Abstract

Excerpted From: Emily R. Edwards, Gabriella Epshteyn, Caroline K. Diehl, Danny Ruiz, Brettland Coolidge, Nicole H. Weiss and Lynda Stein, Prison or Treatment? Gender, Racial, and Ethnic Inequities in Mental Health Care Utilization and Criminal Justice History among Incarcerated Persons with Borderline and Antisocial Personality Disorders, 48 Law and Human Behavior 104 (April 2024) (4 Footnotes/ References) (Full Document Requested )

Objective: Borderline and antisocial personality disorders are characterized by pervasive psychosocial impairment, disproportionate criminal justice involvement, and high mental health care utilization. Although some evidence suggests that systemic bias may contribute to demographic inequities in criminal justice and mental health care among persons experiencing these mental health conditions, no research to date has explicitly examined such differences. Hypotheses: Women and White persons would be more likely to endorse internalizing symptoms and have a more extensive history of mental health service utilization, whereas men, persons from minoritized racial groups, and persons identifying as Hispanic/Latino would be more likely to endorse externalizing symptoms and have more extensive histories of involvement with the criminal justice system. Method: This study examined gender, racial, and ethnic differences in symptom presentation, criminal justice history, and mental health care utilization in a sample of 314 adults with comorbid borderline and antisocial personality disorders enrolled in prison-based substance use treatment programs in the United States. Results: Results suggested that men with these personality disorders were more likely to have early extensive criminal justice involvement, whereas women and White people had more extensive mental health treatment histories. Women were also more likely to endorse a range of internalizing symptoms, and White and non-Hispanic participants were more likely to endorse a history of reckless behavior. Notably, however, many associations--particularly, racial differences in symptom presentation and mental health utilization history and gender differences in symptom presentation--did not persist after we controlled for preincarceration employment and educational attainment. Conclusion: Results highlight a range of gender, racial, and ethnic inequities in criminal justice involvement and mental health utilization among this high-risk high-need population. Findings attest to the likely impact of societal, structural, and systemic factors on trajectories of persons affected by this comorbidity.

Public Significance Statement

Societal, structural, and systemic factors influence illness trajectories of persons affected by comorbid borderline and antisocial personality disorders. Results of the present study suggest that men with this comorbidity are more likely to have early extensive criminal justice involvement, whereas women and White people are more likely to receive a range of mental health services.

The foundational role of systemic racism, discrimination, and anti-Blackness in mass incarceration has been extensively documented. Although some evidence suggests that racial, ethnic, and gender inequities in incarceration are compounded among individuals with mental health concerns, exploration of these inequities among persons with personality disorders has been remarkably limited. Personality disorders tend to be overrepresented among incarcerated populations and are significantly associated with engagement in behaviors that may result in judicial involvement (e.g., aggression and substance use. Thus, clarifying demographic inequities among judicially involved persons with personality disorders promises to have strong implications for treatment planning in carceral settings and broader strategies to combat systemic biases. Toward these aims, the present study compared patterns of prior mental health care utilization and judicial involvement across racial, ethnic, and gender identity groups within a sample of incarcerated persons meeting diagnostic criteria for personality disorders.

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Research and treatment settings focused on BPD and ASPD long have been limited by biased representation of gender, racial, and ethnic groups. Previous research suggests that barriers to care and demographic differences in symptom presentation may preclude mental health treatment utilization and instead promote criminal justice involvement among men and POCs with these personality disorders. However, to date, these potential sociostructural inequities have not been explicitly examined, particularly in high-risk, high-need clinical settings. In the current sample of incarcerated persons with comorbid BPD + ASPD diagnoses, women and White persons were more likely to be connected with mental health services, whereas men and persons from minoritized racial groups were less likely to access mental health services, and men were more likely to have earlier, more extensive histories of criminal justice involvement. Such findings attest to the likely impact of societal, structural, and systemic factors on trajectories of persons affected by this comorbidity. Particularly in work with clients with comorbid BPD + ASPD who are men and/or from minoritized racial groups, mental health providers should assess for criminal justice history and barriers to accessing mental health care, integrating the results of such assessment into working conceptualizations and treatment planning. Providers working in carceral settings may be in a favorable position to facilitate connection of such clients to needed mental health services.

Jennifer Cox served as Action Editor

Emily R. Edwards https://orcid.org/0000-0003-1030-6380

Gabriella Epshteyn https://orcid.org/0000-0002-9266-7763

Caroline K. Diehl https://orcid.org/0000-0001-7792-7400

Danny Ruiz https://orcid.org/0000-0002-8022-1318

Brettland Coolidge https://orcid.org/0009-0008-7619-5605

Nicole H. Weiss https://orcid.org/0000-0002-8245-0616

Lynda Stein https://orcid.org/0000-0002-7116-8834