“You Have to Take Care of Your Own Mental Status”: Incarcerated Women Seeking Care Within and Beyond Mental Health Treatment

Abstract

Incarcerated women in the United States commonly experience prison-based mental health treatment. Feminist scholars stress the need to explore how incarcerated women exercise agency while navigating controlling treatment dynamics and how they experience these dynamics in relation to aspects of their selves (e.g., their thoughts and feelings). To explore these dynamics, we conducted semi-structured individual interviews with 42 incarcerated women in a Midwestern state prison and with life history calendars, elucidated women's treatment encounters over time. Through analysis of these interviews, we contend that women experienced dehumanizing dynamics within treatment, particularly curtailed communication from the staff that silenced women, created unfamiliar selves, and contributed to physical harm and psychological harm. Based on these findings, we conceptualize prison-based mental health treatment as health harm rather than health care. We also found that women responded to controlling dynamics with forms of self-preservation including strategies of treatment decision-making that affirmed their selves, active treatment refusal as self-protection, and forming meaningful connections with others that validated aspects of their selves. Based on women's care-based strategies, further feminist theorizing and practice directions are needed that align with, build upon, and are guided by incarcerated women's varied definitions of care to improve their mental health and well-being.

Keywords

Criminal legal system feminist mental health qualitative theories and research women in prison

Incarcerated women are diagnosed with disproportionately high rates of mental health concerns when compared to other populations (Prins, 2014) and receive mental health treatment at high rates in prisons (Bentley & Casey, 2017). Mental health treatment within US prisons is commonly a site of medical neglect, escalated mental health distress, and human rights violations for incarcerated women (Haassan et al., 2013; Peterka-Benton & Masciadrelli, 2013). These mental health programs often operate with insufficient professional staff, enact questionable medication decisions, and too commonly provide inadequate and abusive treatment, for example, isolating incarcerated adults during mental health crises in solitary confinement (Haassan et al., 2013; Luigi et al., 2020; Peterka-Benton & Masciadrelli, 2013). Forms of gendered carceral control permeate and shape mental health treatment in women's prisons, intertwining the prison's focus on punitive security measures within the policies and practices of “treatment” for women's mental health distress (Jordan, 2010; Pollack, 2020).

Feminist theorizing about incarcerated women's psychological experiences has stressed the need to examine how women experience carceral power dynamics, while examining how they also exercise agency to get their mental health needs met adequately (Kruttschnitt & Gartner, 2003; McCorkel, 2013; Pollack, 2004; Richie, 2004). Therefore, this current study explored incarcerated women's mental health treatment experiences over time and investigated how women navigated power dynamics within treatment while seeking care for themselves. Based on analysis of data from interviews with incarcerated women, we posit that mental health treatment constitutes a form of “health harm” that manifests through silencing incarcerated women, creating and exacerbating physical and psychological distress, and utilizing dehumanizing tactics in everyday practices (McHugh & Cleveland, 2021). Women worked to subvert the harm and control dynamics inherent to prison-based mental health treatment in order to care for themselves through strategies of refusing treatment, strategically leveraging their knowledge of carceral systems, engaging in tactics to be heard, and building connections with other women in prison as a way of reifying their sense of self. We conclude by highlighting incarcerated women's search for forms of care to guide theory, research, practice, and policy directions.

Background

Women, especially those in the most marginalized social positions within our societies, have been imprisoned at alarming rates over the past 40 years as the prison industrial complex continues to expand while social welfare supports are eroded (Richie, 2016). Prisons have long been critiqued as being one of the largest mental health treatment providers following the deinstitutionalization of mental health institutions (Ben-Moshe, 2020). Incarcerated women are diagnosed at high rates with mental illnesses, such as depression, anxiety, and post-traumatic stress disorder (Bronson & Berzofsky, 2017; Prins, 2014). These concerns have been linked to their extensive trauma and adversity histories and to their experiences of socioeconomic marginalization, racism, and other forms of structural violence (Fedock, 2017; Karlsson & Zielinski, 2020). In addition, experiences of incarceration negatively impact their mental health symptomatology, given dehumanizing conditions of overcrowding and lack of privacy, dire isolation, daily degradation, forms of staff abuse, and other traumatic events endured in prison (Fedock, 2017; Van den Bergh et al., 2011). Elucidating dynamics that improve incarcerated women's mental health is an urgent priority (Fedock, 2017).

A large proportion of incarcerated women are deemed eligible for mental health treatment (Beck & Maruschak, 2001). Most women engaged in prison-based mental health treatment receive psychotropic medications and/or therapy, such as cognitive behavioral therapy (Beck & Maruschak, 2001; Kilty, 2012). For example, in a study with a sample of 274 incarcerated women, 77% of women reported they were currently taking psychotropic medication (Bentley & Casey, 2017). Of these women, over half took more than one type of psychotropic medication. Instead of operating as a helpful form of health care, mental health treatment in prison has been described by prison staff and incarcerated women as a tool for “maintaining order” within prisons (Haassan et al., 2013, p. 436) and for “[controlling] and [sedating] women” (Zaitzow, 2010, p. 11). This treatment commonly operates as a form of security management for the prison rather than personalized care for improving women's mental health (Haassan et al., 2013; Kilty, 2012). Some incarcerated women are coerced to take medication, especially by correctional officers who are not mental health treatment staff (Haassan et al., 2013; Kilty, 2012; Zaitzow, 2010). Under these conditions, psychotropic “medication compliance” becomes a tool for maintaining “prisoner obedience” and prison order, rather than improving incarcerated women's well-being (Haassan et al., 2013; Kilty, 2012; Zaitzow, 2010).

Furthermore, prison-based therapies often serve to regulate and discipline women, rather than support them on their own terms. Coupled with the rise of therapeutic governance, prison-based mental health programs promote the psychologization of social problems and discourses of “responsibilization,” encouraging incarcerated women to manage their “selves” (e.g., their thought patterns and emotional regulation) without addressing the social conditions that give rise to distress or violence (Hackett, 2013; McKim, 2008; Pollack, 2007). Through mental health diagnosis, labeling, and the resultant therapy, their selves and their relationships are characterized and treated as inherently flawed, risky, and damaged and in need of “taming” (Leotti, 2020; McCorkel, 2013; Pollack, 2005). Thus, prison-based mental health treatment incorporates regulation of women's selves, rather than prioritizing care.

Navigating Power Dynamics in Mental Health Treatment

While prison-based mental health treatment works to control and regulate, women's mental health needs should be taken seriously. Following Ussher's (2010) critical realist approach, we work from a position of validating women's emotional experiences as “real” without reifying or legitimizing the decontextualizing psychiatric discourses which individualize and pathologize emotional distress. We acknowledge that incarcerated women's expressions of distress are often disregarded or invalidated by prison staff who characterize these expressions as “manipulative tactics” to gather attention and resources (Greer, 2002; Kenning et al., 2010). In addition, racialized dynamics shape who is diagnosed with “legitimate” mental health concerns and pattern the differential provision of mental health treatment (Hedden et al., 2021). For incarcerated women experiencing mental health concerns, having their symptoms validated can be vital to their mental health and well-being, and being prescribed psychotropic medication, in particular, can be helpful for some women in alleviating symptoms (Casey & Bentley, 2019).

The power dynamics of mental health treatment are central to how incarcerated women perceive and engage with this treatment; therefore, power is of central relevance to investigations of mental health treatment in prisons (Jordan, 2010; Kruttschnitt & Gartner, 2003; Leotti, 2021; Pollack, 2020). While attention to the structural dynamics of power in prison-based mental health treatment is necessary, so too is attention toward women's agency. Incarcerated women engage in forms of agentic resistance and creative resilience to the harmful dynamics of prison (Law, 2012; Lawston, 2008). Pollack (2004) advocates for an analysis of the complex and dynamic relationship between structural oppression and personal agency, specifically as it relates to incarcerated women's mental health. As she states, “we need to look at how oppression circumscribes the availability of choices in order to contextualize how and why women make particular decisions” (p. 700). Thus, our current study explored incarcerated women's experiences of mental health treatment, specifically how power operates within treatment and how women experience, survive, and respond to those power dynamics.

In addition, we considered how women experience these power dynamics in relation to their selves. The descriptions of mental health treatment in prisons, especially gendered punitive treatment of women's selves, align with dehumanizing dynamics commonly found in health care in community settings (Diniz et al., 2019). Dehumanization within health care includes ways that individuals are “being perceived and/or treated as passive, homogeneous, reduced to their symptoms, objectified, and/or isolated” (Diniz et al., 2019, p. 475). Dynamics of dehumanization are an affront to aspects of the self, which is the unit of individuality and an indicator of one's humanness. The “self” includes one's thoughts and feelings, perceptions related to health-related decisions, and knowledge and experiences of bodily sensations (Kteily & Landry, 2022; Lebowitz & Ahn, 2016). Dehumanizing dynamics erode informed decision-making and equitable participation of patients in mental health treatment (Diniz et al., 2019). Therefore, we considered, in this study, how dynamics of mental health treatment relate to and impact aspects of the self, for example, women's thoughts, feelings, experiences, knowledge, and self-perceptions.

Methods

We conducted semi-structured interviews, using life history calendars focused on women's time in prison to anchor the interviews, with a sample of 42 incarcerated women. They were housed in a multi-security level Midwestern state prison. Despite capacity limits of 1100 women, the prison has often been over capacity with up to 2000 women.

Sample

We invited 50 incarcerated women to participate in semi-structured interviews. In a previous stage of the study, we collected surveys from 832 incarcerated women in a state prison; 54% of women received mental health treatment, with 86.9% receiving medication as the form of treatment. We then crafted a purposeful subsample of 50 incarcerated women based on their racial identity, length of time incarcerated, and sentence length. Of 50 eligible women, 42 women consented to and completed an interview; four women were paroled before the interviews were conducted, and four women declined to participate. Those who participated ranged in age from 23 to 52 years old, with an average age of 32 years old, and had, on average, two children, with a range of one to nine children. Almost half of this sample (48%) identified as White women, 40.5% as Black/African American women, 9.5% as Latine, and 2% as Asian American. On average, they had spent 4 years in prison, with a range from less than 1 year to 16 years, and had an average of 8 years left in prison, with a range of months to over 40 years left in prison. All women had interactions with mental health treatment as part of the prison intake process. Each interviewee identified as a mother and discussed being in a women in prison. However, we did not formally ask about their gender identities, which is a notable limitation of this study.

Procedures

The interviews were conducted in 2018 and 2019, prior to the start of the COVID-19 pandemic. We met individually with each woman in a room within the prison's education building, which allowed some privacy, and no staff were present during the interviews. We described the voluntary and confidential standards of the study. The study's principal investigator deposited $10 electronically into each of the participants’ accounts as a thank-you for participation; this was the highest monetary amount allowed by the department of corrections. All procedures were reviewed and approved by the University of Chicago's institutional review board, and a National Institute of Health Certificate of Confidentiality was granted for the study.

The interviews were structured with an interview guide in tandem with life history calendars. The life history calendar is a format that has been used to collect rich qualitative data in a methodologically rigorous manner (DeHart et al., 2014). The calendars began with the year that each woman was first incarcerated for her current sentence. The calendars created a shared understanding of the temporal nature of events. Interviews were digitally recorded and transcribed verbatim. We assigned pseudonyms to all interviewees.

Our research team is comprised of clinically trained social worker scholars. We began our interviews with rapport-building questions and heavily relied on our social work engagement skills to build trust and connection with interviewees. Given our research team had previously conducted research throughout the entire prison, some women remembered previously talking to us. We intentionally paired interviewees with our research staff of the same racial identities, when possible, to facilitate discussions about racialized dynamics within their lives; our two interviewers were a Black ciswoman and a White ciswoman, who are mothers. Other members of our research team identify as a South Asian ciswoman and a White ciswoman. However, none of us have experienced prison incarceration. In our research processes, we sought and relied upon knowledge shared with us by people with lived experiences of incarceration, and we critically questioned the limitations of our perspectives given our identities and social positionalities. We came to this work with an evolving anticarceral feminist politic and a commitment to racial justice and antioppressive research methods; we aim to center incarcerated women's accounts as a way of moving forward social work practice, policy, and research.

Analysis

Drawing upon feminist standpoint theories, our starting point was that incarcerated women's pieces of knowledge are shaped by their lived experience and group positionality (Hill Collins, 2000). While women we interviewed shared the experience of being incarcerated and engaging with mental health treatment in some capacity, we are also attuned to individual differences between women based on their differing social locations within intersecting matrices of oppression like heteropatriarchy, capitalism, racism, ableism, and others (Crenshaw, 1991; Hill Collins, 2000).

Interview data were analyzed inductively using constant comparative analysis and grounded theory methods (Glaser & Strauss, 1967). Constant comparison was used at every stage of analysis to facilitate joint coding and to identify key emergent themes in the data (Auerbach & Silverstein, 2003). The first level of analysis included all members of the research team reading the content of each interview line by line through the process of open coding. Divergences in coding were discussed by the research team to ensure congruence across coding. New codes were created as needed, and existing codes were revised based on ongoing coding. Definitions, changes, and notes about each code were recorded in a codebook. The next step entailed organizing the repeating ideas into larger groups that shared a common topic or dynamic to form themes. Finally, from the themes, overarching theoretical constructs were identified to encompass all the themes. As the repeating ideas were organized into themes and theoretical constructs, the research team continued to engage in comparison, refinement, and interpretation to identify patterns in the data (Auerbach & Silverstein, 2003; Charmaz, 2006).

Findings

Women's testimonies revealed that during mental health treatment encounters, they experienced harmful power dynamics that impacted aspects of their selves, including the dismissal of their thoughts and bodily experiences in decision-making processes. These specific dynamics were (a) controlled and curtailed communication dynamics enacted by staff, (b) medication creating physical harm and psychological harm, and (c) intertwined controlling dynamics between mental health and correctional staff that lacked care of women's selves and instead prioritized security and management goals.

Women's accounts also included agentic counter-strategies: ways to resist harmful aspects of mental health treatment, while seeking forms of care that were self-protective. Women responded to the controlling dynamics with care-based strategies, including strategies within mental health treatment of (a) dynamic decision-making, (b) treatment refusal, and (c) activating risk communication. They also sought care beyond mental health treatment with (d) self-work and (e) relational care. In the following sections, we describe each controlling dynamic and then provide details about how some women responded to this dynamic with care-based strategies.

Controlling Dynamics: Controlled and Curtailed Communication

The structure and logistics of mental health treatment created dynamics that limited opportunities for verbal exchange, ultimately limiting women's ability to speak to and be heard by mental health staff. We conceptualize these dynamics as “controlled and curtailed communication,” that is, dynamics that limited women's input and expression of their thoughts, feelings, and experiences. Appointments with the prison's psychiatrists occurred, at most, once a month for 15 min via telehealth. Dynamics of communicative disconnection compounded the dynamics of a limited appointment time. Some women were not able to speak with their psychiatrist for their fully allotted time. Leah shared about a recent appointment:

I’m literally in there like three minutes and he's [the psychiatrist is] supposed to spend like 15 minutes with you. And he’ll be like ‘tell the officer to send the next patient in in 10 minutes’ you know…. He's supposed to spend the 15 minutes with you.

When mental health staff did not maximize the time, some women perceived that this dynamic indicated that staff did not want to talk to them, even for the limited allotted amount of time.

During women's encounters with mental health treatment staff in which they were able to speak, they often experienced a lack of engagement by the mental health treatment staff. Denise recalled, “If I am talking to one of them, they’ll be looking at a calendar to see if they could get an off-day, or they’ll be like uh-huh-uh-huh, and you can be like rice, beans and chicken, they be like ‘yup’.” She poignantly put it, “They don’t hear you. Mental health… they don’t hear you.” Women's words were treated as meaningless, and often mental health staff did not provide indications that they were listening closely to women's words with care, leading women to feel unacknowledged by treatment staff. Therefore, talking to mental health staff did not constitute a “conversation” for many women. They expressed their frustration with not being heard by staff and their desire to talk with others. Amanda stated:

I want to talk. I wish I had someone here I could talk to, like this. This would be fine, somebody that could talk and is talking to me like a normal conversation. Not like a mental health lady- she just sits there and looks at me, like I feel stupid talking.

Emma also shared that her words were treated as meaningless in that mental health staff did not respond to her needs that drove her mental health distress:

To even like speak to a counselor about anything, they’re not even going to do anything. It's like they’re going to type in what we ask them about, and that's it. Like, there's no follow up. There's nothing being done about anything.

These dynamics thus included staff's lack of engagement with women's voices.

Further, many women were not informed about the potential side effects of prescribed medication. In not talking with women about their mental health treatment, staff prescribed women medications that had serious and long-term effects without their full consent. This lack of information limited their embodied futures and bodily autonomy. Aubrey described being surprised to learn that the medication she was on prevented her from becoming pregnant. “I do want to have another child because I lost my child,” she explained. “Not as soon as I get home, but eventually… I like them [the medications], they do me well. I just don’t like that side effect… Like, why does a psych med have anything to do with your ovaries?” She expressed concern that the treatment provider had not asked her about her reproductive future plans nor were the side effects discussed with her (including the rationale for the side effects). In effect, her bodily experiences and desires were not considered or invited into the treatment space.

Not only were women not consulted in the medication process; they were also commonly not listened to when they requested a change in medication. For example, Denise requested medication change due to intolerable side effects. Mental health staff refused her request. “I walked in there, and they told me I couldn’t do it. They told me I couldn’t do it [be taken off the medication],” she recalled. Her informed consent was nullified in this interaction, in effect denying her decision-making power. Like Denise and Aubrey, for many women, being prescribed medication was experienced as a form of social control in which their bodily experiences were not considered or prioritized in treatment decisions.

Women expressed that one specific form of communication was heard and would gather an immediate institutional response with mental health treatment staff: a language of risk. Many women shared the institution's logic of risk management in regard to mental health concerns. Women described being heard only when their words indicated a homicidal or suicide risk. In these situations, their words threatened institutional security dynamics, and then staff listening became an institutional priority. Gabriella shared the logic and corresponding flow of events:

This is what they do. They ask you if you’re suicidal or you’re homicidal. [If] you say either, you’re getting stripped out. After being naked for three days, you’re like ‘I’m not homicidal, I’m not suicidal.’ But you never was in the beginning, you just needed help.

Gabriella spoke to the dynamic of being heard based on risk (i.e., being suicidal or homicidal) and the institutional response to her involved security protocols (i.e., being “stripped out”), while her underlying need for help was unaddressed. Some women were told that crisis response was not for requests to be heard or to share their emotional and cognitive happenings. Natalie stated:

You call a crisis and all you wanted to do was just vent, and they kind of look at you like, ‘that was pointless for you to call a crisis, you just wasted my time.’ No, it wasn’t because I’m supposed to be able to talk to you about my problems.

Kayla also activated mental health crisis staff when she had extreme mental health distress because “they’ll talk to you, but I mean only in that moment. So if I go see them when I’m having a crisis, then they will concede for a moment.” Being listened to by staff was rare. In our analysis, having their voices disregarded was a dynamic related to institutional regulation and control, limiting expressions of their selves (e.g., thoughts, feelings, and bodily experiences). Given women were rarely heard except when posing a risk to the institution, their accounts display how treatment dynamics reflected the prison's priorities of management of their selves.

Controlling Dynamics: Medication as a Risk to Physical and Psychological Health

In addition to a lack of communication about medication risks, women's accounts indicated that the impact of staff use of psychiatric medications caused physical and psychological harm and alienated women from their bodies. Many women experienced negative side effects of psychiatric medications they received in the prison, including excessive hair loss, extreme weight changes, significant sleep changes, and organ damage. Women faced a lack of staff concern when their prescribed medication caused them bodily harm. Denise explained:

This place, they don’t care what they give you. They’ve given me meds that will drop my white blood cells. I was almost being taken out to the hospital because my white blood cells were almost nonexistent… And they will not give you any medical treatment or anything. They be like, ‘Oh, sign up for sick call.’

Emily echoed the sentiment: “I have problems with my pancreas anyways since I been here. It's all the medication they have me on.” She was taking more than 10 medications per day for “bipolar, anxiety, and depression” since arriving in prison. She had not received regularly scheduled blood tests necessary to monitor her organ function; “I was supposed to be getting blood tests all the time to check my kidney function. I wasn’t getting them.” Despite the widespread use of medication as the primary form of mental health treatment, women did not perceive mental health staff as caring about, nor addressing, the effect of medication on their physical health.

Women's accounts also included the ways that medication distanced them from their psychological sense of self, creating unfamiliar selves. Women attributed feeling “sick and crazy” due to medications prescribed by mental health staff. As Kennedy stated, “That stuff makes me sick. They’re not going to mess my head up with the stuff that they give.” For some women, medications exacerbated negative symptoms and experiences which they were attempting to address, for example, those causing the mental health concerns. Denise detailed how medications made her “extremely more aggressive,” and she worried about harming herself while on medication and feared the consequences of staying on medication. For others, medications took away their feelings, a component of their psychological self. Amber described this effect as desired (by her) given the curtailed communication offered by staff:

You can never just say ‘hey I just want to talk.’ You don’t have that, so… and they treat you so bad around here… so you don’t want to talk. You just keep everything bottled in and you just, you go to the psych doctor and just get more meds to numb the pain out.

While this was a desired effect for some women, it was detrimental for those who found it disconnected them from themselves. Several women described this experience as becoming a “zombie” while on medications, a feeling of numbness and being not themselves. As Sonya stated, “They done gave this lady a medicine, she's a zombie now. I grew up with her… I don’t even know her… It's sad.” Renee's account included that mental health medication “makes you gain weight, eat, and I’m not used to hardcore drugs. I’m just used to marijuana and alcohol, so it had me like in a zombie-like state and I didn’t like that feeling. I’ve got to think of something else. I can’t do that [medication].” Medication, in some cases, created a loss of self, of no longer being known by oneself or others. Taken together, these statements indicate the ways that psychiatric medication threatened to make women unrecognizable to themselves and others, taking away a sense of self-control and self-familiarity.

Care-Seeking Strategy: Dynamic Decision-Making

While many women experienced medications and mental health treatment as forms of control and harm, we found that some women still found ways to engage with mental health treatment in self-directed and dynamic ways to take care of their mental health. Women's accounts showed a process of continuous self-evaluation, prioritizing their own embodied knowledge in order to make informed choices regarding (if or) how to engage with medication. Lara, for example, explained that she told her psychiatrist in the prison that she had been diagnosed with depression and anxiety in the past. She talked about this process—from diagnosis information to medication management—as being directed by her experiential knowledge, and she made comments such as “we’re figuring it out.” Similarly, Lila stated, “I’m on some anxiety medication for my own. I did this for myself because the anxiety, my anxiety be through the roof up in this place. So I put myself on some anxiety medication.” For her and others, they engaged with medication as a tool and resource to be used in service of caring for themselves.

However, a majority of women did not provide accounts of being in control of their medication management process. With the combined dynamics of controlled communication and of mental health and prison staff prioritizing women's mental health risk talk, some women learned to perform mental health distress in order to be heard and more so, to be responded to by staff for medication changes. “You want to see crazy? I’ll show you crazy,” explained Sandra in describing the strategies she used to be heard. “They finally listened to me,” she said. “I kept telling them it [the medication] wasn’t working, and they didn’t want to listen to me. So, I acted out.” Many women also described “acting out” in order for mental health staff to respond to their needs. As Amy described, “I had to curse them out, curse out the psych doctor three months in a row and threaten to strip out and call a crisis in order for them to finally, finally find something that was closer to the genetic makeup [sic] of the pill that I used to take.” Women described strategically leveraging their knowledge of the priorities of the prison—namely, risk management and crisis control—in order to resist being silenced and mobilize mental health staff to act.

Care-Seeking Strategy: Treatment Refusal for Self-Preservation

Many women reported completely taking themselves off of medication. The language they used was “I” centric, versus women describing medication as a passive experience (e.g., Leah stating that staff “try this on me, try that on me” in terms of medications). For example, Keira shared, “I actually took myself off of all the medication.” Similarly, Hannah shared that she told mental health treatment staff “that they could shove the clipboard up their ass because I wasn’t going to take any more medication,” and she explained that she thought “they were just making shit up and saying that I had things I really didn’t.” Importantly, their decision to refuse treatment was a form of resistance to being controlled and as an agentic choice to prioritize their sense of self, including their emotionality and ability to access their thoughts. In detailing her decision to go off of mental health medication completely, Kennedy explained, “That stuff makes me sick… They [mental health staff] not gonna mess my head up with that stuff they give.” As Denise stated, “It's what you make it, and long as you don’t let these people bring you down or… let these mental health drugs put you, make you a zombie and control you like that… you gotta be strong.” Similarly, reflecting her attempts to request appropriate medications, Mia described her decision to ultimately stop seeking medications while in prison:

I’m like, ‘No, I can’t keep doing this. You’re going to mess me up even more.’ So, I’ve just come to the resolve that I’m not asking for any more psych meds while I’m here. I go home in four months, I’ll go home and see my primary. I’ll get my meds like I’m supposed to. I’ll see my psych doctor and get on what I need to be on.

While she believed medications were helpful for her mental health, she was not able to access the proper medications because the staff did not listen to her and prescribe her the medications she had previously been using. To resist being “messed up” and losing her sense of self, Mia like many others, made the choice to disengage from mental health treatment as a form of self-preservation. Emily was the most straightforward about her self-preservation strategy; “I have to defend myself. So I got off of them [medication] for a year and a half… [I] refuse to let them do it again, zombie me out.” In the context of being harmed by medication, she took herself off of the medications and emphasized to us, “if ain’t nobody else cares, you gotta care about yourself.”

Controlling Dynamics: The Institutional Lack of Care

The lack of communicative engagement with women by mental health treatment staff conveyed messages that staff did not care about their concerns, their selves, and their lives. A common refrain among women was that staff were disengaged from providing any real “care” and viewed the women, as Deidra stated, “like, you’re bothering them, you’re an inconvenience”; their needs were treated as inconveniences instead of priorities. The lack of care from mental health treatment staff resonated with the forms of lack of care that women received from correctional staff. As Paige stated, correctional staff had a norm of “not helping us when someone says they have a problem, and I mean a real problem.” Women often equated mental health treatment staff with and as correctional staff and shared how none of these professionals actually invested in providing care or real engagement with them.

Women provided their perspectives that care did not occur because caring was not within the job description, expectations, or acceptable norms for correctional and mental health staff. Paige stated that “I’ve learned that the word ‘counselor’ in here means just getting paperwork done and also making sure that we have meds and have that kind of help we need, but not to actually help you. I heard that that's the real definition from an officer.” This norm impressed upon women that they should not expect care within the prison. As a further example, Leah shared how she had been feeling depressed and crying while thinking about her children. When we asked if she had a therapist or counselor with whom she could talk about this, she said “no” and made the lack of care dynamic succinctly clear: “It's their job, not that they care… That's how it is with practically everything here.” Women also provided accounts in which staff dismissed their concerns and disrespected them daily. Deidra described that the staff:

don’t help at all and if you ask them for help it's a…they look at you like you’re seriously bothering them. So, no, there's no support here… our counselors are terrible. If I ask [a staff member] and that's who I’m supposed to go to for help— ‘This is going on can you help me?’ No, you get shot down, I’m bothering you… It's crazy.

She went on to stress that “they don’t really care, they don’t.”

Other women provided examples of disrespectful and dehumanizing treatment by staff, such as, per Lydia, “calling us names, talking down to us” and, according to Samantha, “they call us bitches, hoes, all this, crackheads.” Mia shared that mental health treatment staff told her that she did not get better treatment because “you’re property of [the state].” Even when she responded with “I’m still a human being. I’m not an object… I’m still a person with feelings, with valid thoughts and opinions, I still have rights,” then staff responded with “Well you’re an inmate,” negating respectful treatment that views her as a person. In addition, Alicia described that carceral logic shaped mental health treatment: “we’re not getting what we need to so we feel like people don’t care because it's not happening.” When we asked her to elaborate on what was not happening in regard to mental health treatment, she responded with “I mean, health services takes forever. They go by outdates rather than by urgency.” The use of outdates mimicked the logic of prison programming; programmatic resources were reserved for those being released from prison. Ideas and acts of prioritizing women's “needs” and “care” were largely missing from women's experiences of mental health treatment and were, to some degree, antithetical to staff's roles. Denise furthered this sentiment; “this place, it will not help. It won’t help. These correctional officers… they try to break you and then they’ll try to glue you back together. So you have some that care, but that's almost nonexistent in here.” These sentiments describe how available staff were both the source of suffering and the designated source of help.

Care-Seeking Strategy: Self-Work as Self-Preservation

For many women, prison mental health treatment was simply not enough to actually improve their mental health. Echoing the sentiment described above, Emily explained that “you have to take care of your own mental health status in here.” Part of that process, for many we interviewed, involved a desire to work on or with themselves (e.g., their selves as the dimensions of their thoughts, goals, and feelings). In describing her engagement with mental health services, Tanya found that medications were helpful but “I don’t really talk to mental health… They don’t be talking about nothing. I deal with myself. I deal with myself. I work on myself.” Others echoed this sentiment of “working on the self” as an important part of caring for themselves and their mental health. “That's what coping mechanisms are… Just figuring out who you are as a person,” described Susanna. “I started working with me,” claimed Samantha, expressing her efforts to learn more about herself and work with herself through participating in mental health groups with other women. In describing the various strategies, Emily explained:

You take care of your own. How do I do it? I do it with relaxation, painting, coloring, drawing, doing stuff for other people, doing hair, watching a movie, journaling my feelings, going back and reading my own journal, the old compared to now seeing where I was at then and where I’m at now. Have I changed anything? Doing the self-inventory you know of my stay here.

Many women described writing and journaling as strategies they used to express and process their emotions, while cultivating deeper self-knowledge. For Mariah, writing was “therapeutic in a sense. Because I’m able to rid myself of whatever it is I’m feeling at that moment. I’m able to see that this is how I’m feeling and figure out how to move forward.” While some worked to move forward, for others, knowing themselves involved looking back over their lives. For Samantha, caring for herself involved reclaiming her sense of joy and reconnecting with younger parts of herself. “I started… doing stuff that I liked to do when I was younger,” she stated. “So sometimes you catch me in the corner dancing. You know what I’m saying. Just making me feel good.” For others still, connection to spirituality served as a source of support and renewed belief in themselves. “Coming to terms with my spirituality has given me another portion of the strength that I have got because I am not powerless… I am a survivor, and I am a fighter,” proclaimed Keira. Working on the self, finding moments of joy and connection remind women of their worth and strength in a dehumanizing environment.

Care-Seeking Strategy: Relational Care

While caring for and cultivating the self were important aspects of mental health care, women also stressed the importance of relational care and support. Responding to the ways their voices, knowledge, and experiences were silenced, maligned, and ignored in mental health treatment, women created alternative spaces and relationships to be seen and heard more fully. For example, Keira shared that “working with [other women inside] gives me a different perspective on things with me,” and Kayla spoke to a best friend with whom “if I ever need to talk, I always talk to her.” Ann stressed that “at some point,” she and other women “need to talk to somebody,” and she relied on two close friends to share and to gain “support” for her experiences, especially around missing her children. Descriptions of friendships commonly included words of how these connections brought “hope,” “joy,” “lifted spirits,” “comfort,” and insights to grow; none of the women mentioned mental health treatment eliciting such emotions. Women identified some groups, like religious groups, as spaces where they could talk freely with other women about their lives, including their thoughts and feelings. “I’m in three bible studies a week,” stated Ashley. “And, like, you can talk, share things there, you know. They don’t go back and spread your business. You know, ‘you can talk to us,’ you know.” Other women echoed the sentiment that there were few safe places to be vulnerable and share with others. Emily had remarked that “staff, they want to see you break down,” and in contrast, supportive relationships with other incarcerated women were based in seeing others and being seen (e.g., ‘they want to see you’) and positively influenced her mental health. She stated “It does stuff for me mentally, you know? That I can get along with others. I can help other people so that's good for me… I help my own mental status and I help others in doing things like that.” When Mia was grieving the sudden loss of her father and felt unsupported by mental health, she shared with us that she was able to go through the grieving process and stay safe (i.e., no suicidal or self-harm behaviors) because “I had friends that were there with me… people I can actually say were friends.”

For many women, their children and families were both sources of emotional support and pain. “Yeah, I get depressed,” stated Kennedy. “But I get on the phone to talk to my kids, and my momma, and my friends, and they uplift me a lot, so it makes my day better.” Daphne explained that her mental health distress was due to being away from her children but that “I’m fine now” which she attributed to the outcome of talking with other mothers inside the prison as “they can sympathize with me, you know, being away from my kids, not being not home with them.” In reference to the pain that accompanies family visits in prison, Kerry described the critical role that incarcerated women play in supporting each other and learning from each other:

It's a struggle but that support within these walls… that's what keeps you on. And you learn from their situations and they learn from yours. And you learn that you will get through it. And support each other through it the best way we can. Whether it's a card, it's a talk. Whether it's a hug. Sometimes we don’t even have words. Just to hug each other, which we are not supposed to do… but we need that hug sometimes.

Other women also remarked on the small but significant gestures of care that they express with each other as forms of emotional support. As Maggie poignantly stated, “meds aren’t always what people need. You know. Like sometimes talking to somebody like me crying with you, here.” In a prison environment that discourages and punishes forms of care and connection between women, simple gestures like offering a hug, a shoulder to cry on, or a word of affirmation held great power as reminders that women were seen, known, and valued.

Discussion

Our study explored the lived experiences of incarcerated women navigating prison-based mental health treatment, and our findings enrich our understanding of the specific dynamics of control they encounter within treatment. Our findings contribute to the growing body of literature focused on incarcerated women's subjective and embodied experiences at the intersections of the carceral and mental health systems (e.g., Robert et al., 2007). We found that prison-based mental health treatment relied upon controlled and curtailed communication, which silenced women and invalidated their embodied, affective experiences. This dynamic created bodily harm and constrained women's ability to provide informed consent regarding health decisions. Mental health staff's (over-)reliance on psychotropic medication created “unfamiliar selves” for incarcerated women and contributed to the development or exacerbation of physical health problems. Finally, we found that mental health and prison correctional staff treated women without care or respect, leading many incarcerated women to experience their selves as devalued and less than human. Our findings echo and extend the work of Kilty (2012) and Pollack (2005) who contend that incarcerated women experience dynamics of coercion, silencing, and disengagement while engaging with mental health treatment. Our study displays how the structure, logistics, and practices of mental health treatment in the prison context contribute to women systematically not being heard and respected. We found that these dynamics impact women's psychological and bodily health. Women's accounts regarding dynamics of dehumanizing treatment also align with how mental health treatment professionals have described not wanting to provide treatment to this population and perceiving incarcerated women as less than human (Morris & West, 2020).

Identifying these forms of controlling dynamics develops needed theorizing about the lived experiences of mental health treatment in prison. The controlling dynamics were inescapable within treatment and mapped onto larger and pervasive harmful power dynamics throughout the prison. Taken together, women's accounts indicate that they experience mental health harm rather than mental health care. Building upon the work of McHugh and Cleveland (2021), we conceptualize prison-based mental health treatment as a form of health harm rather than health care, where incarcerated women are silenced and subjected to punitive, coercive treatment that commonly causes damage to their bodily and psychological health. Women's accounts of their interactions with mental health and prison staff align with previous findings of incarcerated people's experiences with prison-based health-care workers in which they are treated more as “prisoners” rather than “patients” (McHugh & Cleveland, 2021). These dynamics erode the possibility of care with mental health treatment.

Despite and because of their experiences of mental health harm and control, women engaged in acts of self and relational care in order to subvert and survive mental health treatment. Our study began focused on mental health treatment encounters, but women's accounts included evolving definitions of and searches for care, within and beyond treatment. For the implications of these findings, we build upon the definition of “radical care” put forth by Hobart and Kneese (2020) as “a set of vital but underappreciated strategies for enduring precarious worlds” (p. 2). For the incarcerated women we interviewed, caring for their selves involved integrating aspects of the self (e.g., bodily experiences, thoughts, feelings, and verbal expressions) and resisting the carceral forces that divided, devalued, and diminished parts of their selves in mental health treatment. Women described seeking wholeness and integration of their body–mind–spirit in order to “figure out who [they] are as a person” and prioritizing their well-being. These strategies of self-care were life-affirming: taking seriously their desires and self-knowledge, while resisting dehumanization and damage-centered treatment. Importantly, here we use “self-care” not in the neoliberal sense of self-management or “treating yourself” but rather as a way of understanding “a self which is grounded in particular histories and present situations of violence and vulnerability” (Michaeli, 2017, p. 53).

Women's strategies of care were bound up in and responsive to the structures, logic, and dynamics of harm within mental health treatment. Through refusing treatment, strategically leveraging their knowledge of carceral systems and logic, and engaging tactics to be heard, women worked to subvert the power and control dynamics inherent to prison-based mental health treatment in order to care for and affirm their selves. Importantly, incarcerated women described their “selves” in relation to others—a “situated self engaged in a complex set of relations” (Hobart & Kneese, 2020, p. 5). Care for the self often involved being engaged in a reciprocal dynamic of care with others, a life-affirming act of subversion and survival in a carceral environment that seeks to destroy connection and pathologize women's capacity for relationships (Pollack, 2007). Relational care within prisons is often penalized through institutional policies that ban giving gifts to each other and hugging, as well as institutional guidance that women actively avoid building any types of relationships with each other (see, e.g., Ohio Reformatory for Women, 2014). Indeed, relational formations have been commonly pathologized within women's prisons. Many incarcerated women in our study described the necessity of relational care: creating networks of mutual support, guidance, and solidarity to ensure collective survival, to know others and be known. Social work efforts are needed that value, uplift, and support these forms of relational care, rather than pathologizing or punishing them.

Our study provides insights to guide a care-oriented research and practice trajectory. However, the findings must be considered in relation to our study's limitations. First, we met with women only once for interviews to discuss their mental health treatment encounters. Future research may consider multiple interview time points to capture women's real-time experiences. Second, we met with each woman individually, which allowed for an in-depth exploration into individual experiences. Future work may explore group-based discussions with women to collectively explore definitions and enactments of care to guide further practice, policy, and theory directions. Third, we recognize that we captured only some of the controlling dynamics that women experience in this one prison, and we consider our work a contribution to the larger bodies of research dedicated to understanding the common and nuanced forms of violence and harm that people in prisons experience that are contoured by White supremacy and racism, transphobia, and other harming systems of power. We also recognize as a major limitation that we did not ask participants about their gender identities and experiences related to transphobia and other forms of gender identity-related harm. Thus, our work is limited in showcasing only some dynamics experienced, not the entirety of experiences. Lastly, we did not explore women's experiences of mental health treatment outside of prison. Given that carcerality is embedded within social services and treatment settings (e.g., Pollack, 2020; Richie & Martensen, 2020), we support further investigations into how carcerality operates within mental health-focused treatment settings and, in addition, explorations to how forms of care subvert carceral dynamics and support improvements to women's well-being. Such work may be especially helpful in guiding social work theorizing, research, and practice directions.

Key Implications and Contributions

Incarcerated women's concepts and strategies of care are especially crucial as guide points for theorizing, research, practice, and policy developments related to women, mental health, and incarceration. From an abolitionist feminist perspective (O’Brien et al., 2020; Richie & Martensen, 2020), we call for investments into building upon and sustaining the myriad of ways that incarcerated women define and desire forms of care, both for their selves and their communities—which requires the field of social work turning to, centering, and prioritizing incarcerated women's definitions and applications of care as forms of valued knowledge development and practice guidance. This framing is a conceptual shift to allow new directions for social work theorizing, practice, policy, and research—what would it mean for social work directions to be based on and arise upon incarcerated women's theorizing and actions related to care? A value of care and a grounding in care strategies have been recommended, theorized, and applied in a variety of forms of social justice-oriented developments over time (e.g., Hobart & Kneese, 2020). Such efforts also move beyond the logic and reliance on dynamics of “carceral care” which consistently remain grounded in and preserve controlling and punitive practices, ideologies, and traditions (Hwang, 2019).

Importantly, we do not call for reforms to current prison-based mental health treatment. Studies such as ours could be used to posit that we need reformist actions of care within prison-based mental health treatment, such as scheduling longer appointments and improving communication skills for mental health staff. These types of changes have been and are already advocated for by a range of leading mental health entities such as the American Psychological Association, National Commission on Correctional Health Care, and Substance Abuse and Mental Health Services Administration. However, these recommendations cannot eradicate the underlying and pervasive presence of controlling dynamics throughout the prison and mental health treatment. They also center institutional priorities and are driven by institutional capacities and limits (e.g., allowing women choice in their treatment is averse to the prison's purpose of limiting autonomy)—such actions stem from existing carceral-based service models of treatment that are already embedded within prison dynamics, rather than emerging from women's definitions of care. As seen in our findings, providing reformed treatment is considered antithetical to staff expectations. Calls for such reformist changes have commonly been co-opted by the carceral state, only to reinforce and build up the Prison Nation (O’Brien et al., 2020; Pollack, 2020; Richie & Martensen, 2020). Instead, like Richie and Martensen (2020) advise, we advocate for an abolitionist social work praxis that is centered upon the needs and desires of incarcerated women, which affirms their knowledge and strategies of care not dependent upon carceral services.

We contend that further work, including theory development and social work practices, be centered on women's varied definitions of care to support their improved mental health and well-being. Policies and practices within this realm of care will need to support women's selves being fully acknowledged, respected, and sustained without division (e.g., connection between mind and body and creating a deeper connection to one's self), including space and respect for their bodily knowledge and voices. Practices will also need to allow space for meaningful connection and support-building among women. Forms of mental health care cannot be wedded to practices, policies, and institutions invested in controlling their selves and intensifying their isolation and disconnections. As defined by Critical Resistance (2008), non-reformist reforms are ones that limit, rather than expand, the reach of the carceral state. We recommend that social work practitioners working with incarcerated women work to subvert the power structures they are working within; this involves being accountable to the women they work with, rather than carceral logic and policies. In this way, social workers can engage what Carey and Foster (2011) call “deviant” social work—using small-scale acts of resistance to subvert carceral dynamics and provide tangible support to incarcerated women centered in their definitions of care. Our findings, along with the growing bodies of work related to abolitionist praxis in social work, support prioritizing women's paths to joy, connection, healing, and thriving; actions based upon this require conceptual and value shifts away from dominant models of social work research, policy, and practice that prioritize punitive strategies that control and limit women's movements toward improved well-being. This study's findings contribute to growing efforts to build care-based social work research and practice.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Joint Research Fund grant provided by the University of Chicago and Chapin Hall at the University of Chicago.

ORCID iD

Gina L. Fedock

Author Biographies

Gina L. Fedock is an Associate Professor at the University of Chicago's Crown Family School of Social Work, Policy, and Practice. Her research focuses on improving women's mental health, particularly for women involved in the criminal legal system.

Sheila Shankar is a PhD student at the University of Chicago's Crown Family School of Social Work, Policy, and Practice. Her primary research interests focus on tensions between care and control, particularly related to gender-based violence, intersectional feminisms, and transformative justice. She specifically explores relationships between the carceral state, intimate partner violence, mothering, and practices of care.

Celina Doria is a PhD student at the University of Chicago's Crown Family School of Social Work, Policy, and Practice. Her primary research interests concern experiences of gender-based violence and healing among Indigenous women in the Americas, as well as the contours of cross-border abortion care for pregnant people.

Marion Malcome is an Assistant Professor at Loyola University Chicago School of Social Work. Her scholarship and community work focus on reducing health and mental health disparities within marginalized communities of color. Her research is situated at the intersection of race(ism), place, and mental health.

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