The Question of Caring for Incarcerated Patients

The Front Lines of Mental Health Care

For several reasons, jails and prisons are now among the front lines of mental health care. First, many people require mental health services behind bars because of the sheer degree of incarceration in the United States. Estimates suggest there are nearly two million people behind bars across the country at a given time.^9,10 In addition, many more people cycle in and out of jails and prisons over the course of a year, with more than seven million admissions over a recent 12-month period.⁹ Put simply, jails and prisons in the United States have become responsible for the care of millions of people every year, many of whom require mental health care.

Second, people experiencing incarceration tend to have a high prevalence of mental disorders, including substance use disorders, often at rates far higher than the general population.^11,12 Social determinants of mental health, such as poverty, homelessness, and lack of education, have considerable overlap with risk factors for incarceration.^13,14 People in the community with severe psychiatric illness or addiction face high risks of police contact and arrest, in which case many patients already have preexisting disorders at the time of incarceration.^15,16 According to one study, approximately one in four people with mental disorders in the United States has a history of arrest.¹⁵ The associations between poor mental health and incarceration are also bidirectional.¹⁴ Incarceration is typically a stressful experience, including often harsh conditions of confinement and disruptions to individuals’ lives, which leads many people to develop psychiatric distress or substance use problems, whether or not they had them before arrest.¹⁷

Third, jails and prisons are legally required to offer mental health services in ways that community mental health practitioners are not required to do so. If a patient calls around for mental health care in the community (e.g., outpatient clinics, private practices), mental health professionals often may not be able to meet the patient’s needs because they are not accepting new patients, have lengthy waitlists, do not take health insurance, or other barriers. Yet courts in the United States have determined that incarcerated patients have a right to mental health services, as deliberate indifference to serious medical needs can represent a violation of constitutional rights.¹⁸ What this looks like in reality varies, as some correctional settings offer limited access to mental health care, whereas others offer extensive services, including inpatient psychiatric care.¹⁹ As summarized in a 2025 article, “carceral institutions may not be the correct environment for them to be receiving care. But that is where a very large number of persons with mental illness in North America currently receive care” (Ref. 20, p 7).

The Work with the Legal System

Working as a mental health professional in the criminal justice system can be challenging and frustrating but also deeply meaningful and rewarding. In a 1985 article, Jonas Rappeport wrote, “as [people] of science we are in an alien world when with the law. As [people] of law they are trying to force us aliens to speak their language” (Ref. 21, p 8). Medicine and law can seem like different worlds at times, and by caring for incarcerated patients, mental health professionals can serve as a bridge between these worlds. Many professionals in the criminal justice system, such as correctional officers, attorneys, and judges, have limited backgrounds in mental health and may harbor stigmatizing views of people with mental disorders or the care they receive; at the same time, legal authorities often want to help connect justice-involved people with mental health needs to necessary treatment services and alternatives to incarceration.^22,–,24 Mental health professionals can provide not only education about the needs of people with severe psychiatric illness and addiction but also advocate on behalf of their patients behind bars.²⁵

Caring for incarcerated patients also offers profound lessons in the structural and social determinants of health that shape patients’ lives. We spend a great deal of our medical education learning about clinical interventions, such as medications or surgeries, that we can use to heal patients. And although clinical care can save patients’ lives, jails and prisons bring into stark contrast the limitations of what health care alone can do for patients. Many patients cycling in and out of incarceration come from backgrounds of poverty, hunger, childhood trauma, homelessness, unemployment, and other forms of desperation.^1,26,27 The austere and traumatic environments of many jails and prisons, for example, with overcrowding, violence, loud noise, limited access to the outdoors, and limited ability to communicate with loved ones, further exacerbate these stressors.^1,26,27 It is difficult to ignore these structural and social determinants of health when “the forces that produce illness [are] as visible and tangible as a physical cage” (Ref. 27, p 390). Providing care in jails and prisons demands a sense of humility and a dedication to helping patients and staff navigate the structural violence that surrounds them.²⁷

Finally, jails and prisons bring to mind routine, uniformity, and predictability, but the criminal justice system is constantly evolving, and mental health professionals can provide input to help guide these changes. For example, although the United States is often viewed as a world leader in incarceration, recent policy reforms have led to substantial changes in incarceration rates, with the number of people incarcerated under state or federal jurisdiction falling by more than 20 percent between 2013 and 2023.¹⁰ James Forman Jr., a former public defender, once wrote, “We often lamented that there were never waiting lists for prison—just for alternatives to prison” (Ref. 28, p 227). Mental health professionals can inform the development of not only policies that better support incarcerated people and staff behind bars but also of community-based alternatives to decrease the need for incarceration.²⁵ Such attention to the disproportionate incarceration of people with severe psychiatric illness and addiction has led to a proliferation of programs, such as mobile crisis response teams, mental health diversion programs, drug courts, and mental health courts, that seek to better address mental health needs in community settings outside of jails and prisons.²⁹ It is often said “the physician is the natural attorney of the poor” (Ref. 30, p 2104); in my experience, accompanying incarcerated patients and standing beside them is essential to better understanding their needs and advocating for policy reforms grounded in health.^25,31

The People Behind Bars

In 2020, The New York Times ran an article reviewing “Marking Time: Art in the Age of Mass Incarceration,” an exhibition at MoMA PS1, an art institution affiliated with the Museum of Modern Art in New York City. According to the article, the exhibition displayed works from more than 40 artists. One piece included “nearly 500 drawings of incarcerated people” housed with the incarcerated artist and “occupie[d] an entire room in the heart of the exhibition” (Ref. 32, p C1). These drawings of incarcerated people sitting for portraits offer a striking reminder of the humanity of people behind bars.

Jails and prisons are often known for neglect and cruelty, but these can also be places where people demonstrate profound resilience, empathy, and simple acts of kindness.¹ Mental health professionals may encounter many different people behind bars, such as volunteers, attorneys, families of incarcerated individuals, and victims of crimes. Nonetheless, there are two main groups with whom we interact on a day-to-day basis and who can provide a deep sense of meaning and companionship in this work.

The first is incarcerated patients. People who have experienced incarceration face considerable public and internalized stigma because of perceptions that they are “criminals,” dangerous, or otherwise shameful.³³ Amid public discussions of crime, punishment, and justice, it is often lost that incarcerated people are just that, people. As the anthropologist and physician Paul Farmer asked, “If health care is a human right, who is human enough to access it?” (Ref. 34, p 1). Approximately half of the people in the United States have an immediate family member who has been incarcerated,³⁵ a stirring example of our shared humanity. Caring for incarcerated patients brings one face-to-face with the tremendous variety of life experiences (and typically impoverished backgrounds) that lead people to incarceration. In a 2022 article, Rachael Bedard, a physician, wrote, “I have spent a lot of time in my life speaking with people who have hurt others. Some were in denial about that harm, and some were sick with regret; still others had figured out how to take accountability for their worst actions without becoming entirely reduced to them and had grown wiser and better in that process” (Ref. 36, p 12). It is remarkable to bear witness to the resilience of incarcerated individuals to stark life circumstances and, oftentimes, the very human capacity to change and grow as a person.

The second is staff working behind bars. Many jails and prisons are notorious for shortages of qualified staff.^5,6 At the same time, there are many dedicated health professionals, educators, custody staff, and others who quietly show up day after day to work difficult jobs behind barbed wire.⁸ A 2001 article on multidisciplinary correctional mental health care highlighted that, “despite differences in their training, culture, and mission, correctional and clinical staff have some common goals” (Ref. 37, p 1347), such as the safety of everyone behind bars. In caring for incarcerated patients, one quickly learns that mental health professionals alone do not have all the answers. Multidisciplinary collaboration is essential to support both incarcerated patients and staff. In my experience, the staff most skilled in verbal de-escalation, crisis intervention, and other mental health techniques behind bars often have no clinical backgrounds at all. Jails and prisons can be traumatizing environments for incarcerated people and staff, yet it is still inspiring to see the dedication of staff who continue to come to work every day, who are able to maintain their sense of empathy, and who care for patients that the rest of society has otherwise turned away from.⁸