28 Healing Incarcerated Communities Through Green Space and Peer Support by Jordan Cook

Introduction
4.9 million people are incarcerated each year and more than 1 in 4 of those are incarcerated multiple times for non-violent crimes because of unmet medical and mental health needs, according to a recent analysis of data by the Substance Abuse and Mental Health Services Administration (Jones and Sawyer). Having been incarcerated myself, I have seen this revolving door of insufficient health and human services in action, having met various individuals who are thrown into the system time and time again because they couldn’t get the help they needed when they needed it. Most of these individuals fail to receive the necessary support required to address these underlying issues in order to restore their quality of life and keep them out of prison. What many people don’t realize is that it isn’t just impacting those that are incarcerated but also their families and friends, affecting the community as a whole. This is only one of innumerable examples that demonstrate the inadequacy of the current system of health and human services. Additionally, many of these individuals growing up lacked access or exposure to green spaces and natural settings that provide an indirect yet powerful mental health benefit. As a result of these inadequacies, our society is suffering from widespread mental health issues that contribute to high rates of poverty, homelessness, crime, suicide, and incarceration, which only increase healthcare costs, strain the penal system and reduce the overall quality of life for individuals and communities. The most effective way to proactively prevent and reverse these negative mental health outcomes is by developing community gardens and green spaces in combination with peer support and mentorship programs that coordinate community and government resources.

Defining the problem
It would stand to reason that mental health and its underlying issues have existed as long as humans have, but it hasn’t been until the last couple centuries that it gained enough attention
to be a relevant focus of exploration and discovery by communities and institutions. In order to understand the current issue, it would be beneficial to understand the background and definition of mental health. An article written by the Department of Mental Health with the World Health Organization (WHO) nicely organizes the long, slow yet steady progress that has led to our current understanding and definition of mental health and its corresponding disciplines and institutions (Bertolote). The term “mental hygiene” was first coined in 1843 (Lewis qtd. In Arieti). Unfortunately, it would be more than half a century before we see the first acknowledgment of a severe lack of sufficient mental health care of existing psychiatric institutions and mental hospitals. The mental hygiene movement was started in 1908 when Clifford Beers published a book that explored his experience in being committed to three mental institutions and the “abuses, brutalities and neglect from which the mentally sick have traditionally suffered.” (Beers qtd. In Bertolote). It wasn’t until 1946 that we see the first technical references to mental health as a field or discipline when the International Health Conference in New York decided to establish the World Health Organization. The federal government initiated mental health policy when it passed the National Mental Health Act that same year and later established the National Institute of Mental Health in 1949 (Bertolote). Then in 1950 the WHO established the definition of mental hygiene at its second Expert Committee on Mental Health session as, “activities and techniques which encourage and maintain mental health. Mental health is a condition, subject to fluctuations due to biological and social factors, which enables the individual to achieve a satisfactory synthesis of his own potentially conflicting, instinctive drives; to form and maintain harmonious relations with others; and to participate in constructive changes in his social and physical environment.” (WHO qtd. In Bertolote). Since then, the terms have often been used interchangeably and a precise, sufficient

definition still has not been established, but it is widely accepted that mental health is a condition while mental hygiene involves the practices that contribute to this condition though the term mental hygiene is rarely used anymore.
Even with the establishment of several healthcare organizations and institutions, there was still a palpable and detrimental inadequacy in mental health care. This was brought to the federal government’s attention in the Action for Mental Health report presented by the Joint Commission on Mental Illness and Health which was responsible for monitoring the resources of and diagnostic and treatment methods for mental illness (Gob in Erickson). This report influenced the passage of the Community Mental Health Act by Congress and its signing by President Kennedy in 1963. This was especially personal to Kennedy after his sister Rosemary received a lobotomy that significantly affected her quality of life. Erickson goes on to outline the inadequate planning, implementation and sustainability of this bill’s optimistic goal to reduce the number of institutionalized patients and federal institutions while establishing community health care facilities. The National Reporting Program for Mental Health Statistics, run by the National Institute for Mental Health since 1947, reported on the growth and change in facilities and patients from 1966 to 1982, showing that facilities increased in several sectors. Non-Federal general hospitals with psychiatric units went from 81 in 1940 to 1,531 in 1982 as well as 129 VA medical centers with psychiatric care as a result of the 1965 passage of Medicare and Medicaid in the Social Security Act. Community Mental Health Centers increased from 125 in 1965 to 691 in 1980, which was only one third of the institutions outlined in the CMHA and only up to one half was completed by 1991 (Grob in Erickson). Other facilities saw a decrease as a result of the deinstitutionalization efforts with the expectation that patients would transfer to these other facilities.

The biggest problem with the ideology of the Community Mental Health Act was first identified by the president of the American Psychiatric Association, C. H. Hardin Branch: “this great amount of support is based on the assumption that psychiatry will be able to find answers to many social problems, rather than to continue merely to treat them . . . psychiatrists must try to distinguish between those areas in which social forces rather than psychiatric illness are at fault . . . then the psychiatrist must be willing to try to meet social needs and handle the wide range of psychiatric problems.” (Branch qtd. In Harrison). The disconnect is exactly where he points out that psychiatrists must be willing to try to meet social needs while trying to handle the wide range of psychiatric conditions. Erickson points out that, “…these same psychiatrists cautioned that commitment to community models required mental health professionals to fully address the social problems – such as poor socialization and lack of housing, food and clothing – that exacerbate mental illness in community settings.” This is an unrealistic expectation to put on health professionals, and it is evident that they are not willing to take on this endeavor on top of their already demanding task of treating these conditions. This really seems to be the root of the issue as the mental health disciplines and organizations continue to address treatment and not prevention especially with the advancements of pharmaceutical knowledge and technology. One has to bear in mind that those were different times compared to today. Psychiatrists were once synonymous with psychologists, but, now with the prevalence of and advancements in psychology and pharmaceuticals, psychiatrists focus more on deciding what medications are necessary according to a psychologist’s assessment and recommendations.
This shift in focus from acknowledging the necessity of prevention to pharmaceutical treatment is evident in the two decades that followed the signing of the CMHA by Roosevelt. According to the the National Institute of Mental Health (NIMH), on August 13, 1967, U.S.

Department of Health, Education, and Welfare Secretary John W. Gardner, Ph.D., transferred control of the federal government’s only civilian psychiatric hospital , St. Elizabeth’s Hospital, to the NIMH. The research done there through its Clinical Pharmacology Research Center made significant contributions to clinical and neurological research that began an industry-wide move toward the development of pharmaceuticals for the treatment of mental illness. In 1970 the FDA approved the use of lithium for mania, a major feature of bipolar disorder. Later that same year, Julius Axelrod, Ph.D., and two others received the Nobel Prize in Physiology or Medicine for their discovery that led to the development of selective serotonin reuptake inhibitors (SSRIs) that were approved by the FDA in 1987 with major results in the treatment of depression that is still widely used today. Of course our current issues are exacerbated by the development of these pharmaceuticals that seem like a quick fix to the problem, but have become more of a bandaid on the hole in this dyke. More people are addicted to prescription drugs and die from overdoses more now than ever before. Also, pharmaceutical companies and mental health care institutions and facilities financially benefit from this problem. “A patient cured is a customer lost” – Unknown. Our current culture has fallen subject to this mindset of convenience and pharmaceutical intervention. Comedian Greg Gerard satirically, yet accurately, captures the apparent commercialization of health in America.
“I can’t watch TV for 4 minutes without thinking I have 5 serious diseases. (Commercial announcer voice)‘Do you ever wake up tired in the morning?’ Oh my god, I have this! Whatever it is, write it down, I have it. Half the time you don’t even know what the commercial is about. You got people running through fields or flying kites, like ‘That is the greatest disease ever! How do you get that?! That disease comes with a hot chick and a puppy!’” Most Americans would laugh at this because they know how true it is. Unfortunately, this is a far cry from the ideology

that President Roosevelt and his administration had for future generations.
Their intentions were good, but not everyone in the country shared the same vision. This optimism without sufficient infrastructure, funding and ongoing responsibility created a cascading problem as more programs were depended on to fill the gaps and care for those who were deinstitutionalized. The 90% decrease in the year 2000 of institutionalized individuals from the peak in 1955 of 558,922 put a lot of pressure on existing mental health care systems (Erickson). This doesn’t mean that these patients were cured. Instead they had to find other avenues of attaining treatment that came with more barriers and hoops to jump through. Funding often depended on SSI, SSDI and food stamps, and many do not qualify for Medicaid and Medicare due to age, financial and bureaucratic application barriers. Families, friends and associates often end up taking responsibility for care that takes a toll on family resources and relationships. Many without homes of their own end up on the streets and many of these enter the revolving door of acute care hospitals, jails, prisons and forensic facilities (Scull). Mentally ill, undereducated, impoverished/homeless and minority populations are over-represented in prisons in correlation with unmet medical and mental needs (Jones and Sawyer). Many people end up committing suicide or committing a crime that ends them up in the criminal justice system with insufficient treatment or support, and even making their condition worse (Scully). Victims of crimes and non-victims’ mental wellness is adversely affected, not to mention the economic burden on the community and the nation (Corneglia, Feldman et. al.). This problem has a widespread effect on the entire nation and the world as fear and pain are easily spread with modern technology such as social media and television. Looking at the prevalence of these worsening issues can be very discouraging if we only focus on the problem and fail to miss the silver lining.

In spite of these conditions, there is an opportunity to learn from situations and programs that show us what works and what doesn’t. Branch was on to something when he pointed to addressing the contributing social problems that exacerbate mental illness, not just treating the symptoms of the mental illness. We are starting to realize how important our environment is when it comes to personal development. Research shows that a lack of green spaces in urban settings contributes to the likelihood of developing psychiatric conditions or mental health issues (Engemann) while their increased presence reduces the rates of suicide in young people (Ryan et al.). We have also seen a significant social, environmental and economic benefit of green spaces and community gardens to communities (EPA). Local churches have successfully implemented green spaces (Covenant United Methodist Church) and even peer support programs (KXLY). Ideally peer support could be used as a preventive instead of just a reactive criminal treatment. I conducted an interview with Caralee Edwards (Appendix A), a woman who was previously incarcerated and now provides mental wellness meetings for inmates here at Idaho Correctional Institution Orofino. In the third of my line of questions, she acknowledges that intervention prior to her arrest was insufficient even though there were plenty of red flags that indicated she needed help. In her mind, incarceration served its purpose and was the only option to get the help she needed, however inadequate and detrimental that was. Through her experience, she recognized what was needed and has dedicated herself to being part of the solution. She now provides tools and education to help inmates take responsibility for their mental health in the hopes that they will stop coming back. We are fortunate to have access to programs like this, but most American prisons fall short of providing adequate mental health treatment or successfully preparing inmates for re-entry into society, especially compared to European Prisons (PSYCH 424;Moore). Other various programs have failed previously because of a lack of organizational support and

ongoing maintenance and responsibilities. The success and failure of these programs points us in a direction that holds substantial merit and offers immense hope for a legitimate solution.
Proposed Solution
The solution I propose is a seemingly simple one though it may not be easy. The US government made the mistake of assuming that their simple, and admirable, idea would be easy to implement. Now looking back, we can see where they fell short and make adjustments.
The first thing that needs to be done is that there needs to be an organization established to take responsibility for these programs and see them through. There are several existing organizations, especially nonprofits, that already do some of these things and would be good candidates(Covenant United Methodist Church; KXLY). However, establishing a new nonprofit organization that is dedicated to this mission would be more effective. Luckily, starting a nonprofit organization is not as mysterious or difficult as some may think in our current age of information. The Nonprofit Kit for Dummies is one example that lays out, step by step, how to set up a nonprofit organization and gear it toward this cause. During this process, members of the nonprofit should be selected according to the mission and goals of maintaining a green space or community garden while providing peer support and mentorship. One convenient benefit of using a nonprofit organization is that funding doesn’t have to be provided up front in order to establish it and accomplish these goals. It will also have more freedom and ability to procure donations and necessary funding than the government. This was another area where the government fell short as it couldn’t provide all of the funding for the proposed facilities and personnel to sustain it in the long-run. Even though technically the government is a nonprofit, it can’t request more funding than it already receives through taxes and would have to resort to deficit spending and increase the already record high national debt. Obtaining funding would

obviously be the next logical step necessary for this nonprofit or other entity to execute these programs, which leads to the practical application.
In order for there to be green spaces or community gardens, there must be a purchase or procurement of strategically located property to put it on. First, the possible locations for this green space must be scouted in areas where underserved members of the community frequent or congregate. Fortunately, those who are most affected by the problem tend to live in lower-income areas and any land for sale would likely be fairly cheap compared to developed and high-end areas. Landowners could possibly even donate land and get a tax write-off while improving their company’s social responsibility image. The key is making the green space accessible to target stakeholders while increasing vegetation in urban areas that lack it. Municipal or business entities could possibly be approached with this mission and have land that is underutilized or that is already developed for this purpose and may even see value in supporting this cause. If the land isn’t already developed, contractors would have to be hired or members of the organization could utilize their own resources and labor in order to keep costs down. Once the green space or community garden is developed and established, the nonprofit members as well as volunteers should be assigned gardening and care responsibilities to make it an inviting and aesthetically pleasing addition to the community. These same people will then become the next phase of the solution.
The final phase of this solution is to develop a peer support and mentorship program. This is the most complex part of the solution and should be the main focus. By this point the members of the organization should mostly be peers of the target stakeholders who have life experiences in common that would make them more effective peer mentors (Miler et al.). One study identifies the major influences on peer support programs as organizational culture, training

and role definition (Ibrahim). Being part of this organization with a clear, common mission is only part of the organizational culture that influences its members. There should be scheduled meetings often to increase the communication and support among program members. Leadership must not forget that its members are stakeholders as well, and they have needs that must be met first in order for them to be effective and successful. Training should be the next logical step in the progression toward the ultimate goals of the organization. Until recently there hasn’t been a whole lot of consistency between peer support certification and informal peer mentorship programs, but now there is a national standard that has been established by the Substance Abuse and Mental Health Services Administration(SAMHSA). They outline three possible certifications: mental health peer certifications, substance use peer certifications and family peer certifications for peer workers with experience as the primary caregiver of a dependent with mental health and/or substance use conditions. Each member of the organization should work to their strengths and choose a certification that most closely relates to their life experiences, but continued education and certification could make them more versatile and more valuable to the organizational mission. Each state has its own certification entities and some effectively utilize the same certification process for more than one type of certification like the Washington State Behavioral Health and Recovery Peer Support Program. The process to become a state certified peer support mentor, according to Edwards in her personal experience, can be long and difficult especially with a criminal record as there are barriers, but it is very rewarding if you’re willing to put in the work (Appendix A q. 8). The last piece to address is the definition of roles and responsibilities. This should be a pretty straightforward process of interviewing and communicating with each member of the organization about their competencies, goals and

desires as well as regular evaluations and an open channel of communication with a focus on preventing burn out and staying informed about changes or concerns.
The program should become self-sustaining as stakeholders benefit from this program and are encouraged to give back by donating time and resources, participating in the community garden, advocating for the organization’s effectiveness and, preferably, eventually becoming a member of the team and becoming certified peer mentors themselves . If these steps are followed thoroughly, the immediate area and eventually the community will begin to see the benefits encouraging municipal, county and government entities to network with and contribute resources to these programs that make them more effective. Once this model is successfully implemented, other communities and possibly even countries may choose to adopt the same approach or make improvements to further its impact.
Justification for Solution
Simply asking someone “Are you okay?” or “What was your childhood like?” makes more of a difference and has a deeper impact than just giving someone medication or putting someone into treatment, jail or an asylum (Cousins). In this news article written by Cousins, he shows how the Adverse Childhood Experiences study that resulted from the collaboration of researchers at Kaiser Permanente’s Health Appraisal Clinic in San Diego and the Centers for Disease Control and Prevention paved the way for teachers in the Inland Northwest to address disciplinary issues in schools. One teacher, Lynn Thompson, who is applying these lessons says that oftentimes people respond to chronic stress and adversity in ways that can look like oppositional behavior or attention deficit disorder and the focus should be more on instilling a feeling of safety and building healthy relationships. A lot of times we just need relationships where we can feel safe and heard. Making a connection with and talking to someone who has

been through what you’ve been through means more than being talked down to by a professional that has no experience and only has knowledge they obtained from a book. This is especially true when dealing with trauma, mental illness, substance use disorders or other types of addiction for adults and youth (Collins et al.;Turuba et al.). Oftentimes, people who are struggling with mental illness or substance use disorders don’t know where to go or how to obtain the help they need and a peer who has been through the process can bridge that gap and help them through it (Turuba et al.). Furthermore, this collaborative environment doesn’t just benefit them, it also benefits the mentors themselves. Being part of a peer mentorship program is great for building skills and credibility in the professional community that could make people more employable and increase job opportunities. These programs rely heavily on training, certifications and working as a team or even leading them, in order to be effective that is, which are all great skills that employers look for. The support and accomplishments these programs provide are ideal for providing hope and a purpose that can change and save many lives.
Just knowing that there is a place nearby where people can go for support, someone to talk to when they’re going through a difficult time or even just a place of peace to get away from the stress and the chaos so they can just think, can reduce the anxiety and remove that feeling of being trapped. Sometimes it’s not even people we need, but some peace and quiet in nature.
Speaking of nature, gardening can be very therapeutic, and simply being able to do something positive can change someone’s outlook on life and give them hope. For them to be able to achieve something as small as helping a plant grow then being able to eat the fruit that it produces can give them a sense of success, connection with nature and show them that they can be a positive and productive person in society and life (Rudolph). Rudolph quotes the executive director of Denver Urban Gardens, Linda Appel Lipsius, as saying, “Community gardening

offers many positive things to participants such as encouraging healthier behaviors, improving mental and physical health, and increasing access to green spaces.” But the benefits of green spaces goes beyond the individual in need. The presence and prevalence of green spaces and vegetation has a direct effect on mental health and the probability that someone will develop a psychiatric condition in every community (Engemann et al.). A community garden offers several unique learning and growth opportunities for volunteers and other participants. Volunteer and community work is a great way to make the best of being unemployed and show potential employers that you can work well in a team environment and develop leadership skills(Bovée and Thill 527). Being able to effectively maintain a garden also requires communication with others, planning and organization. These are additional skills that can contribute to someone’s personal and professional value. Although there is plenty of research and personal experience to prove the positive effect green spaces and nature have, combining it with a peer support program and mentorship significantly increases the chances of positive outcomes and averting disaster for everyone involved.
Opposing views
Although there is plenty of support for this solution, it does present some very real issues and concerns. The biggest issues come from negative experiences with relationships between peer mentors and mentees alike. Any time you deal with the human element, there are opportunities for error or harm, and this is unavoidable. There are some peer mentors who may be set in their ways and think that their solution is the only possible one, but their mentee may be resistant to it or even have past experience with it that caused them harm or trauma. This could leave the mentee feeling even more alone or hopeless. During the interview with Ms. Edwards, she spoke about her resistance to 12-step programs like AA or NA because of the negative

experiences that she’s had. Even she acknowledged that they may be great programs for some, but it’s not the only effective option. She stressed how beneficial it would be to have a mentor that is aligned with the mentee’s beliefs and values instead of one who is close-minded and pushy on one possible solution or approach. This could absolutely lead to a disconnect or resistance in the relationship that would leave the mentee’s needs unmet and even put them in a worse position. This could even create a volatile situation where they could harm each other whether it’s physically, emotionally or even spiritually. On that same token, the very situation of sending mentors out into the community makes them vulnerable and could possibly place them in harm’s way. Humans can be unpredictable, especially when they are desperate or afraid.
Professionals in the healthcare industry may also disagree that peer support intervention is effective or even helpful when combined with physician care. Care for certain mental health conditions should come from a physician or psychiatrist and not from peer support services. Some studies show little or no difference that peer support services have on patient outcomes when dealing with severe mental illness and depression (Fuhr et al.). Others even suggest that it is a waste of resources, according to the literary review by Shalaby et al.
Rebuttal
The concerns about peer mentor relationships and interactions are all valid, but this is where the training and working in pairs comes in. Certification, education, sensitivity training and self defense are essential to protect the peer mentors and mentees alike. Working in pairs ensures that someone is never alone and they can support and keep each other accountable, but also from a legal standpoint they would be able to corroborate anything that happens. Also, I would argue that the body of evidence, as reviewed by Shalaby et al., that backs up peer support

services shows that it does more good overall than any harm that may possibly be done. Still, safeguards and proper training should be put in place to mitigate and minimize these negative outcomes as much as possible.
The view of physicians is understandable in high-income situations where patients are already seeking and receiving the necessary support and guidance from their physician as they should. However, my solution doesn’t address those in high-income situations with active access to healthcare. There is abundant literature available that demonstrates the effectiveness of peer support services in various low-income and marginalized situations as cited by Shalaby et al. At the same time, more recent studies show that many physicians recognize and support the role that peer support services play in contributing to holistic, quality patient care and their outcomes. In the article “‘If It Wasn’t for Him, I Wouldn’t Have Talked to Them’: Qualitative Study of Addiction Peer Mentorship in the Hospital” written by Collins et al. in Society of General Medicine 2019, the title says it all. They demonstrate the ability of peer mentors to positively influence the physician’s care, but also the potential for mentors to advocate for the patient on a professional level in a way that the patient may not know how to communicate, allowing the physician to better understand their needs and devise a more effective plan of care. As opposed to the opposition to peer mentor relationships, the physician’s counterargument against peer support only points out inadequacies instead of harms, and again the body of evidence that supports it far outweighs the possible shortcomings.
Conclusion
Ultimately, high rates of poverty, homelessness, crime, suicide and the annual incarceration of almost 5 million people are evidence of a broken world directly related to inadequate medical and mental health support services. These negative outcomes are prevalent in

every city of our nation and reach beyond our borders with both broad and deep socioeconomic implications contributing to unemployment rates and a diminished workforce. The most realistic and effective solution, as outlined, is to utilize peer support programs along with community gardens and public green spaces that act as a central hub of operations within each community. My proposed approach doesn’t employ one program at a time, although each one is effective in its own right. The idea is to combine both avenues simultaneously to not only be more effective for each individual but also have a significant impact on each community and eventually the world. As more and more people realize the prudence of this model and implement it in their own community, it will spread to every city, and we will start to see these appalling statistics plummet and a culture of compassion will emerge. But until that day, people will continue down these dark paths. Every day this solution isn’t available is another day that someone’s life is destroyed or continues to deteriorate. Every day, families fall apart or lose someone they love because help wasn’t available when it was needed. If we get this ball rolling now, it wouldn’t be unreasonable to see a major impact in the span of a couple years. Right now there is someone in your neighborhood who needs this in their life. It’s up to you and your community to reach out, make the calls, ask the hard questions and find a group of people that are willing to take the steps necessary to put this plan into action and change the world today.
“Be the change you want to see in the world” – Unknown

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