Mental Health Treatment Experiences Before, During, and After Incarceration: Perspectives of Formerly Incarcerated Black Men

Abstract

Black men who have been incarcerated experience worse mental health outcomes than Black men without incarceration histories, reflecting both the trauma of incarceration and barriers to adequate care. This study describes the perspectives and experiences of formerly incarcerated Black men (FIBM) with mental health treatment before, during, and after incarceration. Using a qualitative design with semi-structured interviews and embedded quantitative surveys, we interviewed 29 FIBM. Quantitative data described the sample and treatment histories, while qualitative data were analyzed using reflexive thematic analysis. Most participants (n=26/29; 89.7%) reported receiving mental health treatment at some point in their lives. Three overarching themes emerged: (1) Treatment Timing Relative to Incarceration: treatment before incarceration often misaligned with needs, treatment during incarceration offered access but was constrained by limited resources, and treatment after incarceration offered greater agency; (2) Experiences Across Treatment Modalities: perceptions of individual therapy, group therapy, and medications varied. Positive experiences linked to supportive clinician or peer relationships and skill-building. Negative experiences tied to re-traumatization or reluctance toward medication; and (3) Treatment shaped by institutional surveillance and punishment: mandated care undermined engagement unless autonomy was maintained, and participants expressed mixed views on how substance use disorder treatment related to their mental health needs. Findings highlight that while it is essential to address the mental health needs of FIBM, treatment varies greatly in quality and impact. Future research should examine treatment types, settings, and trajectories over the life course to inform equitable, trauma-informed, and culturally responsive care for FIBM.

The United States (US) has one of the highest incarceration rates in the world (Carson, 2022; World Prison Brief, 2024) and the consequences of exposure to incarceration falls disproportionately on Black men (Bowleg, 2020; Nowotny & Kuptsevych-Timmer, 2018). Approximately one-half of Black men in the US have been arrested by the age of 23 years and one-third has had a felony conviction in their lifetime (Shannon et al., 2017). Extensive research has demonstrated that Black men who have been incarcerated experience worse mental health when compared to Black men without a history of incarceration, including higher depressive and posttraumatic stress disorder (PTSD) symptoms, and general mental distress (Addison et al., 2022; Anderson et al., 2016; Archibald et al., 2018; Assari et al., 2018; Bowleg et al., 2020). Prevalence estimates of diagnosed mental disorders, including substance use disorders, among currently and formerly incarcerated populations vary greatly by sample and method of measurement (ex. self-report, medical records, or clinical interview); however, prevalence is consistently much higher in incarcerated populations (Emilian et al., 2025; S. J. Prins, 2014). In samples of predominately formerly incarcerated Black men, rates of diagnosed mental disorders ranged from 15% - 50% (Ammon et al., 2018; Hagan et al., 2018; Wallace et al., 2016). These adverse mental health outcomes reflect both the trauma of incarceration itself (Assari, 2024; DeVeaux, 2013; Morrison, 2023; Piper & Berle, 2019), as well as the broader structural and sociocultural barriers that prevent Black men from accessing adequate mental health care before, during, and after incarceration. Lack of or inadequate mental health treatment contributes to diminished quality of life (Muller & Bukten, 2019; Shrestha et al., 2017), decreased capacity to manage co-occurring chronic illness (Voinov et al., 2013; Wildeman & Wang, 2017), substance use and overdose (Hotton et al., 2019; Pizzicato et al., 2018), suicide (Jang, 2025; Miller et al., 2024), and reincarceration (Zgoba et al., 2020).

Throughout the life course, Black boys and men are disproportionately exposed to adverse childhood experiences, including those with traumatic consequence (Sacks & Murphey, 2018), and systemic barriers to education and employment (Ajilore, 2020; A. Beaudry et al., 2015). These individual and structural disadvantages not only contribute to poor mental health but also can limit opportunities for comprehensive healthcare coverage, early intervention, and treatment, leaving many Black men without adequate mental health support before they come into contact with the criminal legal system (Auguste et al., 2023; Cogburn et al., 2024). Common barriers to engagement with mental health treatment include lack of insurance coverage and stigma associated with seeking mental health help (Asonye et al., 2020; Bauer et al., 2020; Jacoby, Rich, et al., 2018; Motley & Banks, 2018; Powell et al., 2016).

Notably, evidence suggests that mental health treatment may also prevent arrest and incarceration among those at risk (Handunge, 2022; Jácome, 2021). However, for those who do become incarcerated, their experiences with mental health treatment shift to correctional settings, where access and engagement in mental health treatment is complex and may remain challenging after release. The purpose of this study is to describe the perspectives and experiences of formerly incarcerated Black men (FIBM) with mental health treatment, including substance use disorder treatment, before, during, and after incarceration. Understanding how Black men engage with mental health treatment before, during, and after incarceration is critical for building more effective and equitable systems of care.

BACKGROUND

Correctional facilities are often cited as the largest providers of mental health treatment, serving individuals who lacked access to quality healthcare prior to incarceration (Al-Rousan et al., 2017). Many incarcerated individuals experience their first diagnosis or screening for chronic health conditions, including mental health disorders, while in custody (Al-Rousan et al., 2017; Elumn et al., 2021; Wildeman & Wang, 2017). Although correctional facilities are legally mandated to provide healthcare, including mental health treatment, the quality and availability of care varies significantly (Cropsey et al., 2012; Vandergrift & Christopher, 2021). Experiencing the harmful impacts of inadequate or low-quality care during incarceration, as well as broader intersections of the criminal legal and healthcare systems, may foster distrust and discourage continued health care engagement over the long term (Elumn et al., 2021; Jacoby, Kollar, et al., 2018; Jeffers et al., 2020; Vandergrift & Christopher, 2021).

Evidence regarding access and utilization of mental health treatment by Black men in correctional settings is mixed. Some studies suggest that being male or Black decreases the likelihood of receiving treatment (Koons-Witt & Crittenden, 2018; Severson et al., 2020), while others indicate higher participation rates among Black individuals compared to other racial groups (Fritz & Vaughan, 2023). One study of 250 formerly incarcerated Black men found that 10% received mental health treatment while incarcerated, and this group was eight times more likely to report mental health symptoms within the year following release, suggesting a need for continued care and support (Mahaffey et al., 2018). Qualitative studies have highlighted barriers to treatment engagement including lack of privacy and confidentiality, stigma, limited access, and distrust of health services and professional in correctional settings (Addison et al., 2025; Elumn et al., 2021; Preston et al., 2022).

There are similarly mixed findings from research on access to and engagement with mental health treatment among Black men after incarceration. Incarceration history has been shown to compound existing barriers to mental health treatment, such as socioeconomic disadvantage and inadequate health insurance (Sun et al., 2018; Timmer & Nowotny, 2021; Wallace et al., 2016; Williams et al., 2020; Zhao et al., 2024). However, there is concurrent evidence that suggests that individuals with criminal legal involvement may have higher engagement with mental health treatment despite these barriers; criminal legal involvement and incarceration may mandate or create access to mental health treatment which is then sustained after incarceration (Timmer & Nowotny, 2021).

The relationship between mental health treatment and continued involvement with the criminal legal system after incarceration is also complex. Some studies have demonstrated that mental health treatment following periods of incarceration reduces risk of reincarceration (Visher et al., 2017). Other evidence suggests that early access to mental health treatment may actually raise one’s risk of rearrest for violations of parole and probationary expectations (Domino et al., 2019), as engagement in treatment may increase oversight from the criminal legal system. Clinicians may be expected to report, for example, urine toxicology results, to parole or probation agencies, creating ethical challenges when providing court-mandated treatment to justice-involved clients (Domino et al., 2019). Despite recognition of these challenges, little is known about how formerly incarcerated Black men experience mental health treatment in the context of incarceration.

METHODS

This study is a qualitative secondary analysis (Ruggiano & Perry, 2019) of a parent mixed-methods study of mental health and health-seeking behaviors in FIBM. This paper presents both descriptive quantitative and qualitative findings to illustrate broader patterns of treatment engagement and describe treatment experiences. This study was approved by the [University] Institutional Review Board.

Convenience and snowball sampling approaches were used to recruit adult, self-identified Black men with any lifetime history of incarceration in the Philadelphia, Pennsylvania area. Recruitment was supported by a community partner, a certified peer specialist with lived experience of incarceration and hired as a research assistant, who shared study information through local social networks and reentry organizations. Participants were also encouraged to refer other FIBM in their social networks (Noy, 2008). In total, 29 formerly incarcerated Black men (FIBM) participated: 24 recruited via the community partner or reentry organizations, and 5 through peer referral. Sample size was guided by the concept of information power. Though similar to the concept of ‘data saturation’ for determining sample sufficiency, information power considers study aims, sampling strategy, analytic approach, and data richness together to determine whether a sample and associated data is adequate to generate the information intended to fulfil the aims of study (Malterud et al., 2016).

Data collection

Data collection for the parent study entailed one in-depth, semi structured interview and survey with each participant (n=29) between August 2022 and October 2023 focused on mental health and health-seeking behaviors. The interview guide included questions and prompts about mental health treatment for those who endorse ever receiving mental health treatment, including “Tell me about your experiences receiving mental health treatment” and “How did you get connected to that treatment? Was it recommended or required by a judge, parole, or probation officer?” For the purposes of this study, mental health treatment was defined as treatment for all mental health disorders, including substance use disorders, also referred to a “drug and alcohol” treatment.

Survey questions about mental health treatment history included treatment modality (e.g., individual therapy, group therapy, medication management) and the timing of treatment in relationship to incarceration experiences (e.g., before first incarceration, during any period of incarceration, or after incarceration - including between multiple incarcerations). In this analysis, which is focused on mental health treatment experiences as described in the interviews, description of treatment modalities and timing were broad and often focused on the most salient or recent experiences. The interviews did not include a detailed examination of each of the mental health treatment episodes that each individual may have experienced throughout their lives.

In the survey, validated instruments assessed depressive, anxiety, and PTSD symptoms. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ-2), a 2-item scale assessing depressed mood and anhedonia over the past week (Kroenke et al., 2003; Staples et al., 2019). PHQ-2 scores range from 0–6, higher scores indicating higher symptom severity with scores ≥3 indicating probable depression (Kroenke et al., 2003; Staples et al., 2019). Anxiety symptoms were assessed with the Generalized Anxiety Disorder measure (GAD-2), a 2-item scale with scores ranging from 0–6 and scores ≥3 indicating probable generalized anxiety disorder (Kroenke et al., 2007; Staples et al., 2019). PTSD symptoms were measured using the PC-PTSD-5, a 5-item scale assessing trauma-related symptoms in the past month with scores ranging from 0–5 and scores ≥3 indicating probable PTSD (A. Prins et al., 2016). The PHQ-2, GAD-2, and PC-PTSD-5 are validated screening instruments with demonstrated use across diverse populations, including studies involving Black men with histories of incarceration (Arabadjian et al., 2025; Hagan et al., 2018; Lathan et al., 2023; Ojeda et al., 2025; Staples et al., 2019; Zielinski et al., 2024). Additionally, sociodemographic characteristics (e.g., age, health insurance status) and measures of incarceration history and community supervision status were collected to describe the sample and their exposure to the criminal legal system.

Interviews took place via encrypted video-calling platforms, lasted on average 60 minutes, and were audio-recorded. Responses to survey questions were recorded in a secure web application for survey data collection and management. After each interview participants received a $50 VISA debit card (physical or virtual) and a list outlining free or low-cost behavioral health resources via text or email.

Data analysis

Quantitative survey data were analyzed in STATA (StataCorp., 2023). Descriptive statistics including frequencies and percentages were calculated for categorical variables. Interview recordings were professionally transcribed and verified for accuracy, and transcripts were managed and analyzed in NVivo (Lumivero, 2022). Braun and Clarke’s reflexive thematic analysis was used to analyze qualitative findings (Braun & Clarke, 2021). Participants chose pseudonyms though some were modified due to similarities to any participants’ actual name, and quotes were edited for brevity.

RESULTS

Participant Characteristics

Table 1 presents a summary of participant characteristics, including age, mental health symptoms, and details about their incarceration history. Overall, 26 out of 29 participants (89.7%) reported receiving some form of mental health treatment during their lifetime, most often during (n=19) or after (n=25) incarceration. All participants with who had mental health treatment at some point reported symptoms of depression, anxiety, and/or PTSD at the time of the interview. All participants had active health insurance, predominately Medicaid coverage (96.6%). Table 1 provides additional details on participant characteristics.

Table 1.

Participant Characteristics

Variable	n	%	Mean ± SD
Age
18–24	1	3.4
25–39	13	44.8
40–54	7	24.1
55+	8	27.6
Mental Health Symptoms
Depression Score (PHQ-2)
Mean ± SD	29	-	1.55 ± 1.66
Depression Score ≥ 3	8	27.6
Anxiety Score
Mean ± SD	29	-	1.52 ± 1.45
Anxiety Score ≥ 3	7	24.1
PTSD Score
Mean ± SD	29	-	2.41 ± 1.55
PTSD Score ≥ 3	15	51.7
Health Insurancea
Medicaid	28	96.6
Medicare	3	10.3
VA-Tricare	1	3.4
No health insurance	0	0
Age of first incarceration
≤ 17	14	48.3
18–24	12	41.3
25+	3	10.3
Total number of times incarcerated
Once	7	24.1
2–5 times	10	34.5
5 or more times	12	41.3
Total amount of time spent incarcerated
Less than 1 year	5	17.2
1–5 years	6	20.7
5–10 years	4	13.8
10–20 years	9	31
20 years+	5	17.2
Times since release
Less than 12 months	11	37.9
1 year to 5 years	9	31
More than 5 years	9	31
Current Community Supervision Status
Parole	8	27.6
Probation	8	27.6
Otherb	3	10.3
None	10	34.5

Note.

^aHealth Insurance is greater than 100% due to some participants having two types of health insurance.

^b“Other” for community supervision includes house arrest, and compassionate or medical release.

Theme 1: Treatment Timing Relative to Incarceration

The timing of treatment, whether before, during, or after incarceration shaped participants’ access, experiences, and perceptions of mental health care. Eight participants (27.6%) had received mental health treatment before incarceration, 12 participants (41.4%) received treatment for the first time during incarceration, and 6 (20.7%) received treatment for the first time after incarceration.

Subtheme 1a: Before Incarceration – Early Encounters and missed opportunities

Several participants reflected on mental health treatment they received prior to incarceration, most often during childhood including family therapy and school-based counseling. Participants described these experiences as excessive, inappropriate, or misaligned with their perceived needs. Shawn recounted his early trajectory into mental health treatment, including being hospitalized and medicated for depression, starting at age 12 after his brother died serving in the military: “Maybe somebody could’ve probably walked me through it with some type of grief counselor or something right then or make me understand what death is all about. You don’t just smack me with a whole mental health diagnosis, put me in the hospital and medicate me.” Others believed that they had been inappropriately diagnosed with several disorders throughout their lives. JD, who has also described early and extensive mental health treatment experiences stated, “They’ll diagnose you with anything if you let them.”

Despite this, some participants described missed opportunities for mental health treatment and believed it may have positively shaped their trajectory. David, who is currently in therapy, shared that he should have sought treatment when his younger brothers died, “I feel like if I would have did it earlier in my years it would have been way easier. I would have looked at life a little bit differently.” Yasin, who described past experiences as a victim of bullying and gun violence, shared, “If I were to receive mental health when I was probably younger, that probably would’ve helped me through a lot of situations.” For some, early encounters with mental health treatment contributed to a cycle of psychiatric hospitalizations and incarcerations; for others, the absence of mental health treatment left unaddressed trauma and grief that they believed negatively impacted their trajectory.

Subtheme 1b: During Incarceration – Access to care amid resource limitations

Nineteen participants (65.5%) received some sort of mental health treatment while incarcerated, including medication management (n=8; 27.6%), individual therapy (n=7; 24.1%), and group therapy (n=14; 48.3%) – some participants receiving a combination of these forms of treatments. Most recounted these experiences as inadequate or superficial. Participants speculated that the reasons for inadequate treatment experiences during incarceration were the correctional facilities’ lack of resources and exclusive focus on those at risk for suicide. Malcolm stated, “while the medical and mental health professionals are there, they don’t have the resources to care… I don’t think the facilities are set up to properly rehabilitate anyone.” Shawn shared his experiences with inconsistent medication administration due to short staffing, “The jail that I was in was understaffed and they would never give me my medication. They would give it to me, and then they wouldn’t give it to me for four days. Then, they would give it to me. After a minute, I was like, wait a minute. Do I even need this stuff?” Thomas scoffed at the idea of mental health treatment while incarcerated saying, “Oh, that’s bullcrap. That ain’t nothing. That’s just to see if you want to kill yourself therapy. ‘Are you going to hurt yourself? That’s all we wanna know.’” He later added, “I don’t want to hurt myself, but I need somebody. You don’t get that. It’s either that extreme and you get that, or no extreme and you get nothing.”

Other participants attributed the poor treatment experiences during incarceration to racism and other prejudices. Yasin explained, “That was horrible, I’m not gonna lie. I don’t think that that type of counselor is good for that environment because being upstate in Pennsylvania, it’s kind of racist…they don’t really care.” One participant, Mike, also shared that due to COVID restrictions at the time of his incarceration he received a “pamphlet about addiction” rather than participating in a 12-step program due to social distancing policies. Treatment during incarceration was often the first point of access to mental health treatment, yet participants described it as inadequate due to limited resources, racism, and narrow focus on suicide prevention.

Subtheme 1c: After Incarceration – Greater agency with continued barriers to care

Mental health treatment after incarceration was marked by increased mental health needs, yet participants described both positive and negative experiences when seeking care in the community. Some sought treatment after release but found services to be misaligned with their needs. Mike, who sought care for significant anxiety and distress after being released from a 15-year incarceration described his experience at a crisis response center: “they kept asking me, did I wanna hurt myself? And I didn’t wanna hurt myself… I just needed someone to figure out why these feelings was happening. I didn’t know what was going on.” He has not sought any mental health treatment since.

Others had more positive and impactful experiences that served as an opportunity to unpack past trauma, develop coping strategies, and make sense of their incarceration. Thomas, for example, described how his experience with therapy after incarceration helped him understand his experiences of trauma before and during incarceration; he stated, “and I think therapy is a profound way to kind of understand, not even just with the jail thing, but the trauma that you probably endured coming up.” Still, some participants noted that even in the community, providers often lacked adequate resources or relied on superficial engagement, particularly in mandated settings.

Participants who engaged with mental health treatment after incarceration often used their treatment experiences during incarceration to inform their treatment preferences and judge their current experiences. A couple of participants described staying on the medication regimen they had while incarcerated, often temporarily, to manage feelings of anxiety or depression. However, several others purposefully disconnected from prior treatment experiences and engaged in mental health treatment without continuing medications or services similar to those received during incarceration. Thomas shared how his rejection of medication was informed by his experience during incarceration: “they hooked me up with a psych and they try to give you Prozac and stuff like that. They try to smoke Black men up, man, instead of giving us what we really need and help our mindset… when I came home the first day, they’re like, you need some Prozac? You need some Seroquel? – No, I don’t need none of that. I just need to know how to deal with some things.” Overall, participants described their treatment experiences post-incarceration more positively compared to experiences during incarceration, especially when they could exercise agency in choosing the type of treatment they received.

Theme 2: Treatment Modalities

Participants’ experiences with mental health treatment were not only shaped by timing but by the type of treatment they received including individual therapy, group therapy and other group-based interventions, and psychiatric medication management.

Subtheme 2a: Individual Therapy – Self-expression, skill-building, and reflecting on past trauma

Of the 25 participants who received mental health treatment after incarceration, most engaged in individual therapy. Several described it as an opportunity to express themselves, learn coping skills, and rebuild interpersonal relationships. David appreciated the opportunity to talk without judgment, stating, “You’re able to talk to someone without them giving an opinion… that helps a lot.” John described that therapy improved his daily functioning and relationships: “I’m able to be better with my children. I’m able to be better with myself to get the best out of myself. I’m able to help other people as well. I’m able to communicate better and to function daily, more than I was functioning when I was struggling with PTSD.” Kenny discussed working with his therapist iteratively to develop coping and communication skills. He explained, “therapy itself, it pretty much gave me a toolbox… with certain techniques that I’d try, it didn’t work. And I went back and I said, hey, that didn’t work for me but I’m willing to try something else.” Some found formats, such as telehealth or activity-based sessions, to be particularly helpful. Den described, “It’s going well… We do it differently where we take rides. For example, he comes and pick me up from the crib and we go to different places, and just talk.”

In contrast, some participants described negative experiences with individual therapy, largely when it was consistently focused on past trauma. Duss explained, “The more I talked about it, the more I started to remember stuff that I had forgotten. And the more it made me angry, and I started getting angry. I was reliving certain things that I did not want to relive.” Similarly, Reese shared, “I don’t wanna keep talking about it no more. I got shot four or five years ago… What’s done is done.” Several participants expressed frustration with therapists who seemed disengaged, Antonio noting, “It didn’t really feel like she was there to help me.” A few participants described discomfort with blurred or inappropriate boundaries, including feelings of mutual attraction and “getting too close” to a therapist or perceiving therapists as displaying anger or jealousy. Den described his therapist getting upset and “started almost cussing me out” when he requested to see another clinician. Despite these challenges, individual therapy was most often described as beneficial when participants believed that they gained tools to cope with stressors.

Subtheme 2b: Group Therapy – Collective learning or harmful group dynamics

Several participants shared their experiences with group-based interventions, including processing or diagnosis-specific groups (including substance use focused groups), psychoeducational classes, and therapeutic community units in correctional facilities. Some participants valued the shared environment, reporting that being around others with similar experiences fostered reflection, learning, and a sense of community. Thomas reflected on his time on a therapeutic community unit: “That was the best thing that happened to me in jail… We all learned from each other. That part really helped me.” Tyrell who was engaged in group therapy post-incarceration explained, “I think it helps my mental health because being able to be around people.” Participants appreciated opportunities to mentor others or help lead discussions, which helped them learn, feel empowered, and gain new skills.

However, others experienced dissatisfying, even harmful, experiences in groups. Yasin described the lack of structure and support in a mandated substance use disorder group, describing facilitators who “don’t really educate you… they don’t put no time or no effort into actually teaching you what’s wrong.” Others described their experiences of being triggered or re-traumatized as other group members described their experiences. Duss reflected on his discomfort with group treatment, saying, “My trust level is really low… I don’t like when men start to talk about the surface and glamorize anything that was unlawful or bad for them to do. It angers me.” While some found healing in collective spaces, others struggled with re-traumatizing experiences and lack of adequate group facilitation in group settings.

Subtheme 2c: Medications – Symptom relief, ambivalence and resistance to long-term use

Several participants had experience with psychiatric medications and described medications as helpful, particularly for managing anxiety, sleep disturbances, or trauma-related symptoms. Yet even among those who reported benefits, many expressed ambivalence about long-term use and described actively weaning themselves off medications, only taking them intermittently or taking breaks to assess their reliance on medications. Reese explained, “sometimes if I run out of medication, let’s say I run out Monday, I don’t refill it until Wednesday or Thursday sometimes. Just to see if I’m addicted or not.” Participants acknowledged that some people may really benefit from medications so they would not discourage others from trying medication, they still warned against people becoming dependent on medications. Notably, a couple of participants also described positive experiences using medical marijuana for anxiety and depression and expressed that it allowed for symptom management with minimized legal risks or concerns about dependency.

Participants frequently referenced overreliance on medication in correctional settings and described the processes of getting medications as indiscriminate. Duss recalled his experience, “All they did was give me medication. They never asked what was going on with me, they just got me in line and I took the pills.” Some participants also noted a lack of clarity about why they were prescribed some medications. Others pointed out concerns that “capitalism” and “Big Pharma” led clinicians to push medications and not address actual treatment needs. These perspectives contributed to reluctance in engaging with psychiatric medications post-release or long-term use, instead prioritizing understanding their mental health and building coping skills without medications.

Figure 1. summarizes the number of participants’ mental health treatment experiences by timing relative to incarceration and modality.

Figure 1. Mental Health Treatment Experiences by Timing and Modality.

Note. Participants were first asked about mental health treatment experiences, then probed about substance use disorder (SUD) treatment specifically. “Including SUD” represents participants who initially denied mental health treatment but later reported SUD treatment experience.

Theme 3: Treatment shaped by institutional surveillance and punishment

At the intersection of treatment and criminalization, participants’ experiences with mental health treatment were often shaped by systems of surveillance and punishment, particularly in the context of mandated care and substance use disorder treatment.

Subtheme 3a: Mandated Treatment – Navigating motivation, engagement, and the role of agency

Fourteen participants (48.3%) described being mandated to receive mental health treatment at some point in their lives, often as a condition of parole or probation. While a few acknowledged that mandated treatment introduced them to services they might not have pursued otherwise, most described superficial engagement. James expressed: “It’s just that I had to go to keep from violating my probation.” Participants emphasized that the compulsory nature of mandated treatment often undermined its effectiveness. Despite these challenges, some participants found mandated treatment more tolerable or even beneficial when their autonomy was respected. This included being allowed to opt out of medications or to speak only when they were ready during group sessions. JD explained, “They’re not forcing their diagnosis or their medications on me…that would really mess me up. If you’re going to sit here and tell me that I got to be forced to take some medication. Like, no. So they are helping me in that aspect whereas though they’re not forcing me.” The ability to maintain agency, even in the context of a mandate, was important to their willingness to participate meaningfully.

Subtheme 3b: Substance Use Disorder Treatment – Addressing mental health needs or not

Sixteen participants (55.2%) reported receiving SUD treatment at some point in their lives, often as a condition of parole or probation. Some of these experiences were shaped by the referral process. Several participants noted that their referral to SUD treatment was based solely on being charged for possession of a substance or being intoxicated at the time of their arrest rather than any assessment of their substance use patterns. As a result, treatment felt misaligned with their perceived needs and was viewed as a way to comply with court orders and avoid or reduce time spent being incarcerated. Even when SUD treatment was mandated for participants who agreed that they had a SUD and needed SUD treatment, many described superficial programming and a lack of engagement or follow-up support, which made it difficult to make meaningful efforts towards recovery.

Notably, participants highlighted differing perspectives on whether SUD treatment was considered mental health treatment. Malcolm, who voluntarily sought SUD treatment after the loss of his infant son decades prior to his incarceration, shared, “Back in the ‘90s, I had a stint with drugs. I think that was the time where drug addiction was first becoming recognized as a mental health disease.” For some participants SUD treatment provided opportunities for reflection and growth, even when the treatment was not framed as mental health care. Yasin explained, “It taught me a lot of things about certain aspects of my life. It just educated me on a lot of things that I had wrong with me.” In contrast, some participants emphasized the distinction between SUD, or “drug and alcohol,” treatment and mental health treatment. Victor stating, “I never actually had a mental health session, just drug treatment…that’s part of the drug program. I did have outpatient, but it wasn’t regarding mental health, just related to my addiction.” Overall SUD treatment was experienced as supportive by some and superficial by other participants, with varied perspectives on whether SUD care constitutes mental health treatment.

Table 2 provides expanded exemplar quotes for each theme.

Table 2.

Exemplar qualitative quotes

Theme	Subtheme	Exemplar Quotes
Treatment Timing Relative to Incarceration	Before Incarceration – Early Encounters and missed opportunities	When I was 12 years old, my brother got killed in the Army. So me being very young and my mind very underdeveloped, I had no idea how to take that. I didn’t know how to process that. And I started acting out at school and just period, and my parents thought it would probably be a good idea if I go see somebody, and that’s when I got diagnosed with depression and hospitalized and all that stuff. Even still, that was even wrong then, as I look back on it in hindsight… Maybe somebody could’ve probably walked me through it with some type of grief counselor or something right then or make me understand what death is all about. You don’t just smack me with a whole mental health diagnosis, put me in the hospital and medicate me. That’s really bad. – Shawn During the passing of my little brothers. I felt like if I were to reach out to someone like I am now, things would have been a lot better… I feel like if I would have did it earlier in my years in there it would have been way easier. I would have looked at life a little bit differently. – David If I were to receive mental health when I was probably younger, that probably would’ve helped me through a lot of situations because I was going through a depressed time in my life when I was younger. - Yasin
	During Incarceration – Access to care amid resource limitations	While the medical and mental health professionals are there, they don’t have the resources to care… I don’t think the facilities are set up to properly rehabilitate anyone. – Malcolm That was horrible, I’m not gonna lie. I don’t think that that type of counselor is good for that environment because being upstate in Pennsylvania, it’s kind of racist and the mountain people, they really don’t like city people because whatever reason it is, so they don’t do too much. They don’t teach you anything in them classes. They just have you sit there for hours filling out paperwork. They don’t really educate you on what’s going on around you and things like that, and they just go off topic on a lot of things. And they don’t really care. They don’t put no time or no effort into actually teaching you what’s wrong with your mental state. – Yasin The jail that I was in was understaffed and they would never give me my medication. They would give it to me, and then they wouldn’t give it to me for four days. Then, they would give it to me. After a minute, I was like, wait a minute. Do I even need this stuff? I don’t feel bad. Let me see what happens if I don’t take it. So then I didn’t take it for like 30, 25 days. And I was like, you know what? Maybe I don’t even need it - Shawn
	After Incarceration – Greater agency with continued barriers to care	They kept asking me, did I wanna hurt myself? And I didn’t wanna hurt myself… I just needed someone to figure out why these feelings was happening. I didn’t know what was going on – Mike I think therapy is a profound way to kind of understand, not even just with the jail thing, but [also] – the trauma that you probably endure coming up. …This is one approach that I think that a lot of men don’t even use. – Thomas It lets off a lot of relief when you just sit there and you’re able to talk to someone without them giving an opinion, they’ll just listen to you, and it’s like that – that helps a lot. It helps a lot. It relieves a lot of stress. – David
Experiences Across Treatment Modalities	Individual Therapy – Self-expression, skill-building, and reflecting on past trauma	Somebody who was trained. Somebody who was able to ask those questions, being, what’s the word, unbiased. No matter what the circumstance or situation is…That’s what helped my mental health because it brought me to a point where the conversation didn’t just stop at therapy. I was able to come home and talk to my family. I was able to listen a lot better, like that. Take advice. Because the therapist that I have now, she’ll tell me, my suggestion to you or how I’m asking you to handle a situation may not work for you, but it’s a matter of are you willing to try different things, techniques that work? Because in life, it’s not a one-stop shop. You may try something and it might not work, but that’s don’t mean you give up. But therapy itself, it pretty much gave me a toolbox…a Phillips screwdriver can’t work all the time. Sometimes you need a flathead. Sometimes you might have to get a socket, like that, and you might have to use a wrench. And that’s pretty much what it done because, with certain techniques and certain things that I’d try, it didn’t work. And I went back and I said, hey, that didn’t work for me but I’m willing to try something else. – Kenny That’s the strange thing, they said the more you talk about it the better you feel. The more I talked about it, the more I started to remember stuff that I had forgotten. And the more it made me angry, and I started getting angry. I was reliving certain things that I did not want to relive, or I put to the past. And that was it. I stopped going. - Duss
	Group Therapy – Collective learning or harmful group dynamics	That was the best thing that happened to me in jail…You all learned from each other. You all called each other out on your behaviors with them, and that was intense. Because you’re in that group. So whatever you do out there in the community, somebody is going to bring that back to the group, in your group. You might not even have thought about it. And that was the idea. I’m like, I used to think that was ratting. When I got there, and I was like, no, that’s not ratting. No, we helping each other. That’s what Black men got to get over, the idea of something that can help you. We put a stigma on it because we’re taught not to deal with shit like that. Calling people on shit and telling somebody, oh, this what you do. We don’t do that. You know what I’m saying now? So the idea of doing that and seeing it works. You do that out here on the street, you going to get killed. So that was very – a defining factor in my life. That part of my life really helped me. – Thomas I think it helps my mental health because of being able to be around people … being able to talk people about my past in addiction and staying clean and focused more and not using. Just talk about some past and present things that’s going on and things that I used to do in the past. It helps me see things being able to talk to somebody like a group therapist consistently. – Tyrell I’ve not really been that big with sitting with a circle of strangers. You know, my trust level is like this, really low. And I don’t like sitting near strangers. And I don’t like when men start to talk and they say stuff that – I don’t like people to talk about the surface or glamorize anything that was – that’s unlawful or bad for them to do. It angers me, I mean, I get really angry. I like, I snaps, like I got kicked out of several groups, understand? Especially if a man tell me that he touched people because he was raped and stuff. I was molested as a child but I didn’t wanna touch another little boy. So sitting it groups ain’t for me, never will be. – Duss
	Medications – Symptom Relief, ambivalence and resistance to long-term use	It was like a chill pill. Yeah, like the medication that they prescribed was like a chill pill. It calmed me right down. I was a little aggressive… It’s like they have you in a different world. It’s like you’re there, but you’re not. It’s weird. Now, I don’t prefer that for nobody. I don’t want to [recommend] nobody to take medications. – Tay So when I went to get evaluated they said I got posttraumatic stress disorder. So they put me on medication. I’m only on Gabapentins and Benadryl just to sleep at night. Because I get anxiety…. sometimes if I run out of medication, actually I run out Monday, I don’t refill it until Wednesday or Thursday sometimes. Just to make sure – to see if I’m addicted or not. I gotta fight. So – but it’s hard for me to go to sleep. I’m up longer. I’m a little bit more agitated. I can deal with it, but I’m up a little longer. And I don’t sleep like I’m supposed to. – Reese Do I still take medication and stuff? Yeah and I’m trying to wean myself off of that, too, because all of that stuff, it’s capitalism. We got to be real about it. It ain’t got nothing to do with health. They got to push the big pharma, push the pills and make the money. - Shawn
Treatment Shaped By Institutional Surveillance and Punishment	Mandated Treatment – Navigating motivation, engagement, and the role of agency	It’s court stipulated. Yeah. So I’m following those orders right there. They’re not forcing their diagnosis or their medications on me. They’re not. You know what I mean? Because I don’t want you to force it on me…No, that would really mess me up. If you’re going to sit here and tell me that I got to be forced to take some medication. Like, no. So they are helping me in that aspect whereas though they’re not forcing me. Although, I’m stipulated they’re just not forcing me. – JD I’m gonna be honest with you. No [it did not make a difference]. It’s just that I had to go to keep from violating my probation, or whatever. It was mandatory. – James I got locked up, that was – they locked me up with a little bit of marijuana so they put me in a program. So that’s why I had to do that, but that wasn’t that long. I only had to do that for a couple of weeks - Rob
	Substance Use Disorder Treatment – Addressing mental health needs or not	Back in the ‘90s, I had a stint with drugs. And I think that’s – I think that that was the time where drug addiction was first becoming or becoming recognized as a mental health disease. We’re talking the early ‘90s. And I had – I had – I had twins in 1990. And I lost my son at 28 days. He was 28 days old…he passed away. And although I knew all the perils of drugs, I fell into a tailspin. And subsequently, was – I sought rehab at a mental health institution. So, I think I was in-house for maybe 30, 45 days. And then maybe six months in follow-up. Yeah. But when I say follow-up, I mean going to see a counselor maybe two or three times a day – two or three times a week. Something like that. Being on psychotropic drugs. Things like that. Yeah. – Malcolm I never actually had a mental health session, just drug treatment…that’s part of the drug program. I did have outpatient, but it wasn’t regarding mental health, just related to my addiction. - Victor I was going to outpatient at [clinic name] but that wasn’t mental health, it was drug and alcohol. – James Drug and alcohol is basically going back to school for real, just a bunch of – they teach you about – I don’t even know how to say it – drug abuse and stuff like that. And they teach you about why not to use drugs period and why it messes your mental state up. For me, like I said – I just had inpatient. Inpatient was okay. Inpatient, it taught me a lot of things about certain aspects of my life. It just educated me on a lot of things that I had wrong with me. - Yasin

DISCUSSION

The prevalence of mental health symptoms and diagnosed mental illness among currently and formerly incarcerated individuals has led to efforts to integrate mental health treatment within correctional facilities and the broader criminal legal system, including policing, courts, and community supervision (Munetz & Griffin, 2006). This study’s focus on the mental health treatment experiences of FIBM offers important insights into how incarceration may simultaneously serve as a point of entry into mental health treatment and reinforce mistrust and barriers associated with mental health treatment.

Results revealed that the few participants who had received any mental health treatment prior to incarceration did so during childhood, many believing that these early experiences negatively impacted their life trajectory. These findings are consistent with research establishing Black children and their families often describe mistrust and dissatisfaction towards mental health treatment due to their heightened risk of misdiagnosis or overdiagnosis, coercive care, and loss of civil liberties (Faber et al., 2023; Legha et al., 2022; Scott et al., 2011). The impacts of racism in mental health treatment extend beyond childhood, and lead to “lifelong punitive societal implications, including reduced opportunities, substandard care, increased contact with the legal system, and criminalization” (Faber et al., 2023). In contrast, some participants wished they would have received mental health treatment or other supportive services earlier in their lives. Early intervention and provision of mental health treatment has potential to mitigate the harms of early childhood trauma and adverse experiences, and prevent future incarceration (Hawks et al., 2022; Jácome, 2021). Treatment providers and mental healthcare systems must actively address sources of harm in the mental health system, such as racism, misdiagnosis, lack of diversity in the norming of assessment tools, and coercive care (Faber et al., 2023; Handunge, 2022; Legha & Miranda, 2020), and recognize the impact that prior negative experiences has on the initiation and continuity of treatment.

For nearly half of participants, incarceration was the first point of exposure to mental health treatment, aligning with broader literature identifying correctional settings and contact with the criminal legal system as a mechanism to connect underserved populations to care (Al-Rousan et al., 2017; Munetz & Griffin, 2006; Torrey et al., 2014). However, this entry point raises complex issues around whether carceral settings can adequately serve therapeutic purposes. Participants described mental health treatment in correctional facilities as more focused on control and punishment than healing and empowerment, a perception consistent with existing research (Hörberg & Dahlberg, 2015; Preston et al., 2022). These perceptions can be attributed to the punitive practices that result from prioritizing risk management and liability concerns in correctional mental health services (Barsky, 2022). For instance, restrictive housing for people with mental health conditions has been used in attempts to minimize suicide risk and self-injurious behaviors, however it often fails to prevent these risks or address people’s underlying mental health needs, and may cause additional harm (Barsky, 2022). Participants also expressed discontent as they perceived excessive use of psychiatric medications as the primary form of mental health treatment; a finding aligned with documented concerns that prisons overprescribe psychiatric medications as a strategy to “control the behaviors of inmates” (Nishar et al., 2025; Reutter, 2016; Saisi, 2020; Zaitzow & Brooks, 2007). The resource constraints, a narrow focus on risk management, and overreliance on psychiatric medications within correctional facilities may exacerbate distrust and discourage future engagement in mental health treatment (Reutter, 2016; Elumn et al., 2021).

It is also important to note that many participants’ descriptions of treatment received during incarceration did not appear consistent with evidence-based mental health interventions, despite the fact that there is a growing body of literature supporting the efficacy of specific evidence-based treatments in carceral settings (G. Beaudry et al., 2021; Yoon et al., 2017). For example, several participants expressed a desire to learn practical coping skills but the treatment they received was unstructured and appeared more consistent with supportive counseling. These treatment experiences may be reflective of a time when the availability and implementation of evidence-based treatment in carceral contexts were more limited. Participants’ desires to develop coping skills indicates the potential benefits of implementing structured evidence-based treatments that focus on skill building, such as cognitive behavioral therapy or dialectical behavior therapy, which have been shown to be effective in carceral settings when properly adapted (Berzins & Trestman, 2004; Edwards et al., 2023; Rosenfeld et al., 2024; Winicov, 2019; Zielinski et al., 2023).

Most participants engaged in mental health treatment after incarceration, often voluntarily, to address trauma or symptoms they believed were worsened by incarceration. Experiences with mental health treatment after incarceration were mixed but generally more positive, due to greater autonomy and accessing care aligned with their goals and desires for treatment, in stark contrast to their constrained experiences while incarcerated (Nishar et al., 2025; Preston et al., 2022). Those who received mandated treatment after release often found it superficial or unhelpful. These experiences underscored the importance of a strong therapeutic relationship: empathy, trust, cultural responsiveness, and shared decision-making were critical to meaningful engagement, yet frequently absent in settings shaped by the criminal legal system (Merkt et al., 2021).

Participants’ experiences with mental health treatment were categorized into three modalities: individual therapy or counseling, group-based therapy, and medication management. While some participants had positive experiences with each modality, there were unique considerations within these modalities that shaped participant perceptions.

For individual therapy, participants highlighted the importance of being able to discuss their problems and develop insights and skills to solve them, aligning with contemporary approaches that emphasize solution-oriented approaches that identify strengths and empower clients (Jerome et al., 2023). While there may be increased needs and demand for mental health services for individuals after release from incarceration, healthcare providers in community settings report low levels of confidence in being able to assess and address the needs of formerly incarcerated individuals (Patil et al., 2024). Those who had negative experiences described misalignment between their goals for treatment and their clinician’s goals, such as many participants wanted to learn new coping skills whereas their clinician encouraged the processing of past trauma. Efforts should be made to empower clients to establish their own goals in treatment, rather than the clinician unilaterally identifying goals, as goal consensus is one of the strongest predictors of a positive therapeutic alliance and effective therapy (Wampold, 2015).

Group therapy, which was most common during incarceration, varied significantly in structure, focus, and facilitation. Group psychotherapy was initially designed to be process-oriented and focused on interpersonal dynamics within the group (Yalom & Leszcz, 2020). This type of group therapy is rarely offered for individuals with criminal-legal involvement. Instead, group therapy tends to be psychoeducational, in which group members are taught coping skills but rarely have time to reflect and process. Opportunities to connect with peers, and foster community and mutual support were described as the most salient benefit of groups, while participants consistently discussed a lack of structure and depth, and, at times, an outright disregard for the needs of participating individuals.

Experiences with medication management were mixed, though largely negative during incarceration. Many participants described being medicated without adequate explanation, follow-up, or therapeutic support. After incarceration, participants chose to discontinue medications and avoid medications when seeking and engaging in mental health treatment. This aligns with prior research that Black men with mental illness were less likely to receive psychotropic medications or mental health treatment but were more likely to engage in self-help programming (Koons-Witt & Crittenden, 2018).

The criminalization of behaviors related to mental health conditions such as substance use, and the integration of mental health treatment in the criminal legal system has led to the emergence of mandated treatment, which is often deemed to be problematic. Some participants described positive experiences with mandated treatment, when they felt they could still exercise autonomy in how they engage with treatment and goal setting. Where that autonomy was absent, participants often disengaged or viewed treatment as an extension of carceral control and punishment. Mandated treatment can harm the therapeutic alliance by placing therapists in a complex dual role in which they are responsible for caring for, and having control over, their clients (Hachtel et al., 2019). Research has revealed that the perception of coercion is harmful to the therapeutic alliance (Hachtel et al., 2019). Although research has shown that mandated treatment can be effective and may reduce re-incarceration (Visher et al., 2017), evidence suggests that behavioral changes last longer when they are a result of intrinsic motivation (Hachtel et al., 2019). Behavior changes that occur as a result of extrinsic motivation only tend to last as long as the extrinsic controls are in place (Hachtel et al., 2019). When treatment is mandated, it is important that clinicians make efforts to build intrinsic motivation, such as motivational interviewing techniques, rather than relying on extrinsic motivation based in legal mandates.

Substance use disorder treatment stood out as something distinct from other forms of treatment. These treatments were often tied to drug-related charges, whether or not any diagnosed substance use disorder or other clinical need was identified (Paquette et al., 2025). The distinctions participants had between mental health and drug and alcohol treatment underscore the need for integrated, trauma-informed care that acknowledges the complex and overlapping needs of justice-involved individuals (Edwards et al., 2025; Paquette et al., 2025). Overall, the findings of this study support the need for more nuanced, evidence-based mental health treatment programs that account for the structural and racialized realities of healthcare needs associated with incarceration in the context of drug criminalization and enforcement.

Limitations

Findings of this study should be interpreted in the context of its limitations. Several participants had numerous mental health treatment experiences during and after incarceration, and most also had multiple incarcerations. Timing of treatment was limited to categories of before first incarceration, during incarceration, and after incarceration (including in between multiple incarcerations). Treatment experiences could have been measured more thoroughly and longitudinally for enhanced clarity on how and when different treatment experiences occurred in relationship to different incarceration experiences. This present study is a secondary data analysis of a mixed-methods study examining mental health and health-seeking behaviors, thus relevant data that would have strengthened this analysis including, mental health diagnoses, lengths of treatment episodes, the use of evidence-based treatment approaches, and whether each treatment episode was mandated or otherwise coerced, were not collected. Nonetheless, this is one of the first studies to examine mental health treatment experiences among FIBM by timing and modality, providing a foundation for future research that can examine mental health treatment episodes more thoroughly. Some participants were incarcerated during COVID restrictions which impacted the treatment they received. Although SUD treatment experiences were included in our analysis and captured in quantitative surveys, participants may have de-emphasized these experiences in qualitative interviews, as many did not view SUD treatment as a form of mental health treatment. As a result, our qualitative findings may underrepresent these experiences.

Implications and Conclusion

Overall, the findings of this study carry important implications. First, while incarceration may serve as an entry point to identify unmet mental health needs, mental health treatment often reinforce carceral logics by prioritizing surveillance, punishment, or control, especially within correctional facilities or otherwise linked to the criminal legal system such as mandated care (Elumn et al., 2021; Preston et al., 2022; Vandergrift & Christopher, 2021). Community-based mental health providers and health systems should work towards making trauma-informed, culturally responsive, and voluntary mental health treatment more accessible (Faber et al., 2023; Legha & Miranda, 2020; Levenson & Willis, 2019). While increasing access to mental health treatment is important, such treatments are not uniform, and it is essential for future research to examine how different modalities, settings, processes, and other factors affect the quality of mental health care provided and the resulting mental health outcomes and reincarceration.

The mental health field has long struggled with a lack of diversity in practitioners, and underrepresentation of Black mental health professionals is especially pronounced (Ajluni & Michalopoulou, 2025). Racial and ethnic differences between mental health professionals and patients, when combined with unaddressed structural biases, are associated with misdiagnosis, inadequate treatment and reduced patient engagement (Ajluni & Michalopoulou, 2025; Cabral & Smith, 2011); thus, it is imperative that efforts are made to recruit and retain a racially and ethnically diverse mental health workforce in carceral settings, alongside training that supports culturally responsive care for all patients. Lastly, FIBM in this study prioritized care that was relational, empowering, and practical. It is essential to promote shared decision making within a therapeutic alliance and empower clients to set treatment goals (Hachtel et al., 2019; Sotero et al., 2016). Future efforts to address the mental health needs of people who have been incarcerated may be more engaging and effective when they center values of agency, trust, and community as core strategies of mental health treatment.

Public significance statement:

This study describes how formerly incarcerated Black men experience mental health treatment before, during, and after incarceration. Findings highlight that while incarceration can serve as an entry point for care, treatment shaped by punishment, minimal resources, and racism may be harmful and discourage continued engagement. Participants valued care that fostered agency, skill-building, relationships, and community, underscoring the need for trauma-informed, culturally responsive approaches tailored to individual needs.