- The intersection of America's criminal justice system with mental health is long and often misunderstood.

Today's guest tells us that America's largest mental health institution isn't a psychiatric hospital.

It's Cook County Jail in Chicago, Illinois.

She's Dr. Christine Montross, this week on Story in the Public Square.

(uplifting music) Hello and welcome to Story in the Public Square, where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

Joining me from his home in Rhode Island is my friend and cohost G. Wayne Miller of the Providence Journal.

Each week we talk about big issues with great guests, authors, journalists, artists and more to make sense of the big stories that shape public life in the United States today.

This week, we're joined by Dr. Christine Montross, a professor of psychiatry at Brown University and the author of Waiting for an Echo, a powerful look inside America's prison system.

Christine, thank you so much for being with us.

- [Christine] I'm delighted to be here, Jim.

Thanks for inviting me.

- So there's a lot we want to talk to you about the new book, but I'm also curious about how you came to be a psychiatrist in the first place.

- I was a poet before I went to medical school and was never one of those kids who thought that I was gonna grow up to be a doctor.

Wasn't dissecting squirrels in my backyard or anything like that.

Actually majored in French in college.

And then in graduate school for poetry, started writing these kind of romantic poems about madness and the ways that the mind can derail.

Then I started teaching high school English with a group of really underprivileged kids who had quite a number of psychosocial stressors going on and began to see that my romantic ideas about madness were not at all based in reality in terms of the struggles that people really went through when they were dealing with psychosocial stressors and sometimes real psychiatric illness.

So I felt really compelled and interested in working with kids in that realm.

And so I started thinking maybe about a career in mental health, which was also boosted by the fact that I was a pretty terrible high school teacher.

(laughing) I thought about going into psychology programs or social work, but really we were learning so much about the brain at that period in time.

And a lot of my kids were on psychiatric medications, that I thought that if I really wanted to have the broadest base of understanding and the broadest toolkit of things to offer people, I might have to go to medical school.

- Do you think that your, so I'm not gonna even call you a former poet, because my guess is that you're still a poet, but do you find that that part of your own psyche makes you a better physician, a better psychiatrist?

- I don't know any other way, but I certainly lean on that part of my thinking and my way of looking at the world a great deal in my clinical work.

I think I've always been someone who's used writing to make sense of the world.

And so when I encounter things in medicine that I don't understand, writing is a tool I use to try to make sense of that, whether that's dissecting a cadaver in medical school or working with mentally ill patients.

And I also think poetry teaches you to draw larger conclusions from looking very closely at small things.

And after all, that's very much what medicine is about, whether we're looking under a microscope at a collection of cells and trying to reach a diagnosis or looking at a collection of symptoms in a psychiatric patient and trying to assess how we can help and cure.

- So I'm curious, do you use poetry or writing in your treatment with your patients?

Does that ever come up?

I mean, obviously you're still writing and still a poet, but do you bring that into your practice ever?

- I don't write with patients, although there are physicians that do, and I'm fascinated by that work and how it can work for me.

It's mostly a chance for reflection.

I think in our clinical encounters increasingly, we have so much of a constrained period of time with patients.

So we might have 10 or 15 or 20 minutes with a patient.

And psychiatric illness is complex and human beings are complex.

So I find that when there are cases or people that really gnaw at me, where I'm trying to more deeply understand what they're going through, what their illness may be, how to best move forward, that taking time on my own to really reflect on that and write about it and sometimes take deep tangential dives into medical history or psychiatric history, that that gives me an opportunity to then think differently and probably more deeply about their own experience.

- So what led you to your new book, Waiting for an Echo?

What prompted you?

What were the issues?

What were you seeing that led you to write this amazing book?

And you can see it here.

I've got it right up here in the back.

A great book.

- Thank you, Wayne.

I work as an inpatient psychiatrist now.

I work with hospitalized people on units called the intensive treatment unit.

So these are the psychiatric versions of the ICU.

So the patients that I see are actively hearing voices or seeing visions, have paranoid beliefs, are really manic or are actively trying to hurt themselves or other people.

And what I see over and over again, and what really prompted this look into our prison system was that my patients often come in contact with police and they often serve time in jail or prison.

And when they do, frequently, it's not due to some sort of criminal intent or scheme.

It's really due to a manifestation of their symptomatology.

So they're shouting in the Starbucks or they're charging through TSA because they believe they need to get on a plane to save the world.

And in those moments, the police are called and my patients are often taken to jail.

And I recognized how difficult it is for them to sometimes follow directions or adhere to norms within a therapeutic environment like the hospital.

So I really wondered what must it be like when instead they're in a more authoritarian punitive environment like jail or prison.

And that's really what launched the investigation of Waiting for an Echo.

- So what do you see in terms of training that law enforcement officers get in dealing with people living with mental illness?

I know it varies department by department, and my guess is that larger departments have more training than small, but can you give us an overview 'cause it has to vary tremendously from informed understanding to no understanding.

- Absolutely.

You see that full range of the spectrum.

Increasingly, I think there's a call for police to receive some kind of training in deescalating psychiatrically ill patients and recognizing when someone is ill rather than just being obstinate.

But I think it really invites a larger question.

And that question that I think about is, why are police the first line of response to psychiatric illness emergencies.

When we have other health emergencies, when someone's in a car accident or having a heart attack or having a stroke or a diabetic crisis, we'd send EMTs and paramedics who are trained clinicians who can intervene, they can administer oxygen or they can provide insulin, they can stop bleeding, they can stabilize a fracture, and then they are trained to safely transport someone to a therapeutic environment.

I don't see any reason why we can't also have trained mental health clinicians that know how to intervene in these emergencies in the same way that paramedics and EMTs do, and then transport people to therapeutic environments.

So the question of how much should police be trained in this is a good question, but it might be the wrong question in terms of who should really be the first responders to these sorts of emergencies.

- That seems like a tremendously reasonable idea.

Is there anybody anywhere in the world doing it that way?

- There are.

There are more and more places that are beginning to experiment with this.

And one of the things that's really exciting about it to me is that there is buy-in from various different stakeholders.

And what I mean when I say that is police themselves really struggle with being the first-line responders to psychiatric illness.

They often, as Wayne mentioned, don't have the kind of training.

Families at a loss often don't know how to get their loved ones help other than to call police.

And we also know that people with mental illness are 16 times more likely to be killed by police than people who are mentally well.

So the places that have done this well, one example is an organization called CAHOOTS in Oregon that does exactly what I've described.

They send clinicians that have police backup, should they need it, when psychiatric emergency calls come in.

The number of incarcerations of mentally ill people has really plummeted.

The clinicians go, they know mental health resources that they could hook up the person to, whether that's inpatient or outpatient.

They can call police, should they need to.

They are unarmed.

They've never had an injury of a worker.

They've never had a fatality of a person who called them.

And they rarely have to call for police backup.

But it frees up police to do other things.

And it reduces the police budget substantially.

So you see buy-in from various corners and that's really encouraging to me.

And it also seems humane.

- That sounds like a great model.

And we'd certainly hope that other departments in parts of the country would embrace that.

You hit on a point that I wanted to get into a little bit more before we talk about the book and incarceration.

And there's so much to talk about there.

And that is the tragic consequences that often result when police show up.

They're armed.

Someone is having a psychiatric crisis and they get shot and killed.

No judge, no jury, no treatment.

Talk about that.

That is not a rare event.

That happens regularly.

It's happened here in Rhode Island many times and across the country.

- Right, and we see examples of that in the news all the time.

And imagine the desperation of a family who often, often it's the family members themselves who have called for police for help because their loved one is ill. And then to have that kind of a catastrophic outcome is so devastating.

So we see that over and over again.

We also see that in the prison system.

And one of the things that I, one of the dynamics that I think is really at play, whether it's correctional officers or police officers, is that I know from my training that when someone is deeply paranoid or when they're psychotic and hearing voices and seeing visions, often they are also extremely afraid.

So they're in a very defensive position.

When that is met with the kinds of manners, mannerisms that police and correctional officers use, shouting commands, cornering people, insisting on compliance, that fear can really rev up and people's behavioral discontrol can really escalate.

So you're more apt actually to have people act in aggressive ways in that moment because they feel very afraid and cornered.

What we know in the hospital is, first of all, we can identify when people start to behave in ways that make us understand that they are feeling afraid, are feeling cornered, are apt to maybe rev up into a period of aggression.

And we know you do the opposite of what often police and correctional officers do.

You speak more quietly.

You might back away a little bit.

You really look for ways to ally with the person instead of to create conflict with them.

You give them options instead of cornering them with one option only that they can do.

And that's a more collaborative model.

It's also a more effective model, and it's a safer model, both for the clinicians or police or officers involved, and for the mentally ill person.

- Well, let's talk a little bit more about the issues of mental health in an incarceration setting.

How big a problem are we talking about?

How many people with mental health issues are in America's prisons today?

- It's an enormous problem, Jim.

So about 20% of the people in American jails and about 15% of people in prisons have severe mental illnesses.

And when I say that, I mean schizophrenia, schizoaffective disorder, bipolar disorder, major depression.

Adds up to about 350,000 people who are incarcerated in America.

And we understand how this came to be.

We understand that in the 60s, 70s and 80s, when we closed the state hospitals, there was a promise of funding for community mental health centers in an attempt to take people out of these institutions that were draconian institutions at the time.

The problem was that that funding, that promised funding never materialized.

So you had people who were mentally ill who needed a high level of care, and suddenly they were out in the community without adequate medication, without housing, without food provided to them.

So then you see people starting to sleep in doorways, sleep in parks, beg for food, beg for money, and suddenly police are called in those instances.

So there's this shift of people from the therapeutic realm to suddenly what we'd call the criminalization of mental illness, that people with symptoms are now in the realm of the legal system.

So that really began a vast influx of the mentally ill out of a therapeutic environment into our punitive environments.

- It's one of the great failures of American public policy over the last many decades.

And of course, bear in mind that many of these psychiatric institutions were inhumane.

And so the reason behind it, the rationale was to give people a better way of living, and of course, the money didn't follow in the community program.

Some of them sprang up and some of them sprang down and were gone, and we are where we are today.

Can you give us sort of a demographic overview of these approximately 350,000 people in terms of poverty, education, race, gender, and so forth?

- Yeah, so what we know across the board, whether you're talking about mentally ill people or mentally well people, is that people who are incarcerated in our country are more likely to be poor, and they're more likely to be people of color.

And so the demographics in our prison systems are overwhelmingly people who are in disadvantaged groups in our communities.

Many of us commit crimes.

Those of us who end up in jail and prison are disproportionately people with fewer means and people of color.

So racism is just an intrinsic part of our judicial system that we're beginning to understand better.

Of course, Michelle Alexander's book The New Jim Crow lays this out beautifully and convincingly for anyone who needs convincing.

But there's just no question.

In my book, I looked at this even from the earliest level.

When we look at juvenile detention facilities, Black kids are more than twice as likely to be arrested for the same thing as white kids are.

They're less likely to have their cases diverted out of the court system into say community service.

They're less likely to be sentenced to probation instead of jail time.

And they're more than four times as likely to be sentenced to a juvenile facility than white kids are.

So this kind of racial bias starts at the earliest, earliest stages in our judicial system.

And it continues all the way through.

- So these are people largely without power, without a voice, don't have the means to hire a good lawyer, even any lawyer, and are facing stigma in general, which already is in place in society.

It's just a terrible situation.

- And that was really my motivation for writing this book.

I think my first book, as I said, it was about dissecting it cadaver.

It was much more of a memoir and delving into medical history.

This book is really more of a kind of call to advocacy.

And I think it draws just as much from my experience as a clinician, just as much from the anecdotes of my interactions with people in jail and prison.

I perform competency to stand trial evaluations of people in jails and prisons, and much of the book comes from the things that I have witnessed in performing those evaluations.

But really, I think as a physician, I have the privilege of witnessing the things that my patients encounter and endure.

But with that privilege, I think comes a responsibility to give voice to their experience in a way that they are not always able to do because of their symptoms or their stigma or their relative powerlessness sometimes.

- Christine, one of the things that absolutely floored me when I read it in your book was that the Cook County Jail in Illinois is the largest mental health facility in the United States.

It's an absolutely staggering fact.

But what are the services that you receive if you're incarcerated?

And are they effective?

- Yeah.

It's an appalling truth, that fact about the Cook County Jail, and it's not alone.

There are many other jails and prisons in our country that hold far more people than our psychiatric hospitals do.

And what I would say, again, is that the treatment provided really varies.

Cook County in particular, is trying hard to meet the need of their mentally ill detainees.

So the sheriff there, Sheriff Tom Dart, is sort of a maverick.

And he is really, he appointed a psychologist in one of the most prominent positions in his prison.

He's really implementing programming with the whole drive of helping people's mental health while they're incarcerated in the hopes that they don't come back.

But even as he does this, he acknowledges that there's a part of it that feels really misguided.

He said to me when I went there to visit and to interview him, he said, what I'd like to do is not provide any of these services.

Let the whole thing fall down and force the legislature to provide these services somewhere else, because there is a way in which they believe people can get these services in prison.

And he said, but the problem is you're talking about people's lives.

So you can't play fast and loose that way when people's lives are at stake.

- And plus, you're talking about being in prison, which certainly exacerbates mental illness, I would think in most cases, maybe all cases, with the bars, the rules, with isolation, solitary confinement, which we can get into in a minute.

Talk about that.

This is not a therapeutic environment.

It's anything but - Yeah, and I think that there are two really critical prongs to understanding that.

One is the ways in which the environment is intended to make people suffer.

One of the really fascinating things that I delved into into the book was looking at prison architecture, which is really designed to be as unpleasant as it possibly can for people who are held within.

So we can imagine how this worsens people's mental health.

And I think we're in a unique moment right now in our culture where we understand how isolation is damaging to even those of us who are living in the comfort of our own homes.

And a friend of mine described solitary confinement as, imagine your bathroom, and then imagine spending the next seven years of your life there.

This is really a cruel and unusual thing that we ask of people.

The second prong, I think is that there's this fundamental misalignment between the expectations of prison and the way that mentally ill people are able to conform to those expectations.

So when you're commanded to do something and you are hearing voices and visions or you're extremely paranoid, you're not always able to follow those commands.

If that happens in a hospital, we have all kinds of ways that we can intervene if we need you to behave in a certain way.

But if you don't behave in prison the way you're told to, you can quite easily accumulate additional charges that mean you spend more and more years of your life in prison, and it can be an extremely vicious cycle.

- You know, I've written about mental health in prisons for many years, and a few years back, three or four years back, I went inside a maximum security unit, actually here in Rhode Island to look at people who are in solitary confinement.

And I have to tell you that it really was one of the most horrifying experiences of my long career in journalism.

There were people, it was men in this case, who were in cells smaller than a bathroom, 23 hours a day who had nothing, literally nothing.

And that one hour that they got out, it was highly regulated.

They were taken to eat in an area and then they could go outside if it was good weather, in what I can only describe as a cage with the razor wire on top.

And it was just horrifying and the correctional officers and the people who took me through there sorta confided, yeah, but this is what we have.

Talk about what being in that environment, 23 hours a day with potentially no hope of ever getting out, or at least you don't think of any hope.

You have no contact with the outside world.

You don't have visitors.

What does that do to a person living with mental illness?

I guess the answer is pretty obvious, but maybe we can have you give it.

- Sure.

It's unequivocally psychiatrically damaging.

It's unequivocally damaging.

And one of the most interesting things that I found in researching that precise thing was that we have research in a variety of realms that shows how isolation affects human beings.

So some of that research has been done at like, at scientific stations in Antarctica, from people who've been shipwrecked, from pilots who fly at long distances without any kind of visual or sensory input, from Korean prisoners of war.

And across the board what we see is that when human beings are isolated, their functioning and their psychological wellness diminish dramatically.

So what's important for those of us to remember when we think about that is, first of all, there are people in prison who are innocent.

So some of the people who are being subjected to that have committed no crime whatsoever.

Second of all, that solitary confinement is a punishment that is adjudicated entirely within the prison system.

So there's no judge or jury who sentences someone to solitary confinement.

A mere accumulation of infractions can send someone into that kind of setting.

Another thing that's critically important for us to realize is that 95% of the people in our jails and prisons come back to our communities.

So when we have degraded and damaged someone through weeks, months, years in solitary, they sometimes come directly from solitary confinement to our neighborhoods and streets.

And so we need to think about how that not only disserves the people who are held in those facilities, but it actually disserves the safety of our own communities.

- Christine, we're in, as we tape this, I think it's month 12 of a global pandemic.

Wondering how that has affected the mental health of inmates.

We've seen terrible reporting about the incidents of the disease inside America's jails and prisons.

How has that manifested itself in terms of mental health?

- Yeah.

So what we're seeing in mental health in general in America and across the world is not just incarcerated people, but free people as well.

We're seeing steep rises in depression, anxiety, substance use, suicidality.

We're seeing that across the board.

That's not different in prison.

And you're exactly right that the COVID protection and protocols have been really awful in some prison facilities.

So there've been huge outbreaks in prisons that have affected not only detainees, but the people who work in the facilities as well.

I also though, I always try to look for bright spots in these kinds of things and silver linings.

And I do think that it gives us a rare sense of empathy and understanding of what we're doing intentionally to people when we isolate them and incarcerate them.

I think that the pandemic has, for so many of us, made us understand how awful and unnatural it is not to be able to go to the bedside of a loved one who is dying, to not be able to go into the hospital and be with someone you love who is ill, to not be able to see your children or your grandchildren or your elderly relatives.

That there's something that feels deeply, deeply wrong about that.

And for us to now understand this is what we intentionally do to people when we incarcerate them and we separate them from their families and we enact policies that make visitation and family connection harder.

That we are intentionally enacting this kind of isolation and disconnection.

And I think we understand better what that means now.

So I also think it's an opportunity for a reckoning.

- So 15 seconds.

What do we need to do?

- We need to really acknowledge that, the question is, do we want suffering and vengeance or do we want safety and justice?

Right now, we're excellent at suffering and vengeance, but it does not yield the results we want.

It's expensive.

Our recidivism rates are very high.

And I would say it's morally demeaning to us as a country to treat our prisoners this way.

If we want safety and justice, we have to have more humane facilities.

We have to have rehabilitation and education within them.

We have to shift our mindset away from suffering and vengeance and toward using periods of incarceration constructively so that people emerge better able to be our neighbors and to be tax paying citizens in our country.

- That's where we need to leave it.

It's a powerful point.

She's Dr. Christine Montross.

The book is Waiting for an Echo.

It's an important read.

That's all the time we have this week, but if you want to know more, please check us out on Facebook and Twitter or visit pellcenter.org where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes, asking you to join us again next time for more Story in the Public Square.

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