Excerpt from Waiting for an Echo by Christine Montross, plus links to reviews, author biography & more

I also came to recognize that as a society we have decided to mitigate nearly all forms of loss—from theft and trespass to assault and murder— with incarceration. To repay harm with time. And only some of the people who are locked in our nation's correctional facilities are there by virtue of their guilt. Many others languish within prisons and jails because of their poverty, their race, their addiction, or their mental illnesses. Our aggressive carceral practices have meant that we relegate our convicted citizens to a system of imprisonment that is overcrowded, underregulated, and too often unjust.

My medical expertise is in mental health—specifically in acute cases of danger and distress. And what I found once I began working in the prisons was a system that runs counter to every principle of human flourishing that I know. Our correctional practices prioritize vengeance and suffering over justice and rehabilitation. Incarceration in America routinely makes mentally ill people worse. And just as routinely it renders stable people psychiatrically unwell. Our system is quite literally maddening—a truth that categorically undermines our stated goals of safe and secure communities.

The trajectory of my patients' lives veers sharply when law enforcement is involved. The consequences of these interactions are unpredictable. If psychiatrically ill people are sick enough or afraid enough to be potentially assaultive, the earliest decision by police as to whether they belong in jail or the hospital—a decision often made in the moment of the police encounter—may shape the course of the next many years of their lives. When the outcome is hospitalization or access to treatment, the result can be stability and safety. But when mentally unwell, dysregulated people are taken to jail, the result can be sheer disaster.

As an example, some years ago I evaluated a man named Henry in the visiting area of a men's jail. Henry was thin and disheveled, and he looked at me with guarded suspicion when the correctional officer (CO) brought him into the room where I was already seated. He was wearing a khaki prison jumpsuit with a white T-shirt underneath—and he smelled as if he had not showered in many days. I immediately noticed that Henry's mouth was in constant motion with the involuntary movements of tardive dyskinesia, a rare but permanent side effect that can be caused by long-term use of antipsychotic medications.

Henry had been paranoid at the time of his arrest, and his paranoia had not abated in jail. He was refusing to speak to his attorney, prompting the judge to order a competency evaluation.

According to the police report, Henry's legal involvement began when he did not leave the premises of a convenience store after the manager instructed him to. Henry hid behind the store's dumpster, refusing to come out when approached by police, and shouting paranoid statements about interrogation tactics and torture and the Connecticut militia. When he finally emerged, Henry was taken to jail. His charges—criminal trespass and resisting arrest—carried a maximum combined sentence of two years in prison.

But Henry's situation, like that of many psychotic detainees, became far more dire. Henry was prescribed an antipsychotic medication in jail but refused to take it. He might have been paranoid about the pills' safety or might not have had insight into the fact that he needed treatment. At some point shortly after his arrest, he would not come out of his cell when asked to do so. He was then forced out by COs—a procedure called a "cell extraction." Still paranoid, but now with no dumpster to hide behind, Henry resisted this time by fighting back.

In our nation's correctional facilities, detainees who become assaultive are typically sent to administrative segregation—a punitive form of solitary confinement known to exacerbate symptoms of mental illness. Worse still, assaulting a correctional officer is a felony charge, which in Henry's state carries a maximum sentence of fifteen years in prison and a fifteen-thousand-dollar penalty. If convicted, Henry would spend years in prison, where mentally ill people face a disproportionate risk of being victimized. He would eventually leave prison on probation, with legal requirements that would be difficult for him to manage if his symptoms returned—setting him up to incur additional time behind bars.

From Waiting for an Echo by Christine Montross, published by Penguin Press, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright © 2020 by Christine Montross.