Front Matter

Peter N. Novalis, M.D., Ph.D., is a psychiatrist in Las Vegas, Nevada. He has more than 30 years of clinical experience, most of it in public psychiatric institutions, including state and federal psychiatric hospitals and correctional facilities. Early in his career he developed an interest in supportive psychotherapy and was the primary author of the first major textbook on the subject, Clinical Manual of Supportive Psychotherapy. Recognizing a need for the application of supportive psychotherapy in correctional facilities, he has developed the current project along with his coauthors.

Virginia Singer, D.N.P., is a nurse practitioner, board certified in psychiatric mental health and addictions. She has more than 25 years of experience in mental health and has worked in jails, state prisons, inpatient psychiatric hospitals, and inpatient and outpatient drug and alcohol treatment centers.

Carol M. Novalis, M.A., is an adult educator and researcher with 30 years of experience in both private and public institutions. She has a special interest in improving the education of socially disadvantaged adults.

2020 and the years that followed were difficult ones, and it seems like we’re still counting. The world had to deal with a biological injustice called COVID-19, and at the same time in the United States there broke into flames some issues of social injustice that had been smoldering for hundreds of years. Ironically, scientists encouraged the public to aim for “herd immunity” to the virus, while legal scholars urged the abolition of “qualified immunity” for police officers. Attention was called to the unequal treatments of minority groups and increased harassment of persons of color, women, Asian American–Pacific Islanders, LGBTQ individuals, immigrants, the poor, the disabled, and others as well. There was moderate success in addressing the biological injustice of the disease (which itself was inflicted disproportionately on certain groups such as elderly, Hispanic, and Black persons and economically disempowered groups such as immigrants and women) and its social and economic effects. There was perhaps partial success followed by ongoing efforts to deal with the multiple social injustices especially in American society.

These issues may not seem germane to psychotherapy in prisons and jails, but they are perhaps central to it. Social consciousness of the problems created by confining people has increased and become more important to policy-making. The term “carceral” is increasingly used to emphasize the fact that persons are held against their will within walls and that the term “criminal justice system” is self-contradictory in its meaning. The specter of COVID-19 caused fear, infection, and death within prisons over and above the usual numbers. It drew attention to the existing injustices throughout the American criminal justice system, not just the carceral component and the predominantly American propensity to arrest and lock people up. And persons with enlightened social consciousness were called “woke,” a term (and its variants) that actually goes back to the antebellum era and its use by antislavery proponents.

In January 2021, the American Psychiatric Association apologized for its institutional history of racism and devoted its May annual meeting to (among many) issues of properly diagnosing Black persons and recruiting Blacks to a profession where they have been conspicuously absent (Warner 2021). It is also of note that historical racism includes the attributions of mental illness, violence, and criminality to minority groups. This apology did not exactly come on the heels of the one made by the American Medical Association (Associated Press 2008). However, there had been a history of efforts to address the racial disparities and injustices, including the attention drawn to the issue by APA’s first Black president, Altha Stewart (Richmond 2018).

Cultural sensitivity is not a new concept in psychotherapy, although the upheaval in social consciousness of these years drew attention to the need for sensitivity in working with persons of diverse cultures in the criminal justice system. But even cultural sensitivity can be a double-edged sword. As therapists are exhorted to eschew damaging stereotypes, such as reading emotion as anger in Black men, they can also risk losing their sensitivity to knowing their patients completely as individuals (e.g., approaching a Latino man with the expectation that he will have only macho attitudes rather than getting to know him as a unique person).

In this really challenging year—or two, or three—we have tried to be cognizant enough of the above-mentioned issues to write usefully about psychotherapy that, in the circumstances we practice, is highly focused on treating the poor, minorities, and traditionally disadvantaged persons. There is still a tremendous variability in criminological theories, some of which might well attribute all criminal behavior to social injustice, and theorists who think that the American system should become completely “uncarceral” (i.e., prison-free). Your personal attitudes toward these issues will definitely affect your style and the content of therapy, but we hope we have produced a book that works for most people who are willing to deal with the stresses and challenges of doing psychotherapy in prison and jails.

While this book is not overtly political, we are concerned primarily with the individuals we treat. We are informed by and hope we reflect the need to “do right” by our patients in the light of the problems that are present in, and in many cases caused by, the system itself. In addition to the cultural issues that reflect various ethnic, class, gender, and physical subgroups of the prison population, we also need to address the culture of the prison, the staff and justice system that underlie the circumstances of our patients, the criminal backgrounds of the group as well as of the persons we are treating, and the circumstances of their interactions with the system. Understanding our patients’ experience within this system may start with recognizing their distrust of us and of anything to do with their current situation and anyone who has not been in that situation, not just people who work for the system.

The humanity of the person we treat must always be the first consideration. Our patients are not defined as people sentenced to incarceration: what they did to get into prison is not the only measure of who they are. In reading such works as The New Jim Crow (Alexander 2020), Caste (Wilkerson 2020), or Social (In)justice and Mental Health (Shim and Vinson 2021), one learns how policy, assumptions, and history have led to injustice and suffering. One need only look at the rates of incarceration, arrests, and even killings by police of unarmed persons of color to see the effects of slavery, persistence of poverty, and bigotry and to get an indication of the pervasive nature of social injustice. Robert T. Carter and his colleagues have identified and defined race-based trauma as a factor in the emotional well-being of oppressed people, especially African Americans, exacerbating social adjustment and mental health issues in oppressed populations (Levine 2020). While we can only do so much in our individual roles within this system, understanding the history and its current consequences can help us understand the individuals we treat. As El-Amin and Sufrin (2020) comment, this is hard work and everyone, including staff and patients, may be affected by racism in prison environments. To the extent that this engenders outrage and, perhaps, fear response, it affects therapy and therapeutic alliances in complex ways. We must individually commit to speak up, and not be bystanders but upstanders (p. 14). There is something to be said about an advocacy role as discussed further in Chapter 1.

Correctional institutions may lack funding, but they have a wealth of data and research about themselves. Throughout the United States, legislators at all levels are intensely interested in issues such as trauma, drugs, suicide, and opportunities for education and rehabilitation within jails and prisons. Most research has as its goal the reduction of recidivism, the rate at which released prisoners return in 1, 3, 5, or 7 or more years. We have had to set our own “funding” limits on what we could cover in one volume, and our emphasis is on treating individuals.

This book is about doing psychotherapy, in particular a type of psychotherapy known as supportive psychotherapy, in correctional institutions. We have limited the scope to individual psychotherapy with adults. Mostly, we concentrate on psychotherapy with individuals who are involuntarily confined, although there is nothing terribly different when doing psychotherapy with those who are not incarcerated. However, one issue that is uniquely relevant to working with confined populations is what can be said to them to prevent them from coming back after they are released.

Stepping into a jail or prison might be likened to entering an alien space vessel. The denizens dress oddly and speak a strange lingo. It is a challenge to learn the customs by which they behave, and you are certainly concerned that you will not fit in or belong, or perhaps stir up some hostility you did not intend to create. In science fiction terms, such a meeting is called a Close Encounter of the Fourth Kind. Although it is used to describe the experience of entering an alien spaceship, it is typically invoked when someone has abducted and experimented upon you. Such might be your impression when you enter a prison for the first time, thinking you are the subject and they are working their experiments upon you. And you would be right.

Is there any kind of travel book or Fodor’s guide that can ameliorate this culture shock of entering a place that is so alien to normal society? Mark Twain’s Innocents Abroad is highly critical of the travelogues that have gone before him, as noted in the Wikipedia entry for the book: “If all the poetry and nonsense that have been discharged upon the fountains and the bland scenery of this region were collected in a book, it would make a most valuable volume to burn” (Wikipedia 2020b).¹ Books about prisons and prisoners do run the range from poetry to nonsense, and if put together they would make quite a pile to burn. (Ironically, some of Mark Twain’s own books, such as Huckleberry Finn, were banned, and probably some were also burned.) Where do you find the truth? How much do you have to read? How many years do you need to work?

Is what matters here “the truth” or “the truth, the whole truth, and nothing but the truth”? Popular mystery writer (and Amazon Prime executive producer) Michael Connelly writes of his protagonist detective Harry Bosch that there are two kinds of truth. One is an immutable kind upon which you can base your whole life mission, but the other is malleable and belongs to such folks as corrupt lawyers and politicians because it can be molded to any purpose (Connelly 2017, p. 132). We mention this because we think the field of corrections abounds with these two kinds of truth, and it takes a lot of digging, and sometimes a modicum of courage, to distinguish the two and be willing to work for the truth. Which truth is it that you believe about prisons and prisoners? And FYI, there may be two kinds of truth, but Harry Bosch says there are NO coincidences (TV Tropes 2021)!

Psychotherapy is done by psychologists; social workers; physicians, including psychiatrists; psychiatric nurse practitioners; and physician assistants. Licensed nurses, including registered nurses and licensed vocational or practical nurses, are involved in counseling inmates. There is also a group of correctional counselors for whom there are specialized textbooks. We have greatly benefited from reviewing the knowledge base in that area, and we do hope this book will be of value to most people who counsel inmates, provided that they do not undertake anything that is beyond the scope of their licensure. Prisons are also able to cost-effectively use trained personnel for therapy who might not have licenses in the outside world. (For an example, see the use of master’s-level therapists for the psychotherapy of depression in Chapter 9.)

Our experience in these areas has been in state and federal men’s and women’s jails, prisons, forensic units, and mental health units. We have also had years of experience in private hospital and office practices, so we know the differences in standards and practice between these worlds. The experts, of course, say that the standards and practices should be the same, but the world has not caught up with that ideal.

Occasionally, we have put in brief case vignettes. Unlike the lengthy and detailed studies of individuals you might find in some texts, we like short stories that make a point, although we based these vignettes on our actual experiences or those of our colleagues, with the usual alterations to avoid HIPAA concerns.

We have tried to reference many of the things that we consider important, interesting, or both. But this is not a scholarly book, which would have hundreds or even a thousand more references. However, you can easily find “everything else.” It just requires judicious use of the prefix “www” and in our country the suffix “.gov.” As you can see from the individual bibliographical entries, many can be found, read, and printed for free.

Here is the arrangement we thought best. Part I is an introduction to psychotherapy in corrections and supportive techniques. In Chapter 1 we introduce the subject and talk about the relationship of supportive psychotherapy and corrections. Chapter 2 is a minihandbook of supportive therapy techniques. Chapter 3 carries the knowledge base into the prison itself, dealing with issues that affect new or returning prisoners. Finally, we expand on the issues of managing therapy in Chapter 4. Part II addresses core issues in helping prisoners: self-harm and suicidal behavior in Chapter 5, trauma in Chapter 6, and substance use in Chapter 7. Part III covers key disorders encountered in corrections, including serious mental illness, or SMI (Chapter 8), and mood disorders (Chapter 9). Then, in Chapter 10, we cover personality disorders, including psychopathy, addressing related issues of violence and anger. Part IV addresses important considerations that will be relevant to many readers. We discuss women in prison in Chapter 11. Chapter 12 is about behaviors and problems that tend to disrupt or impair good care, such as hunger strikes and malingering. Chapter 13 covers a variety of special topics, such as cultural issues, that could probably fill a bookshelf each if they were covered in depth but can here only be touched on. Chapter 14 covers the issues about going home and reducing the recidivism we mentioned above. Then there are a few concluding remarks.

Out there are also many books ranging from the textbooks you might have used in your course work and scholarly treatises to individual memoirs, often poignant or heartbreaking. We hope to impress upon our readers that there is more to a person than their crime, and to try to humanize the subject and our patients as much as possible. There are many persons caught up in criminal justice systems from whom we have learned much—of what it is to be an imperfect, fallible, or just unfortunate human being born in the wrong place or the wrong time in the wrong family, dominated by a different culture or caught up in circumstances beyond their control. Yet, there are those who are somewhat beyond the reach of well-meaning helpers. Good or evil, or the usual mixture of both—we have learned a little or a lot from each of our patients. Likewise, we hope that here you will learn through us from them.²

We try to vary pronouns for males and females except when the context makes it desirable to refer to one rather than the other. We have decided to usually use “Black” and “white” and similar terms, but sometimes we will use “African American,” usually to reflect the preference of a source being discussed. (The designation “Black” is now capitalized, reflecting the change in the editorial practices of the major news organizations in the summer of 2020.) We strive to use correctly the terms “Hispanic” and “Latino,” which are not synonymous. Some writers are now using the term “Latinx” to avoid the gendered terms “Latino” and “Latina,” but that has not become general usage, so we have continued to use the present terminology.

But let’s consider who is the person being treated. Is he or she a client, patient, resident, inmate, criminal, prisoner, detainee, incarceree (a newer term that was originally used to refer to those in Japanese interment camps during World War II), or offender? The term client does not seem right because of the involuntary settings, but for anyone receiving direct treatment it seems appropriate to use the term patient. Many persons in jails or prisons have not have actually broken any law if they are in a pretrial setting or innocent of the crimes of which they are accused. Detainee does appropriately apply to many persons awaiting trial or in immigrant detention centers. During the preparation and publication of this book, there has been a concern among advocates of better care to eliminate what is felt to be dehumanizing language regarding persons who have been incarcerated. This includes the elimination of the terms prisoner and inmate in lieu of person-first descriptions such as an “incarcerated person” or a “person with a substance use disorder” (National Commission on Correctional Health Care 2021). We recognize the importance of person-centered terminology, but as a descriptive rule it is not yet seen in recent publications, in the media such as The New York Times, or among the professionals with whom we work. We have adopted the practice of the advocacy group The Marshall Project of continuing to use the word prisoner but attempting to eliminate the term inmate (Solomon 2021); the latter may be still found in articles and books (e.g., Batastini et al. 2020) and in references to the research using such terms. We shall also comment on the use of the term criminal in a later chapter.

We also have made a concerted effort to avoid objectifying diseases, so, therefore, we do not call a person who has schizophrenia a “schizophrenic” or a person who has borderline personality disorder a “borderline.” Some practices, such as not applying diagnoses to women because traditional oppression has created their symptoms, are worth understanding, but we have considered them “a bridge too far” for this work. At the end of our introduction above, however, we did refer to a “psychopath.” In that case, our justification is that psychopathy is not a mental illness.

The Substance Abuse and Mental Health Services Administration of the U.S. National Institutes of Health is usually referred to as “SAMHSA.”

There are two major diagnostic resources. One is the International Classification of Diseases, Tenth Revision, which is referenced worldwide in multiple versions (www.cdc.gov/nchs/icd/icd10.htm). This will be referred to as ICD-10. Some authors are making references to ICD-11, and there are some diagnostic differences that will affect researchers, but we will continue with ICD-10 until it has been effectively replaced.

Our most used diagnostic reference manual is, of course, usually called “DSM-5,” which refers to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (Arlington, VA, American Psychiatric Association, 2013). A text revision, DSM-5-TR, was published in March 2022 and is also discussed where relevant. There are also a few other revisions and text revision editions, but we do not refer to them in a substantial way in this book. A list of the editions we refer to is as follows: