Mental health as surface-level reform
Mental health can operate as conservative reform, limiting radical change through the individualization and depoliticization of suffering. The dominant paradigms and lived dynamics of psychotherapy, psychiatry, and social work limit the potential for social critique and thereby obstruct prison abolition progress. Yet, at the same time, mental health services provide emotional support and allow for the legitimization of psychological suffering as a point of entry into critiquing and altering the systems and conditions of incarceration. In the words of bell hooks: “Mental health is the revolutionary political space for Black people” (The Real bell hooks 2015). We can understand mental health in the context of incarceration through the paradox articulated by Rev. Angel Kyodo Williams in Radical Dharma
Without inner change, there can be no outer change. Without collective change, no change matters. (Williams, Owens, and Syedullah 2016:89)Mental health advocacy and treatments can be utilized on an abolitionist path to liberation. Mental health concerns are also an important consideration in ensuring the provision of basic human rights – such as healthcare – and dignity to incarcerated people.
I will explore non-dominant and potentially liberatory approaches to the most common mental health problems among incarcerated women – substance use disorders, PTSD, and depression – through Joy DeGruy’s book Post Traumatic Slave Syndrome, and Ann Cvetkovich’s book Depression: a public feeling. I will also discuss more broadly critical psychologies that represent alternatives to the dominant perspectives of mainstream psychology. I focus on critical race alternatives to the homogenizing narratives of medical models rooted in whiteness, due to the disproportionate incarceration of women of color under mass incarceration. Yet I also believe that critical race explorations of mental illness have much to offer to incarcerated white women as well, for understanding and healing the impacts of white supremacy on their lives. As Paulo Freire notes, “as the oppressors dehumanize others and violate their rights, they themselves also become dehumanized” (Freire 2018). I recognize the need for intersectional alternatives that more explicitly include feminist psychologies. I explore feminist analyses throughout this paper, yet I recognize this as an area warranting further development, particularly an intersectional feminist critical race lense.
The mental health of incarcerated women is of particular concern due to the masculine structures, logic, and atmospheres of prisons and jails that delegitimize the suffering and coping of women, as well as exacerbate their struggles with mental health. Here, also I seek to highlight the gravity of the situation by discussing the comorbidity of mental health and incarceration among women. Both the conditions of intersectional oppression outside as well as inside places of incarceration contribute to the mental health problems of incarcerated women. The consideration of the conditions of incarceration as exacerbating the mental health problems of incarcerated women is equally important to understanding the conditions of “life on the outside” that contribute to the initial onset of mental health problems and incarceration
Women in American society have life experiences that differ from men’s in important ways. Many of these-- sexual assault, domestic violence, poverty and discrimination-- hurt women’s mental and physical health. (American Psychological Association)Incarcerated women are at a disproportionately high risk for mental health problems and substance use disorders. 73% of women incarcerated in state institutions and 47% of women incarcerated in federal institutions used drugs regularly prior to incarceration, according to the Bureau of Justice Statistics (Mumola 1999). Given the comorbidity of substance use disorders and mental health problems, the high rate of substance use remains an important contextual factor for understanding and treating the mental health of incarcerated women. Depression, substance abuse, and PTSD are among the most prevalent mental health problems for incarcerated women. Some studies even report figures as high as 80% for the prevalence of at diagnostic criteria for at least one lifetime psychiatric disorder among incarcerated women (Jordan et al. 2002; Teplin, Abram, and McClelland 1996).
There exist great differences in the mental health experiences of incarcerated women versus incarcerated men, as well as incarcerated women versus non-incarcerated women. These differences illuminate the need for an intersectional perspective that highlights the role of patriarchal and racist systems of oppression that exacerbate the mental health problems and incarceration struggles of women, particularly women of color. “Incarcerated women are more likely than their male counterparts to report extensive histories of physical, sexual, and emotional abuse” (Bloom and Covington 2008; Messina et al. 2006).
[73%] of women in state prisons had mental health problems versus 55% of males, and 75% of women in local jails had mental health problems versus 63% of males. [23%] of females in state prisons and local jails said that they had been diagnosed with mental disorders by mental health professionals in the past year (James and Glaze, 2006). This is nearly three times the number of male inmates (8%) who had been told they had mental disorders. (Bloom and Covington 2008:3)The gendered-disparities in mental health problems among incarcerated women vs. incarcerated men illustrates the necessity of psychotherapeutic experiences that are shaped to the lived experiences of incarcerated women. The universalizing tendencies of psychology obstruct the complex narratives of experience and are particularly detrimental to incarcerated women, given the deviation of their experiences from the privileged norms of psychology’s base. Although multicultural therapies exist, most multicultural therapies tend to focus on including people of color within already existing models of illness and treatment rather than creating new models or understanding the psychological impacts of racism (Cvetkovich 2012:165). We need multicultural, feminist, and anti-racist therapies, otherwise therapeutic practices within prisons and jails will serve to function as forms of colonialist assimilation. Furthermore – despite the comorbidity of substance abuse, PTSD, and other mental health problems – these conditions are often treated separately, highlighting the lack of an integrative mental health approach for incarcerated women that acknowledges the complexity of lived experience – in the vein of intersectionality.
Although a history of abuse and family-related problems are common issues among female inmates, many correctional systems do not screen for childhood or adult abuse when determining possible therapeutic interventions (Morash, Bynum, and Koons-Witt 1998). There exists a deep lack of personal and collective historical considerations in the therapeutic interventions provided to incarcerated women. As feminist Black author Arica Foreman articulates:
The ‘try-this-and-take-that’ approach removes root causes, erases any cultural or historical context. I suppose, in a way, the language of mental illness revolves around Western, mainstream ideas of happiness, which are coded with privilege, false conceptions of normalcy, and lots of forgetting. (Anon 2015).This inadequacy means that practitioners fail to consider the personal histories of abuse as well as the collective history of abuse suffered by women, particularly women of color due to the intergenerational nature of trauma stemming from the Residual Effects of Slavery (RES).
The disparity in rates of mental health problems between incarcerated women and non-incarcerated women highlights both the criminalization of mental illness as well as the causal effects of incarceration on mental illness. 73% of women in state prison, 61% in federal prison, and 75% in local jails have symptoms of a mental illness, compared to just 12% of non-incarcerated women (James and Glaze 2006). Even when controlled for age and ethnicity, incarcerated women have significantly higher rates of schizophrenia, major depression, substance use disorders, psychosexual dysfunction, and antisocial personality disorder (Ross, Glaser, and Stiasny 1988) Such disparities even among one’s own community highlight the role of prisons – as our nation’s primary provider of mental health care – as well as the effects of incarceration in perpetuating and worsening the mental health problems of incarcerated women. Furthermore, given the racial disparities of mental illness and incarceration, the criminalization of mental illness highlights the continued role of white supremacy in what many believe to be a post-racial United States, following the Civil Rights Era. Systems of oppression manifesting in everyday realities of “life on the outside” interact with the carceral apparatus (itself a part of systems of oppression) to both exacerbate mental health struggles and then criminalize – thereby worsening their conditions – those who manifest symptoms, with a disproportionate and racist emphasis on women of color.
With the limitations of mental health treatment for incarcerated people in mind, we must also recognize the vital necessity of mental health treatment in assisting incarcerated people heal (from their often abusive and fraught life histories) and reintegrate into society.
A study by Green, Miranda, Daroowalla, and Siddique (2005) that explored exposure to trauma, mental health functioning, and treatment-program needs of women in jails found high levels of exposure to trauma (98%) – especially interpersonal trauma (90%) – and domestic violence (71%) among incarcerated women, along with high rates of PTSD, substance abuse problems, and depression (Bloom and Covington 2008:4; Green et al. 2005)These mental health struggles of incarcerated women represent yet another barrier to re-entry that obstructs their capacity to rebuild their lives post-incarceration.
The authors emphasize that, unless traumatic victimization experiences, functional difficulties, and other mental health needs are taken into account in program development, incarcerated women are unlikely to benefit from in-custody and post-release programs. (Bloom and Covington 2008:4)Mental health care services are a vital tool in assisting incarcerated women post-incarceration. We also need mental health treatments to help combat the traumatic experiences of prison life itself.
Although marketed as centers of rehabilitation, prisons are sites of punishment and the suffering incurred by women during their incarceration is testament to this. The lack of mental health care, the rates of sexual assault committed by prison staff against incarcerated women, and the psychological effects of solitary confinement stand out as just a few of the horrific ways in which prisons themselves contribute to the mental health decline of incarcerated women. Even beyond these far too regular events, the psychological toll of daily prison life – dull, violent (most often between correctional officers and incarcerated women than among incarcerated women), and stigmatizing – contribute to the overwhelming dehumanization of incarcerated people that then manifests as ‘mental health symptoms.’ The gross reduction of these contexts of injustice to psychological diagnoses represents the oppressive consequences of the dominant paradigms of mental health treatment. Yet, at the same time, the presence and prevalence of these precipitating factors necessitates the need for mental healthcare in prisons.
In order to better understand the mental health issues among incarcerated women, we should explore critical analyses of the the most common diagnoses: PTSD (or trauma), depression, and substance use disorders. I seek to situate these disorders within intersectional, sociological perspectives that highlight history and political contexts and contrast the individualism and depoliticization of mainstream psychology. There remains an unsatisfied need for frameworks of mental health specifically designed for incarcerated women. Such a project might begin my combining the critical frameworks offered here with the narratives of incarcerated women, for instance those included in Interrupted Life (Solinger et al. 2010). Such an undertaking is, unfortunately, beyond the scope of this paper.
Ann Cvetkovich, in her book Depression: a public feeling, explores critical alternatives to the dominant medical conceptualizations of and treatments for depression. She begins the analytical second half of her book – preceded by her queer, feminist memoir – with a critique of the medical model approach.
Depression should be viewed as a social and cultural phenomenon, not a biological or medical one … What is taken for granted in cultural studies is not the commonsense view elsewhere, and that disconnect is my real interest … Within medical and scientific circles that construct depression as a treatable disease, the premise that depression is social and cultural can seem not so much suspect as irrelevant, especially in the context of practical urgencies of treatment and new pharmacological discoveries (Cvetkovich 2012:99)Despite the complexities of social and cultural critique, these avenues lead to more fruitful understandings of depression that could, if undertaken on a more collective scale and with political support, grant far more expansive and effective treatments for depression, shifting the emphasis of pathology from the individual to society. Viewing depression as a disease obstructs the conceptualization of depression as merely the individual manifestation of social and collective forces.
Cvetkovich boldly advocates for a form of “history as critique of the medical model,” quoting Gary Greenberg, author of Manufacturing Depression:
History can be therapy too. And reading a book in which you understand how a doctor came to say to you ‘You have a biochemical imbalance and here’s the drug for it’ could be as therapeutic as exercise, as therapy, and as taking Prozac. (Greenberg 2010)Cvetkovich notes that historical accounts of depression are necessary for more radically exploring the causes and treatments for depression. Mainstream accounts of depression, on the other hand, “stop short of any real consideration of the social causes of depression or the social transformations that might address it” (Cvetkovich 2012:90). Cvetkovich then moves on to explore how such an historical approach to depression would speak to the voices of Black authors who for decades, centuries even, have been offering alternative accounts to the hegemonic narratives of the medical models imposed upon Black bodies and minds.
She begins her discussion of critical race perspectives on depression by quoting Cornel West
But if whites experienced black sadness … (Pause.)
It would be too overwhelming for them. (Pause.)
Very few white people could
actually take seriously
black sadness and the lives that
livin’ in denial
“Oh it couldn’t be that bad”
And they have their own form of sadness
Tends to be linked to
the American Dream
But it’s a very very very different kind of
Cornel West in Anna Deavere Smith, Twilight: Los Angeles (Smith 1997)In this quote, West articulates the lived experiences of oppression of Black people to challenge the universalizing accounts of depression offered by the medical model. The whiteness of the medical model can then be understood as obscuring the historical causes – such as slavery, Jim-Crow, mass incarceration and other forms of systemic oppression and inequality – of depression in Black people. Cvetkovich urges us to ask:
What if depression, in the Americas at least, could be traced to histories of colonialism, genocide, slavery, legal exclusion, and everyday segregation and isolation that haunt all of our lives, rather than to biochemical imbalances? (Cvetkovich 2012:115)A critical race understanding of depression fundamentally challenges the colorblind ideologies of post-Civil Rights United States.
Eduardo Bonilla-Silva’s book, Racism without Racists, sheds light upon colorblind racism in the contemporary United States. Bonilla-Silva names individualism and universalism as two key components of colorblind racism frameworks (Bonilla-Silva 2017). Bonilla-Silva’s analysis proves quite useful in understanding critiques of mainstream psychology – or medical models of depression - which emphasizes individualism (the individual is the central focus and unit of study and treatment) and universalism.Psychological theories and treatments, in their attempt to control for variables, generalize their findings, and achieve standardized and predictable therapeutic efficacy, are far too rigid to accommodate the complexities of people’s experiences but rather operate to universalize them. As Cvetkovich notes “One of the problems with medical discourses, whether about trauma or depression, is not just that they pathologize but that they homogenize and universalize a nuanced range of feelings” (Cvetkovich 2012:115).
Saidiya Hartman emphasizes that historical considerations of slavery remain relevant to contemporary manifestations of psychological suffering due to the persistence of white supremacy, despite the claims of colorblind frameworks and post-Civil Rights Era notions of a post-racial society.
If slavery persists as an issue in the political life of black America, it is not because of an antiquarian obsession with bygone days or the burden of a too-long memory, but because black lives are still imperiled and devalued by a racial calculus and a political arithmetic that were entrenched centuries ago. This is the afterlife of slavery – skewed life chances, limited access to health and education, premature death, incarceration, and impoverishment. I, too, am the afterlife of slavery (Hartman 2008:6).Hartman’s eloquent elaboration on why slavery remains so vitally important to the lived experiences of Black people is further contextualized by recent work on the intergenerational nature of trauma – such as the persisting negative effects of slavery –, the concept of the Residual Effects of Slavery (RES), and the work of Dr. Joy DeGruy exploring Post-Traumatic Slave Syndrome (PTSS).
The Residual Effects of Slavery, as a concept, refers to efforts to incorporate the enduring consequences of racism into the health sciences (Wilkins et al. 2013). Incorporating the Residual Effects of Slavery into psychological ideologies and methods could allow mental health practices to acknowledge and treat the psychological manifestations of oppression.RES in a psychological context can be traced back to the dehumanization of Black people stemming from the Transatlantic Slave Trade along the Middle Passage. Being stolen from their homelands, chained together, subjected to horrific conditions – often death – on lengthy sea trips, in and of itself represented the dehumanization of Black people but also contributed to the enduring conceptualization of white as pure and Black as tainted. “To rationalize the inhumanity of slavery, Africans were reduced to subhuman status and labeled ‘primitive’” (Wilkins et al. 2013:16). The brutality and dehumanization of slavery has persisted through racism – including structures of oppression and cultural notions of inferiority – and collectively affected the psychological health of Black people in the United States. Black people were not given psychological support to help cope with the trauma of slavery following their emancipation but rather faced rapes and lynchings, subjecting them to further, untreated trauma.
The multigenerational nature of trauma has been well documented, demonstrating the lasting scars of trauma on future offspring as well as entire communities (Yehuda and Lehrner 2018). The concept of Post Traumatic Slave Syndrome (PTSS), coined by Joy DeGruy, is a particular framework that acknowledges the Residual Effects of Slavery. PTSS places knowledge of the multigenerational effects of trauma and undiagnosed and untreated PTSD in the context of slavery, lynching, Jim Crow Laws, and mass incarceration to contextualize maladaptive experiences – such as lowered self-esteem, anger, and feelings of inferiority – as rooted in survival strategies (DeGruy n.d.). DeGruy discusses contemporary feelings of hopelessness in Black communities as rooted in both the contemporary structures of racism and persisting inequalities that are all too prevalent for Black people – and all too ignored by white people. De Gruy contextualizes Black suffering in the continued presence of deep, unaddressed intergenerational trauma, piled up over the years across communities and through generations in the violence, dehumanization, and subordination that occurred during and after slavery.
As the core components of Post Traumatic Slave Syndrome DeGruy draws attention to “vacant esteem (hopelessness, depression, and self-destruction), “marked propensity for anger and violence,” and racist socialization and internalized racism (DeGruy n.d.). Important to an understanding of Post Traumatic Slave Syndrome is an intersectional perspective. For instance, an intersectional analysis of the intersecting identities of both Black and woman acknowledges the sexual violence suffered by Black women during and after slavery, further adding to the the lasting effects of untreated and unacknowledged PTSD as a Residual Effect of Slavery. Furthermore, the communities of violence and the prevalence of domestic violence in contemporary United States that affect Black women can be understood as themselves residual effects of slavery, shifting blame from communities of color towards the white supremacist society that imposed the roots of violence upon these communities over hundreds of years of oppression and has yet to seriously make strides towards repairing those roots.
The concept of RES and PTSS highlight the need for frameworks grounded in historical and intersectional analyses in order to best serve the mental health needs of incarcerated women of color. In their article calling for the formation of a Critical Race Psychology, Glenn Adams and Phia S. Salter (2011) highlight Black and Afrocentric psychologists, multicultural counseling, critical psychology, liberation psychology, and cultural psychology as fields to draw upon (Adams and Salter 2011). Furthermore, Adams and Salter outline the main components of a Critical Race Psychology as a “self-critical, identity-conscious, reflexive form of inquiry that acknowledges the positionality and ideology inherent in theory and method” (Adams and Salter 2011:1364). In fundamentally questioning and calling for the restructuring of psychology as an institution with respect to challenging racist baselines of society, the promotion of a Critical Race Psychology can be viewed as an anti-subordination project. Mainstream psychology’s scientific standard of producing “objective” insights into human behavior through lab settings that are intended to universalize experiences actually functions to obscure cultural and historical contexts. Mainstream psychology overemphasizes commonalities to the point of ignoring differences; the commonalities of psychological experience surely exist, but indeed so do their differences, as emphasized by an intersectional analysis.
The main tenets of Black and Afrocentric psychologies are that mainstream psychologies rooted in Euro-American paradigms of society and the individual are ill-equipped to understand, let alone address, the experiences of Black people (Stevens 2015). Multicultural counseling perspectives “advocate purposeful consideration of one’s own identity positioning within the profession, including awareness of one’s values, assumptions, and biases, attempts to understand culturally different worldviews, and the development of culturally appropriate interventions and practices” (Adams and Salter 2011:1365). Multicultural counselors acknowledge how a practitioner’s ignorance of the impacts of racism on mental health (RES) can replicate forms of domination and actually cause further psychological harm to clients.
Adams and Salter discuss Critical Psychology as a field that acknowledges that mainstream psychology is rooted in ideologies and systems of power and strives to promote new understandings of psychology to subvert these systems of oppression. However, Adam and Salter critique Critical Psychology for treating “race (and racism) as a topic rather than an epistemological position from which to conduct critical work” (Adams and Salter 2011:1368). We can further understand the limitations of critical psychology in its lack of an intersectional analysis, in its compartmentalization of the different fields of radical psychology that fall under its umbrella, such as Black, Feminist, Liberation and Queer psychologies. Adams and Salter praise Liberation Psychology for its commitment to addressing social justice and the needs of oppressed peoples as well as for its use of forms of knowledge and methodology that originate in the lived experiences of the oppressed (Adams and Salter 2011).
Adams and Salter note that Cultural Psychology offers the ability to highlight the positionality of ideologies within mainstream psychology and to challenge the “objective” nature of psychological research rooted in paradigms of white supremacy and patriarchy. First, Cultural Psychology offers the ability to normalize psychological phenomenon that mainstream psychology attempts to portray as abnormal. We can understand Black people’s struggles with mental health with respect to the Residual Effects of Slavery through a Cultural Psychological lense that encourages us to see Black people’s perceptions of racism as “not a distortion of objective reality, but [rather a reflection of] accurate knowledge of ongoing racism in American society” (Adams and Salter 2011:1369).
Shelter and Adams conclude by necessitating the formation and practice of a Critical Race Psychology to challenge the colorblindness of psychological science. They note that although social psychological research can and has been useful to support the claims of Critical Race Theory, the “conceptual and ideological tools” employed to conduct such research are a product of and replicate systems of oppression. Mainstream psychology ignores the racism inherent to dominant, objective paradigms of science and perpetuates an “atomistic conception of racism, as individual prejudice, that promotes a limited understanding of ways in which systems of oppression cause harm” (Adams and Salter 2011:1377).
Feminist understandings of psychology are also extremely relevant to these conversations, particularly given the history of psychology in suppressing the liberatory concerns of women. Hysteria – meaning emotional excess – was used to dismiss and silence women medically, to pathologize rather than legitimize women’s concerns and feelings. Such a perspective would be vitally necessary for cases involving domestic violence. For instance, many women are still charged with murder despite Battered Women Syndrome diagnoses, highlighting how mental health needs to occupy a more radical space, with a more politicized feminist lense, in order to best support women. “Feminism … has promoted the idea that feelings of unhappiness that get classified by categories such as depression are better served by social revolution than by medication” (Cvetkovich 2012:165). Such a critical analyses might shift away from pathologizing women and failing to support them towards more seriously critiquing toxic masculinity and abuse committed by men.
Critical psychologies are vitally important for providing mental health treatment to incarcerated women. Without such perspectives, the historical contexts and factors of mental health problems among incarcerated women remain ignored and purposefully forgotten, despite their reality in the present day. Furthermore, the individualizing of mainstream psychology obstructs critiques of prisons themselves as being sites of oppression and dehumanization and thereby obstructs abolitionist goals. The individualizing paradigms of mental health that obscure oppression and social flaws parallel the claim of abolitionists like Ruth Wilson Gilmore that “prisons are catchall solutions to social problems” (Kushner 2019).
However, cultural psychology allows for wider, more critical perspectives. This field allows for the denaturalization of psychological phenomenon that mainstream psychology normalizes, such as colorblind or post-racism perceptions held by many white people. For instance, borrowing from the American Psychiatric Association’s definition of mental disorders in the DSM-5, we can frame the denial of racism as a “significant disturbance in cognition that reflects a dysfunction in the psychological and developmental processes underlying mental functioning” (van Heugten-van der Kloet and van Heugten 2015). A recent psychological study explored and supported the “Marley hypothesis – that group differences in perception of racism reflect dominant-group denial of and ignorance about the extent of past racism” (Nelson, Adams, and Salter 2013:213)). A denial of history and the past and present realities of racism represents delusional thinking, an impairment in cognition stemming from inadequate, white-supremacist educational practices that have stemmed proper psychological development. Understanding such ignorance as a group-level dynamic through the Marley hypothesis, we can begin to actually pathologize whiteness on a collective level.
We can and should understand white supremacy and the patriarchy as an obstruction to societal change and collective liberation. Particularly given the fact that our white supremacist patriarchal society imposes conformist narratives and structures upon incarcerated people and people with mental illness that emphasize their ‘deviance’ and threat to the social order, I find the task of understanding whiteness and masculinity as much greater threats to social order a particularly important one. Recent work developing and conceptualizing a new theory of the Post Traumatic Slave Master Syndrome is
utilized to critically correlate historic patterns of lynching Black women to contemporary violent state (actor) responses to Black women’s resistance, specifically relating to the neo-lynching of Korryn Gaines and Sandra Bland. This work deviates from the tradition of analyzing the history and contemporary effects of racism and white supremacy, patriarchy, lynching, policing, and state-sponsored violence from the perspective of the effects upon the victim and instead critiques how white supremacy affects the perpetrator. (Spencer and Perlow 2018)We should be shifting our mental health treatment of incarcerated women away from pathology models towards community-based models grounded in sociological analyses, historical knowledge, and socio-culturally sensitive practices. If anything deserves the taint of ‘disease,’ it is not the resilience, coping, and suffering of incarcerated women manifesting in ‘depression,’ PTSD, or substance use disorders, but rather whiteness and the oppression of carceral logic.