Occupational Therapist Role
"Reintegrating prisoners back into the community - do occupational therapists play an important role within forensic settings?"
Forensic psychiatry is a sector of mental health that manages the assessment, treatment, containment and community management of mentally disordered offenders (Couldrick, 2003). Forensic services primarily aim to reintegrate patients back into the community accompanied by a risk and treatment plan (Cronin-Davis, Lang, & Molineux, 2004). Offenders receiving psychiatric treatment in the criminal justice system are frequently referred to as forensic patients, which is a term that is used throughout this critical analysis (O’Connell & Farnworth, 2007).
The defining role of an occupational therapist is to engage …show more content…
and enable patients to participate in meaningful occupations. Occupational therapist’s use the word occupation to encompass everything people do to occupy their time, across the domains of self-care, productivity and leisure (Christiansen & Townsend, 2010). To combine forensic psychiatry and occupational therapy, the roles of the occupational therapist aim to empower patients to take responsibility, address patients’ loss of autonomy and establish meaningful daily routines that match an individual’s volition (Cronin-Davis, et al. 2004).
Occupational therapy in forensic psychiatry in Australia began in 1978 and is a clinical specialty that is developing rapidly (Farnworth, et al. 1987, as cited in Farnworth, Nikitin & Fossey, 2004). Forensic occupational therapy engages patients and facilitates their participation in meaningful daily activities whilst assisting in the development of their increased personal capacity and pro-social values, identity and skills (Duncan, 2008). According to Duncan (2008), forensic occupational therapists work in a variety of settings including regional secure units, low secure units and hospitals.
Within occupational therapy, meaningful, productive, freely chosen occupations are a medium through which people maintain their physical, social and mental health. In secure settings, a person’s capacity to freely choose how, when, and in which occupations they will engage in is restricted (Farnworth & Munoz, 2009). Consequently the question arises: Do Occupational therapists hold a meaningful, important role within forensic settings?
Occupational Performance Issues Experienced by Forensic Patients
There is considerable evidence of the risk factors that influence the behavior of offending forensic patients. The Social Exclusion Unit (2002) has identified nine key factors which include: lack of education and employment; drug and alcohol misuse; poor mental and physical health; destructive attitudes and no self-control; undeveloped life-skills; lack of housing; financial support and debt; and poor family/social networks. The onset of most of these risk factors commonly occur during late adolescent or young adulthood, with a resulting interruption to secondary and tertiary education. This interruption can impair the development of essential social skills, such as problem solving, time management, motivation and the use of initiative, which can significantly affect an individual’s ability to engage in healthy productivity (Fitzgerald, 2011).
Within forensic settings, patients often experience occupational deprivation; a state in which an individual is unable to do what is necessary and meaningful in his or her life (Whiteford, 2000). Forensic patients are vulnerable to occupational deprivation as they can be contained indefinitely for an extended period, and they are in a social and physical environment, which is under constant surveillance, creating a restricted or repetitive choice of occupations which may lack meaning (Farnworth et al. 2004). Whiteford (2000), drawing upon results from her completion of an occupational needs assessment in a high security Australian prison, argued that occupational deprivation was a significant barrier to community reintegration. Whiteford (2000) suggests that patients became so estranged from occupational roles of community life, and the need to structure their time to meet challenges of community participation, that the likelihood of successful community reintegration is significantly diminished.
Occupational imbalance is a lack of balance or disproportion of occupation resulting in decreased well-being (Wilcock, 2006, as cited in Farnworth & Munoz, 2009). How people spend their time is one way to examine occupational imbalance, and time use may also provide an indicator of quality of life. Farnworth et al. (2004) explored time use of a group of hospital based forensic patients. Personal care and leisure occupations were dominant where 89% of personal care was spent sleeping and 78% of time reported in recreation involved passive leisure activities such as watching television. Participants were dissatisfied with their time use, describing themselves as “killing time”, “inactive” and “bored”. Daily routines filled with meaningless occupations can have detrimental effect on an individual’s health including physical deterioration, demoralization, breakdown of habits, and loss of abilities (Kielfhofner, 1977, cited in Farnworth et al. 2004).
According to Eggers, Munoz, Sciullli & Crist (2006) majority of offenders released from correctional settings in any given year will be re-incarcerated within three years. This is due to the lack of necessary skills needed to successfully reintegrate into the community. In addition, Eggers et al. (2006) reports that offenders often leave prison and revert to occupational patterns that promote reoffending for example, using illegal substances, engaging in problematic activities and committing parole violations. Occupational therapist have the skills required to rehabilitate offenders by introducing core life skills and reducing the effects of occupational deprivation and imbalance by providing opportunities for forensic patients to engage in occupations that support both in and outside forensic services (Eggers et al. 2006)
Occupational Therapy Interventions Commonly used within Forensic Settings
In a report written by Social Exclusion Unit (2002) looking at the issues of re-offending by ex-prisoners, the authors propose that custodial sentences should be reformed to promote successful community reintegration and reduce re-offending. There is a role to be forged by forensic occupational therapists in helping achieve this change (Couldrick, 2003). Occupational therapy, because of its key role in coordinating, implementing and evaluating activity, is well placed to support social inclusion in forensic settings and advocate for change at an upstream level (Fitzgerald, 2011).
Forensic patients often lack skills in forward planning, abstract thinking, problem solving and have poor attention, concentration and memory (Gilmour & Edment, 2001). Within forensic settings, therapeutic rehabilitation helps patients expand on these skills to assist in the re-integration process. Occupational therapists run groups and programs with forensic patients such as community living skills and social skill training programs. Community living skills programs focus on skill acquisition and practice a range of activities of daily living deemed necessary for community survival, such as personal care, meal preparation, nutrition, budgeting, shopping and use of public transport (Fossey et al. 2007). Social skills training programs include tools such as role-play and homework tasks to facilitate development (Fossey et al. 2007). Both these programs are pivotal for patients to develop essential daily living skills that will support their community reintegration post release.
Having a productive occupation is seen as fundamental to an individual’s health and wellbeing and gaining and maintaining work is a highly valued goal for many people with a mental illness (Kennedy-Jones, Cooper & Fossey, 2005). However, when reentering the community, forensic patients trying to acquire employment face a number of barriers, due to limited work readiness skills, poor daily living skills such as time and illness management and stigma associated with being an ex-offender (Tschopp, Perkins, Hart-Katuin, Born & Holt, 2007). It is therefore necessary that occupational therapists provide meaningful productive occupational opportunities for individuals while they are in secure settings, and equip individuals with the skills necessary to continue with these roles once they are reintegrated back into society (Dunn & Seymour, 2008). This process is commonly known as ‘vocational rehabilitation’, which involves providing individuals with opportunity opportunities to further develop the skills and knowledge necessary for them to engage in productive occupations such as work. Intervention strategies include constructing a CV, practicing interviewing skills, developing effective time management skills and establishing daily routines (Kennedy-Jones et al. 2005).
Other intervention strategies occupational therapists offer is in-vivo training through the use of structured leaves into the community (Law, Baum & Dunn, 2006, as cited in Farnworth & Munoz, 2009). Leave is a process run in most forensic psychiatric hospitals in Australia. Forensic patient leave aims to assist the rehabilitation process and provide a gradual progression towards a return to community living that is consistent with the needs of the individual and community safety (Department of Health, 2012). Leave will typically begin with outings to medical appointments, the local park, café and strip shops where patients aim to achieve the goals of learning basic community skills (managing finances, using ATMs and purchasing items), social communication and responding to stressors, and normalization of family dynamics (Department of Health, 2012).
Occupational therapists hold the key to helping people re-engage in occupations that gives their lives meaning and value. Through developing essential life skills, occupational therapists help reconnect forensic patients to their society and culture in which they live in which not only promotes health; but may also mitigate alienation and antisocial behavior and decrease the chance of patients reoffending (Couldrick, 2003).
Challenges to Occupational Therapy Interventions in Forensic Settings
The provision of rehabilitation within secure environments over often-lengthy sentences, for optimal community reintegration on release is a challenge (Lindqvist & Skipworth, 2000, as cited in Farnworth et al. 2004). The combination of being disconnected from social groups upon incarceration, and being placed in groups where the opportunities for roles and activities are severely restricted, can have a profound effect on competence for everyday life. Whiteford (1997, as cited in Farnworth & Munoz, 2009) suggested that prolonged lack of meaningful and purposeful opportunities to work, education, skill acquisition and social interaction in secure environments could result in forensic patients becoming so estranged from their roles of community life that they lose the capacity to structure their time to meet day to day challenges. However, within secure settings, legal restrictions often prevent the opportunity to engage in meaningful programs which significantly limits the opportunities occupational therapists have to intervene and successfully develop habits and routines in pro-social, positive activities (Farnworth & Munoz, 2009).
Occupational therapy in forensic settings is a rapidly developing area of practice, yet the current evidence to support forensic rehabilitation programs and forensic occupational therapy needs is sparse and requires strengthening (Duncan, Munro & Nicol, 2003). Although there has been a call for further research, few authors have added to the evidence base. Duncan et al. (2003) conducted a study exploring the research priorities in forensic occupational therapy using a questionnaire survey. Three specific research priorities were clearly defined: the development of appropriate outcome measures, the development of rigorous and effective group programs and the development of effective risk assessment tools. These prioritised research areas identify a distinct lacking in current evidence and opens up the doors for the much needed future research to occur.
Author’s perspective
Implication for general occupational therapy practice and the profession
As discussed above, currently there is still debate on how security and therapy can reconcile. McMurran, Khalifa & Gibbon (2009) purport that security still appears to be prioritised over therapy. As a current occupational therapy student soon to be embarking on my own career path, I find this debate to be both interesting but very difficult to accept.
As outlined above, it is evident that the reason for the patient being in hospital is not to serve time but to be rehabilitated (Carroll et al.
2004). As the number of incarcerated persons with serious psychiatric disabilities continues to increase, concepts such as occupational deprivation and occupational imbalance provide useful conceptual frameworks to understand the negative impact incarceration has on the performance patterns of habits, routines and roles required for community living. I believe that such concepts dictate the need for occupational therapists to be involved and frame interventions aimed at maintaining and developing daily living skills and roles that will support community reintegration post release. Yet in reality, there still lacks concrete belief that occupational therapy is not only useful but also vital to forensic …show more content…
rehabilitation.
Since June 2012, I have been completing my OCC4071 PCP project at high secure psychiatric facility, Thomas Embling Hospital. My project aims to increase patients’ participation in meaningful occupations through developing employment opportunities patients can apply for and extending the current vocational programs offered within the hospital. Throughout my time I have worked alongside occupational therapists and patients who have all supported this project, as they feel it will help patients develop the necessary skills that will assist with community reintegration. When speaking one on one with a patient at Thomas Embling Hospital about the developing job opportunities, she stated, “the project will be life changing, it could give me a purpose and a reason to wake up in the morning”.
Research strategies that analyse both patient and system factors, which interact to affect rehabilitation outcomes, are needed to establish evidence-based practices in this area (Farnworth et al. 2004). Research is needed in future to focus on which rehabilitation practices are correlated with establishing positive outcomes after release.
According to Farnworth and Munoz (2009) there is a priority for research to include validation of tools to assess outcomes of occupations, that are sensitive to change, and predictive of successful community functioning, to establish the effectiveness of occupational therapy rehabilitation interventions. I urge occupational therapists working in this field to focus on establishing current literature that critically and validly determines the effect occupational therapy practice has on specific areas of occupational performance pre and post release. As a result, occupational therapy practice within the forensic setting will stand as an evidence-based practice, which I believe will be both respected and required.
Implication for future practice of new graduates
Occupational therapy students and new graduates should be encouraged to enter this area of practice and delve further into the work and research through completion of a masters program, which involves a lengthy research project. New graduates completing further research of an occupational therapists role in forensic settings can assist in building up this area of practice so that it is more solid, developed and respected.
Currently occupational therapists can share ideas and projects on forensic occupational therapy through an e-group on yahoo, http://uk.groups.yahoo.com/group/forensic_occupational_therapy. I have personally used this yahoo group throughout completing my project at Thomas Embling Hospital to ask specific questions regarding my project and when I received responses, I found the information extremely valuable. Using the internet as an information forum is a fantastic way to share information world-wide. In my experience, I received several responses and had further contact via phone calls with an occupational therapist from the UK who provided me with information on a similar project she had implemented within her forensic setting. Nevertheless, information sharing is still limited due to the low number of users. New graduates are often tech-savvy and have completed their studies relying on obtaining information through internet means. I believe new graduates interested in entering this area of practice could contribute significantly to the literature base by actively using and contributing new information in online information sharing centers such as the forum mentioned above. The potential contribution new graduates can offer is infinite.
Conclusion
Although there is limited evidence based literature, from the studies presented above and my own personal belief, it is clear that occupational therapists have the appropriate tools and intervention strategies needed to assist forensic patients in developing the skills and abilities necessary for improving mental health status and successfully reintegrating back into the community once released. There is extremely limited published research on evidence-based occupational therapy interventions used within forensic settings aimed at successful community reintegration of forensic patients. Consequently, investigating occupational therapy interventions aimed at assisting patients for community reintegration within a forensic setting is an important, much needed area of research for occupational therapy.
References
Christiansen, C., & Townsend, E. (2010). An introduction to occupation. In C. Christiansen & E. Townsend (Eds.), Introduction to occupation: The art and science of living (2nd ed.). Upper Saddle River, New Jersey: Pearson.
Couldrick, L. (2003). So what is forensic occupational therapy? In L. Couldrick & D. Alred (Eds.), Forensic occupational therapy. Chichester: Whurr Publishers Ldt.
Cronin-Davis, J., Lang, A., & Molineux, M. (2004). Occupation science: The forensic challenge. In M. Molineux (Ed.), Occupation for occupational therapists. Oxford: Blackwell Publishing.
Department of Health. (2012). Forensic leave panel - annual report 2011. Melbourne.
Duncan, E., Munro, K., Nicol, M. (2003). Research priorities in forensic occupational therapy. British Journal of Occupational Therapy, 66(2), 55-64.
Dunn, C. & Seymour, A. (2008). Forensic psychiatry and vocational rehabilitation: where are we at? British Journal of Occupational Therapy, 67(7), 319-322.
Duncan, E. (2008). Forensic occupational therapy in J. Creek, L. Lougher, & H. Bruggen. (2008). Occupational therapy mental health (4th ed.). Churchill Livingstone: Elsevier.
Eggers, M., Munoz, J. P., Sciulli, J., Crist, P. H. (2006). The community integration project: Occupational therapy at work in a county jail. Occupational Therapy in Health Care, 20(1), 17-37.
Farnworth, L. & Munoz, J. (2009). An occupational and rehabilitation perspective for institutional practice. Psychiatric Rehabilitation Journal, 32(3), 192-198.
Farnworth, L., Nikitin, L., & Fossey, E. (2004). Being in a secure forensic psychiatry unit; every day is the same, killing time or making the most of it. British Journal of Occupational Therapy, 67(10), 1-9.
Fitzgerald, M. (2011). An evaluation of the impact of a social inclusion programme on occupational functioning for forensic service users. British Journal of Occupational Therapy, 74(10), 465-472.
Fossey, E., Grigg, M., Minas, H., Leggatt, M., Macdonald, E., & Meadows, G. (2007). Chapter 15: treatment and rehabilitation skills. In G. Meadows, B. Singh, M. Grigg (Eds.), Mental Health in Australia: collaborative community practice (2nd ed.) (pp. 365-382). Australia: Oxford University Press.
Gilmour, A., & Edment, H. (2001). Supervising the rehabilitated patient in the community. In C. Dale, T. Thompson & P. Wood (Eds.), Forensic mental health: issues in practice. Edinburgh: Bailliere Tindall.
Kennedy-Jones, M., Cooper, J., & Fossey, E. (2005). Developing a worker role: stories of four people with mental illness. Australian Occupational Therapy Journal, 52, 116-126.
O’Connell, M., & Farnworth, L. (2007). Occupational Therapy in Forensic Psychiatry: a review of the literature and call for a united and international response. British Journal of Occupational Therapy, 70(5), 184-191.
Social Exclusion Unit (2002) ‘Reducing Reoffending by ex-Prisoners’. London: Social Exculsion Unit.
Whiteford, G. (2000). Occupational deprivation: Global challenge in the new millennium. The British Journal of Occupational Therapy, 63(5), 200-204.
Appendix 1
AT5 Search Strategy Template
1.1 Initial searchable question
The initial search question was developed based on the concepts of PICO.
Population: Forensic Patients
Intervention/Treatment: Occupational therapy interventions within forensic setting
Comparison: No Comparison
Outcome: Successful Community Reintegration
Search Question: “Do occupational therapy interventions assist forensic patients with successful community reintegration?”
1.2 Data bases Searched
To answer my search question, I used several databases including: OTDBASE, CINAHL Plus, AMED: Allied and complementary medicine, and OT seeker. OTDBASE was very valuable resource for finding relevant articles as it provided a wide range of journal articles specifically related to occupational therapy. In addition, CINAHL being non occupational therapy specific provided a wide variety of useful journal articles on the general aspect of forensic and secure settings and the common barriers patients’ experience.
1.3 Search terms/key words
The key search terms used included using the population and the outcome eg. “Forensic Patients AND Community Reintegration” and using the population and intervention eg. “Forensic Patient AND Occupational Therapy Interventions”.
Key Terms | Alternate key words or phrases | Forensic Patients | Psychiatric patients, Mental Health patients, forensic service users | Forensic Settings | Psychiatric hospital, Forensic psychiatry, secure setting, mental health settings, Forensic facility, Forensic services | Community Reintegration | Community, Society, Community integration, Community reentry | Occupational Therapy Interventions | Programs, Rehabilitation, Psychosocial rehabilitation, Therapeutic Rehabilitation, forensic occupational therapy, Daily living skills training, Occupational therapy groups/programs, social skills training, social inclusion, vocational rehabilitation.
| Occupational performance issues | Occupational imbalance, Occupational deprivation, social exclusion |
1.4 Inclusion/Exclusion
The exclusion for this search strategy was based on publication dates of journal articles, however there was an exception if the journal article was strongly relevant to the search question. Within the 23 identified journal articles relevant to this research topic only one was published 15 years ago or more. Within the 23 identified journal articles 16 were published within the last 10
years.
The inclusion criteria for this search were based on the relevance to the research topic. The studies describing experiences of forensic patients, occupational therapy interventions within forensic settings and community integration of forensic patients were part of inclusion criteria.
1.5 Refined Search Question
When I had commenced researching the databases I was provided with very relevant journal articles and apart from changing key words to expand my search it wasn’t necessary to refine my search question.
“Do occupational therapy interventions assist forensic patients with successful community reintegration?”
1.6 Search History
1.7 Relevant References Identified- type of evidence
Methodology of study Retrieved | References – Author and Year | Practice Guidelines | | Systematic Review/Meta-analyses | | Research based: inc RCTs, Post-test only/Post-test studies, case-control, analytic studies | Fitzgerald, 2011 | Research based: Qualitative including descriptive and individual case studies | Duncan, Munro, Nicol, 2003Eggers, Munoz, Sciullli & Crist, 2006Farnworth, Nikitin, & Fossey, 2004Kennedy-Jones, Cooper, & Fossey, 2005 | Expert opinion including literature review, consensus statements | Department of Health, 2012Dunn & Seymour, 2008Farnworth & Munoz, 2009O’Connell & Farnworth, 2007Whiteford, 2000 | Other | Christiansen & Townsend, 2010Couldrick, 2003Cronin-Davis, Lang, & Molineux, 2004Duncan, 2008Fossey, Grigg, Minas, Leggatt, Macdonald, & Meadows, 2007Gilmour & Edment, 2001Social Exclusion Unit, 2002 |
Forensic psychiatry is a sector of mental health that manages the assessment, treatment, containment and community management of mentally disordered offenders (Couldrick, 2003). Forensic services primarily aim to reintegrate patients back into the community accompanied by a risk and treatment plan (Cronin-Davis, Lang, & Molineux, 2004). Offenders receiving psychiatric treatment in the criminal justice system are frequently referred to as forensic patients, which is a term that is used throughout this critical analysis (O’Connell & Farnworth, 2007).
The defining role of an occupational therapist is to engage …show more content…
and enable patients to participate in meaningful occupations. Occupational therapist’s use the word occupation to encompass everything people do to occupy their time, across the domains of self-care, productivity and leisure (Christiansen & Townsend, 2010). To combine forensic psychiatry and occupational therapy, the roles of the occupational therapist aim to empower patients to take responsibility, address patients’ loss of autonomy and establish meaningful daily routines that match an individual’s volition (Cronin-Davis, et al. 2004).
Occupational therapy in forensic psychiatry in Australia began in 1978 and is a clinical specialty that is developing rapidly (Farnworth, et al. 1987, as cited in Farnworth, Nikitin & Fossey, 2004). Forensic occupational therapy engages patients and facilitates their participation in meaningful daily activities whilst assisting in the development of their increased personal capacity and pro-social values, identity and skills (Duncan, 2008). According to Duncan (2008), forensic occupational therapists work in a variety of settings including regional secure units, low secure units and hospitals.
Within occupational therapy, meaningful, productive, freely chosen occupations are a medium through which people maintain their physical, social and mental health. In secure settings, a person’s capacity to freely choose how, when, and in which occupations they will engage in is restricted (Farnworth & Munoz, 2009). Consequently the question arises: Do Occupational therapists hold a meaningful, important role within forensic settings?
Occupational Performance Issues Experienced by Forensic Patients
There is considerable evidence of the risk factors that influence the behavior of offending forensic patients. The Social Exclusion Unit (2002) has identified nine key factors which include: lack of education and employment; drug and alcohol misuse; poor mental and physical health; destructive attitudes and no self-control; undeveloped life-skills; lack of housing; financial support and debt; and poor family/social networks. The onset of most of these risk factors commonly occur during late adolescent or young adulthood, with a resulting interruption to secondary and tertiary education. This interruption can impair the development of essential social skills, such as problem solving, time management, motivation and the use of initiative, which can significantly affect an individual’s ability to engage in healthy productivity (Fitzgerald, 2011).
Within forensic settings, patients often experience occupational deprivation; a state in which an individual is unable to do what is necessary and meaningful in his or her life (Whiteford, 2000). Forensic patients are vulnerable to occupational deprivation as they can be contained indefinitely for an extended period, and they are in a social and physical environment, which is under constant surveillance, creating a restricted or repetitive choice of occupations which may lack meaning (Farnworth et al. 2004). Whiteford (2000), drawing upon results from her completion of an occupational needs assessment in a high security Australian prison, argued that occupational deprivation was a significant barrier to community reintegration. Whiteford (2000) suggests that patients became so estranged from occupational roles of community life, and the need to structure their time to meet challenges of community participation, that the likelihood of successful community reintegration is significantly diminished.
Occupational imbalance is a lack of balance or disproportion of occupation resulting in decreased well-being (Wilcock, 2006, as cited in Farnworth & Munoz, 2009). How people spend their time is one way to examine occupational imbalance, and time use may also provide an indicator of quality of life. Farnworth et al. (2004) explored time use of a group of hospital based forensic patients. Personal care and leisure occupations were dominant where 89% of personal care was spent sleeping and 78% of time reported in recreation involved passive leisure activities such as watching television. Participants were dissatisfied with their time use, describing themselves as “killing time”, “inactive” and “bored”. Daily routines filled with meaningless occupations can have detrimental effect on an individual’s health including physical deterioration, demoralization, breakdown of habits, and loss of abilities (Kielfhofner, 1977, cited in Farnworth et al. 2004).
According to Eggers, Munoz, Sciullli & Crist (2006) majority of offenders released from correctional settings in any given year will be re-incarcerated within three years. This is due to the lack of necessary skills needed to successfully reintegrate into the community. In addition, Eggers et al. (2006) reports that offenders often leave prison and revert to occupational patterns that promote reoffending for example, using illegal substances, engaging in problematic activities and committing parole violations. Occupational therapist have the skills required to rehabilitate offenders by introducing core life skills and reducing the effects of occupational deprivation and imbalance by providing opportunities for forensic patients to engage in occupations that support both in and outside forensic services (Eggers et al. 2006)
Occupational Therapy Interventions Commonly used within Forensic Settings
In a report written by Social Exclusion Unit (2002) looking at the issues of re-offending by ex-prisoners, the authors propose that custodial sentences should be reformed to promote successful community reintegration and reduce re-offending. There is a role to be forged by forensic occupational therapists in helping achieve this change (Couldrick, 2003). Occupational therapy, because of its key role in coordinating, implementing and evaluating activity, is well placed to support social inclusion in forensic settings and advocate for change at an upstream level (Fitzgerald, 2011).
Forensic patients often lack skills in forward planning, abstract thinking, problem solving and have poor attention, concentration and memory (Gilmour & Edment, 2001). Within forensic settings, therapeutic rehabilitation helps patients expand on these skills to assist in the re-integration process. Occupational therapists run groups and programs with forensic patients such as community living skills and social skill training programs. Community living skills programs focus on skill acquisition and practice a range of activities of daily living deemed necessary for community survival, such as personal care, meal preparation, nutrition, budgeting, shopping and use of public transport (Fossey et al. 2007). Social skills training programs include tools such as role-play and homework tasks to facilitate development (Fossey et al. 2007). Both these programs are pivotal for patients to develop essential daily living skills that will support their community reintegration post release.
Having a productive occupation is seen as fundamental to an individual’s health and wellbeing and gaining and maintaining work is a highly valued goal for many people with a mental illness (Kennedy-Jones, Cooper & Fossey, 2005). However, when reentering the community, forensic patients trying to acquire employment face a number of barriers, due to limited work readiness skills, poor daily living skills such as time and illness management and stigma associated with being an ex-offender (Tschopp, Perkins, Hart-Katuin, Born & Holt, 2007). It is therefore necessary that occupational therapists provide meaningful productive occupational opportunities for individuals while they are in secure settings, and equip individuals with the skills necessary to continue with these roles once they are reintegrated back into society (Dunn & Seymour, 2008). This process is commonly known as ‘vocational rehabilitation’, which involves providing individuals with opportunity opportunities to further develop the skills and knowledge necessary for them to engage in productive occupations such as work. Intervention strategies include constructing a CV, practicing interviewing skills, developing effective time management skills and establishing daily routines (Kennedy-Jones et al. 2005).
Other intervention strategies occupational therapists offer is in-vivo training through the use of structured leaves into the community (Law, Baum & Dunn, 2006, as cited in Farnworth & Munoz, 2009). Leave is a process run in most forensic psychiatric hospitals in Australia. Forensic patient leave aims to assist the rehabilitation process and provide a gradual progression towards a return to community living that is consistent with the needs of the individual and community safety (Department of Health, 2012). Leave will typically begin with outings to medical appointments, the local park, café and strip shops where patients aim to achieve the goals of learning basic community skills (managing finances, using ATMs and purchasing items), social communication and responding to stressors, and normalization of family dynamics (Department of Health, 2012).
Occupational therapists hold the key to helping people re-engage in occupations that gives their lives meaning and value. Through developing essential life skills, occupational therapists help reconnect forensic patients to their society and culture in which they live in which not only promotes health; but may also mitigate alienation and antisocial behavior and decrease the chance of patients reoffending (Couldrick, 2003).
Challenges to Occupational Therapy Interventions in Forensic Settings
The provision of rehabilitation within secure environments over often-lengthy sentences, for optimal community reintegration on release is a challenge (Lindqvist & Skipworth, 2000, as cited in Farnworth et al. 2004). The combination of being disconnected from social groups upon incarceration, and being placed in groups where the opportunities for roles and activities are severely restricted, can have a profound effect on competence for everyday life. Whiteford (1997, as cited in Farnworth & Munoz, 2009) suggested that prolonged lack of meaningful and purposeful opportunities to work, education, skill acquisition and social interaction in secure environments could result in forensic patients becoming so estranged from their roles of community life that they lose the capacity to structure their time to meet day to day challenges. However, within secure settings, legal restrictions often prevent the opportunity to engage in meaningful programs which significantly limits the opportunities occupational therapists have to intervene and successfully develop habits and routines in pro-social, positive activities (Farnworth & Munoz, 2009).
Occupational therapy in forensic settings is a rapidly developing area of practice, yet the current evidence to support forensic rehabilitation programs and forensic occupational therapy needs is sparse and requires strengthening (Duncan, Munro & Nicol, 2003). Although there has been a call for further research, few authors have added to the evidence base. Duncan et al. (2003) conducted a study exploring the research priorities in forensic occupational therapy using a questionnaire survey. Three specific research priorities were clearly defined: the development of appropriate outcome measures, the development of rigorous and effective group programs and the development of effective risk assessment tools. These prioritised research areas identify a distinct lacking in current evidence and opens up the doors for the much needed future research to occur.
Author’s perspective
Implication for general occupational therapy practice and the profession
As discussed above, currently there is still debate on how security and therapy can reconcile. McMurran, Khalifa & Gibbon (2009) purport that security still appears to be prioritised over therapy. As a current occupational therapy student soon to be embarking on my own career path, I find this debate to be both interesting but very difficult to accept.
As outlined above, it is evident that the reason for the patient being in hospital is not to serve time but to be rehabilitated (Carroll et al.
2004). As the number of incarcerated persons with serious psychiatric disabilities continues to increase, concepts such as occupational deprivation and occupational imbalance provide useful conceptual frameworks to understand the negative impact incarceration has on the performance patterns of habits, routines and roles required for community living. I believe that such concepts dictate the need for occupational therapists to be involved and frame interventions aimed at maintaining and developing daily living skills and roles that will support community reintegration post release. Yet in reality, there still lacks concrete belief that occupational therapy is not only useful but also vital to forensic …show more content…
rehabilitation.
Since June 2012, I have been completing my OCC4071 PCP project at high secure psychiatric facility, Thomas Embling Hospital. My project aims to increase patients’ participation in meaningful occupations through developing employment opportunities patients can apply for and extending the current vocational programs offered within the hospital. Throughout my time I have worked alongside occupational therapists and patients who have all supported this project, as they feel it will help patients develop the necessary skills that will assist with community reintegration. When speaking one on one with a patient at Thomas Embling Hospital about the developing job opportunities, she stated, “the project will be life changing, it could give me a purpose and a reason to wake up in the morning”.
Research strategies that analyse both patient and system factors, which interact to affect rehabilitation outcomes, are needed to establish evidence-based practices in this area (Farnworth et al. 2004). Research is needed in future to focus on which rehabilitation practices are correlated with establishing positive outcomes after release.
According to Farnworth and Munoz (2009) there is a priority for research to include validation of tools to assess outcomes of occupations, that are sensitive to change, and predictive of successful community functioning, to establish the effectiveness of occupational therapy rehabilitation interventions. I urge occupational therapists working in this field to focus on establishing current literature that critically and validly determines the effect occupational therapy practice has on specific areas of occupational performance pre and post release. As a result, occupational therapy practice within the forensic setting will stand as an evidence-based practice, which I believe will be both respected and required.
Implication for future practice of new graduates
Occupational therapy students and new graduates should be encouraged to enter this area of practice and delve further into the work and research through completion of a masters program, which involves a lengthy research project. New graduates completing further research of an occupational therapists role in forensic settings can assist in building up this area of practice so that it is more solid, developed and respected.
Currently occupational therapists can share ideas and projects on forensic occupational therapy through an e-group on yahoo, http://uk.groups.yahoo.com/group/forensic_occupational_therapy. I have personally used this yahoo group throughout completing my project at Thomas Embling Hospital to ask specific questions regarding my project and when I received responses, I found the information extremely valuable. Using the internet as an information forum is a fantastic way to share information world-wide. In my experience, I received several responses and had further contact via phone calls with an occupational therapist from the UK who provided me with information on a similar project she had implemented within her forensic setting. Nevertheless, information sharing is still limited due to the low number of users. New graduates are often tech-savvy and have completed their studies relying on obtaining information through internet means. I believe new graduates interested in entering this area of practice could contribute significantly to the literature base by actively using and contributing new information in online information sharing centers such as the forum mentioned above. The potential contribution new graduates can offer is infinite.
Conclusion
Although there is limited evidence based literature, from the studies presented above and my own personal belief, it is clear that occupational therapists have the appropriate tools and intervention strategies needed to assist forensic patients in developing the skills and abilities necessary for improving mental health status and successfully reintegrating back into the community once released. There is extremely limited published research on evidence-based occupational therapy interventions used within forensic settings aimed at successful community reintegration of forensic patients. Consequently, investigating occupational therapy interventions aimed at assisting patients for community reintegration within a forensic setting is an important, much needed area of research for occupational therapy.
References
Christiansen, C., & Townsend, E. (2010). An introduction to occupation. In C. Christiansen & E. Townsend (Eds.), Introduction to occupation: The art and science of living (2nd ed.). Upper Saddle River, New Jersey: Pearson.
Couldrick, L. (2003). So what is forensic occupational therapy? In L. Couldrick & D. Alred (Eds.), Forensic occupational therapy. Chichester: Whurr Publishers Ldt.
Cronin-Davis, J., Lang, A., & Molineux, M. (2004). Occupation science: The forensic challenge. In M. Molineux (Ed.), Occupation for occupational therapists. Oxford: Blackwell Publishing.
Department of Health. (2012). Forensic leave panel - annual report 2011. Melbourne.
Duncan, E., Munro, K., Nicol, M. (2003). Research priorities in forensic occupational therapy. British Journal of Occupational Therapy, 66(2), 55-64.
Dunn, C. & Seymour, A. (2008). Forensic psychiatry and vocational rehabilitation: where are we at? British Journal of Occupational Therapy, 67(7), 319-322.
Duncan, E. (2008). Forensic occupational therapy in J. Creek, L. Lougher, & H. Bruggen. (2008). Occupational therapy mental health (4th ed.). Churchill Livingstone: Elsevier.
Eggers, M., Munoz, J. P., Sciulli, J., Crist, P. H. (2006). The community integration project: Occupational therapy at work in a county jail. Occupational Therapy in Health Care, 20(1), 17-37.
Farnworth, L. & Munoz, J. (2009). An occupational and rehabilitation perspective for institutional practice. Psychiatric Rehabilitation Journal, 32(3), 192-198.
Farnworth, L., Nikitin, L., & Fossey, E. (2004). Being in a secure forensic psychiatry unit; every day is the same, killing time or making the most of it. British Journal of Occupational Therapy, 67(10), 1-9.
Fitzgerald, M. (2011). An evaluation of the impact of a social inclusion programme on occupational functioning for forensic service users. British Journal of Occupational Therapy, 74(10), 465-472.
Fossey, E., Grigg, M., Minas, H., Leggatt, M., Macdonald, E., & Meadows, G. (2007). Chapter 15: treatment and rehabilitation skills. In G. Meadows, B. Singh, M. Grigg (Eds.), Mental Health in Australia: collaborative community practice (2nd ed.) (pp. 365-382). Australia: Oxford University Press.
Gilmour, A., & Edment, H. (2001). Supervising the rehabilitated patient in the community. In C. Dale, T. Thompson & P. Wood (Eds.), Forensic mental health: issues in practice. Edinburgh: Bailliere Tindall.
Kennedy-Jones, M., Cooper, J., & Fossey, E. (2005). Developing a worker role: stories of four people with mental illness. Australian Occupational Therapy Journal, 52, 116-126.
O’Connell, M., & Farnworth, L. (2007). Occupational Therapy in Forensic Psychiatry: a review of the literature and call for a united and international response. British Journal of Occupational Therapy, 70(5), 184-191.
Social Exclusion Unit (2002) ‘Reducing Reoffending by ex-Prisoners’. London: Social Exculsion Unit.
Whiteford, G. (2000). Occupational deprivation: Global challenge in the new millennium. The British Journal of Occupational Therapy, 63(5), 200-204.
Appendix 1
AT5 Search Strategy Template
1.1 Initial searchable question
The initial search question was developed based on the concepts of PICO.
Population: Forensic Patients
Intervention/Treatment: Occupational therapy interventions within forensic setting
Comparison: No Comparison
Outcome: Successful Community Reintegration
Search Question: “Do occupational therapy interventions assist forensic patients with successful community reintegration?”
1.2 Data bases Searched
To answer my search question, I used several databases including: OTDBASE, CINAHL Plus, AMED: Allied and complementary medicine, and OT seeker. OTDBASE was very valuable resource for finding relevant articles as it provided a wide range of journal articles specifically related to occupational therapy. In addition, CINAHL being non occupational therapy specific provided a wide variety of useful journal articles on the general aspect of forensic and secure settings and the common barriers patients’ experience.
1.3 Search terms/key words
The key search terms used included using the population and the outcome eg. “Forensic Patients AND Community Reintegration” and using the population and intervention eg. “Forensic Patient AND Occupational Therapy Interventions”.
Key Terms | Alternate key words or phrases | Forensic Patients | Psychiatric patients, Mental Health patients, forensic service users | Forensic Settings | Psychiatric hospital, Forensic psychiatry, secure setting, mental health settings, Forensic facility, Forensic services | Community Reintegration | Community, Society, Community integration, Community reentry | Occupational Therapy Interventions | Programs, Rehabilitation, Psychosocial rehabilitation, Therapeutic Rehabilitation, forensic occupational therapy, Daily living skills training, Occupational therapy groups/programs, social skills training, social inclusion, vocational rehabilitation.
| Occupational performance issues | Occupational imbalance, Occupational deprivation, social exclusion |
1.4 Inclusion/Exclusion
The exclusion for this search strategy was based on publication dates of journal articles, however there was an exception if the journal article was strongly relevant to the search question. Within the 23 identified journal articles relevant to this research topic only one was published 15 years ago or more. Within the 23 identified journal articles 16 were published within the last 10
years.
The inclusion criteria for this search were based on the relevance to the research topic. The studies describing experiences of forensic patients, occupational therapy interventions within forensic settings and community integration of forensic patients were part of inclusion criteria.
1.5 Refined Search Question
When I had commenced researching the databases I was provided with very relevant journal articles and apart from changing key words to expand my search it wasn’t necessary to refine my search question.
“Do occupational therapy interventions assist forensic patients with successful community reintegration?”
1.6 Search History
1.7 Relevant References Identified- type of evidence
Methodology of study Retrieved | References – Author and Year | Practice Guidelines | | Systematic Review/Meta-analyses | | Research based: inc RCTs, Post-test only/Post-test studies, case-control, analytic studies | Fitzgerald, 2011 | Research based: Qualitative including descriptive and individual case studies | Duncan, Munro, Nicol, 2003Eggers, Munoz, Sciullli & Crist, 2006Farnworth, Nikitin, & Fossey, 2004Kennedy-Jones, Cooper, & Fossey, 2005 | Expert opinion including literature review, consensus statements | Department of Health, 2012Dunn & Seymour, 2008Farnworth & Munoz, 2009O’Connell & Farnworth, 2007Whiteford, 2000 | Other | Christiansen & Townsend, 2010Couldrick, 2003Cronin-Davis, Lang, & Molineux, 2004Duncan, 2008Fossey, Grigg, Minas, Leggatt, Macdonald, & Meadows, 2007Gilmour & Edment, 2001Social Exclusion Unit, 2002 |