Psychiatrist: America's 'Extremely Punitive' Prisons Make Mental Illness Worse

Jul 16, 2020
Originally published on July 16, 2020 2:42 pm

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."


Interview highlights

On what police call a "compassionate arrest" of mentally ill people

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. - Dr. Christine Montross

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

Penguin Random House

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"

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. - Dr. Christine Montross

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.

Copyright 2020 Fresh Air. To see more, visit Fresh Air.

DAVE DAVIES, HOST:

This is FRESH AIR. I'm Dave Davies, in today for Terry Gross. My guest, psychiatrist Christine Montross, has spent years treating people with serious mental illnesses, and she's noticed that many of her former patients end up in jails or prisons, where their conditions inevitably deteriorate. In her new book, Montross notes that, in America today, there are 10 times as many people with serious mental illness behind bars as there are in our state psychiatric hospitals. Incarceration, she says, usually makes mentally ill people worse and renders stable people psychiatrically unwell, making the prison system literally maddening.

Dr. Montross' book explores the reasons people with mental illnesses get arrested and incarcerated. She takes readers to many prisons for a firsthand look at the harm the experience does, and she explores an alternative model for confinement and rehabilitation in effect in Norway. Christine Montross is a 2015 Guggenheim fellow in general nonfiction, an associate professor of psychiatry and human behavior at the Brown University Medical School and the author of two previous books. We spoke about her latest; it's called "Waiting For An Echo: The Madness Of American Incarceration."

Christine Montross, welcome to FRESH AIR.

CHRISTINE MONTROSS: Thanks so much, Dave. I'm delighted to be here.

DAVIES: You're a practicing psychiatrist. You treat a lot of patients with serious mental illnesses. What's taken you to so many jails and prisons?

MONTROSS: So I work in an inpatient psychiatric hospital, and I work on floors that are called the intensive care units, which is, like, the psychiatric version of an ICU. I've been struck over the years that my patients routinely come into contact with police, and sometimes those outcomes are helpful ones - police bring them to the hospital - and sometimes those outcomes are really punitive ones - police take them to jails and prisons. And as I talked to my patients, they would often explain that the circumstances that led them to the police encounter were essentially the same reasons that brought them into the hospital - so undertreated symptoms, you know, shouting in the Starbucks or causing a disturbance in the community - that really were more about their symptoms of mental illness than about any kind of criminal behavior or intent.

So I started to think about how my patients must do in these moments of the police encounter and then how it must be for them to be in jails and prisons. So I decided I wanted to look for myself and see what those environments were like for the mentally ill people who are held in them.

DAVIES: So you visited a lot of correctional facilities, doing research. You also do work in court cases - right? - evaluating psychiatric patients.

MONTROSS: Right. So I visited a lot of prisons, and I also began working in jails, doing competency-to-stand-trial evaluation. So when the court asks whether someone is able to understand their court case, the proceedings, the charges that they're facing, whether they're mentally well enough to work with their attorney, they often ask for the expert opinion of psychiatrists. So I began performing these evaluations as well to learn more about what goes on when mentally ill people are charged with crimes.

DAVIES: Right. And I wonder if you could just contrast the experience of talking to a patient in a treatment - in a clinical setting and going to a prison, where you're asking questions for a different purpose, in a very different atmosphere.

MONTROSS: So there are two really remarkable differences in those circumstances. One is the environment, and one is what I'm being asked to do. And I had to learn a great deal about the difference in those two things. So the first one, in terms of what I'm being asked to do - when I am seeing patients in a psychiatric hospital, I'm really charged with their care, and it is my job to diagnose them, to treat them, to comfort them in the midst of their suffering, to work with them and their families and the nurses that are providing their care and really try to help them manage and cope with the symptoms of their illness and help improve that as much as I can.

When I'm working - doing evaluations in the jails and prisons, I'm really asked to be an objective analyst and to ask questions that try to determine almost a snapshot of the person's mental state in that moment. But it's not a clinical or treatment encounter. And so that was an important thing for me to learn, that my job in that role was not to treat but was really to provide an objective analysis of what I was seeing in the moment.

The other piece of the question is really a critical one as well, and we're talking about the difference between a punitive environment and a therapeutic one. And one of the things that was so striking to me when I started working in the jails and prisons were that the people that I was seeing in these two places were indistinguishable; so the patients that I was seeing in my hospital were indistinguishable many times from the men and women that I was evaluating in jail. But the environments were so markedly different - one charged with, again, trying to help and heal, and the other really designed to control and punish.

DAVIES: I want to talk about what you've seen in correctional institutions, but I want to talk a little more about this phenomenon of people with mental illnesses being arrested and incarcerated. Why is it that so often people with mental illnesses, who are clearly acting out their symptoms, not intending to necessarily steal or disturb the peace or - you know, or make people feel uncomfortable, end up in jail? You write that there's a phenomenon known as a compassionate arrest, which seems like an ironic term.

MONTROSS: Right. So to really understand the origins of why there are so many mentally ill people in jails and prisons in America, you really have to go back to the '60s and '70s and '80s, when large numbers of people were moved out of our state-run hospitals, psychiatric hospitals, with the goal of shifting mental health care from institutions to the communities. And as you said in the opening, that was an enormous shift that closed down state psychiatric hospitals largely due to the 1963 Community Mental Health Centers Act that passed to enact this change of shifting people from hospitalized, institutionalized lives into the community to receive their care.

The great problem with that was that funding for community care was never adequately allocated. So people who had required very significant levels of care and support in hospitals and institutions were suddenly without treatment, without housing, without funds. And the people who had been in these state hospitals were suddenly turning up on the streets of our cities, begging, sleeping outside, causing disturbances. And that shifted people from the realm of the health care system into the realm of the legal system.

So that's when we start talking about the criminalization of mental illness, when a health care problem really becomes a legal problem. And that gives rise to the situation that you describe, where we talk about compassionate arrest, which is the idea that police officers, sometimes in an attempt to provide mentally ill people with treatment, have said things to me like, 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 arrest someone to make sure that they received treatment for their cancer; we only do that in the situation of the mentally ill. And that, to me, seems like a travesty.

DAVIES: You know, you write sometimes police end up arresting people out of frustration because, you know, they've tried to get some help, right?

MONTROSS: Right. So I heard the Portland police commander speak about a situation like this that she and her officers found extremely frustrating. And she offered it as an example that was common for them, where she described a situation on the Portland waterfront where a mentally ill man was swinging above his head a gallon jug filled with some kind of liquid, making it really heavy. And he was swinging it on a chain, and it was really scaring people down in this common area. The police were called, and she described that after a long period of time, the police were able to de-escalate the situation, to get the man into their car without any kind of force or violence, and she said it took a couple of hours for them to do this.

They took him to the hospital emergency room, and she described there - that there were no psychiatric beds available and that the man was discharged back into the community immediately. And her phrasing was, he was out before we had finished our paperwork. So very quickly, he went back to the waterfront, started doing the exact same thing. And the police arrived, and this time, they knew that they would have the same outcome if they took him to the emergency room, so instead, they took him to jail.

DAVIES: So give us an example of how incarceration makes people with mental illnesses worse.

MONTROSS: 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's a misalignment between the straightforward system and their ability to comply.

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. 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.

DAVIES: Talk a little bit about how prisons can make people who come in mentally stable unwell themselves.

MONTROSS: This has been something that I think we've actually come to have a greater degree of understanding and empathy for as a society in the recent months with the pandemic. One of the things that has struck me so often and so strongly when I have seen people in prison is that being isolated from one's family, from one's everyday life takes a profound toll on any of us.

And so I think now that those of us who live free lives have also experienced a condition where we are not able to go to our loved ones when they are ill; we're not able to visit people in the hospital when they need us; we're not able to go to weddings and to funerals; we're not able to see our elderly loved ones - and I think that gives us a tiny beginning of a taste of what it - what we do to people when we incarcerate them.

But there's so much more than that, as well. And that fundamental misalignment that I spoke about earlier really gets at the heart of that. And that is that people who are mentally ill to begin with are in circumstances that are not therapeutic and supportive at all, that are extremely punitive and that they're often punished more for their symptoms. But also, people who enter into prison in a psychologically stable state are put in circumstances that are meant to degrade and meant to dehumanize, and it's unrealistic for us to imagine that people can emerge from those situations psychologically intact.

DAVIES: You have a chapter in the book called "Nutraloaf." What is that, and why did you organize a chapter on that?

MONTROSS: So 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 prisons - often as punishment, oftentimes within realms of solitary confinement - where 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, put into a loaf pan, baked and then sliced into chunks. Or sometimes, there'll be a very detailed list of ingredients that go into a loaf that is actually baked as its own thing.

The ingredients include things like beans, oats, margarine, mechanically separated poultry, you know, 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 carceral 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. So serving someone an incredibly disgusting, known to be tasteless at best and really foul-tasting at worst item of food, knowing that they are going to perhaps not eat that at all - or, if they do, find it to be an extremely unpleasant experience - that, to me, was just a crystal-clear example of how the intention behind how we treat people is not aligned with what we say our intention is when we incarcerate people.

DAVIES: Christine Montross is a psychiatrist who treats patients with serious mental illnesses. Her new book is "Waiting For An Echo: The Madness Of American Incarceration." We'll talk more after a break. This is FRESH AIR.

(SOUNDBITE OF AVISHAI COHEN SONG, "GBEDE TEMIN")

DAVIES: This is FRESH AIR. We're speaking with Christine Montross. She's a clinical psychiatrist, and she has a new book about the damage prison life does to mental health and how things might change. It's called "Waiting For An Echo: The Madness Of American Incarceration."

You write about Norway, which has adopted a strikingly different model of incarceration, but this is really just in the last 25 years or so. You want to just say a little bit about what their penal system used to be like and what prompted a search for something different?

MONTROSS: So 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 recidivism rate at that time was between 60% and 70%, which was on par with - the three-year recidivism rate in the U.S. right now is 68% - so really similar outcomes and similarly fraught environments within the jails and prisons themselves.

They looked at the situation - the government looked at the situation and acknowledged that it wasn't working, that they weren't having the outcomes that they desired, and they also had a system where there were escapes; correctional officers had been killed. 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.

And as I learned more about the system, 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, that this idea of a hardened criminal becoming more hardened in a prison setting was something that they really thought was true.

They also, when they say start meeting hard with soft, meant that what they were really noticing was that people were coming into the prison system with these deficiencies in various realms of their lives that were keeping them from succeeding outside of prison. So they decided to do a needs assessment of everyone who came in to prison immediately 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 when you - 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.

DAVIES: You know, what struck me about this as I read it was that the approach in Norway is to focus on the future - what's going to happen to the inmate in the future, what's going to happen to his relationship with the community - as opposed to, in the United States, where I think you quote Anthony Kennedy, the justice, as saying that, you know, here we tend to think of the justice system as imposing sentences and don't really think beyond that, don't really think about what actually happens in the prison system when sentences are imposed.

MONTROSS: That's right. The principle that really guided some of this decision-making was - exactly as you say, Dave - that we need to be forward-looking. So when I talked to people in those systems, they would say the crime is the one thing we cannot change. That's the thing in the past. It's not our job to look backwards to the crime which we cannot change. What we can change now is the outcomes going forward.

Another really key element of this, in terms of their approach, was to say, the punishment is your loss of liberty. That's the entire punishment. You don't get to sleep at home with your family. You don't get to structure your day like you want to. That's the entire punishment of incarceration. There's not additional punishment that means that you have to suffer more, that you have other rights taken away. It's merely your loss of liberty. So then given that that's the punishment that just exists by you being here, then when you are here, let's use the time constructively.

DAVIES: And the outcomes in this case is not just the outcome for the prisoner; it's the outcome for the community that will - eventually, he'll rejoin.

MONTROSS: No question. So as I said, Norway had this recidivism rate in the 1980s and '90s that was between 60% and 70%, and that recidivism rate has dropped to 20%. So only 20% of Norwegian prisoners are now arrested in the two years after their release. It's taken a lot of work for them to get to this place, and it isn't just as simple as saying, we're going to provide programming.

So a really critical shift occurred in the role of the prison officer, our term for a correctional officer, where they said that instead of just being a guard, instead of being purely about security and control, that the prison officer was now going to become someone with a really complex role that was assisting in this process of bolstering a person's development and strength as they moved through the prison system.

So it was a role that was more akin to a social worker. In addition to the security duties that the person had, they would also have an ability to talk with the person about why they committed the crime that they committed, what kinds of things they needed moving forward, how they could set themselves on a more constructive path moving forward. And that role really shifted and changed in a very pronounced way.

DAVIES: Christine Montrose is an associate professor of psychiatry and human behavior at the Brown University Medical School and the author of "Waiting For An Echo: The Madness Of American Incarceration." She'll be back and talk more after a break. I'm Dave Davies. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

DAVIES: This is FRESH AIR. I'm Dave Davies, in for Terry Gross. We're speaking with Dr. Christine Montross, a psychiatrist who treats patients with serious mental illnesses. She has a new book about the prison system in America and the harm she says it does both to those with mental illnesses and those who are mentally stable. Her book is called "Waiting For An Echo."

We were talking about the alternative system of confinement and rehabilitation in effect in Norway's prisons, and the differences are quite striking. You went to - you visited a place called Halden Prison. What did it look like when you arrived?

MONTROSS: Completely antithetical to any prison I had ever seen, Dave. So 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, you know, there's historical precedent for this, even in our own country, that our 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 that was understood even back then to be restorative. But that was very much implemented intentionally in the design of Halden Prison.

And then the living quarters for the men who are held there - and 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 looked like a new and clean youth hostel or a 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. 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 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 as someone who's trained to look for risk, you know, I'm seeing all of these implements that could be used to - for one person to hurt another. But these men used the knives to cook their own meals, and they used the darts to entertain themselves in the evenings before they all go to their rooms for sleep, and they used the silverware to eat their meals. And the level of personal responsibility is so much greater, and that's reflected in the environment. It was really striking.

DAVIES: Right. And these - their rooms, they actually have - they can lock the rooms, is that right?

MONTROSS: That's right. Their rooms have locks on the inside. And, again, that idea is that they are entitled to privacy just like the rest of us. Some of these philosophies are grounded in the United Nations Mandela Rules for incarceration - this idea that they call in Norway the principle of normality, that when you are in prison, you are removed from the community but that you are supposed to have as much - as close an experience to normal life as possible.

So you are supposed to have the responsibility of getting up and going to work, shopping for your own groceries at the prison grocery store and preparing your own meals, of laundering your own clothes. You're supposed to have the right to your own privacy and to your own entertainment and your own exercise because the idea is not that you're supposed to be deprived of these things, but that the deprivation of your liberty in and of itself is the punishment.

DAVIES: All of the staffing and space and equipment does sound extravagantly expensive, certainly compared to American prisons. How do the costs compare?

MONTROSS: The differences that you might imagine are not nearly as great, and I think that was an important misconception for me to address and look at head on. But I think we have this idea in our minds that Scandinavian societies are so very fundamentally different than American society, that the level of taxation is so markedly high. And when I really dug into the numbers of what we spend on incarceration and what they spend on incarceration and how they pay for that versus how we pay for it, I realized that the differences are actually much smaller than we would imagine.

For example, the annual cost to hold a prisoner in Halden Prison for a year is about $93,000. The average amount to hold a prisoner in an American supermax prison is from $60- to $75,000. But that number actually varies really widely. And in my research, I came across places that cost as much as $208,000 to hold someone in prison for a year in America. So that range is really high. But in addition, their level of recidivism is so low that they may be paying a higher amount per year but there's so many fewer prisoner years that accumulate, whereas we might be paying a slightly lower rate per year, but then people are returning over and over again to our prisons, so we're paying that yearly rate so many more times.

And in addition, I found that the discrepancy between taxation rates between our country and theirs is actually totally overblown, much to my surprise. So our average taxation rate is around 37%, and Norway's is around 38.5%. So I think some of the ways that we write off the fact that this wouldn't be possible for us are really based more on mythology than in truth.

DAVIES: It sounds almost idyllic, but there must be conflicts among - these are people who committed crimes. There must be prisoners who get oppositional or damage property or steal stuff. How do they deal with it?

MONTROSS: So they deal with it in many of the same ways that we deal with what we call behavioral dyscontrol in my hospital. So there are consequences that are within a framework of greater understanding, but they're not so different than how many of us might handle our children when our children act out. So if someone misbehaves at Halden Prison, they're separated from the community. So they might be asked to stay in their room for a day. They might be asked to stay in their room for a couple days, or they're not allowed to participate in certain activities.

They do have, within Halden Prison, a room that someone could go in for essentially isolation, but they're very strictly mandated. This would be only in a situation - unlike in our American prisons, where people can be sent to solitary confinement for the accumulation of minor, nonviolent grievances, you can only be sent to this specific room in Halden Prison for very particular violent actions - so aggression or self-injury. And if you are in fact sent there, there are strict parameters on how long a person can remain there. And it's a matter of days, which was such sharp contrast to me from the fact that people in America can languish in solitary confinement for months, years, even decades. So they do have the ability to separate people from the community if it is, in fact, really necessary to do so. But when I asked these exact same questions, you know, they said it's very unusual for us to have to do that, you know? The guards are 50% female. None of the guards are armed. And they have not once had an episode of aggression from a prisoner to a guard.

DAVIES: You know, I have to say, it sounds too good to be true that literally never been an attack by a prisoner on a guard after years in operation. I mean, are there critics in Norway or journalists who have raised questions about these claims? I mean, are you sure you just didn't get the, you know, the tour in which you kind of - things are buffed up and look better than they might be?

MONTROSS: The dog and pony show, right?

DAVIES: (Laughter) That's exactly what I mean. Yeah.

MONTROSS: So there are journalists who have written on both sides. There are plenty of journalists who have dug into this and have found the same things that I have found. And then the critics are largely critics of the philosophy. The outcomes can't really be criticized. I mean, when you look at recidivism rates, when you look at the outcomes of safety and justice in Norway, those are objective statistics. So the outcomes cannot really be criticized.

There are certainly people who critique the system for the fact that it seems super luxurious. (Laughter) I mean, I think that there are people who hold the same tenets that I think are a fundamental tenet of the American criminal legal system, which is that this is too nice, too much for people who have committed crimes. But, I think, from the government's standpoint, if it's working then it's justified.

DAVIES: Christine Montross is a psychiatrist who treats patients with serious mental illnesses. Her new book is "Waiting For An Echo: The Madness Of American Incarceration." We'll talk more after a break. This is FRESH AIR.

(SOUNDBITE OF AHMAD JAMAL'S "THE LINE")

DAVIES: This is FRESH AIR. We're speaking with Christine Montross. She's a clinical psychiatrist. And she has a new book about the damage prison life does to mental health and how things might change. It's called "Waiting For An Echo: The Madness Of American Incarceration."

You know, one of the things I can imagine people saying is, well, maybe this works in Norway. But American - you know, U.S. society is so different. Norway is thought of as being more ethnically homogenous and probably having fewer inequities in the distribution of wealth and income so that you don't have these huge, terribly poor, struggling communities, which make it harder, sometimes, for people to rebuild their lives when they get out of prison. I don't know. What about that? Are Scandinavian countries just in a better position to undertake this kind of change?

MONTROSS: Well, there's no question that Scandinavian countries are smaller than America, right? There's no question about that. But to me, it was very interesting to think about Scandinavian countries compared to American states. And the reality is that prison business is conducted, really, on a state-by-state level. So policy decisions about state jails and prisons are really made within the states. So you can see quite a bit of difference from one state to the next in terms of prison conditions, prison policies, sentencing trends - all those kinds of things.

So it was useful to me to begin to think about how the experiment of a prison approach like that in Norway could be transferred to our states. And so that was one of the frames that I used to think about those very differences that you raise. And again, I found those differences to be somewhat overblown. So as an example, the population of Norway is around 5.3 million people. So that puts it just smaller than Colorado and Minnesota, just larger than South Carolina and Alabama, so - and, you know, in the realm of our states. The population of Oslo is similar to the population of Nashville numbers wise.

So then I - so when I saw that, I thought, all right, well, so let's compare American city to Norwegian city. And I looked really closely at the demographics between Oslo and Nashville. Nashville is 60% white. Oslo is 70% native Norwegian. That's not a gigantic difference. The other 30% of Norwegians are either immigrants or were born to immigrants. And the major ethnic groups that make up that 30% are Pakistani and Somali, not light-skinned Norwegian people, as I think we so often imagine. And there are also immigrants from many other countries in the region - Iraq, Iran, Turkey, Vietnam, Morocco, the Philippines.

And maybe one of the things that was most interesting to me is that 40% of the kids in Oslo primary schools speak a language other than Norwegian as their first language. So I think when we have an idea of Scandinavian communities as these very homogenous communities that really differ a great deal from our own, I think that that is, perhaps, an antiquated view.

DAVIES: You know, the racial and ethnic divisions within American prisons are often pronounced. I mean, people may join gangs or form cliques among people that share their ethnicity or race. Does that happen in the prisons in Norway?

MONTROSS: That's such a prominent discussion in American prisons. It's a real problem that is brought up over and over again. They're certainly talking about how the country is adapting to the shifting representation of different ethnic minorities within the Norwegian community, and that you absolutely are seeing people who are starting to question some of the closely held tenets of socialism that, you know, provide benefits to people in the country. Some of those - there are issues of racism that are beginning to emerge in the country, for sure. But I heard about those conversations much more as a part of the cultural conversation. And I didn't hear about them within prison populations.

DAVIES: We're at a time when there's more of an appetite for criminal justice reform than we've seen in a long time. You know, states and local governments run a lot of prisons and jails. Do you see places where different approaches, different models, may be tried or are being tried?

MONTROSS: Definitely. There are projects going on around the country where people are beginning to look at these very issues. And, in fact, there's been a fantastic program out of California that is taking groups of legislators and also prison correctional officers and wardens to visit European prisons that are having better outcomes. And part of this has been aimed at an effort to reduce the use of solitary confinement in American prisons. Solitary confinement is a practice that we think of as reducing violence and promoting security. In fact, when we look at the numbers, that's not the case. We don't have the outcomes from solitary confinement that would justify its use given how damaging a practice it is.

And so this group in California is taking the stakeholders over to visit prisons in Germany, prisons like Halden in Norway, to try to show them how alternative methods are working, and so that they can see firsthand the environment, how the practices are implemented and how the outcomes are better not just for the prisoners, but also for the people who work in these conditions. You know, one of the things I learned - I'm working here in Rhode Island, which is a very insular, tiny, little state with a very, very long institutional memory.

And so you have people who are working as correctional officers in the prisons who - if a correctional officer was killed by an inmate 10 or 20 years ago, there are still correctional officers working in the prisons who remember that incident and use that incident as justification to continue the practice of solitary confinement because of that risk of the situation that happened many, many years ago. And that's, you know, a justifiable fear, of course, when we're asking people to take on these dangerous jobs.

But one of the things that this group in California has realized is that if you take the correctional officers who are the ones shouldering this fear and you show them the environment - it's not just academics, it's not just psychiatrists who are talking about how to make this situation better. But you actually have prison officer speaking to prison officer, talking about how things have improved, that that's really a locus for change.

And I think that those kinds of situations bring a lot of promise because the system has to be fixed. The 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.

DAVIES: Well, Christine Montross, thank you so much for speaking with us.

MONTROSS: Thank you, Dave. I really enjoyed it.

DAVIES: Christine Montross is an associate professor of psychiatry and human behavior at the Brown University Medical School and the author of "Waiting For An Echo: The Madness Of American Incarceration." Coming up, TV critic David Bianculli reviews the new video streaming service Peacock from NBCUniversal. This is FRESH AIR.

(SOUNDBITE OF TODD SICKAFOOSE'S "BARNACLE") Transcript provided by NPR, Copyright NPR.