopted interdisciplinary collaboration and peer support practices in the delivery of health services (Harrison & Benedetti, 2009). Despite these promising practices to date, there has been little research done in this area to