Forensic, or correctional, settings include more than just prisons and jails (Moreton et al., 2015). Drug and alcohol treatment centers, youth facilities, probation departments, community corrections facilities, and forensic hospitals also fall within this category (Moreton et al., 2015).
The U.S.' incarceration rate is the highest in the world (Al-Rousan et al., 2017). The number of individuals incarcerated in prisons within the U.S. has nearly quadrupled over the past forty years and accounts for approximately 20% of the world's incarcerated population despite the nation accounting for a small fraction of the world's overall population (Al-Rousan et al., 2017). This has happened despite evidence that large-scale incarceration is an ineffective way to achieve public safety (The Sentencing Project, n.d.). Meanwhile, funding has decreased for rehabilitation, education, and other programming. The recidivism rate of formally incarcerated individuals also remains alarmingly high (Muñoz et al., 2016). In the year 2018, more than 2.2 million individuals were in U.S. prisons and jails (Bureau of Justice Statistics, 2020a; Bureau of Justice Statistics, 2020b). Furthermore, the most recent 2018 report highlighted that over 4.5 million adults, or one in every 55 adults, were on probation or parole in the U.S. in the year 2016 (Bureau of Justice Statistics, 2018). Every year the U.S. spends approximately $8-$21 billion on the incarceration of adolescents. According to Erickson (2012), adolescent incarceration rates have been steadily rising since the 1970s. Over 66,000 juveniles were also reported to be in residential facilities as of 2018 (Juvenile Residential Facility Census Databook, 2020). Statistics on the total number of juveniles on probation is unavailable due to inconsistent data acquisition across jurisdictions (National Criminal Justice Reference Service, 2020). The number of individuals within forensic settings is substantial and upwards of 7 million (Kaeble & Cowhig, 2018).
The demographics of individuals who are incarcerated display alarming trends. Throughout the world, many of the countries' detention centers hold a disproportionate number of individuals from disadvantaged social and economic backgrounds (Easley, 2011; Muncie, 2013). Individuals who are considered ethnic and racial minorities within the countries they reside in are also grossly overrepresented within the prison systems (Wacquant, 2013). Blacks are incarcerated in state prisons five times the rate of whites and at a rate of least ten times the rate of whites in five states (Nellis, 2016). This is supported by a 2020 report by the Bureau of Justice which found that black males, in particular, were found imprisoned at 5.8 times the rate of white males and black women 1.8 the rate of white females in the year 2018 (Bureau of Justice Statistics, 2020a). Blacks also account for more than half of the total state prison populations in twelve states (Nellis, 2016). Furthermore, Hispanics are incarcerated at 1.4 times the rate of whites in state prisons (Nellis, 2016).
Socioeconomically disadvantaged people are also disproportionally represented (Rabuy & Kopf, 2016). The median annual income for individuals before incarceration has been found to be less than $16,000. Therefore, many incarcerated people were living in poverty prior to detainment and are incapable of posting bail for low-level crimes (Rabuy & Kopf, 2016).
These individuals commonly possess complex personal histories that are multifaceted and likely increased their susceptibility or vulnerability to incarceration. Oftentimes their socialization skills were formed within disorganized and unpredictable family structures (Jones et al., 2013). Many of which exposed them to domestic violence (Richie as cited in Muñoz, 2016). They frequently have a high prevalence of psychiatric illnesses (Fazel & Seewald, 2012) or substance abuse (Prins, 2014). Furthermore, research by Assadi et al. (2007) and Cahill et al. (2012) found a high incidence of sensory, neurological, or sensory disorders with this population. Most notably, it's common that an incarcerated individual has experienced all of these factors (Penal Reform International, 2015).
In a study of over 8,500 inmates by Al-Rousan et al. (2017), it was found that approximately half of the individuals had a history or a current diagnosis of mental illness, and almost a third of all inmates present with a serious mental illness. For specific mental illnesses, depression and major depressive disorders were the most prevalent conditions, present in 18% of all inmates, and accounting for 38% of all the mentally ill inmates. The next most common were anxiety and panic disorders, present in 17% of all inmates. Males were identified as having a higher likelihood of being diagnosed with neurotic depression, impulse control disorders, and dysthymia. Whereas females we identified as being more likely to be diagnoses with depression, major depressive disorders, bipolar disorder, PTSD, eating disorders, developmental disabilities, movement disorders, and sleep disorders (Al-Rousan et al., 2017). According to the National Institute of Drug Abuse (2016), 80-90% of incarcerated adolescents have a substance abuse disorder. Individuals in a community re-entry center are those who have previously been in prison and are, therefore, subjective to the above mental health disparities as well.
Individuals in a state hospital have been identified as having a severe mental illness (Munoz, 2011). Some are transferred from prison or jail. Others were deemed unfit to stand trial from the beginning of their interaction with the correctional system, were found guilty but determined to be mentally ill, or were found not guilty due to insanity (Munoz, 2011). Civil patients are also often present in state hospital which are not involved with the correctional system (Wik et al., 2020). Generally, there has been an increase in the ratio of forensic patients to civil patients over the period of 1999 to 2016 (Wik et al., 2020).
In theory, incarceration is a process in which an individual can receive rehabilitation to tackle the foundational issues that supported their engagement in criminal occupations and, as a result, reduce the likelihood of reoffending (Raphael, 2011). However, in practice, incarceration does not prioritize rehabilitation (Raphael, 2011). Rather it is primarily about accountability, punishment, and public safety. Individuals are often released back into the community having learned new skill sets that actually support their performance as criminals rather than those that discourage it (Ristad, 2008). They may also acquire or reinforce attitudes and habits that increase their chances of engaging in illegal behavior to earn an income upon release (Hutcherson, 2012).
The National Institute of Justice (2018) investigated prisoner recidivism between the years 2005 and 2014 in the U.S. and determined the rate of recidivism is approximately 68% within 3 years of release, 79% within 6 years of release, and 83% within 9 years of release. These high rates of recidivism indicate that these individuals are not gaining prosocial, productive patterns of occupation during their time of incarceration and are generally not prepared for engaging in an alternative lifestyle upon release (Muñoz, 2011). In 2011 alone, the U.S. spent an estimated seven billion dollars on the recidivism of adolescents (Justice Policy Institute, 2014).
A study performed by Van der Put et al. (2014), examined the differences between juvenile offenders that abstain from substance abuse, substance-using juvenile offenders, and juvenile offenders with substance abuse issues. The study found that recidivism, a relapse in criminal activity (National Institute of Justice, 2014), was highest in offenders with substance abuse issues, followed by substance-using offenders. This is likely due to the fact that many adolescents do not receive rehabilitative treatment. Offenders with substance abuse disorder require aftercare treatment and long-term management after release (Van der Put et al., 2014). In general, individuals with substance use disorders will likely experience anxiety when reintegrating back into society which contributes to an increased likelihood of recidivism (Thompson et al., 2019).
Impact While Detained
Correctional settings such as prisons, jails, state hospitals, and community re-entry programs disrupt an individual's entire life which can negatively impact their ability to be functional and to maintain a sense of identity and purpose. Detainment demands adjustments to an individual's roles, habits, routines, environments, and support systems. The environments lack opportunities for individuals to engage in meaningful activity (Muñoz, 2011). Individuals often experience occupational deprivation, alienation, imbalance, and apartheid. Because humans are occupational beings, these occupational limitations has the impact to negatively affect an individual's mental, physical, and psychological well-being (Ozkan et al., 2018). Therefore, those subjected to incarceration experience occupational injustice (Rabuy & Kopf, 2015).
An environment of occupational deprivation affects an individual's autonomy to participate in personally meaningful activities and results in a decrease in motivation and ability to successfully participate in many occupations (Jaegers et al., 2019). Occupational deprivation for a prolonged period of time can result in health consequences, negatively impact an individual's well-being, lower self-efficacy, decrease time management skills, and reduce the ability to adapt (Wilcock, 2006).
Overcrowding within correctional facilities has been deemed an obvious contributing factor and cause of many health issues such as mental health issues and infectious diseases (Penal Reform International, 2018; UNODC, 2013). Individuals with mental illness have been reported as exhibiting difficulty coping with everyday life while incarcerated (Hassine as cited in Munoz, 2011). Furthermore, they are often manipulated into snitching on others by correctional officers or their peers leading to an increased likelihood of being victimized, stigmatized, and isolated by means of self-initiation (Hassine as cited in (Muñoz, 2011). Individuals in these environments often experience extended periods of excessive sensory stimulation (Muñoz, 2011) and sensory deprivation (Haney, 2018). Extremes in sensory experiences have been shown to dramatically impact mental health including the onset of mental illness and symptom exacerbation (Haney, 2018).
The practice of individuals being removed from their community and then later reintroduced without sufficient support has a significant impact on the individual, community, nation, society, and economy. (Brinkley Rubinstein & Cloud, 2020; Morenoff & Harding, 2014). It is common for these individuals to encounter housing, health, and transportation challenges. They experience barriers to accessing employment and social dynamic shifts with family and friends. Those with a felony face profound barriers as they are frequently excluded from many types of financial, nutrition, transportation, housing, civic participation, and employment access or assistance (Morenoff & Harding, 2014). Individuals may become so estranged from their previously held occupational roles within the community that they lose the ability to meet the demands necessary for community participation (Muñoz, 2011). This occurrence leads to a decreased likelihood of successful, adaptive community reintegration (Muñoz, 2011). Furthermore, adolescent incarceration often results in poor adult outcomes, drainage of millions of dollars from social services agencies, and high recidivism rates (Steinberg et al., 2004). These poor outcomes are the result of an unstable foundation. Many adolescents are incarcerated during the prime years of adult development when most people are pursuing education or job training (Steinberg et al., 2004).
Meghan Hughes is an OT doctoral student at the University of St. Augustine for Health Sciences. She is currently completing her doctoral capstone project with Stewart Marchman Act Healthcare at a residential adolescent substance abuse treatment program. She has developed a program, "Skillin' It", focusing on life skills for successful reintegration to community life. This is an emerging practice area for OT and Meghan is excited to provide OT-based interventions addressing roles, routines, IADLs, leisure, career and education exploration, and coping. She is delighted to be a positive role model in these adolescents' lives and is eager to see where her career takes her!