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

Compare Henry's situation to that of Robert, a psychotic man who caused a similar disturbance in the community. Robert, too, was plagued by paranoid delusions. He had come into contact with police while yelling loudly in the streets of his neighborhood that he was an unwitting experimental subject in a secret government program. But unlike Henry, Robert was admitted to my inpatient unit after police decided to bring him to the hospital rather than to jail.

Robert was a large, muscular man in his late fifties with a lumbering gait and erratically mussed white hair. He sat on the periphery of the unit and regarded everyone around him with suspicion. Once he was hospitalized, Robert's paranoia became rooted in a fervent belief that the hospital environment was a front and that he was, in fact, being held in a covert government facility where he was awaiting execution. Like Henry, he refused to take prescribed antipsychotic medication. As a result, his paranoid symptoms had improved little since admission.

One night new personnel were being trained on the hospital ward. Robert was in the kitchen when a staff member began demonstrating how, in case of an emergency, electronic safety blinds could be activated to cover the wall of windows that separated the kitchen from the rest of the unit. Robert became terrified by the movement of the security blinds and, in the throes of his paranoia, interpreted their closure as a signal. He believed that the unit staff was cordoning off the kitchen in preparation to execute the patients held within.

Robert ran out of the kitchen, screaming to the other patients, "Tonight's the night they're going to kill us all!" In what he believed was self-defense in a moment of mortal peril, he began attacking the staff. In less than a minute, he assaulted and injured numerous staff members. Two female mental-health workers suffered concussions, one of them hit so hard by Robert that her supervisor later said that "she flew off her feet like a rag doll." A male staff member who intervened and tried to subdue Robert was brought to the floor by him, kicked in the head, and eventually required knee surgery for injuries sustained in the altercation.

Despite the severity of the attack, none of the injured workers felt that it was appropriate to press charges. They each offered the same explanation: Robert was clearly ill and had been acting out of his illness. He inflicted an enormous amount of damage, but no one perceived him to have done so with malicious intent. As the unit's nursing supervisor said to me in describing Robert's aggression, "He was in pure terror. He thought he was fighting for his life."

Robert eventually began taking appropriate medications, and his paranoia diminished. After fifteen days he was discharged home with outpatient treatment arranged by the hospital team.

Henry, in contrast, remained incarcerated, facing the prospect of spending the next decade and a half of his life in prison.

Henry's story is not an aberration. I have seen countless detainees who faced significant time in prison in just these sorts of circumstances. A man who spent six months in jail for tearing up toilet paper in a shopping mall and shouting profanities at passersby. A woman who spent thirty-eight days in jail after being arrested for sleeping on the floor of a city hospital that, when she was booked for the crime, she listed as her home address.

If these mentally ill detainees become assaultive or are unable to follow police instructions or jail rules, the manifestations of their symptoms lead to harsher punishment, longer periods of incarceration, and lost years of their lives. In precisely this way, our overcrowded correctional facilities become inundated with the psychiatrically ill, straining our prison system and draining money from state coffers.

The first part of this book, then, is about how people wind up in prison. It is not what we have assumed.

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.