Families post-release: Barriers and pathways to family therapy.

Family therapy has helped repair relational ruptures and restore stability within families for decades. However, service can be inaccessible and underutilized among many minoritized and stigmatized groups, including families post-release. Harmful sociocultural and relational experiences pose considerable risks to families before, during, and after incarceration. While not exhaustive, this article highlights potential attitudinal, relational, and logistical obstacles to family therapy engendered by therapists, clients, or both. Feasible and accessible clinically oriented conceptual and practical pathways of support to combat such obstacles are outlined to help therapists attract and retain families post-release.

INTRODUCTION

An estimated 600,000 individuals leave prison each year (Carson & Golinelli, 2012). Of those released from incarceration, the vast majority intend to re‐unify with their families (Welch et al., 2019; Yocum & Nath, 2011). However, family stabilization post‐release is complex and arduous. The more common challenges include divorce, intimate partner violence, family estrangement, and diminished relationship satisfaction (Comfort et al., 2018; Turney, 2015). These familial experiences may in part stem from cumulative stressors, including but not limited to employment, housing, financial constraints, poor mental health treatment, social stigma, and discrimination (Tyler & Brockmann, 2017; Visher et al., 2008; Visher & Travis, 2003; Western, 2014).

Services that aim to re‐unify and stabilize families post‐release require the attention and participation of multiple systems, including the larger clinical community, policymakers, the carceral system, 1 and local communities. Yet, these systems often fail to combat the powerful and intergenerational effects of incarceration on families (Cochran et al., 2018; Davis & Shlafer, 2017). Thus, services that aim to meet the needs of families directly warrant closer examination. Family therapy is a process proven to improve re‐unification and stabilization efforts of families with various presenting concerns and social locations (Datchi & Sexton, 2013; Lucero et al., 2018; O’Farrell & Clements, 2012; Wesselmann et al., 2018). Despite not being empirically studied, the use of therapy for families post‐release has been encouraged among scholars (McKay et al., 2016).

For family therapy to succeed, therapists must understand the rich and complex contexts of the families they serve (Breunlin & Jacobsen, 2014; McDowell et al., 2019). Even well‐intentioned and skilled therapists may be stymied if they fail to understand the unique and cumulative stressors post‐release families face (Tadros et al., 2021). To that end, this article intends to inform therapists about some barriers to treatment as well as the procedures and resources needed to attract and support families in therapy post‐release. The article mainly focuses on therapy that includes at least one parent released from incarceration and their family of procreation (i.e., child, spouse, the child's other parent). However, the barriers and pathways discussed may reasonably extend to relationships between the person released from incarceration and their family of origin (i.e., parents, siblings). Chosen kin, biologically unrelated individuals who regard each other in kinship terms, may also be key support people (Taylor et al., 2013) for individuals post‐release and may similarly benefit from participating in family therapy.

Families post‐release

Many children whose parents are involved with the carceral system experience behavioral challenges, delinquency, social isolation, and decreased educational success (Cochran et al., 2018). However, stable parental engagement can combat the effects of incarceration on children and is among the strongest predictors of their emotional, psychological, and educational achievement (Craigie et al., 2018). Regrettably, the stress and challenges of re‐entry can strain or fracture parental relationships further (Geller, 2013). For instance, at times, fathers post‐release are forced to renegotiate their parenting roles based on their ability to provide financial support (Geller, 2013). Consequently, that can impact fathers’ identity and relationship with their children. Moreover, Western and Smith (2018) found that post‐release parents engaged in amicable exchanges were more likely to have regular contact with their children.

Individuals returning to committed relationships have greater success with re‐entry (Lindquist et al., 2009). Despite that, maintaining healthy romantic relationships post‐release is challenging (Comfort et al., 2018). It is not uncommon for partners to expect returning members to contribute financially, provide long‐awaited emotional support, and participate in active caregiving and disciplining of children (Yocum & Nath, 2011). At the same time, individuals released from incarceration may lean heavily on partners for instrumental and emotional support (Visher et al., 2004). Unmet expectations within relationships can provoke tension and conflict between partners (Comfort et al., 2018) and contribute to high incidents of intimate partner violence, separation, and divorce (Few‐Demo & Arditti, 2014; Turney, 2015). Of particular concern is the risk of intimate partner violence. McKay et al. (2016) estimated that the risk for intimate partner violence among partners post‐release was five to six times higher than for those reported in the general U.S. population.

BENEFITS OF FAMILY THERAPY POST‐RELEASE

While there are important services aimed at families post‐release, including parent training courses, family‐inclusive case management, and mentorship programs, this article focuses on utilizing family therapy to help strengthen families post‐release. Compared to other services, family therapy is typically approached from a systemic framework, used to capture the perspective of multiple family members and their interpersonal interactions first‐hand. Furthermore, extensive research points to the benefits of using family therapy to improve relationships, even for nonparticipating family members (Cornett & Bratton, 2014). Family therapy can also be as effective, and in some cases, more effective than individual treatment for serious mental health conditions (Pharoah et al., 2010). Among other benefits, family therapy can help heal attachment injuries in the parent–child relationship (Wesselmann et al., 2018), regulate delinquent youth behaviors, and mitigate symptoms associated with substance use disorders (Bartle‐Haring et al., 2018; O’Farrell & Clements, 2012; Pharoah et al., 2010).

There is some evidence to show the usefulness of family therapy during incarceration (Bobbitt & Nelson, 2004; Tadros & Finney, 2018). For example, Bobbitt and Nelson (2004) found families who participated in therapy provided emotional and physical support that benefited the family member released from prison. The same study found that 30% of families with access to therapy utilized the service. While there is growing support for using relational perspectives and interventions to serve families post‐release (Few‐Demo & Arditti, 2014; Garofalo, 2020), little research focuses specifically on family therapy. An exception to this includes a study by Datchi and Sexton (2013), which revealed family therapy post‐release decreased familial contention and adverse mental health symptoms and increased familial connectedness and functioning. Compelling evidence, based on samples outside the carceral system, suggests that family therapy can effectively address many of the unique challenges experienced post‐release. Some of these challenges include mental health disorders, substance use, recidivism, re‐unification challenges, and negative familial interactions (Bartle‐Haring et al., 2018; Garofalo, 2020; McKay et al., 2016; O’Farrell & Clements, 2012; Pharoah et al., 2010).

There is no empirical evidence to show how systemic‐relational theories or models have been culturally responsive to the needs of families post‐release. However, some literature speaks to clinical theories and models that may support families post‐release. Faust (2018) outlines specific strategies for re‐unification therapy to help repair the relationship between separated parents and children. Consistent with this, Landers et al. (2020) highlight some family therapy models that may support families reconnecting after a period(s) of separation, including structural family therapy, narrative therapy, contextual family therapy, and strategic family therapy. Garofalo (2020) recommends using emotion‐focused family therapy and cognitive‐behavioral family therapy with families post‐release. Family therapy models such as multisystemic therapy, functional family therapy, multidimensional treatment foster care, and brief strategic family therapy are also used to treat conduct disorder and delinquency (Henggeler & Sheidow, 2011).

CONCEPTUAL FRAMEWORK

A wide variety of factors limit the access and continued use of individual and family therapy within the general community (Reardon et al., 2017). Barriers to therapy may be more distinct among families after incarceration, given the complex, contentious, and unbalanced relationship often experienced between family members during and after incarceration and between family members and the carceral system. Therefore, the first aim of this article is to identify the salient barriers that clients may encounter when trying to access and utilize family therapy after incarceration. Therapists may also experience intrapersonal and interpersonal obstacles when accessing and retaining families post‐release. Thus, the second aim of this article is to explore therapist‐specific barriers. The final aim is to highlight pathways to mitigate said barriers to therapy for both clients and therapists. Client‐centered and therapist‐centered barriers will be addressed concurrently within each respective category, with applicable pathways succeeding.

To organize the article's aims, we used three categories of barriers (attitudinal [e.g., perceived stigma of therapy; Walsh‐Felz et al., 2019], relational [e.g., family cohesion], and logistical [e.g., cost, Garland et al., 2011]). Given the divergent personal experiences and social locations of families post‐release, it is worth underscoring that the suggestions provided in this article are not intended to be exhaustive or comprehensive and should be modified, as needed, to best serve their needs.

ATTITUDINAL BARRIERS AND PATHWAYS

Stigma

Among the most commonly stigmatized people are those involved with the carceral system (Cooper‐Sadlo et al., 2019) and those seeking psychotherapy (Kupers, 2005). When considered together, some family members may be less inclined to participate in any form of therapy, including family therapy. Moreover, misconceptions that stem from a lack of knowledge of the processes and function of family therapy may leave families more vulnerable to stigma (McFarlane et al., 2003). For these reasons, therapists working with families are encouraged to pursue multiple pathways to combat stigma. For instance, therapists may consider communicating openly and clearly about how family therapy helps (i.e., locates the problem outside of the clients, acknowledges systemic factors like racism, respects client autonomy; Samuel, 2015) when initially corresponding with family members and referral sources (e.g., transitional living facilities, parole officers), as well as in marketing materials. Therapists should also consider replacing the word therapy with phrases like “transition services” (Garland et al., 2011) when marketing while remaining transparent about services offered.

To mitigate the distrust and stigma associated with more traditional and eurocentric forms of psychotherapy, therapists should also consider adopting different modalities of support for families post‐release. Family enrichment workshops or events, or multifamily group work in communities where traditional therapy is deemed shameful and inaccessible may be received more openly and build community (Samuel, 2015). Families that report feeling closer post‐release than they did before or during incarceration (Arditti & Few, 2006) may specifically benefit from enrichment workshops and group work. The use of offices may also reinforce the stigma associated with therapy. Conducting home sessions may provide families more anonymity and challenge them to reimagine the confines of therapy.

Therapists working with families post‐release may also benefit from collaborating with gateway providers like religious and community organizations to combat misunderstandings about the nature of mental health and therapy. For example, a study showed that some African‐American youth released from detention believed mental illnesses to be contagious or hereditary, untreatable conditions (Samuel, 2015). In addition, some participants endorsed religious beliefs. For example, they questioned the usefulness of therapy, believing their faith would be rewarded if they depended solely on God for help. (Samuel, 2015). Such ideas, coupled with effects of stigma and shame, are perpetuated and amplified within peer groups and family systems. These barriers may be best addressed in a local communal setting with a trusted religious or community leader.

Concern about therapists’ cultural competency and responsiveness

Few family therapist trainees receive education on or training opportunities with families in incarceration and re‐entry (Tadros et al., 2021). Not surprisingly, therapists who fail to demonstrate an understanding of the hardships associated with the carceral system tend to be distrusted by post‐release clients (Tadros et al., 2019). To reduce the knowledge and training gap, therapists are encouraged to grow their competence through professional development focused on better understanding the carceral system, the inequalities within that system, the intra‐ and interpersonal implications of incarceration (Tadros et al., 2019), and cumulative stressors associated with postincarceration. All that said, families post‐release should not be treated as monolith (Comfort et al., 2018). No amount of education and training focused on families during incarceration and post‐release is a substitute for assessing each family's circumstances and needs and responding to the family using culturally responsive practices.

Like individual psychotherapy, family therapy is predominantly rooted in eurocentric and Western perspectives and practices that sometimes offend and harm minoritized groups (Hare‐Mustin, 1994; McDowell et al., 2019). Many therapists fail to look beyond interpersonal relationships between family members and struggle to be cognizant of how cultural contexts influence the way families establish and re‐establish themselves (Graham & Harris, 2013). Engaging in culturally responsive practices with families post‐release is vital given the unique, highly stigmatized, and traumatic experiences that stem from separation, incarceration, and post‐release challenges (Arditti, 2012). Sociocultural, political and economic factors profoundly influence families’ experiences before, during, and after incarceration (Graham & Harris, 2013; Tadros et al., 2019; Tyler & Brockmann, 2017).

We suggest several pathways to improve therapists’ cultural sensitivities and practices with families post‐release. First, therapists must understand the locations and contexts in which they built their knowledge (Hare‐Mustin, 1994). To do that, they must recognize and regularly reassess their own identities, social location, and worldviews (McDowell et al., 2019). Such critical self‐examination is important among therapists whose personal and social identities are considerably disparate from the families they support. With greater self‐awareness, therapists are better positioned to acknowledge and respond to the gross inequities in the carceral system that correspond to race, class, and other social identities to mitigate therapeutic harm and the perpetuation of such inequities. For instance, large racial disparities between therapists trained to work with families (an estimated 83% identified as White by the American Association of Marriage and Family Therapy; Todd & Holden, 2012) and those involved with the carceral system (an estimated 63% identified as Black, Latinx, or other Persons of Color; Carson & Golinelli, 2012) combined with grave and harmful racial inequities in the judicial system (Tyler & Brockmann, 2017) highlight race as at least one discernable area of their own identity that therapists should explore.

To avoid responding to cultural differences as pathological or deviant, therapists are encouraged to circumvent assessments and conceptualizations of familial relationships and behaviors that maintain colonial practices exclusively rooted in dominant cultures’ values (Hare‐Mustin, 1994; McDowell et al., 2019). The use of nonpathologizing frameworks and interventions may be particularly salient for those released from incarceration; for the carceral system, potential employers and families repeatedly expose them to humiliating interpersonal treatment that leaves them bound to the label of a felon (Pogrebin et al., 2015). Using language that is inclusive and humanizing is also important (Tran et al., 2018). Consistent with that, we suggest therapists avoid language that could be construed as condemning and punitive (i.e., dangerous, bad, criminal), for it may trigger feelings of mistrust, defensiveness, or other feelings that impede therapeutic progress (Tadros et al., 2021). Modeling such behaviors in session may also encourage family members to adopt more compassionate and supportive language toward each other.

Additionally, therapists are encouraged to explore the converging effects of race and other social identities (e.g., religion, socioeconomic status) on the families’ relationships during incarceration and post‐release (Graham & Harris, 2013; Tadros et al., 2021). For instance, during a co‐parenting session, a therapist may ask the parent who was not incarcerated how their personal, social, or intergenerational identities influenced their experience as a single parent during the other parent's incarceration. More explicit demonstrations of support and inclusion of minoritized communities are also encouraged. For instance, we suggest therapists adopt information, language, and tasteful images on their website that highlight various backgrounds, including families affected by incarceration. Settings that incorporate art, magazines, and music that appeal to diverse communities (Sue et al., 2007) and highlight issues of social justice are also recommended. While such recommendations may seem trivial, they can help mitigate microaggressions transmitted subtly and ambiguously to minoritized groups (Sue et al., 2007) through various modalities, including but not limited to images, music, physical space, and language. Adopting inclusive content should supplement and not substitute therapists’ genuine efforts to engage the carceral community.

Community engagement

Many therapists are far removed from the everyday lived experience of individuals and families involved with the carceral system. Therapists’ knowledge about the carceral system and its systemic impact is often limited and based on what they read in literature. With that in mind, therapists are encouraged to increase their social awareness and responsibility by engaging community members directly affected by the carceral system and establishing rapport with service providers working with people post‐release. Community engagement may help humanize the experiences of those impacted and harmed by the carceral system and offer a more nuanced understanding of families affected by said system. It may also challenge therapists to critically examine their assumptions about the carceral system.

Volunteering (e.g., client advocacy, group facilitation, teaching a mental wellness course, tutoring, fundraising) is one way to more consistently and intimately engage individuals involved with the carceral system. Alternatively, therapists may establish connections with community providers involved with the carceral system. Therapists that extend their network to include members of the families’ larger system may better understand the roles and functions said providers serve for families post‐release. Service providers may include re‐entry case managers, transitional living facility staff, parole officers, business and vocational training administrators, and clinicians within community agencies contracted to offer re‐entry programming. Contact information for agencies and providers is readily available online and by calling local health and human services helplines. For example, therapists in active search for families to work with may consider searching online for their respective state parole division, which provides contact information for parole officers.

When contacting providers, therapists are encouraged to inform them of the nature of their services, for many may not be familiar with family therapy. Furthermore, before asking for support with recruiting clients, therapists should notify providers about the multiple benefits of healthy family relationships, including reduced recidivism, improved mental health, and reduced substance use. The reason for this is because individuals unfamiliar with family therapy or system theories may not prioritize the importance of family functioning directly after incarceration, particularly under conditions where individuals post‐release have not secured basic needs such as housing and employment. In addition, therapists offering pro‐bono or reduced costs services should make that clear to other providers upfront. Providers who see therapy as a financial burden may not be inclined to help therapists recruit families. Finally, before offering family therapy within transitional living facilities, therapists should ensure conditions at sites meet the clinical standard of care for confidentiality and safety.

It is worth noting that the first author began her professional work with the carceral system as a volunteer, working three years as a mental wellness and family educator at a halfway house for individuals leaving prison. Subsequently, she developed and delivered multiple relationship education trainings to individuals in residential treatment after incarceration. Currently, she is offering pro bono couple and family therapy services for members of a vocational re‐entry training program.

Power and privilege

The combination of prejudice, oppression, and the abuse of institutional and individual power within the carceral system, mainly perpetuated against racially, ethnically, and economically minoritized groups (Tyler & Brockmann, 2017), calls for therapists to be vigilant about their use of power in therapy (Hare‐Mustin, 1994; Tadros et al., 2021). Therapists who fail to manage their power and ignore their privileged identity risk causing unforeseen and unintended harm to families post‐release through their use of culturally unresponsive ideologies (e.g., the myth of meritocracy) and practices (Hare‐Mustin, 1994). The use of directives and problem‐focused therapy models used by family therapists (Bartle‐Haring et al., 2018; Breunlin & Jacobsen, 2014) are examples of how therapists may inadvertently perpetuate power differences. Thus, regardless of the theory or model used, we encourage therapists to demonstrate curiosity and collaboration scrupulously and highlight strengths often minimized or ignored within dominant cultures (McDowell et al., 2019; White, 2000) with families post‐release. One way to accomplish this is by using what White (2000) refers to as double‐listening. For instance, a therapist listens simultaneously for examples of the family's agency in the problem‐filled stories they may share. Therapists may then underscore the family's resilience in the face of challenges posed by imprisonment, re‐entry, and re‐unification and help them recognize how they have exercised personal agency in and outside of therapy.

We also suggest therapists initiate more explicit discussions about privilege in the early phase of therapy. For example, therapists with little personal experience with the carceral system may consider acknowledging their majority status and the possibility that they benefit from the long‐standing systematic and institutional oppression and discrimination of minoritized race, ethnic, and class groups in the carceral system. Therapists who fail to acknowledge and then address their privileged identities with clients as well as see how clients’ minoritized and oppressed identities impact their families’ circumstances are, in effect, exercising privilege and reinforcing harmful dominant discourses (Hare‐Mustin, 1994). It is worth noting that clients are more likely to avoid initiating discussions about therapeutic power and privilege to protect the therapeutic relationship (Addison & Thomas, 2009). That may be even more likely the case for people readily exposed to considerable hierarchical and power imbalances and oppression by institutions and individuals that wield authority (Hare‐Mustin, 1994), as is often the case within carceral settings.

Saving face

Discourses about motherhood

Many mothers released from incarceration report feeling immense shame, guilt, and difficulty rebonding with their children (Cooper‐Sadlo et al., 2019; Few‐Demo & Arditti, 2014). That coupled with prescriptive ideas of motherhood across cultures (Arditti & Few, 2006) call for therapists to demonstrate heightened sociocultural and emotional attunement when working with families wherein the mother was incarcerated. Conversely, therapists should avoid language and practices that inadvertently reinforce socially constructed ideas and definitions of motherhood (i.e., having primary custody, primary attachment relationship; Garcia, 2016), for they may exacerbate feelings of shame and guilt for mothers once separated from their children. Through collaboration, we encourage therapists to explore what motherhood looks like through the narratives of mothers post‐release. For example, a therapist working with a family struggling to find a connection since the mother's release from prison should consider asking each participant to define and discuss what motherhood means to them and how those meanings are situated in social contexts.

Confidentiality

In prison settings, mental health staff serve a different function and may have to report actions deemed “illegal” as well as those that threaten the “safety and smooth operation of the prison” (Kupers, 2005, p. 715). Such duty exceeds the Tarasoff requirement, leaving communications by those incarcerated open to future prosecutions (Kupers, 2005). Consistent with this, a client under parole may lose important privileges triggered by a report of child or elder abuse and face harsher ramifications when threats of harm or drug use, however minor, are discussed in family sessions (Steen et al., 2013). Thus, it is reasonable that individuals released from incarceration, particularly those on parole, may misperceive therapists to be extensions of the carceral system (Samuel, 2015). Concerns about therapists’ roles and how they manage confidentiality could discourage families from participating in therapy. To mitigate concerns about confidentiality and reporting, therapists may wish to include information on their websites and phone consultations that helps potential clients distinguish confidentiality in and outside of prison. They may also emphasize their independence from any governmental agencies and delineate the limits of mandated reporting about matters such as intimate partner violence.

Confidentiality may become more complicated when working with multiple family members, particularly those living apart for prolonged periods, under divergent behavioral and cultural norms. Each participant may reveal new information to the therapist and other family members in sessions. While therapists, with a few narrow exceptions, are legally bound to hold each adult clients’ confidence, no such rule governs the other participating clients (Corey et al., 2019). Consequently, a family member who exploits information shared in confidence during therapy may jeopardize another participating family member's parole status. This context heightens the importance of encouraging clients to maintain confidentiality about information shared in sessions, except when clients are at imminent risk. Again, a clear delineation of the therapist's reporting duties can help clients determine how much to disclose.

RELATIONAL BARRIERS AND PATHWAYS

Physical distance

A sizable number of individuals do not reside with or near their families after prison (Comfort et al., 2018; Few‐Demo & Arditti, 2014) due, in part, to required physical distance, travel restrictions, or curfews set forth by probation and transitional living or in‐patient facilities (McKay et al., 2018; Welch et al., 2019). As a result, the physical distance between family members can reduce the accessibility and utility of family therapy. To mitigate the physical distance described above, therapists should consider the use of telemental health (online therapy). It is proven to be a reasonable alternative for those with restricted physical access to family members (Garofalo, 2020) and limited access to transportation (Walsh‐Felz et al., 2019). While most research on telehealth focuses on treating individuals, there is some evidence to suggest the benefits of online therapy with parents (Owen, 2020). Separate from this, online therapy may be a safer alternative to in‐person therapy for families where a parent with a history of abuse lives in a different location from the other family members.

Online therapy is not without its limitations. In general, therapists could face difficulty accessing clients if crises arise during sessions (Doss et al., 2017; Racine et al., 2020). Additionally, online therapy may not be appropriate for families with maltreatment histories (Doss et al., 2017). Securing a private space for sessions may be of particular concern for family members living in transitional living facilities after incarceration. Clients with short attention spans, which is not uncommon among young children, may experience difficulty engaging in sessions (Racine et al., 2020).

Seeking consent

In addition to living in different homes (Comfort et al., 2018), a sizable number of family members post‐release engage in parental gatekeeping and have limited contact with each other (McKay et al., 2018; Mowen & Visher, 2016). Furthermore, many children live in kinship care, typically with grandparents or other relatives (Graham & Harris, 2013) during and for some time after a parent's incarceration. Thus, we recommend that therapists contact family members directly responsible for the child participating in therapy (with the permission of the person initiating therapy) to invite them to therapy, even if for collateral sessions. That may be especially important given each caregiver's vital role in shaping the other caregiver's relationship with the child (McKay et al., 2018). Furthermore, parental rights are often restricted and sometimes terminated for those incarcerated (Abbruzzese, 2019). Therefore, before conducting sessions, therapists should confirm that the parent with legal custody consents to any family sessions attended to by their child(ren), mainly when the child(ren) is under 12 years of age.

Family conflict

Existing conflicts between family members can pose barriers to therapy. For example, those with unresolved feelings of anger and disappointment toward other family members for events that happened before, during, and after incarceration may have little or no interest in re‐unification (Cooper‐Sadlo et al., 2019; Visher & Travis, 2003). While not every family member needs to participate in therapy, it is preferred, especially when conflict between a participating and nonparticipating family member may impact progress in therapy (Breunlin & Jacobsen, 2014). Additionally, some families may feel uneasy and reluctant to enter vulnerable spaces such as family therapy particularly after an extended separation.

In general, the exchange of culturally responsive expressions of respect reduces conflict and improves satisfaction between family members (Hendrick et al., 2010). The issue of respect may be particularly salient for families involved with the carceral system and may help with retention. Studies show that those involved with the carceral system often feel perpetually disrespected by family and society (Arditti & Few, 2006; Kupers, 2005). Additionally, many feel humiliated and rejected by family, employers, and the parole system (Pogrebin et al., 2015). Consistent with this, familial experiences of disrespect may be perpetuated by racially and economically marginalized individuals’ long‐standing experience of institutional, structural, and interpersonal disrespect. For these reasons, therapists are encouraged to mindfully and consistently demonstrate and encourage culturally responsive respect both implicitly and explicitly to all family members from the beginning of therapy. Expressions of respect may be particularly important in therapy for families to brave discussions about painful experiences (e.g., trauma, ambiguous loss). One way for therapists to promote expressions of respect is by discussing them directly.

Mental health

Mental health comorbidity is extraordinarily high among those involved with the carceral system (Hartwell, 2004). For instance, rates of post‐traumatic stress disorder and the association between it and other mental health issues (depression, anxiety, substance use) are higher among those inside compared to those outside the carceral system (Facer‐Irwin et al., 2019). Experiences post‐release often perpetuate harmful mental health symptoms, leaving people feeling powerless and emotionally withdrawn from their relationships (Visher & Bakken, 2014). Consistent with this, Mowen and Visher (2016) highlight the deleterious effects of mental health conditions on family relationships post‐release. The loved ones of family members once incarcerated also exhibit significant psychological distress and mental health challenges (Arditti, 2012). Family therapists are uniquely positioned to address existing mental health issues in the context of the family system, as opposed to using individualistic and pathologizing approaches adopted more commonly within other fields.

Despite the bidirectional relationship between mental health and family relationships, some families may promote individual treatment for the member assumed to have the issue and refuse or downplay the need for family treatment (Breunlin & Jacobsen, 2014). Those willing to participate may be reluctant to address their mental health concerns with other family members in sessions. For the reasons mentioned above, family therapists are encouraged to promote the value added when families receive treatment together. Furthermore, when assessing families, therapists should be mindful of how the stigma of mental health (Hartwell, 2004) and involvement within the carceral system may influence how family members report and respond to their mental health symptoms and others in the family. To a considerable degree, therapists should also acknowledge and address experiences of post‐traumatic stress disorder and other serious mental health concerns using systemic‐relational frameworks (Lucero et al., 2018).

Stark contrasts between how emotional vulnerability is encouraged and received inside and outside of prison (Kupers, 2005) may also impact a family's therapy experience. To mitigate such contrasts, therapists are encouraged to ease families into compassionate and comfortable conversations about mental health symptoms using attunement strategies (Greenberg, 2014). Conversely, family members with untreated or serious mental health issues may benefit from being referred for individual treatment focused on managing or stabilizing their mental health before or in concert with family therapy (Lucero et al., 2018). This way, family sessions can focus on the system's specific needs over the needs of any one family member exclusively. That said, engaging in two therapeutic services may be difficult to afford and cause financial strain for families post‐release.

Substance use

Many individuals released from incarceration report a history of excessive substance use (Visher et al., 2004). Substance use that continues post‐release may pose barriers to family therapy. To increase access to therapy for families impacted by substance use, therapists are encouraged to seek referrals from and offer onsite services in outpatient and inpatient substance treatment programs. To retain families in therapy, therapists are encouraged to carefully attend to the relationship between the family and the substance use. To start, it is important that clinicians screen for active substance use before beginning family therapy. Active substance use by one or more family members is too often considered a contraindication for family therapy (Wolska, 2011) and may require the therapist to suspend services until the substance use is managed. However, there are ways to engage the family in treatment while one or more members receive targeted substance use support. For example, therapists could provide family therapy services concurrently with inpatient and outpatient substance use treatment.

Therapists who continue treatment are encouraged to become well‐versed in evidence‐based therapies applied using a nonreductionist approach to address substance use in the family unit (O’Farrell & Clements, 2012). For instance, therapists should recognize and consider talking with families about the systemic factors involved in the development and maintenance of substance use (e.g., trauma, generational patterns of addiction, poverty, lack of adequate mental healthcare services, experiences in the carceral system) and the convergence between post‐release stressors and substance use (Johnson et al., 2015).

Toxic masculinity

Proliferated acts of toxic masculinity serve to protect men from psychological and physical harm in prison (Kupers, 2005). However, such behaviors quickly become maladaptive post‐release and can be one reason why clients may avoid therapy (Kupers, 2005) or struggle to show vulnerability during family sessions. Therapists who work with families that overcome this barrier are encouraged to assess how dominant discourses govern how and to what extent masculine attitudes and expressions are adopted (Sinclair & Taylor, 2004). For instance, a therapist working with a family where the father expresses feeling ashamed for not contributing financially during and after incarceration (often due to employment barriers associated with their involvement in the carceral system) may respectfully challenge harmful discourses that perpetuate narrow perspectives about parental gender roles.

Except for when abuse is suspected or reported (Corey et al., 2019), we recommend therapists avoid challenging clients’ hypermasculine beliefs and behaviors too quickly. Instead, demonstrations of hypermasculinity in therapy that induce posturing, resistance to therapy, and provocation between family members should be addressed carefully using emotional attunement. Furthermore, therapists are encouraged to acknowledge and understand the juxtaposition between the adaptive function that hypermasculinity serves during incarceration and its harmful effects on familial relationships post‐release. Clients who adopt a similar perspective may begin to differentiate behaviors needed to survive incarceration and those required to nurture interpersonal relationships post‐release. They may also find it easier to feel and provide more empathy and compassion, as well as demonstrate increased patience.

LOGISTICAL BARRIERS AND PATHWAYS

Low‐wage jobs, poor access to reliable and convenient transportation, and restrictions on travel, housing, and employment during post‐release force many to prioritize their basic needs (Comfort et al., 2018; Grieb et al., 2014; Tyler & Brockmann, 2017). Services like family therapy may not be prioritized if deemed nonessential to one's immediate survival. At the same time, those who prioritize re‐establishing familial relationships post‐release (Yocum & Nath, 2011) may face logistical challenges that inhibit their efforts to seek therapy. Some studies highlight the need for collaborative care during post‐release to improve access to various services (i.e., Johnson et al., 2015). Consistent with this, therapists who work exclusively from or contract with settings that offer multiple services (i.e., support with food, employment, transportation, housing) may be more accessible to families post‐release (Walsh‐Felz et al., 2019).

Financial costs

Individuals released from incarceration often have fewer opportunities for education and employment and are employed at lower wages (Visher et al., 2008; Western, 2014). Financial hardships can make it more difficult for families post‐release to receive services. In a study by Garland et al. (2011), formerly imprisoned men cited psychosocial issues, including relationship distress, as the most salient stressor upon release, more so than employment, money, and housing instability. However, these same men admitted to sacrificing mental health and medical care due to costs (Garland et al., 2011).

While the Affordable Care Act significantly expanded access to healthcare coverage, it did not increase the use of mental health benefits among individuals released from incarceration (Howell et al., 2019). The reasons for this are broad and multifactorial. For instance, strict guidelines govern the reimbursement of mental healthcare services for family therapy. A child within the treatment unit must typically receive a mental health diagnosis to qualify the family for reimbursement (Doss et al., 2017). The utilization of mental health benefits for adults can also be challenging to navigate and focus primarily on treatment for individual mental health diagnoses rather than relational issues (Clawson et al., 2018).

Marriage and family therapists are uniquely situated to address families’ needs; however, they are accepted by only some states as Medicaid providers and by none as Medicare providers (Frank, 2018). Such limitations are prevalent in government‐funded healthcare, which tends to be the primary source of coverage for those in the post‐release community (Howell et al., 2019). Separate from this, many private mental health providers opt out of insurance panels partly because reimbursement rates have not increased to keep up with costs (American Psychological Association, 2019).

Therapists declining insurance but still interested in serving families post‐release may consider offering some of their services pro bono or on a sliding scale. However, offering free or low‐cost therapy is meaningless to families unaware of affordable therapeutic services. We suggest that family therapists promote their services through the Department of Corrections and community organizations that assist those transitioning out of incarceration (Walsh‐Felz et al., 2019). Community organizations, in particular, serve as an important resource for this population in their efforts to secure healthcare services post‐release (Walsh‐Felz et al., 2019).

FUTURE RESEARCH

The influence of incarceration and post‐release on families is cumulative and complex. Moreover, there is minimal research about families post‐release in therapy. Therefore, exhaustive or comprehensive recommendations for therapists were not provided in this article. Instead, recommendations from this article are intended to raise the consciousness and curiosity of therapists working with families post‐release and encourage them to challenge traditional family therapy ideologies and practices. In‐depth recommendations should be guided by empirical data, which to date is scarce. With that in mind, therapists are encouraged to consider and empirically examine what theories, models, or practices effectively serve families in therapy post‐release. Other important clinical considerations that should be examined closely include a family's potential experience with intimate partner violence and child abuse and the use of extended family, local community, and broader social network in a families’ treatment plan. Although some of the familial implications of incarceration and post‐release run parallel, we were intentional not to conflate the distinct effects each has on families. Accordingly, researchers are encouraged to study the experiences from prison that influence healthy family functioning post‐release so that therapists may understand the importance of addressing both periods in therapy. Lastly, the resilience and strengths within families involved with the carceral system are worthy of special attention and promotion among researchers and clinicians.

CONCLUSION

Damaging sociocultural and relational experiences before, throughout, and following incarceration pose considerable risks to families post‐release. While family therapy expands opportunities for developing protective strategies and reorganizing the family unit, it may be less accessible and utilized by families post‐release for the reasons outlined in the article. While not comprehensive, the article highlights some feasible and accessible ideas and practices worth considering for clinicians interested in supporting families after incarceration.

CONFLICT OF INTEREST

We have no known conflict of interest to disclose.