What Are the Psychotherapy Needs of Incarcerated Individuals?

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It goes without saying that incarcerated individuals need and deserve to have the full range of services that would be available to them in the community. The therapeutic methods used should depend on the treatment plan developed to match the needs of the individual receiving the psychotherapy with the resources available, including the skills of the therapist. For example, the therapist may rely less on psychoanalytic methods, which require commitments of time and education that cannot be met by the typical person in an institution.

However, one should avoid imagining that there is a “typical” incarcerated person. Some people have a long history of crime and may be likely to commit crimes upon release. These individuals need to reshape their criminal thinking styles via a confrontation of people, including their peers, that is often best done in group formats. In fact, many of the mental health needs of incarcerated individuals are best met in a combination of group therapies for certain topics (such as criminal thinking or intimate partner abuse) coupled with individual therapy for issues that cannot or should not be aired in groups.

The time frame for therapy may be strongly dependent on the individual’s sentence, since much psychotherapy is given in pre-sentence settings to persons with unknown stays due to the uncertain outcomes of the legal process. Therefore, it helps to be prepared to use brief psychotherapy strategies when the time frame is not firmly established.

Entry or re-entry into a jail or prison is often a crisis and engenders what has been called disenfranchised grief, that is, the loss of the many things (income, housing, family relationships, self-esteem) that is not typically acknowledged in our society. Elements of crisis and grief therapy are therefore important. In addition, the leading complaints of newly admitted persons are anxiety and insomnia, but many medical directors are reluctant to allow medication treatment; this leaves open the use of therapies such as progressive relaxation, guided imagery, and CBT-I (cognitive-behavioral therapy for insomnia), which can be learned effectively in as little as a single 90-minute session.

Since most incarcerated individuals are eventually released, preparing them for transitioning back to the community should be routine, just as discharge planning starts at the time of admission to an acute care psychiatric unit. Assessing for suicidality and addressing suicidal and self-harming behaviors (even those that may occur after release) are standard fare and take a lot of interdepartmental coordination.

A number of studies address the effectiveness of therapies for people in correctional settings; see the study by Isabel A. Yoon, M. Sc., et al., noted at the end of this article. The evidence basis that supports many forms of psychotherapy is called the common factors theory and is sometimes linked to a famous expression from Alice’s Adventures in Wonderland that “Everybody has won, and all must have prizes.” For more about this, see the study by Bruce E. Wampold, Ph.D., et al., also noted at the end of this article. But even if most psychotherapies are winners, not all get the first prize. I believe that the type of psychotherapy best suited for people in crisis who have uncertain time schedules, limited education and coping skills, and minimal trust in their therapists is supportive psychotherapy—a form of psychotherapy that is unfortunately often devalued in the community in comparison with its more psychodynamic neighbors. Supportive psychotherapy has traditionally placed emphasis on educational and informational processes, even if the use of education seems to evoke the notion of cognitive therapies. With its emphasis on the development of a trusting relationship with a therapist, the core techniques of supportive psychotherapy are also what I would liken to the stem of a flower, which nurtures its petals. These core techniques can be combined with more specialized techniques that are tailored to the skills of the therapist and the needs of the individual.

For example, it is possible to engage in confrontations of an individual’s criminal behavior by combining them with underlying supportive psychotherapy techniques. The therapist’s ability to provide support to individuals with personality disorders also tends to counter a tendency to engage in therapeutic nihilism, that is, the belief that nothing is available to help such individuals. Whichever specialized methods are used, there is a common core of alliance building and other techniques (for example, dealing with the oppositional behaviors often called “resistance”) that are fundamental to working with incarcerated persons.

Pause for a moment to reflect upon the last two words of the preceding paragraph. Attention to the reasons individuals become incarcerated has led many groups including APA to examine the effects of social injustice in creating mental health issues and in placing individuals in jails and prisons. Social inequality, social injustice, the predominant cash bail system, and an emphasis on incarcerating persons who commit misdemeanors, in addition to systemic racism, result in a vast overrepresentation of Black and Hispanic persons in jails and prisons and create a concomitant awareness on their part that they have been treated unjustly. The last word of the previous paragraph, “persons,” also draws attention to the need for person-oriented terminology when discussing persons in jails and prisons.

Many advocacy groups have been purging their vocabulary of objectifying nouns such as “felon,” “convict,” and “prisoner” in lieu of terms such as “incarcerated person,” similar to the avoidance of objectifying nouns such as “a schizophrenic” or “a borderline.” Consistent with some advocacy groups, I have continued to use the term “prisoner” in recent writing, but I will reconsider that in the future.

When doing psychotherapy with incarcerated persons, I recommend that you do the following:

• Become familiar with techniques for crisis, trauma, and grief management and address initial adjustment problems such as insomnia.

• Learn and use the techniques of supportive psychotherapy as your basic repertoire. Assess for suicidality and view the treatment of self-harming behaviors as a new challenge every time they occur.

• Try to see each person you treat as an individual and avoid unsupported generalizations. Find out why a person has committed a crime and consider what type of approach will address future behaviors including interpersonal violence.

• Understand that for many incarcerated individuals, social injustice has affected their placement in a correctional institution and their experience of mental illness. In conjunction with this, consider that some individuals may be labeled as having mental illness due to the effects of social injustice (a fact that is known to be true historically).

• Learn basic criminology and examine your own attitudes toward criminal behavior and even the more general concepts of good and evil (see The Anatomy of Evil by Michael H. Stone, M.D.)

• Examine your countertransference to your patients, but don’t confuse sympathy (which you may find unlikely) with empathy (which you should never lose). ■

Peter N. Novalis, M.D., Ph.D., has more than 30 years’ experience treating people with serious mental illness, mostly in the public sector. He has primarily been a clinician with a long-term interest in supportive psychotherapy. He is the lead author of Psychotherapy in Corrections: A Supportive Approach from APA Publishing. APA members may purchase the book at a discount