After decades of living with a criminal justice system that is far more focused on punishment than rehabilitation, many Americans have seemingly resigned themselves to, and in some cases embraced, the dehumanizing narrative that people in prisons and jails belong there — and that even the most terrible treatment they may receive can be justified.
However, for Dr. Christine Montross, an associate professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University and a practicing inpatient psychiatrist, prisons are more often filled with people who do not belong there at all and, especially for the mentally ill, can make those who are sick even more unwell.
In her new book, Waiting For An Echo: The Madness of American Incarceration, Dr. Montross uses the stories of men and women held inside our nation’s prisons and jails to expose the debilitating realities of life behind bars, and to investigate in particular why so many of the mentally ill find themselves entangled in a legal system that neither truly understands nor accounts for them.
In a recent conversation with The Crime Report, Montross discussed why society is so quick to denigrate and misjudge both our nation’s prison population and the mentally ill, describes how the very architecture of prisons contradicts the goal of rehabilitation, and suggests where we can look to find examples of positive reform in this country today.
Below is a slightly edited and abridged version of the conversation.
The Crime Report: What prompted you to work on this project?
Christine Montross: The project really began in the midst of my work at psychiatric hospital units. I am an inpatient psychiatrist who works with severely mentally ill people who are hospitalized. Over the course of my work with them, I was surprised to learn how often they came in contact with the police and how often they went through periods of incarceration. And what I learned in talking with so many of them was that, when they had encounters with the police, those times very rarely had anything to do with criminal intent — but, instead, often had quite a lot to do with their symptomatology.
These were people who were shouting in a Starbucks or charging through TSA with the delusional belief that they had to get on a plane to Washington D.C. What I began to see was that, in the moment of the police encounter, there were clinical decisions being made. Police were deciding whether someone should be brought to the hospital or to jail and those environments are obviously incredibly different: one has a therapeutic intention and one has a punitive intention. My patients predictably fared very differently depending on where they were taken.
So, I started performing competency-to-stand-trial evaluations in the jails and prisons to get a first-hand look at what was happening to people in the system. The book began to take shape as I saw not just that people with mental illness got worse in prison, but also that prison was really designed to be a place where even psychologically stable people became less well.
TCR: Your book reveals that this design and purpose is exhibited in the very architecture of these facilities.
CM: I was so interested to learn that criminal justice architecture was a specialty. I was then shocked to learn that the field was not necessarily driven by the intent to design places with hope and healing at the center, but that, instead, utility drove much of it and there was a real emphasis on having the environment itself be a punitive design.
One architect spoke about wanting nothing soft, wanting the design to be very hard. This is in a supermax prison in Connecticut where the noise just reverberates in jarring ways off of concrete and metal at all times. You feel when you go in as if you are underground, even though you aren’t. And the architect describes the desire for the design to have an intentional sense of foreboding, wanting detainees to enter into that space, and feel as if they have this long, long road ahead of them. I was saddened to learn about a field where, in addition to the punishment of taking away someone’s liberty, we are also designing spaces with the intention that they be unpleasant and dehumanizing to live within.
TCR: What are some of the psychological effects of being in those spaces, and how do they exacerbate the already dangerous environment of prison?
CM: We know as human beings that we have fundamental needs for connection, movement, fresh air, quiet, sunshine, etc. Many of these things are restricted or eliminated in these prison environments. One of the concepts that was fascinating in learning about prison architecture was the idea of borrowed light: that there are ways that light can be provided internally in a building without actually providing access to a window or a view of the outside. There are ways to have light shaped and bent in such a way that people have illuminated spaces without actually being able to see outside.
I thought about how healing it is for all of us, just to sit in front of a window or sit in a place with a horizon. So, the idea that we would want to restrict people’s ability to have those moments of reflection and calm and centering was really striking to me. There is a long history in this country, from the earliest days of American hospitals and asylums, of really understanding that fresh air, sunshine and a beautiful view have important healing effects for all of us. But think about being exposed to extreme levels of loud noise for periods of time or having sensory deprivation from not seeing anything other than the three walls of your cell 23 hours a day in solitary confinement.
You have these real extremes of sensory overload from unpleasant stimuli, and sensory deprivation from not seeing color, daylight, other people, etc. Those contrasts are really two ends of a spectrum. Neither is healthy for human beings.
TCR: Why does society generally misunderstand the people who wind up in prison?
CM: I think it is more comfortable for us as a society to believe that everyone who is in prison belongs there and that the people who are in prison are fundamentally different than those of us who are not. The chapter in the book, “Born on Third Base,” comes from a saying that the adults in my life in Indiana would use about someone who overestimated their own worth or accomplishments. They would say he was born on third base and thinks he hit a triple. And the more closely I looked into who we were incarcerating as a country, the more plain it became that the people we are incarcerating are not just people who are committing horrible acts; they’re also people who are our most vulnerable: the poor, racial minorities, in particular African-American men, the mentally ill, and the substance addicted.
People wind up in prison many times due to psychiatric reasons, addiction, and our prejudices as a society. I wrote that chapter in part to acknowledge that it is dishonest to say that those of us who live free lives do not break the law and that people who are incarcerated are fundamentally different from the rest of us. A group of my friends got together at a dinner party and I asked them to list all the ways that they’ve broken the law. We came up with this enormous list. These are responsible tax-paying parents and professionals. The purpose of that exercise was to say that the difference is not in our capacity to commit crimes, but in our ability to extricate ourselves from them.
It’s easier to want other people to suffer when you see them as very different from yourself. If people are ever going to agree that it’s wrong to cause people suffering in the way that we do when we incarcerate them, then it’s critical to say that some of the people whom we are harming are innocent, and some are serving time for crimes that those of us who live free lives have committed without consequence.
TCR: Many of those people are also children. How does incarceration affect them?
CM: The current moment is providing a rare opportunity for people to have an empathic understanding of what we do to kids when we incarcerate them. There has been this real outcry and shared understanding of how the pandemic has isolated children, in particular adolescents, from each other at a time that we know is really critical for them to be having contact, especially physical contact, with their peers.
These are things that we are aware of as parents and a society that our children are missing out on and that concerns us; and it should. The obvious correlation to that is to think about the fact that our society is one that sends children into these facilities to live in cages. We are sending children behind bars where we intentionally separate them from the adults in their lives, from their peers, their schools, their sports, and their routines. This has the capacity to do grave damage at a time of really critical neurodevelopment.
Studies show that kids who are institutionally reared, kids who are raised in orphanages and other institutions, have a different neurological makeup than kids who are raised outside of institutions. When we send children into these institutions we have to reckon with the damage that we are doing and try to mitigate that damage. Two parts that are critically important is that we have to acknowledge that we disproportionately send black and brown children to these environments rather than community service or probation, and that we still allow kids to be sent to solitary confinement for extremely prolonged periods, even up to a year. Just think about the needs that the developing brain of a child has for interaction, touch, schedules, responsibility, education—and then how devastating it must be to be incarcerated in solitary confinement as a child.
TCR: How does prison potentially make good people worse and necessitate an embrasure of violent behavior just to be seen?
CM: We know there are high rates of violence in prison. There are also very high rates of self- injury in prison. These are people who are cutting themselves, banging their heads against walls, things like that. And in the prison environment that behavior is almost always interpreted as sociopathy, as bad behavior, as acting out, seeking attention, and trying to cause trouble in the prison system.
What I came to understand while researching how human beings respond to situations in which they are isolated, in which they lose their avenues of expression and control, is that these are really predictable ways for human beings to respond to draconian environments. One of the examples that really stood out for me was a report on Cuban migrants who were attempting to come to the United States by boat. These were migrants attempting to cross under the “wet foot/dry foot policy,” the idea that if they could get a dry foot on U.S. soil then they would be allowed to stay. So, in desperation, the migrants were doing things that you would never have imagined: swallowing dangerous objects, ingesting dangerous chemicals, harming themselves in ways that would necessitate that they be brought to a hospital in order to be permitted to stay.
When we have a prison environment in which we constrain every means of movement, liberty, and self-expression, where we so often don’t meet even the fundamental needs of people held therein, then the only means of communication and protest that exist for them is to behave in these primitive ways. Rather than seeing this as something that people were doing as an act of misbehavior, I came to see it as behavior that was a product of the environment and, in fact, a last resort.
TCR: How do we expand society’s understanding of these kinds of human complexities, especially when it comes to dealing with mental illness?
CM: We have to make a safe space for people to share their own experiences. When people begin to feel as though they can write about, talk about, and express their or their family members’ experiences with mental illness without judgement, then we have a broader understanding of both how mental illness can manifest itself and how pervasive it is in all of our families. The reduction of stigma is important to that.
We also have criminalized mental illness in a way that makes people fearful of it. This is different from how people perceive diabetes or cardiac disease. When someone is having a psychiatric emergency, and the only response we have available is to call the police, that narrows our understanding and reduces our empathy for the mentally ill because it sends a signal that this is something dangerous and to be feared. The consequences of that, as we’ve seen with Daniel Prude, can be catastrophic.
The fact that police are the front line of mental health emergencies means that you are calling on them to respond to what should really be a clinical situation. What’s so tragic in these situations is that it’s often family members who are desperate for help, don’t know where to turn, don’t have resources available, who call the police. The reality is that people with mental illness are 16 times more likely to be killed by the police than people who are mentally well. We have taken mental illness out of the auspices of health care and put it under the auspices of police and prisons. That does a disservice to our understanding of, and compassion for, mental illness and the people who struggle with it.
TCR: You demonstrate the importance of practicing de-escalation and empathy when dealing with prison populations, whether mentally ill or not. Do you think it’s possible for police and corrections officers to achieve the same level of expertise in that area?
CM: When I write about the deescalations that take place with my staff, those are in a psychiatric hospital, not in jails and prisons. It’s important to understand that those types of approaches of understanding, targeted treatment, and de-escalation skills are very much the norm in therapeutic environments. They are not the norm in our nation’s jails and prisons because the primary goal of a hospital is healing and health, while the primary goal of jails and prisons is security and control. We can’t pretend to have the same expectations for both places.
Why It’s ‘Inappropriate’ to Imprison People with Severe Mental Illness
But our understanding of the difference in those places should underscore for us how inappropriate it is to have people with severe mental illness in jails and prisons where they cannot reliably comply and obey in the ways that those environments insist upon. And the argument about police is a critically important one.
In my mind, the question of whether police could learn to better handle psychiatric emergencies is the wrong question. The question should be: Who are the best people to respond to psychological emergencies? How does our society want to respond to mental health crises?
I would argue it should be no different than other health care emergencies. Just as we have EMTs who show up on the scene and are capable of assessing what’s going on and starting an IV, stopping bleeding, stabilizing someone, supplying oxygen, we also ought to have psych teams and mental health teams that are the first responders to psych emergencies and are equally trained and skilled to assess and intervene in therapeutic ways, rather than the knee-jerk response of involving law enforcement.
TCR: Police are responding to these situations largely because there’s a gross lack of social services for the mentally ill in communities around the country. How do we tighten that social safety net and provide the services these people need to keep them away from police and out of prisons?
CM: We need to be honest about the severity of the mental health cuts that our country has carried out really since the 1950s. Look back to the 2008 recession, when psychiatric beds were [reduced] across the country and enormous numbers of dollars were cut from mental health budgets everywhere as well.
When psychiatric treatment is not available either in the communities on an outpatient basis, or in a hospital setting, we have the situation where jails have an ironclad no-refusal policy. Someone may be taken to a psychiatric emergency room and the hospital might not be able to care for them because they don’t have any beds. Jails never say that. What you have is a system where sometimes police see that the only option for someone to obtain the treatment that they need or remain safe is to take them to jail. There is even a term that has been developed for that. It’s called “compassionate arrest.”
We need to consider this within the framework of health care. We would never take someone to jail to ensure that they got treatment for their hypertension or incarcerate someone to make sure they got their chemotherapy. This is another example of the unjust ways that we look at mental illness differently from other issues in health care.
TCR: One of the most unjust and dehumanizing treatments of those incarcerated is the use of solitary confinement. Why are we still a country that maintains something as torturous as solitary confinement; and how has it become the go-to punishment in prisons?
CM: There are two main contributing factors. One is that solitary confinement as a punishment is entirely adjudicated within the prison facilities themselves. Unlike sentencing, where there’s oversight, public knowledge, where it’s within the framework of our judicial system, there’s no outside judicial system involved in sending someone to solitary. People don’t get sentenced to solitary confinement; they accumulate often nonviolent infractions, like having too many postage stamps, or too many pencils, or refusing certain meals, that result in them being sent there.
The second piece is that, as a society, we take the stance that once you are in prison that proves you’ve done something wrong, and therefore there’s no limit to the degree to which you should be permitted to suffer. People will often say if you can’t stand the time don’t do the crime. That’s essentially saying if you have been found guilty of something and find yourself in jail or prison, then people can do whatever they want to you because you have failed morally. But if we pause to think clearly about those we incarcerate, people wind up in prisons for all kinds of different reasons. Huge numbers of people in our nation’s jails are pretrial detainees who have not been found guilty of anything.
The idea that we can just blanketly mistreat people is a dangerous one. It’s also dangerous because 95 percent of people in our country’s correctional facilities are released. It’s a disservice to ourselves and our communities to degrade and dehumanize people while they are incarcerated because they’ll return to our communities less stable, less strong, and less well. We say we want safety and justice, but if we really want those things our priorities can’t also be suffering and vengeance.
TCR: The environments of suffering and vengeance in these facilities also have a detrimental effect on the people employed there.
CM: That’s a critical piece of this equation. When we talk about facilities that are intentionally designed to feel jarring and unpleasant, it affects not only the people who are incarcerated in them but also the people who go to work there every day. We have to acknowledge that these are difficult places for people to work and that the often antagonistic relationships that are established between correctional officers and detainees are hard on both sides of that equation.
There are models of places where that relationship is more collaborative and job satisfaction is much higher in those kinds of arrangements. But it’s an incredibly stressful job to be in these environments, which are sometimes fraught with violence and danger. We know that the suicide rate among correctional officers is higher even than police. Job satisfaction is low and levels of PTSD are very high. It’s an extremely difficult job and we do a disservice if we just make this a black and white issue.
Many of the correctional officers that I met felt as though they were doing a service to their community by doing this incredibly hard job that few want to do. It’s also important to acknowledge that the job of the correctional officer is that much more difficult when talking about the incarcerated mentally ill. Those of us who work with psychiatrically ill patients in facilities are especially trained to do so. It’s hard work, but we’ve been given a specific skill set and education to help us understand and intervene.
The Damage to Correctional Staff
That’s not the case for corrections officers. They are charged increasingly in these overcrowded environments with asserting control, often with people who have symptoms of mental illness that officers haven’t been trained to handle. We have to understand what we’re asking officers to do. Many whom I spoke with shared my sense that mentally ill people did not belong in this environment. The system is really damaging to everyone, whether they work in it or are held in it.
TCR: Your research took you to similarly purposed facilities in Scandinavia. What did you learn there?
CM: A couple of the really key concepts that we would do well to incorporate in America have to do both with the sense of the purpose of the sentence and also the philosophy behind that sentence. When people are incarcerated in Norway and in Sweden, the first step of their incarceration is a needs assessment, where they do an in-depth interview to understand what are the factors of a person’s life that led them to criminal behavior.
Then the objective of the period of incarceration is to address those needs so that when the person leaves prison they are less apt to commit a crime. If you have substance abuse problems, you will use the time of your sentence to get treatment and counseling. If you lack job skills there will be job training that you’re involved in. If you need education you’ll go to school. Anger management, parenting classes, relationship counseling, financial planning—all of these will be provided as ways to shore up any deficits in a person’s life that may have contributed to their involvement in criminal behavior. The sentence is viewed as a constructive period of time with a very clear aim: You’re going to leave here, you’re not going to commit crime, and you’re not going to come back.
That’s what we say we want as a society. What Norway and Sweden demonstrate is that their way works. We know from our recidivism numbers that our way doesn’t. When programming is provided, when education is provided, when health and mental health treatment are provided, we obtain the goals that we set for recidivism. We would be wise to pay attention to that. But what gets in the way is the philosophical part.
Norway’s Philosophical Shift
Norwegian prisons went through a time where they had much of the same upheaval and discord that mars our prisons today: violence in their prisons, detainees who were escaping, correction officers being killed, and very high recidivism rates. Then there was a philosophical shift that emerged where they decided to stop meeting hard with hard and start meeting hard with soft.
Harsh draconian environments, vengeance, and strict control, were not yielding the outcomes they wanted, so they shifted; and the primary shift was to redefine the role of a correctional officer so that it was more akin to the role of a social worker. They were meant to provide security, but also to really get to know the detainees and to try and talk with them about why they had done the things they had done, what they needed to do to change, and what their plans were for the future. This redefined role reduced antagonism between officers and detainees, created a more collaborative environment, and reduced recidivism from numbers in the 70th percentile to numbers in the 20th percentile. The philosophical change demands a change in our outlook.
We need to stop insisting upon prison being unpleasant, dehumanizing and degrading. We have to be willing to say that if we really want outcomes of safety and justice, then we have to treat the people that we hold in our prisons with humanity and provide some help to them while they are in our facilities.
TCR: What are the ethical costs of this punitive philosophy of criminal justice and incarceration and how do we change it?
CM: It starts with a willingness to look both at the people we’re incarcerating and the places that we are sending them. What I found often as I was writing this book was that people would voice their support for being tough on crime. But then, when I asked them about a specific person that I had encountered, they offered a very different opinion. One example from the book is about a woman who was pregnant and was told that she would not be permitted to take her baby home from the hospital if she didn’t have a car seat. She was destitute, so she shoplifted items from a store in order to sell them to buy a car seat. She was picked up by police and taken to jail.
When I asked people what should happen to her, the very same people who said we need to be tough on crime, gave a range of responses from her having to repay the store for the items she stole, to having to do community service, to being connected with organizations that could provide a poor mother with a car seat. What happened was she was taken to jail, was unable to post even a minor sum of bail, and actually delivered her baby in jail. People are appalled and shocked to learn this.
There’s a fundamental disconnect between our sense that when we vote tough on crime we are somehow helping people in our communities when, in fact, we are the ones who are sending children to detention facilities, who are sending men and women to solitary confinement, who are sending women to jail to birth their babies behind bars.
What gives me hope is that when I tell these personal stories to people, or describe the conditions in prisons that I see, people are justifiably upset by them. I hope that if we can show people what our practices are doing, then the fundamental decency in human beings will kick in. For so long prison has been a place that we don’t want to look. We send people there, lock them up, throw away the key, and don’t think about them because they’re “bad people.” But the truth is far more complicated than that.
TCR: Are there any tangible signs of change that make you optimistic for the future?
CM: There are lots. There are groups of police who are having social workers and mental health clinicians ride with them in police cars. There are prisons that are beginning to seek alternatives to solitary confinement. There’s a group in California that, through the prison law office, is taking groups of stakeholders from different state prisons, legislators, wardens, and corrections officers, over to Germany and Norway to show them how these practices are working and help them gain understanding and buy in for how this situation is better for outcomes, detainees, and people who work within the prisons.
There’s a movement afoot in lots of different realms. Our states have so much autonomy and power over their jail and prison systems and I think that some are showing interest in experimenting with eliminating cash bail. I also have a lot of hope for the current moment when we as a nation are reckoning with policing.
I think that the natural extension of policing is our jails and prisons. It gives me quite a bit of hope that we are really looking critically for the first time at our nation’s legal system and determining what we want it to look like. We are acknowledging that there should be humanity in our legal system and asking how important it is to us that fairness and justice are at the center of that system.
Isidoro Rodriguez is a contributing writer for The Crime Report. He welcomes readers’ comments.