Mental Health Outcomes for Female Inmates without a Mental Disorder: Imprisonment and Post-release Effects of Confinement with Women with a Mental Illness

Abstract

This study explores the well-being of women offenders without mental disorders during imprisonment and reentry after having been confined with mentally ill female inmates. We found that this joint confinement causes great distress to the mentally stable female inmates, harming both their mental, physical, and emotional condition and their reentry process and rehabilitation. Our findings led us to conclude that women prisoners should be separated from those with mental disorders or be offered a wide range of psychological and emotional coping tools as well as variety of rehabilitative treatment programs.

Keywords

women inmates mental illness reentry rehabilitation

Introduction

Living with individuals with mental illnesses has been studied extensively (Chang & Horrocks, 2006), especially in familial and social contexts (Katz et al., 2015). Besier et al. (2010), for example, examined the impact of living alongside individuals with mental illness on the mental and emotional state and behavior of siblings and their secondary victimization. Similarly, Van Loon et al. (2014) analyzed the impact of living with a parent with a mental illness on the mental functioning of their children.

Prison is a unique social environment which accommodates individuals diagnosed with various emotional, cognitive, and mental health problems. Numerous studies have revealed relatively high rates of mental disorders such as bipolar disorder, major depression, and schizophrenia among inmates, due either to the harsh and stressful carceral environment or the personal characteristics of the inmates (Al Rousan et al., 2017).This state of affairs appears to be intensified in women’s prisons, where, compared to general society, high rates of bipolar disorder, major depression, schizophrenia, post-traumatic stress disorder, and obsessive compulsive disorder are found among incarcerees (Wooldredge & Steiner, 2014).Consequently, many imprisoned women, both with mental illness and without, deal on a daily basis with various stressors related to their fellow inmates’ mental disorders(Brown & Bloom, 2009), as well as effects from the oppressive, restrictive, and humiliating reality of prison environments (James & Glaze, 2006). These concerns have been found to aggravate ongoing traumas, harm women inmates’ well-being in prison (Carlton & Segrave, 2011), and disrupt successful reentry into society (Baldry, 2010).

Interestingly, regardless of the plethora of studies focusing on women prisoners’ issues (Araya et al., 2006)—the pains of imprisonment (Chamberlen, 2016; Chen et al., 2014), physical and mental issues (Iversen et al., 2015; Stanton et al., 2016) and life alongside individuals with mental disorders (Katz et al., 2015; Van Loon et al., 2014)—the impact of incarcerating women offenders with mentally ill female inmates on the mental health and well-being of the former has not been studied systematically. Notably, nearly all studies regarding women inmates and their mental state have focused on prisoners with a mental illness. Very few studies have concentrated on women prisoners with no mental illness and the impact of imprisonment on their mental well-being (Harner & Riley, 2012). Moreover, no research has been conducted on the effects of living alongside mentally ill inmates on the former’s mental and emotional state. The aim of this study, therefore, is to provide an in-depth analysis of how women ex-prisoners perceive and experience the impact on their well being in prison and at release from having been confined in close proximity to female prisoners with mental illness. In this way, we seek to broaden the criminological, penological, sociological, and psychological understanding of women’s prisons and of the variables that affect the well-being of women prisoners both in prison and during reentry.

The empirical material consists primarily of semi-structured, in-depth qualitative interviews with 22 women ex-inmates, who had experienced joint confinement with women prisoners with a mental illness, for a period of 24 months and more.

Neve Tirza Prison

NeveTirza Prison is the only correctional facility for women in Israel. At full capacity, the prison holds 225 criminal (as opposed to security) inmates. All inmates, regardless of their nationality, live and socialize together. In spite of the political and ethnic conflicts in Israeli society between Arabs and Jews, ethnic clashes rarely take place in prison. NeveTirza is a maximum security prison built and run to provide around-the-clock surveillance. With strong concrete walls and barred windows, the prison is secured by fences, watch towers, and armed prison officers. Inmates’ activities are closely monitored by closed-circuit television and other electronic devices used indoors and outdoors but not in the cells (Einat, in press).

By Western standards, this is a rather crowded prison, with an allocation of 2.8 m² per inmate (Einat & Chen, 2012a). The facility has three major wings, each housing 60 inmates: the Kalanit and Tsivoni wings are designated for former drug addicts, while Savionis is reserved for “clean” inmates. There are also three small wings—a treatment wing, rehabilitation wing, and isolation wing—which house 12, 5, and up to 6 inmates respectively. The treatment wing accommodates former addicts who wish to continue their rehabilitation treatment and have been found highly motivated by the prison’s social workers. The inmates of this wing are kept isolated from other inmates. The rehabilitation wing accommodates former addicts nearing the end of their sentence who are considered rehabilitated by prison staff. These inmates, who are also kept isolated from other inmates, leave the prison daily to work outside the prison and return to the prison at night. The isolation wing houses inmates who have violated prison regulations for a maximum period of seven continuous days.

The facility includes two small factories: a sewing workshop which employs 30 inmates and a carton factory which employs 35 inmates. The prison also has an educational wing which runs literacy classes and a variety of vocational and leisure courses such as painting, occupational therapy, and drama. All inmates are obliged to work or participate in educational activities during the daytime.

Mental Health of Women Inmates

Numerous studies have documented high rates of mental illnesses among women prisoners (Al Rousan et al., 2017), mainly due to abuse in childhood and adolescence (Chen & Gueta, 2015).

Marzano et al. (2011) conducted a quantitative and qualitative study of 120 women inmates in an English Prison to identify socio-demographic, psychological, societal, and criminological variables associated with the near-lethal self-harm incidents among women prisoners (i.e., life events, childhood trauma, exposure to suicidal behavior, and other contributory and precipitating factors). The findings revealed that the two main personality parameters for predicting future suicidal behavior are despair and low self-esteem. These were found to be amplified by the total institution environment of the prison and its accompanying harsh pains of imprisonment. The main environmental parameters found to be related to future near-lethal self-harm were social isolation, bullying by prison personnel, and maladjustment to prison life.

Fazel and Baillargeon (2011) examined, among others, the prevalence of mental disorders (i.e., psychosis, depression, anti-social personality disorder, alcohol and drug misuse, PTSD, and intellectual disabilities) among men and women prisoners. The study reveals that women in prison seem to have higher rates of most psychiatric disorders compared to incarcerated men (see also: Steadman et al., 2009; Trestman et al., 2007) and the general population (of similar ages) (Bosgelmez et al., 2010). Further, the high prevalence of mental illness and substance misuse in women prisoners might result from an association with violent crime (see also: DeHart et al., 2013; Harner et al., 2015), a shortage of inpatient psychiatric beds, failure to divert appropriately from court to hospital high rates of mental illness in homeless people (see also: Fazel et al., 2008), and mis-identification of mental disorders on prison reception.

The Impact of Imprisonment on Women Prisoners’ Mental Health

Bosgelmez et al. (2010) analyzed the link between imprisonment of at least 1 month in Kocaeli Prison in Turkey and the appearance of psychological symptoms among 30 female and male prisoners. Their findings show that imprisonment, especially with regard to the loss of privacy and control, negative social stigmatization, and separation from family members, provokes strong feelings of stress and anxiety which, in turn, lead to post-traumatic stress disorder and depression among incarcerees.

Harner and Riley (2012) analyzed women’s perceptions of how incarceration in a maximum-security prison facility affected their mental health. Using both focus groups (12 focus groups; n = 65 participants) and a Prison Health Survey (PHS), the researchers studied incarcerated women’s perceptions of “How has prison impacted their mental health?” (p. 29).They concluded that women’s mental health might worsen, might improve, or might remain the same as a result of incarceration. In addition, women’s accounts provide evidence to support the need for all women’s correctional institutions to adopt a trauma-informed approach to care for this vulnerable population.

Green et al. (2016) used factor analysis to examine patterns of traumatic events experienced by women in jail, and explored how these patterns were associated with four psychiatric disorders (posttraumatic stress disorder [PTSD], major depression, bipolar disorder, and substance use disorder) observed in a sample of 464 women from nine US jails in four geographic regions. The researchers report that family dysfunction (FD) and interpersonal violence (IPV), contributed independently to the odds of having each of the four mental disorders studied, and that stressful external events (EE) made a unique contribution to the likelihood of having PTSD. Consequently, the researchers concluded that assessing trauma exposure of women in jail, especially the family context, as well as mental health is of major importance, and that implementation and testing of evidence-based treatment approaches that address trauma-related distress in correctional settings is necessary.

Lastly, Slotboom et al. (2011) applied the ISWI (International study on women’s imprisonment) questionnaire (Dunkel et al., 2005), the IES (impact of events scale) (Horowitz, 1979), and the negative life events (LE) instrument (Kraaij et al., 2003) to explore characteristics of 251 women inmates in four women’s prisons in the Netherlands. The investigation sought to examine their experiences of confinement, assessing their psychological reactions to imprisonment and the relative impact of importation and deprivation factors on indicators of well-being. Their main conclusions were that deprivation factors, mainly treatment by staff and other prisoners, and environmental stress, have greater impact on measures of well-being (i.e., depression, irritability, and self-harm) than importation factors. Additionally, previous treatment for psychological problems was the most important covariate for psychological complaints and post-traumatic stress. Accordingly, the researchers suggested that in order to further the understanding of women prisoners’ adaptations to incarceration, greater attention should be directed to their conditions of confinement and less to histories of victimization and drug abuse.

Imprisonment and the Reentry of Women Prisoners into Society

Women’s prisons tend to be characterized by constant supervision, strict and demanding schedules, and suppression of the prisoner’s personality (Severance, 2004, 2005). Research on women prisoners documents that they experience “pains of imprisonment” that include: the stigma of incarceration, anxiety about their children, mental, physical, and emotional problems accompanying their withdrawal from alcohol and drugs, insensitivities, and abuses of power by staff or fellow inmates, the claustrophobia of confinement, and cognitive dissonance caused by not knowing how or whether to express their feelings (Jiang & Winfree, 2006).

Mumola (2000) and Powell and Nolan (2003) asserted that in addition to the aforementioned deprivations and distresses (common to men inmates as well), women prisoners cite the lack of companionship and separation from their children and families as major pains of imprisonment. This difference may derive from the fact that many of them are single mothers with children younger than the age of 18 for whom they are the sole caregivers and providers. Their inability to rely on a significant other to care for their children during their incarceration may therefore add to their stress and anxiety (Dodge & Pogrebin, 2001). Moreover, Lindquist and Lindquist (1997) learned that women prisoners feel isolated from family, friends, and life outside prison. As there are only a few women’s prisons, many inmates are incarcerated in facilities located far from their homes.

Another group of studies has investigated the relationship between the length of imprisonment and women’s adjustment to prison life. Carlen (1985) revealed that the pains of imprisonment were more likely experienced among long-term inmates than among their short-term counterparts, leading to one of four outcomes: death, institutionalization, self-mutilation, or mental breakdown. Thompson and Loper (2006) discovered that women serving longer prison sentences found it harder to adjust to prison than women serving shorter sentences, mainly due to “limited contacts with family members, particularly children” (p. 728). These emotional and social problems accompany women prisoners from their very first day of incarceration and often affect their conduct inside the prison.

The majority of studies on women’s pains of imprisonment have maintained that they have various psychosocial modalities for coping with the prison environment and alleviating their physical, psychological, and emotional suffering (Thompson & Loper, 2006). First and foremost, they embrace violent behavior, thus gaining power and control over other prisoners, or consume drugs and alcohol (Severance, 2005). Other ways of coping include seeking social support by developing close relationships with other inmates (Bosworth, 1999; Severance, 2005).

In view of the complexity of prison life and its negative objective and subjective impacts on the physical, mental, and emotional health of many prisoners, several researchers have pointed to the need to construct integrative, multifaceted, and long-term treatment and rehabilitative programs in prison and in the community (Hopkin et al., 2018). Such programs, focusing on the mental and physical health of prisoners, their occupational stability, and their education, are perceived as beneficial for their well-being both in prison and after release (Goodkind & Spjeldnes, 2009). Regardless of this recognition and the variety of existing rehabilitation and treatment programs for women prisoners and ex-prisoners, the recidivism rates of women inmates are relatively high and many fail to rehabilitate themselves and reenter society successfully. It has been suggested that this is due to inadequate educational and professional training in prison, economic distress and misguided economic conduct, drug abuse, and a range of psychopathological problems (Cobbina, 2010).

Another significant factor in the failure of women ex-prisoners to reenter society successfully is the disregard or lack of adequate attention of the designated care programs to the complexity of the distresses and traumatic experiences of incarcerated women and their impact on the women’s emotional well-being (Hopkin et al., 2018). This lack of attention appears all the more critical in light of research that has demonstrated successful outcomes of trauma-focused treatment in the early stages of women inmates’ rehabilitation process and a reduction of post-traumatic symptoms and consumption of psychoactive substances (Hein et al., 2004).

It thus appears that a general understanding of the factors that inhibit the chances of women prisoners’ successful reentry into the community and the need for appropriate treatment and rehabilitation programs could reduce recidivism rates and significantly improve their chances of successful integration into society (Visher & Bakken, 2014). The current research aims to explore and understand one unique and ignored factor that damages the well-being of imprisoned women and their successful reentry to society—joint confinement with women inmates with mental illnesses.

The Impact of Living with Individuals with a Mental Illness on their Family Members

Aldersey and Whitley (2015) conducted a study among 54 patients diagnosed with mental illness to investigate the perceived influence of the family as a factor which promotes recovery from severe mental illness. Their findings uncovered a dual situation. On the one hand, family members supported the mentally unstable relative emotionally and economically, thereby helping improve their symptoms. On the other hand, this support demanded considerable emotional energy from the family members, resulting in feelings of severe distress and rejection toward the mentally unstable relative, which eventually damaged the latter’s improved symptoms. Similar results were documented by Drost et al. (2011) in a Netherlands-based study. Drawing on interviews with 534 participants (12–24 years old) who used a web-based preventive intervention based on chats with experts helping them to cope with a family member’s mental illness, the study revealed that children (12–18 years old) are at an increased risk of developing a severe mental disorder themselves.

Wrosch et al. (2011) revealed a correlation between living alongside a parent with a mental illness and a child’s own development of mental illness, while Sanders et al. (2014) examined the effects of coping with a family member with a mental illness on the adjustment of family roles among siblings. The study, conducted among 33 individuals who lived for an average of 4.4 years with a sibling with a mental illness, established that life with the latter drained the former’s emotional energy, leaving them feeling lonely, trapped, anxious, and afraid of sudden and violent reactions. According to the researchers, the siblings became secondary victims of the mental illness.

Method

The objective of the present study was to examine the effects on the well-being of women inmates without mental disorders during imprisonment and post release from joint confinement with women prisoners with a mental disorder. The research drew on the responses as subjectively presented and perceived by a sample of 22ex-prisoners and employed a qualitative, constructive strategy (Creswell, 2007).The main assumption of constructivism is that human beings create the world they know and understand from the interaction between the sensations that impact on them and their responsive acts of cognition. Such an approach enabled us to incorporate unexpected content and accommodate data upon its emergence, thereby enhancing the quality and authenticity of the findings (Charmaz, 2014).

Research Tool

Semi-structured in-depth interviews (Silverman, 2013) were conducted in the form of conversations. The interviews, following an interview guide, focused on a number of issues related to the impact of the joint imprisonment of mentally stable women inmates with mentally ill women prisoners on the well-being of the former, both during and after incarceration. In an effort to ensure consistency, the authors themselves facilitated each interview. Due to the flexible method of questioning, the design of the interview could be modified as new findings emerged (Harris et al., 2015). The advantage of this research tool lies in its ability to portray the interviewee’s world of meanings in a comprehensive manner.

Participants

The participants were 22 Israeli women who had been imprisoned for a period of at least 2 years in the single Israeli female correctional facility, NeveTirza Prison, and released 1 to 3 months prior to the initiation of the study to a community-based agency managed by the Israeli Prisoner Rehabilitation Authority. After obtaining consent from the executive director of the agency, we recruited the research participants through a non-probability and deliberate sampling method (Setia, 2016). Given that understanding and knowledge of prison life corresponds with, among other things, length of imprisonment (Einat & Livnat, 2013), a criterion of at least 2 years’ imprisonment was determined for engaging in the research. All the women were diagnosed as without a mental disorder by the Israeli Prison Service upon their admission to prison and by the Israeli Prisoner Rehabilitation Authority upon their release.¹ Initially, 27 ex-prisoners were allocated to the research. However, after 22 interviews, we noted a repetition of central findings with few new issues or themes emerging (i.e., the point of saturation [O’Reilly & Parker, 2012]), and thus decided to stop interviewing.

These 22 ex-prisoners represent approximately 24.4% of the total number of women who were imprisoned in NeveTirza prison for a period of 24 months and more at the time of the study. Thirteen of the 22 were incarcerated in Kalanit and Tsivoni wings (designated for former drug addicts), and nine interviewees were confined in the Savion wing (designated for clean prisoners). Sixteen (from all three wings) were imprisoned in the rehabilitation wing for periods of 4 to 16 months prior to their release from prison. Given the fact that the majority of Neve Tirza prisoners, housed in the aforementioned three major wings, are diagnosed as mentally ill (Chen & Gueta, 2015), we speculated that the length of proximity of the research participants to mentally ill women was more or less similar (i.e., at least 2 years). The ethnic ratio of the group was 60% Jewish (n = 9), 27% Muslim (n = 4), and 13.3% Christian (n = 2). This ratio is almost representative of the ethnic ratio of the entire prison, which stands at 62%Jewish, 30% Muslim, and 8% Christian. The respondents’ mean age was 38 (SD = 12.32) compared to 38.1 among the entire prison population (Einat & Chen, 2012a). The average length of incarceration was 35 months (SD = 2.70), compared to 31 months for the entire prison population (Einat & Chen, 2012b).

Procedure

In order to conduct the investigation, a request was sent to the Israeli Prisoner Rehabilitation Authority’s Research Unit and to the ethics committee of the Department of Criminology at Bar-Ilan University. The community-based agency was chosen because of the IPS’s refusal to implement the study in its facilities. The request presented the research objectives and invited women ex-prisoners to take part in the study voluntarily. After obtaining the necessary approvals, a meeting was conducted between the researchers and the head of the Israeli Prisoner Rehabilitation Authority’s Research Unit in which we requested assistance in recruiting as many appropriate participants as possible. Eventually, 27 ex-prisoners volunteered.

All research participants were informed of the general purpose of the study (i.e., to analyze the well-being of Israeli women prisoners) and were asked about their willingness to participate. The confidentiality of the interviews was ensured, and all volunteers signed an informed consent form approved by the University’s Review Board. This consent form included a statement from each woman declaring her voluntary agreement to participate while acknowledging her right to withdraw at any time.

In the ensuing 5 = months, one of the researchers conducted 61 hours of in-depth semi-structured interviews with 22 ex-prisoners (each interview lasted an average of 2 hours).Seven were interviewed twice (due to lack of sufficient time in the first interview). In addition, all the women were asked to write notes regarding their prison experience and return them to the researchers (by hand or by email) following the interviews.

The interviews were scheduled a week in advance. Participants were encouraged to share their prison experiences in a setting conducive to a sense of interpersonal involvement: one researcher and a single participant sitting in a large, comfortable room. There were no interruptions during the session, and the atmosphere was calm and friendly. All interviews were conducted in Hebrew and were recorded verbatim with each woman’s consent and began with a similar open-ended broad question: “What were your main difficulties in prison?” Only after the participants answered, mentioning “living alongside women with mental disorders” as one of their major difficulties, did we initiate a series of questions on the impact of these living conditions on their well-being, both during imprisonment and after release. The final stage of the study included transcription and analysis of all recorded interviews.

Data Analysis

In light of their qualitative nature, the findings were subjected to content analysis, which relates to the words and descriptions of the interviewees as reflections of their feelings, thoughts, beliefs, and knowledge and of their grasp on the reality in which they function (Elo et al., 2014). This type of analysis has four stages: (a) repetitive reading of the contents of the interviews; (b) identification and classification of the major topics emerging in the interviews; (c) categorization of major themes and sub-themes; and (d) creation of a theoretical structure through the various themes and sub-themes, linked to both the literature and the theory (Silverman, 2013).

Three key themes emerged from our analysis: (1) the impact of the integration of women with no mental disorder with mentally ill women prisoners on the former’s mental and physical health; (2) the impact of the integration of women with no mental illness and women with mental disorder on the former’s reentry into society; and (3) attitudes toward the appropriate policy that should be implemented by the Israeli Prison Service regarding the integration of women with no mental disorder and mentally ill prisoners. The analysis is, therefore, essentially thematic and based on the categorization of content areas. This system serves to pinpoint the most salient perceptions of mentally stable ex-prisoners regarding the implications of living alongside mentally unstable inmates.

To ensure the validity and credibility of the findings (Golafshani, 2003), three methods were implemented: (a) Engagement of multiple methods - The researchers gathered data by occupying two approaches: interviews and notes (emailed or physically handled to them by the research participants) (Einat et al., 2015); (b) Triangulation/peer validation (in accordance with the constructivist paradigm), in which the data were interpreted and analyzed by one external reader (the second author) at a different time and location (Silverman, 2013); and (c) the study was written as a “thick description” (Tracy, 2010) and thus includes information about the context of the topics presented with corresponding quotations from the participants as well as an open conceptual discussion (Marshall & Rossman, 2010).

Findings the Impact of the Integration of Female Prisoners and Women Prisoners with a Mental Illness on the Former’s Physical and Mental Health

The first major finding is presented in two sub-categories: behavioral characteristics of women prisoners with a mental illness; and the effect of the behavior of the women prisoners with a mental illness on the mentally stable female prisoners.

Behavioral Characteristics of Women Prisoners with a Mental Illness

The topic of women prisoners’ mental health has received vast academic attention (Tripodi & Pettus-Davis, 2013). The research literature documents that many women prisoners suffer from a range of mental pathologies (Cobbina, 2010) which are expressed by various endangering behaviors, such as self-harm (Bosgelmez et al., 2010), and violence toward others (Brown & Bloom, 2009). In line with those findings, the current study found that women inmates with mental disorders often exhibit different violent (verbal or physical) behaviors.

A., a 25-year old ex-prisoner who was incarcerated for a year and a half due to a fraud crime, related to the above:

The psychiatric [prisoners]. . .who are mentally ill. . .for real, they are not okay [laughing], they shouldn’t be in prison. . .they should be in Abarbanel [a psychiatric hospital], they don’t respond. . .or when they do, I don’t know. . .suddenly they start talking to people who aren’t there. There was this one who was screaming all the time. . .and she screamed. . .and when this phase was over. . .you start asking her who she’s talking to. . .and then she starts saying it’s her neighbor, who stole her husband. . .and that because of her she is in prison. . . and then, suddenly, she is in that phase again, screaming.

B., a 21-year-old ex-prisoner who was incarcerated for 13 months due to aggravated assault and conspiracy to commit murder, and N., annex-prisoner (refused to reveal her age) who was incarcerated for 13 months due to drug trafficking, reinforced the same finding:

You don’t know when the day will come and it will “erupt” in your face. . .I had a violent incident in my room. . .it was in the middle of the night. . .I was with someone who. . .she was a bit off. . .not right in the head. . .so, okay I got it you [the mentally unstable prisoner] don’t want to watch movies [on TV] in Russian, but you fall asleep early, so what do you want? That even when you’re asleep I’ll put on [a TV program] in Hebrew? So, one day when I was watching a series [in Russian], she got up, start shouting. . .I had a DVD in my room that I had borrowed from one of the girls. . .she grabbed it and smashed it on the floor. (B.)

You enter a cell with other girls. . .one of them is crazy and the other doesn’t know what she is doing. One is peeing in her bed. All the time. . .[the mentally ill women were] full of anxieties. . .aggression. That was very scary. What do I have in common with them? They [the Israeli Prison Service] should have locked me in a cell with girls like me [a woman without a mental disorder]. (N.)

These quotes demonstrate that the mentally ill inmates’ conduct creates severe feelings of stress and discomfort among many of the women without a mental disorder. These feelings are reinforced by the intensive physical interaction between the two, eventually deteriorating and destroying the well-being of the prisoners without a mental disorder.

The Effect of the Behavior of the Women Prisoners with a Mental Illness on Other Inmates

The intimate and often long-term encounters with prisoners with a mental illness lead to increased feelings of distress, helplessness, fear, and frustration among many of the other women inmates. The latter perceive these feelings as damaging their well-being, as can be seen in the following reports by S., a 44-year-old ex-prisoner who was incarcerated for 8 months due to fraud and extortion, and the aforementioned B.

They were not stable! Many of them there were not stable. . .It was scary. You often think, if she [the mentally unstable prisoner] can do this, just imagine what she could do to you? The craziness could emerge unexpectedly. She had those moments where suddenly she. . . got into this state of panicking, screaming, and crying. . .it was terrifying. I wasn’t used to these kind of things. . .it was a nightmare. . .It meant waking up in fear, going to bed in fear. . .I couldn’t sleep at nights. I was scared to death. I was so scared that I told one of the officers that he had to relocate me to a different prison wing. I didn’t care where they sent me. . . I didn’t care about anything, as long as they move me to a different wing. (S.)

It was the stuff of nightmares. . .how can they [mentally ill prisoners] do that?! I mean, at first, when you hear about someone who does something so horrifying, it disturbs you. . .you simply try to avoid that person. Someone who murdered a woman and dismembered the body. . . and she is sharing a cell with me! How can a human being do such a thing?? It’s terrifying. . . terrifying. . .I couldn’t tell what was going on in her head. What if she suddenly thought I was bad? Would she cut me open?! It makes you want to die there. (B.)

In accordance with other research findings (Besier et al., 2010) showing that siblings of individuals with a mental illness tend to suffer over time from mental and physical distress due to the proximity and intimacy of their relationships with the former, many of the respondents related to their anxieties, fears, alienation, and depression due to their ongoing intensive interaction with women incarcerees with a mental illness. H., a 32-year-old ex-prisoner who was incarcerated for two and a half years due to domestic violence and attempt to murder, reported:

It was terrifying. . .everybody was on [psychiatric] pills. . .and if she [mentally ill prisoner] did not take her pill on time, then she lost it. Whenever I saw that. . .I got scared. . .increasingly scared. I became more and more introverted. . .couldn’t sleep. I would cover my ears, so that I couldn’t hear her. I was so scared for my life. . .I thought that if I spoke. . .even said one word. . .she might possibly kill me. I couldn’t sleep. . .I was done in. . .dead. When I entered prison, I weighed54 kilograms, and then it got to 47! In three weeks! Yeah. . .the stress. . .the fear. . . I remember one [mentally unstable] prisoner who used to cut her wrists with the tuna knife, and it was like “chop, chop,” like she was cutting some sort of meat. . .I saw this and started shaking. . .my heart dropped. . .I was frightened. . . so scared. . . I started crying.

S.’s narrative reinforced the previous quote:

Look, the trauma. . .fear was always present. . .I could barely sleep. . .barely, barely, barely. I was exhausted. . .weak. I saw someone who cut herself right in front of my eyes. They [prisoners with a mental illness] were using the tuna knife, which we used for salads. . .so one day she [a prisoner with a mental illness] got into this state where she went out the dining room. . .and stab, stab [S. demonstrated the action of wrist cutting] it was over. It is constantly in my head. . .it stays with me and it will be a part of me. I go to bed with it and wake up with it. No, there is no way to handle this. I don’t even believe there is a way to handle such things. . .it’s like being in a war. . . there is no way to handle such trauma. No matter how much you talk about it. . .no. . . it’s already in your subconscious. . .very deep in the subconscious, there is no way of forgetting it!

The policy of integrating female prisoners with women prisoners with a mental illness thus appears to have a harmful and devastating impact on the well-being and mental and emotional state of the former. Following other research that has demonstrated the overwhelming and upsetting longitudinal outcomes of living with individuals with a mental illness on the well-being and mental health of their family members (Aldersey & Whitley, 2015; Sanders et al., 2014; Van Loon et al., 2014), our research participants revealed profound feelings of fear and panic and perceived the impact of their confinement jointly with prisoners with mental illnesses as ongoing and destructive.

The Impact of Joint Confinement of Mentally Stable Women Inmates with Mentally Ill Female Inmates on the Former’s Reentry into Society

The study’s second main finding links to the perceived relations between the research participants’ damaging encounters with prisoners with a mental illness and their subsequent rehabilitation and reintegration into society.

Carlton and Segrave (2011) analyzed the effects of imprisonment and trauma on suicidal behaviors among Australian women ex-prisoners and discovered they were around 10 times more likely to exhibit self-harm or suicidal behaviors than women in the general population. According to the Neve Tirza women, their intensive and unavoidable interaction with mentally unstable women prisoners damaged their mental and emotional state while in prison, resulting in severe sleeping difficulties, anxiety, and frustration, as well as their mental state and social functioning upon release.

Similarly, many of the current study’s respondents related to their perceived correlation between the fear inspired by women with a mental illness in prison and difficulties in their reintegration into society after release. S. reported:

[Some of the prisoners with a mental illness] would cut their wrists. There are women there who are constantly looking for ways to harm themselves. It is horrible. . . . It’s inside my head and follows me; it will probably follow me forever. It’s as if I cannot escape from this place [prison]. Even now, I wake up in the middle of the night and just stay awake.

Likewise, both L., a 55-year-old ex-prisoner who was incarcerated for 10 years due to two murder attempts, and N., annex-prisoner (no age given) who was incarcerated for 13 months due to drug trafficking, emphasized the long-term, negative, and traumatic effects of their interactions with mentally ill prisoners on their lives after release. Specifically, they both suffer from permanent restlessness, despair, depression, and deterioration in the quality of their sleep.

As the years pass [since my release from prison], I feel like I’m not a human being anymore. I am just. . .existing. Even though they [members of normative society] tell me, “enough with it, move on. . .keep on going with your life”– this is the phrase I hate the most –I think I would need a lobotomy[in order to do so].Maybe I need to be reborn. There hasn’t been a week [since my time of release from prison] that I haven’t had nightmares about prison. After these dreams. . .I feel down for at least a week. . .depressed. You are imprisoned with all these psychotic women for so many years. . . whether you like it or not, it will get to you. (L.)

The depression. . .the depression is still with me. It somehow accompanies me. I remember how I was there [in prison]. . .the dreams of prison, the nightmares. For example, there was one [mentally ill] woman who poured a boiling cup of coffee on another prisoner, and there was another [mentally unstable] prisoner who brought a razor blade and cut herself and all I could see was blood. Nothing is OK [with me] to this very today. It is still affecting me today and will affect me for the rest of my life. (N.)

Attitudes toward the Appropriate Policy That the Israeli Prison Service Should Implement Regarding the Joint Confinement of Mentally Stable Women Inmates with Mentally Ill Female Inmates

A third significant finding concerns the relationship between living in prison alongside inmates with a mental illness and prisoners’ successful reentry into society after release. Nearly all of the research participants maintained that they lacked the basic mental, cognitive, and social tools necessary for dealing with female inmates with a mental illness and had received no psychological or emotional support from prison personnel. Consequently, they suffered—and still suffer—from traumatic and upsetting memories which they claimed harmed their successful reentry into society.

C., a 36-year-old ex-prisoner who was incarcerated for 3 years due to attempted murder, asserted that the lack of separation between prisoners and inmates with a mental illness harms and reduces the former’s chances of successfully reentering society and therefore leads them back into crime:

There is no separation [between women with a mental illness and prisoners]. I can’t understand why they don’t do this. If they had done so, then they would have been able to invest more time in prisoners’ rehabilitation and treatment. A few prisoners receive some kind of treatment; others receive nothing. That’s why the recidivism rates are so high. If they [the prison service] don’t separate women without a mental disorder from mentally ill women and those who cope with prison life from those who don’t, then most of the women will not manage on the outside.

A more radical and assertive viewpoint is presented by A., who claimed that women prisoners are treated by the Israeli Prison Service as no more than numbers and, consequently, receive no humane attention or proper professional assistance for their needs or distress. It therefore did not surprise her that the prison service ignores the problematic nature of integrating women not diagnosed with mental disorders with female inmates with a mental illness, both technically (housing them in joint cells) and therapeutically (assigning them to similar therapeutic programs, if at all):

There was this one [prisoner with a mental illness] who had to be hospitalized in Abarbanel [a psychiatric hospital] and not in NeveTirza. She was crazy! She couldn’t understand what was happening around her. . .she was living in a world of her own. Such madness can only be observed in NeveTirza [laughs]. The Israeli Prison Service doesn’t care about you when you are in [prison] or out. . . in general, it does not care about you at all. Once, they placed a prisoner [with a mental illness] in my cell. I told the prison officer that they needed to remove her immediately! He told me that he didn’t want to deal with it and didn’t care whether I slept at night or not. And, I couldn’t in fact sleep for many nights. . . . It was a nightmare.

Both Dirkzwager et al. (2012) and DeVeaux (2013) saw that carceral environments and their ongoing exposure to stressful events have an adverse effect on the mental state of men and women inmates during their time of incarceration and post-release and on their chances of successful rehabilitation and reentry into society. Correspondingly, Burch (2016) underscored the necessity of implementing strategies for mental, social, and physical therapeutic mechanisms for ex-prisoners in order to help them manage their ongoing psychological trauma from prison and reenter society successfully. The participants in the current study maintained that the Israeli Prison Service, in contrast to these findings and perceptions, totally ignored their mental and emotional needs and thus harmed their psychological well-being.

A broader overview of our findings indicates that the integration between mentally well and mentally ill inmates has a significant negative impact on the former, as manifested in their strong and permanent feelings of frustration, tension, helplessness, and despair both in prison and during reentry.

Discussion

This aim of this research was to examine the effects on the mental and physical well being of mentally stable women inmates in prison and after release from their joint confinement with mentally ill female inmates as introspectively illustrated by study participants. Although a considerable body of research has been dedicated both to the impact of living alongside individuals with mental illnesses on the well-being of family members(Katz et al., 2015) and to the various mental, physical, and emotional problems of women prisoners (Houser & Welsh, 2014; Wakai et al., 2014), no study has focused on the impact of living alongside women inmates with mental illnesses on the well-being of female inmates without mental disorders. Hence, this explorative study provides a new systematic and scientific perspective on the direct and indirect effects of this forced integration both during their time of incarceration and upon release.

A major finding of the study is linked to the relationship between intensive engagement with prisoners with a mental illness and the physical and mental well-being of prisoners. The harsh, violent, and insane behavior patterns of mentally ill inmates are perceived by their counterparts as terrifying and destructive, causing strong feelings of helplessness, distress, fear, and anxiety. This ongoing state of mind caused many to suffer from a variety of pathological and psychopathological symptoms both during imprisonment and after release, including sleep disturbance, loss of weight, constant restlessness, and despair.

This mental and emotional state supports other investigations that have shown a correlation between the prolonged exposure of individuals to insane behaviors and the damage caused to their mental and emotional state and general well-being (Varshney et al., 2016). This state of affairs appears particularly disturbing in light of the intensity and expressions of the outrageous behaviors performed by inmates with a mental illness and the general negative impact of the pains of imprisonment on women prisoners’ well-being (Jiang & Winfree, 2006; Thompson & Loper, 2006).We therefore recommend the implementation of a new housing policy in women’s prisons whereby mentally healthy and mentally ill inmates are totally separated. If it is not feasible to implement such a policy (for financial or technical reasons), we recommend that correctional services equip female inmates with a wide variety of cognitive, mental, and emotional tools to assist them in coping with such harsh and enduring difficulties. For example, they could be presented with tense and contentious situations they have encountered or are likely to encounter with women inmates with mental illnesses and be given the opportunity to discuss them thoroughly, being offered a variety of professional means to help them manage these complex situations appropriately and successfully (Jiang & Winfree, 2006).

The second major finding relates to the perceived effects of daily and intensive contact with mentally ill women inmates on mentally stable women prisoners’ reentry into society. According to all research participants, life alongside mentally female inmates with a mental illness was a traumatic nightmare that negatively impacted their reentry process and their everyday life long after their release. More specifically, the interviewees related to heightened feelings of tension and anxiety during reentry and a deterioration of several behavioral and cognitive functions (as expressed in anxiety, sleeping disorders, weight loss, a desire to be alone, etc.). This led many of them to long for isolation from general society. Such symptoms resemble those of individuals suffering from mental trauma (DeVeaux, 2013). Almost all the respondents maintained that these adverse and dramatic dynamics were reinforced by the harmful environment of the prison (DeVeaux, 2013) and the obliviousness of the Israeli Prison Service and the Israeli Prisoner Rehabilitation Authority, which did not provide them with adequate coping tools and mechanisms.

Given the many studies indicating the correlation between rehabilitation and treatment programs in prison and in the community that improve prisoners’ well-being both inside the prison (Constantino et al., 2016; Mansoor et al., 2015) and after release (Roman & Chalfin, 2006), this study’s results may point to a destructive incarceration policy for women prisoners by the Israeli Prison Service that actively, multi-systematically, and significantly harms the mental and physical state of female inmates, both during their imprisonment and upon reentry into society. In other words, women inmates suffer from major mental and physical difficulties, and lacking the necessary mental and social resources, consequently face significant problems when reentering society (Richie, 2001).

The findings of this preliminary exploratory investigation add to the existing knowledge base about the pains of imprisonment and the difficulties experienced by incarcerated women. This may provide criminologists, prison researchers and practitioners with a better understanding of the role and dynamics of the joint confinement of mentally stable female inmates with those that are mentally ill, its impact on the well-being of the former, and the appropriate policy changes necessary to prevent such harmful consequences.

Limitations

This exploratory study is limited by the validity of the ex-prisoners’ responses and the small sample size. First, data were collected through qualitative semi-structured interviews. Such a research design has been shown to result in under- or over-reporting, thus casting doubt on the credibility of the testimonies (Kunselman et al., 2002).The application of other sophisticated data collection methods, such as ethnographic observation, may facilitate additional or more detailed data that were not obtained in this study.

Second, the results of this research are based on interviews with 22 women ex-prisoners. We cannot ensure that the viewpoints of these participants regarding the impact of their joint imprisonment with mentally ill female inmates truly represent the opinions and experiences of most women prisoners in Israel. The examination of a larger sample might reveal more detailed and significant attitudes as to the impact of such joint confinement.

Despite these limitations, this study’s results enhance the research literature regarding the reality of women’s prisons in general and the mental, physical, and emotional effects of joint imprisonment with mentally disordered inmates. The findings portray a complex and destructive reality. Further investigations should examine these effects on women inmates in other carceral settings and analyze its post-traumatic impact on ex-prisoners without a mental disorder a few years after their prison release. The suitability and appropriateness of treatment methods and rehabilitation strategies for imprisoned women and during reentry may also prove noteworthy for deepening our understanding of women’s prisons.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Diana Cantini Vaisman, MA, is a rehabilitative criminologist. She is a youth services coordinator at “ELEM”—A non-profit organization for youth in distress in Israel.

Tomer Einat, PhD, is an associate professor in the Department of Criminology, Bar-Ilan University, Israel. His areas of expertise include penology, male and female prisons, sexuality among male and female prisoners, and alternatives to incarceration.

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