Psychotherapy in Corrections

Dr. Laura Roberts (00:16):

Hi, I'm Dr. Laura Roberts, editor in chief for the books portfolio of the American Psychiatric Association, and welcome to the APA Books Podcast.

Dr. Laura Roberts (00:33):

Hi everybody, it's Laura Roberts. Welcome back to Psychiatry Unbound. Today we're welcoming authors of a wonderful book, Psychotherapy in Corrections. The book was edited by Peter Novalis, Virginia Singer, and Carol Novalis, and I'm delighted to have Peter and Carol with me today. Peter is phenomenal, he has more than 30 years of clinical experience, most of it in public psychiatry, and has worked and stayed in federal psychiatric hospitals, correctional facilities and was the primary author of the first major textbook on supportive psychotherapy, the Clinical Manual of Supportive Psychotherapy, also published by APA Publishing. That book is now in its second edition. Carol Novalis is an adult educator and researcher also with 30 years of experience in both private and public institutions. She has a special interest in improving the education of socially disadvantaged adults.

Dr. Laura Roberts (01:25):

And then Virginia Singer, I think is the second author on this book, she's a nurse practitioner board certified in psychiatric mental health and addictions with more than 25 years experience in mental health. She has worked in jails, state prisons, inpatient psychiatric hospitals, inpatient and outpatient drug and alcohol treatment centers. I really want to start by saying how much I admire you both. We all work often with forgotten populations, but I think you work with doubly forgotten populations and also are bringing a sense of hope and inspiration to this work and concrete skill building that I just think is really, really remarkable and very, very worthy of admiration.

Dr. Laura Roberts (02:17):

Your dedication of this book is quite moving. It says, "Dedicated to the courageous people fighting the pandemics of the world, disease, violence, crime, poverty, incarceration, and social injustice. And to the survivors of these pandemics who deserve a better life." I mean, I just can't help but ask you why of all the paths that you could have undertaken, why is this your path? And I guess I'll turn first to Peter. Why this path among so many?

Peter Novalis (02:55):

Well, in my residency, I had some exposure to the forensic side of psychiatry and did a rotation with Dr. Jonas Rappaport, who was one of the leading figures in forensic psychiatry back quite some time ago, and he gave me an exposure to people involved with the criminal justice system. We did evaluations in the Baltimore court system and did evaluations of people for competency and having various involvements with criminal justice. And then my whole residency at that time was in a public mental health system, which is called St. Elizabeths Hospital, but despite the name St. Elizabeths, as many people know, was actually the oldest federal mental health hospital in the United States. It opened up after the Civil War to deal with casualties and problems after the Civil War. And so the name St. Elizabeths is actually the name of the land grant for it, but it's always been a federal mental hospital.

Peter Novalis (4:19):

At the time I was doing my residency, it was in a process of transition from the National Institutes of Health to the District of Columbia, so it now belongs to the District of Columbia Mental Health System, but it was always a public mental health system. I did my rotations in that system and these were with people who could definitely be called underserved, uninsured people in the mental health system. So that's basically how I got my training with, as I mentioned, with the forensic exposure with Dr. Rappaport, so I kind of had an interest in that. But after a number of years in public psychiatry, I just had the opportunity to get into the federal prison system in Springfield, Missouri, at what's called the Federal Medical Center and worked there for a while seeing mental health patients. And that's part of what's called the Federal Bureau of Prisons.

Peter Novalis (05:26):

They have four, maybe more now, but they had four national centers where the most severely mentally ill people were sent for specialized treatment and the one I worked at was one of them in Springfield, Missouri. So that was my first exposure to people in mental health settings and in specifically correctional settings. Then many years later, I worked for the mental health, worked as a psychiatrist in the Nevada State prison system. And after that, some interesting experience in an immigration and customs enforcement system in California where people in various stages, including a group of people that are very well known now, asylum seekers, are often kept while they're undergoing evaluation treatment. So I guess you could say I've always had an interest in public psychiatry but specifically in people who are involuntarily confined and what their problems are. Sorry for the long talk there, but you asked and I answered. That's it.

Dr. Laura Roberts (06:38):

No, no, it's good. I mean, it is interesting to think about people with limited freedoms. And I guess, Carol, I'd ask you the same, your calling to work with disadvantaged folks, where does that come from and why is that your focus?

Carol Novalis (06:53):

My first job out of college was with high school dropouts in New York City. The American Banking Association had a program, an educational program for them, and I was the social studies teacher and it was very interesting. They were very interesting people and they were very confident, but they didn't have the opportunity to enter the white collar or even other professions. And so it was fascinating to me to see how personable... it wasn't just personable, they were engaged, and they were interested in pursuing a career other than what might have been of expected of them coming from the low income areas. Along the way, I did research on parent education and how people are encouraged to... my master's thesis was on how to reward people for learning... and along the way I was doing research and articles and all that stuff. I taught GED programs for a while in Baltimore and mostly been doing research since and helping write books.

Dr. Laura Roberts (08:12):

Well, so this book really centers on psychotherapy in correctional settings, and so perhaps you could comment on why the world needed this particular book on psychotherapy in correctional settings in the context of so much mental health need?

Peter Novalis (08:30):

Yes, as you may know, Dr. Roberts, this is a book we discussed right after we had completed the other one you mentioned, the second edition of our Clinical Manual of Supportive Psychotherapy. We were talking, in fact, about where I was working, which was in the correctional field at the time, and it occurred to all of us that there really was not a book specifically about psychotherapy in corrections. It turns out there are many books about the so-called subject of correctional counseling because there are a wide range of people who do counseling in correctional settings, and there are many such books but there was no specific resource for people who have more specific psychotherapy roles, including psychologists and clinical social workers as well as mid-level practitioners and psychiatrists. There was no specific book for them, not that I'm excluding the correctional counselors, but there was no book for the people who are really the designated psychotherapists in corrections.

Peter Novalis (09:49):

There's a lot of independent kind of scattered research articles and guides about how to work with people in correctional settings, but nothing really for the therapists. So it wasn't like we were duplicating anybody's title. There is nothing else called Psychotherapy in Corrections, not at the book or textbook level, and we decided we would write it. Since our original emphasis is on supportive psychotherapy, we took a supportive tone to it, although we included discussion of a lot of the other programs including the cognitive therapy programs and specialized programs for substance abuse and the like, substance use, it's now called substance use disorder.

Dr. Laura Roberts (10:35):

And have you talked with colleagues about this book project that you've undertaken? Do other people kind of get it that there's a difference between correctional counseling and psychotherapy involving people with limited freedoms in a correctional setting?

Peter Novalis (10:54):

Yes, in gathering the information from my colleagues they were very enthusiastic about it. They didn't have any resources either, because most of the colleagues where we were working were mid-levels and psychologists. And in fact we didn't really have anybody... since it was basically an inpatient residential facility I was working in at the time... didn't really have any people who were separately counseling. Well, we had substance use counselors, that's true, but nothing specific for the psychotherapy needs of the people we were seeing. So I think they recognized that it fulfilled a niche in the field that had not been addressed.

Dr. Laura Roberts (11:46):

I hope you don't mind me telling you a personal story. When I was in my child psychiatry training at University of New Mexico, in child psychiatry, one of our rotations was at the Bernalillo County Juvenile Detention Center. And my assignment was to go and work with a group of young people who were incarcerated who had committed very violent crimes to do group psychotherapy. And I have to say, all of my training up until then, I didn't feel very prepared to go in. What I ended up doing... I don't know what you'll think of this... was I brought in ingredients to make pies. They had pudding, Cool Whip, milk... we made pies, everybody made their own pie and then the therapeutic question I asked them was who would they give it to and why would they give this pie? Who would they share it with?

Dr. Laura Roberts (12:44):

I mean, it really was one of the most powerful formative experiences in my development because just as you were saying earlier, Carol, it just kind of disintegrated all the prior myths about young people who would be an incarcerated subject in settings where they would just talk about people they loved and the hard experiences they had. And we moved right into working mode. So I don't know what you think about that. I kind of had to invent it on the fly one day. But I looked at that time and I looked when we first talked about your book idea a few years ago, there really isn't much to help people in their training or in their practice to work in correctional settings in a truly psychotherapy sort of way anyhow.

Carol Novalis (13:30):

Oftentimes, we've talked a couple of people, one guy we met at the bookstore the other day, the other week, he got introduced to an author and the author told him to write something. And he wrote something and now he's self-publishing and he has his own business. Now that he's out of prison he's self-publishing a book, he has all kinds of businesses that he is into. And it really inspired... you talk about these things that change your life, similar to that story there are all these kinds of things, but if the person in prison is not treated as a person but rather as part of an institution, they don't always have those experiences and that's what psychotherapy can do. So that's where we come from.

Dr. Laura Roberts (14:18):

So it really sounds like it's transformational for the therapist as well as for, one would hope, for the client or the patient. Yeah, that's great. Okay, so it sounds like this is definitely filling a need that is out there. And there are so many hundreds and hundreds of thousands of people who are in incarcerated settings or have been recently released and are trying to adapt into a way of life that is good for them. There's so many people that this could potentially help, I guess is what I'm trying to say. Very inspiring. What was the best thing about putting the book together and what was the hardest thing about putting the book together? Tell us about the project itself.

Peter Novalis (15:05):

Well, the two things I think, I tend to read this in the prefaces of a lot of the books that are coming out now and everyone seems to be saying the same thing. It was Covid affected everything that was written over the last two and a half years starting from March 2020. And I see that in the prefaces of a lot of books, even fictional books, where people say, "Thanks for helping me to work at home," and the like. So the most limiting factor was Covid. It resulted in a change for me in that I spent more time doing telemedicine and working at home because of the risks in the institution. It also created a lot of anxiety and problems in our patients who were extremely worried about the sanitary conditions in their institution and of catching Covid, and on the outside were worried about their families and needing closer contact with their families, needing to know what was happening to family members who were ill and in the hospital and kind of worrying about them moment to moment.

Dr. Laura Roberts (16:28):

So it affected our patients and it also affected the care in the institutions and the policies in the institutions, which created a lot of stress. Just the policies of locking people down and doing social distancing within a correctional institution. So Covid had a major effect. The other thing that as you know happened in the spring of 2022, were new developments in social justice in the United States, starting with the death of George Floyd in Minneapolis. And a much greater awareness of social justice for people involved in the criminal justice system as George Floyd had been in his past, and attention to his treatment and the way people with criminal justice involvement are treated.

Dr. Laura Roberts (17:27):

It gave us a chance to write more about that in the book from the very start about what it's like to be incarcerated and the differential in the way people of color are incarcerated at a much higher rate than other people and we address that throughout the book as well. So those were two things, Covid and social justice, to summarize, were the two things that made it both more interesting and more of a challenge to address in the book.

Dr. Laura Roberts (18:02):

Yeah, the book is a big book. When it came in... wow.

Carol Novalis (18:06):

We had to cut it.

Peter Novalis (18:09):

They cut it down too. I had written more and they said, "Enough is enough." But you know how it's hard for writers to cut down their books. I think you remember, what was that, Tom Clancy and the Hunt for Red October and all that. Tom Clancy, he's passed now, but he wrote a lot of books and at the end all his books were thousand page books. He said his editors just let him go. People loved it. He wouldn't cut down a word and they were afraid to touch anything he had written.

Carol Novalis (18:45):

But ours wouldn't.

Peter Novalis (18:47):

Yeah, but our editor did have us cut it down. Well, right, I don't think it's something anymore that anybody would necessarily read cover to cover. The first few chapters are about techniques. Again, focusing on supportive psychotherapy and how it differs from other therapies and also the evidence and research basis for it. And then, if I may put in a mention of our previous book the Clinical Manual Support of Psychotherapy, then it kind of breaks out into disease related chapters so that there's a chapter on serious mental illness and mood disorders and substance use. And so it's the kind of thing you can read as you need to, when you come up with a person with a specific problem. Or at your leisure pick a chapter about one of the diseases that you're more interested in at that time and just read that one chapter.

Dr. Laura Roberts (19:46):

Finally, it kind of goes through a natural progression and the last chapter not only of the book but programmatically for people is about going home and how to deal with the transition outside of communities, and what they now call a warm handoff. Meaning, trying to actually meet with the counselors and case workers who are going to see your patient after they leave. And that's getting to be, not only is it better, but it's now getting to be more and more practiced in correctional institutions.

Dr. Laura Roberts (20:18):

Yeah, it's a beautifully structured book. And the comment I was going to make about the length is, you can tell it's very engagingly written. It's very, very nicely written. And I agree it's a wonderful resource that people could pick up and just tap into a particular chapter related to the patients that they're caring for. But also I think people could just sit down and read it straight through as I did. I think it's really engagingly written. It's a wonderful resource. And my feeling as I went through it was that as you built the book, it was rich, it was a very rich kind of treatment of the topic. So anyways, I thought it was a fantastic book and I hope our listeners will find it and take a look at it and use it in their work.

Peter Novalis (21:05):

I hope so too. As you've said, I think it's fulfills a niche. It's not just one more of anything. It is the first book really for therapists who are at a somewhat higher level of education and background than just correctional counselors. But the correctional counselors can certainly get a lot out of it too. They do have some other resources in their field that they can tackle, but the psychotherapists from mid-level and above really don't, not until now, because I think it will fulfill a use for them. Way back when I did the first edition of our Clinical Manual of Supportive Psychotherapy, I was a believer that psychiatrists do psychotherapy. And I'm certainly glad that APA Press, APA Publications, has agreed that this is a book for psychiatrists. Not just psychiatrists who do the kind of psychotherapy that's associated with medication, but psychiatrists who really do psychotherapy sessions with people with or without medicine. I'm still a believer that psychiatrists do psychotherapy and that shouldn't be just the realm of everybody else.

Dr. Laura Roberts (22:27):

I totally agree. And definitely APA Publishing is supportive of that whole approach. I also think in practical terms, it's so fulfilling in the ways that we've been talking about it, it's so fulfilling. It helps people have these long, very rich careers in our field if they're doing it, at the very least a balance, if not a great deal of psychotherapy in their practice. Thank you very much. I hope our next conversation is about your next book that you're going to do with APA Publishing.

Peter Novalis (23:00):

I do have a plan, but I guess I'll save that up and write a formal proposal about it, but I do have something in mind.

Dr. Laura Roberts (23:08):

Great. Stay tuned. Thank you so much for taking a break from your conference to join us. It's wonderful to talk with you.

Iain Martin (23:27):

Psychiatry Unbound is hosted by Dr. Laura Roberts and produced by Ian Martin. Our original music is by Willow Roberts and our executive producer is Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing. Be sure to visit psychiatryonline.org/podcast to join the conversation, access show notes and a transcript, and discover new content. Or subscribe to us on your favorite podcast platform. Thank you for listening.