PSIP Literature Review

It is well documented that difficult or traumatic childhood experiences are risk factors for mental illness and involvement with the criminal legal system. The profound effects of childhood trauma extend well into adulthood and include psychological, behavioral, social, and even biological changes. These effects, “are associated with longer-term consequences, including risk for further victimization, delinquency and adult criminality, substance [use disorders,]. . . poor school performance, depression, and chronic disease.” 

The Adverse Childhood Experiences (ACE) questionnaire has gained traction as a means for evaluating correlations between difficult / harmful childhood experiences and mental and physical health outcomes. The questionnaire has been invaluable in illuminating the impact of economic and racial discrimination on lifetime disease prevalency, incarceration, and employment outcomes.

Research demonstrates both a correlation and a causal pathway between ACEs and mental illness. ACEs may evoke toxic stress responses that can affect the development and functionality of neurological, immune, and endocrine systems. These changes may both contribute to mental distress and increase exposure to additional risk factors, such as socioeconomic status, health behaviors, educational attainment, and employment challenges.

Adverse childhood experiences may cause PTSD or increase the likelihood of developing PTSD and are correlated with depression, substance use disorders, anxiety, psychosis, personality disorders, and suicide.

ACEs are also strongly correlated with incarceration. According to the CDC, about 64% of adults report experiencing at least one ACE, and about 17% report experiencing at least four. In contrast,  a shocking 98% of incarcerated people have experienced at least one ACE, and more than 75% report experiencing at least four events.

Research shows people of color have “substantially higher prevalences of four or more types of adverse childhood experiences, compared with whites.” For instance, Black youth are almost twice as likely as their white peers to fall into the “High [Socioeconomic Status] Adversity and Paternal Incarceration” class, which is “characterized by above average probabilities of experiencing family economic hardship, parental separation, low maternal education, and paternal incarceration.” Importantly, ACE events that are more common among racialized communities may be more significantly correlated with incarceration. For example, children who experience parental incarceration are five times more likely to enter the criminal legal system themselves. In a review of ACEs, researchers found race and ethnicity are linked to different patterns of exposure, highlighting the need for culturally tailored treatments and interventions.

While experiences captured in the ACE measure demonstrate mutually reinforcing associations between childhood adversity, race/ethnicity, mental health, and likelihood of criminal-legal-system contact, the ACE measure may not be optimally designed to capture experiences especially common and impactful among low-income communities and communities of color. The measure does not adequately capture cultural, structural, and systemic forms of oppression, including income inequality, racism, and unhealthy housing conditions, which are more common among Black and Latino youth. Moreover, the measure does not reflect the frequency or severity of traumatic events, which engenders limitations on nuance and granularity. Therefore, while research using the ACE measure does support the finding that adverse childhood events are a risk factor for criminal legal system contact and adult mental health disorders, the impact of childhood adversity among system-impacted people may be even higher than the measure can conceive.

Interactions with the criminal legal system may cause new mental health issues or exacerbate symptoms that existed prior to entry. While more research is needed to better understand mental health before and after system contact, preliminary studies indicate that arrest and incarceration have harmful consequences for mental health, especially among those from and returning to highly oppressive social conditions. Research also finds incarceration is independently correlated with subsequent mood disorders and disabilities. 

Incarceration is a highly variable experience with many direct and indirect consequences compromising the physical and mental health of incarcerated people, their families, and their communities. Incarceration disconnects and separates families; creates a loss of autonomy; and subjects people to intense surveillance, the ongoing threat of punishment, cruel and unpredictable conditions, and exceptionally high rates of exposure to traumatic events, including experiencing and witnessing violence. Notably, the risk of harmful outcomes in a penal institution tends to vary based on one’s race, gender identity, physical and developmental disability status, etc.  

Countless studies have examined the high levels of violence and related traumatic events in prisons and jails, while 2018 data from the Bureau of Justice Statistics shows prisons are becoming increasingly dangerous. At least 35% of incarcerated men and 24% of incarcerated women have experienced some form of physical victimization behind bars, while 10% of men and 25% of women have been sexually victimized.

A meta-analysis found that traumatic experiences during incarceration – such as abuse, victimization, solitary confinement, and coercion – are strongly linked to PTSD. In contrast, prior mental health conditions and the length of time spent incarcerated were not significantly related, suggesting that what people experience while incarcerated has a greater impact than their mental health history.

In addition to causing or exacerbating mental distress, the criminal legal system can also interfere with an individual’s access to health care. Once a person is convicted of a crime, and even after they have completed their sentence, they are left to grapple with any combination of the more than 45,000 state and local laws and regulations that limit, if not prohibit, their access to employment, housing, healthcare, voting, education, occupational licensing, and other opportunities. These restrictions impact an individual’s ability to find, receive referrals to, or afford treatment. Such barriers, widely known as “collateral consequences” of a criminal conviction, include the exclusion of currently incarcerated people from being eligible for Medicaid, causing a gap in insurance coverage upon release. For many, this can be fatal. Subpar care in penal institutions and the post-release healthcare coverage gap “are pivotal factors in the heightened risk of death after release” and other catastrophic clinical outcomes. Various studies have found the risk of death (including from suicide and drug overdose) is particularly high within the first year after release. “Many of these deaths following release are preventable with appropriate medical, mental health, and substance use interventions, which usually require health insurance. But because people are released from prisons and jails without insurance, they are less likely to receive the necessary interventions upon release.”

Rates of posttraumatic stress disorder (PTSD) among system-impacted people may be difficult to accurately determine due to lack of treatment and subsequent underdiagnosis; cultural, class, and gendered differences in self-disclosure; cultural differences in conceptualizing mental health; confounding medical issues; and the prioritization of physical health issues among highly marginalized communities. To help address these constraints, researchers have often preferred to study proxies for PTSD, including trauma exposure or self-reported symptom severity. To that end, studies have found more than 90% of people who experience incarceration have experienced at least one traumatic event that meets DSM-V diagnostic criteria for PTSD. Furthermore, studies frequently report high rates of incarcerated people who experienced or witnessed physical violence and/or sexual abuse during childhood.

One meta-analysis found the prevalence of PTSD among 50 international samples ranged from 0.1% to 27% for incarcerated men and 12% to 38% for incarcerated women. It is important to note, however, lifetime prevalence of PTSD was found to be higher in the US than other developing countries, likely due to differences in rates of incarceration, solitary confinement, economic inequality, systemic racism, healthcare access, and incarceration environment. Smaller studies and studies within high-security prisons report higher prevalences of PTSD. Variability aside, it is clear SIP have much higher rates of PTSD than the general public. 

Research is also divided in determining the impact of incarceration on PTSD. It is challenging to study whether traumatic events experienced during incarceration cause PTSD due to the high prevalence of pre-incarceration PTSD and other mental illnesses. It is likely, however, that prison exacerbates pre-existing PTSD. One meta-analysis found that imprisonment trauma was strongly correlated with trauma disorders. According to a self-report survey of PTSD symptoms among a sample of formerly-incarcerated people, 72% of recently released participants reported struggling with prison-related PTSD, with only 11% having a PTSD diagnosis prior to incarceration. Studies also report high rates of trauma exposure during incarceration. A meta-analysis reports about 90% of incarcerated people experience potentially traumatizing events. As many as 35% of males and 24% of females report directly experiencing physical assault during incarceration, though additional studies indicate these numbers may be much higher. Another study found, on average, incarcerated people experience potentially traumatizing events every month. The bottom line is: studies consistently report a positive correlation between trauma exposure during incarceration and the occurrence and severity of posttraumatic stress and depression symptoms.

Even when released, formerly-incarcerated people are more likely to develop PTSD than the general population, in part due to the late onset of PTSD following removal from a traumatizing environment. Prison culture is a direct catalyst for constant exposure to PTSD-associated environments, comparable to experiencing military combat, acts of terrorism, sexual assault, and overall abusive and toxic environments. The obstacles SIP face upon reentry likely exacerbate PTSD or subject SIP to additional trauma. 

It is important to note the limitations of existing diagnostic materials. For example, the DSM-V diagnosis of PTSD must be linked to a single or series of events and, therefore, is limited in its ability to measure the compound effects of severe trauma histories marked by diverse or distinct traumatic events. The recent addition of Complex-PTSD (C-PTSD) in the International Classification of Diseases 11th Revision (ICD-11) may support research efforts to investigate PTSD severity with greater granularity. In contrast to PTSD, C-PTSD is “typically associated with chronic and repeated traumas and includes not only the symptoms of PTSD but also disturbances in self-organization reflected in emotion regulation, self-concept and relational difficulties.” The ICD-11 description of C-PTSD identifies traumatic events “from which escape is difficult or impossible” which may be of particular consequence for evaluating the severity of incarceration-related trauma due to its coercive nature.

Nonetheless, both the DSM-V definition of PTSD and the ICD-11 definition of C-PTSD exclude many types of acute and chronic trauma people of color tend to experience with greater frequency and intensity compared to other groups, including racial trauma and some sources of developmental trauma. These limitations impact our ability to estimate the severity and nature of posttraumatic stress and the effectiveness of treatment options among SIP communities before, during, and after incarceration. Finally, people with PTSD often struggle with simultaneous mental health disorders. PTSD is strongly associated with major depression and anxiety disorders, more so among incarcerated adults than youth. There is also a “significant association between PTSD and suicidality, with risk estimates slightly higher among [incarcerated men].” Lastly, incarcerated people with PTSD are significantly more likely to have a comorbid substance use disorder.

The current global drug control mechanism has caused a significant increase in prison and jail populations. The criminalization of drugs has resulted in the de facto criminalization of addiction, often addressed via punishment rather than rehabilitation. According to the National Institute on Drug Abuse, 65% of the prison population has an active substance use disorder (SUD), while an additional 20% did not meet the criteria for SUDs but were under the influence at the time of their crime. Around 25% of newly incarcerated people have an alcohol use disorder, with an estimated 25% of men meeting the criteria for alcohol use disorder upon arrival. The frequency of drug use disorders is comparable to that of alcohol use disorders, though the prevalence of drug use disorders is higher among incarcerated women.

 Despite the high prevalence of SUDs in prisons and jails, there is a clear “treatment gap for SUDs inside prisons.” Treatments vary widely across prisons and jails, with only a minority of incarcerated people receiving SUD treatment from a trained clinician. Consequently, incarcerated people lack access to evidence-based treatment despite a high availability of illicit substances in facilities, often smuggled in by staff and visitors (Office of the Inspector General, 2003). Without a comprehensive strategy to address SUDs, incarcerated people will continue to face an increased risk of premature mortality and drug-related recidivism after release.

System-impacted people are especially vulnerable to SUDs upon release. A history of drug use disorders was found in 45% of recently released people and associated with post-release substance use, with 24% of those with a history of substance use disorders self-reporting substance use after release.

Formerly-incarcerated people frequently return to environments that trigger relapse to drug use and put them at a higher risk of overdose in the immediate post-release period. During this time, return to drug use most often occurs when people have inadequate access to social, medical, and financial resources to support their re-entry. It is important, then, to highlight that people convicted of drug-related crimes may be impacted by legal and social restrictions on economic opportunities, federal limits on the provision of public housing and other social safety nets, and legal and social barriers to community participation. Those who want to stay away from drugs may face additional social isolation. Some formerly-incarcerated people intentionally overdose as a way to escape re-entry stressors, and others accidentally overdose due to their decreased tolerance.

Structured drug treatment programs, spirituality, religion, and family can prevent relapse and overdose. Infrequent or unsustained contact with community-based mental health and substance use treatment services, however, does not protect against reincarceration (and “may even be iatrogenic”).

There have been widespread increases in depression in the United States, and the prevalence of major depression has specifically been on the rise in prison populations. Incarceration is associated with a 45% increased likelihood of lifetime major depression, though a causal connection is difficult to establish, as the relationship between incarceration and psychiatric disorders are sensitive to childhood background factors and substance use. Overall, 14% of incarcerated women and 10% of incarcerated men have been diagnosed with major depression, with one in seven incarcerated people experiencing depression or psychosis. Psychosis is an important metric because it increases the risk of suicide and self-harm during incarceration.

 From 2001 to 2019, suicides increased by 85% in state prisons, 61% in federal prisons, and 13% in local jails. These rates are correlated with increases in major depression, and a majority of the suicides in state and federal prisons occur after an individual has served more than a year. Even though mental health issues are increasing in prison, the prison system does not provide nearly enough support to treat these issues.

Research has determined involvement in the system may exacerbate existing, if not cause, mental health issues in young people. One study found youth incarcerated for less than one month had higher rates of depression in adulthood than similarly-situated youth who were not incarcerated. Meanwhile, young people who were incarcerated for one year or more were over four times more likely to experience depression and twice as likely to have suicidal thoughts in adulthood compared to those who had not been incarcerated. Among youth involved in the juvenile legal system, “including those who have been referred to court or those who have been adjudicated and placed in a residential facility . . . only a small percentage . . . in need of services can access treatment”, with several studies finding less than 10% of convicted youth in various systems being referred for mental health services. Even incarcerated young people with diagnosed psychological disorders have less than a 25% chance of receiving treatment, with several studies shedding light on race-, gender-, and age-based disparities in which youth are most likely to be referred for treatment. Collectively, studies have found white youth, girls, and younger youth (usually those under 15 years of age) are most likely to be referred for mental health placement.

Since the founding of the United States, racism has had a profound and devastating effect on the distribution of resources and power, impacting the socioeconomic status of racial groups across the spectrum. One can trace the thread of racism through centuries of forced displacement, genocide, and related atrocities committed against peoples indigenous to what is now considered US territory. This same thread weaves through the economic exploitation of Black people during slavery, indentured servitude, and now low and unpaid prison labor. Commingled throughout this history are other innumerable examples of the impact of systemic racism on socioeconomic status, such as employment discrimination and the well-documented practice known as “redlining,” which involved the denial of financial services such as mortgages and insurance loans to people, especially Black Americans, in specific neighborhoods. Together these factors paint a clear picture of how the deliberate and systematic extraction of human labor and other social and economic resources over centuries created an economy that benefits a majority-white ruling class and prevents people of color from building and maintaining financial stability, never mind wealth.

Low-income communities experience a higher prevalence of poor mental health outcomes due to social factors, including housing insecurity, inconsistent access to financial resources, environmental obstacles, high rates of crime and violence, and inadequate public education. All low-income communities are at increased risk of mental disorders, regardless of race or ethnicity. Nonetheless, the mental health of people of color is more likely to be impacted by poverty because they are more likely to have lower incomes and to live in historically oppressed and exploited neighborhoods with fewer resources, including adequate mental health services. 

People of color are also less likely to utilize mental health services. Material barriers to mental health treatment options include lack of financial resources, adequate and consistent health insurance coverage, access to transportation, and time. Given the inflexibility and instability associated with low-wage employment, low-income families struggle to make doctor visits that are often during business or working hours. Low-income people of color experience additional psychological barriers to seeking care, including cultural stigma and, perhaps more importantly, fear and mistrust of the medical system due to interpersonal and historic harms such as institutionalization, misdiagnosis and overmedicalization, family separation, abuse, and the compounded psychological effects of centuries of systemic racism. 

Together, these factors – combined with the United States’ reliance on incarceration as a default response to mental illness and the disproportionate policing of Black and brown communities – have produced a punishment system defined by the systemic overrepresentation of people of color in prisons and jails. This overrepresentation, in turn, disproportionately exposes Black and brown communities to the well-documented physical, psychological, and social harms associated with incarceration and broader contact with the criminal legal system.

Psychological Consequences in the Black Community of “Secondary” Contact with the Criminal Legal System

A growing body of research is exploring the impact of witnessing police brutality on the mental health of Black communities. A 2018 study found “police killings of unarmed [B]lack Americans have a meaningful population-level impact on the mental health of [B]lack Americans.” Specifically, law enforcement officer(s) killing an unarmed African American triggered days of poor mental health for Black people living in that state over the following three months. Researchers noted these findings are likely underestimating the cumulative mental health impact of these killings, especially in light of their widespread news and social media coverage. The same effect was not found among white respondents, and there was no observable effect in either demographic following police killings of unarmed white Americans or armed Black Americans. The researchers emphasize the episodic nature of racialized police brutality to explain the widespread mental health impact of the single event. They posited their “results point to the importance of structural racism as a driver of population health disparities”, arguing that “[r]acial disparities in law enforcement and legal treatment have a long history in the USA, and state-sanctioned violence in particular has been used to terrorise, dehumanise, and subjugate [B]black Americans.” Police killings of unarmed Black people are perceived by many as “manifestations of structural racism and as implicit signals of the lower value placed on [B]lack lives by law enforcement and legal institutions—and by society at large.”

Some have articulated the concept of “accelerated aging” or “biological weathering,” based on evidence that “African Americans are aging biologically more rapidly than whites” as a result of the accumulated stress of experiencing systemic racism, including exposure to the criminal legal system, even if it is indirect or vicarious. More research is needed to better understand this phenomenon and how it may impact long-term mental health, especially among communities most heavily policed and exposed to the carceral system.

Diagnostic-based frameworks may be critical tools for ensuring adequate treatment and resource allocation for people struggling with mental distress, including for low-income people of color impacted by the criminal legal system. These frameworks, however, are not developed or employed in a psychodynamically sterile, objective clinic. While this series is not the appropriate place for an in-depth critique of the DSM-V Diagnostic Manual or related frameworks, it is critical to mention some of the ways SIP may be harmed by over-medicalizing symptoms of distress and the therapeutic interventions that rely on such frameworks. 

The most digestible criticisms, and the easiest for medical institutions and practitioners to quickly address, are that the DSM-V diagnostic criteria and diagnostic tools do not adequately capture racial differences in clinical presentations of symptoms and that the subsequent inadequacy, mixed with physician bias, results in disproportionate misdiagnosis of low-income people of color. The history of schizophrenia and bipolar diagnoses serve as excellent examples of this phenomenon. 

Many studies since the 1970s have revealed that the racial disparity in the diagnosis of schizophrenia and bipolar disorder is illegitimate. Black patients, especially men, are more likely to be diagnosed with schizophrenia and less likely to receive diagnoses for mood disorders. Yet when the same patients are screened with gold-standard diagnostic tools or screened explicitly for depression, rates of schizophrenia and depression do not meaningfully differ between Black and white populations. Similarly, several studies have revealed that only about 30% to 40% of patients diagnosed with bipolar disorder actually met clinical criteria, and bipolar disorder misdiagnosis is most likely to affect people from low-income communities of color with histories of traumatic experiences, major depression, and comorbid substance use disorders. 

The history of schizophrenia overdiagnosis among Black patients is a critical case study because the story reveals the intricate ways social issues and discourse affect the implementation of mental health diagnostic frameworks. For example, New York psychiatrists Walter Bromberg and Franck Simon capitalized on the 1968 publication of the DSM-II to publicly advance the idea that the activism characterizing the Black Power movement was both an example and cause of schizophrenia. This idea circulated in medical journals, pharmaceutical advertisements, news coverage, and magazine articles. By creating the caricature of the violent, insane Black patient in the US public and medical spheres, these racist tropes set the stage for the misperception, overvaluation, and misdiagnosis of “psychotic” symptoms within Black patient populations, which has contributed to the overdiagnosis of lifetime personality disorders, overprescription of antipsychotics, inappropriate mental health treatment, institutionalization in hospitals and prisons, and the use of medicine as a disciplinary mechanism for non-compliant subjects.

This history reveals a deeper critique of diagnostic-based frameworks, begging scientific questions about the clinical usefulness and validity of mental health diagnoses and anthropological and legal questions about the role of power and hegemony within the practice of medicine. A relevant critique is that contemporary diagnostic-based frameworks engage in what has been described as the “privatization of stress”, whereby natural, and sometimes even healthy, responses to political and environmental factors, such as poverty, war, climate collapse, targeted policing, and systemic racism, are conceived as pathological symptoms of a disorder with genetic or neurological etiologies. This is often done with insufficient scientific evidence to support the purported etiology. As a result, individuals end up pathologized in ways that significantly affect their economic and social opportunities and self-concept, rendering them vulnerable to ineffective voluntary and involuntary treatment, while the underlying systemic cause of the distress is obscured. More broadly, some have argued contemporary psychoanalysis and psychotherapy have traditionally played a role in seeking to produce compliant subjects “well-adjusted” to, if not accepting of, their own oppression.

For these reasons, the development of new treatment options for low-income people of color impacted by the carceral system must necessarily involve the leadership, advocacy, and voluntary participation of those impacted by the same systemic issues. Community-based participatory research and advocacy may support the development of treatment models that effectively reduce individual and community distress while simultaneously addressing systemic issues.

[Note: this section does not appear in the full, downloadable literature review. We’ve included this information here to offer a deeper understanding of the disparate impact the criminal legal system has on different communities]

Women impacted by the criminal legal system face distinct and often compounded mental health challenges shaped by high rates of prior trauma, structural inequality, and gendered pathways into incarceration. The US has a history of criminalizing survivors of sexualized and physical abuse and domestic violence, especially women. Arrest rates have been rising for women for the past 25 years, particularly in drug charges where there has been a 216% increase in women while only having a 48% increase in men. About a quarter of women in jail are held on drug charges while 75% of incarcerated women have been victims of domestic violence at some point in their life. Researchers have pointed to the combination of financial instability and domestic violence as key factors contributing to this increase in women charged with drug offenses, the majority of whom are women of color and the wives, girlfriends, mothers, daughters, and sisters of men involved in the drug trade.

Histories of trauma are especially prevalent among incarcerated women, with many also reporting experiences of childhood sexual abuse and other forms of interpersonal violence. This cumulative trauma is strongly associated with elevated rates of posttraumatic stress disorder (PTSD), depression, anxiety, and substance use disorders. For many women, substance use may function as a coping mechanism for unaddressed trauma, further entrenching their involvement in systems that prioritize punishment over care.

Incarceration itself often compounds these harms. Women in custody face heightened risks of re-traumatization through invasive surveillance and exposure to physical and sexual violence. 25% of incarcerated women have been sexually victimized. Rates of sexual violence have been so concerning that, in 2003, Congress unanimously passed the Prison Rape Elimination Act (PREA), intending to analyze incidences of and protect individuals from prison rape. Several, however, have written about PREA’s inability to engender systemic and lasting change, with some specifically highlighting the Act’s failure to reduce “the gender-based and sexual violence against incarcerated people that is perpetuated most frequently by correctional staff”

Many system-impacted women also face the impact of being separated from children and family networks. This disruption of caregiving roles is particularly consequential, as many incarcerated women are primary caregivers prior to incarceration, creating intergenerational impacts on families and communities.

Despite these heightened needs, gender-responsive and trauma-informed mental health services remain limited within carceral settings. Treatment programs often fail to account for the relational, social, and economic contexts shaping women’s experiences, resulting in significant gaps in care both during incarceration and upon reentry. Addressing the mental health needs of system-impacted women requires approaches that center trauma, ensure continuity of care, and invest in community-based, culturally responsive support systems.

[Note: this section does not appear in the full, downloadable literature review. We’ve included this information here to offer a deeper understanding of the disparate impact the criminal legal system has on different communities]

Queer and transgender people impacted by the criminal legal system face distinct and compounding mental health challenges shaped by stigma, discrimination, and structural violence. LGBTQ+ individuals – particularly Black and brown trans people – are disproportionately subjected to policing, criminalization, and incarceration due to factors such as housing instability, employment discrimination, survival economies, and targeted law enforcement practices. These pathways into system involvement are often rooted in systemic exclusion from basic social and economic resources.

Prior to incarceration, queer and trans people experience elevated rates of trauma, including family rejection, bullying, sexual and physical violence, and barriers to affirming healthcare. These experiences are strongly associated with higher rates of depression, anxiety, substance use disorders, and suicidality. For many, chronic exposure to stigma and discrimination produces ongoing psychological distress that is further compounded by economic marginalization and social isolation.

Incarceration frequently intensifies these harms. Carceral settings are often profoundly unsafe for LGBTQ+ individuals, particularly trans and gender nonconforming people, who face disproportionately high rates of harassment, physical violence, and sexual victimization by both staff and other incarcerated people. Placement decisions based on assigned sex at birth, rather than gender identity, can increase vulnerability to abuse, with transgender people in state and federal prisons being nearly ten times more likely to be sexually victimized by other incarcerated people and staff than the general prison population. In addition, access to gender-affirming healthcare, including hormone therapy and mental health support, is inconsistent, frequently denied, or contingent on burdensome requirements, contributing to significant psychological distress.

The use of solitary confinement, often justified as a protective measure for LGBTQ+ individuals, can further compound mental health harms. Prolonged isolation is associated with increased rates of depression, anxiety, self-harm, and suicidality, and may be particularly damaging for individuals already experiencing trauma and marginalization.

Following release, queer and trans people continue to face significant barriers to stability and care. Discrimination in housing, employment, and healthcare, combined with the collateral consequences of a criminal record, can limit access to affirming and consistent mental health services. For trans individuals in particular, disruptions in gender-affirming care during and after incarceration can have severe and lasting psychological impacts.

Addressing the mental health needs of system-impacted queer and trans communities requires approaches that are trauma-informed, culturally responsive, and explicitly affirming of gender and sexual diversity. This includes ensuring access to gender-affirming healthcare, protecting individuals from violence within carceral settings, reducing reliance on punitive forms of “protection” such as solitary confinement, and investing in community-based supports that promote stability, autonomy, and healing beyond the criminal legal system.

Reentry poses many challenges to formerly-incarcerated people, such as accessing adequate healthcare, employment, and housing, and reintegrating into their familial role and community. Successful reentry is especially challenging for formerly-incarcerated people with mental health issues, with this group being significantly more likely to recidivate and experience homelessness, especially when their mental health diagnoses are left untreated.

The combination of overcrowded jails, long sentences, and unqualified staff has limited incarcerated people’s access to meaningful programming during and post-incarceration. Prison staff are also incentivized to keep mental health classifications low to save on healthcare and pharmacotherapy costs. A majority of incarcerated people do not receive treatment or treatment continuity for mental health conditions within prison. One study found 83% of recently released participants reported not being offered any mental health or general counseling in prison. Meanwhile, carceral systems with established mental health services are often woefully substandard and lack the privacy (including protection from correctional officers) necessary to be effective. Untreated mental health diagnoses are costly, not only for formerly-incarcerated individuals but also their families and communities and for society writ large.

Generally, regardless of criminal-legal-system involvement, exploited and oppressed communities, particularly those of color, are less likely to receive care or complete treatment for mental health disorders. For those being released after a period of incarceration, unresolved mental health issues interfere with the ability to re-integrate into a social network and employment setting, as well as the ability to resume a familial role. As a result, upon release, many formerly-incarcerated people struggle to transition back into society and become susceptible to health risks and reoffending, harming themselves, remaining alienated from their communities, and problematic or illicit substance use. Those with PTSD face severe occupational and social-functional impairment, high comorbidity with other psychiatric disorders, high medical comorbidity, and reduced quality of life.

Despite substance use disorders being highly prevalent in incarcerated populations, prisons and jails rarely use any evidence-based treatment for addiction. Instead, most use psycho-education, self-help groups, or peer counseling. Upon release, there is often no continuity of substance use treatment unless court-ordered.

Returning to a historically oppressed neighborhood after incarceration means facing depleted resources in employment, treatment programs, and housing and difficulties staying out of trouble. Formerly-incarcerated people who struggle with substance use disorders may be tempted by the presence of drugs in their environment. Additionally, some communities face higher risks of violence, causing some formerly-incarcerated people to avoid leaving their homes. This contributes to higher vigilance and hostility toward others, triggering an increase in depressive symptoms and motivation for the use of illicit substances. Formerly-incarcerated people’s concerns over their neighborhood environments predicts their social withdrawal and mental health deterioration. The situation is often a lose-lose one: either they give in to the temptation of social substance use and risk recidivism or isolate themselves and worsen their mental health.

There is also a lack of effective government programs to assist formerly-incarcerated people transitioning back into society and in need of mental health treatment. There is, however, evidence of a small number of community-based programs using effective models to support this population. For instance, Homeboy Industries in Los Angeles, CA, provides free job training and social services to previously incarcerated individuals. The organization has a mental health department providing trauma-informed, individualized clinical services uniquely designed to meet the needs of their formerly-incarcerated clients. Researchers additionally suggest three areas of policy interventions to ease the transition from prison to home: significant changes in the normative structure of prisons, transitional services to prepare for community release, and community-based services to facilitate and maintain re-integration.