Women in prisons represent a unique and complex population throughout the world. The authors have provided psychiatric consultation, diagnoses and treatment for hundreds of these women over the past three decades in the United States. We have identified five factors that can precipitate a cascade of consequences that result in women coming to prison. Sometimes it is a one-time experience; other times, women repeat offenses, ending up in prisons for longer periods. These factors include 1) being sexually abused and/or prostituted as a child, 2) alcohol abuse, 3) legal and illegal psychoactive substances use and abuse, 4) conspiracy with an intimate partner, and 5) mental disorders. We provide quotes from some of the many women interviewed in prison who have experienced at least one of these precipitant factors. We hope that our reflections offer insights into the complexity of incarceration and the pressing need to address the mental health concerns of these disenfranchised and vulnerable women in our prison systems.