I work as a psychiatrist in the mental health clinic at the Anna M Kross Center (NY, USA), the largest jail on Rikers Island, where I evaluate and provide continuing care for patients following their arrest. My patients are mostly black and brown men, 80% of whom are awaiting trial and innocent under the law, living through the profoundly dehumanising experience of detention. Physical contact, privacy, freedom of movement, and a quiet place to sleep are among the many things lost to them. The vestigial language of the jail system (eg, “bodies” instead of people, and “pens” instead of waiting rooms) reduces them to objects or animals. Since the start of the coronavirus disease 2019 pandemic, they have been locked away in close, sometimes unsanitary, quarters with a predator they cannot see, watching the news, helpless and terrified, as the same predator kills their relatives and cripples their communities.
When patients have serious mental illness, I refer them to the hospital or to special jail units for treatment. However, the hardest and most rewarding part of my job is to differentiate symptoms of mental illness from the inherent stress of jail, and manage each of these appropriately. Sometimes, medication and therapy are indicated. Other times, I learn from my patients and encourage their resourcefulness. When a patient who could not sleep told me he had made earplugs by using his toothpaste cap to punch holes in the foam soles of the shower shoes sold in commissary, I passed his invention along to other patients with insomnia.
I recently evaluated a 56-year-old African-American man for a psychiatric assessment. As a 12-year-old boy, Mr M had been playing basketball with friends when a detective offered each child US$5 to be interviewed about a robbery in a nearby building, and then arrested him. During his 3-year incarceration, he was sexually assaulted and learned to fight to protect himself. He developed depressed mood, hypervigilance, nightmares, and a constant, simmering rage he struggled to control. Upon release, he coped with his trauma for nearly 20 years without treatment. At age 44, he was assaulted again, and began self-medicating with cocaine and cannabis to manage his worsening symptoms. His drug use led to the loss of his job as a barber and the dissolution of his marriage.
Mr M was skeptical during our first session. He had told his story before and the solutions he had been offered, ranging from reassurance to antipsychotics, failed to alleviate his symptoms and invalidated his experience. We discussed the ways that he had been affected by racism in the justice system and the malevolence of trauma—the way it lurks in the body for years, sharpening nerves, stoking fear, and destroying the capacity for pleasure. I told Mr M that his symptoms were a normal, even inevitable response to his experience—of course they were worsened by jail, the site of so much torturous memory. In such a bleak environment, it is tempting to try to medicate away anger and despair and to offer platitudes of optimism. However, to do this negates my greatest privilege as a correctional psychiatrist: the ability to be with my patient in the reality of their situation, to acknowledge it, and to help them bear its weight. As he did not meet the criteria for post-traumatic stress disorder, I diagnosed other specified trauma and stressor-related disorders while explaining that we lack the diagnostic language to fully capture the impact of years of racism, confinement, danger, and adversity. Mr M had been treated with antipsychotic medication after reporting explosive anger, but it dulled his thinking while his anger remained. We discussed tapering off the antipsychotic and started an SSRI for anxiety, and prazosin for his nightmares and insomnia. At the end of our visit, I asked Mr M how he felt about our plan. He smiled warmly and told me that, for the first time since his arrest, he felt seen.
Like many of my patients, Mr M's resilience inspired me. During our next few meetings, I worked with him to manage his expectations about treatment: his anguish and rage were justified and could not be medicated away. I hoped the medications would make his time in jail tolerable and gradually improve his symptoms enough to allow him to engage with the world in a fulfilling way. We developed a warm, familiar rhythm. He made fun of my sneakers. I printed out Maya Angelou poems for him to read in his dorm. His nightmares improved and he felt more like himself once the antipsychotic was discontinued. When we practised slow breathing, I watched his forehead smooth and the tension melt from his shoulders.
Psychiatrists are taught that pathology resides within the individual. But in approaching symptoms that arise from a system that is, itself, broken—an environment in which suffering is expected, and even intended—we must remember how important it is to listen completely and try to understand before we can fix. My work is hard, but it is enormously gratifying to be present with my patients during their darkest moments—to let them know they are seen and heard when they feel invisible, to joke and laugh when they need a moment of levity, to bear witness to their pain and helplessness, share in their rage, and help them hold the feelings that are too heavy to carry alone.
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