Psychiatrist Christine Montross has spent years treating people with serious mental illnesses — sometimes in hospitals, other times in jails or prisons.
"The patients that I was seeing in my hospital were indistinguishable many times from the men and women that I was evaluating in jail," Montross says. "But the environments were so markedly different. One [is] charged with ... trying to help and heal, and the other [is] really designed to control and punish."
Montross is a 2015 Guggenheim fellow and an associate professor of psychiatry and human behavior at Brown University's medical school. In her new book, Waiting for an Echo: The Madness of American Incarceration, she writes that in the U.S., people with serious mental illnesses are far more likely to be incarcerated than they are to be treated in a psychiatric hospital — despite the fact that incarceration often makes mentally ill people worse.
"People who are mentally ill to begin with are in circumstances that are not therapeutic and supportive at all, that are extremely punitive," she says. "It's unrealistic for us to imagine that people can emerge from those situations psychologically intact."
Montross advocates for rethinking the U.S. approach to mental illness and incarceration. While researching her book, she studied Norway's prison system, which focuses on reducing recidivism by treating the behaviors that led to the arrest.
"That fundamental shift in philosophy was really fascinating to me," Montross says. "The [American] system is broken, but we don't have to reinvent the wheel in order to fix it. There are places that can show us a road map for how to achieve the outcomes we desire without us starting from scratch."
On what police call a "compassionate arrest" of mentally ill people
Police officers, sometimes in an attempt to provide mentally ill people with treatment, have said things to me: "We know if we take them to jail, they will at least get 'three hots and a cot.' They will at least get their psychiatric medications." And so taking them to jail feels like an act of compassion.
So this idea of a "compassionate arrest" struck me so deeply, because we would never do something like that for someone to make sure that someone received their treatment for diabetes. We would never arrest someone to make sure that they received treatment for their cancer. We only do that in this situation of the mentally ill, and that, to me, seems like a travesty.
On how incarceration makes people with mental illnesses worse
When you are in the prison system, the expectations are very clear. You're given a set of rules; you're meant to follow those rules. If you don't follow the rules, there are consequences, and the consequences result in greater punishment, greater control. When a person with mental illness enters into that system, there is a misalignment between the straightforward system and their ability to comply with that system. So if someone is not thinking clearly, if they're feeling extremely paranoid, they are not going to trust the rules that are being told to them or the people who are expressing those rules. ...
When mentally ill people are not able to comply with the instructions and expectations that are laid out for them in jail, the result is greater and greater punishment. So one of the things that we see frequently is that as punishments escalate, the end-of-the-line punishment is solitary confinement. So if people run afoul of the rules in prison enough times, they can be sent to solitary confinement — which is a disastrous outcome for people with mental illness.
On a disgusting and dehumanizing prison meal known as "nutraloaf"
Nutraloaf is a nutritional approach, for lack of a better word, in many correctional facilities across our country. It goes by many different names, but essentially it is a food item that is supplied to people in prison — often as punishment, oftentimes within realms of solitary confinement. Nutrition, the nutritional needs of the person, are all ostensibly met, but they are met by grinding up, for example, the leftovers of several prison meals, having those ground-up [leftovers] put into a loaf pan, baked and then sliced into chunks. Or sometimes there'll be a very detailed list of ingredients ... like beans, oats, margarine, mechanically separated poultry — ingredients that tick off a checklist of nutritional needs but are then combined and prepared in a way that is absolutely disgusting when you hear people describe the experience of eating it.
It's intended to be disgusting. And so the reason that I wrote about it was really to get at the urge that I see so much in our nation's [incarceration] practices, which is to make people suffer. I think nutraloaf, to me, was just a prime example of how blatant our intention is that we say that we incarcerate people to rehabilitate them or to keep our communities safe, and yet the foremost thing that I saw over and over again is how much we want people to suffer once they're held within our jails and prisons.
On how Norway changed its prison system
In the 1980s and '90s, Norway had a prison system that looked very much like our prison system. They had quite a bit of violence within their jails and prisons. They had a high recidivism rate. ... The government looked at the situation and acknowledged that it wasn't working, that they weren't having the outcomes that they desired. ... And so they took a very hard look at the prison system to revamp it, to see how their outcomes could improve and how the safety of the system could improve. ... They assigned a working group within the justice system to look at changes that could be made. And one of the central tenets that came out of that working group was to stop meeting hard with hard and start meeting hard with soft. And what I learned they meant by this was that if you take a harsh stance of punishment toward people when they enter the legal system, you don't get the outcomes that you desire. ...
So they decided to do a needs assessment of everyone who came into prison immediately and when they arrived to see, "Do you have a substance use problem? Well, then we will use the time that you're incarcerated to get you mental health treatment for your addiction. Do you need job training? Do you need education? Do you need language assistance? Do you need anger management classes or parenting classes? What are the root causes of the behaviors that are getting you arrested that we can try to address so that we'll use this time in prison constructively, so that when you leave prison, you don't come back?" And that fundamental shift in philosophy was really fascinating to me.
On visiting Halden Prison in Norway and being shocked by what she saw
[It was] completely antithetical to any prison I had ever seen. I was picked up at the train station by the warden, driven onto these very parklike grounds in a really beautiful setting. And the warden explained to me that when the architects designed the facility at Halden Prison, that it was really important to them to have the prison feel as though it was set in nature. And there's historical precedent for this, even in our own country — asylums and hospitals in days of yore. It was seen to be really critical that people had fresh air and fresh water and a beautiful view. That was understood even back then to be restorative. But that was very much implemented intentionally in the design of Halden prison. ...
These are men who have committed extremely serious crimes — no different from men who are held in high-security prisons in America. The living quarters essentially look like a new and clean youth hostel or spartan dormitory. Each man has his own room with a door that closes. He has a bed with a colorful bedspread, and he has his own bathroom. There's a TV on the wall ... and the door closes because part of the Norwegian philosophy is that everyone is entitled to their own privacy. And that's not something that you lose when you are incarcerated.
Then there's a communal living area that looks kind of like a living room would be in a dormitory, and there's a kitchen. And one of the things that was extremely surprising to me, and I think is surprising to all visitors that come from America to Halden Prison, is that there was a magnetic knife strip on the wall of the kitchen with all manner of cooking knives. There was a dart board [and] a silverware drawer.
As someone who's trained to look for risk, I'm seeing all of these implements that could be used for one person to hurt another. But these men use the knives to cook their own meals, and they use the darts to entertain themselves in the evenings before they all go to their rooms for sleep, and they use the silverware to eat their meals. The level of personal responsibility is so much greater, and that's reflected in the environment. It was really striking.
Sam Briger and Thea Chaloner produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the Web.