Managing High Security Psychiatric Care (Forensic Focus)
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With these, occupational therapy prepares the person for community life and protects the individual from recidivism [ 5 ]. This is not the sole benefit of occupational therapy. The forensic population is growing all over the world and brings challenges with this growing population [ 5 , 6 , 7 , 8 ]. The thing that should never be ignored is the legal context, and the therapists must consider the needs of individuals in the legal context [ 9 ]. The methods are similar to other mental health settings.
The key focuses for the occupational therapists working in forensic settings are assessment, prevention of occupational deprivation, development of occupations to prevent recidivism, preparation for discharge and activities of daily living ADLs , preparation to community and the vocational rehabilitation. This chapter describes the occupational therapy in forensic settings such as prisons, secure hospitals and community reintegration services.
The chapter also discusses the assessments, models that can be used in forensic settings, interventions and challenges in forensic settings. Correctional settings are a way to facilitate the mental health recovery of the inmates. Since, many of the inmates have serious mental disorders, the forensic unit, of the correctional facility, plays an important part in their recovery.
The unit reduces the risk associated with the inmates and facilitates their transition into the community or less restricted settings. However, the same results could be achieved with occupational therapists. The two main methods that are adopted by occupational therapists OTs are the reduction of occupation deprivation and increasing skills by occupational participation.
Hence, the inmates are provided with an opportunity to play a purposeful and meaningful occupation in society [ 3 ]. Patients, who are admitted to the forensic units and get in contact with the criminal justice system as a consequence of their committed crimes, are detained in accordance with the country-specific mental health legislation.
However, some patients are admitted due to severe behavioral issues. There are several types of correctional settings where charged offenders are held. The main institutions are forensic mental health settings, jails and prisons. Jails and prisons are the main correctional facilities since they are able to hold the greatest number of people.
There are approximately 12 million jail admissions, which is approximately 19 times that of state and federal prisons [ 12 ]. Jails and prisons served for different purposes; have restricted opportunities for rehabilitation; offer a similar grade of occupational deprivation, inadequate access to health services and poorly planned methods; are temporary in nature and lack systematic regulation and resources [ 13 ].
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Jails and prisons provide care for mentally disturbed offenders in ill-equipped correctional institutions. In particular, jails are used for temporary confinement and are usually lacking in mental health screenings and treatment received by inmates in jails is more limited. Prisons, however, might offer inmates the opportunity to access consulting service for substance abuse treatment even though the service delivery is generally insufficient [ 14 ]. Jails serve as an introduction to the incarceration system.
They are local correctional facilities operated by a city or country instead of the federal or state government. The main purpose of jails and prisoner distribution centers is to confine a person before and after court judgments and to filter prisoners to and from courts and other correctional facilities. Some people in jails have been sentenced, while others might be waiting to be convicted. Judgment is mostly a complex process of sentencing. In this respect, inmates in forensic settings might either be arraigned or experiencing the trial process. Prisons are classified as high, medium and low security institutions that are typically used for convicted criminals who have been sentenced to at least a year of imprisonment in U.
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Federal Bureau of Prisons. In addition, depending on the severity of the crime, some individuals are sentenced to either state or federal prisons. However, compared to jails, prisons offer a far more stable environment for the inmates and restrict their interaction with society for longer periods of time [ 3 ]. The primary purpose of prisons is to ensure public safety and the security of inmates. In addition to incarcerating criminals, prisons offer them programs to address their criminogenic needs related to education, substance abuse, employment and transition to the community.
Basic services in prisons involve intake and screening of psychotropic medicines and to provide occupational therapy services. Those services are substantially provided for prisoners to decrease their social isolation and increase their problem solving and adaptation skills, self-efficacy and self-esteem. The occupational therapy services also promote emotional regulation abilities and social and emotional skills in order for the inmate to deal with prison life and take this opportunity to improve on self-efficacy and occupational engagement [ 15 ].
High-security units: Individuals classified as high risk to public safety have been sentenced to life imprisonment and are receiving long term treatment, are housed in high-security prisons. The physical environment in these facilities consists of a number of physical and structural barriers between the facilities and the external environment of the institution. Each cell is equipped with a toilet, screwed to its floor, and prisoners are permitted up to three min showers per week. Movement is firmly restricted and activity within the cellblock does not occur without other constraints, such as handcuffs, leg irons and corrective officer escorts [ 3 ].
Orientation can be considered as essential because it gives the staff the chance to be acquainted with the prisoners. The ward program focus areas, such as improving awareness of self, others and the environment; orientation to time, place and situation; probing cognitive abilities and teaching of new skills to improve leisure time use and psychomotor activation, should be maintained after discharge [ 16 ]. Medium-security prisons usually have a wide diversity of work-oriented and treatment programs. Patients included in the rehabilitation process are integrated into community life by developing intellectual and emotional insight, self-care and self-expression skills and general work abilities.
Low-security prisons: These facilities have windows and open spaces that allow the prisoners to move and interact freely within the environment. Even though low-security prisons are surrounded by double-rings, they have no prison fences or other secured perimeter and are often unpatrolled by armed guards. In open wards low or minimum-security prisons , during the therapeutic leave and discharge periods, greater priority is given to preparation of patient participation.
Patients are expected to adhere to hospital rules and regulations, but are allowed to freely leave their wards and take the opportunity to practice skills acquired in the medium secure wards and joining educational training programs outside the health services [ 3 ]. The intensive life skills training program is comprised of communication, conflict management and criticism handling, problem-solving, money handling budgeting, current price trends and work-related skills job seeking, application for a job, writing of curriculum vitae, work interviews through the use of role play.
In addition, recreational activity program, and specific work skills-related programs are implemented to enhance psychosocial interactions [ 15 , 16 ].
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Forensic psychiatric settings are generally located in secure units that rehabilitate individuals deemed unfit to stand trial or not criminally responsible. Those inmates pose a serious threat to either themselves or others because of severe mental illness. A forensic psychiatric setting provides treatment-based approaches with a view to rehabilitating patients while keeping the public safe. Patients, temporarily transferred from correctional facilities or incarcerated environment, are assessed and treated for mental illness in the facility that consists of secure, closed and open common units [ 17 ].
Forensic psychiatric hospitals reintegrate patients systematically into the community with well-equipped and specialized clinical services, as well as an exhaustive range of vocational and rehabilitative programs. Reentry centers are facilities that help inmates by offering structured and supervised residential settings just before or after their release.
In addition to providing a permanent residence to the individuals, assistance in financial management and facilitating, their return to the society is also arranged. These centers might be especially useful, because the psychological adaptation required for offenders, with expansive criminal histories, returning to the community after a long period of imprisonment, can be particularly demanding.
A crucial component of community reentry centers is substance abuse management and mental health treatment and counseling. Growing prison populations are largely due to drug-related crime and drug abuse, but relatively few prisoners receive the appropriate treatment.
In this respect, community-based correctional settings have launched out prison-based drug treatment programs during the past few years [ 3 ]. There are two main models of psychology about correctional treatment.
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Purvis describes 11 primary human goods Tables 2 [ 20 ]. If it is examined the models, both are similar, but RNR Model is based on cognitive-behavioral and the GLM is based on humanistic philosophy. Depending on these criminal risk factors, it is argued that the criminal procedure of the individual can be predicted and therefore the criminal procedure can be prevented by taking the necessary precautions.
However, the RNR model is not compatible with occupational therapy outlook in the view of the possibility of irreversible risk factors and bias holding against the individual. The use of occupational therapy models in forensic rehabilitation focus on client-centered, holistic and occupation-focused practice with the approach of clinical reasoning based on individual preferences and needs.
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Individuals who need forensic rehabilitation face some participation limitations to all or a combination of activities and this can cause occupational deprivation additionally to the sense of hopelessness and poor mental health [ 6 , 11 , 15 ]. Moreover, community life skills and performing daily living activities and interaction with the environment of the individual can be limited.
Therefore, group or individual occupational therapy programs often target basic living skills, self-care, vocational skills, adaptive coping strategies, creative arts and anger or stress management. The general aim of occupational therapy is to enable individual to experience occupational enrichment and achieve optimal occupational functioning.
Occupational enrichment in forensic settings can be considered as both the goal and process of occupational therapy interventions, so evidence-based practice is very important [ 15 ]. Occupational therapy guideline recommendations show that Model of Human Occupation MOHO and its associated assessments are the most used occupational therapy model in forensic occupational therapy.
The model was developed in the s by Professor Gary Kielhofner and has had some revisions and collaborations until now.