Forensic: Support for OT

Forensic OT is defined as OT services aimed at decreasing an individual's risk of reoffending (Connell, 2016). Forensic OT is based on five key components: an occupational approach to risk assessment and formulation, volitional realignment, improving protective factors, community reintegration, and increasing the understanding of forensic OT (Connell, 2016). Research demonstrates that individuals with mental illness that participated in OT had increased motivation, process skills, and interaction skills (Burson et al., 2017).   

OT's Role

An OT's role in mental health treatment involves increasing engagement in activities to improve overall mental health (Swarbrick & Noyes, 2018). Occupational engagement is crucial because it can increase overall health and transition to independence. OTs have expertise in activity analysis and are able to identify service users' strengths and goals. OT can address an individual's challenges and support them through functional interventions (Swarbrick & Noyes, 2018). OT's can also assist with community reintegration and meeting role responsibilities (Gibson et al., 2011). Psychosocial rehabilitation, vocational training, and advocacy are also common in OT intervention (Forward et al., 1999). OT focuses on an individual's ability to complete occupations independently while addressing the client's overall wellbeing and quality of life (AOTA, 2017a). OTs can play a significant role in mental health and have the expertise to provide holistic care through meaningful occupation to assist clients with the treatment of mental illness (D'Amico et al., 2018) and the reintegration of incarcerated individuals into community life (AOTA, 2017a). 

Risk Assessment and  Formulation

Risk assessment is utilized to gauge an individual's potential of committing an additional offense and to evaluate their risk of being violent (Munoz, 2011). Static and dynamic risk factors are typically considered. Characteristics of an individual that cannot be changed such as gender, age, and personal histories including prior offenses are considered static risk factors. Dynamic risk factors include variables that can be changed and may include socioeconomic status, family support, substance abuse, employment status, marital status, and criminal networks (Lindsay & Beail as cited in Munoz, 2011). Risk assessment is predominately performed by psychologists and psychiatrists; however, OTs commonly contribute their own observations and judgments to improve the interdisciplinary team's treatment approach (Munoz, 2011). Also, OTs can address the identified risk factors to facilitate an improved likelihood of successful occupational engagement, reduce chances of recidivism, and minimize the risk of violence (Munoz, 2011). 

Improving Protective Factors 

Characteristics that serve as strengths for an individual are considered protective factors (De Ruiter & Nicholls, 2011). Approaches that combine risk assessment methods with a strengths-based approach are thought to facilitate successful reintegration into the community for individuals who have been incarcerated (Schlager, 2018; Seiter, 2017). Strengths-based approaches can include positive relationships between the correctional employees and incarcerated individuals that prioritize the empowerment of detainees through resiliency techniques, an emphasis on collaboration, and community collaboration that recognizes and values detainees after release (Schlager, 2018). OTs have been known to address interpersonal communication, coping strategies, wellness skills, stress management, community living skills, and employment opportunities (Muñoz et al., 2016). OTs can also facilitate skills in health management, sexual participation, self-care, community mobility, financial management, caretaking skills, and more (AOTA, 2014). These are prime examples of approaches to improve dynamic risk factors and to reduce risk by improving protective factors. Consideration for an individual's protective factors may also increase insight into an individual's capacity for recovery and growth (De Ruiter & Nicholls, 2011). This insight can be utilized to foster motivation (De Ruiter & Nicholls, 2011).

Volitional Realignment

Volitional realignment is concerned with acquiring or improving motivation to engage in meaningful and healthy occupations. As discussed prior, incarceration has a large impact on autonomy and, therefore, a significant impact on personal drive, decision-making skills, and self-efficacy. When combined with the multitude of barriers present at post-release and the static risk factors of an individual, it is easy to understand how the individual may lack motivation and fall back into old habits and routines. The facilitation of establishing autonomy, acquiring life-skills, participation, and health management can help realign volition towards positive and meaningful occupational engagement. OT's are accustomed and trained to utilize motivation in a client-centered manner to improve client outcomes. 

Community Reintegration

An individual's roles, rituals, and routines are disrupted during detainment. Community- and evidence-based treatment is necessary to transition individuals back into their communities. According to the AOTA (n.d.), transitions are described as a movement from one stage to the next. It can include changes in daily life, functional abilities, or environment. Ju & Tang (2016) state that transition outcomes can be improved with transition planning and implementation. Positive transition outcomes are considered living independently to the maximum extent, having meaningful employment, or attending further education. Effective transition programs should teach a variety of skills, including academic, functional, social, behavioral, and occupational skills (Ju & Tang, 2016). Research shows that if offenders receive holistic reentry support it can reduce recidivism rates. Effective reentry programs focus on behavior intervention. Behavioral intervention programs often use DBT strategies that typically focus on the core principles of mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation (Nymathi et al., 2017). According to the AOTA (n.d.), the aim of OT transition services is to prepare, plan, and perform task analysis and environmental adaptation to provide opportunities for individuals to identify preferences, make choices, and participate in activities. These services can be provided through community reentry programs.

OT-Specific Programming

Discussions about OT's role in forensic settings have been taking place for nearly 45 years (Bartholomew, 1976; Penner, 1978). However, despite the recognition of OT's potential to make a significant contribution within correctional systems for decades, OTs have failed to establish guidelines for the scope of OT in these settings and their role remains unclear (Munoz, 2016). Below are some examples of OT specific programs that support OT's role within forensic settings.

A study by Eggers et al. (2006) described an OT led community reentry program within a county jail during pre- and post-release of detainees. The program achieved a 98% successful reintegration rate of those who reentered the community (employed and remained in the community) after 11 months in the program. The program addressed four areas which included life skills; education and employment; wellness; family and support. The program was created on the idea that occupation-based assessment and preparation of individuals may facilitate productive and meaningful reintegration after incarceration (Eggers et al., 2006).

In a systematic review by D'Amico et al. (2018), the researchers examined evidence supporting OT interventions addressing ADLs, IADLs, leisure, and rest and sleep. This study collected 61 articles, between the years 2008 to 2016 and were Level I to III evidence. Strong evidence was discovered to support the use of OT interventions for ADLS and IADLs. OT interventions in residential settings provided to improve ADL and IADL performance in individuals with mental health issues. Leisure interventions demonstrated moderate evidence. Participants often participate in leisure activities during intervention; however, activities were not continued after treatment. Evidence for rest and sleep interventions was moderate. There was strong evidence to support the use of occupation-based social participation interventions. Improved social skills resulted in improvements in sleep, comping, lifestyle, and social participation. Client-centered OT interventions resulted in improved outcomes in overall performance. Occupation based interventions implemented by an OT resulted in better outcomes compared to other instructors (D'Amico et al., 2018).      

A study by Fitzgerald (2011), in Britain, implemented an OT-based social inclusion program utilizing the MOHO domains for forensic clients with serious mental illness in a low-secure, rehabilitation forensic service at Pennine Care NHS Foundation Trust. All 62 individuals in the long-stay units were included in the social inclusion program, of which 43 agreed to have their data utilized in the research. Participants continued to receive normal treatment with the addition of one-on-one goal planning with an OT, and graded community engagement. All participants had a history of poor engagement and insight.  Over half also had a history of violence. The MOHOST was utilized to measure change. After the social inclusion program, there were significant differences in motivation for occupation, pattern of occupation, motor skills, and environment (Fitzgerald, 2011). 

Fan et al. (2016) conducted a retrospective study in England involving a longitudinal analysis of occupational participation among six forensic hospitals. Seventy-eight OTs utilized the MOHOST to rate 489 patients receiving OT services in low and medium secure units over two years. It was determined that there were improvements in the patients' overall occupational participation over time. Participation improved in five of the six MOHOST domains in particular including motivation for occupation, process skills, pattern of occupation, communication/interaction skills, and environment (Fan et al., 2016)