Role of a US–Norway Exchange in Placing Health and Well-Being at the Center of US Prison Reform

Living and working conditions in many US correctional facilities are damaging to the health of incarcerated people and correctional staff.^1,2 In response, experts have called for efforts to improve the health of incarcerated people, and correctional systems have invested in “officer wellness” programs.^1,3 Some correctional systems outside the United States have taken a different approach to these challenges: developing a correctional culture (defined here as the values, beliefs, and norms of a correctional institution or system) that deliberately puts health, humanity, and rehabilitation at the forefront of correctional practice.⁴ We describe the feasibility and early results of Amend, our program adapting practices from one such system, the Norwegian Correctional Service, for implementation in four facilities in one US state correctional system housing residents of all security levels, backgrounds, and needs.

POOR HEALTH IN US CORRECTIONAL ENVIRONMENTS

Until the late 1960s, US correctional facilities subscribed to the goal of rehabilitation—the belief that positive personal change could maximize incarcerated people’s postincarceration success and reduce crime. In the early 1970s, this goal was largely abandoned, and the United States entered an era of mass incarceration.⁵ Increasingly overcrowded correctional facilities transformed into dehumanizing, punishment-oriented regimes.⁵ Despite an emphasis on institutional security, many correctional facilities became plagued by violence, sexual assault, and suicide.⁵ Incarceration under these conditions has deeply negative physical and psychological effects that, as a result of inequitable odds of incarceration in the United States, disproportionately befall people of color, the poor, and those with mental illness or substance use disorders.⁶

While the health of correctional officers is an understudied topic of study, emerging evidence suggests that correctional staff experience disproportionately high rates of chronic disease and behavioral and mental health problems alongside profound environmental stress and exposure to workplace trauma.^2,4 For example, the California Correctional Officer Survey (2017) documented high rates of chronic disease (e.g., diabetes 22%, heart disease 16%) among the 50% of participants who reported feeling unsafe at work.⁷ Symptoms of depression, anxiety, and posttraumatic stress disorder were also common; 10% of participants reported suicidal ideation.⁷

AMEND: CHANGING CORRECTIONAL CULTURE

A number of initiatives have sought to address the pains of imprisonment, including a national campaign to reform solitary confinement, litigation to improve correctional health care, and efforts to reduce the number of incarcerated persons. Initiatives to address correctional officer health and wellness have also been undertaken.³ These initiatives represent important reforms, both to address the occupational health and well-being of a large, nationwide workforce and to ensure that prison reform initiatives have the buy-in needed to be successful, particularly from often politically powerful constituents such as correctional officer unions and correctional leadership. Yet few if any officer wellness initiatives directly address the often violent, high-stress, and dehumanizing culture inside correctional facilities. Culture change interventions are needed to ensure the safety and health of incarcerated individuals and correctional staff.

In response to this need, we developed Amend, an international exchange, officer training, and technical assistance intervention that adapts practices from the Norwegian Correctional Service for implementation in the United States. Because the US and Norwegian cultures and populations differ, the program does not directly apply Norwegian correctional policy or practice to the United States but, rather, takes Norway’s correctional approach as inspiration for distinctly American reforms. The Norwegian Correctional Service believes that people go to court to get punished and they go to prison to become better neighbors; their officers are trained to play an active role in residents’ rehabilitation by using positive incentives and motivational interviewing, engaging residents in health-focused programming and providing intensive mentorship and positive socialization. Our program works with US participants to develop correctional policies and practices that are influenced by the Norwegian approach but account for the specific needs and constraints of their particular context.

From 2015 to 2017, we enrolled policymakers and government officials in an immersive program in Norway designed to introduce them to a radically different approach to correctional work. In 2018, we expanded our program to engage frontline correctional staff to change the culture in their home institutions. We enrolled 10 participants (wardens, correctional captains, sergeants, and officers) from a US state correctional system in a 10-day learning and job-shadowing program in Norway. Upon their return to the United States, these staff were joined by 54 of their colleagues representing four correctional facilities to participate in an intensive, 20-hour training delivered across three sessions designed in partnership with the Norwegian Correctional Service and led by Norwegian officers. The training is modeled on principles of adult learning and features didactics, discussion, scenario-based learning, and practical (hands-on) exercises. Topics covered include theories of crime and punishment, behavioral psychology, risk assessment, interpersonal communication and motivational interviewing, ethics, use of force, and others.

Our preintervention questionnaires, conducted at the start of the training, confirmed that US correctional work is associated with poor health and well-being. For example, 60% of participants agreed that “correctional work negatively affects time with my family”; 37% reported experiencing fear of being seriously injured or killed at work; and participants reported responding to approximately 2 incidents of interpersonal violence per month on average. Despite an average age of 39 years, 45% reported having hypertension, 30% reported symptoms of posttraumatic stress disorder, 40% had a positive screen for depression, 32% said a loved one had expressed concern about their drinking, and 13% said they had thought about or attempted self-harm. Moreover, while 84% believed rehabilitation should be a goal of their work, only 45% felt they made a positive difference in incarcerated people’s lives.

A pre–post self-assessment of the training revealed gains in knowledge and skills including in motivational interviewing, de-escalation, risk assessment, understanding incarceration’s negative effects, and reducing use of solitary confinement; 40% said the experience was “life-changing.” Within 6 months of our program, all housing units from which officers were selected by exchange participants and facility leaders to participate in the training and receive technical assistance from our team reported significant changes to their operational values, goals, and practices (Table 1).

TABLE 1—

Findings From Posttraining Survey and Qualitative Evaluations of a Correctional Culture Change Intervention in the United States Based on the Norwegian Correctional Approach

Finding	Supporting Data
More humane, health-promoting correctional environments enhance prison safety and job satisfaction.	78% of participating staff said Norwegian correctional concepts will enhance officer safety. 94% said the training provided new perspectives on how prisons could change for the better.
The training demonstrates early efficacy in critical knowledge and skills transfer and changing correctional practice.	“[This program] renewed my hope for our profession. It has inspired me to focus on activities and prison life that will enhance the inmates’ lives and make them healthier, better neighbors.” “I am proud to say that this Father’s Day, inmates will wear their own clothing for visitation with their children. We started an inmate council and a new, more compassionate approach with suicidal inmates. We are making change.” “We have begun to get a highly assaultive inmate (42 staff assaults in 3 years) out of his cell without restraints on a regular basis. Yesterday officers took turns playing monopoly with him for 2 hours. It’s working.”
A workforce training that introduces correctional officers to an alternative approach to correctional work—one that emphasizes humanization, health, and rehabilitation—is feasible, well-received by the workforce, and can transform the professional lives of participants.	“I am forever grateful for the opportunity I had to see a different correctional model completely challenge everything we do.” “We take things from inmates that act out. We do this so they will behave, and also for staff safety or their own. . . . But [after this experience], I can’t go back to that way of thinking. It’s hard when you have seen the other side. When you have seen and know that it can be better for both staff and the adults in our custody.” “On the last day of training we had a big disturbance, I found myself touching a participant on the shoulder and saying, ‘I’m going to take care of you right now.’ . . . I went 10 years without touching an inmate in a non–use-of-force situation. I just didn’t touch people. More, I’m not about to tell an inmate ‘I’m going to take care of you.’ This has continued since then. I’ve seen it in all my interactions. I have more inmates saying ‘thanks for helping me’ and more inmates that are talking to me first before they bang on cell doors or kick and scream. It’s amazing.”
Residents say the intervention positively transforms their experience of incarceration and better prepares them for life in the community.	“On a 1–10, my depression was a 10 or 11. I made some poor decisions due to my unstable emotional state and my actions drew the attention of [staff]. To my surprise, shock even, I received a lot of outreach and support from officers. . . . All of these people went above and beyond their job, treating us inmates with a measure of humanity and dignity. . . . I realized that it may be time for a perspective shift. An update to my whole us-versus-them mentality.” “I was pulled out [of my cell] one day and brought into a conference room where 10 staff told me they all had a vested interest in my success. At first I was in shock, then skeptical . . . then they escorted me unrestrained outside for the first time in a long time [and] there was an overwhelming flood of emotional feelings that gradually turned into confidence I hadn’t felt in years. After meeting with this group several more times it became more of a protective feeling because they truly cared about me . . . [it has] changed my outlook on my life and gave me a strong sense of pride and accomplishment . . . these people treated me like anyone in society would treat me rather than being a burden. This ultimately has made me feel like I’m equally worthy of returning back into society with confidence and for this I am truly grateful.”

Note. Surveys were completed by 64 correctional staff participating in a multiday training delivered by Norwegian Correctional Service trainers and program leadership; the training followed a 10-day immersion learning experience in Norway in which 10 of the staff had participated. Qualitative data are excerpted from staff and resident comments in the 6 months following the training, during which program leadership provided Department of Corrections leadership and staff with strategy and technical assistance support to change correctional practice in participating housing units.

FUTURE HEALTH-ORIENTED PRISON REFORM

The dangerous, high-stress, and dehumanizing environments that characterize many US correctional facilities in the era of mass incarceration have worsened racial and socioeconomic health disparities and undermined the health and safety of correctional staff. Our culture change intervention successfully introduces US correctional officers to an alternative approach to correctional work that emphasizes humanity, health, and rehabilitation. Engaging correctional staff directly in prison reform is important because everyone in these systems can benefit from smaller, more humane institutions in which staff are empowered to work closely with residents to promote health, healing, and rehabilitation. Participants’ responses to the program (Table 1) are consistent with emerging evidence that humane, health-promoting, and rehabilitation-focused correctional environments enhance prison safety and produce better public safety outcomes.^4,5 Our experience suggests that there are critical opportunities to develop new correctional academy training curricula, identify important skills gaps and retrain the existing correctional workforce, and pilot policy reforms that eliminate dehumanizing practices and conditions of confinement.

Addressing mass incarceration in the United States will require that everyone involved in these systems—including correctional leaders and staff—promote and support correctional cultures that are firmly rooted in humanity, health, and rehabilitation. Our program shows that the large US correctional workforce is an important if overlooked ally in this effort.