Return to Work After Release From Prison

Abstract

Work preservation is crucial for the reintegration of ex-prisoners and the prevention of recidivism. We describe the application of an interdisciplinary diagnostic protocol (occupational health visit, psychiatric interview, psychological counselling and testing) in the case of a dairy industry worker (female, 45-year-old), released on half-freedom after approximately a year of detention in prison for attempted murder. This crime can seriously hamper job resumption. The evaluation revealed a slightly depressed mood (consistent with recent life events), in the absence of major psychiatric disorders or other disturbances that could compromise working abilities or represent a danger for the coworkers. The patient was, therefore, judged able to resume her job. At six months follow-up, she had fully served her sentence and had returned to her previous job, with good relations with her colleagues. However, she encountered hostility from her employer, which induced her to find a new job as a secretary. Her mental health status was improved. The interdisciplinary approach described here may allow ex-prisoners to return to work by helping the company physician to formulate the judgement of job fitness, offering at the same time suggestions for a rational occupational reintegration.

1. Introduction

Work preservation after release from prison is a main issue for social reintegration and to prevent recidivism [1, 2]. After detention, however, workers experience complex health challenges and problems resettling into the community. Consequently, interventions to improve employment should focus not just on starting or resuming a job but also on ensuring that work is of good quality and that the individual has the skills and support to sustain employment [3]. In this context, the judgment of job fitness may be particularly challenging and require collaboration between the occupational physician (analysis of task features and related risks) and the psychiatrist (job adaptation to mental status, evaluation of possible risk for coworkers). This synergistic approach may serve multiple purposes: to provide indications about working capabilities and modalities of job maintenance, minimize health risks, and improve prescription compliance, allowing a safe and well-informed return to work.

We describe here the application of an interdisciplinary diagnostic protocol (used successfully at our Institute since the beginning of the 2000s for work-related psychopathological issues [4, 5]) in the case of a female worker in a half-freedom regime after detention for attempted murder. This conviction can severely hinder a return to employment. No previous case report has documented the possible role of this integrated strategy for work resumption after jail for serious crimes.

2. Case study

A 45 year-old woman (ex-prisoner in half-freedom) was referred to our Institute by her company physician for diagnostic in-depth investigations aimed at job fitness evaluation, in accordance to the Italian Legislative Decree n. 81/2008 (article 39, paragraph 5). The subject was evaluated using an interdisciplinary protocol: occupational medicine, psychiatry, and psychology (counselling and testing).

2.1. Medical and Occupational History

Nothing relevant was found in family, physiological and remote pathological anamnesis. Legally separated from her husband, without children. Active smoker (10 cigarettes/day) since age 35. After completing her studies (high school degree), the patient started working at the age of 20 at the municipal dairy of her hometown as an administrative office worker.

At the age of 39, after separating from her husband, with whom she was sharing the office at work, the patient was diagnosed with reactive anxious-depressive syndrome and asked for a task change. She was, therefore, transferred to the management and storage (cold room) of unsold or expired dairy products. Equipped with safety shoes and subjected to annual sanitary surveillance (occupational risk factors: mechanical traumatic agents, manual handling of loads, cold microclimate, chemical disinfectants). Day shifts (08.00-14.40, Monday to Saturday). Occupational activity had been interrupted 17 months before our evaluation due to incarceration.

2.2. Judicial Vicissitudes

After the breakup with her husband, the patient began a relationship with another partner, who turned out to be addicted to illicit substances, not inclined to work and violent. During a quarrel, the patient, fearing to be physically attacked (as already happened previously), stabbed the man in the abdomen with a kitchen knife, causing laceration of his spleen and haemoperitoneum. The man was saved by emergency surgery, and the patient was tried and convicted for attempted murder (with plea bargaining of the sentence and recognition of mitigating circumstances). After about a year in prison, she was granted home detention and then half-freedom (with the possibility of returning to work).

2.3. Physical Examination

At our evaluation, the patient was severely underweight (height: 163 cm; weight: 42 kg; body mass index: 15.8). Nothing else was relevant.

2.4. Neuropsychological Evaluation

Global cognitive function was largely normal, with a mild selective deficit in the verbal working memory capacity (without interference on the level of autonomy in daily life activities).

2.5. Psychiatric Evaluation

At the psychiatric interview, the patient retraced her life story, focusing on the separation from her husband and her most recent legal vicissitudes. These traumatic events had an important emotional impact, configuring a situation of acute stress in a subject with personality aspects characterized by emotional fragility, poor insight capacity and a tendency to manifest depressive symptoms in response to environmental triggers.

A slightly depressed mood, consistent with the life events reported, was found. The woman was strongly intolerant of the continuation of the interruption of her work activity, in particular of the loss of her rhythm of life, her work role, and the monthly economic income, which were fundamental for maintaining her autonomy.

No major psychiatric disorders or other psychological disturbances that could compromise working abilities were identified.

2.6. Diagnostic Conclusion and Advice for Work rRsumption

Overall, the multidisciplinary evaluation highlighted a slightly depressed mood, consistent with recent life events, in the absence of major psychiatric disorders. Presence of marked discomfort due to the interruption of work activity and the consequent absence of economic remuneration. The patient was judged able to resume the job she did before the legal events, with the prescription to avoid particularly stressful conditions.

2.7. Follow-up

At six months follow-up, the patient had served her full sentence and was once again a free woman. At the same time she had returned to work, with good relations with her colleagues but encountering a certain hostility from her employer, who (according to the patient) called her “privileged” for having returned (considering her past), and often left her alone to manage two cold rooms, without giving her the opportunity of getting a license to drive the forklift. Therefore, also due to the recent onset of lumbar disc herniation with limitation in the movement of loads, she had resigned and found a new job as a secretary at an insurance company.

The state of health was improved overall, with weight gain and regression of the depressive disorder.

3. Discussion

In all countries of the civilized world, work plays a pivotal role in prisoners’ rehabilitation and social reintegration [6]. In Italy, article 15 of the Penitentiary Regulation (Law n. 354/1975) identifies work as one of the elements of re-educational treatment, establishing that, except in cases of impossibility, the convicted person should be guaranteed employment. This principle applies even more to prisoners in half-freedom, as in the case described here. Indeed, half-freedom represents an example of individualized treatment with progressive reintegration, that is granted precisely to allow the prisoner to spend part of the day outside the penitentiary institution to participate in work, educational or otherwise useful activities for resocialization (Italian Penitentiary Regulation, art. 48). Unfortunately, employment of convicts encounters considerable difficulties in practical application, due to prisons overcrowding, as well as various other political and organizational problems. Less than a third of Italian prisoners are working [7].

Occupational and social reintegration at the end of the sentence is even more problematic, especially for women [8] or high-profile offenders [9]. When searching for a job, former prisoners experience several barriers and difficulties related to their deficits in human and social capital (e.g., low education, poor employment experience, limited skills), psychiatric disturbances (e.g., substance use disorders), and the stigma associated with having a criminal record [10]. Generally, incarcerated women have lower education and more significant gaps in their occupational histories. Moreover, under a male model of corrections, females have less access to training and education while in prison, and it is harder for them to find a job upon release because they frequently have to care for others [8].

Unemployment after release from prison is strongly associated with detrimental health effects (especially mental problems), economic difficulties, and a high risk of committing new crimes [2, 8].

In the case of individuals wishing to return to work after violent crimes (such as the woman described here), the company occupational physician (“medico competente” ex Italian Legislative Decree n. 81/2008, who must by law evaluate the fitness and the suitability for the specific task) generally faces a double problem: not only evaluating the compatibility of the job with the changed psychophysical conditions of the individual, but also excluding that his/her re-employment could constitute a risk for other workers. In the reported case, the company physician referred the subject to us for a second-level evaluation. We, therefore, used the interdisciplinary approach, which has already been proven successful (at our Institute), to diagnose work-related psychological problems, to define job fitness in subjects with psychiatric disorders, and to address such patients towards an appropriate therapeutic path to promote their psychological well-being and occupational reintegration [4, 5].

After occupational medicine examination, psychiatric interview, and psychodiagnostic testing, no major psychiatric disorders were identified. However, the patient presented a slightly depressed mood, reactive to the separation from her husband (a well-known major stressful event [11]) and mostly to her recent imprisonment. This is not surprising as the prison climate is notoriously detrimental to the mental health of inmates, especially women [12, 13].

The state of unemployment was a further factor of serious discomfort, and the patient was strongly motivated to return to work. Given the absence of physical or psychological disturbances that could prevent the resumption of the previously performed task, compromise her working abilities, or constitute a danger to her coworkers, we suggested that employment recovery, besides not being contraindicated, could have an important therapeutic and rehabilitative value. Indeed, our advice was followed, and the patient resumed work without encountering relational problems with her colleagues and with a significant improvement in her mental health.

However, at follow-up, she reported hostility from her employer, which, in combination with the concurrent onset of back problems, had led her to seek a different job. This confirms, once again, that occupational recovery after detention is a process that encounters considerable obstacles and prejudices [8-10].

Some prisons offer educational and skill development programmes, work programmes, and supervised work release. These operate on the assumption that improving the prison population’s limited education and work experience will increase the likelihood of successfully securing future employment. Following the release, support programmes for employment, provided by statutory and non-statutory services, vary in their approach from focusing singularly on employment to those which offer more holistic interventions, incorporating help in finding work, preparation for employment, support, and psychological guidance [3]. There is currently encouraging (though limited) evidence for the effectiveness of such interventions. For example, prisoners who had participated in a supervision program of the Israeli Prisoner Rehabilitation Authority showed better integration into employment, a higher wage level, and a lower rate of reincarceration [1]. A recent meta-analysis of randomised controlled trials (conducted in the USA) demonstrated a significant increase in the number of people starting employment and the amount of time worked following release. However, no evidence of effectiveness was found on indicators of sustained employment [3].

We believe that programs aimed at prisoner employment should include psychophysical evaluation, possibly task-oriented. From this perspective, the multidisciplinary approach successfully used for the subject of this report seems promising. Studies on other similar patients are needed in the future to confirm our uncommon preliminary observation. However, the experience documented in the single case described, which demonstrates the real possibility of work resumption for a female worker convicted for a violent crime, may serve as a reference for the resolution of other similar cases.

4. Conclusion

In the case reported here, our evaluation favoured the resumption of employment and improvement of mental health conditions. The interdisciplinary approach utilised can allow ex-prisoners to keep their jobs or find new employment, helping the company occupational physician formulate the judgment of fitness and suitability for the job while at the same time offering suggestions for a rational return to work.

Funding:

This research was funded by the Italian Ministry of Health (“Ricerca corrente”).

Institutional Review Board Statement:

The study was conducted according to the guidelines of the Declaration of Helsinki. The ethics committee of ICS Maugeri IRCCS approved the utilization of the patient’s clinical data (in anonymous form) for the present scientific report.

Informed Consent Statement:

Informed consent was obtained from the subject involved in the study.

Declaration of Interest:

The authors declare no conflict of interest.

Author Contribution Statement:

S.M.C. and F.S. are responsible for the manuscript’s design, interpretation, and writing; D.M. performed the occupational medicine evaluation and the follow-up and contributed to the psychological assessment. C.N. performed the psychiatric evaluation and contributed to the psychological assessment.