Deinstitutionalization in the United States, reduction of mental health resources, and a trend toward increasingly severe sentencing for drug offenses are reflected in a shift in the demographic features of jail populations (Bronson & Berzofsky, 2017; Muñoz, 2019). Providing effective, culturally responsive interventions to this population is difficult because of a variety of factors, including co-occurring medical problems, a history of trauma, inadequate social supports, poverty, and homelessness (Bronson & Berzofsky, 2017; Bronson, Stroop, Zimmer, & Berzofsky, 2017; Steadman, Osher, Robbins, Case, & Samuels, 2009). Jail environments regularly prevent people from engaging in meaningful daily routines, which can result in isolation and occupational deprivation (Muñoz, 2019; Whiteford, 2000). When released from jail, many individuals cannot successfully reintegrate into the community (Neller, Vitacco, Magaletta, & Phillips-Boyles, 2016). Those who do not have the necessary skills to become productive members of society often recidivate, reentering the criminal justice system (Bender, Cobbina, & McGarrell, 2016; Neller et al., 2016; Petersilia, 2011).
Correctional programs, such as prisons, most often focus on discussion-centered topics that are intended to prepare participants for community reentry (Petersilia, 2011). These programs focus primarily on work-related programming and minimize other skills and services that prepare people to be successful in the community after release. Likewise, county jails do not offer comprehensive services to support the development of life skills and community reentry (Bronson & Berzofsky, 2017; Muñoz, 2019). Many traditional jail programs do not provide hands-on life skills training, specifically in independent activities of daily living (IADLs). Using a client-centered approach, occupational therapy (OT) provides people with the opportunity to learn or relearn a variety of skills to meet their individual needs. These needs include the development of IADLs that can be used to access available community resources (American Occupational Therapy Association [AOTA], 2014).
An essential belief of the OT profession is that humans learn best through doing (Nelson, 1996). Occupation, as described by Wilcock (1998), is a dynamic relationship of doing, being, and becoming. Active engagement in occupations (doing) influences the individual's self-discovery (being) and transformation (becoming). Skills can be developed through active engagement in activities and tasks (Law, 2010). However, when an individual is incarcerated, loss of participation in meaningful occupation affects the dynamic relationship of doing, being, and becoming and may result in occupational deprivation. This deprivation affects the person's overall health and well-being (Muñoz, 2019; Whiteford, 2000). Evidence shows that programming provided in correctional settings that is centered on changing behavior and teaching marketable skills prepares participants for community reentry (Bender et al., 2016; Bronson & Berzofsky, 2017; Neller et al., 2016; Petersilia, 2011).
Occupational therapists are well equipped with the skill set and practice domains to develop and implement programming to meet the occupational needs of people in the criminal justice system (Muñoz, Moreton, & Sitterly, 2016). A five-module Life Skills Program that features active engagement focused on doing, being, and becoming and the development of skills necessary for successful community reintegration was created for a Midwest county jail. Occupational therapy services are commonly found in prisons, not county jails, making this setting a unique and emerging practice area. This program employs hands-on educational interventions that promote doing and is designed to facilitate the development of skills in interpersonal communication, employment, financial management, leisure, and community resources. This description provides an overview of the development and implementation of the program.
Theoretical Foundations and Considerations
The Life Skills Program is conceptually grounded in the primary tenets of the Model of Human Occupation (MOHO) developed by Kielhofner (2009). The MOHO conceptualizes a person's occupational performance using three interrelated components: volition, habituation, and performance capacity. Volition consists of individuals' interests, values, motivations, and self-efficacy, also understood as their belief in their ability to live and function on a daily basis. Habituation addresses how people transition basic skills learned at various life stages to become habits and routines that help them to structure, order, and create routines for daily living that generate efficiencies for their necessary life roles. Performance capacity reflects the physical, psychological, and social skills and abilities that are necessary for effective daily occupational performance. Every individual has a different performance capacity, or skill level, across a variety of basic skills that are typically required for daily living. Occasionally people have disruptions in their ability to perform daily occupations because of physical disability, disease, trauma, mental health, and/or substance use. Further, the MOHO supports the idea that all occupation occurs, is influenced, and is given meaning by the physical and sociocultural environment. This model offers a conceptual way to consider individual needs and is an effective way for OT practitioners to address the occupational performance needs of people who are incarcerated (Connell, 2016).
The Kawa model, developed by Iwama (2006), provides a distinct perspective for considering a person's life history and the occupational choices, disruptions, and supports that affect occupational performance. In this jail-based OT program, participants, guided by the OT student, are asked to draw a flowing river using specific items to represent life supports and significant positive and negative life issues. Subsequently, clients discuss their perception of positive life supports and structure and/or potentially significant issues that prevent them from reaching maximum routine occupational performance. These metaphorical river images often reflect opportunities for change and can facilitate improvement through collaborative planning of OT interventions designed to meet the person's identified needs.
The five modules of the Life Skills Program offered at the jail fit with the MOHO and the information obtained from the Kawa drawings. Each module can be adapted and customized to meet individual needs, determine goals, and provide interventions tailored to address the development of IADLs. For example, using a MOHO perspective, effective communication may be considered a component of volitional, habitual, or performance capacity. Addressing interpersonal communication with a volitional approach allows the OT practitioner to facilitate interventions that address appropriate communication skills to meet person-centered goals. Lack of opportunity or exposure to poor role models may result in habitually ineffective communication. In this case, interventions that require repetition to review appropriate habits would be necessary to develop communication skills for effective daily living. For others, ineffective communication skills may be a function of poor performance capacity. A person may not have learned basic rules of interpersonal communication and may require interventions to learn and practice these skills. These intervention approaches can help individuals at all functional levels to exhibit effective communication skills that not only are consistent with the goals of the program and the module but also are consistent with the program's conceptual foundations in the MOHO. The river drawings in the Kawa model are used to elicit rich descriptions of problems, and the person's interpretations of the drawings help to contextualize specific factors that affect occupational performance, such as environmental, social, and family considerations (Iwama, 2006; Leadley, 2015; Richardson, Jobson, & Miles, 2010). These drawings provide the participant and the OT practitioner with specific information about prioritized issues, people, and support systems. Additionally, this information provides key evidence that allows the OT practitioner to determine the most effective way to frame the focus and rationale for interventions included in the program modules (Iwama, 2006).
The OT department of the University of Findlay has been engaged in community-based OT practice since 2003, beginning with programs in outpatient mental health. In 2011, a full-time faculty position was created to provide direct services in the county jail and supervise Level II fieldwork for students assigned to the jail and various community programs. In 2012, OT programs were initiated in the jail and were regularly delivered by students performing Level II fieldwork.
The jail facility includes the sheriff 's department and a 98-bed full-service jail that is used to detain adults for more than 120 hours or 5 days (Sheriff–Hancock County, n.d.). Most employees who work directly with the people incarcerated at the jail are considered corrections staff. There are four types of corrections staff: jail administrators, jail sergeants, correctional officers, and clerks. The OT practitioner, OT students, case managers, and counselors are considered ancillary staff. Individuals who are incarcerated are not permitted to move through the facility independently and must be escorted to meetings with lawyers, visits with family/friends, scheduled arraignments, visits to the nurse or doctor, special programs, or recreation time. Because of safety concerns with transportation, these individuals do not leave the facility for psychiatric assistance, nor does a psychiatrist come to the facility. However, a physician is in the building 3 days a week, and a nurse is available daily to provide health care services. Correctional and ancillary staff from the jail coordinate with employees from the local mental health and substance abuse outpatient clinic to address specific mental health issues.
Target Population and Inmate Profile—Demographics
The jail primarily houses men and women who are incarcerated for traffic, drug, alcohol-related, and property offenses (Sheriff–Hancock County, n.d.). Other crimes include forgery, petty theft, and misdemeanor assault. The male-to-female ratio is typically 80:20. The predominant race is White, and the typical marital status is single. Approximately 25% of the people incarcerated at this jail have a diagnosed mental illness, such as depression, schizophrenia, or bipolar disorder, and 70% to 80% are reported to have a dual diagnosis, such as alcoholism and bipolar disorder (Sheriff–Hancock County, n.d.).
The OT process begins with administration of an occupational profile that summarizes data on demographics, previous activities of daily living, IADLs, previous and current time usage, medical history, self-defined strengths and weaknesses, and preferred outcomes defined by the participant. The Allen Cognitive Level Screen (ACLS) is administered to determine the person's cognitive level, gauge his or her capacity for learning and goal setting, and focus on intervention delivery (Asher, 2007; Brown et al., 2019). This tool assesses ability to follow directions, attention to task, problem-solving skills, and judgment (Allen, 1991; Brown et al., 2019). Sensory responses to environmental input collected by the Adolescent/Adult Sensory Profile provide valuable information about this population. This self-report questionnaire defines sensory processing capacities as low registration, sensation-seeking, sensory sensitivity, and sensation-avoiding behaviors based on responses to questions that are structured as “I feel . . . when.” Responses are rated on a frequency-focused Likert scale with responses that range from “almost never” to “almost always” (Asher, 2007; Brown et al., 2019). Because of the known prevalence of trauma among this population, the Adverse Childhood Experiences (ACE) score is used in the evaluation process. This self-report questionnaire asks individuals about childhood traumatic events with a yes/no answer format (Centers for Disease Control and Prevention, 2019). Scores range from 0 to 10, with higher scores indicating a greater number of traumatic experiences. These assessment tools were selected for their established reliability and validity and are widely used in OT across practice settings, including corrections (Brown et al., 2019). Collectively, these assessment tools provide a holistic profile that reflects the complex factors that affect the occupational performance of a population of individuals who often have various co-occurring medical conditions and a history of trauma.
The demographic features of this population are reflected in a composite profile of 59 participants who completed the program. This group included 46 men and 13 women, with a mean age of 30 years. Approximately one third of the participants (19) had completed some high school, and the vast majority did not have a high school diploma (86%). One inmate was working toward earning high school-level academic skills through a General Educational Development (GED) program, 13 already had a GED, 17 had some college credits, and 1 had an associate's degree (Table 1).
Characteristics of the Participants (N = 59)
Assessment showed total mean scores for Sensory Profile quadrants as follows: Quadrant 1, 33.203 (low registration); Quadrant 2, 47.898 (sensory seeking); Quadrant 3, 34.237 (sensory sensitivity); and Quadrant 4, 35.271 (sensory avoiding). Each quadrant has a maximum possible score of 75. For cognitive level, the total mean ACLS score was 5.125, whereas the mean score for men was 5.117 and for women was 5.169 (exploratory action level). The total mean ACE score was 4.7, with a mean score for men of 4.63 and a mean score for women of 5.154 (Table 2).
Assessment Results (N = 59)
The most frequently identified outcomes from the occupational profile included the desire to develop healthy, positive decisions and supports. In addition, the findings identified a need for improved concentration, time management, motivation, and coping skills. Information obtained from the occupational profile and the other assessments was beneficial when identifying and tailoring occupation-based interventions that emphasize the importance of doing for people to learn and develop the necessary skills for successful employment and reentry to the community.
Program Development, Description, and Modules
The five-module Life Skills Program, with set objectives identified for each module, is the product of a comprehensive needs assessment. The results of the needs assessment, including a review of the literature, led to the identification of focused attention on interpersonal communication, employment, financial management, leisure skills, and community resources (Neller et al., 2016). These modules were implemented initially as a short-term pilot program and were subsequently determined to meet the needs of the population. Specific educational topics and doing activities were chosen based on information gathered from group participants. Before beginning each module, participants complete a survey to prioritize areas of skill development. This survey allows participants to create personal goals to facilitate accountability and investment in the program. This goal-setting activity builds on processes of goal identification after completion of the Kawa diagram and consideration of personal barriers and attributes that affect occupational performance. At the end of each module, group members complete a survey to identify specific skills that they have learned.
The overarching goal for the OT program in the jail is to have participants develop and use the life skills necessary to pursue long-term engagement in productive, positive occupations after release. The program includes five 1-week modules that address interpersonal communication, employment, financial management, leisure skills, and community resources. Each group accommodates six to eight men or women. Participation is voluntary, and group members are selected and referred through a screening process that includes jail staff, ancillary staff, inmate self-referral, and OT students. After a referral is received, potential participants are screened to gather baseline information. Program modules are structured to address broad population needs, focusing on the dynamic interaction of the participants, their environment, and their choice of activity. Each module is tailored to address the varying needs of group members.
Interpersonal Communication Module
A positive self-image and authentic communication are important to an individual's state of well-being (Cole, 2018). A change in life roles or a stressful event can disrupt many areas of occupational performance. Recognition of continuous dysfunctional patterns in daily life is imperative for a person to begin the process of making important life changes (Kottorp, Heuchemer, Lie, & Gumpert, 2013). The interpersonal communication module is designed to increase awareness of dysfunctional habits and empower group participants to develop a positive self-image, increase positive coping skills, and practice effective communication. This module incorporates cognitive and behavioral concepts that are consistent with the MOHO (Kramer, Kielhofner, & Forsyth, 2008). It was chosen as the first module because it includes concepts related to interpersonal communication that are reinforced in subsequent modules. This module uses Kawa river drawings to facilitate initial group discussions. The Kawa drawing offers participants an opportunity to look at their personal situation objectively, reflect on the lives of others, identify similarities and differences, and increase self-awareness. In the first session, goals are set for the development of interpersonal communication skills to use in routine life circumstances and environments. Since the program was initially designed, this module has evolved to include interventions that focus on coping skills and self-regulation techniques to increase the likelihood of success in situations where effective communication skills are necessary.
Participants also learn and practice other important aspects of effective interpersonal communication, such as nonverbal communication and body language. As self-awareness increases, participants are encouraged to recognize and consider that others may have preferred communication styles that differ from their own, and they are provided with opportunities to practice adapting their own communication approaches. The module includes activities and training to address sensory needs, assertiveness, and coping skills, and participants discuss and practice self-regulation techniques. Participants are encouraged to incorporate these regulation techniques while incarcerated to improve interpersonal communication on community reentry.
People with a history of incarceration are challenged to find employment after release (Bender et al., 2016; Harrison & Schehr, 2004). The search for meaningful work opportunities is often hindered because of employment restrictions and the stigma of a criminal record, imposing an additional barrier for ex-offenders who are seeking employment. According to correctional staff, much of the population was unemployed before population and many of these individuals do not have the skills needed to secure employment after release (Captain R. Kidwell, personal communication, March 25, 2011). The employment module is designed to help participants to gain the necessary skills to locate, obtain, and maintain employment, and it often focuses on preemployment skill development. Sessions include how and where to look for a job in today's employment market, how to participate in employment interviews, and how to complete and submit job applications and résumés. In this module, participants learn how to manage interview questions about convictions and crimes. Participants are coached on how to construct a script that addresses what they have learned from being incarcerated, changes they have already made, and their future plans for employment. Participants engage in mock interviews with OT students to enable them to practice explaining their conviction and to build confidence. Seeking and securing a job is often an unfamiliar process for people in this program. During one of the employment groups, participants create a pocket card that includes all of the information typically required to complete a job application. This practice provides structure and allows participants to complete actual job applications in an organized and timely manner. The final activity in this module is participation in a mock job interview. Participants demonstrate skills learned throughout the week and receive feedback on ways to present themselves positively and effectively.
People who are incarcerated often do not have basic financial skills and can benefit from training to facilitate successful community living (Koenig, 2007). In the finance module, participants are exposed to the basic principles of budgeting, managing a bank account, understanding credit and insurance, and financing. They participate in practice scenarios to develop basic financial skills through a variety of daily activities that are designed to increase personal financial responsibility and develop competency in money management. Initial considerations include developing an understanding of the differences between wants and needs and recognizing the effect that these concepts have on the ability to meet regular financial obligations. For example, participants learn how to manage monthly bills and routine expenses and how to develop a budget that allows them to exert a level of control over the costs of independent community living. In addition, they receive information on how to manage bank accounts and pay bills and are given tips and strategies for saving money. They practice these skills with an innovative money management game that was developed specifically for this program. During this module, participants are fictitiously assigned a job, a salary, and other routine expenses that they must manage throughout the week by applying the skills that they have learned. Participants receive daily life scenario cards that present them with real-life circumstances and require the application of their newly acquired skills. These exercises give participants an opportunity to discuss possible solutions with other group members and the OT student group leader. Participants routinely express appreciation for the practice scenarios and for the opportunity to enhance their abilities through simulated activities. Many participants state that the development of IADLs can help them to develop financial goals and lead more effective and productive lives after release.
Leisure participation is an area of occupational performance that OT practitioners regularly address with individuals who are incarcerated (AOTA, 2014). Leisure activities can be used to achieve cognitive, physical, social, and psychological benefits that are necessary for balanced and healthy living (Bundy & Du Toit, 2019). In this module, participants explore, identify, and participate in multiple leisure activities. These activities are used to reinforce and practice social skills, increase attention to tasks, and improve self-efficacy and self-esteem. The leisure module is designed to assist participants to commit to positive and healthy leisure choices that support a prosocial life. This module offers participants the opportunity to identify and reflect on their previous leisure activities and identify times when difficulties arose. The module explores ways to minimize participation in ineffective leisure strategies and encourages participants to consider healthy alternatives (Bundy & Du Toit, 2019). This module is the least structured and most flexible of all of the modules because it attempts to integrate the participant's specific leisure interests. Participants complete a leisure checklist to facilitate their consideration of options for healthy and productive leisure occupations. To promote continuous self-awareness, participants complete activities that consider work/life balance to develop competencies that allow them to create a healthy balance for their daily routine. Each day, a group member or the group facilitator selects and teaches a different leisure activity that may include crafts, games, food preparation, appropriate holiday activities, dancing, or exercise. Participants also learn about volunteer activities and the fulfillment that they can provide. During this module, participants often complete activities that build and/or support leisure skill development. Many participants report few opportunities to learn and develop socially acceptable leisure activities. Participants are encouraged to consider alternative healthy leisure activities for unstructured times, which may reduce engagement in criminal activity after release. This module provides an opportunity to learn a process to explore and acquire new leisure skills.
Community Resources Module
This program prioritizes connection to community resources and supports. During the final module, participants are introduced to community resources that can help to meet their needs after release. A key component of this module is the development of an individualized plan that emphasizes setting boundaries and identifying positive supports that promote success on release. This module was originally conceptualized as a housing module, but it quickly expanded to introduce additional services offered by a variety of community agencies that support community reintegration. Significant effort is made to develop rapport with participants to increase their awareness of specific community services. The module focuses on how to navigate the process of working with community agencies. Representatives from these agencies routinely attend group sessions to share their knowledge and explain the required processes. This personal connection has been a hallmark of this module and has increased participants' use of community services to achieve short- and long-term goals. The importance of developing healthy boundaries and appropriate relationships for support is emphasized.
The Life Skills Program at the Hancock County Jail highlights the importance of understanding the connections among trauma, mental illness, substance use, and sensory processing. Trauma, mental health issues, and substance use add a layer of complexity that affects all aspects of the lives of men and women who are incarcerated (Muñoz, 2019). This county jail OT program is unique in the corrections community, and the evidence suggests that there are few, if any, OT programs available in county jails.
Occupational therapy adds a distinct value to existing jail programming that emphasizes rehabilitation and recovery by focusing on community living skills. This focus is consistent with the historical domains of practice in OT (Eggers, Muñoz, Sciulli, & Crist, 2006; Muñoz, Moreton, & Sitterly, 2016). The introduction of a comprehensive occupational profile for participants has enabled this OT program to meet both collective and individual needs. The collection of baseline data has allowed for consideration of the many factors that contribute to the skill sets of participants and the establishment of appropriate goals. The dissemination of this OT modular Life Skills Program is the first step in the evolution of this emerging practice area in county jails. The implementation of this program to meet an identified community need is the first in a series of related projects that are being developed to address the occupational needs of this growing, emerging population.
The limitations of this project relate to the initial sequence of events that led to early program development and implementation. When the opportunity arose to develop this program, initial efforts were focused on needs assessment and program development and implementation. At the program's inception, program evaluation and data collection were still being determined. As a result, the initial stages of the program included few documented or formal outcomes. However, the program and modules became more firmly established in 2015 as additional faculty joined the team and the structure and delivery of modules became routinized. This modular program is now continuously delivered by Level II graduate students enrolled in the University of Findlay's master of OT program and is supervised by an OT faculty member. Rotation of students through 12-week fieldwork experiences leads to regular turnover of the students who deliver this program and reduces the reliability and consistency of inmate assessment and delivery of the program modules. Finally, space and security limitations at the county jail affect the doing aspects of this program and limit opportunities for interventions that can be included in the program modules.
The faculty of the University of Findlay's OT program determined in 2010 that the county jail provided an opportunity to demonstrate the distinct value of OT to those working in the corrections system, specifically, the county jail. Since that time, the greater community, the mental health community, and the local corrections community have shared the value of the doing aspects of OT to improve individuals' chance of achieving successful reentry and productive community living. Members of the corrections staff, correctional officers, and jail administrators have expressed their appreciation for the way in which OT facilitates the development of life skills that are necessary for productive community living. The OT focus on practicing these skills in a hands-on manner (becoming) compared with other services that are provided primarily through discussion and educational sessions has been well received by jail staff and participants. The OT Life Skills Program is provided eight times each year, totaling approximately 629 OT group interventions annually.
The importance of the addition of this program to the county jail has become evident to the jail personnel and to the faculty and students who deliver the program. Participants are better prepared when they encounter and respond to routine life tasks and situations on reentry to the community. A more structured system of collecting, recording, and analyzing participants' data has been developed and is being implemented to provide more thorough and consistent outcomes that reflect the value of the program. Additionally, to enhance the current results, qualitative measures are being considered to explore the benefits of the program as perceived by participants and jail staff. It is hoped that this information will provide further insight into the effectiveness of this program.
The OT program faculty believes that the development and implementation of this program embodies the intent and spirit of the American Occupational Therapy Association Vision 2025 (AOTA, 2017) by demonstrating the distinct value of OT in an emerging practice area. Observations by OT faculty and informal feedback from other constituent groups have indicated that this OT Life Skills Program is important and should continue. Subsequent studies are under development to provide data to assess the overall effectiveness of this innovative and ongoing program.
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Characteristics of the Participants (N = 59)
|Age, mean (range), years|
| Total||30.2 (18–57)|
| Male||30.0 (18–51)|
| Female||30.8 (19–57)|
|Educational level, total, na|
| Did not finish high school||13|
| Completed high school||8|
| Completed a GED||12|
| Completed some college||12|
| Did not finish high school||4|
| Completed high school||2|
| Completed a GED||1|
| Completed some college||6|
Assessment Results (N = 59)
|Initial occupational therapy assessment||M||Range|
| SP Q1|
| SP Q2|
| SP Q3|
| SP Q4|