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Abstract

This study investigated barriers to accessing mental health care among criminal-legal involved women with opioid use disorder (OUD) by triangulating perspectives across affected women (n = 20), criminal legal professionals (n = 10), and substance use disorder (SUD) treatment professionals (n = 12). Themes from qualitative interviews conducted in 2022 identified two primary types of barriers: physical access and stigma. Findings converged regarding challenges associated with accessing mental health care during incarceration and reentry and difficulties accessing timely care. However, while women expressed concern about stigma around seeking mental health medications, some of the professionals expressed stigmatizing views about potential misuse of medications. These findings highlight a need for system-level changes in correctional facilities to reduce stigma and bolster well-being and SUD treatment outcomes among criminal-legal involved individuals with dual diagnoses. Future work should strive to expand the literature around interconnected issues associated with concurrent OUD and mental health challenges.

Keywords

women criminal justice substance use mental health treatment mental illness substance use disorders

Introduction

Dual Diagnosis Overview and Prevalence

Over the last decade, substance use disorders (SUDs), severe mental illnesses (SMIs), and dual diagnoses have all shown significant increases in prevalence (Lipari & Van Horn, 2017; Richter et al., 2019). To specify, individuals with SUDs refer to those who have met the diagnostic criteria for drug and/or alcohol use disorders (Lipari & Van Horn, 2017). Individuals with SMIs refer to those with psychiatric and mood disorders that pose limitations to day-to-day functioning, such as schizophrenia, major depressive disorder, and bipolar disorder (Zumstein & Riese, 2020). A dual diagnosis is the presence of one or more SUDs concurrently with one or more SMIs (Hakobyan et al., 2020).

The 2022 National Survey on Drug Use and Health (NSDUH) estimated that 7.4 million U.S. adults who have an SMI also have an SUD (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023). Dual diagnoses are also disproportionately high among criminal-legal involved women, with some recent studies estimating that between 10% and 20% of incarcerated women have a dual diagnosis (Baranyi et al., 2022; Nowotny et al., 2014). While the dual diagnosis population includes individuals with any drug and/or alcohol use disorders (Lipari & Van Horn, 2017), the present study focused specifically on criminal-legal involved women with opioid use disorder (OUD).

Although there are no known estimates of how many criminal-legal involved women have a co-occurring SMI with OUD, one report found that approximately half of all incarcerated women had an OUD in 2012 (Fazel et al., 2017). Research has shown that opioid misuse and criminal legal involvement are associated with greater economic struggles and trauma burdens among women, which likely contributes to higher rates of dual diagnosis in this population (Harris et al., 2024; Lutgen-Nieves & Petty, 2024; Monazzam & Budd, 2023).

Dual Diagnosis and Access to Mental Health Care Among Criminal-Legal Involved Women

The uptick in prevalence of SUDs and SMIs holds especially important implications for affected women involved in the criminal legal system. This population experiences a continuous cycle of reincarceration and unmet health needs due to the absence of integrated approaches in institutional management and treatment for their co-occurring conditions (Badour et al., 2023; Egart, 2024; Israel et al., 2024; Jobe et al., 2024). Previous studies have also shown that having a dual diagnosis is associated with a greater likelihood of experiencing both unintentional and intentional overdoses—especially among legal-involved women (Keen et al., 2022).

Although individuals—particularly women—involved in the criminal legal system have a disproportionately higher likelihood of having a dual diagnosis (Baranyi et al., 2022; Fazel et al., 2017), little is known about the experience of navigating dual diagnoses within criminal legal settings. The literature is largely mutually exclusive, focused on outcomes among criminal-legal involved individuals with either SUDs or SMIs. Despite this gap, previous studies addressing one diagnosis or the other do find points of convergence around factors that exacerbate these conditions and hinder treatment access. One such factor is incarceration itself. Speaking first to its influence on SMIs, in Harner and Riley’s (2013) study on women in a maximum-security prison, some participants mentioned that the experience of incarceration has a negative impact on well-being due to a lack of access to timely mental health services. Accounts from other studies (Bright et al., 2023; Wennerstrom et al., 2022) have corroborated this finding.

Additional evidence suggests that experiences of incarceration exacerbate SUDs as well (Volkow, 2021). One recent study found that, in the first year following release from prison, individuals had a high likelihood of using drugs—especially if their SUD went untreated or treatment was discontinued while incarcerated (Western & Simes, 2019). Taken together, research on SUDs and SMIs have shown that the experience of incarceration can exacerbate both conditions, pointing to a need for research to investigate barriers to mental health services and integrated, accessible care options.

Beyond experiences of incarceration, criminal-legal involved women often face several challenges reentering society, such as difficulties around finding secure housing, employment, and a supportive environment to return to (Jones et al., 2025; Strong-Jones et al., 2024). Previous research converges on how reentry can be especially difficult for women with dual diagnoses, identifying stress related to child custody and maintaining familial relationships upon reentry, high financial distress, and disruptions to treatment and daily routines as potential triggers for returning to use or worsening mental health challenges (Johnson et al., 2015; Liu et al., 2023; Stanton & Rose, 2020). Moreover, women with dual diagnoses may use substances to cope with the distress related to the challenges associated with reentry, which can exacerbate their SMI and further intensify their SUD in a compounding cycle (Dobmeier et al., 2021). To address the impact of these difficulties experienced during reentry on women with dual diagnoses, there is a great need for research examining mental health care barriers during reentry and comprehensive services that treat both conditions.

Stigma is another factor that can worsen symptoms of both conditions and hinder treatment access. While literature addressing dual diagnoses is limited in this domain as well, one study looking at the attitudes of criminal legal professionals reported high levels of stigma toward both SMIs and SUDs (Lowder et al., 2019). Research specific to criminal-legal involved individuals seeking psychiatric care found high levels of perceived stigma regarding their mental health, which was associated with low levels of medication adherence during both incarceration and reentry (Farabee et al., 2019). Moreover, another study examining stigma among individuals with SUDs found that perceived stigma contributed to lower rates of treatment uptake and retention (Crapanzano et al., 2019). Looked at in tandem, systemic barriers can impede access to integrated health care in correctional settings, and stigma may contribute to a fear of seeking help—both of which can perpetuate a cycle of reincarceration and hinder recovery.

Comorbid mental health issues are highly prevalent and elevate the risk of adverse outcomes such as reincarceration and overdose, necessitating improved access to comprehensive, integrated treatment for criminal-legal involved women with dual diagnoses (Baranyi et al., 2022; Zaller et al., 2022). With data indicating that only 7% of affected incarcerated individuals received services for both their SUDs and SMIs concurrently in their lifetime, it is clear: expanded insight around and access to integrated SUD and mental health treatment is a necessity (Hunt et al., 2015). Studies often focus either on how people with SUDs can access SUD treatment or on how people with SMIs can access mental health treatment; the literature is largely mutually exclusive. Taking this into consideration, there is a great need to investigate how people with SUDs who also have SMIs can access not just SUD treatment but also mental health care.

Current Study

This study aims to investigate barriers to accessing mental health services for women with SUDs involved in the criminal legal system. The observed gaps in access to care for these women may result from the complex interconnected issues associated with dual diagnosis of SUD and recurring mental health challenges, along with the additional barriers imposed by criminal status. To explore the lived experiences of criminal-legal involved women with SUDs in accessing mental health services, we triangulated perspectives from affected women, SUD treatment professionals, and criminal legal professionals. Study findings can inform the implementation of evidence-based practices within correctional facilities, community-based reentry programs, and other criminal legal settings, thereby bolstering comprehensive support for women with dual diagnoses within the criminal legal system.

Methods

The research team conducted a qualitative study utilizing in-depth interviews from May to July of 2022 with 42 participants. This larger qualitative study that the present article draws from was carried out as part of the pre-implementation phase of an intervention study (Jones et al., 2025). Its overarching purpose was to identify facilitators and barriers to the uptake and retention of MOUD treatment for criminal-legal involved women who use drugs and inform the development of an intervention addressing these areas. To highlight a range of perspectives, the participants consisted of (a) women previously or currently using any type of MOUD (such as methadone, buprenorphine, or naltrexone) with a history of criminal legal involvement (N = 20), (b) SUD treatment professionals working in community settings with women presently or formerly involved in the criminal legal system (N = 12), and (c) criminal legal professionals working with women who use opioids (N = 10).

We drew from participants’ lived experiences through multiple perspective interviewing, an increasingly utilized research methodology that involves triangulating insights from diverse stakeholders within interconnected groups (Vogl et al., 2019). Our approach not only included women with OUD involved in the criminal legal system but also professionals in the SUD treatment and criminal legal sectors. While the individual perspectives of these women are valuable in and of themselves, the professionals could add context to the women’s stories as they had extensive experience working with women with OUD. These professionals tend to be actively engaged in their clients’ treatment journeys, leaving them well-positioned to offer thoughtful insights. Merging the perspectives of these three groups allows for a nuanced, well-rounded understanding of mental health care barriers for women with a history of OUD involved in the criminal legal system.

In Pennsylvania (PA), where this study was conducted, there are vast disparities in the availability and accessibility of MOUD across correctional facilities due to independent operations of jails within each county. While Pennsylvania state prisons provide both new and continuing buprenorphine and naltrexone treatment (The Pew Charitable Trusts, 2020), county jails exhibit a varying range of practices. Some do not offer any MOUD treatment, others only continue treatment for those already using MOUD and do not initiate new MOUD treatment, some provide limited types of MOUD, and a few offer the full range of MOUD types for both new and continuing patients (Abner et al., 2022).

Participant Recruitment

Each of the three participant groups had a different set of eligibility criteria and recruitment procedures (Apsley et al., 2024; Jones et al., 2025; Skogseth et al., 2024; Strong-Jones et al., 2024). The eligibility criteria for the affected women (N = 20) held that the participants must have (a) been 18 years or older, (b) resided in PA at the time of the study, (c) had a history of probation, parole, and/or incarceration, (d) had a lifetime history of enrollment in a MOUD treatment program, and (e) been willing to provide informed consent. Recruitment methods included targeted sampling through social media advertising, chain referrals, and distributing flyers at MOUD treatment facilities throughout PA.

To recruit SUD treatment professionals (N = 12), we obtained a list of Opioid Treatment Programs (OTPs) in PA certified by SAMHSA and made direct calls to these clinics. We also relied on online advertising and chain referrals to include treatment professionals outside of OTP contexts. Eligible participants were those who (a) provided informed consent, (b) practiced within PA, and (c) engaged in activities such as prescribing MOUD, caring for individuals in MOUD treatment as part of their professional responsibilities, or offering complementary behavioral modification counseling as part of a MOUD program.

To recruit criminal legal professionals (N = 10), direct calls were made to correctional facilities in PA; we also relied on chain referrals and online advertising. The eligibility criteria for these professionals included that, at the time of the study, they must have (a) provided informed consent, (b) practiced within PA, (c) had professional experience working with women who have used or currently use opioids, and (d) occupied positions within law enforcement, correctional settings, probation or parole, courtroom proceedings, or treatment court.

The Research Electronic Data Capture (REDCap) was utilized to conduct a brief web screening to ascertain participants’ eligibility. This screening also collected essential information, including age, gender, and other demographic data. Participants who did not meet the eligibility criteria were excluded from the study.

Interview Procedures

Following the recruitment and eligibility screening processes, those who agreed to be interviewed were contacted by trained personnel from the Survey Research Center at Penn State. One-on-one interviews were conducted via telephone, and each session lasted approximately 1 hr. The interviewing team was comprised of women who were experienced research interviewers with advanced degrees in relevant social science fields. These interviewers had similar demographic profiles to the study participants but no established prior relationships with them.

At the beginning of the phone interview sessions, the participants provided verbal consent after being duly informed about the study. For each interview, the interviewer utilized a semi-structured guide that explored the women’s lived experiences receiving MOUD treatment and the professionals’ experiences working with women receiving MOUD treatment. Participants described their experiences regarding MOUD treatment, consisting of methadone, buprenorphine, and/or naltrexone. They also discussed the different types of settings wherein MOUD treatment was received, such as inpatient treatment facilities, outpatient treatment facilities, OTPs, other medical facilities, and correctional facilities. No questions were explicitly asked about mental health care; rather, this topic was repeatedly brought up by participants when discussing their SUD treatment experiences both in correctional and community settings. The participants were at liberty to skip any questions or end the interview at any time. As compensation for their time, each participant received a $50 gift card.

Data Analysis

The interviews were recorded, transcribed, de-identified, and stored on secure servers. Thematic analysis (Braun & Clarke, 2021) was then conducted using the qualitative software, NVivo. After a thorough review of the transcripts by three members of the research team, primary codes were generated inductively. These primary codes served to span all the major topic areas arising from the transcripts. This process was followed by the generation of more specific secondary codes within each primary code, which captured nuances and patterns identified by the research team’s analysis of the major topic areas. Taken together, this coding process involved multiple readings of the transcripts for the research team to actively construct and categorize the major and minor themes in the interviews.

Members of the research team subsequently coded each transcript. The Principal Investigator (PI) then reviewed all coded transcripts. To achieve consistency, when discrepancies arose between how the PI and a transcript’s primary coder interpreted a single transcript, they were discussed by both parties and resolved collaboratively. The PI also identified any differences in the primary coders’ interpretation across transcripts, and the discrepancies were then discussed collectively and resolved as a group. Overall, both types of discrepancies were minimal, which offers support for interpretations being predominantly consistent among the study team.

The present study utilized the following primary codes from the larger qualitative study: Barriers to Treatment Success, Facilitators to Treatment Success, Reasons Contributing to Opioid Use or Relapse, and Chronic or Long-Term Mental/Physical Health Issues Related to OUD. In analyzing these codes, we began with a systematic review of the women’s experiences. We then analyzed the coded text from the professionals’ interviews to assess alignment with the women’s accounts, to check for any discrepancies, and to understand the systemic factors contributing to the women’s reported experiences.

Results

Participant Characteristics

The study consisted of a total of 42 participants. The age range of the women (n = 20) in the study was 24 to 54, with an average age of 37. Most of these women self-identified as White and non-Hispanic, accounting for 70% of the sample (n = 14). The study also included 12 SUD treatment professionals, including nurses (n = 2), case managers (n = 4), a treatment program director (n = 1), counselors (n = 4), and a research assistant providing services as part of a MOUD randomized controlled trial (n = 1). Among these SUD treatment professionals, ten were women, and two were men, with an age range of 38 to 54 years and an average age of 48. Most also self-identified as White and non-Hispanic, constituting almost 70% of the group. Finally, the sample included ten criminal legal professionals, including prosecutors (n = 2), treatment court professionals (n = 4), law enforcement (n = 3), and a corrections worker (n = 1). Seven of the criminal legal professionals identified as women and three as men, with an average age of 44 and ages ranging from 34 to 56. Nine self-identified as White and non-Hispanic, while one self-identified as Black.

Themes

Through our thematic analysis, we identified two significant types of barriers hindering access to mental health care. The first category, focused on physical access, encompasses challenges involving incarceration and reentry, long waitlists for care, and geographical proximity to care. The second category, focused on stigma, sheds light on the societal prejudices and misconceptions surrounding mental health issues. By addressing these themes, our analysis highlights the complexity of barriers to mental health care faced by criminal-legal involved women with OUD.

Physical Access

Our findings highlight various factors contributing to physical access as a barrier to obtaining quality mental health care. These factors include challenges arising from incarceration, insufficient support during reentry, lack of provider availability, and provider inaccessibility. Ultimately, our results point to the multifaceted obstacles faced by criminal-legal involved women with OUD in obtaining mental health care.

Challenges Associated With Incarceration and Reentry

Many of the women in our study expressed facing difficulty obtaining access to mental health care and medications while incarcerated and thereafter. These women saw their SUDs as intimately connected with their mental health issues and felt that lack of mental health care exacerbated their SUDs. One woman with OUD (Participant 31) told us that her OUD is a symptom of untreated mental health issues:

I’ve seen psychiatrists since I was 16 years old . . . I have panic disorder, I have anxiety, I have PTSD, and I have trichotillomania—it’s like an anxiety disorder, where I pull my hair. I have that . . . [and] I have depression.

She disclosed that she was initially not given her mental health medications while incarcerated and had to repeatedly advocate for herself to receive them. These were medications she had been taking for years for disorders she had also had diagnoses for years. She told us, “The whole time I was in jail, I’d been fighting for my anxiety medication back.”

Several criminal legal professionals corroborated the women’s accounts, affirming that access to mental health care, especially access to prescribed psychotropic medications, can be difficult in correctional facilities. One state prosecutor (Participant 15) spoke from their experiences with their mother’s dual diagnosis. While the participant did not disclose specifics related to their mother’s mental health, they shared that she had an OUD, had received treatment for OUD and her mental health, and had been incarcerated multiple times. When asked about challenges faced by incarcerated women with OUD, the participant answered:

My mother, because she’s on mental health meds, she has a really hard time getting her approved medication while she’s in [correctional] facilities. She’s not the only person that I’ve heard that from. Especially if you’re in there for a long amount of time, it can take a while to get your meds, and they’re needed.

This participant explained that the process of receiving necessary medications while in confinement can be difficult and time-consuming.

Access to mental health treatment is especially needed, as the structure of incarceration itself, namely the isolation and lack of healthy human interactions, can adversely impact mental well-being. Speaking to how incarceration can be a contributing factor to poor mental well-being, one woman with a history of OUD (Participant 25) stated, “You sit in a block for 24 hr a day, 7 days a week, nobody comes in and talks to you about anything that is going on with you.” What’s more, she explained that in addition to experiencing long stretches of isolation, in county jail especially, the waitlist to see a therapist can be quite long—sometimes even longer than people are there:

Especially around my area, the jails are so small and there’s like one counselor or therapist or whatever, and the waitlist is even longer than your sentence. What’s the point? You know what I mean? Of course, when you put somebody in jail and you don’t teach them anything and you let them out doing the same behaviors, and then you’re standing there, scratching your head saying, “Well, what? I just don’t understand.”

This participant felt like the lack of mental health care she received in jail can contribute to cycles of reincarceration for women suffering from dual diagnoses.

A criminal legal professional, a mental health coordinator in a correctional facility (Participant 19), corroborated this woman’s account of how long the wait for mental health care can be. She shared, “People are waiting months to see the one psychiatrist. He’s booked up [for] 6 months.” But in addition to highlighting how difficult it is to access timely, effective mental health treatment while incarcerated, this participant also told us about the costs and insurance complexities that arise when mental health issues involve medications. She continued, “Now let’s drive up the medical bills and the insurance class because this person’s trying to get meds, or the jail forgets to give them medication when they get out of the jail.” This participant alluded to her perception of the futility of trying to address these wait times and navigate through financial and insurance complexities, especially when there is a high possibility of medication discontinuity when women are released from jail.

Women also told us about the barriers they faced continuing their mental health medications post reentry. To open this section, we quoted one woman with OUD (Participant 31) who reported having to fight to get her mental health medications while incarcerated. Eventually, she was able to start taking them again in jail. However, after being released, she once again lost access to her medications and struggled to get new prescriptions. She told us, “I got out [of] jail. [Then] couldn’t get to my psychiatrist’s appointment.” She went on to share that this inability to get her mental health treatment impacted her OUD recovery journey. She continued, “I got out of jail on (redacted). I relapsed one time that month. [I] was fighting the whole time for my meds [and] couldn’t get them.” This participant’s experience illustrated how difficulties related to accessing mental health care and medications do not end following incarceration. Instead, after her release, she faced new obstacles to obtaining necessary medications and experienced dire consequences to her well-being as a result.

Further complicating the difficulties accessing mental health care upon reentry is that mental health issues can compound due to incarceration. One participant (Participant 23), a woman with a history of OUD, disclosed phobias and mental health issues she developed due to her incarceration. She was seeing a psychiatrist, but she did not feel that this specific mental health professional was adequately assisting her through her post-incarceration trauma:

She [her psychiatrist] just really hasn’t been working with me with the meds that I think that I need to live a normal everyday life. A functioning life. Especially in public because I have like, a phobia, I guess, of going out in the public. It’s sad. I’ve never been like that except for after I got out of prison, I started acting different ways. I noticed and it freaked me out.

This participant’s experience sheds light on both how incarceration can contribute to poor mental well-being and the difficulties faced accessing effective, relevant treatment options upon reentry.

Challenges Associated With Provider Availability and Accessibility

Although many women faced barriers accessing quality mental health care due to incarceration and reentry, women who were not incarcerated or recently released still experienced continued struggles. One prominent barrier addressed by participants is the dearth of mental health care providers to meet demand. Several of the women expressed a desire for greater access to mental health services, as there were not enough providers to meet their needs in a timely manner. For example, one woman with a history of OUD (Participant 37) told us:

I would love to get back on my meds. I was on a series of six different psych meds . . . it’s really difficult to find a doctor to prescribe meds right now, especially hard to get in anywhere. Always six months and nine months. There’s always a huge waiting list, and that’s not helpful for someone like me.

This statement emphasizes the participant’s desire to resume her medication; she believed restarting medications would aid in her recovery journey. However, the primary challenge she encountered was finding a doctor to get new prescriptions. She experienced significant difficulty accessing timely appointments, experiencing waitlists ranging from 6 to 9 months.

Our participants underscored that the issue of finding providers is particularly acute in rural areas. In discussing her experience trying to seek treatment for her bipolar disorder diagnosis, one affected woman (Participant 22) told us, “I just need to get in the right doctor, and it’s really hard to find around small areas [like] where I’m at.” A similar account was provided by a case management director (Participant 5) who told us, “A lot of our people, when they call to make appointments, it’s a 6 to 8-month waitlist just to see a therapist or a psychiatrist. We shouldn’t be making them wait.” This participant worked at a facility in a rural county in Pennsylvania. In her response, she highlighted how long waitlists can become an even more pervasive issue in rural areas, where shortages of mental health care providers are particularly severe.

An additional issue compounding the difficulties associated with scheduling mental health care services is a lack of available appointment times; sometimes there are providers accepting new clients, but they may have limited availability. Similar to the previous participants’ experiences, another woman with a lifetime history of OUD (Participant 36) revealed that she would like to receive mental health services but has not been able to acquire them due to timing and scheduling, in addition to long waiting lists. When asked if there were any services that she would like to receive, she told us:

Some are like therapeutic mental health, but it’s not because of lack of being able to, it’s really scheduling and timing [that] I really can’t . . . Then when COVID hit, now it’s like no one’s accepting new patients, so it’s difficult . . . I don’t think they have really much control over it, but I wish there was more availability of drop-in centers.

This quote highlights the participant’s challenging experience with accessing mental health services due to scheduling constraints associated with work and motherhood. She acknowledged that the additional barrier of limited availability due to the impact of COVID-19 compounded scheduling challenges. She suggested that accessible drop-in centers could be a possible solution—having a space where she does not need an appointment would allow her to seek care in moments when she needs it most.

Even when participants are able to find available providers, they often encounter barriers to physical accessibility due to a lack of geographical proximity and reliable transportation options (Skogseth et al., 2025). Recall Participant 22, who explained that providers are hard to find in her small town. While she could locate more providers if looking at a larger catchment area, finding a distant provider would introduce new challenges. When asked about what other barriers were keeping her from receiving mental health care, she answered, “Just time . . . scheduling, having transportation to get to an appointment and things like that.” Without access to public transportation, this participant drew attention to how she would need to find a ride, and how this could be time-consuming and require juggling more scheduling logistics for both her and the person willing to drive her.

Another prominent issue that compounds barriers to mental health treatment is having to navigate multiple providers that all have long waitlists. One woman (Participant 30) with a lifetime history of OUD spoke to this in greater detail, sharing:

It [seeking mental health treatment and MOUD treatment simultaneously] just makes for more appointment running around, too . . . I have to go over here for my mental health meds, and then maybe yet over here for my regular general practitioner. At the end of the day, I’m a single mom and I work 50 hours a week, it’s mandatory overtime. I can’t get to all of these things. What am I going to do?

This woman’s experience illustrates the difficulties a lack of integrated care poses; there are more providers to navigate and appointments to attend than she has time available to realistically do so. To aid in addressing physical accessibility barriers to seeking treatment among criminal-legal involved women with OUD, participants expressed the desire for integrated care that would streamline this.

Stigma Due to Dual Diagnoses

In addition to the physical barriers they face accessing mental health care, due to the confines of incarceration, the discontinuity imposed by reentry, and lack of provider availability/accessibility, women also reported encountering stigma, particularly from mental health professionals. They noted that this stigma could impact their substance use trajectory and potentially contribute to recidivism. The results from this study uncover the severe impact of stigmatization and the challenges it presents to women in obtaining quality mental health care.

In discussing stigmatizing attitudes around their dual diagnoses, participants told us about their experiences of feeling like their mental health professionals are not willing to prescribe their mental health medications due to their SUDs. One woman with a lifetime history of OUD (Participant 31) told us:

Once you get an addict label, you can’t get the right meds . . . My psychiatrist was treating me like I was a drug addict, not giving me the right help I need . . . I guess the biggest thing for me is I wish it would be easier for me to self-advocate and not just get treated like I’m a drug addict . . . I ended up putting myself into the psych ward for the first time in my life, trying to get the correct meds.

This individual expressed her frustration with her psychiatrist, whom she felt labeled her as an “addict” who was seeking drugs for pleasure rather than as necessary treatment. She believed mental health medications would help her SUD recovery, but because of her SUD and her criminal legal background, she felt she had a more difficult time accessing them. Even when she checked herself into a hospital for inpatient mental health treatment though, she still could not access her medications. She continued,

When I left there [the psych ward], I was like, “If I go home and end up overdosing, and dying, or killing myself, I hope that when I’m dying, I can still write a note, because I’m going to blame it on [. . .] healthcare, and that psychiatrist there.”

This participant feared that a lack of her mental health medication could lead her to return to use as self-medication, and she worried about the chance of overdose if she were to do so. At the time of her interview, she was still trying to find a way to restart her medication.

Some of the SUD treatment professionals who were interviewed indeed voiced some of the stigma and judgment that these women shared with us. One participant (Participant 7), a psychiatric nurse, told us “I think we over-medicate psych clients right now. I really do.” This perspective from a SUD treatment professional suggests a belief that there is an excessive reliance on medication for women with a history of OUD, which is contrary to the experiences shared by women in the study. A criminal legal professional (Participant 18) working for a drug treatment court affirmed this sentiment, noting their concerns regarding misuse of mental health medications among women with a history of OUD. He told us, “There’s different medications now that are being heavily abused that a lot of places aren’t testing for like Neurontin, or even just mental health meds.” These professionals’ statements provide supporting evidence that the women do likely encounter stigmatizing concerns that they will misuse mental health medication. Yet, paradoxically, these concerns may keep them from accessing medications that could aid them in their pursuits of abstaining from illicit opioids.

Discussion

Overall Findings

The goal of this study was to investigate barriers to accessing mental health care among criminal-legal involved women with OUD by triangulating multiple perspectives across three relevant subgroups. Themes spanned two domains of barriers: physical access and stigma. Findings across subgroups converged regarding challenges associated with accessing mental health care during incarceration and reentry and difficulties accessing timely care particularly in rural areas. However, while women expressed concern about the stigma they faced seeking mental health medications, some SUD treatment professionals and criminal legal professionals themselves expressed stigmatizing views about women’s potential misuse of these medications.

Barriers to Mental Health Care during Incarceration and Reentry

One key point of convergence across subgroups involved prolonged wait times for receiving mental health care while incarcerated and in reentry. Participants spoke to the insufficient availability of mental health services, noting that there are few psychiatrists and therapists available, especially in smaller jails and especially in rural community settings. Past studies corroborated these accounts, reporting that correctional facilities, whose populations experience disproportionately high rates of SUDs and SMIs, have an insufficient number of mental health professionals and available services for incarcerated individuals (Morris & Edwards, 2022; Wennerstrom et al., 2022). Moreover, when the mental health of incarcerated individuals goes untreated, evidence indicates that they may be at a greater risk of reincarceration following their release, which is likely compounded in individuals with dual diagnoses (Reingle Gonzalez & Connell, 2014). These findings also extend our previous work, where we have highlighted the steep barriers women involved in the criminal legal system face accessing substance use treatment services both inside (Jones et al., 2025) and outside (Skogseth et al., 2025) of corrections settings, and the steep barriers they face accessing reentry support services generally (Strong-Jones et al., 2024). To best serve the needs of individuals with concurrent SMIs and SUDs while incarcerated, there is a clear need for more mental health professionals in correctional facilities, collaborative partnerships between criminal legal systems and mental health treatment systems, and options for individuals to receive supplementary support while waiting for appointments.

In addition to insufficient provider availability, the affected women specifically identified difficulties in obtaining prescribed medications for mental health conditions both while incarcerated and during reentry. One criminal legal professional also spoke to this when recounting their mother’s experience. Previous research aligns with these findings; evidence shows that individuals often face disruptions to psychiatric care during the transition from incarceration to release, have limited access to psychiatrists, and are unable to continue existing treatment plans, with only 50% of individuals taking medications for their mental health conditions prior to incarceration able to continue to do so during their sentence (Casey & Bentley, 2019; Reingle Gonzalez & Connell, 2014). These factors likely contribute to situations described by our participants, such as having to advocate for the approval of their medications while incarcerated or lapses in treatment following their release that have adverse effects on their mental well-being. Especially because incarcerated individuals may have their Medicaid enrollment suspended or terminated during incarceration, ensuring that these individuals have benefits reinstated immediately upon release to ensure continuity of care is imperative (National Alliance on Mental Illness, 2021). Ultimately, these findings make the case that future interventions and policies centering criminal-legal involved individuals with dual diagnoses should investigate mechanisms of bolstering timely access to prescribed medications and treatment plans.

Challenges With Managing Multiple Mental Health Needs

Even for women who were not recently incarcerated or released, participants across subgroups articulated issues of care inaccessibility. Participants spoke to high wait times for mental health services, limited provider availability, and scheduling difficulties, all of which are compounded by affected individuals having to manage their dual diagnoses and day-to-day stressors. Participants noted waitlists for seeing a psychiatrist or therapist to be between 6 to 8 months, and even if an appointment finally became available, it could be difficult to schedule when raising children and balancing other demands like work schedules. Previous research has found that high wait times for receiving mental health care have the potential to exacerbate the severity of one’s symptoms as well as decrease the likelihood that the individual will initiate treatment once moved off of the waitlist (Krendl & Lorenzo-Luaces, 2022; Peipert et al., 2022). It is likely that not receiving time-sensitive mental health care has the potential to adversely impact one’s recovery from SUD as well as their mental well-being.

Offering a potential solution to scheduling conflicts and waitlists, one of the affected women voiced her desire for more drop-in centers. Present in some communities, drop-in centers offer services for individuals to meet their basic needs; they also often provide spaces for individuals to receive SUD treatment and/or mental health care (Pedersen et al., 2016). Opening more drop-in centers in rural areas could help address the risks posed by long waitlists for mental health services, which may be particularly beneficial for individuals with dual diagnoses. Telehealth also offers flexibility in addressing the need for more accessible mental health care and SUD treatment, as it expands service provision, reduces the need to travel to and from a facility, and often has less of a delay than in-person care (Zaller et al., 2023). Ultimately, the participants’ discussions of the challenges associated with managing multiple mental health needs directs attention to the importance of expanding adaptive, flexible mental health services.

Divergent Views Around Psychiatric Medications

While the affected women in our study overwhelmingly voiced the value of receiving prescribed psychiatric medications, some SUD treatment and criminal legal professionals held contrasting opinions. One SUD treatment professional, a psychiatric nurse, shared that she thought individuals with OUD and psychiatric conditions were over-reliant on medication. This echoed attitudes of some SUD treatment professionals who view MOUD treatment as something to be tapered off from instead of used as a long-term solution—that relying on the medication is an impairment to “true recovery” (Dickson-Gomez et al., 2020). One participant working for a treatment court further mentioned the possibility for “abuse” of mental health prescription medications. These views can be stigmatizing to individuals with dual diagnoses and can make it harder for people with SUDs to access mental health medication prescriptions.

Looked at in tandem, these divergent views call attention to a disconnect between what the affected women and some SUD treatment and criminal legal professionals think of medications and their ability to support SUD recovery and mental well-being, which may influence individuals’ engagement with treatment and their overall outcomes. Recent research not only offers evidence that these stigmatizing views held by SUD and criminal legal professionals can serve as a significant barrier to care for this population (Crapanzano et al., 2019; Farabee et al., 2019; Lowder et al., 2019) but also provides a path forward in addressing these views. Specifically, an ongoing study is testing behavioral strategies through an evidence-based training program to combat stigmatizing views held by criminal legal professionals toward criminal-legal involved individuals with SUDs (Moore et al., 2023). If found to be effective, it is likely that the positive outcomes of this intervention and those like it could extend to reduce stigma toward criminal-legal involved individuals with dual diagnoses and support treatment uptake and retention altogether.

Limitations

The results from this study should be interpreted in light of its limitations. One constraint is generalizability. Our participants included women with OUD, SUD treatment professionals, and criminal legal professionals who resided in PA; thus, the scope of our findings is likely narrowed and may be specific to this geographic area. Relatedly, the women with OUD in our study were between 24 and 54 years old and predominantly self-identified as White, which also limits the generalizability of our results. To speak to the experiences of more women with OUD, future work could replicate our study design in other regions and seek out diverse populations to contribute to the growing literature in this research domain.

An additional limitation worthy of consideration is the reliance on responses to semi-structured interview questions as well as self-report data. Because of this structure of data collection, not all participants provided information related to their mental health conditions, and more specifics around timing and type were not always probed. Had participants consistently reported these data, this study could offer an even more comprehensive picture of their experiences as well as more detailed insights related to dual diagnoses—an area of study that presently sees a dearth of existing literature and inconsistencies in definition (Gonzales et al., 2022). Nevertheless, through the information our participants offered, this study contributes to the growing body of literature related to interconnected issues associated with concurrent OUD and mental health challenges.

A third limitation of our study involved its qualitative design. Through holding our semi-structured interviews over the telephone, we potentially missed important changes in body language or other nonverbal cues that could have deepened our understanding of participants’ experiences and inspired further clarifying questions. Conversely, the telephone modality may have strengthened our findings, as it offered an element of anonymity to participants that would not have been present had the interviews been face-to-face. This modality could have contributed to a comparatively more comfortable environment, which may have put participants at ease to discuss their experiences more openly.

A further constraint of this current analysis is that it focused exclusively on the experiences of criminal-legal involved women and did not include a comparison group. This analysis was not carried out with the intent to explain how women’s experiences may differ from those of others, nor do we claim it is representative of the experiences of all affected women. Nevertheless, the insights gleaned from this study are not diminished. These findings can serve as a foundational starting point in deepening the understanding around barriers to mental health care access that may be gender-specific. Future research could build on these findings to investigate within-group or between-group similarities and differences in mental health care accessibility for those with dual diagnoses within the criminal legal system.

Conclusions

In conclusion, the comprehensive insights gleaned from triangulating the perspectives of women with a lifetime history of OUD, SUD treatment professionals, and criminal legal professionals highlighted physical access and stigma as significant barriers to mental health care access. Participant responses converged around insufficient provider availability, long waitlists for mental health care, and interruptions to treatment plans and the receipt of prescribed psychiatric medications during the transition in and out of incarceration. Regarding medications, however, findings revealed a significant disconnect between individuals with OUD, who predominantly viewed their medications as supporting their journey toward recovery; and some SUD treatment professionals and criminal legal professionals, who voiced concerns about overreliance on medications and the potential for misuse.

Taken together, the findings from this study hold several implications. To reduce stigma and bolster positive mental well-being and SUD treatment outcomes among individuals with dual diagnoses, there is a need for system-level changes in correctional facilities. Correctional facilities should ensure the sufficiency of the number of clinicians to serve their population and by conducting assessments to determine whether care is needed for each incarcerated individual. They should implement specified procedures that help ensure safe, timely access to mental health care and medications, and in the meantime, they should put supports in place for individuals who are waiting to receive mental health services and access their prescribed medications. Reentry planning services should also ensure that incarcerated individuals are connected to the care and medications they need after release, without a gap or delay. Funds from opioid settlements could be one potential source of funding to institute these services to expand care within correctional settings (Johns Hopkins Bloomberg School of Public Health, 2022).

Outside of the correctional setting, there are other opportunities to make mental health care services more accessible. This may involve increasing the number of drop-in centers in communities and a more widespread implementation of telehealth. Recognizing that telehealth and drop-in centers may be difficult to finance, however, it is also important to develop and promote policies that would support the expansion of these services and advocate for their funding—particularly in rural areas. One funding mechanism could be funds from opioid settlements. For example, some of the opioid settlement revenues in Pennsylvania have been used to fund drop-in centers within the state (Pennsylvania Department of Drug and Alcohol Programs, 2024).

Overall, the findings from this study make a strong case for improving the accessibility of mental health care for criminal-legal involved individuals with dual diagnoses. Future research should strive to expand the literature around interconnected issues associated with concurrent OUD and mental health challenges in this population.

Footnotes

Author’s Note:

The authors have no conflicts of interest to declare. Research reported in this publication was primarily supported by the National Institute on Drug Abuse K01DA051715 (PI: Abenaa A. Jones) and partially supported by the National Institute of Child Health and Human Development Grant Number T32 HD101390 (Trainee: Sienna Strong-Jones).

ORCID iD

Emma M. Skogseth

Emma M. Skogseth is a PhD candidate in the Department of Human Development and Family Studies at Pennsylvania State University. Emma’s research involves examining pathways to treatment and treatment outcomes among women with co-occurring substance use disorder and serious mental illness to inform the development of interventions targeting both diagnoses.

Sienna Strong-Jones is a PhD candidate in Human Development and Family Studies. Her research interests center on intergenerational trauma, substance use, and resilience in historically oppressed communities. Her work integrates culturally tailored approaches to understand and address the impacts of historical oppression on family and individual well-being.

Kristina Brant is an Assistant Professor of Rural Sociology at Pennsylvania State University, where she also holds an appointment with Penn State Extension. Her research focuses on the social and structural determinants of rural health, with an emphasis on criminal-legal involved individuals and their families.

Oluwaseyi H. Quadri is a second-year doctoral candidate in the Department of Human Development and Family Science at Pennsylvania State University. Her research focuses on substance use prevention and intervention, especially within marginalized populations, with an emphasis on criminal justice-involved women with opioid use disorder and their children.

Abenaa A. Jones, PhD, is the Ann Atherton Hertzler Early Career Professor in Health and Human Development and an Assistant Professor in the Department of Human Development and Family Studies, Pennsylvania State University. Dr. Jones’ expertise lies in the social and structural determinants of substance use among vulnerable populations.

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Mental Health Care Barriers for Women Involved in the Criminal Legal System With Substance Use Disorders: A Qualitative Study

Abstract

Keywords

Introduction

Dual Diagnosis Overview and Prevalence

Dual Diagnosis and Access to Mental Health Care Among Criminal-Legal Involved Women

Current Study

Methods

Participant Recruitment

Interview Procedures

Data Analysis

Results

Participant Characteristics

Themes

Physical Access

Challenges Associated With Incarceration and Reentry

Challenges Associated With Provider Availability and Accessibility

Stigma Due to Dual Diagnoses

Discussion

Overall Findings

Barriers to Mental Health Care during Incarceration and Reentry

Challenges With Managing Multiple Mental Health Needs

Divergent Views Around Psychiatric Medications

Limitations

Conclusions

Footnotes

Author’s Note:

ORCID iD

References