Lessons From My Uncle: Mental Health Care Access, Incarceration & Structural Racism in Rural America

A Center for Community Resilience ‘Emerging Voices in Public Health’ guest blog by Katherine Hill, MPH ’22, George Washington University Milken Institute School of Public Health

My uncle was eighteen years old when he became involved with the criminal justice system. Coming from a poor, rural family, he did not have access to treatment for his mental illness. In 1997, he had a manic episode spurred by his untreated bipolar disorder. He called the police, thinking they would be able to help him. However, the police found crack cocaine in his motel room, and he was arrested for possession and intent to distribute. Since then, he has been incarcerated or under community supervision for the entirety of his adult life.

My uncle is White, yet his experiences with systems — including lack of access to supports and treatment — are the result of structural racism embedded within our nation’s systems, from criminal justice to mental health services and beyond. It might be hard to understand how a White person can be harmed by, rather than benefit from, structural racism.

My uncle, along with many other White people living in poor, rural areas, are churning through the same systems that were designed to oppress people of color. It is essential to dismantle these racist structures and repair the harm done to the people of color they were designed to subjugate. What often gets missed is that doing so will benefit .

Class: A Tool of Structural Racism

Structural racism is designed to ensure White Supremacy as an outcome; therefore, our systems prioritize Whiteness and wealth and deny people of color power and economic mobility. Yet, as my uncle’s experience demonstrates, structures like the criminal justice system fail poor people, regardless of race. This is not to say structural racism acts upon all of us equally — it does not. While my uncle’s race as a White person is not a liability, his social position — or class — as a person living in poverty in a rural community is a liability. With this in mind, we can begin to explore how class stratifies people in a hierarchy that reinforces the structures created to uphold a belief in White Supremacy. An honest examination of structural racism is necessary to develop strategies aimed at reducing the extraordinary racial inequities produced by mass incarceration. A focus on increasing access to mental health care, including in rural areas, will benefit communities of color and underserved rural populations — two populations disproportionately impacted by mass incarceration and lack of access to mental healthcare.

Rural America

It is predominately rural areas that have been driving the rising jail rates, despite the fact that rural areas have lower crime rates on average. The rising jail rate in rural areas is attributed to increasing rates of pre-trial holds and an increase in the number of rural jails that rent beds out to other local governments, or even federal or state governments.

However, we cannot synonymize White and rural, as that would lead to erasure of the growing racial/ethnic diversity of rural America.

Rural jails have stark racial disparities, as the rate of incarceration for Black people more than doubled in rural jails from 1990 and 2013. And while the racial gap is closing in jails, it’s not due to vast improvements in Black incarceration rates. Instead, it is in part due to the increasing number of White people in jails, which is associated with the opioid crisis. Overall, county-level poverty is the largest predictor of the urban-rural differences in jail rates, as counties with higher concentrations of poverty to have less access to services for processing cases, less funding for diversion programs, and a greater number of people who cannot afford cash bail. Thus, the cash bail system works to punish poverty, as those who cannot afford to pay bail are forced to stay in jail while they await trial.

Mental Illness

Individuals with serious mental illness are overrepresented in our prisons and jails in comparison to their proportion of the population. As correlational data shows, states with a lack of mental health care access tend to have higher rates of incarceration. Approximately 60% of people with a mental illness go without treatment, with most of the unmet need falling disproportionately on people in rural areas, racial minorities, and people experiencing poverty.

Reimagining Our Systems

If we can find creative solutions and policies for rural communities to reduce racial inequities in rates of mass incarceration through a focus on mental health care access, it is hopeful we will be able to find solutions for other communities as well. Promising tactics include:

  • Funding Crisis Team First Responders. We can prevent arrests to limit criminal justice system involvement. While police officers specially trained to respond to mental health crises are often deployed, they frequently still use violence against or arrest those with mental illness. One solution would be diverting funding from this form of policing to non-law enforcement crisis teams.
  • Diversion to Care. There must be an increase of diversion programs into mental health or substance use services, which can decrease the amount of time people are incarcerated. These programs alone will not achieve racial equity in mass incarceration, as there is evidence of racial disparities in rates of granting pretrial diversions to Black people. Thus, programs must be carefully designed to limit racial biases seeping in at this prosecutorial level.
  • Increasing Access, Leveraging Technology. We must increase access to quality mental health care, especially for people of color, people experiencing poverty, and those in rural communities. This can be achieved through schools, primary care, community-based programs, peer-support programs, or improving access to psychiatric beds. In rural communities where these services can be difficult to implement, alternative options like telehealth services or mobile applications might be beneficial. Substance use services should also be available, as the co-occurrence of serious mental illness and substance use can be a significant factor in rates of incarceration.
  • Strategic Behavioral Health Assessments & Data Use. There is a lack of relevant data regarding the prevalence of mental illness in our jails, which hampers our ability to improve outcomes. Implementing required behavioral health assessments for people entering local jails would help improve prevalence data while also increasing the likelihood of referrals to services.

Ultimately, we must interrogate our systems by identifying the mechanisms that perpetuate a racial and class hierarchy via a system of structural racism. We cannot assume that discriminatory policies and practices have impact exclusively along racial lines. Class hierarchies can reinforce systems that were designed to subjugate people of color can have deleterious impact on impoverished communities regardless of color. As demonstrated by my uncle’s story, White poverty is a reliable predictor of one’s outcomes in many of our social and economic systems. Thus, it is imperative that people are critically consciousness of both race and class if we hope to collectively strive towards equity in public policy.

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Center for Community Resilience

A Milken Institute School of Public Health collaborative seeking to address the root causes of childhood & community adversity.