Article highlights
- The Washington State Department of Corrections is collaborating with the Amend Program at the University of California San Francisco to improve the humaneness of the corrections system.
- Amend’s principles, derived from Norway’s prison system, aim to reduce negative health effects of incarceration and focus on human rights.
- The article emphasizes the need for well-being to thrive in prisons, highlighting universal needs such as security, connection, identity, meaning, opportunities for growth, autonomy and moments of joy.
- The challenges faced include isolation from human kindness, a sense of uselessness, and a lack of meaning for incarcerated individuals, which can lead to disruptive and toxic mental, physical, spiritual, and social health.
- The Norwegian approach emphasizes rehabilitation and individualization, providing incarcerated individuals with opportunities for personal growth, responsibility and trust, leading to positive transformations and reduced recidivism rates.
By MaryAnn Curl, MD, MS
The Washington State Department of Corrections is working with the Amend Program at the University of California San Francisco to bring greater humanity to corrections. The principles of Amend – a public health and human rights program aimed at reducing the negative health effects of prisons and jails – are drawn from Norway’s prison system, which is considered the most humane in the world.
Washington, along with California, Oregon and several other states, has begun to implement principles learned from the Norwegians. A contingent of leaders from the West Coast visited the country in May 2023, and I want to share some reflections from the trip. I am indebted to Amend and the profoundly generous people of Norway who shared their lives with us.
What does it take for well-being to thrive?
On July 22, 2011, a far-right terrorist parked a van filled with a homemade fertilizer bomb near government buildings in downtown Oslo. When it exploded, it killed eight people and wounded more than 200. While authorities were distracted by the aftermath of the bombing, the extremist made his way to a nearby summer camp on an island and killed 67 more people. Most of the victims were teenagers.
Humans seek solidarity. In the face of unspeakable evil, the Norwegian people found solace in unity and a resolute insistence on the sanctity of human rights. For many of us, the bridges they are willing to cross in that pursuit are mind-boggling. The warden where the terrorist is now held recounted daily polite conversations and shared home-cooked Kurdish meals they made as overtures to awaken his “better angels.”
Hearing about that horrific day in 2011 was the endcap to our week’s visit, but in many ways, it perfectly encapsulated the challenge. How do we, as thoughtful and principled people, begin a path of lifting ourselves from a space where imprisonment is allowed to be painful to realize that the time of incarceration is a window of opportunity? How do we go from allowing trauma monsters to plague adults in custody to purposefully removing the painful stimuli so the experience can create better neighbors who leave prison healed and ready to live a whole life?
For well-being to thrive, there are universal needs: security, connection, identity, meaning, opportunities for growth, appropriate autonomy and moments of joy. For persons incarcerated or within the legal process, I see three main despondencies. These are isolation from human kindness, a sense of uselessness and a lack of meaning. Isolation, uselessness and meaninglessness are disruptive and toxic. They destroy mental, physical, spiritual and social health. For persons whose lives before legal issues contained trauma, the additional feeling of low worth can perpetuate the cycle of grief, loss, shame, stress and dysfunction. In our tours we confronted that employees working with humans who endure this condition are not immune, nor can they shelter from it. We are traumatized by witnessing the misery.
One woman living in an Oslo halfway house put it well: “The problems that brought you to prison don’t just go away,” she said. “You don’t get sentenced and suddenly become stronger. Loss and grief are the norm.” She said it feels like you lose the life you led before prison. “Time and memory-making are suspended. Your loved ones go on with separate lives.”
The visits preserve the connection, but no current stories are told. This is to shield loved ones from the hard reality. As she put it, knowing your life and feeling the tragedy is too stark. “It starts to be that the only people who know the current you are those in prison,” she said. If they are all wounded or devoid of compassion and empathy, people can believe that’s all there is – pain, desperation and nothingness. Therefore, our transformation must succeed, and corrections must evolve. If incarceration continually causes fresh trauma, the protective scars thicken, and people can’t get healthy.
A man echoed that the “fishbowl” of high security keeps you frozen. The microtrauma barrage and absence of normal adult behavior in the prison environment disconnected his soul. He was first in a brutal South American prison where he suffered a skull fracture and nearly died. Daily beatings made survival the only goal. In the humane prisons of Norway, he recounts being no less at risk as his anger drove him to project and react continually. “Every other person was the source of my pain,” he told us.
He ate voraciously and refused work, becoming morbidly obese and pervasively unhealthy. Only upon reaching the island prison of Bastøy could he thaw the icy veneer that held his heart. Now he is “taking back my liberty one day at a time.” He no longer hides once the stark reasons for anger and projection were removed – no concertina wire, no impossible walls, no mandatory routine.
“Now I have to deal with my issues and cannot blame anyone,” he said. “In max, they treat you like a child – no choices, no trust, no responsibilities. The routine makes you feel like a zombie.” He recalls a retreat toward the end of his time in high security being the turning point. This self-selected time of reflection aimed for insight. He recalled, “I figured it could not get worse and thought, ‘If I don’t get freedom in prison, how could I handle it on the outside?’” After his retreat, he moved to Bastøy, and life began. “They trust me – that is a treasure. It makes me want to live up to it.”
He arrived at 130 kilograms and was unsure of his freedom. This is where the training of the Norwegian contact officers transforms. Open prison individualizes. “I have a chance. I challenge myself and change myself.” Being treated as capable and worthy is key. “Your contact officer cares – it awakens your sense of worth,” he added. “You don’t want to misuse their trust.” They are responsive, invested and inspiring.
‘Take the prison out of them’
This echoed in the Pathfinders drug rehab unit in Oslo Prison. They said it takes radical honesty and bidirectional trust. One officer said, “When you want to take someone out of prison, you must help take prison out of them.” Staff encourage the incarcerated to “keep going – we affirm their ability to change.” When asked if people returning to prison is discouraging, he said, “No, because we learn and go forward. If they return, it just means there is more work to do.”
One of the men said, “I was living a life of no personal responsibilities and making bad choices. Even in prison those first several years I was not holding myself to account. I did drugs and didn’t act like an adult. Treatment was a chance. I want a life.” When asked what changed, he said, “I am responsible for my own change. There is no one to blame.” The officer added, “We work with people – not machines. We have different roles here but the same humanity. All human beings are born free and equal in dignity and rights. They are our future neighbors and could have been us except for different choices.” So, they normalize and humanize. When the person has progressed to be able to handle it, they give choice.
They told us a great story at Oslo Prison: One day an officer took three inmates for a therapeutic bike ride in the city. The day was sunny and warm. In the reverie, one inmate got ahead. The other three were sure he would soon realize. They waited, but after 30 minutes they surmised he’d become lost. The officer asked the two men to wait while he found the third. As the sun began to set, the officer had not returned. Thinking the prison would be looking for them, they went back. In the meantime, the officer found the lost man. He had gotten turned around trying to find them and was relieved to be found. The four men had a good laugh and a great story to tell later that night back in the prison.
Our Amend mentor, Tom, said, “You don’t have to like inmates, but you must not dislike them. You go on the principle that you provide not what the person deserves but what they need.” Visits are needed and positive. A good attitude costs nothing and means everything. Treatment over punishment. Isolation to enable calm but not to punish. Reasonable risks are encouraged; feedback is foundational. The officers reflect each day: “Did we do right? Say right? What effect did today have on me?” “We talk with them rather than about them” – a rule for inmates as well as fellow staff.
Progress is expected. One man said, “The first furlough is like a stress test – a challenge on every turn.” As they are able, they go from four hours to eight, then four days up to 30 days a year. They test their wings. As my friend at the halfway house said, “You must regain your ability to be yourself. When you take a vacation for 2–3 weeks, your brain takes a while to come back. Imagine three years in prison!”
Many women arrive with low education and histories of compromise, abuse, trauma and drugs. There is a heavy shame burden, especially for the mothers. They need a skill to feel worthy. It could be something as simple as how to make pancakes.
“When you lift a mother – whether she’s lost custody or not – you lift her children,” the Oslo woman said. “If they gain skill or knowledge, it can’t be taken away.
“I am pursuing painting and writing. Before prison, I was an architect. I wanted to be an artist but settled for a useful profession. This house allows me time to become me again. I know I don’t have purple scales on my face or ‘inmate’ stamped on me, but it’s printed on my soul. Living here makes it possible for me to test myself in the community and gradually regain myself.”
The contingent from Washington, Oregon and California in front of Halden Prison in Norway. (Photo/WADOC)
The goal is efficacy of self
So, how do we lift the burden? As Warden Kristian taught us, “We work it out – we talk it out. We share issues rather than adding them to our emotional backpacks, where they would eventually weigh us down so much we couldn’t stand.”
When our staff takes positive steps, we applaud them. When they stumble, we know learning is a process. We empower them. We prioritize them. When they are uncertain or feel ambivalent – like this change is just too much or too hard – we encourage them. We value staff wellness knowing that healthy staff are a prerequisite to this culture. For health services, medical diagnoses do not define us as humans. Health services staff must support and help our patients experience their fullest lives, with illness or health concerns not taking over. When there are decisions to make, we should have a “nothing about me without me” approach. Paternalism is not the way to build trust, confidence or longstanding health literacy. Our goal is efficacy of self, whether in situations that will resolve or in the face of life-limiting challenges.
Empowerment and shared decision-making celebrate autonomy, inspire growth and counter exclusion. The goal of Amend, the change in corrections culture that is afoot, is parallel and in every way complementary to patient-centered care. We are starting to walk this path and we must be brave, smart, resolved and collaborative to continue.
About the author
MaryAnn Curl, MD, MS, is chief medical officer for the Washington State Department of Corrections (DOC). She has a Bachelor of Science degree in biology from Abilene Christian University in Abilene, Texas, and a Master’s in physiology from the Baylor College of Dentistry. She received her medical degree from the University of Texas Southwestern and completed her residency at University of South Carolina. Curl is board certified in both internal and geriatric medicine.
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