Law and Human Behavior

In the public domain 2024, Vol. 48, No. 2, 104–116

ISSN: 0147-7307 https://doi.org/10.1037/lhb0000557

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
Emily R. Edwards1, 2, Gabriella Epshteyn1, 3, Caroline K. Diehl4, Danny Ruiz1, Brettland Coolidge1, 5,
Nicole H. Weiss3, and Lynda Stein3
1
Veterans Integrated Services Network 2 Mental Illness Research, Education, and Clinical Center, James J. Peters VA Medical Center,
Bronx, New York, United States
2
Department of Psychiatry, Yale School of Medicine
3
Department of Psychology, University of Rhode Island
4
Department of Psychology, University of California, Los Angeles
5
Department of Psychology, University of Central Florida

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.

Keywords: borderline personality disorder, antisocial personality disorder, mental health care, criminal
justice, demographic differences

Supplemental materials: https://doi.org/10.1037/lhb0000557.supp

Jennifer Cox served as Action Editor. Work for this article was supported by the Department of Veterans Affairs
and the VISN 2 MIRECC. The views expressed here are the authors’ and do
Emily R. Edwards https://orcid.org/0000-0003-1030-6380 not necessarily represent the views of the Department of Veterans Affairs.
Gabriella Epshteyn https://orcid.org/0000-0002-9266-7763 Nicole H. Weiss also acknowledges support from the Centers of Biomedical
Caroline K. Diehl https://orcid.org/0000-0001-7792-7400 Research Excellence on Opioids and Overdose funded by the National
Danny Ruiz https://orcid.org/0000-0002-8022-1318 Institute of General Medical Sciences (P20 GM125507).
Brettland Coolidge https://orcid.org/0009-0008-7619-5605 Analyses outlined in this article used data from the Criminal Justice Drug
Nicole H. Weiss https://orcid.org/0000-0002-8245-0616 Abuse Treatment Studies, publicly available through the Interuniversity
Lynda Stein https://orcid.org/0000-0002-7116-8834 Consortium for Political and Social Research (ICPSR 27963). The subsample
continued
104
 PRISON OR TREATMENT IN PERSONALITY DISORDERS 105

The foundational role of systemic racism, discrimination, and anti- men, men tend to (a) experience greater challenges with mental
Blackness in mass incarceration has been extensively documented health engagement and (b) connect with mental health programming
(Alexander, 2011; Blankenship et al., 2023). Although some evidence at lower rates (Al-Rousan et al., 2017; Belenko & Houser, 2012;
suggests that racial, ethnic, and gender inequities in incarceration are Robertson et al., 2020).
compounded among individuals with mental health concerns (e.g.,
Appel et al., 2020; Flores et al., 2023; Robertson et al., 2020), Cluster B Personality Disorder Constructs
exploration of these inequities among persons with personality
disorders has been remarkably limited. Personality disorders tend to Across demographic groups, justice-involved individuals are
be overrepresented among incarcerated populations (Prins, 2014) and disproportionately diagnosed with Cluster B personality disorders
are significantly associated with engagement in behaviors that may (Chen et al., 2016; Sansone et al., 2014; Sijtsema et al., 2014).
result in judicial involvement (e.g., aggression and substance use; However, few studies have investigated how sociostructural
Darke et al., 2004; Howard et al., 2014; Moore et al., 2018). Thus, variables, including race, ethnicity, and gender, impact legal and
clarifying demographic inequities among judicially involved persons treatment trajectories for individuals with these diagnoses. Cluster B
with personality disorders promises to have strong implications for personality disorders, as defined by the fifth edition of the
treatment planning in carceral settings and broader strategies to Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
combat systemic biases. Toward these aims, the present study American Psychiatric Association [APA], 2013), are severe mental
compared patterns of prior mental health care utilization and judicial health conditions characterized by pervasive emotion dysregulation
involvement across racial, ethnic, and gender identity groups within a and impulsive behavior that interfere with relationships, daily
sample of incarcerated persons meeting diagnostic criteria for functioning, and psychological well-being (APA, 2013). Personal
personality disorders. and societal costs of these disorders are vast and include elevated
rates of mortality (Cailhol et al., 2017), criminal conviction (Chen et
al., 2016; Sansone et al., 2014; Sijtsema et al., 2014), and inpatient
Mental Health Inequities in Carceral Settings
and outpatient psychiatric care (Cailhol et al., 2017; Comtois &
Research attests to sizable racial inequities in carceral settings. For Carmel, 2016; Newton-Howes et al., 2021) as well as substantial
example, although Black and Hispanic individuals account for only burden on loved ones and caregivers (Bailey & Grenyer, 2013).
12% and 19% of the general population in the United States, Of the four Cluster B personality disorders (i.e., borderline,
respectively, they represent approximately 38% and 30% of the antisocial, narcissistic, and histrionic personality disorders), most
incarcerated population, respectively (Federal Bureau of Prisons, research to date has invested in understanding the needs and outcomes
2023; Jones et al., 2021). These inequities appear exceptionally of individuals affected by borderline personality disorder (BPD) and
pronounced among persons with psychiatric difficulties. For antisocial personality disorder (ASPD). Briefly, BPD is characterized
example, a recent analysis of incarcerated persons in Los Angeles by marked instability in interpersonal relationships, affect, behavior,
County jails found that Black individuals composed 30% of the cognition, and self-image, whereas ASPD is characterized by persistent
overall incarcerated population but 41% of the population in jail impulsive, risky, and often illegal behavior (APA, 2013). Despite
mental health housing (Appel et al., 2020). Similarly, in a nationally disproportionately high rates of BPD and ASPD among individuals
representative sample of adults, Black and Latinx adults with a receiving psychiatric care and/or experiencing incarceration (Conn et
history of serious psychological distress were significantly more al., 2010; Lenzenweger et al., 2007; Trull et al., 2010), these diagnoses
likely to experience criminal-legal involvement than White adults routinely remain critically overlooked in both clinical and research
(Flores et al., 2023). Despite this disproportionate representation of settings (van den Bosch et al., 2018; Zimmerman & Gazarian, 2014).
persons of color (POCs) with mental illness in carceral settings, A large body of literature attests to strong comorbidity between
research suggests that POCs tend to experience greater barriers in BPD and ASPD, particularly among men, adults, and individuals with
accessing needed services while incarcerated, including lower rates criminal justice involvement (D. F. Becker et al., 2000; Robitaille
of referral to traditional mental health services and higher rates of et al., 2017; Sher et al., 2019; Zlotnick et al., 2002). Although exact
solitary confinement (Kaba et al., 2015), suggesting that the prevalence estimates remain unclear, some evidence suggests that the
representation of POCs with mental illness in carceral settings is prevalence of this BPD + ASPD comorbidity may be higher than the
likely greater than what is typically documented. prevalence of BPD alone in some samples (e.g., Robitaille et al.,
Gender also appears to be associated with differential access to 2017). Overall, individuals with comorbid BPD + ASPD tend to
and/or utilization of mental health services in carceral settings. For experience more severe symptomatology and impairment than those
example, although justice-involved women are more likely to be with either BPD or ASPD alone, including higher rates of comorbid
diagnosed with mental illnesses compared with justice-involved substance use disorder, comorbid psychopathy, criminal justice

and subset of variables relevant to these analyses are also available via the Open editing. Brettland Coolidge played a supporting role in writing–original draft
Science Framework (https://osf.io/yue9r). and writing–review and editing. Nicole H. Weiss played a supporting role in
Emily R. Edwards played a lead role in conceptualization, formal analysis, supervision and writing–review and editing. Lynda Stein played a supporting
and writing–original draft and an equal role in writing–review and editing. role in writing–review and editing.
Gabriella Epshteyn played a lead role in writing–review and editing and a Correspondence concerning this article should be addressed to Emily R.
supporting role in conceptualization, formal analysis, and writing–original Edwards, Veterans Integrated Services Network 2 Mental Illness
draft. Caroline K. Diehl played a supporting role in conceptualization, writing– Research, Education, and Clinical Center, James J. Peters VA Medical
original draft, and writing–review and editing. Danny Ruiz played a supporting Center, 130 West Kingsbridge Road, Bronx, NY 10468, United States.
role in conceptualization, writing–original draft, and writing–review and Email: [email protected]
106 EDWARDS ET AL.

involvement, violent behavior, substance overdose, and suicide deaths et al., 2007; Sansone & Sansone, 2011; Sher et al., 2019).
and lower rates of high school completion and employment (Darke Furthermore, two studies of treatment-seeking persons with BPD
et al., 2004; Howard et al., 2014; McGirr et al., 2007; Robitaille et al., found that POCs with BPD tended to endorse greater affective
2017). Nevertheless, only limited research has explicitly sampled or intensity, emotion dysregulation, and thoughts of interpersonal
studied individuals affected by this comorbidity, limiting insight into aggression and fewer self-harming behaviors relative to their White
the needs of this exceptionally high-risk population. counterparts (L. G. Becker et al., 2023; Newhill et al., 2009). In
Ample research attests to heavy stigma often assigned to these contrast, a study of incarcerated persons with BPD reflected no
disorders, potentially contributing to the underassessment and racial differences in likelihood of violent behavior, suggesting that
understudy of personality disorders. For example, individuals with these differences may not generalize to carceral settings (Yasmeen
BPD and/or ASPD are often judged as “difficult,” “dangerous,” et al., 2022). Although preliminary, some evidence suggests that
“manipulative,” and “untreatable,” even by highly trained mental emotion dysregulation, a core feature of BPD, may be linked to race-
health professionals (Ring & Lawn, 2019; Sheehan et al., 2016). These related stress and trauma among youth of color, highlighting a
judgments often lead individuals with these diagnostic labels to be potential pathway by which structural racism may give rise to
denied access to needed services, treatment, and/or accommodations, differences in symptom manifestation (Roach et al., 2023).
particularly within the criminal justice system (Sheehan et al., 2016; In contrast to the BPD literature, research on ASPD tends to
Wayland & O’Brien, 2013). Some scholars also have expressed oversample men and POCs in part because of a tendency to sample
concern that modern conceptualizations of personality disorders as from incarcerated or otherwise justice-involved populations in which
enduring, intrinsic patterns of dysfunction disregard sociopolitical and men and POCs are overrepresented (e.g., Edens et al., 2015;
contextual factors that contribute to the manifestation of symptoms, Wojciechowski, 2020). In community samples, ASPD is approxi-
particularly among individuals with marginalized social identities mately three times as prevalent among men than women (Alegria et
(Rodriguez-Seijas et al., 2023). Developing empowering and equitable al., 2013; Trull et al., 2010). Men diagnosed with ASPD tend to
pathways to treatment for persons affected by personality disorders, present with more violent and otherwise antisocial behaviors and
particularly within carceral settings, will therefore require updated comorbid substance use disorders, whereas women diagnosed with
theory that considers system-level contributions to impairment and has ASPD are more likely to endorse a history of potentially traumatic
the potential to inspire structural interventions (Diehl et al., 2023). experiences, greater functional impairment, and lower social support
(Alegria et al., 2013; Sher et al., 2015). Generalization of these gender
Race and Gender in Borderline and Antisocial differences in clinical presentation to incarcerated samples, however,
remains unclear (Trestman et al., 2007). Substantial evidence also
Personality Disorders
attests to a likely gender bias in the diagnosis of ASPD; men are more
To date, BPD research has almost exclusively sampled White likely than women to receive an ASPD diagnosis even when
women, ignoring potential disparities across race, ethnicity, and displaying identical clinical presentations (Crosby & Sprock, 2004;
gender. For example, in a longitudinal study, examining 10-year Flanagan & Blashfield, 2005; Samuel & Widiger, 2009).
trends in mental health treatment utilization among persons with To date, the relation of race and ethnicity to ASPD assessment and
BPD, 87% were White and 77% were female (Hörz et al., 2010). diagnosis remains understudied. However, structural barriers and
Similarly, clinical trials of dialectical behavior therapy—commonly discrimination contributing to inflated rates of judicial involvement
considered as a gold standard treatment for BPD (Choi-Kain et al., (a strong predictor of ASPD diagnosis) among POCs attest to a
2017)—are routinely completed with exclusively or predominantly potential inherent racial and ethnic bias to the ASPD construct (Shim
female samples (Harned et al., 2022). Treatment settings mirror this & Vinson, 2021). For example, even when engaging in identical
bias toward an overrepresentation of White women and underrep- behaviors, POCs are significantly more likely than White people to be
resentation of men and POCs. Despite similar rates of BPD across arrested, incarcerated, given harsher sentences, and denied bail
demographic groups in epidemiological studies (Ellison et al., (Kovera, 2019). Similarly, racially minoritized (particularly Black)
2018), POCs with BPD tend to receive less treatment and a narrower youth are more often subject to harsh school disciplinary practices
scope of treatment relative to White persons with BPD (McGilloway (e.g., referral to law enforcement and school-based arrest) that increase
et al., 2010). Men with BPD tend to receive less treatment, lower carceral system contact and impede educational success, thereby
rates of diagnosis, and poorer prognosis estimates by providers increasing likelihood of later criminal justice involvement (Barnes &
relative to women with BPD (Bjorklund, 2006; Eubanks-Carter & Motz, 2018; Marchbanks et al., 2018; Nance, 2015). Some evidence
Goldfried, 2006; Goodman et al., 2010). Such inequities highlight also suggests that ASPD diagnoses are strategically deployed in court
notable social justice concerns surrounding the accessibility of proceedings to prosecute and punish defendants of color (Argueta-
needed services for persons with BPD. Cevallos, 2021), highlighting how the diagnostic label carries different
Although largely preliminary, some research suggests that implications for the legal treatment of POCs versus White persons.
clinical presentation and/or assessment of BPD symptoms also
may differ across race, ethnicity, and gender, potentially exacerbat-
The Present Study
ing representation bias in studies of BPD. For example, women with
BPD tend to endorse more internalizing symptoms, such as suicidal American culture is more likely to criminalize POCs, men, and
ideation, self-harming behaviors, feelings of emptiness, identity externalizing behaviors than White persons, women, and internaliz-
disturbance, and comorbid eating disorders, whereas men with BPD ing behaviors (Crocker et al., 2009; Kovera, 2019; Loue, 2003;
tend to endorse more externalizing symptoms, such as impulsivity, Peterson et al., 2014). Furthermore, extant research appears to
substance use, and comorbid antisocial and narcissistic personality demonstrate racial, ethnic, and gender inequities in symptom
disorders (Hoertel et al., 2014; Johnson et al., 2003; McCormick presentation and/or assessment; mental health treatment engagement;
 PRISON OR TREATMENT IN PERSONALITY DISORDERS 107

and criminal justice involvement among persons with BPD and/or Table 1
ASPD. Specifically, women and White persons may be more likely to Participant Sociodemographic Characteristics
endorse internalizing symptoms and connect with mental health
services, whereas men and POCs may be more likely to endorse Demographic n (%)
externalizing symptoms and have more extensive involvement with Participant gender
the criminal justice system. Such inequities would have notable social Male 184 (59.4)
justice implications regarding the accessibility of mental health Female 126 (40.6)
services for persons with BPD and ASPD as a function of race, Race
White 139 (50.5)
ethnicity, and gender, particularly in high-risk, high-need, and Black/African American 85 (30.9)
underserved populations, such as those receiving treatment in carceral Native American 13 (4.7)
settings. However, to date, these potential demographic comparisons Asian/Pacific Islander 0 (0)
have not been explicitly examined. The present study addressed this Other 38 (13.8)
Ethnicity
gap in the literature using a sample of incarcerated, treatment-seeking Hispanic 104 (33.5)
persons with comorbid lifetime BPD + ASPD, thereby informing the Non-Hispanic 206 (66.5)
broader literature on gender, racial, and ethnic disparities among Marital status
persons affected by this comorbidity. Never married 117 (37.7)
Married 73 (23.5)
Living as married 30 (9.7)
Method Separated 23 (7.4)
Divorced 60 (19.4)
Participants Widowed 7 (2.3)
Highest education level attained
Data were drawn from the Criminal Justice Drug Abuse Less than high school 182 (58.7)
Treatment Studies, publicly available through the Interuniversity High school/GED 53 (17.1)
Consortium for Political and Social Research (ICPSR 27963; Sacks Beyond high school/GED 75 (24.2)
Employment prior to the admission
& Melnick, 2011) and approved as exempt nonhuman research by
Full time 141 (45.5)
the institutional review board at the University of Rhode Island. Part time 46 (14.8)
Participants in the parent study included 353 adults admitted to one Unemployed, looking for work 15 (4.8)
of four prison-based substance use treatment programs in Colorado, Disabled 16 (5.2)
Rhode Island, Texas, or California between August 2004 and Retired 1 (0.3)
Unemployed, not looking for work 79 (25.5)
October 2006. For the purpose of the present study, only participants Homemaker 3 (1.0)
with a lifetime history of both BPD and ASPD were included in the Other 9 (2.9)
analyses (n = 310, 88% of the original sample). Demographically,
Note. GED = general equivalency diploma.
these participants predominantly were White, men, and unmarried
and had less than a high school education (see Table 1).
BPD and seven diagnostic symptoms of ASPD. In accordance with the
Measures diagnostic criteria of the DSM-5, a diagnosis of BPD is given when five
or more symptoms are present and cause clinically significant distress
Demographics and/or functional impairment, and a diagnosis of ASPD is given when
Key demographic variables—including participants’ self- three or more symptoms are present and cause clinically significant
identified gender, racial, and ethnic identities; history of preincar- distress and/or functional impairment (APA, 2013). Notably, the SCID-
ceration employment; and history of educational attainment—were II was developed in accordance with the diagnostic criteria as outlined
assessed via self-report. Notably, participant demographics were in the fourth edition of the Diagnostic and Statistical Manual of Mental
coded according to prespecified coding groups and therefore likely Disorders (DSM-IV). However, because these criteria remained
underestimate the demographic diversity of the sample. Race was unchanged from the DSM-IV to the DSM-5, the SCID-II remains a
coded as White, African American, Native American, Asian, Pacific valid assessment of DSM-5-defined personality disorders. The SCID-II
Islander, or other; ethnicity was coded as Hispanic/Latino or not is commonly considered as a gold standard for the assessment of
Hispanic/Latino; and gender was coded as male or female. Because personality disorders and has demonstrated strong construct validity,
gender was coded binarily (men/women) and did not assess whether test–retest reliability, and interrater reliability across a range of samples
participants identified as cisgender or transgender or offer an option of (Lobbestael et al., 2011; Ryder et al., 2007).
reporting a nonbinary gender identity, analyses were not equipped to Select personality disorder symptoms were coded according to
examine differences across a wider range of gender identities. the responses on the SCID-II. Coded BPD symptoms included those
focused on (a) unstable relationships (shifting back and forth
between strong love and strong hate for people to which the person
Lifetime Personality Disorder Diagnoses and Symptoms
is closest), (b) behavioral recklessness (giving in to urges to do
Lifetime personality disorder diagnoses were made using the things that the person was sure would get them into trouble), (c)
structured clinical interview for DSM-IV axis II personality disorders fears of abandonment (making desperate attempts to avoid feeling or
(SCID-II; First et al., 1994), a clinician-administered, semistructured, being abandoned), and (d) prior suicide attempts (self-reported
clinical interview to assess personality disorders. The interview includes history of one or more suicide attempts). Coded ASPD symptoms
guided questions to assess each of the nine diagnostic symptoms of included those focused on (a) work instability (inability to maintain
108 EDWARDS ET AL.

employment for more than a few months), (b) lack of feelings of Last, logistic regression analyses were used to compare participants
remorse (feeling bad when hurting or mistreating someone), and (c) identifying as male versus female, identifying as White versus a
engagement in lying or conning behavior (lying or conning to serve minoritized racial group, and identifying as Hispanic/Latino versus
personal purposes). Symptoms were coded dichotomously to not Hispanic/Latino on symptom presentation and reported histories
indicate the presence or absence of each symptom. The Criminal of mental health care utilization. To account for the potential impact
Justice Drug Abuse Treatment Studies public data set does not of key social determinants of health on observed associations, we
provide data on other personality disorder symptoms or data to included participant educational attainment (coded as “less than high
calculate interrater reliability of SCID-II administration or coding. school/GED [general equivalency diploma]” or “at least high school/
GED”) and preincarceration employment status (coded as “em-
ployed” or “not employed”) as covariates throughout Phases 2 and 3
History of Criminal Justice Involvement
of the analyses. In preliminary analyses, educational attainment was
History of criminal justice involvement was assessed using a significantly associated with participant ethnicity (χ2 = 4.84, p = .03),
series of self-report items, including (a) the lifetime frequency of and preincarceration employment status was significantly associated
prior arrests, (b) the age at first arrest, (c) the frequency of arrests with participant gender (χ2 = 20.18, p < .01). Otherwise, covariates
before the age of 18, and (d) the lifetime duration of incarceration. did not significantly differ across gender, racial, and ethnic groups.
Although self-reported criminal justice history was not verified In analyses of health and social science data, collapsing participants
through comparison against official records, previous research with diverse ethnoracial identities into a single group risks obscuring
suggests self-report to be a generally valid means of assessing unique experiences associated with different minoritized identities
criminal history (Morris & Slocum, 2010; Nieves et al., 2000). To and risks portraying White participants’ experiences as the “default”
avoid unnecessary bias stemming from overestimations of prior (Call et al., 2023). However, the racial distribution of participants in
criminal history, we excluded extreme outliers (i.e., reported arrest the present study provided inadequate statistical power for examining
frequencies of >50, corresponding to the top 5% of original sample; differences across all represented ethnoracial groups. Thus, analyses
range = 53–1,800) from analyses. focused on broad differences between experiences of participants
with minoritized racial identities and those of White participants, with
the goal of identifying the potentially differential impact of White
History of Mental Health Care Utilization
privilege versus systemic racism on the trajectories of persons with
History of mental health care utilization was also assessed using a comorbid BPD + ASPD.
series of self-report items, including prior (a) necessity of mental health
care, (b) speaking to a mental health professional, (c) receipt of
psychiatric medication, and (d) psychiatric hospitalization, each coded Results
dichotomously. Again, self-reported history of mental health care Descriptive Statistics
utilization was not verified through comparison against official records.
Regarding BPD symptoms, 68% of participants reported a history
of unstable relationships, 85% reckless behavior, 57% fears of
Procedure abandonment, and 18% histories of suicidal ideation and/or attempts.
All measures were administered in two face-to-face sessions Regarding ASPD symptoms, 37% endorsed a history of work
scheduled within 1 month of each other. Consent procedures and instability, 94% lack of remorse, and 79% chronic lying/conning
administration of self-report items took place during the first session, behavior. Most participants reported extensive histories of criminal
and the SCID-II interview was administered in the second session. justice involvement, including an average of 14.09 prior arrests (SD =
All measures were administered by trained, experienced inter- 11.52, Mdn = 10.00) and more than 5 years of total incarceration (M =
viewers. Because a primary purpose of the parent study was to 66.40 months, SD = 67.41, Mdn = 48.00). Age at first arrest varied
develop and validate novel assessment measures, separate inter- widely; approximately half of first arrests occurred in adulthood (M =
viewers administered each session, and interviewers of the second 18.08 years, SD = 6.79, Mdn = 17, range = 6–61).
session had no knowledge of the results of the first session. See Approximately 64% reported having previously perceived a need
Sacks et al. (2007) for further information about study procedures. for mental health services, 66% previously receiving mental health
services, and 53% previously receiving psychiatric medication.
Approximately one in five participants (21%) reported a history of
Data Analysis Plan psychiatric hospitalization. Consistent with common difficulties and
Analyses were completed in three phases. In the first phase, co-occurring disorders associated with BPD and ASPD, 51% of
descriptive statistics were calculated to characterize the overall participants reported a history of depressive symptoms, 51% anxiety
symptom presentation, mental health history, and criminal justice symptoms, 8% hallucinations, 49% cognitive difficulties, and 26%
history of the sample and for demographic subsamples. In the second difficulties controlling violent behavior (for descriptive statistics
phase, analyses of variance were used to compare participants across demographic groups, see Supplemental Table S1).
identifying as male versus female; identifying as White versus a
minoritized racial group (i.e., African American, Native American, or
History of Criminal Justice Involvement
other; Asian and Pacific Islander racial groups were not included in
these analyses because the sample size for each respective group was Results of the multivariate analyses of covariance reflected
0); and identifying as Hispanic/Latino versus not Hispanic/Latino in significant differences among participants identifying as men versus
reported histories of criminal justice involvement. women in reported histories of criminal justice involvement after we
 PRISON OR TREATMENT IN PERSONALITY DISORDERS 109

controlled for educational attainment and preincarceration employ- employment, however, we noted no statistically significant differ-
ment, Wilks’s λ = 0.88, F(4, 281) = 9.56, p < .01. Follow-up ences across racial groups (all ps > .06). With respect to the ethnicity,
univariate analyses reflected that men became involved with the participants identifying as Hispanic/Latino were less likely than
criminal justice system at younger ages, F(1, 284) = 23.02, p < .01, participants identifying as not Hispanic/Latino to endorse histories of
had significantly more arrests as a minor, F(1, 284) = 5.18, p = suicide ideation or attempts, χ2(1) = 4.89, p = .03, and recklessness,
.02, and had significantly longer durations of lifetime incarceration, χ2(1) = 6.56, p = .01. Such differences persisted even after we
F(1, 284) = 20.91, p < .01, relative to women. However, men did not controlled for educational attainment and preincarceration employ-
report significantly more lifetime arrests, F(1, 284) = 2.28, p = .13, ment (β = −0.76, p = .04, and β = −0.68, p = .05, respectively).
than did women, which is inconsistent with our hypotheses.
Multivariate analyses reflected no statistically significant differences
in criminal justice history across racial groups after we controlled for History of Mental Health Care Utilization
educational attainment and preincarceration employment, Wilks’s
Consistent with our hypotheses, results of the logistic regression
λ = 0.97, F(4, 248) = 2.04, p = .09, or among participants identifying
analyses suggested that histories of mental health care utilization
as Hispanic/Latino versus not Hispanic/Latino, Wilks’s λ = 0.97, F(4,
varied significantly by participant gender. Specifically, women were
281) = 9.56, p = .06, which is inconsistent with our hypotheses. See
significantly more likely than men to have reported histories of
Figure 1 for observed differences across participant groups in
perceiving a need for mental health care, χ2(1) = 17.04, p < .01,
reported histories of criminal justice involvement.
receiving psychotherapy, χ2(1) = 5.33, p = .02, receiving psychiatric
medication, χ2(1) = 18.85, p < .01, and psychiatric hospitalization,
Symptom Presentation χ2(1) = 12.54, p < .01. After we controlled for educational attainment
In partial support of our hypotheses, results of the logistic and preincarceration employment, only differences in histories of
regression analyses suggested largely minimal gender, racial, and perceiving a need for mental health care (β = −0.90, p < .01) and
ethnic differences in participants’ experience of personality disorder psychiatric hospitalization (β = −0.69, p = .04) remained statistically
symptoms. Women were significantly more likely than men to significant. See Figure 3 for observed differences across participant
endorse a history of fears of abandonment, χ2(1) = 4.28, p = .04, and groups in reported histories of mental health care utilization.
suicide ideation or attempts, χ2(1) = 5.47, p = .02, consistent with the White participants were significantly more likely than participants
previous research suggesting that women experience more internal- from minoritized racial groups to have reported histories of talking
izing symptoms. However, after controlling for educational attain- to a mental health professional, χ2(1) = 5.95, p = .02, and receiving
ment and preincarceration employment, we noted no statistically psychiatric medication, χ2(1) = 7.34, p = .01, which is consistent
significant gender differences (all ps ≥ .07). See Figure 2 for observed with our hypotheses. No significant racial differences were noted in
differences across participant groups in symptom presentation. reported histories of perceiving a need for mental health care,
White participants were slightly more likely than participants from χ2(1) = 3.65, p = .06, or psychiatric hospitalization, χ2(1) = 0.96,
minoritized racial groups to endorse a history of recklessness, χ2(1) = p = .33. After we controlled for educational attainment and
4.06, p = .04, which is inconsistent with the previous research; preincarceration employment, however, observed associations were
after controlling for educational attainment and preincarceration not statistically significant (all ps > .11).

Figure 1
Gender, Racial, and Ethnic Differences in Criminal Justice History
25

20

15

10

0
Age of 1st Arrest Lifetime Frequency of Arrest Frequency of Arrests as Lifetime Duration of
Minor Incarceration (Years)

Male Female Racial Minority White Hispanic/Latino Not Hispanic/Latino

110 EDWARDS ET AL.

Figure 2
Gender, Racial, and Ethnic Differences in Symptom Presentation
100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Male Female Racial Minority White Hispanic/Latino Not Hispanic/Latino

Note. ASPD = antisocial personality disorder; BPD = borderline personality disorder.

With respect to the ethnicity, participants identifying as Hispanic/ BPD + ASPD (relative to men and persons from minoritized racial
Latino were less likely to report a history of perceiving a need for groups, respectively) had more extensive mental health treatment
mental health care, χ2(1) = 6.00, p = .01, having talked to a mental histories. Incarcerated women (relative to men) with lifetime BPD +
health professional, χ2(1) = 6.54, p = .01, and having received ASPD were also more likely to endorse a range of internalizing
psychiatric medication, χ2(1) = 9.34, p < .01. After we controlled for symptoms, and White (relative to minoritized racial groups) and non-
educational attainment and preincarceration employment, however, Hispanic participants (relative to Hispanic participants) were more
no statistically significant differences were observed (all ps ≥ .12). likely to endorse a history of reckless behavior. Notably, however,
many associations did not persist after we controlled for preincarcera-
tion employment and educational attainment, attesting to the likely
Discussion impact of societal, structural, and systemic factors on trajectories of
Extensive research has illustrated how systemic biases and persons affected by this comorbidity.
structural barriers to care contribute to racial, ethnic, and gender Results underline gender differences in histories of criminal
disparities in mental health service utilization, highlighting important justice involvement and mental health utilization, which persisted
social justice considerations surrounding accessibility of care. even after we controlled for key social determinants of health and
However, to date, very little research has explicitly examined these despite similarities in symptom presentation. Findings are consistent
differences within the context of high-risk, high-need, and underserved with theorized barriers to care and systemic biases that preclude
samples. The present study contributes to this growing literature accessing mental health services and instead promote criminal
by highlighting racial, ethnic, and gender disparities in symptom justice involvement among men.
presentation and/or assessment, criminal justice involvement, and Findings have direct implications for the treatment of BPD and
mental health care utilization among incarcerated, treatment-seeking ASPD in both carceral and community settings. First, results imply
persons with comorbid lifetime BPD + ASPD. that community mental health providers of men and/or persons from
Partially consistent with our hypotheses, results broadly suggested minoritized racial and ethnic groups with BPD and/or ASPD should
that incarcerated men (relative to women) with these personality be familiar with the range of difficulties that commonly accompany
disorders were more likely to have early, extensive criminal justice criminal justice involvement, including barriers to employment,
involvement, whereas incarcerated women and White people with housing, and relationships (Batastini et al., 2014; Edwards &
 PRISON OR TREATMENT IN PERSONALITY DISORDERS 111

Figure 3
Gender, Racial, and Ethnic Differences in Mental Health History
90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
Needed Mental Health Help Talked to Mental Health Psychiatric Medication Psychiatric Hospitalization
Professional

Male Female Racial Minority White Hispanic/Latino Not Hispanic/Latino

Mottarella, 2015; Moschion & Johnson, 2019); the implications of groups, such as limited availability of services, financial costs,
these difficulties on treatment engagement and success (Timmer & scheduling and/or transportation inconvenience, and criminalization
Nowotny, 2021); and the consequences of structural barriers within of mental illness (Green et al., 2020; Grekin et al., 1994). Supporting
the criminal justice system for persons with personality disorders this explanation, observed racial differences in the history of mental
(e.g., common ineligibility for jail-diversion programs; Edwards et health services did not persist after we controlled for educational
al., 2020). Because men with comorbid BPD + ASPD may be more attainment and preincarceration employment. In addition, racially
likely to have earlier and more extensive legal histories than women minoritized individuals’ utilization of mental health care may be
with comorbid BPD + ASPD, they may also face these associated limited by medical mistrust resulting from a long history of racism
difficulties at higher rates. Therefore, men with these personality and abuse in institutionalized medicine (Jaiswal & Halkitis, 2019).
disorders likely require additional support and services around Cumulatively, these factors lead many racially minoritized indivi-
navigating the consequences of prior legal involvement. Nevertheless, duals to seek support from other sources (e.g., clergy) rather than
considerations for a history of legal involvement are rarely integrated health care settings (Snowden, 2001; Suite et al., 2007; Woodward
into established treatments for personality disorders. Of the 16 et al., 2011).
randomized clinical trials completed for dialectical behavior therapy, When ethnoracially minoritized persons with BPD and/or ASPD
for example, only one assessed history of legal involvement ultimately connect to mental health care, they often experience
(Rosenfeld et al., 2019). Furthermore, although some adaptations services as Eurocentric, with limited cultural responsiveness, and
of dialectical behavior therapy have been developed for justice- heavily stigmatized against persons with personality disorders
involved persons (e.g., Edwards, Dichiara, et al., 2023; Edwards, (Sheehan et al., 2016; Shundi, 2021). POCs in mental health care
Epshteyn, et al., 2023; Shelton et al., 2011), these adaptations have settings also are disproportionately likely to experience violations of
often not received the same level of rigorous scientific investigation as agency that resemble carceral practices. For example, a recent study
traditional programs for dialectical behavior therapy. The elevated found that patients with minoritized racial or ethnic identities were
prevalence of legal involvement among persons with BPD and/or more likely than non-Hispanic White patients to receive inpatient
ASPD (Sansone et al., 2014; Sijtsema et al., 2014), particularly among mental health treatment at facilities with higher documented rates of
men, necessitates more routine assessment of patient legal histories abuse, restraint and seclusion of patients, and consumer complaints
and integration of legal considerations into treatment planning of (Shields, 2021). Similarly, within psychiatric emergency rooms,
standard programming for persons affected by these personality POCs are more likely than White patients to experience physical and
disorders. chemical restraint (Nash et al., 2021; Robinson et al., 2022; Wong et
Second, results suggest that incarcerated persons from minoritized al., 2021). Taken together with this prior literature, findings from the
racial groups with comorbid BPD + ASPD may perceive a similar present study highlight a pressing need to address racial inequities in
need for mental health services and use emergency psychiatric treatment access and to make structural changes in treatment
services at rates similar to those of incarcerated White persons with provision that facilitate affirming, antiracist, and anticarceral care.
comorbid BPD + ASPD. However, they may also be less likely to Results of the present study also suggest that providers in carceral
access traditional mental health services (i.e., psychotherapy and settings may be in a favorable position to connect men and persons
psychiatric medication). This finding may reflect the disproportionate from minoritized racial groups with comorbid BPD + ASPD to
impact of structural barriers to help seeking among racial minority needed services. In the present sample, incarcerated men and
112 EDWARDS ET AL.

persons from minoritized racial groups with comorbid BPD + analyses surrounding race were limited to broad comparisons
ASPD were less likely than incarcerated women and White persons between participants from minoritized racial groups and White
with comorbid BPD + ASPD to have connected with mental health participants. Furthermore, although descriptive statistics appeared
services. Men were also less likely to endorse a range of consistent with the broader literature, which consistently demon-
internalizing symptoms, including suicide behavior, which com- strates pervasive racial and ethnic differences in criminal justice
monly prompt mental health service connection. Providers within involvement, these differences were not statistically significant in
carceral systems and/or assisting in reintegration following statistical analyses. Additional studies with larger and more diverse
incarceration may therefore serve a critical role in helping to samples are therefore needed to clarify how inequities manifest across
combat structural and attitudinal barriers to mental health care, different ethnoracial identity groups (Call et al., 2023), particularly
thereby promoting engagement with effective mental health services given the specific relationship of anti-Blackness to both psychology
among these populations. and incarceration (Alexander, 2011; Auguste et al., 2023).
Various factors may contribute to differences in diagnostic rates Second, because the parent study coded gender identity in binary
and/or clinical presentation across social groups, including biases terms, the present study was unable to examine inequities in
inherent in the definitions of disorder constructs (Metzl, 2010), bias outcomes for transgender, nonbinary, genderqueer, intersex, two
on the part of diagnosticians (Garb, 2021; Shim & Vinson, 2021), or spirit, and other gender diverse individuals. This is an important
true differences in symptom manifestation that result from factors direction for future research, particularly given recent evidence that
such as racism, minority stress, gender socialization, and culture BPD is diagnosed at higher rates among transgender and gender
(e.g., Anglin, 2023; DeVylder et al., 2023; Thomas et al., 2021). For diverse people than among cisgender people (Zimmerman et al.,
example, research into disproportionate diagnosis of psychotic 2022) and that minority stress related to gender identity may be
disorders among Black and Latinx individuals suggests likely misdiagnosed as—but can also contribute to—BPD symptoms
systemic bias in clinical assessment (R. C. Schwartz & Blankenship, (Goldhammer et al., 2019).
2014; E. K. Schwartz et al., 2019) and increased exposure to Third, data collection for the parent study was completed in the
psychosis risk factors associated with structural racism (Anglin, mid-2000s, raising questions of generalizability to current samples.
2023; Shim, 2022). Within the current sample, nearly all participants Since the time of data collection, there have been considerable
received a lifetime diagnosis of BPD and ASPD, limiting statistical cultural shifts in mental health awareness and acceptance (Oswalt et
power to examine whether demographic groups were differentially al., 2020; Pescosolido et al., 2021) and expansion of programs that
likely to receive such diagnoses. Therefore, without further research, offer diversion away from the traditional justice system for persons
it remains unclear which, if any, of these factors may underlie with mental illnesses (Edwards et al., 2020; Lindquist-Grantz et al.,
observed demographic differences in personality disorder symp- 2021). Therefore, it is possible that recent societal shifts have
toms within the current sample. Because sociocultural and lessened the magnitude of observed inequities in mental health care
contextual factors likely influence both the perception and the and justice involvement among persons with BPD and ASPD.
manifestation of personality disorder symptoms (Rodriguez-Seijas Conversely, some evidence posits that racial inequities in mental
et al., 2023), further research is needed to understand both biases in health care access have increased since the mid-2000s (e.g., Lê Cook
personality disorder diagnosis and potential identity-based differ- et al., 2017), suggesting that observed patterns may be more
ences in clinical needs. pronounced in modern samples.
Fourth, although the present study examined histories of criminal
justice involvement and mental health care utilization, all participants
Limitations
were enrolled in a correctional substance use program at the time of
The present study is novel in its exploration of gender, racial, and data collection. Thus, results likely overestimate the prevalence of
ethnic differences in criminal justice and mental health histories criminal justice involvement and mental health care utilization among
among persons with comorbid BPD + ASPD. However, results persons with comorbid BPD + ASPD more broadly. Results may not
should be understood within the context of several methodological generalize to unincarcerated or community-based samples.
limitations. First, the study’s modest sample size precluded Last, participants in the present study had higher-than-average rates
investigation of the potential impact of intersecting identities of co-occurring disorders. Therefore, it remains unclear to what extent
(e.g., women of color). A vast and growing body of literature observed findings are specific to persons with comorbid BPD +
highlights complex patterns of intersectional inequities in mental ASPD or reflective of broader demographic differences in criminal
health and mental health service use that are not apparent when justice involvement and mental health utilization among persons with
single demographic factors are examined (Rhead et al., 2022; Trygg mental health difficulties. Considering these limitations, we recom-
et al., 2019). Within the carceral system, intersectional inequities are mend that future research employ larger, contemporary, and more
also evident; for example, comparatively harsher sentences typically heterogeneous samples as feasible. Sampling across a range of
are given to Black and Hispanic men and more lenient sentences settings, including carceral, psychiatric, and community-based
typically are given to younger women (Steffensmeier et al., 2017). settings, is also recommended to ensure representation across levels
Given these patterns, future research employing larger samples is of functioning and contexts.
needed to further explore the potential role of intersectionality in
observed patterns of mental health service use and criminal justice
Conclusion
history among persons with personality disorders.
Relatedly, the study’s modest sample size may have limited the Research and treatment settings focused on BPD and ASPD long
ability to detect potentially meaningful differences between groups. have been limited by biased representation of gender, racial, and
For example, as discussed previously, because of power concerns, ethnic groups. Previous research suggests that barriers to care and
 PRISON OR TREATMENT IN PERSONALITY DISORDERS 113

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