CHAPTER TEN
Mary L. Colavita, Kate Lieb, Alexis Briggie, Sonal Harneja, and Howard L. Forman
Sometimes the feelings inside me get messy like dirt… and I like to clean things, pretend the dirt is the feelings. This floor is my mind. That is coping. And the COs don’t care because they like things clean. And that is called symbiosis.
–Suzanne Warren, Orange Is the New Black
It could be said that two of America’s favorite activities are incarcerating people and making television shows about incarcerating people. Whether documentary (Making a Murderer on Netflix), reality TV (60 Days In on A&E), or drama (The Night Of on HBO), America can simply not get enough entertainment based around this topic. It should be no wonder that a population that incarcerates approximately one out of every 100 adult citizens would have an interest in this topic.1
Incarceration rates in the United States have more than sextupled in the last 40 years, from just below 200,000 in 1970 to just over 1.5 million in 2014.2 For growth of such magnitude, it is unlikely that a single explanation will be sufficient. Certainly the rising crime rate from the 1960s through the 1970s, including a doubling of the homicide rate, did much to stir the sense that stemming the tide demanded greater deterrence through punishment.3 Some theorists pin the rise in incarceration on the political leaders elected during this era, with the Nixon administration focusing on increasing sentencing lengths, the Reagan administration starting the “War on Drugs,” and the “Three Strikes” policy of the Clinton administration leading to life imprisonment of many repeat offenders.4
Unrelated to increases in crime and political responses to it, those in the public health sector have a different explanation of increased incarceration rates, one that gained its momentum from the civil rights movement and was spurred on by humanitarian impulses. This movement, called deinstitutionalization, was the sum of all actions taken to remove people from state hospitals and integrate them into the greater community. In 1954, there was the first report of chlorpromazine successfully treating psychosis in the United States.5 Within a few years, psychiatrists working with the most severely mentally ill patients—patients who would have been confined to state hospitals for the remainder of their lives and exposed to treatments of certain discomfort without clear benefit—came to regard this drug as a “miracle drug.”6
The advent of the antipsychotic era (the class of which chlorpromazine would be known once additional similar drugs were developed) allowed for the possibility that masses of people could rejoin society at large. The civil rights movement encouraged people to question state-imposed limitations of personal autonomy, as occurred in the Jim Crow South. State psychiatric hospitals filled with involuntarily committed patients were similarly viewed as “cruel and inhumane.”7 Such institutions deprived citizens of their rights to freedom. Under the guise of promoting integration of state psychiatric patients into the communities they came from, the federal government took many financial steps to ensure the closure of state hospitals. Federal benefits programs including Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Medicaid (insurance funded through state and federal funding) and Medicare (federally funded health insurance) were all created during the 1960s. When created, patients hospitalized in state mental hospitals were specifically excluded from receiving these benefits, leaving states to shoulder the financial burden for housing and treating these patients.8 Since many patients would become immediately eligible for these programs following discharge, there was not a tremendous financial carrot for states to discharge patients from their wards regardless of whether infrastructure was in place yet to treat them effectively.
Deinstitutionalization did not lead to the dreamed-of vision of severely and persistently mentally ill patients living in the community and receiving outpatient psychiatric treatment suitable to their needs. In fact, today there are only 35,000 state hospital beds for the mentally ill, yet there are 10 times more severely mentally ill persons housed in prisons and jails.9 This is almost the exact inverse of the state of affairs in 1969, when there were over 350,000 state hospital beds and fewer than 30,000 severely mentally ill inmates.10 This has led many to term “deinstitutionalization” as “transinstitutionalization.”11
Jenji Kohan’s Netflix series Orange Is the New Black is one of many television series that has familiarized mainstream audiences with the trajectory of mental illness within the legal system. Based on the 2010 memoir of Piper Kerman, the series revolves around Kerman’s actual experiences at the minimum-security Federal Correctional Institution in Danbury, Connecticut (more widely known as the facility that has housed various television, music, and business personalities). The TV show follows the main character, renamed “Piper Chapman,” who is sentenced to 15 months in the fictional federal prison of Litchfield Penitentiary for her involvement in a drug smuggling operation ten years prior. The show focuses on Piper’s experiences with the other inmates in real time, while interweaving flashbacks to build the backstories of these supporting characters.
Following its premier on July 11, 2013, the series began to receive critical acclaim for humanizing and illuminating the diversity of the prisoners and their experiences. In addition to addressing issues of sexuality, gender, race, ethnicity, age, and family, the series also reflects on the above legal and social trends that impact some of our more psychiatrically complicated criminal offenders. The effects of transinstitutionalization are displayed quite vividly. We see the plight of the mentally ill inmates of Litchfield and witness possible missed opportunities for care both prior to and during incarceration. Orange portrays issues that often arise from incarcerating severely mentally ill patients, who tend to be more vulnerable to victimization by other inmates within the prison system.
The show appropriately speaks to the prevalence of mental illness among female offenders and the social relevance of this trend. Although men are incarcerated at much higher rates than women, mental illness is present in a higher percentage of female inmates. As a reflection of these trends, the absolute number of female mentally ill inmates is higher than prison population statistics alone would predict. Many would be surprised to learn that 14.5 percent of male jail inmates have severe mental illness, yet that percentage pales in comparison to the 31 percent of female inmates who suffer from severe mental illness12 Moreover, incarceration of women, regardless of race, is rising at a more rapid rate than men’s incarceration, according to former New York state commissioner of corrections, Phyllis Harrison-Ross, MD. Before her death in January 2017, Ross was a psychiatrist, pediatrician, and medical school professor emeritus.13 Perhaps the general public intuits this trend without necessarily accessing specific statistics, and this recognition partially explains the popularity of this production at this given time.
Suzanne Warren, most commonly referred to as “Crazy Eyes” in Orange Is the New Black, is a 32-year-old black female incarcerated at Litchfield Penitentiary. She is the prototype of the mentally ill incarcerated woman with a violent past who will urinate on your floor if you reject her. She smacks her head feverishly when in distress, has been “removed from the puppy program,” breaks into Shakespearian soliloquies when the opportunity arises, and she “will cut you, bitch.” Suzanne herself comments that she has had repeated visits to the psychiatric ward for her diagnosis of intermittent explosive disorder: “When I get angry, sometimes I can’t control myself…. They give me medication to make me calm, but that just makes me sleepy. Sometimes they tie me down like a balloon, so I don’t fly away. Once you go to psych, you’re lost to psych.” It is for this role that actress Uzoamaka Aduba received Primetime Emmy wins for Outstanding Guest Actress in a Comedy Series in 2014 and Outstanding Supporting Actress in a Drama Series in 2015, and the Screen Actors Guild Award for Outstanding Performance by a Female Actor in a Comedy Series for two years in a row.
Making a psychiatric diagnosis in a real human being can be quite difficult; formulating a diagnosis in a fictional character, although possible, is increasingly complicated due to the obvious limitations of not being able to explore various aspects of the character’s history in adequate detail and not being afforded the opportunity to experience in vivo transference, which has significant diagnostic and therapeutic utility. Through the juxtaposition of Suzanne’s flashbacks with her present journey, it becomes quite obvious that her fragile sense of self has been compounded by repeated experiences of loss, familial shifts, and complex racial/social identifications. As a young black child adopted by white parents who eventually have their own biological daughter, Suzanne repeatedly experiences alienation from the community of which she desperately struggles to be a part.
Suzanne displays many features of mental illness, and although she is widely known as “Crazy Eyes,” we prefer to call her by her name so as not to perpetuate the stigma that has been imposed upon her throughout much of her life. To parallel Suzanne’s emphatic response to one of her fellow inmates, “No! I am not crazy. I am unique!” In the following chapter, Suzanne’s rich history will be explored to identify the various cognitive, personality, and affective components that she displays and the coping skills that she has developed as a means through which she strives to reconcile and protect her complicated sense of self.
Although it is difficult to confirm Suzanne’s cognitive functioning due to limited information regarding her developmental milestones and academic accomplishments, it may be assumed that Suzanne exhibits traits of neurodevelopmental disability based on her repeated deficits in communication and interaction with her fellow inmates. In other words, were she not incarcerated, she would likely have qualified for special services through commissions for the developmentally disabled and the cognitively impaired (previously known as “mental retardation”) as well as from her local office of mental health or its equivalent, which specifically serves persons with general mental illness.
She either comes on too strong and scares others away, or she leaves herself so vulnerable that she becomes an easy target for manipulation. This is displayed quite vividly in the first season, when Suzanne develops a rapid and unreciprocated attachment for Piper, the newest inmate at Litchfield. She nicknames her “Dandelion,” writes poetry for her, threatens other inmates in Piper’s defense, and places a request, unbeknownst to Piper, that they share a room. She is unable to perceive Piper’s lack of interest, as she continues to refer to her as her wife and as she sings about their partnership as a “chocolate and vanilla swirl.” These deficits in communication further resonate throughout the course of the second season, as Suzanne falls under the influence of a new inmate, Vee, who acts as a motherly figure in order to manipulate and exploit Suzanne’s vulnerabilities. She uses Suzanne as a pawn in her drug operation, has her commit dangerous acts with little reward, and then has her assume responsibility for a very violent crime against another inmate that she did not commit. As explained in DSM-5, “gullibility” and poor awareness of risk are often features of intellectual disability, as these patients can be easily led, victimized, and exploited by others resulting in unintentional criminal involvement and false confessions.
Also consistent with neurodevelopmental disorder, Suzanne displays repetitive behaviors in response to difficult self-management of emotions, as illustrated by frequent episodes of hitting herself repeatedly on the head while saying “no no no no no.” She seems to be hyperreactive to sensory input, often demonstrating irritability and self-harming behavior when overstimulated. Her insistence on sameness and her struggle to achieve personal independence is quite literally displayed by her maintenance of the same hairstyle for approximately a quarter of a century. In real life and in psychiatric circles, we witness similar repetitive behaviors in persons diagnosed with autism spectrum disorder, which falls under the rubric of “developmental disability.”
We are given insight into the pervasiveness of Suzanne’s developmental difficulties, via flashback, when 10-year-old Suzanne is pushed by her mother to socialize with her sister, Grace, and Grace’s friends, who are four to five years younger: “We just feel it’s important for Suzanne to have the same social development as Grace…. You know which kids suffer in this world, Melanie? The ones who are told they’re different.” As spectators, we wonder about the inadvertent stress imposed on Suzanne by denying Suzanne’s differences from her sibs (who are white while she is black). Even viewers who have no professional background in either psychology or sociology ask themselves if this homogenization further deprived Suzanne of an individual identity, and further strained this intellectually challenged child’s ability to understand herself.
When at the party, Suzanne struggles to read the room, and takes her turn to complete a princess-themed story telling game with a very macabre ending: “But then, a dragon came, swooping in, breathing fire out of its dragon nostrils—some of the family runs outside, but the little girl gets trapped inside, screams for help, sits and cries by herself and gets burned up by the fire and dies alone.” This scene illuminates both the vast age difference between Suzanne and her six-year-old peers and her difficulty adapting to their social needs. Further, the character in the story parallels Suzanne and the loneliness that she herself experiences as a little girl who is constantly reminded that she is different, as she desperately struggles to be like those around her. Suzanne echoes, “I’m not weird, I’m just like everyone else.”
Suzanne’s desperation for love and validation comes with such vulnerability to repeated victimization that her suspected neurocognitive diagnosis is likely complicated by the oftentimes comorbid pathology of disinhibited social engagement disorder. This diagnosis is characterized by indiscriminate social behaviors that result in complicated peer relationships in response to a pattern of insufficient care. Like many mentally ill women who are incarcerated, it seems that Suzanne has a history of suspected trauma and poor attachments. We never learn about Suzanne’s biological parents, but it is possible that they were abusive or neglectful of Suzanne. Perhaps she was malnourished or exposed to harmful drugs.
Although her adoptive parents appear quite loving and supportive, it seems that they don’t understand Suzanne’s needs and limitations. In the flashback wherein a 4–5-year-old fairy-winged Suzanne comes to visit her newborn sister Grace for the first time, she notes that Grace looks much more like her mother and father, as she is their biological child. She rapidly attaches to Grace, commenting, “Hello Grace, I’m your best friend and your big sister, Suzanne. Just me and you, you and me, you and I.” She then has a tantrum when her parents try to lift the baby up from her arms, but is quickly appeased by a maternal black nurse who seems to be more attuned to Suzanne’s physical and emotional needs. The baby nurse relates to Suzanne calmly and provides her with a hairstyle that is maintained for decades. This hairstyle remains unchanged until restyled by Vee, one of Suzanne’s more sinister maternal figures in prison. It isn’t until the third season, when Suzanne develops an attachment to a more supportive maternal figure with Tasha “Taystee” Jefferson, that we eventually see our character able to gain some autonomy, style her own hair, and engage in her first reciprocal romantic relationship in a carefully paced manner.
Suzanne’s resoundingly fragmented and unstable sense of self in the context of repeated trauma contributes to her behavioral pattern most consistent with borderline personality disorder (BPD). As mentioned earlier, Suzanne has a history of unstable interpersonal relationships that result in frantic and potentially psychotic attempts to avoid abandonment, even if this means taking the blame for a crime she didn’t commit. When Vee critically assaults one of the other inmates, she encourages Suzanne to assume responsibility by convincing her that she committed the violent act. Vee then disappears, which reactivates Suzanne’s struggle with abandonment. This sense of abandonment is then exacerbated by the stress of being interrogated for a violent crime that Suzanne is not sure that she committed. In response to the simultaneous loss of her love object and stress of being interrogated, Suzanne becomes briefly psychotic, strips naked in the hallway, becomes internally preoccupied, and displays thought disorganization: “I thought I was mopping in the warehouse, turns out I was slocking in the greenhouse. I must have mixed up ware and green or mop and slock. That can happen, right?” During these scenes, she frantically attempts to attach to others to reconcile her fragmented sense of self, insofar as attaching to the detectives: “Those men who were here said I did—shouldn’t I believe them?” The psychosis resolves once Suzanne develops the aforementioned healthy and supportive attachment to Taystee, who encourages her autonomy.
Also in line with BPD, Suzanne demonstrates affective instability, impulsivity, and transient stress-related dissociation, most evident when she blacks out during rageful violent acts. This is illustrated in season 2, when Suzanne freezes up onstage at the Christmas play. She flashes back to an episode from youth wherein her mother forces her to sing at her high school graduation, and she similarly freezes, shouts, and repeatedly strikes herself in the head. After the Christmas play, Suzanne is mocked by her peers, and in a panic, she runs outside and ragefully punches Piper while shouting: “No Mommy, I don’t want you! You’re always pushing me to do these things. Pushing me. No more, Mommy! No more!” This scene illustrates both the complicated relational and trauma pattern that contributes to BPD, in addition to the affective instability and dissociative episodes that can result.
Though it is hard to pigeonhole a fictionalized character into diagnostic groups, we can use Suzanne to look more broadly at the experiences of mentally ill persons who are incarcerated. In a June 2016 interview with Variety, Uzo Aduba reflected on the social conversation that is brought about by her character: “She is not in full possession always of herself. It asks a lot of questions: How is it that someone who isn’t in full possession of herself winds up in this form of rehabilitation? Is it rehabilitating? Is this the form of treatment she should be receiving?”14
Notes
1. Bruce Western and Becky Pettit, “Collateral Costs: Incarceration’s Effect on Economic Mobility,” The Pew Charitable Trusts, 2010, http://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2010/collateralcosts1pdf.pdf.
2. The Sentencing Project, “Fact Sheet: Trends in U.S. Corrections,” December 2015, http://sentencingproject.org/wp-content/uploads/2016/01/Trends-in-US-Corrections.pdf.
3. Bruce Western and Steve Redburn, “The Underlying Causes of Rising Incarceration: Crime, Politics, and Social Change,” in The Growth of Incarceration in the United States: Exploring Causes and Consequences, National Research Council of the National Academies, National Academies Press, 2014, http://www.nap.edu/read/18613/chapter/6#112.
4. Todd R. Clear and Natasha A. Frost, The Punishment Imperative: The Rise and Failure of Mass Incarceration in America (New York: New York University Press, 2014).
5. N. William Winkelman Jr., “Chlorpromazine in the Treatment of Neuropsychiatric Disorders,” JAMA no. 155 (1954): 18–21.
6. Thomas A. Ban, “Fifty Years Chlorpromazine: A Historical Perspective,” Neuropsychiatric Disease and Treatment 3, no. 4 (August 2007): 495–500.
7. Daniel Yohanna, “Deinstitutionalization of People with Mental Illness: Causes and Consequences,” AMA Journal of Ethics no. 10 (October 2013): 886–891.
8. E. Fuller Torrey, et al., The Shortage of Public Hospital Beds for Mentally Ill Persons: A Report of the Treatment Advocacy Center, 2015, http://www.treatmentadvocacycenter.org/storage/documents/the_shortage_of_publichospital_beds.pdf, accessed February 22, 2017.
9. E. Fuller Torrey, et al., “Treatment of Persons with Mental Illness in Prisons and Jails,” TACReports.org, Research from the Treatment Advocacy Center, April 8, 2014, accessed February 22, 2017, http://www.TACReports.org/storage/documents/treatment-behind-bars/treatment-behind-bars.pdf.
10. Gregory Sokolov and Talmadge Jones, “Mental Health Courts and the Criminalization of People with Mental Illness” (Slideshow/Lecture presented at general meeting of NAMI Sacramento, Sacramento, CA, March 9, 2007), accessed February 22, 2017, http://www.namisacramento.org/advocacy/docs/Mental%20Health%20Court-Board%20of%20Sup-3-9-07.pdf.
11. SJ Prins, “Does Transinstitutionalization Explain the Overrepresentation of People with Serious Mental Illnesses in the Criminal Justice System?” Community Mental Health Journal 47, no. 6 (2011): 716–722.
12. David Cloud, On Life Support: Public Health in the Age of Mass Incarceration (New York, NY: Vera Institute of Justice, 2014).
13. Phyllis Harrison-Ross and James E. Lawrence, “Women in Jail: Mental Health Care Needs and Service Deficiencies” in Women’s Mental Health Issues across the Criminal Justice System, eds. Rosemary L. Gido and Lanette Dalley (New York: Pearson, 2009).
14. Geoff Berkshire, “Uzo Aduba on ‘Orange is the New Black’ Season 4, the Big Death and Mental Health,” Variety, July 21, 2016, http://variety.com/2016/tv/news/uzo-aduba-orange-is-the-new-black-season-4-interview-suzanne-crazy-eyes-warren-poussey-washington-samira-wiley-1201799903/.