International Journal of Law and Psychiatry 89 (2023) 101905

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International Journal of Law and Psychiatry

journal homepage: www.elsevier.com/locate/ijlawpsy

Stigma management during reintegration of older incarcerated adults with

mental health issues: A qualitative analysis
Helene Seaward a, *, Sophie Dieffenbacher b, Jens Gaab c, Marc Graf d, Bernice Elger a, e,
Tenzin Wangmo a
a
University of Basel, Institute for Biomedical Ethics (IBMB), Bernoullistrasse 28, 4056 Basel, Switzerland
b
Psychiatric Hospital of the University of Basel, Division for Psychosomatics and Psychotherapy, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
c
University of Basel, Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, Missionsstrasse 62, 4055 Basel, Switzerland
d
Psychiatric Hospital of the University of Basel, Forensic Psychiatric Hospital, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
e
University of Geneva, Center for legal medicine (CURML), Medical faculty, Rue Michel-Servet 1, 1211 Genève, Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The number of older prisoners with mental health issues released from prisons and forensic psy­
Stigma chiatric institutions is rising. Their successful integration is important due to its implications for the public’s
Double stigma safety and the individual’s health and well-being. However, reintegration efforts are hampered due to the double
Old
stigma attached to ‘mental illness’ and ‘incarceration history’. To alleviate the burden of such stigma, affected
Prison
Forensic
persons and their social networks employ stigma management strategies. This study sought to investigate the
Reintegration stigma management strategies of mental health professionals supporting older incarcerated adults with mental
Resettlement health issues in their reintegration process.
Methods: Semi-structured interviews with 63 mental health professionals from Canada and Switzerland were
carried out as part of the overall project. To address the reintegration topic, data from 18 interviews were used.
Data analysis followed the thematic analysis approach.
Results: Mental health professionals emphasized the double stigmatization of their patients which impaired their
quest for housing. Lengthy searches for placement frequently resulted in patients’ unnecessary long stays in
forensic programs. Nevertheless, participants outlined that they were at times successful in finding appropriate
housing for their patients due to the use of certain stigma management strategies. They stated that they, first,
established initial contacts with outside institutions, second, educated them about stigmatizing labels and, third,
provided ongoing collaboration with public institutions.
Discussion: Incarcerated persons with mental health issues face double stigmatization that affects their reentry
process. Our findings are interesting as they illustrate ways in which stigma can be reduced, and how the reentry
process can be streamlined. Future research should include the perspectives of incarcerated adults with mental
health issues to shed more light on the various options that they seek for successful reintegration after
imprisonment.

1. Introduction Central issues upon release are finding a place to live, securing
employment, and (re-) establishing social networks (Cantora, 2015;
In Europe, 111 incarcerated persons per 100.000 inhabitants were Cherney & Fitzgerald, 2016; Wyse, 2018). The stigma attached to
released in 2017 (Aebi & Tiago, 2019). Successful reintegration of these imprisonment is one critical factor challenging all dimensions of the
individuals is important as they tend to have high recidivism rates with reentry process into society (Harding, 2003; Moran, 2012).Individuals
2-year reconviction rates ranging from 26 to 60% (Yukhnenko, Sridhar, are stigmatized due to possessing a trait or characteristic that conveys a
& Fazel, 2019). Successful reintegration also results in better health and devalued social identity in a particular social context (LeBel, 2008).
well-being of the formerly incarcerated person (Semenza & Link, 2019). Goffman (1963) described it as ‘an attribute that is deeply discrediting

* Corresponding author.
E-mail addresses: helene.seaward@unibas.ch (H. Seaward), sophie.dieffenbacher@upk.ch (S. Dieffenbacher), jens.gaab@unibas.ch (J. Gaab), marc.graf@upk.ch
(M. Graf), b.elger@unibas.ch (B. Elger), tenzin.wangmo@unibas.ch (T. Wangmo).

https://doi.org/10.1016/j.ijlp.2023.101905
Received 3 April 2023; Received in revised form 30 May 2023; Accepted 31 May 2023
Available online 15 June 2023
0160-2527/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
H. Seaward et al. International Journal of Law and Psychiatry 89 (2023) 101905

within a particular social interaction’ (p.3). He created a framework for the institutionalization such as dependence on institutional structures and
concept of ‘stigma’, embedding the process of stigmatization in social contingencies as well as social alienation and withdrawal (Correctional
interactions, not within the stigmatized individual. This stigmatization Services Canada, 2019; Shantz & Frigon, 2009). Their reentry needs are
process occurs when people identify certain characteristics of others that complicated due to increased mental and somatic health needs (Maschi,
are believed to violate a social norm. A criminal conviction represents Morrisey, & Leigey, 2013) including multiple chronic health conditions
one such marker that carries a stigma (LeBel, 2012). It characterizes a and end-of-life issues (Higgins & Severson, 2009). They often lack family
person as dangerous, dishonest, unreliable, aggressive, unpredictable, support and have a small social network (Kamigaki & Yokotani, 2014;
disreputable, and untrustworthy (Anazodo, Ricciardelli, & Chan, 2019; Williams & Abraldes, 2007; Wyse, 2018). Additionally, they commonly
Hirschfield & Piquero, 2010; LeBel, 2012; Moran, 2012). Being stig­ have few financial resources and low prospects to return to the labor
matized as a formerly incarcerated person negatively affects successful market (Williams & Abraldes, 2007; Wyse, 2018).
reentry into society through reduced access to housing, employment, or There is little research on what the reentry process entails for
educational opportunities (Keene, Smoyer, & Blankenship, 2018; Link & formerly incarcerated older adults with mental health issues and how
Phelan, 2001). It consequently interferes with their reintegration pros­ stigma affects their search for housing during reintegration. At the same
pects after release (Moran, 2012). time, the reentry process is central in avoiding criminal and clinical
Moreover, formerly incarcerated persons are often affected by mul­ recidivism and scholars emphasized the need for special programs and
tiple burdens of stigma due to race/ethnicity, economic circumstances support options for older incarcerated adults returning to the commu­
(disadvantaged backgrounds, low financial resources), mental health or nity (Shantz & Frigon, 2009; Wahidin & Powell, 2001). This study fo­
substance use issues (Anazodo et al., 2019; Gausel & Thørrisen, 2014; cuses on the experiences of mental health professionals on reentry
LeBel, 2008; van Olphen, Eliason, Freudenberg, & Barnes, 2009). The planning, specifically finding appropriate housing for older incarcerated
combination of different stigmatizing categories within one individual is adults with mental health issues and their stigma management strate­
thought to increase the stigmatization experience manifold. For gies. This research, therefore, fills an important gap, as it sheds light on
instance, incarcerated adults with mental health issues combine the la­ the reintegration process of an under-researched population.
bels ‘mentally ill’ and ‘incarceration history’. When considering the
‘mentally ill’ label separately, persons are often labeled as dangerous 2. Methods
(unpredictable and violent), weak, strange, disruptive, incompetent, and
blameworthy (Ran et al., 2021; Tyerman, Patovirta, & Celestini, 2021). This article follows the “Journal article reporting guidelines” for
For the ‘incarceration’ label, perceived dangerousness is the strongest qualitative research by (Levitt et al., 2018). Moreover, to describe the
predictor of stigmatization and social distancing (Hirschfield & Piquero, population of interest, we refer to ‘older adults with mental health is­
2010). Further, the combination of both labels disproportionally sues’ to follow recommendations on the use of respectful language
strongly affects the reentry process of such formerly incarcerated per­ suggested by Tran et al. (2018). Incarcerated persons with mental health
sons with mental illness (Livingston, Rossiter, & Verdun-Jones, 2011; issues are housed either in forensic psychiatric institutions or in prisons,
West, Vayshenker, Rotter, & Yanos, 2015). depending on the respective state’s referral system. A great proportion
Some stigmatizing characteristics are visible, while others can be of research focuses on forensic patients exclusively. Our study targeted
hidden, at least to some extent (Gausel & Thørrisen, 2014). Both, a both parts of this population (in prisons and forensic institutions), which
criminal conviction as well as mental health issues are markers that can is additional reason why we used the general description ‘older adults
be concealed (LeBel, 2008). The person carrying that stigmatized label with mental health issues’ instead of solely referring to ‘forensic pa­
can therefore choose the conditions of disclosure, with some exceptions tients’. However, some mental health professionals interviewed in this
such as jobs where employers ask routinely for a copy of the criminal study used the term ‘forensic’ patients when talking about older incar­
record before establishing a work contract. In most other situations, the cerated adults with mental health issues. We transcribed the interviews
individual can decide when, how, where, and to whom potentially verbatim and therefore did not change this wording.
stigma-inducing information will be disclosed (Camacho, Reinka, &
Quinn, 2020; Cherney & Fitzgerald, 2016). Each strategy will have 2.1. Study design
consequences on the experience of social exclusion or prejudice from
others as well as feelings of belonging (Camacho et al., 2020; Newheiser This qualitative study is part of a larger research project on the
& Barreto, 2014). These strategies are not only applied by stigmatized mental health of older persons in detention (Agequake in Prisons –second
persons but also by their social networks and caregivers (Cherney & part: Mental health care and forensic evaluation of aging prisoners and
Fitzgerald, 2016). Given the importance of stigma during the reinte­ persons serving security measures in Switzerland; SNSF grant number
gration process, it is central to skillfully handle the disclosure of stig­ 166043). The overall goal of the project was to provide insight into
matizing information. aging in prison, experiences with prison mental health care, and living
Within the last two decades, the number of older incarcerated adults with mental disorders in the prison context. The project used a mixed-
has risen (Baidawi & Trotter, 2016; Di Lorito, Vӧllm, & Dening, 2018). methods approach, collecting qualitative and quantitative data. The
Alongside this development, the number of older adults reentering so­ quantitative data collection aimed at estimating prevalence rates of
ciety has also grown (Wyse, 2018). For instance, in Switzerland, the mental disorders amongst incarcerated older adults as well as depicting
percentage of older adults reentering society after incarceration has the mental health care provided. The qualitative data collection applied
grown from 7% in 1998 to 15% in 2021 (Bundesamt für Statistik, 2022). an explorative approach to examine complex social phenomena around
In Canada, The number of older supervised persons released to the aging and mental health in prison.
community in Canada has risen from 2.310 in 2009 to 3.486 in 2018 The analyses provided in this article are based on one section of the
(Correctional Services Canada, 2019). With these growing numbers, data gathered from the qualitative interviews. This article focuses
more weight is given to the subject matter. exclusively on health care providers’ knowledge of stigmatization dur­
Further, current literature on the reentry process of former prisoners ing the reentry process of older incarcerated adults. Other topics have
is based on the ‘average’ incarcerated adult (Wyse, 2018), who are been analyzed and presented elsewhere (see for example Haesen, Merkt,
predominantly young adults. However, the needs of older adults in the Elger, & Wangmo, 2021; Merkt et al., 2021; Merkt et al., 2021; Mussie,
reentry process differ substantially. For instance, while most incarcer­ Pageau, Merkt, Wangmo, & Elger, 2021; Pageau et al., 2021; Pageau,
ated younger adults return to self-reliant housing, older adults will often Seaward, Habermeyer, Elger, & Wangmo, 2022; Seaward et al., 2021;
seek placement in nursing homes or other forms of assisted housing Seaward et al., 2021; Shaw, Seaward, Pageau, Wangmo, & Elger, 2022;
(Aday & Krabill, 2012). They are more likely to show effects of Wangmo, Seaward, Pageau, Hiersemenzel, & Elger, 2021).

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H. Seaward et al. International Journal of Law and Psychiatry 89 (2023) 101905

We obtained ethics approval from the lead regional ethics committee practice to use Standard German in writing. All interviews were audio-
(Ethikkommission Nordwest- und Zentralschweiz, EKNZ) and from the recorded upon the consent of the participant and transcribed verbatim,
local ethics committees (Bern, Vaud, Zürich) in May 2017. Further, BE paying particular attention to the anonymization of the information
and TW designed the research project. Both have many years of research collected.
experience on the topic of older incarcerated adults and in the appli­ Moreover, to describe the population of interest we refer to ‘older
cation of qualitative methodology. (Elger, Handtke, & Wangmo, 2015a, adults with mental health issues’ to follow recommendations on the use
2015b; Wangmo et al., 2015; Wangmo et al., 2016; Wangmo, Hauri, of respectful language suggested by Tran et al. (2018). Incarcerated
Meyer, & Elger, 2016). Two research assistants who completed their persons with mental health issues are housed either in forensic psychi­
doctoral education as part of this project conducted the interviews. Both atric institutions or in prisons, depending on the respective state’s
were trained in qualitative data collection and received supervision by referral system. Our study focused on both parts of this population,
TW and BE throughout the data collection and analyses processes. which is additional reason why we used the general terminology ‘older
The rationale for including participants from the two countries, adults with mental health issues’ instead of solely referring to ‘forensic
Switzerland and Canada, as part of our project was due to their similar patients’. However, some mental health professionals interviewed in
developments in regards to aging of their prison populations, as outlined this study used the term ‘forensic’ patients when talking about older
in the introduction. Certain key characteristics of this older prison incarcerated adults with mental health issues. We transcribed the in­
population are comparable, such as high disease burden, high utilisation terviews verbatim and therefore did not change this wording.
of prison health services, as well as increased support need for care We completed 63 interviews with mental health professionals in
during and after incarceration. Interviewing experts from both countries Canada and Switzerland. Please see Table 1 for details on the participant
is valuable because the data may reveal similar views about the chal­ characteristics. We performed data analysis along with ongoing data
lenges, but also present different opinions about strategies to address collection. In so doing, we were able to identify when data saturation
them. was reached and were able to include more participants if needed. We
identified data saturation by applying the principles presented by (Fusch
2.2. Data collection & Ness, 2015); the ability to obtain additional new information has been
attained, further coding is no longer feasible, and there is enough in­
We conducted semi-structured interviews with mental health pro­ formation to replicate the study.
fessionals working with incarcerated persons. The face-to-face in­
terviews were held between April 2017 and January 2018. We applied
2.3. Data analysis
convenience and purposive sampling to select mental health pro­
fessionals MHPs. Included participants were those with a background in
We processed and organized the qualitative data using the software
psychiatry, psychology, psychiatric nursing, and social work. They were
program MAXQDA. We conducted the analysis using the thematic
required to have a minimum of 10 years of overall work experience and
analysis approach by Braun and Clarke (2006). As a first step, five of our
some practice in working with older incarcerated adults. We included
project members read and coded collaboratively eight interviews. This
mental health professionals working at psychiatric clinics that house
in order to create a consistent basic coding tree. During this process, the
forensic units and forensic psychiatric services that provide mental
study team discussed various nuances that became apparent in the data
health care to correctional institutions. All Swiss and Canadian partici­
and reached consensus on the dimensions identified by each code, its
pants working in forensic institutions were recruited directly by one of
name, and its definition. In a next step, three members of the study team
the authors (HS). Participants working in institutions run by Correc­
(two of whom were HS and TW) coded all remaining transcripts indi­
tional Services Canada were directly recruited by this federal govern­
vidually and met to discuss the new codes, resolve disagreements, and
ment agency.
sort the final coding tree. The interviews were analyzed in their original
Potential participants were first contacted via email or phone. We
language for the entire data analysis process, as all study team members
then provided study information and informed consent documents to all
were proficient in the languages included. Only the final quotes used in
participants via email. We clarified questions regarding study partici­
this article were translated into English, the translations were checked
pation and the purpose of the research project before we scheduled an
by an English native speaker.
interview. We obtained written informed consent before the start of the
Given the wealth of information collected and the broader scope of
interview, either via email or in person. At the scheduled time and place
the interviews, exclusively the coded data on reentry and stigma per­
of the face-to-face interview, the researchers again explained the pur­
ceptions and management were extracted and examined in this paper. It
pose of the study, pointed out that all data would be treated confiden­
is important to note that this topic was not specifically addressed in our
tially, and reminded the respondents that they could refuse to
interview guide but emerged spontaneously during our conversations
participate at any time. We interviewed participants in person or via
telephone. We did not provide compensation for participation.
The semi-structured interview followed a topic guide specifically Table 1
Participant characteristics.
developed for the purpose of this study. The open-ended questions
covered topics on specificities of mental health care provided for older Switzerland Canada Total
adults, particular needs of older incarcerated adults, access to mental Number of participants 29 34 63
health care, role conflicts, and risk assessments of older incarcerated Participants’ gender Female 8 22 30
adults. The topic of stigmatization during reentry emerged spontane­ Male 21 12 33
Interview length Range 48–90 28–92 28–92
ously in the conversation with various participants, without being spe­ (in minutes) Mean 71 60 41.18
cifically asked as part of the topic guide. Standard 14.16 11.49 17.36
Interviewer and participant met for the first time on the day of the Deviation
interview, thus, there was no relationship prior to data collection. Only Language regions German-speaking 16 – 16
French-speaking 13 5 18
one interview meeting took place with each participant and no repeat
English-speaking – 29 29
interview was done. Interviews were held in the language spoken by the Number of Participants Penal institutions 23 21 44
participant, either English, French, German or Swiss German. Thereafter per type of Forensic-
the interviews were transcribed verbatim in the language of the inter­ institution Psychiatric 6 13 19
view, except for Swiss German interviews, which were transcribed in Institutions

Standard German. Swiss German is a spoken dialect and it is common

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H. Seaward et al. International Journal of Law and Psychiatry 89 (2023) 101905

with the interviewees. For this reason, not all 63 participants discussed should not have to carry the burden of their past, as they served their
the topic but was brought up by a large proportion of participants from sentence and are released. The public should not judge these persons any
both countries. Namely, 18 participants raised the issue of which 14 longer based on their offence for which they have already served their
were from Canada and 4 from Switzerland. The two main authors SD time: “When someone is released from the measure [court-mandated treat­
and HS carefully read this data segment in its entirety and reanalyzed it ment], then it is something else, he has the right to be looked at as a blank
in light of the purpose of this study. This in-depth examination of a sheet.” (S863). Similarly, another participant emphasized how society
theme was also conducted using thematic analysis. The results were should not exclusively judge forensic patients by the stigmatizing part of
discussed with all co-authors and are presented below in the form of two their identity, but see them as a whole person who has committed a
major themes depicting first the experiences with stigmatization during crime, has an illness and has served the time for the crime plus received
the reentry process and second the stigma management strategies the treatment: “But recovery is kind of, you know, how we also look at the
applied to alleviate the impact of the ‘forensic label’ to find community clients as a whole, beyond just their status as an offender.” (C652).
placement. Both themes are divided into subthemes, please see Fig. 1 for Participants claimed that the mental health issues that their patients
an overview. Further, the participants from Canada and Switzerland are experienced were particularly rare. This is because their patients
presented jointly as no considerable differences were found. Neverthe­ frequently suffered from severe forms of mental disorders such as
less, for reasons of transparency and traceability Canadian interviewees treatment-resistive schizophrenia. These severe courses of psychiatric
are presented as CXXX and participants from Switzerland as SXXX. diseases are uncommon even for mental health specialists in the com­
munity who usually treat milder cases. Thus, the forensic label was
3. Results particularly tied to the severity of patients’ disorders possibly exacer­
bating stigma experienced by the older forensic patient.
3.1. Mental health professionals’ experiences of stigma during the reentry “So, our community-based agencies are not really used to dealing with
process of older incarcerated persons people who are/ who have active psychosis, who have treatment-resistive
symptoms. (…) there is still a lot of stigma”. (C646).
3.1.1. Double stigmatization In a similar fashion, respondent C663 expressed his/her rejection
Many respondents emphasized that forensic patients carried the experiences with the incarceration label: “So why are you not taking him?
burden of two stigmatizing labels: First, being a person with a history of ‘He’s an offender’. That’s the only response I get back, nobody wants of­
incarceration, and second, having a severe mental illness. “We have fenders.”. Some participants explained that the incarceration history
mental health stigma and of course then this offender stigma as well.” (C647/ influences people to maintain social distance partly due to anxiety, as
C648). They stated that stigma associated with these two labels have illustrated by (S975) “I think that is an obstacle, where many people are
hampered their efforts to find placement in public institutions for their afraid of contact when something like that raised, that someone has a
older patients: criminal background.” Moreover, a few participants emphasized that the
“And really, they are, they are difficult to market. When you can take a, degree of stigmatizing experiences was much greater when both labels
you know, a little granny that lives in the community and is quiet versus you were combined:
saying ‘hey will you take somebody from the pen?’ They get to choose “I think people aren’t given uh fair opportunities once they have that label
(laughing).” (C660). (…) it’s more exponential than rather just double the stigma. (…) if you put
A few respondents challenged the stigmatizing attitudes of society. them together um you know it’s just that much more difficult.” (C654).
They stated that as part of recovery, a person who finishes his/her In addition, a few participants explained that age did not play a role
sentence should be considered a full member of society again. They as a stigmatized label, once they carried the forensic identity: “But the,

Fig. 1. Main topics on participants’ experiences with double stigma and their stigma management strategies.

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H. Seaward et al. International Journal of Law and Psychiatry 89 (2023) 101905

the inhibition is often very high for public institutions, to take on forensic patient from the community and have the same day-to-day concerns and
patients, virtually no matter how old.” (S968). Several respondents stated behavioral problems and symptoms, but the ‘offender’ label is certainly a
that when they are looking for housing to place their older incarcerated barrier to get/ an additional barrier to get into any of these community care
patients, the label ‘forensic’ elicits fear in members of the general. Thus, facilities.” (C673).
because of the incarceration piece of their patients’ stigmatized identity, The same respondent explained that these higher levels of care
their request for their older patient’s placement being rejected by public reduced the older patients’ housing opportunities. Older incarcerated
institutions. One reason for this anxiety was claimed to be a person’s fear adults can frequently not return into self-reliant housing but need to be
of something that is completely unknown to them, that they have never placed in institutions that are able to provide a high level of care such as
come in contact with, as explained by participant C643: nursing homes:
“Especially once they/ unfortunately once they have that forensic label so “It is particularly difficult because in in terms of release prospects, they
to say. It um/ there is that fear of the unknown with the general you know, seem to have fewer release prospects just because of the level of care they need
public and it can create some difficulties.” now.” (C673)
Further, the incarceration history highlights the fact that the person Additionally, some participants highlighted that once older patients
was imprisoned for a crime committed, thus symbolizing that the person no longer posed a risk to society, they should be eligible for public
is aggressive and a risk to society. A few respondents highlighted that geriatric services. They also emphasized how they were unrightfully
this ‘incarceration’ label takes the spotlight and consequently triggers kept within the prison system due to a lack of appropriate housing and
fear, as illustrated by S968: “So, if you committed a crime, then you are held back from advancing their lives past imprisonment.
like, then you’re perceived uh, often you’re reduced to the delict and of course “As soon as they are not a risk anymore then they should not be in this
that triggers anxiety.”. system. They should be just um able to access you know general geriatric
“Um most people are touched by mental illness in some way or form. Um services if they need that for health issues. Or to go live their lives, you know
it’s more so the forensic piece (P1: Yeah, I agree) I find that is the biggest (…) without the constraints of our system.” (C646).
people are worried about the forensic title.” (C647/C648).
In the particular case of older forensic patients, public nursing homes 3.2. Stigma management strategies to alleviate the impact of the ‘forensic
were concerned about formerly incarcerated persons being a risk to their label’
other patients. This fear resulted in the rejection of forensic patients
from the nursing home before a first encounter could have happened: 3.2.1. Establishing initial contacts with outside institutions
“Our elderly patients that we would refer to a long-term care nursing home Several participants stated that the key concern in finding placement
would be denied immediately because of the fact that they’re forensic and for their patients was to establish initial contact with public institutions
that’s scary.” (C647/C648). Several participants explained that they so that these patients are placed in the community. Due to the forensic
tried to vouch for their older patients to enable initial contact with label, they frequently experienced social rejection that prevented a first
future landlords and nursing home administrators. However, they were encounter with public institutions. To avoid such rejection, pro­
frequently not seen as reliable sources as they were working in the in­ fessionals would hide their affiliation with the prison system. For
terest of their patients. instance, a few respondents explained that when they emailed landlords
“Because they do not/ we find that we are not a trust/ they don’t see us as or long-term care homes, they would erase their email signature, as
a trustworthy source. They see us as someone that is trying to get them into the illustrated by C647/C648:
community, and they are seeing forensic elderly populations as high risk to the So any time we show up with a client to view an apartment. ‘Well, who are
other clients that are living there. Even if we say they are stable.” (C643). you?’ and ‘what do you do’ and the questions start. Or if I were to email a
landlord, I always erase my email signature so that people don’t see [name of
3.1.2. Unnecessary long stays in forensic programs institution 1] ‘mental health and the law program’ you know, because then
Several Canadian respondents explained that they struggled to find that’s like… (…) people are worried about the forensic title.”.
placement for their older patients in public institutions due to social Others emphasized that this first getting to know each other was the
rejection and exclusion that was linked to the stigma attached to the key to succeeding in their goal of placing their older patients in an
combined label of ‘mentally ill’ and ‘incarceration history’. Their appropriate community housing. One respondent made this contact
inability to find housing for their patients led to patients remaining in happen by “asking if we can get in the door for a tour.” (C646). By using
forensic programs longer than necessary. Participants further stressed different tricks and techniques, the same respondent stated that
that once patients are ready for release, they naturally do not require the “Because of the forensic label um it has been very difficult to establish
highly specialized resources that are offered in forensic services, which partnerships with the long-term care facilities here. Um but we/ we are getting
are consequently wasted due to prolonged stays, as summarized by better at it.” (C646).
respondent C643: In a next step, after establishing initial contact between the public
“But we were able to make fairly good progress um in you know, drawing institution and representatives of the prison system, contact needed to
attention to the fact that they are improperly housed within the forensic be made between the older patient and the nursing home or landlord so
program. They, they do not require the services of forensic mental health band that the latter sees the patient like any other older person. For instance,
and it is a/ really a waste of resources and dollars to have someone who could some respondents explained that they enrolled one of their patients in a
be fully supported in the community and then in a different area provided the nursing home’s day program in order for the staff and other individuals
funding was available. You know, as opposed to um to being stuck in a at those institutions to address their own implicit biases:
forensic program.” “We will get them going in the day program and then get them accepted
One respondent claimed that not only resources were wasted but also into the day program and then look at placement. Once they are accepted into
the older patients could be better cared for in public institutions, where a day program normally that relationship is built enough that we can place
they are specialized for geriatric care: “And because the forensic geriatric them in other nursing homes because they sa/ we can say ‘well they go
doesn’t necessarily get placed in the community where they would probably independently to the day program there and they are fine. And you can ask
strive a lot better in terms of the environment, hum and resources.” (C651). their staff’” (C646).
Along the same lines, a few participants emphasized once forensic pa­ Another respondent further elaborated how the older patients’
tients got older, their needs changed. Cognitive issues and the need for involvement in the nursing home program “helps to bring down the stigma
care became more dominant while risk needs became less relevant in of the ‘forensic’ label when we have them partake in community stuff.”
their daily care: (C644). In addition, a patient’s attendance at public programs served as
“They might look very much like an Alzheimer’s patient or a dementia a sort of reference that the older person moved beyond the criminal

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career and that this person was stable, as illustrated by respondents “We have developed a program in our department called the ‘liaison case
(C647/C648): manager’, (…) to facilitate the connection with the institution that will receive
“When the administrator would call the CCAC [Community Care Access them afterward. Those will do connecting work between the prison and the
Center] person and say, ‘what’s this?’ and ‘what’s forensic?’ and she would institution and will maintain continuity in the relationship between patient
say ‘well he was accepted to [name of institution 2] and they know him, and and prison.”
he attends um he attends programs there and he’s very well liked and like that Other interviewees explained that they developed a ‘role clarifica­
part of his life is over. He’s stable, there’s no difference’.” tion sheet’ to delineate roles and responsibilities to provide low-
threshold access to support and information:
3.2.2. Educating about stigmatizing labels “It’s role clarification sheets. So, it’s um a/ just a document that kind of
Once an initial relationship between public institutions and nursing outlines who to call, when um if someone is requesting something. It’s kind of
homes was built, respondents emphasized a shift towards educating like a guide that’s meant to be helpful to/ it can be helpful to family, patient
their partners in public institutions. Several respondents claimed that and the placement, the people working there, um about what to do when and
both the mental health issues and incarceration labels carried a stigma how to better understand and also inviting them to call forensic outreach
that needed to be challenged by educating the general public. For services if they have questions and not be afraid to do that.” (C647/C648).
instance, the participant (C651) stated that “And there again, getting so­ These easy and fast communication channels to obtain assistance
ciety to learn more about it rather than the sort of dramatized visions that you with (former) forensic patients were central in providing the feeling that
see in the media or the movies, that stigmatizes mental health.”. This need “there is another support that is going to help them monitor, you know, issues
for more information on mental health issues was not limited to the or whatnot.” (C646). This guaranteed integration into an assistive
general public, even “staff need to have a better understanding of mental network increased the public institution’s willingness to accept older
health. There is a lot of stigma.” (C667). forensic patients, as summarized by the interviewee (S696):
In addition to education on mental health, information about the “And, um, we realized that it, it makes it easier, it makes institutions say:
peculiarities of ‘forensic programs’ are needed. Respondents explained Ah well… if there is a c/ the case manager who is also there to help us to… to
that typical questions revolved around the content and purpose of the take care of these people, and who can reassure us, and well, we agree to take
program as well as the implications for the older person’s dangerous­ him.”
ness, as summarized by respondents C647/C648: Most participants described the nature of their support as being only
“So, the nursing home still needed a lot of education on forensics (…) an arm’s reach away to clarify any questions on the phone but also to be
yeah that even within our mental health agencies they’ll s/ yeah, they’ll say, on site regularly to meet patients and staff personally. Most importantly,
‘well what is that?’ and ‘what do you mean, a disposition?’ and, and you interviewees explained that “We have to talk to them.” (C643). It was
know ‘well is this person dangerous?’ that’s/ I mean that/ I’ve had a couple considered vital to engage in an ongoing dialogue that allows identifying
community mental health frontline workers ask me that about my clients. So, challenges and potential areas where help was needed. For instance, one
you have to do education on that as well.” (C647/C648). respondent explained that s/he “would say ‘how might we help? What can
Several respondents described providing education as creating an we supply you with?’ and mobilize those resources out.” (C645). Another
atmosphere that invites their partners from public institutions to ask respondent described how they provided face-to-face contact by visiting
unresolved questions and to discuss reasons and objectives of the one institution on a biweekly rhythm:
cooperation. Amongst others, it was key to delve into conversations “I believe like building those relationships with um/ like we have two
about issues such as how the forensic program was structured and how workers going there - he is a couple hours away - they go there um/ between
recovery was pictured by the representatives of forensic programs. For the two of them they are up there at least once every two weeks visiting the
instance, participant C645 explained that they needed to clarify “how we patient (I: Ok) and speaking to the staff, you know and building that rela­
might approach situations, how we care for people who are elderly and have tionship and that support. So that helps.” (C644).
mental health [issues]and I think that that is really where the focus needs to This ongoing support and collaboration that the forensic liaison team
be”. These interactions were described as essential in creating a mutual provides was described as resembling the support replacing what close
understanding of how to support the patient, as outlined by the family members would usually do for their close ones. Namely, discuss
following participants: the problem and needs of their older family member, look for support
“Just try to do our best to, to decrease the stigma where it does exist (…) options in the community, and to keep in touch to assure needs are still
answering questions like if people have questions inviting them to ask so that met. This was summarized by interviewee C664:
we can help develop an understanding and hopefully if we develop a mutual “If grandpa is not doing well in the community the family does not get
understanding and they understand that there’s all these supports wrapped together and throw him in a prison, right? They get together and come up with
around this person then they’re deserve/ you know (…) Continue in educa­ a plan for grandpa. And so they call the local health authority, they engage
tion in the nursing homes and with CCAC as well um with staff and just you with a case manager, they look at supportive housing. And that is the same
know giving education/ uh providing education about what the program is, response we need for our offenders who are on conditional release. So we are
how we see peoples’ recovery, how this is a rehabilitation program um that still theoretically supervising them but they are community members. But I
sort of thing too.” (C647/C648). think what we are missing here is that sort of advocacy and that family
support.”
3.2.3. Ongoing collaboration with public institutions
Several participants explained that next to education about the 4. Discussion
particularities of forensic patients, it was central to provide long-term
support for partner institutions. Once the older patient was placed in a To our knowledge, this is the first study to investigate the combined
day program or similar, the focus shifted towards “developing a rela­ stigma of older persons suffering from mental health issues with a his­
tionship with them” (C646). Most participants emphasized that solid tory of incarceration and its influences on finding housing during their
collaborations were built by regular meetings, ongoing dialogue, and reentry. Using a qualitative interview methodology, we assessed mental
prompt support. Several respondents highlighted that the support from health professionals’ experiences with stigma and reintegration man­
forensic programs needed to entail clear allocations of roles and agement. This research focuses on older adults, who are a particularly
approachable contact persons. Some respondents explained designating under-researched population within prison studies, while at the same
one person or one department, here called “liaison case manager”, time possessing different reintegration needs in comparison to their
responsible to organize support and to offer information, as illustrated younger counterparts. Additionally, it sheds light on the perspective of
by the respondent (S696): mental health professionals, who play a critical role in facilitating the

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successful reintegration of formerly incarcerated adults. consequence of a lack of low and medium-security long-term care units,
Our research highlights that older incarcerated adults who have which required patients to remain in high-security facilities longer than
mental health issues are particularly limited in their housing options needed (Harty et al., 2004; Pierzchniak et al., 1999; Reed, 1997). This
after their release from prison due to their double stigma. The most raises ethical and financial concerns as secure services come with severe
dominant consequences of stigma mentioned by the study participants restrictions, which are not proportional for these older patients who
were social rejection by members of the general public that resulted in have served their time and the additional particularly costly continued
restrictions in housing opportunities after incarceration and prolonged care that must be provided.
stays in forensic programs. One reason for the reported public’s rejection Particularly in regards to older incarcerated adults, numerous au­
of ‘forensic’ patients was their unfamiliarity with this specific group of thors have already pointed out this problem of inadequate housing and
people. As a result, the stigma management strategies applied by the lack of special programming within correctional institutions and in the
mental health professionals targeted at increasing knowledge, famil­ community (Aday & Krabill, 2012; Kamigaki & Yokotani, 2014; Shantz
iarity, and personal contact with this population. & Frigon, 2009; Walker, Griffiths, Yates, & Völlm, 2021; Williams, Stern,
Even though the European Prison Rules state that “all prisoners shall Mellow, Safer, & Greifinger, 2012). To ensure the smooth reentry of
have the benefit of arrangements designed to assist them in returning to free older formerly incarcerated adults, transitional programs need to be
society after release” (33.3.) (Council of Europe: Committee of Ministers, developed to increase the chances for successful reintegration (Williams
2006), incarcerated persons reentering society are often left alone et al., 2012). Particularly in light of the effects of stable housing on
(Weber, 2018). Our sample of healthcare providers, who assisted their reduced recidivism and well-being (Keene et al., 2018; Wong, Bouchard,
patients in the reintegration process, might be an exception to the norm. Gushue, & Lee, 2019). Nevertheless, our findings illustrate that care
These results are consequently likely to not represent the full reality of providers were able, at times, to secure placement for their older pa­
reintegration processes but provide important implications to facilitate tients in public institutions, that were not specialized for forensic pa­
persons’ successful return to society. While most health care pro­ tients but for older adults needing intensive care. The key here seemed to
fessionals are working on re-integration processes during incarceration, be, to provide expert knowledge on forensic populations to the nursing
they are often underfinanced and struggle to provide equivalent health home staff. Thus, the lack of specialized units for older (formerly)
care during incarceration (Bretschneider & Elger, 2014; Elger, 2008). incarcerated adults could be compensated by providing well-managed
This might limit the time available for preparing release from prison, support teams. One important aspect of this form of support was clear
especially for older incarcerated persons where it is particularly difficult allocations of roles and responsibilities with approachable contact per­
to find housing options. sons from the prison system, who offered information and organized
Above all, it is noteworthy that our participants confirm previous additional support where needed.
findings that the combination of multiple stigmas weighs particularly Further, our findings showed that certain strategies were successful
heavily. This interaction of several stigmatizing identities cannot be in placing older forensic patients in public nursing homes: participants
equated with a simple addition of factors but represents rather an ad­ tended first to conceal their patients’ stigmatized identity to facilitate an
ditive effect, creating highly discriminating situations (Hirschfield & encounter between the program’s representatives and the patient. In the
Piquero, 2010; LeBel, 2012; West, Mulay, DeLuca, O’Donovan, & Yanos, next stage, the stigmatizing ‘forensic’ label would no longer be con­
2018). One explanation for this effect might be due to an intensification cealed but explained to increase knowledge and awareness of this
on three levels: Both labels, ‘mentally ill’ and ‘incarceration history’, population. Thus, after overcoming initial resistance and reluctance by
independently contribute to perceptions of rarity/unfamiliarity (Feld­ using concealment strategies, participants shifted towards full disclosure
man & Crandall, 2007; Hirschfield & Piquero, 2010), perceived strategies. In other words, participants emphasized that after getting the
dangerousness (Corrigan & Kleinlein, 2005; Feldman & Crandall, 2007; foot in the door, all efforts were aimed at debunking the stigma by
LeBel, 2012), and perceived responsibility for their stigmatized identity providing education about this population, enabling personal contact,
(Corrigan & Kleinlein, 2005; Gausel & Thørrisen, 2014; Schnittker, and providing support in responding to their specific needs.
2014). The combination of both stigmatized identities might amplify the These stigma management strategies have previously been linked
perceptions of the general public on these dimensions, leading to higher with differing risks and consequences (Cherney & Fitzgerald, 2016). For
levels of stigmatization from others. Similarly, our findings indicated instance, concealing one’s stigmatized identity prevents instances of
that the unfamiliarity with this population, the perceived dangerousness prejudice and discrimination (Camacho et al., 2020). At the same time,
due to the crime committed, and the severity of mental illnesses (e.g. concealment can negatively affect the well-being of stigmatized persons
treatment-resistive symptoms) contributed to fear and anxiety from the through thought suppression, hypervigilance to stigma-related cues, and
general public that resulted in the occurrence of stigma. These are the anticipation of discrimination (Camacho et al., 2020) and is linked to
important findings as the bulk of previous research focused on the effects adverse health outcomes (Quinn, 2017). Interestingly, our participants
of one stigma only (Gausel & Thørrisen, 2014; LeBel, 2008) while the have not illustrated experiencing any negative consequences from con­
‘forensic’ combination is notably under-researched (Hirschfield & cealing or disclosing their patients stigmatized identity. This could
Piquero, 2010; LeBel, 2012; West et al., 2018). suggest that those in charge of health care and release planning are able
Further, our participants underlined that it was a difficult endeavor to shield their patients from these undesirable side effects and buffer
to find placement for their older patients in public institutions. Stigma initial stigmatizing experiences such as social rejection (Livingston et al.,
was considered one important aspect that contributed to the difficulties 2011). At the same time, they might withhold situations from their
in finding housing for older (formerly) incarcerated adults, as also patients during which they could learn to manage stigmatizing experi­
highlighted by other authors (Chiricos, Barrick, Bales, & Bontrager, ences and grow from them. Future research needs to assess patients’
2007; Hirschfield & Piquero, 2010; LeBel, 2012; Pogorzelski, Wolff, Pan, perceptions of risk and consequences of surrogates’ support during
& Blitz, 2005; Skipworth & Humberstone, 2002). Their lengthy search reentry.
for housing led to prolonged stays of their older patients in forensic Contact and education-based interventions are common and effec­
programs that they were already residing in. This resulted in inadequate tive methods in reducing stigma (Livingston, Milne, Fang, & Amari,
placing of their patients as they did not require the intensive care pro­ 2012; Rao et al., 2019). Particularly face-to-face contact that allows
vision and the security level of the forensic program. In fact, it is esti­ direct interaction with members of the stigmatized groups have been
mated that one to two-thirds of all forensic psychiatric patients are shown to be effective in changing attitude, knowledge, and behavior in
inappropriately placed with respect to their level of risk, at most members of the general public (Corrigan & Rao, 2012; Dalky, 2012;
commonly higher security levels than needed (Hare Duke, Furtado, Guo, LeBel, 2008). Our participants stated that regular contact decreased
& Völlm, 2018). This misplacement was explained to be the perceived dangerousness and reduced anxiety towards forensic patients.

7
H. Seaward et al. International Journal of Law and Psychiatry 89 (2023) 101905

Older patients’ regular contact with public institutions happened or who held positions providing enough time to do it. Thus it is partic­
through their participation in nursing home’s day programs. This ularly relevant, that even these mental health professionals encountered
contributed not only to less stigma but also served as a reference for their significant difficulties to plan reintegration due to multiple stigma.
stability and integrity. This is particularly important as previous authors Second, social desirability might have affected the opinions expressed
have emphasized the need for formerly incarcerated persons to have during the interviews. However, we emphasized anonymity and confi­
members of the general public vouching for them, to increase chances to dentiality to attenuate the effect of social desirability. Third, our results
obtain employment or housing (Anazodo et al., 2019). are not generalizable to all contexts but provide some transferability to
Further, it is worth emphasizing that interviewees exclusively dis­ other forensic settings. Last, it is interesting that the gender distribution
cussed nursing homes as housing options for older adults leaving amongst participants was contrastive in the two countries with more
correctional or forensic institutions. Literature discussing ‘average’ female participants being amongst the Canadian participants and vice
adults leaving prison highlight the importance of finding housing simi­ versa for Switzerland. However, we have not seen any striking differ­
larly but discusses the difficulties of returning to self-sustained housing ences in the opinions raised between genders.
(Keene et al., 2018; Schartmueller, 2020). Older incarcerated adults’
health status is worse in comparison to their younger counterparts as 5. Conclusions
well as when contrasted to same-aged adults living in the community
(Fazel, Hope, O’Donnell, Piper, & Jacoby, 2001; Wangmo et al., 2015). Incarcerated persons with mental health issues face double stigma­
Their high needs profiles might be a reason why a big proportion of older tization that affects their reentry process. Social rejection resulting from
adults reentering the community return to care homes instead of inde­ this stigma interferes with the efforts of the personnel planning release
pendent living options. Nevertheless, not every older person will require from prison to public housing. Due to the strong impact of stigma,
the intensive care of a nursing home when returning to society. Future mental health professionals adopt strategies that facilitate their search
studies examining the perspectives of incarcerated adults could shed for their older patients’ placement. After first concealing their patients’
more light on the various options that older adults seek after stigmatized identity to get a foot in the door, they will shift towards
imprisonment. disclosing the stigmatized label with contact and education-based stra­
tegies. Additionally, the lengthy searches for placement and lack of
4.1. Limitations and future research specialized placement options at release often resulted in prolonged
stays in forensic programs, calling for greater focus on low security and
Our findings are limited to the perspective of mental health pro­ halfway houses. Our findings are interesting as they, on the one hand,
fessionals who may have supported (formerly) older incarcerated adults illustrate ways in which stigma can be reduced but on the other hand
in finding housing. However, to assess the reentry process to a wider how the reentry process can be streamlined.
extent, the views of the population at stake and their close social net­
works should also be examined. This is particularly important in light of Declaration of Competing Interest
the relationship between public stigma and self-stigma. Self-stigma is
the internalization of public stigma, which refers to the stigmatizing None.
perceptions that the public holds about a certain group. Self-stigma is
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