Narrative Inquiry into Shelter-Seeking by Women with a History of Repeated Incarceration: Research and Nursing Practice Implications

Abstract

Nurses who provide care in the community to women with a history of repeated incarceration may struggle to understand the full extent of the barriers faced by this population and as a result risk giving suboptimal care to an already underserved group. This narrative inquiry study of stories told by ten women with histories of repeated incarceration fulfilled two purposes: to demonstrate how women’s shelter-seeking stories exposed uniquely complex patterns of health opportunity and risk and to demonstrate how storytelling as a method of data collection might serve as an informative mode of nursing health assessment for this population.

According to the most recent Bureau of Justice estimates, as of December 2015, there were over 1.2 million women incarcerated in jails or prisons or under some form of community corrections in the U.S., approximately one-tenth of the total.¹ Women’s incarceration rates, unlike men’s, have climbed over the past decade, increasing 18%, while men’s decreased 3.2%.² Most jail-incarcerated persons will be released to return to their families and communities in less than a month.³ Within three years of release approximately 68% of those persons will be rearrested.⁴ In the U.S., prisons and jails both serve as detention centers for persons convicted of crimes, but they are not the same. Prisons, which may be federal or state, house persons convicted of felonies which generally carry sentences of one year or more, while jails in the U.S. are usually municipal-, county-, or state-run and hold persons for shorter periods.⁵ Persons detained in jails include those who are sentenced for misdemeanors or other crimes that carry sentences of less than a year, persons who are held prior to sentencing, and those returned to custody for technical violations of a probation.⁵ Community corrections, which constitutes the largest group of persons supervised by the U.S. criminal justice system include persons released on parole or assigned a probation term.⁵ Community corrections often involve periodic, mandated drug testing; residential or day-program substance use treatment; curfews; and constraints on social congress and geographic movement.⁶

Research indicates that women with a history of repeated incarceration constitute a distinctive population that shares numerous social and economic as well as health and safety vulnerabilities, including disproportionate rates of mental health problems and lifetime interpersonal trauma, including childhood sexual abuse, adult rape and intimate partner violence, and captivity.^7,8 Traumatic experiences are associated in the research on women with a history of incarceration with a high prevalence of substance use disorder, which exposes the women who experience trauma to further violence and, often, reincarceration.^7–9 For many women with serial incarcerations, maintaining health and safety in the community is tremendously challenging process for which there is little formal assistance.^10,11

For nurses who encounter women with a history of repeated incarceration in clinical or community care settings, the complex, overlapping social determinants that influence both women’s criminal justice involvement and their health status may go undetected or their impact on women’s choices and behaviors underappreciated. As works by Colbert and by Maeve indicate, nurses could play a key role in helping women with a history of repeated incarceration achieve health and safety in the community.^12,13 However, there is no particular training or specialized role for nursing in this population outside the carceral setting. So, on one level, this study explores a specific experience of women with a history of repeated incarceration—the quest for shelter—from their perspective in order to better understand how they perceive and manage complex challenges to health and safety. On another level, I offer the storytelling approach as a potential tool of assessment, one that could provide nurses with means to understand patient circumstances beyond conventional screening. Assessment through storytelling has been promoted, though only sporadically, in nursing, social work, and medical fields.^14,15,16 From the standpoint of holistic nursing practice, storytelling offers a uniquely humanistic mode of patient assessment.

Background

Underlying the physical and mental health vulnerabilities of women with a history of repeated incarceration is the low socioeconomic status of this population.^17,18 Both men and women with criminal records pay what researchers call an “incarceration penalty,” a kind of tax levied through lower wages, lost experience, and increased difficulty securing employment following an incarceration.^19(p395) This is true for men and women and for those who are imprisoned long term as well as those, like many of the women in this study, who cycle in and out of short-term detention.^11,17 Depending on state rules, having a criminal record can stand in the way of employment and complicate or preclude a persons’s eligibility for public assistance, including food stamps and government subsidized housing.^20–23 For women in particular, studies show that obtaining employment, finding housing, and reestablishing family ties after an incarceration are sources of much struggle.^12,24–27

Housing is a known source of hardship for persons reintegrating after an incarceration²⁶ and especially so for women.^17,24 One study found that women leaving a jail incarceration listed housing as a top concern prior to release at least as often as health and reunification with children.²⁵ In general, homelessness among jail inmates prior to incarceration is estimated to be 7.5 to 11.3 times higher than in the general population.²⁸ Recent research has recognized the mutually reinforcing character of the relationship between homelessness and incarceration (wherein the social conditions of insecure housing function both as contributors to and results of offending) while also citing a lack of understanding about mechanisms.²⁹ We do know that women and men with a criminal record and particularly those ever having had a felony drug conviction face multiple structural barriers to housing assistance, including screening procedures and exclusions related to drug use, drug manufacture, and other convictions.³⁰ Public housing agencies, federal laws, and court findings often underwrite the imposition of inequitable standards on housing applicants on the basis of past conviction.^30–32 To meet the need for shelter, many turn to informal sources of social support, such as friends, lovers, family, acquaintances, and even strangers.^11,24,26

Research Questions

My purpose in this study was two-part. The research question I posed for the interview study from which this analysis was drawn was broad and centered on social support; I asked, “How do women with criminal justice involvement perceive and manage social relationships for health and safety?” I sought to understand from the women’s own perspectives how interpersonal support—access to social resources obtained from lovers, friends, family, and acquaintances—was understood and psychically managed in a context where material resources were low and risk of both disease and injury from violence was high. In the present analysis, I asked the same question but specifically in the context of stories that focused on shelter-seeking. I asked: “How do women with a history of repeated of incarceration perceive and manage social relationships to obtain housing?”

Second, as a nurse hearing women recount stories about managing relationships in order to survive, it quickly became evident to me that these methods of data collection and analysis, with modification, had distinctive potential for nursing practice. The analysis of stories or narratives takes time and patience and comes with no checklists. It requires skills in inference and interpretation. But, as a mode of assessing risk and opportunity, storytelling offers the advantage of allowing women to represent their circumstances in the fuller, more complex contexts of lived experience.³³ Storytelling gives women opportunity to select and prioritize, to connect cause and effect as they see them, and to assign meaning in ways that are relevant for their health but likely to be missed in more conventional modes of assessment.³⁴ In this narrative inquiry then, I advance simultaneously 1) an argument about what the stories that I collected from women with a history of repeated incarceration indicated about the health and safety potentials of seeking a particular, necessary resource (housing) through social connections, and 2) an assertion or provocation about how and why nurses might benefit from incorporating storytelling into their assessment approach when providing care in community contexts to women with a history of repeated incarceration.

Conceptual Framework

The methodology governing this study was naturalistic, and the worldview that informed it was constructivist. My research question implied the mediation of experience by perception and language: I inquired into women’s perceptions and focused on how women gave shape to and invested perceptions with meaning.³⁵ I was interested in how women used storytelling to give form to experience and what that shaping revealed about their health and safety vulnerabilities. I was aware that my participation as interlocutor and interpreter meant that what came to be constructed as a meaningful in this text was in part the result of my shaping as well as the women’s.^33,35

Data and Methods

Case Selection and Recruitment

Ten participants were invited to interview from a parent intervention study that assessed the effects of an education and empowerment cervical health literacy intervention on knowledge, beliefs, and self-efficacy in a jail-incarcerated female population.³⁶ The parent study enrolled 262 women in three county jails located in a Midwestern metropolitan area. Eligible participants were adult women (over 21), English-speaking, and admitted to the jails between September 2014 and March 2016, with exclusions occurring only when indication of severe psychological disturbance or emotional volatility was observed.³⁶ Because the objective of my interview study was to explore what stories about relationships told by women with a history of repeated incarcerations revealed about their perceptions and management of health risk and opporunity, my sampling was purposeful: the selection criteria I used to invite women for the interviews were the complexity and richness of detail in the stories told by the women about interpersonal relationships during the small-group sessions in the jails that formed part of the parent study intervention. Additionally, I sought to include women from older and younger ranges of the parent study sample, both White and Black women, and at least one case that was socioeconomically divergent. Recruitment for the interview study took place variously, with a few participants being enrolled during their jail incarceration but most invited to participate during the weeks and months after their release. Recruitment ended after I conducted initial interviews with 10 women, when I determined, following Patton’s criterion,³⁷ that the group was yielding a range and complexity of relationship stories sufficient to answer my research question. All the women who were invited to participate agreed to do so; retention of participants was 100% over the 12-month period of data collection, ending in December 2016. Approval for the interview protocol and procedures was granted by the institutional review board at the sponsoring academic institution for the parent study and, in the few cases where interviews took place during an incarceration, procedures were approved by the administrators at the jails.

Data Collection

Each woman completed two interviews, an initial and a follow-up, both face-to-face and semi-structured, and most of them in the community after a woman’s release. During each woman’s initial interview, I used a single introductory prompt: “Think of your life as a book made up of chapters in which each chapter centers on a key relationship. Tell me the story of your life in relationships, chapter-by-chapter.” In the follow-up interview, I presented an outline of the overarching life story from the initial interview, asked for verification, solicited additional narrative, and queried for detail. Interviews were conducted in person and audio recorded, at sites that participants proposed, including temporary residences, cars, coffee shops, fast-food restaurants, a public library, and a church. Three interviews (two initial interviews and a follow up) took place in meeting rooms at one of the jails, and one follow-up interview took place over Skype.

Data Analysis

The narrative inquiry approach that informed this study centered on stories that participants told in response to the main interview prompt. The analytical process included noting the way the chapters women narrated on individual relationships fit into the overall life stories the women narrated and also, within each chapter, identifying embedded stories. In this study, the unit of analysis was embedded stories in which women addressed the challenge of finding housing. I chose that focus because narratives that involved housing were so repeated and prominent in the interviews. Where, how, with whom, and with what result housing occurred commanded a great deal of the women’s storytelling attention and energy. The embedded housing narratives, similar to the embedded trauma narratives on which I have reported elsewhere³⁸ were also notably linked in the stories to women’s thoughts on health and safety.

The work of analysis involved reading, coding, and memoing on interviews as each transcription was completed and then rereading and memoing in light of each new interview. In generating thematic patterns, I initially performed line-by-line coding of every interview based on a list of descriptive codes that were devised for the parent study and that focused on relationships, trauma, and health care. These helped me focus at first on drawing out broad, repeated themes of health and wellbeing and enabled me to trace formal outlines (e.g., beginnings, conflicts, resolutions) for embedded stories that developed around those given themes. This was necessary because the embedded narratives that I analyzed were not standalone stories recounted in response to specific individual questions (i.e., “Tell me a story about how you found housing”) but were delineated from responses to my very open-ended initial interview question. During the data analysis process, I also memoed analytically³⁹ on the stories I found. Over the course of the year of concurrent data collection and analysis, two colleagues from the parent study independently read and memoed on my story transcriptions and field notes. Our biweekly meetings provided a forum in which to critically examine my interpretations of themes and formal elements.

Finally, related to the analytic approach, narrative and story are used interchangeably in this article, with both terms pointing to ways in which the women gave order to experience and used language and the performance of telling to imbue their accounts with purpose and meaning.³³ An advantage of using narrative as basis for analysis in research is that narrative or story provides access to information from within the social world of a storyteller.⁴⁰ Because narrative inquiry begins with a storyteller’s constructions in a time and place, rather than abstracted categories or concepts established beforehand by researchers alone, stories can give a more holistic picture, preserving information that gets lost when variables are preselected and conditions of collection closely controlled.^33,41 The longer segments of text analyzed in narrative inquiry introduce elements of voice and persona, giving play to the unique while enabling comparison of shared formal and thematic patterns across a group of stories.⁴² In that way, stories remind us that behind numbers lie persons.⁴³

Ethical Issues

Participants in this study were initially encountered during a jail incarceration, and most continued to be subject to some form of community corrections and thus constituted a vulnerable population requiring additional human subjects protection.⁴⁴ All participants gave written, informed consent to be interviewed as part of the original consent process for the parent study. Data were stored on a secured university server. The women themselves chose pseudonyms, and these appear here and were used in place of the women’s names in fieldnotes, memos, and other study materials. A National Institutes of Health Certificate of Confidentiality was in place to safeguard recordings and other documents related to the study from seizure or discovery by law enforcement. Though it never proved necessary, to further protect women from harms resulting from participation, I reminded them that I could provide referrals for mental health support should an interview lead to distress.

Findings

Participants

The ten women in this study averaged 39 years of age. Six women identified as Black and four as White. By the end of data collection, all but one of the women had served time in prison as well as one or more jail sentences, including the stay in which they were recruited for the parent study. Along with trauma, women most often described struggling to secure safe, affordable housing, a fundamental requirement for well-being. Baseline survey results in the parent study sample (n = 182) indicated that at least 24% of the sample were homeless or staying place-to-place before the incarceration in which we met them, and 71% felt they had barely enough or not enough money to live on each month.⁴⁵ At the time of the story interviews, of the 10 women in the present study, half had moved at least three times since their release from jail.

Housing Support through Social Connections

Of the ten, none of the women had a place of her own to which she could return after jail, so a main priority post-incarceration, as they repeatedly made clear, was to establish a safe place to stay. The need for housing was also not, in most cases, summarily satisfied; it continued over weeks and months to dominate women’s attention and energy. In their narratives of housing support, the women described multiple instances when, in the months after returning to their communities, they looked to family, friends, acquaintances, and even strangers for housing assistance and found themselves presented variously with opportunity for improved wellbeing and threat of further risk to their health and safety.

Finding shelter through close or family bonds; or “I have four sisters and two brothers, okay? Why am I out here in the cold?”

Four of the women interviewed in this study told stories about seeking and receiving housing support from family members after release from jail. Susan, a Black woman in her late thirties, who reported having served one term in prison but estimated that she had been jailed between 5 and 10 times for drug sales and various misdemeanors, had no children but was herself one of seven siblings. Over the years, Susan had periodically declined shelter with her family; she attributed her reluctance to accept support in terms of a culturally normative script of self-reliance, announcing at one point, “I was a female on my own since 13. You don’t want to depend on nobody. You don’t want to ask nobody for nothing, you feel like you—you can do it on your own.” Susan went on to say that despite a continuing desire to be self-sufficient after her most recent incarceration she was “tired of going from house to house, and this and that,” so she broke down and took shelter with her brother.

Interviewer: How did you feel when he said, “Of course, come on in,” you know? How did that feel inside?

Susan: It felt good, it felt good. But it took me about a week to do it. He kept calling my phone—“When you coming? I put your key in the mailbox—when you gonna come and move in?” He kept—he was anxious. He was excited too. We had the best time, do you hear me—the best time. We went out, ate, we did brothers and sisters stuff. Just me and him doin’ brothers and sisters stuff. And then we had my nephews and nieces on the weekend and stuff. It was cool, do you hear me? I love my oldest brother. I love all of them, but I’m just saying, I love them. Because I never asked none of them—you know. Like my sister, I only stayed there two days. It was a wrap—pshooom. But I maintained it with him. I think he was trying, too. He kept me cause he don’t like to see me in the streets. […] He was like a brother’s supposed to be, you know what I mean?

Getting to the place where the positive “brothers and sisters stuff” occurred took time both thematically and performatively in Susan’s storytelling: she circled around the narration of living with her brother, emphasizing before and after how unusual her acceptance of such help was and setting the positive experience against a previous, less agreeable co-housing situation with her sister. But once she got to the stay with her brother, Susan’s account of housing support was comparatively free of entanglement. In Susan’s case, living with family meant an alternative to drug activity and street violence. Susan spoke fondly of the living arrangement and expressed awareness of the heightened sense of family belonging to which it led. Receiving aid from family was not depicted as simple, but it was a relatively safe and positive experience. In this respect, Susan’s narrative of accessing shelter represented an empowering exception. Almost all the other stories about seeking housing through family ties featured more mixed results.

Natalie, for instance, also a Black woman and mother in her late thirties, reported that she had earned General Education Development equivalency and then a college degree. Natalie described herself as a heavy drinker and occasional abuser of opioids who lost custody of her children when she was sentenced to several years in prison a decade earlier. Natalie also reported more than 10 jail incarcerations and a prison term. Following release from the jail stay in which we met, Natalie lived temporarily with her father and his wife. Natalie noted three details about living in her father’s home: the frequent criticism she received about the weight she gained in jail, her stepmother’s padlocking the kitchen cabinets and prohibiting her from using the kitchen, and a strict curfew according to which Natalie was barred from re-entering the premises after 10 p.m. Although shelter with her father was physically safe and drug-free, Natalie found the rules and demeaning treatment uncongenial and soon moved out.

Over the ensuing year, Natalie lived in an abandoned building, a car, a shed, a rented bedroom, and briefly out of state with her fiancé’s mother. In mid-winter, city officials confiscated her things and locked Natalie and her fiancé out of the abandoned house in which they were illegally squatting. In the following excerpt from Natalie’s narrative of her extended search for shelter, she describes going to one of her brothers for help:

My brother, I called him, and I’m like, “Bro, it’s cold—can you help me out on the room or whatever? Terence’s at work, at the part-time job up here—can you help me out with at least $30?”

[Pause] [Speaking in a man’s voice:] “I need to check with my wife and see.”

“Why you need to check with your wife? I’m your sister tellin’ you I’m in the cold and I just told you what happened—we got to get out of this house. What’s so hard for you? I ain’t askin’ you to come to your house. I’m just askin’ you to help me out.” …

I have four sisters and two brothers, okay? Why am I out here in the cold? Couldn’t none of my sisters and brothers ever be out in the cold and I have my own place.

In some ways, the story Natalie narrated represented the inverse of Susan’s. While Susan described having held herself apart while her family attempted to draw her in, Natalie described a narrative of exclusion, one that recurred in her interviews. In situation after situation, Natalie reported being left out, abandoned, or betrayed by family. Natalie assured me, following the account of this appeal to her brother, “I don’t have no family, I never had no support. But if my little sister called one of them—ahhh, they breaks they neck.” Underlying the focus on exclusion was Natalie’s perception of a moral claim on her family, its logic encapsulated in “I have four sisters and two brothers, okay? Why am I out here in the cold?” The assumption was that families have an obligation to support members in trouble. The brother’s response—“about how I need to get my life together”—represented a counter claim, one based on a principle of reciprocity in social support, namely that social assistance takes place in a system of exchange to which all parties are expected to contribute something. It is not difficult to infer that, while Natalie felt excluded, her family felt overburdened by the persistence and magnitude of her needs. Indeed, the same brother and his wife had been raising three of Natalie’s children for the past decade.

Natalie’s story highlighted several of the primary sticking points of relying on family or other close bonds for housing: the difficulty that a woman with significant lifetime trauma would have meeting conditions of reciprocity; the likelihood that the needs of a woman with a repeated history of incarceration, especially if long-lasting, would at some point exhaust or overstrain her network’s ability or willingness to meet them; and the possibility that the woman in need might fail or refuse to comprehend why she was being denied help

Finding shelter with friends and acquaintances; or “They wasn’t sending me out for me to be free. They were sending me out to be in hell.”

Often the women in this study did not find shelter through close ties in a bonding network. Similar to Natalie after she left her father’s home, the women moved frequently, staying with casual friends and acquaintances in situations that entangled them by posing threats to their health and rendering them vulnerable to violence and reoffending. Neta, a Black woman, 46 years old, reported a long history of incarceration, including numerous jail incarcerations and a 16-year prison sentence. Neta had exchanged sex for shelter, drugs, food, and other goods and resources for many years and was highly networked in the urban community that formed around one of the main strolls, or areas in the city where commercial sex is common. Her extended story of shelter seeking is best understood through the lens of recurrent abuse and traumatic loss. Sexually molested by her father at age eight, Neta experienced further sexual abuse in foster homes; multiple incidents of brutalization by adult partners; the sudden death of a newborn in the home; and her own near-death experience after being raped, shot in the abdomen, and left bleeding at a bus stop. Following the jail incarceration in which we met, Neta first went to live with her new husband. When the marriage began to replicate violent patterns of her past, Neta was forced out:

Neta: After awhile, I didn’t even want him to touch me. I moved my bed into another room and let him stay in there. […] Then the violence started, he wants to try to fight me. I didn’t get married to get beat on. It was really crazy.

Interviewer: Did you fight back at all?

Neta: Course. That’s why it didn’t work. I tore his ass up. I ain’t gonna lie. You not going to beat me—I’m not going through that. And, you know, of course it clicked […]—the first thing I clicked back to was my mom bein’ beat. […] He would wait till I turned my back and try to hit me in the head with something. Or if I would fall asleep—God is good, though, I’m telling you—the first time he tried it, I was asleep. He hollered out, “Bitch, I’m tired of you!” […].

I left.

In this brief account of sheltering with her husband, his violence “clicked” Neta back to memories of her mother’s being brutalized by her father. For Neta, housing with her spouse meant finding herself entangled in increasing intimate partner violence that triggered trauma memories from her childhood and put her at heightened risk of injury, death, and extreme mental strain. Blocked thus from safe shelter in what should have been home, Neta turned to other options, including accepting shelter with four men she knew, two of whom were unemployed and all of whom drank and smoked crack. While her shelter seeking stories indicated that each new housing situation kept Neta temporarily off the street, none offered much security or any leverage to improve her status, and each posed new threats to Neta’s health and safety.

Shelter support accessed through informal social ties was perceived or experienced by most of the women I interviewed as putting them at risk of not just several kinds of harm but reincarceration as well. Another participant, Sarah, a 52-year-old Black woman with over 30 years experience as a professional sex worker (her designation), a couple of prison sentences, and over ten jail incarcerations, was assaulted and permanently disabled after being released from the incarceration in which we met. When I interviewed Sarah, she reported that approval of her victim’s compensation and Social Security insurance benefits was pending. In the meantime, Sarah lived with a male acquaintance who “takes meds for hepatitis C and tuberculosis, and he smokes crack and he drinks liquor, and it alternates him and he changes.” Between our first and second interviews, this person “jumped on” Sarah, she defended herself, the police were called, and the man was taken into custody on domestic assault charges. Counter claims were made, and, while all charges were dropped, the police involvement triggered a probation violation for Sarah. She spent another 30 days in jail.

In the year following the jail incarceration in which we met, only a few of the women in this study had access to public services or benefits that provided housing. The exceptions were both White women. These included Cat and the one socioeconomically divergent participant, Jennifer, who, in addition to being White, came from a middle-class background and had a college degree and professional work experience. Although race was rarely discussed in explicit terms by the women in the interviews, both overt racial prejudice and more covert forms of racially inflected decision-making may have played a role in women’s access to public housing benefits. Of those who identified as White, Jennifer and her daughter were placed in a two-bedroom apartment in transitional housing through Drug Court. Cat’s serious mental illness gave her access to benefits that enabled her to pay for independent housing. Sarah, who was Black, was on the verge of receiving a housing voucher due to her loss of eyesight but ended up being disqualified at a point after the conclusion of the study. She and the rest made do. They found shelter, as Susan said, “from house to house, and this and that,” through family, friends, and acquaintances, in this way echoing Carol Stack’s classic work on social networks as dynamic sources of social support in a primarily Black 1960s Chicago community.⁴⁶ Perhaps the most striking testament to the difficulty of securing a safe and stable place to sleep for women with repeated history of incarceration was given by Neta, who told me that even jail seemed at times preferable to the constant, exhausting, punishing quest for shelter:

Each time I went back to jail and came out, it got worse. I mean, I didn’t care. Couple times I asked them to keep me. They thought it was funny, but I was serious as hell.

“We’re gonna send you back out.”

I said, “Why?” I said, “My feet still hurt. I’m tired.”

They wasn’t sending me out for me to be free. They were sending me out to be in hell.

Shelter meant getting off the street, off porches and park benches, and out of cars. But for from the perspectives of women struggling with history of trauma and serial incarceration, finding shelter through social connections also led to a host of further difficulties. Women saw shelter through close family relationships as entailing obligations that were difficult to meet or required them to endure demeaning treatment or abuse. When shelter support was obtained from mere acquaintances, women indicated that the drug habits and mental conditions of those on whom they depended put them in direct line for disease and further violence, and in two cases among those I interviewed, led directly to reincarceration. Shelter arrangements through social connections of any kind did not last long and only very rarely facilitated access to more than survival. Instead, finding help through social ties too often meant being subject to stressful, volatile, unsafe, and, at best, socioeconomically stagnant situations.

Discussion

The situations of women with histories of repeated incarceration are often quite complex, and the most important threats to their health and safety may not rise to the surface in the quick, focused encounters that take place in public health departments, low-cost community clinics, and hospital emergency departments where many of the women receive care.^12,26,47 Nurses in these comparatively transient care contexts may face barriers in working with women who have a history of repeated incarceration arising from a lack of understanding of the unique combination of socioeconomic and health challenges that the women face.⁴⁷ Although the storytelling approach would need to be modified a good deal to accommodate the time and resource constraints under which most nurses work, developing as part of patient-focused practice, the skills in listening to patient stories for patterns of health opportunity and risk might enable nurses to access otherwise obscured information that could prove valuable in assisting women in this group to achieve health and safety.

In my analysis of women’s perceptions and management of social relationships in stories of shelter-seeking, I discerned both patterns of opportunity and patterns of heightened health risk. The latter in particular are congruent with current research in the use of social support to access necessary goods in low-resource populations. Theorists have defined social support as resources that are available to individuals through social connection and that function to prevent or alleviate stresss.⁴⁸ Social support can take a variety of forms, including instrumental, financial, informational, appraisal-oriented, or emotional.^48–50 Social support is transmitted through social networks in which relationships that connect people are characterized in a variety of ways—as weak or strong, near or far.^51,52 Several women in the current study survived in the months following a jail incarceration by accessing shelter through the close family networks that social capital and social network theorists have described as bonding networks.⁵² Though such ties can be sustaining, in low resource situations bonding relationships often yield only the most modest forms of support,⁵³ and some findings suggest that social support in similar contexts does not have a positive effect on health.⁵⁴

Natalie and especially Susan were among the more health empowering or opportunity-oriented cases that I analyzed, meaning that the access they gained to shelter through social connections had aspects that appeared promotive of health and safety. Nonetheless, their accounts also suggested that access to housing assistance through strong ties in bonding social networks (i.e., family) could be restricted by the general unavailability of resources in overburdened structures. Natalie’s perception of her siblings’ failure to extend support when she faced homelessness was in keeping with what other researchers have found, namely, that in low-resource networks benefactor members for their own survival tend to be stricter about enforcing reciprocity rules with members who are especially or very frequently in need.^53,55 Obtaining shelter support from family could have an additional effect of precluding involvement in what are variously called leveraging, linking, or bridging relationships^52,56 that women like Natalie might have formed with those outside their close networks through employment or college courses. Linking ties can provide opportunities to advance social status—to get ahead rather than just survive.^55–57 Researchers have also found that when women in low resource situations receive support through close social network connections, such assistance can lead to shame and in some cases withdrawal and social isolation.⁵⁸ Though none in the study group disclosed shame directly, several spoke of a related unwillingness to become dependent on others, claiming, as did Susan, that “you don’t want to ask nobody for nothing or you don’t want to, you feel like you—you can do it on your own.”

In addition to shelter that was obtained through close networks that mainly involved family, women with a history of repeated incarceration frequently described brief periods of housing with weaker social connections, such as acquaintances whom they described as drug-involved and/or suffering from inadequately treated mental health conditions. In this study, such arrangements threatened more in the way of health risk than sheltering obtained through close bonding ties involving family members. Neta’s experience with the four men and Sarah’s sheltering with an acquaintance whose violence toward her led to her reincarceration fit the parameters of a disposable ties concept developed by Desmond to account for the intense, short-lived relationships formed between near-strangers to meet housing needs after an eviction.⁵⁹ Desmond’s idea of disposable ties neatly captures experiences in which, to avoid homeless shelters or the street, women like Neta relied on intense, quickly formed and quickly dissolved ties that came with high potential costs to health and desistance from criminal offending.⁵⁹ And it bears noting, finally, that some of what I include under the rubric of social support—such as Neta’s experience with her husband—might not qualify as social support at all but more properly be designated social conflict.⁵⁴

Due to their frequent justice-involvement and cumulative trauma, the women I interviewed were not just women living on low-incomes trying to put together the means to keep a roof over their heads, as have been the subject of research by Harknett and Hartnett,⁵³ Lein and Edin,⁶⁰ Lavee and Offer,⁶¹ and Nelson.⁵⁷ Nor did their needs correspond neatly with those related in Leverentz’s study of women living in a transitional home in Chicago following release from several or more years of a prison incarceration.⁶² While a number of the women in this study served prison time in the past, all but two were interviewed after a short-term jail incarceration, and most reentered the community with no access to transitional shelter services. Their stories highlighted in detail how the barriers faced by women who cycle in and out of jail and who are frequently on probation can be uniquely challenging, caught between the demands of an at times surveilling and stigmatizing criminal justice system “and community influences, which involve them in the risks and rewards of daily life in predominantly socially and economically disadvantaged communities.”^63(p1) As stories told by women in this study indicated, those community influences may be women’s sole source of housing and other resources for survival.

The literature on women reentering the community after an incarceration has documented that achieving affordable, safe shelter after incarceration is of primary importance to them.²⁵ Lack of secure shelter can result in disease, injury, or reincarceration.^26,28,64 Unfortunately, outside of the small community of researchers who study the ways in which social determinants affect the health and health care of women who have a history of incarceration, the overlapping and intertwined connections between criminal justice history, housing, poverty, safety, trauma, and health may not be especially evident, especially in rushed clinical settings. That lack of visibility can affect the nursing care women receive. Storytelling has been proposed in the nursing and medical literature as an unconventional but potentially productive and uniquely humanistic mode of patient assessment.^16,34 Nurses working in the community with women who have a history of repeated incarceration could learn much about the health risks and opportunities their patients face through storytelling as a mode of assessment.

Implications and Recommendations

Understanding the patterns of opportunity and risk at play in women’s stories of seeking shelter means acknowledging the complexity of the psychological landscape in which women with a history of repeated incarceration make choices. For nurses in particular, understanding the potential of storytelling as a means of assessment means acknowledging that women’s stories may provide access to important information about health that might go unremarked in a conventional interview, exemplified in this study by stories of shelter seeking. Moreover, stories are potent motivators that could, it might be hoped, prompt nurses to advocacy for health-promoting policies for women with frequent criminal justice involvement. The potential political power of nursing is enormous, and a deeper understanding of the struggles of women with a history of repeated incarceration could lead to more focused participation by nursing in the design and support of programs, such as wraparound, community-based transitional housing. Such programs enable clients to establish independent or semi-independent households while avoiding the entanglements of either strong or weak social connections—nearly all of which seemed to embroil the women in this study in situations of abuse and injury, relapse into drug use, and reincarceration. Some work in this direction has been attempted in New York City; Oakland, California; and Cook County, Illinois, where innovative housing first programs for persons recently released from large urban jails show encouraging outcomes on health and recidivism indicators.^65,66

Where funding and programmatic support for transition housing are lacking, nurses who provide care to women with histories of incarceration will need to organize politically to advocate for such services, while also exerting efforts to improve their practice in ways that would allow for more holistic, narrative-based assessments in which nurses would assist patients in identifying and securing safer shelter options and safety plan when necessary. The frustrating and unfortunate fact is that, without any material change in the circumstances that make homelessness a threat—i.e., the current high cost of housing and the difficulty of accessing housing benefits for women with a criminal record—such efforts are likely to run aground on the shore of inadequate real options.

Limitations

This study was limited by the nature of the data and the study design. First, the number of participants was small and the number of stories selected for analysis still smaller—even for qualitative inquiry. This is perhaps less troubling for narrative inquiry, which does not aspire to the discovery of probablistically generalizable knowledge but to insights about experience and its meaning as generated from the form, content, and performance of closely interpreted narrative.⁴² Still, I imply something akin to generalizability—transferability—based on the reader’s persuasion that the interpretive reasoning I applied to the stories is transferable to other, similar situations.⁶⁷ I am aware that the findings would benefit from additional interviews with women from different geographic contexts and demographic profiles. Due to time and budget constraints, I drew cases from a single jail, in a single city, in the Midwest U.S.

Conclusion

In the narratives told by women with a history of repeated incarceration, no single aspect of survival seemed to demand as much energy and attention than the challenge of finding safe housing. The narratives that women constructed about obtaining access to shelter through social connections reflected opposed though intertwined patterns of opportunuty and risk. Opportunity was manifest when women perceived and managed social support to obtain housing in ways that facilitated health and safey, providing a buffer from criminogenic social networks and, more rare, space for personal growth or social advancement. Risk was evident when women were pulled into living situations where drugs, mental illness, and violence threatened their health, safety, and likelihood to avoid rearrest. Storytelling gave women a vehicle in which to convey perceptions and experiences, to signal priorities and assign meanings. The potential of storytelling as a mode of assessment was advanced as having the potential to improve nursing practice in the community by increasing the recognition by nurses of the complexity of the life circumstances of women with a history repeated incarceration. Finally, women’s stories pointed to the conclusion that, without programs and policies to support readily accessible, safe shelter, women with justice involvement and a history of interpersonal trauma will find ways to survive post-incarceration, but only just barely, and they will be unlikely to thrive. Policies to increase the availability of safe housing for persons as they seek to stabilize their situation after a brief incarceration need to be a priority. In their absence, nurses who work in the community with women with a history of repeated incarceration might at the very least learn to hear the competing strains of risk and opportunity in women’s stories and collaborate with them to identify and promote empowering housing options and minimize the harms of those that are more entangling.