Mental Health Chapters 39 and 44

Occupational imbalance

"A lack of balance or disproportion of occupation resulting in decreased well-being" In correctional institutions, the environment creates conditions that can significantly limit the opportunity for a person to experience a balance of physical, mental, social, and restful occupations. Wendell is 72 and attempting reintegration after 21 years in prison. A "busy" day is when he cleans his small apartment and takes a walk to a local park where he sits for hours watching squirrels play.

bench warrant

A judge's order for the arrest of a person

parole

A period of control and monitoring that occurs after a person's release from incarceration

global functioning interventions

Addressing emotional function, and quality of interactions, helps the occupational therapist understand the challenges the service member or veteran is experiencing and his or her level of self-awareness A service member sustained a femur fracture during a vehicle accident. She completes a functional scale and reports she cannot walk more than a block without experiencing pain in her leg. She reports staying in her room because of pain and worries about being discharged from the military. The service member is depressed, tired, and feeling useless. Assess the service member's insight into her injury and structure therapeutic groups to focus on pertinent topics. For example, identify three local grocery stores that will allow the service member to conserve her energy

incarceration

Being held in a jail, prison, or other criminal justice setting to serve a sentence or await disposition

bail bond

Financial obligation signed by the accused to ensure he or she appears at trial; the accused will lose this money if he or she does not appear for the trial

sleep interventions

Many service members and veterans find it difficult to maintain healthy sleep cycles because of chronically poor sleep hygiene. Many report that they wake up multiple times throughout the night because of pain, nightmares, restlessness, or insomnia A service member experiences night terrors because of his last two deployments that are so horrific he refuses to sleep with his wife for fear that he may hurt her. After waking he is unable to stop his racing thoughts and will get up and watch TV or play video games Within a group setting the occupational therapist educates the service member on proper sleep hygiene and relaxation techniques, such as guided meditation, grounding, or diaphragmatic breathing.

deposition

Testimony of a witness or a party taken under oath outside the courtroom

Occupational reconciliation

This concept describes a person's submissive response to stifling environmental conditions. Loneliness, lack of stimulation, and limited resources can lead a person to "give way to their circumstances and engage in limited occupations because of their restricted opportunities" Confinement spaces can be overcrowded, boring, and dangerous. For example, Francis has resigned himself to a routine in which he spends a lot of his time alone and he chooses not to engage in opportunities to develop his potential. He is alone even when eating in common spaces, and does not exercise, read, or participate in any prison activities. Francis's reaction to this environment was to "just do my time."

Community-Based Services

Veterans living in the community who are working through BH challenges because of dysfunction, disorganization, or a transition into civilian life Any occupational therapy practitioner working in the community who addresses needs such as homelessness, leisure exploration, student-based services, or transition to civilian services. ADLs, IADLs (leisure), professional development, goal setting, and life skills (e.g., social skills, time and money management)

noncustodial sentence

If the adjudication process results in a conviction, a judge imposes a sentence that may include incarceration, or it can be a ______________ (i.e., a penalty other than incarceration) -In most countries there exist a range of noncustodial sentences. -For example, offenders may complete unpaid community service as an alternative to incarceration or be ordered to pay restitution (i.e., compensation for their criminal behavior) or a fine Individuals on probation often have court-defined directives that impact participation in occupations or environments -For example, the person may be banned from possessing alcohol or firearms and be expected to meet routinely with a probation officer, a person assigned to supervise the offender -The person may be expected to find employment, may be restricted geographically, or may be prohibited from contacting victims, minors, or known accomplices

Recidivism

Repetition of criminal behavior resulting in a return to incarceration

Adjudication

The formal delivery of judgment about whether a law was broken and, if so, the sentence for the person convicted of the crime

Occupational apartheid

"Refers to the segregation of groups of people through the restriction or denial of access to dignified and meaningful participation in occupations of daily life on the basis of race, color, disability, national origin, age, gender, sexual preference, religion, political beliefs, status in society, or other characteristics" This concept challenges practitioners to examine the social, economic, and political conditions that deny or restrict opportunities for participation for justice-involved individuals. For example, in some states, people convicted of a felony are disqualified from registering to vote, voting, and in some cases from running for office; are restricted or not eligible for federal loans or grants for education; and may not be eligible for government assistance such as welfare or supplemental nutrition assistance programs

Occupational alienation

"Sense of isolation, powerlessness, frustration, loss of control, estrangement from society or self because of engagement in occupation which does not satisfy inner needs" A person can be challenged to feel connected, productive, or to have a sense of purpose when his or her rhythm of life is monotonous and repetitive in a criminal justice setting. Once released, Mr. Hardy continued a well-practiced pattern of isolation he demonstrated in prison. Despite having a vibrant community center operating literally next door to his home, his sense of immobilization and inertia made it impossible for him to utilize this resource.

Occupational enrichment

"the deliberate manipulation of environments to facilitate and support engagement in a range of occupations congruent with those that the individual might normally perform" Criminal justice settings place significant restrictions on inmates' opportunities for engagement in meaningful activities -Expanding opportunities for engagement is a useful strategy for occupational enrichment However, unique challenges to occupational enrichment exist in justice settings -it is difficult to find ways to individualize interventions in a context where conformity is a valued method for confinement and control. -Modification of the physical and social environment, which are hallmarks of implementing a PEO approach, can be challenging when the environment and rhythm of routine are designed to severely restrict the inmates' capacity to gain any measure of control over their environment -it is challenging to provide offenders with a choice regarding how they orchestrate their daily routines in an environmental context where nearly every activity is completed in a manner dictated by the correctional institution Relative to incarcerated populations, occupational enrichment refers to direct interventions in the social, physical, and cultural environment that address occupational deprivation. For one person attempting reintegration, constructing a raised garden box in her grandmother's yard generated opportunities for her to rekindle her interest in gardening, interact with her grandmother around a common interest, and, eventually, engage neighbors when she shared or sold her produce.

Occupational deprivation

"the influence of an external circumstance that keeps a person from acquiring, using, or enjoying something", is a tacit dimension of the environment in correctional institutions. not only limits opportunities for participation while the person is incarcerated, but can also pose significant barriers to successful community reintegration post-release The end result of occupational deprivation can include diminished capacities, reduced self-efficacy, and significant loss of identity as a citizen of the community "Deprivation of occupational choice and diversity because of circumstances beyond the control of individuals or communities" "Deprivation is distinguished from a disruption in occupational choice because it is a process that occurs over a long period of time" Occupational deprivation is an implicit characteristic of correctional settings. The impact of systematically denying a person's ability to make choices for participation in meaningful and health-promoting occupations can negatively impact reintegration. For example, Jonathan is recently released after a 12-year incarceration. Postrelease, he finds he is easily overwhelmed by the adjustment to unstructured time, open spaces, and crowded environments, which trigger his anxiety and feelings of incompetence

Combat Operational Stress Control (COSC) Unit

(on battlefield) Service members deployed to a theater of operation who are experiencing a potential stress reaction Normalize the reaction through therapeutic use of self to enable service members to successfully complete the deployment. Work hardening and life skills (e.g., coping skills, leisure management, communication skills)

Maintaining Security in the justice system

-Any keys should be concealed and secured. -Never put keys down anywhere. -Educate yourself to know how offenders can use keys, tools, food, chemicals, and cleaning or medical supplies to escape or cause injury to self or others. -Know how to call for emergency assistance if needed, and be clear on how you should respond should an alarm sound. -Understand procedures for maintaining and controlling materials and tools within the occupational therapy environment. -Organize workspace to always maintain clear access to an exit and to emergency alarm systems. -Always double check gates, doors, cabinets, windows, and so on, to confirm that the lock is functioning. -It is your responsibility to fully understand security procedures and requirements, to find out when you are not sure, to ask when you visit a new facility, and to make sure you always follow procedures (e.g., policies for escape prevention, emergency response, custody escorts, lockup units, tool control, syringe counts, key control). -Strictly observe rules for what can and cannot be taken into a correctional setting, and limit the personal possessions you carry as much as possible.

General Strategies for Working With Offenders

-Wear appropriate, modest clothing. -Do not make promises that you may not or will not keep. -Know the consumer; seek out information about any risk that any consumer may represent. -Do not give or accept gifts. -Guard personal information (e.g., personal circumstances, family details, home address, telephone number). -If an offender is distressed or escalating at the end of your therapy session, make sure to communicate this to corrections staff. -Always share information when an offender discloses any intention of self-harm, suicide, physical violence, uprising, or escape. -Always disclose to staff if an offender at your setting is a personal friend or relative. -Do not do favors (e.g., run errands, mail letters, make phone calls) for offenders or ask them to do a favor for you. -In community corrections settings, do not agree to transport a resident anywhere if you have not read a detailed risk assessment; even then, make sure you carry a mobile phone and that other staff know your travel plan, including expected departure and arrival times. -Avoid meetings in your own community, and do not give details that disclose where you live

courts

A country's court system is responsible for adjudication, or making judgments about whether a law was broken and, if so, defining the sentence for the person convicted of a crime. The way in which the court system works depends on which part of the system has jurisdiction, or the authority to make a judgment. -In the United States, jurisdiction can occur at various levels, including the local, city, state, or federal levels and can also be determined by a tribal government or the military Criminal justice systems differ across countries As an occupational therapy practitioner working in a criminal justice setting, it is useful to have a general understanding of the hierarchy of courts and a specific

diversion

A disposition before or after adjudication; the court diverts the defendant from incarceration to participation in a work, educational, or rehabilitation program

Acquitted

A judgment, by a judge or a jury, that the person being charged has been found not guilty of the offense(s)

probation

A judicial sentence of community-based supervision or a requirement that a person fulfill certain conditions of behavior in lieu of incarceration; probation can include a fine, a jail sentence, or both

correctional officer (CO)

A person who maintains custody and security of justice-involved individuals, usually within the confines of a correctional institution

Risk management

A process of identifying, controlling, and minimizing the impact of negative events, such as systematically applying policies, procedures and practices, and vigilance when identifying, evaluating, addressing, and monitoring risk

felony

A serious crime, often involving violence, punishable by imprisonment of at least 1 year that may result in a death sentence

Halfway or transitional house

A transitional facility where the offender lives and is involved in school, work, training, and so on, while stabilizing for reentry to the community

work release

An alternative to continuous incarceration whereby offenders work for pay in the community but return to the correctional institution during nonworking hours

misdemeanor

An offense that is less serious than a felony but punishable by a fine or incarceration, usually in a local confinement facility and typically for 1 year or less

Justice System Demographics

Different countries have different objectives for incarceration, but most often the stated goal is public safety. -Incarceration maintains secure control of a person and deprives the person of certain liberties and occupations While incarcerated, a person can receive rehabilitation to address underlying issues that led to criminal behavior and reduce the possibility of recidivism, or the repetition of criminal behavior that results in incarceration. -In practice, rehabilitation is often not the focus of incarceration In the United States, people with significant physical and mental health conditions are often incarcerated in justice settings; treatment for these conditions is not optimal, and most leave incarceration without health care -While incarcerated, many individuals are further transformed into criminals, which can lead to post-release occupational patterns of reoffending and recidivism

Evaluation of Service Members and Veterans

Assessing the service member or veteran for inpatient, outpatient, or group therapy intervention is similar to civilian occupational therapy BH care An initial intake interview is typically utilized to generate the occupational profile of the service member or veteran. -Practitioners with an understanding of military culture can deepen their understanding of the individual by considering their occupational history and performances through the lens of the military mindset -A deeper understanding of the service member or veteran can be gained by considering potential work stressors or role identity challenge The practitioner also collects data on the individual's current or potential living arrangements, which may further inform the amount of social support available -Knowing their assigned unit will provide additional insight into their operational tempo (e.g., schedule of deployments and training cycles) and additional work and family separation stressors. In addition to interviews, the occupational therapy practitioner needs to familiarize himself or herself with other assessment tools that may be part of the service member's medical record. -These tools are often completed by other members of the BH team, such as the psychologist, neuropsychologist, or psychiatrist and may include the PTSD Checklist (PCL-5), the PTSD Checklist-Military Version (PCL-M), and the Mississippi Scale for Combat-Related PTSD (M-PTSD) In addition to the PTSD questionnaires, the neuropsychologist and other members of the medical team often complete assessments such as the Military Acute Concussion Evaluation (MACE) and post-deployment health assessments (PDHA) to assess for concussion or TBI.

Combat and Operational Stress Control Units

Combat units have exhausting deployment schedules and continuous operations that can physically and emotionally deplete even the most resilient service member In the early 1990s, the Army Medical Department recognized that education and awareness of COSR were instrumental in preventing more severe BH pathology -The need for unit commanders to offer an expedient intervention to service members who present with COSR, which focuses on normalizing reactions and reinforcing coping mechanisms, led to the formation of COSC unit -The Army began deploying these specialized BH units to provide prevention and treatment interventions on the battlefield with the primary goal of keeping the service member with the unit. COSC units provide restoration, reconditioning, reconstitution, and stabilization focusing on returning service members to duty -The units are multidisciplinary and include psychiatrists, psychiatric nurses, psychologists, social workers, occupational therapists, occupational therapy assistants, chaplains, chaplain assistants, and BH specialists from all branches of service COSC personnel seek to re-instill service members' sense of self-efficacy and return them to duty as quickly and as safely as possible. -Service members who are unable to RTD may be evacuated to a combat support hospital located near the battlefield or to a larger MTF overseas or in the United States

problem-solving court

Courts designed to address a defendant's underlying problems and assign remediation, restitution, or rehabilitation as alternatives to incarceration (e.g., drug courts, mental health courts, and veterans' courts)

Occupational Risk Factors

Criminal justice settings are contexts that create unique problems and obstacles to implementing occupation-based practice. -These settings are established to confine; therefore, the primary goal is to maintain order and security, not to provide rehabilitation -Maintaining security often results in practices that significantly restrict opportunities for engagement in a wide variety of occupations A person with mental illness experiencing prolonged confinement may feel isolated, bored, and frustrated at the lack of opportunities for participation in activity Occupational deprivation provides a useful conceptual framework for understanding the environmental contexts of criminal justice settings -Occupational engagement provides a conceptual lens for designing skill-building and role development interventions that can provide opportunities for participation despite contextual limitations and may help practitioners create skill building approaches that can support successful community reintegration post-release

Skill Sets for Practitioners in Justice Settings

Evaluation -Choose measures that reliably assess performance and measure change. -Generate an occupational history and profile inclusive of criminal history. -Elicit the person's perspectives on performance, employment, and social participation. -Assess and address gender-specific needs. Interpersonal -Initiate therapeutic relationships with inmates. -Collaborate effectively with criminal justice personnel. -Practice effective listening skills. -Develop strong deescalation strategies. -Cultivate strong culturally responsive communications skills. Intervention -Collaboratively develop occupation-based, recovery-focused interventions. -Facilitate the person's ability to engage in constructive use of time and opportunities to self-structure time use. -Deliver interventions that emphasize skill and attitude development and habits for productive role functioning and employment. -Utilize interventions emphasizing health, wellness, and mindfulness Judicial systems -Learn about justice systems, including structure, processes, and terminology. -Become familiar with justice subculture and criminogenic lifestyles. -Understand process and methods for risk assessment and management. -Recognize the range of pre-release and post-release options. -Appreciate the importance of social participation and the critical role that family, friends, and social networks contribute to recovery. -Understand social, occupational, and restorative justice perspectives Practical skills -Document clearly and concisely, and always maintain confidentiality. -Practice coping skills to manage institutional and environmental stressors. -Be vigilant and proactively recognize, assess, and manage risk. -Learn self-defense to ensure personal safety. -Scan community environment to be able to access programs having expertise serving ex-offenders with mental illness. Professional development -Practice consistent professionalism and show confidence in your professional identity. -Demonstrate a strong commitment to ongoing professional development. -Advocate for the creation of occupationally enriched environments within the structures of secure environments. -Advocate by defining the role and delineating how occupational therapy contributes to the intervention team and the person's success at recovery

assessment tools in the justice system

Evidence from the literature reveals that occupational therapy practitioners in justice settings are using a wide variety of assessment tools -Overall, occupational therapy has not designed and tested assessment tools specifically tailored to people involved in the criminal justice system An interview can help a practitioner develop a comprehensive occupational profile. -One interview tool specifically designed to assess the explicit needs of incarcerated populations is the Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) -The OCAIRS is a semistructured interview based on MOHO -Interview questions have been modified for use with forensic populations. -Questions are designed to elicit data on roles, habits, personal causation, values, readiness for change, interests, skills, goals, interpretation of past experiences, and the physical and social environment For individuals who understand the metaphors used when considering one's life as a flowing river, the Kawa Model interview process can be a useful interview approach -This method asks the person to portray his or her life as a river that has problems (rocks) to contend with and elicits useful data for understanding how the person's social and physical contexts (river banks) impact his or her life and problem-solving. -In this process, the person identifies assets and attributes (driftwood) that he or she brings to managing his or her life situation -The overall image that is created can help better understand the person in context, and a skilled practitioner can use the image as the basis for focused interviewing and collaborative intervention planning -Most often it is used in a way to help the person portray his or her current life situation, but it can also be used to encourage the individual to represent his or her life history. The Offender Reintegration Scale (ORS) is an example of a self-report tool specifically designed for justice populations -The ORS measures the apprehensions and barriers that people facing reentry are concerned about. -It is structured to be self-scored and self-interpreted; however, similar to most self-report tools, an effective approach is for the practitioner to complete this tool collaboratively with the person -Reviewing the results of this measure with the person can help ensure meaningful transition planning -The ORS surveys the respondents' concerns for basic needs, job searching, family relationships, life skills, and career development. The Model of Human Occupation Screening Tool (MOHOST) is designed to provide an expansive overview of a person's occupational participation -The MOHOST is a good choice when the practitioner has regular opportunities to interact with the person and the person can participate in meaningful occupations that allow the practitioner to effectively evaluate performances. -When the practitioner has sufficient evaluation information, the MOHOST is effective as a screening tool to identify challenges a person may have in his or her occupational performances -It helps the practitioner focus on areas where follow-up with specific assessments can support the development of a comprehensive occupational profile.

Mental Illness and the Criminal Justice System

In 2011 to 2012, approximately one in seven individuals held in state or federal prisons and one in four jail inmates self-reported symptoms consistent with serious psychological distress -The most commonly reported disorders were depression, bipolar disorder, anxiety disorders, posttraumatic stress disorder (PTSD), personality disorder, and schizophrenia, in that order Because of differences in measurement, accurate prevalence of mental illness is not known, but major reviews conclude that prevalence rates for mental illnesses in people in the criminal justice systems are significantly higher than rates in the general population -A systematic review of studies examining prevalence rates for psychiatric disorders in older prisoners reported that, when compared with older people in the community, prisoners had higher rates for depression; PTSD; psychoses; and bipolar, anxiety, and personality disorders -In a meta-analysis of 42 studies examining the prevalence of attention deficit-hyperactivity disorder (ADHD) in incarcerated populations, the prevalence rate in youth populations was five times higher (30.1%) and the prevalence rate of adult prisoners was 10 times higher (26.2%) than rates found in the general population -researchers noted more problems in youth when there were family problems of alcohol and drug use, where parental incarceration existed, and when the youth reported drug use, depression, bullying, or sexual assault There is clear evidence that the number of people with mental illness in U.S. jails and prisons is substantial and that, at least in the United States, the ability to provide sufficient mental health services to offenders is inadequate -in 44 of 50 states there were more people with mental illness imprisoned in each state than there were in state psychiatric hospitals in the states -For many individuals, entering the criminal justice system represents the first opportunity to access substance abuse treatment and mental health counseling as well as other aspects of health care.

legislators

In democratic countries, legislatures or parliaments have the authority to make new laws or refine old ones. -Legislators who craft and vote on these laws are often very cognizant of societal concerns and political pressures for addressing criminal behavior Occupational therapy practitioners need to appreciate how laws and policies reflect the country's values and beliefs, as well as their approaches toward crime prevention, punishment and rehabilitation, and the social, political, and economic realities of their country

residential reentry centers

In the United States, the Bureau of Prisons contracts with community-based residential reentry centers to provide structured, supervised community reentry services These centers are not specifically designed to address the unique needs of a person with mental illness; however, it is a well-established fact that ex-offenders have a high rate of mental illness, that prisoners attempting to reintegrate into the community face a multitude of challenges that can negatively impact their mental health, and that women, veterans ,people with addictions, and sex offenders all experience significant mental health challenges. -Community reentry centers assist residents with reintegration planning, job placement, and financial management; help them to locate permanent housing; and connect residents with an array of community services that can support their recovery and return to the community Generally speaking, these centers expect rigid adherence to a strict schedule, and periodic, random head counts are common -Residents are not restricted to the center, but they must sign in and out of the facility, and random calls or visits to employment sites can be used to monitor their location -Random drug and alcohol tests can also be administered to people sentenced to a community reentry center. The level of security at community reentry is similar to a minimum security setting, and multiple strategies are used to monitor the movements of the residents -Those with noncompliant behavior can be restricted to the center, whereas on the other end of the continuum, those who are meeting obligations and who have a release plan may be able to spend extended time at their own or a family member's home to support their transition

Leisure Exploration Programs

Individuals with conditions such as anxiety, depression, or PTSD may exhibit isolation and loss of interest in activities. -This often increases stress, anger, and fear, while decreasing self-esteem and quality of interpersonal relationships through maladaptive behaviors Leisure and social participation intervention have been identified to have a positive effect on veterans with PTSD, such as a decrease in symptoms of PTSD and depression, increase in positive mood and affect, a heightened awareness of their emotions, and overall reports of increased quality of life Practitioners using behavioral modification techniques can facilitate identification of maladaptive responses and assist the service member or veteran to re-engage in meaningful activities. Engagement or reengagement in meaningful leisure can help overshadow derogatory or self-defeating responses and bring pleasure to activities, resulting in overall well-being

Military Treatment Facility: Inpatient (MTF)

Service members or military dependents who are seeking care because of BH concerns Identify the current challenges or dysfunction and create a plan to improve coping skills. ADLs, goal setting, and life skills (e.g., anger, time, money, and medication management)

stress interventions

Many service members or veterans have stressful jobs and lack the ability to manage their stress A service member has been in the military for 13 years and recently returned from his third deployment. His wife is expecting their first child and he is having a hard time adjusting to being home and is terrified that he won't be a good dad. The service member's perceived stress scale score is high. Determine the reasons why he thinks he will not be a good dad and challenge those beliefs through group therapy and purposeful activity. The therapy can focus on leisure activities that he is skilled in and enjoys. This can give him a sense of accomplishment that can transition to his parenting style Occupation-based interventions for managing stress is a BH challenge for service members, veterans, and the general public alike. Poorly managed stress is a typical feature within many military personnel diagnosed with depression, anxiety, PTSD, and substance-related disorders and is a contributing factor to high rates of suicide

OT Process in Justice Systems

Occupational therapy practitioners around the world have recognized the fact that the profession has an important role to play in the rehabilitation of people within criminal justice systems for more than 70 years Despite recognition of occupational therapy's potential role in justice systems, the profession has moved slowly to articulate clear roles and establish guidelines for the scope of occupational therapy services within criminal justice systems. -One exception is the practice guidelines developed in the UK, which offer recommendations for occupation-focused practice in secure hospital settings

Role of OT in MTF

Occupational therapy practitioners working in a MTF may work in inpatient or outpatient BH settings. -Similar to the COSC, the BH team is multidisciplinary and may include psychiatrists, psychologists, social workers, psychiatric nurse practitioners, occupational therapy practitioners, and BH technicians Inpatient BH goals focus on transitioning stable patients from inpatient to outpatient clinical services. Outpatient occupational therapy BH services focus on the service member's individual goals and restoring full function to RTD or transition to civilian life. -Service members who transition to civilian life and have service-related illness or injuries may continue their health-care services at a VHA facility Occupational therapy practitioners are an integral part of the outpatient and inpatient BH teams at the MTF -practitioners conduct relevant screening and evaluation procedures to identify strengths, needs, problems, and concerns regarding the service member's occupational engagement, organization, and successful performance of ADL and instrumental ADL (IADL) tasks -Using the results of specific assessments, their understanding of military culture, and the service member's goals, the practitioner and the BH team design and implement an individualized treatment plan The most important component when determining the treatment plan continues to be the person receiving the treatment and his or her desired goals

Mindfulness and Yoga

Occupational therapy-led relaxation programs, such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), can help service members and veterans who are experiencing anxiety and having difficulties coping with symptoms arising from their experiences -MBCT and MBSR are BH approaches that incorporate elements of cognitive behavioral therapy with mindfulness-based programming Yoga, another relaxation technique, has the potential to complement other nonpharmacological approaches used to address anxiety

Military Treatment Facilities

Off the battlefield, the first level of care in which military occupational therapy practitioners provide services is in MTFs, such as hospitals and ambulatory clinics -These facilities are typically located at military installations throughout the United States and overseas, and provide health-care services to service members and their families The extent of BH services (inpatient and outpatient) offered at a MTF varies depending on the size of the facility, geographical location, and population served -Smaller MTFs and ambulatory health clinics are equivalent to civilian community hospitals and clinics and offer a variety of outpatient services, including BH services. -The larger MTFs are medical centers, equipped with state-of-the-art technologies, and are designed to handle complex long-term care and provide highly specialized services focused on the medical needs of the military population, such as burn and amputation care, as well as acute inpatient and outpatient BH rehabilitation care.

Veterans Health Administration

Once the service member has separated from the service, an option for continuum of care is the VHA -The VHA mission is to, "honor America's veterans by providing exceptional health care that improves their health and well-being" In the VHA, there are varying mental health services unique to veterans' health care and dependent on the size and location of the VHA Hospital System. -One service is the Domiciliary, which is part of the Mental Health Residential Rehabilitation Treatment Programs (MHRRTP). -These facilities provide a structured housing environment to address issues such as homelessness, substance use disorders, vocational training, and rehabilitative care needs The VHA also provides outpatient care in a psychosocial rehabilitation and recovery center (PRRC) for veterans with serious mental illness and significant deficits in function and occupational performance Finally, there are programs that assist veterans with BH needs through specific vocational training, such as transitional work programs, supported employment, or incentive therapy

Occupational Therapy Interventions in the justice system

Scaffa and Reitz suggested that services that focus on skill development, relapse prevention, community reintegration, and employment are appropriate interventions for occupational therapy programming in criminal justice settings -Collectively practitioners in these countries have developed intervention programs that focus on skill development, primarily vocational skills, as well as time management, self-awareness, leisure and life skills, and, to a lesser extent, focus on education, family, social skills, and role functioning -In the United States, there are several universities with community-university partnerships that are focused on meeting the needs of people in criminal justice systems

churning

The constant movement of people in and out of the criminal justice system, especially jails

Risk assessment in the justice system

One area of assessment specific to the criminal justice setting is risk assessment. At a practical, everyday level, practitioners working in justice settings need to recognize that assessment of risk is a dynamic process, and vigilance to ensure safety and security is a consistent component of the environmental context in these settings -Risk assessment involves therapeutic reasoning about whether the person may carry out high-risk behaviors that can include harm to self or other PEO model could frame risk assessment in secure settings for occupational therapy practice -the practitioner would consider aspects such as the person's past history, especially if it includes violent behavior; the person's current state of mind (e.g., one of motivation and purpose or frustration and resentment); and the person's self-regulation behaviors -Practitioners need to proactively manage risk by maintaining a secure environment, considering how the therapy environment is structured and maintained, and limiting access to equipment and supplies to ensure accountability for these materials. -Managing risk can also be accomplished through effective activity analysis and thoughtful consideration of the occupations presented in therapy Risk assessment is also a crucial management function in justice settings because it is a means to gauge a person's potential to commit another offense and evaluate the risk of violence -Risk assessment is typically performed by psychologists and psychiatrists -Common risk assessment measures include the Psychopathy Checklist-Revised (PCL-R), the Level of Service Inventory-Revised, and the Violence Risk Appraisal Guide

Pain interventions

Pain is common after experiencing a traumatic event and may be an indicator of stress and anxiety. The occupational therapist will gain insight on the service member's/ veteran's tolerance for specific activities or times of the day by evaluating pain levels before, during, and after treatment sessions. This in turn will assist the occupational therapist and service member in planning daily activities. A service member suffers from frequent migraines. After tracking her daily activities and pain levels for 1 week she realizes that if she does not eat anything for more than 5 hours then becomes involved in activities she will experience a migraine. By assisting the service member to identify a correlation between daily activities and migraines, the service member was able to make a change. The occupational therapist encouraged setting cues, such as an alarm, to remind her to eat regularly and encouraged her to participate in the local relaxation classes to manage her stress levels.

defendant

Person charged with a crime

Community reintegration planning

Planning a person's return to the community in a law-abiding role; ideally, the process begins when the person is incarcerated, follows the person through release, and includes aftercare and interagency coordination

Evaluation and assessment in the justice system

Practitioners working in UK forensic settings overwhelmingly utilize assessments grounded in the Model of Human Occupation -For more than a decade, a steady stream of voices from researchers who have studied occupational therapy practice in criminal justice settings have urged practitioners to utilize reliable and valid outcomes measures -Overall practitioners need to use their best therapeutic reasoning skills and choose assessment tools that fit the person and the context.

Disparities in Justice System

Prisons and jails are filled with people who are economically and socially disadvantaged. There is a clear overrepresentation of racial and ethnic minorities in the U.S. criminal justice system -The arrest rate of Blacks is 2.3 times higher than that for Whites From an economic perspective, if the individuals who are arrested and detained were contributing to the household economics and food security of their families, after release these racial and ethnic minorities are likely to return "home" to homelessness, unemployment, and debt, which in turn can lead to recommitting a crime In the United States, one of the fastest growing jail populations during the past decade has been women -Most women are women of color -Many women in jail have not been charged with a crime but are awaiting trial -compared with men, many women have lower incomes and often cannot post bail Women in jail are disproportionately poor or low income, survivors of domestic violence and trauma, and have high rates of physical and mental illnesses and substance use -A high percentage of women in jail are single mothers The existence of educational disparities of people who are incarcerated is an established fact -Women, at least in state prisons, tend to be better educated than men; however, regardless of race, ethnicity, or gender, people incarcerated in U.S. jails and prisons are drawn primarily from the least educated segments of society Many U.S. state prisons and to a lesser degree federal prisons offer some form of educational program, and many inmates take advantage of such programs during their incarceration -Education is a route of social mobility -Limited access to occupations of schooling and the roles of students and education that may occur in less enriched educational environments has consequences before and after incarceration -education both reduces the probability of arrest and incarceration and is a consistent factor in reducing recidivism

Homeless Veterans Programs

Recent statistics suggest that homeless veterans make up 11%, or 47,725, of the 436,921 homeless adults in the United States, and they receive services from numerous disciplines According to the U.S. Department of Housing and Urban Development, there are hundreds of thousands of veterans in nonpermanent housing situations -Within programs for this population, occupational therapy practitioners can address a variety of issues including participant role identification, motivation for change, and self-efficacy Community-based programming in these settings is diverse Practitioners working with the homeless veteran population can address several of the performance patterns found in the occupational therapy practice framework such as habits, routines, rituals, and role identity -Specific areas of occupational performance to address can include money management, food management, safe community participation, room care, or self-care

Care for Service Members and Veterans

Service members receive BH care services on the battlefield in Combat and Operational Stress Control (COSC) units and off the battlefield in Military Treatment Facilities (MTFs) and in Warrior Care and Transition Programs (WCTPs). Once service members are discharged from the military they are considered veterans and may continue care at the MTF, be eligible for care at the VHA, or have access to community-based care. Regardless of the setting, the primary mission of BH occupational therapy in the military is to keep service members and veterans operational and functional within their occupations or communities.

Warrior Care and Transition Program (WCTP)

Service members who are struggling to work through BH challenges because of a medical condition that prohibits them from completing required duties in their unit Identify a long-term plan focusing on daily life function and living life to its fullest. The occupational therapy practitioner, as part of the care team, evaluates and treats wounded, ill, and injured service members through a comprehensive, interdisciplinary process. ADLs, IADLs, professional development, goal setting, and life skills (e.g., coping skills, stress management, social skills)

Relapse prevention

Strategies to help people learn coping and other skills for diminishing stress and resisting environmental triggers that can lead them back into drug use or other criminal activities

Group interventions

Support groups and group therapy are often primary interventions used in settings that serve veterans with BH issues The most common frame of reference when conducting PTSD-based groups is a cognitive behavioral therapy approach -Using this approach, practitioners can reinforce concepts learned and skills introduced in individual sessions while fostering social bonds with other group members One method used in group interventions is addressing the irrational thoughts that individuals with PTSD often have about their abilities or their faulty beliefs about their environment. -These thoughts and beliefs often lead to behaviors that ultimately interrupt their performance in meaningful occupations. -By utilizing a cognitive-based approach in occupational therapy group sessions, practitioners are able to help clients control their thoughts and behaviors in order to better regulate themselves and participate in meaningful occupations. Group therapy interventions are common practice in many BH occupational therapy settings. -In the military, these interventions often focus on goal setting, effective communication, leisure, relaxation techniques, self-affirmation, relationship management, anger management, and ADLs. The practitioner's task is to provide activities that present graded challenges and interpersonal risks while maintaining a therapeutic environment where the service members or veterans feel safe to practice their newly acquired skills

Models of practice in the justice system

The Model of Human Occupation, PEO models, and the Canadian Model of Occupational Performance are three practice models in particular that are identified most often in the occupational therapy literature and in recent surveys of justice-based practice -Other models include the Occupational Adaptation Model Each of these models can be described as comprehensive models of occupational functioning. -Each, to a greater or lesser degree, offers specific concepts for considering the physical and social environment and provides one or more assessment tools for evaluation

Role of OT in CPT

The Triad of Care is a term used in the military to describe an interdisciplinary team of clinical and nonclinical professionals who work closely with each service member during the CTP process to coordinate and enhance recovery and transition -Professionals include the primary care manager, nurse case manager, social workers, occupational therapy practitioners, physical therapists, patient advocates, chaplains, and many other professionals The occupational therapy practitioner's role on this team is vital. -In the CTP process, goal setting is a key element of intervention -Service members often have difficulty with goal setting. -Most of their military career and lifestyle has been structured and regimented; therefore, the self-initiation of individualized goal setting may feel foreign and challenging. Practitioners on these teams serve as key facilitators of the "goal setting phase." -The goal setting phase is divided into two parts. Phase I is completed within 21 days of the service member's arrival to the unit and facilitated by the occupational therapy practitioner on the team -This process guides the service member, and in some cases his or her family, in the systematic development of short-term goals that support the overarching transition goals -These goals support priority areas in each of the six previously mentioned domains (career, physical, emotional, social, family, and spiritual). In Phase II, the service member and his or her family expand their knowledge of the goal setting process and begin to set their longer term goals -During this time, service members create action statements that support their healing and transition plan. -All goals and action statements follow SMART criteria Part of the role of the practitioner in Phase II includes co-facilitating a 16-hour block of instruction during a 3-day period that includes the development of key mental skills, attention control, confidence building, goal setting, and energy management

disposition

The action taken because of the defendant's court appearance (e.g., dismissed, acquitted, convicted or sentenced, placed on probation)

Forensic psychiatry

The branch of psychiatry focusing on the study of crime and criminality

History of OT in the military

The integration of occupational therapy philosophies in the United States military can be traced to the Civil War -In these early days, purposeful activities provided occupation for the mind and body to manage what the U.S. military now calls posttraumatic stress disorder (PTSD) or combat operational stress reaction (COSR) Psychiatric understanding of the etiology and interventions to address the trauma of war and the military management of these symptoms has advanced -For example, military health-care practices changed with the realization that many service members who were evacuated far to the rear of the battlefield became chronic psychiatric patients. -In contrast, those service members treated quickly and in proximity to their units were more likely to recover and return to duty (RTD) The first civilian occupational therapists were called reconstruction aides and they brought military application of occupational therapy interventions to the U.S. Army in June of 1918 -Reconstruction aides were civilian women who worked stateside in military hospitals to treat the wounded and also were deployed near the front lines to treat service members with neuropsychiatric conditions -Their mission was to rehabilitate physically and mentally war-injured service members using curative crafts, such as basketry and beadwork, and workshop activities, such as carpentry, painting, and modeling

Incarceration rates

The rate of incarceration in the United States easily exceeds every other nation in the world, and the United States has a higher rate than the United Kingdom, Canada, France, Italy, Norway, Denmark, and the Netherlands combined Probation and parole are both alternatives to incarceration -Probation is a judicial sentence of community-based supervision or a requirement that a person fulfill certain conditions of behavior in lieu of incarceration; probation can include a fine, a jail sentence, or both. -Parole is a period of control and monitoring that occurs after a person's release from incarceration. -Both probation and parole represent a contract between the justice system and the person, as they require varying levels of supervision and rules the person must follow to meet the terms of the contract Individuals who have not reached the age of 18 are detained in juvenile justice settings -Most juvenile detention centers were publicly operated (54%), required residents to attend school (87%), and routinely evaluated residents for substance abuse (74%), mental health needs (58%), and suicide risk (90%).

The environment

The role of a criminal justice system in any country is to ensure an ordered society and standards of behavior that safeguard individuals, property, and the public -The justice system delineates what constitutes criminal behavior, legislates laws and policies that prevent or limit crime, ensures laws are enforced, tries those accused, and sanctions those convicted of committing crimes. Justice systems reflect the culture, history, traditions, and needs of the country that created them In order to understand the justice system in their countries, practitioners can examine three components inherent in all criminal justice systems: 1. the legislative system that creates laws 2. the courts responsible for judging and sentencing law breakers 3. the correctional institutions that enforce sentencing

Role of OT in COSC

The role of occupational therapy in COSC units is largely guided by the Person-Environment-Occupation (PEO) model. -Occupational therapy practitioners provide creative and innovative environments of care, ensuring that BH interventions are focused on the service member (person), the deployed setting (environment), the service member's military tasks/responsibilities (occupation), and the interactions among each During interventions, it is critical that the occupational therapy practitioner "set the environment" to prevent service members from adopting a "patient" or "sick" role. -COSC personnel ensure that service members adhere to all military customs and courtesies, and participate in necessary military duties and routines -Practitioners use the expectations of the environment to support the service member's recovery -Participating in these roles helps the individual maintain his or her identity as a service member. Practitioners in COSC units consistently employ purposeful activities, such as team building exercises and life skills, to meet therapeutic and the service member's goals and to return the service member to duty as appropriate -Service members typically enjoy participation in purposeful activities that foster competition, which is a routine element of military culture -These activities serve as an emotional outlet to reduce stress Purposeful, occupation-based activities vary and are determined by local resources, enemy engagement, and mission requirements. Empirically understood as a powerful therapeutic tool, therapeutic use of self is a necessity in occupation-based processes -This is particularly effective in the COSC restoration and reconditioning environments of care. Within days of assimilation into group settings, service members can demonstrate transitions in thought behavior from irrational to rational, which transitions into improved reaction and positive communication with others -When they experience the decision-making processes of leadership firsthand, they often come to see that their belief that leaders do not value their opinions was an irrational thought In a group setting, therapeutic use of self empowers service members by integrating new thought considerations, alternate insight, and a sense of belonging under the guidance of a facilitator -Combined with purposeful activity, this method becomes a powerful tool that solidifies abstract concepts into tangible applications Practitioners conducting restoration and reconditioning programs increasingly emphasize the use of higher level, social-oriented, team-building activities as practice tools to enhance functional performance and integrate behavioral change via application

Role of OT in the VHA

The role of occupational therapy in the VHA is similar to that in many health-care settings: to emphasize prevention, population health, and well-being through education, research, and service. -Occupational therapy services in the VHA include a wide variety of settings Practitioners working in the VHA system have the same access to networking, technology, and research that is available at many nonmilitary job sites and offers unique opportunities for practitioners specifically interested in BH. -The VHA system provides BH services and programs that include inpatient and outpatient BH care, homeless programs, substance use programs, and specialized PTSD services, all of which occupational therapy practitioners can either consult with or provide direct services. Practitioners at many VHA facilities can access state-of-the-art technologies and are often able to work with a variety of new assistive technologies designed to promote independence of veterans. -Similar to many work settings, clinical education and research are present in every VHA hospital.

combat operational stress reaction (COSR)

This refers to symptoms that emerge in response to combat that can manifest in physiological (e.g., somatic signs), mental (e.g., difficulty concentrating, loss of concentration), emotional (e.g., anxiety, anger), or behavioral (e.g., recklessness, hypervigilance) symptoms COSR is an expected and fairly predictable reaction to combat experiences. Different from PTSD, COSRs are considered adaptive and more temporary in nature What is now termed COSR was called "combat exhaustion" during World War II and "stress response syndrome" during the Vietnam War

The Warrior Care and Transition Program

Under the WCTP are specialized military medical and BH units called Warrior Transition Units (WTUs) -WTUs were created to provide oversight, medical management assistance, and transition assistance to service members as they navigate the medical treatment system -outcomes for these service members are to either successfully reintegrate back into the military or transition into civilian life A standard practice for a service member who enters a WTU is to begin the Comprehensive Transition Plan (CTP) program. -The CTP aligns well with the occupational therapy process as it is a "dynamic, living plan of action" that focuses on the service member's future -Similar to the holistic approach of occupational therapy, the CTP incorporates six domains: career, physical, emotional, social, family, and spiritual. -Each of these domains lead to established goals that map a service member's transition plan, either to remain in the military or transition into civilian life.

Military Culture

Understanding the basic tenets of the military, including their work environments, the importance of unit cohesiveness, and the resolute temperament of the service member seeking BH services, greatly assists the occupational therapy practitioner in establishing rapport, fostering therapeutic relationships, and developing and implementing individual treatment plans Aspects of military culture can vary between each branch of service; nonetheless, there are core values common to all uniformed services and these values are grounded in the enlistment oath all service members take "to support and defend the United States Constitution against all enemies, foreign and domestic" -Fundamental values for all the military services include honor, selfless service, and integrity -Another common element is the hierarchical organization of military leadership. -Finally, the performance requirements of all service members, regardless of their branch of service, are dictated by comprehensive and detailed regulations, instructions, and field manuals that delineate expectations for behaviors ranging from an individual's personal grooming standards to conducting military operations on a global scale The most visible aspect of military culture is the uniform -For the occupational therapy practitioner who is in the military, wearing a uniform can help establish a therapeutic bond, as the uniform conveys that the service member and therapist have a shared military experience, signified by the insignia of the uniform (e.g., combat tour, rank, and specialty). Regardless of their job specialty, all service members are required to maintain a certain level of physical fitness and operational readiness, and those standards may be higher or lower depending on the military specialty, geographic location, and assigned unit. -A general understanding of a service member's specific occupation and assigned unit can reveal many characteristics that can assist the practitioner in developing and implementing an effective treatment plan In civilian life, every job and lifestyle has its own set of unique stressors; this is no different in the military, but service members are exposed to a variety of additional stressors that are specific to the military culture -Throughout their careers, service members may experience multiple relocations, which may include overseas and stateside -Career advancement and promotion require competition for needed training and educational programs to support advancement. -Depending on the political climate, service members may be required to participate in numerous training exercises, pre deployment trainings, and deployments to hostile or non hostile environments. The constant need to adapt to new environments, occupational stresses, and family separation can impact even the most resilient service member's mental health and well-being, potentially leading to relationship problems and a variety of psychosocial issues.

Veterans Health Administration (VHA)

Veterans who require access to health-care services for medical, psychiatric, vocational, educational, or social problems in hospital or outpatient settings Identify the current challenges or dysfunction and create a plan to improve coping skills and transitional care to the community ADLs, IADLs, goal setting, vocational readiness, and life skills (e.g., social skills, time, money, anger, and stress management)

appeal

When a person found guilty of a crime petitions for a rehearing in an appeals court, which has the jurisdiction to review the decisions of a lower court

arraignment

When a person is officially called to court, informed of his or her charge(s), and given the opportunity to enter a plea or response to the charges

diversion

a defining characteristic of sentencing in problem-solving court proceedings ________ from prosecution and incarceration requires the person to agree to meet sentencing guidelines for completing restitution, education, work, drug, or mental health treatment can sometimes occur before the person is charged -In these situations, the police officer or teams of mental health professionals respond to potential arrest situations that involve mental health crises and divert the person from arrest procedures to treatment Post-charge diversion processes require that specialized personnel work in concert with prosecutors, judges, and defense attorneys to divert people with mental illness or addiction to community based mental health providers Some jurisdictions only consider individuals with misdemeanor charges as candidates for diversion, whereas others may accept someone with a more serious felony charge -The type and level of supervision can vary Upon successful completion of the conditions of their diversion, some individuals may have their charges dropped, and some may have their records expunged or the charges erased from their record. -Others will have records that reflect a guilty plea but recognize that the sentence was deferred. -Some will be required to continue on probation The team approach in diversion that pairs law enforcement and mental health personnel provides occupational therapy practitioners opportunities to advocate roles as members of these community evaluation and treatment team

Veteran treatment courts

a specific type of mental health court that is designed to keep veterans with mental illnesses from being incarcerated by diverting them to mental health services.

low security prisons

have consistent security routines, but prisoners generally have opportunities for movement, interaction, work, and treatment -There is often more open space, and perimeter security tends to be less extensive. -Offenders in these settings may work on agricultural, transportation, and conservation projects

Community-based program

a term used to describe a wide variety of different services designed and developed to address the needs of youth and adults in the criminal justice system -This includes programs addressing the needs of those who are at-risk of entering or reentering criminal justice settings. Funding for these programs may come from a variety of public and private sources. Some are faith-based programs. -These programs may target a specific population such as women, mothers, youth, offenders with intellectual disabilities, those with addiction problems, sex offenders, or elders released after serving long prison sentences -Some of these programs are specifically designed for people with serious mental illness and the majority target mental health. The services provided at community-based programs can vary. -They may include providing assistance and training that support employment by providing job-seeking classes, organizing job fairs, and developing connections with local employers and industries willing to hire people with criminal histories. -These settings also support residents as they look for housing A critical component of many of these programs is offering substance abuse and mental health treatment and counseling. -Family support services and financial and legal planning may also be provided Community-based settings may provide one of the best contexts for authentic occupational therapy intervention -The focus on reintegrating into the daily routines of community life and the development of the skill sets necessary to support reintegration resonate with the basic mission and philosophy on which the profession was founded -An evaluation of occupational performance and a thorough and convincing occupational profile reflecting the person's potential for functional and prosocial occupational performance can support the person's recovery and reentry and provide his or her defense attorney with a vision of participation that lets him or her advocate for sentencing that considers the person's rehabilitation potential. Programs that help demonstrate a clear link between incarceration alternatives, functional occupational performance, and reduced recidivism can elicit the attention of the many communities searching for and experimenting with alternatives to incarceration -Practitioners will need to market their skill sets within the criminal justice system, with judges, lawyers, reentry program directors, and community programs that are already addressing the needs of this population and advocate for occupational therapy's place in the development and delivery of these program

Forensic occupational therapy

a term used to describe the application of mental health specialty practice within the criminal justice system. -This includes working with people who are in or at risk of entering the criminal justice system

criminal justice system

an ordered structure of agencies and institutions that apprehend, prosecute, defend, sentence, and punish individuals who are suspected or convicted of breaking the laws. -Occupational therapy practitioners working within criminal justice settings require specialized knowledge of the justice system and unique skill sets, attitudes, and perspectives to inform their practice.

Problem-solving courts

designed to address a defendant's underlying problems and assign remediation, restitution, or rehabilitation as alternatives to incarceration -Examples include drug courts, mental health courts, and veterans' courts The common denominator in problem-solving courts is that they all seek to divert offenders from traditional criminal justice processes of court proceedings and incarceration -Collectively, they are judge-centered and non adversarial, meaning that the individual can expect more direct conversation with a judge to problem-solve the approach to the offense -Sentencing processes include discussions on treatment options and monitoring processes, which facilitate collaboration between the person and his or her mental health team and assumes community engagement

Mental health courts

designed to address the mental health needs of the individual -They combine judicial supervision, community mental health, and support services in an effort to both reduce crime and address the mental health needs of the perpetrator - connect people with mental illness who are suspected of or detained for committing a crime to the resources they need for medication, employment, social functioning, housing, and other support services in lieu of incarceration

Secure psychiatric hospitals

facilities that evaluate, treat, and rehabilitate individuals with mental illnesses who have entered the criminal justice system or those who, because of their conditions, are considered unfit for trial or are deemed not criminally responsible Some individuals who have not committed crimes but who present with a complex set of disorders and behavior that may be too challenging to address in a general psychiatry ward may also be confined in a forensic hospital -A primary difference between secure psychiatric hospitals and mental health care for non-offenders is that these settings have the dual responsibility to treat the mental illness and address the individual's offense -Secure settings use the physical environment, person-staff relationships, and procedural measures within the setting to deliver interventions in a safe and protected environment Approaches for managing prisoners who are severely mentally ill vary considerably among facilities, and the primary form of treatment is psychiatric medication Some correctional settings house prisoners with mental illness separately only when the person is in crisis or acutely symptomatic; when the prisoner exhibits severe decompensation in the general population; or when the person is considered dangerous, suicidal, or at significant risk of self-harm -In some states, inmates with mental illness are not housed in a mental health unit but in segregated disciplinary sections of the prison or they are assigned to a high security prison setting Both prisons and jails do transfer the most severely mentally ill offenders to secure units in state mental hospitals or public forensic psychiatric hospitals -In addition to treatment of their mental illness, forensic psychiatric hospitals address the person's offense-related treatment needs When forensic units are housed in state hospitals, occupational therapy practitioners can encounter many of the same resources found in large mental health institutions. -Security concerns will always add a layer of watchfulness, protection, and safety, but practitioners may offer comprehensive programming such as life skill, prevocational, or social skills training

Jails

local justice facilities operated at the city or county level rather than by the state or federal government. -Generally smaller than prisoners confine people who are awaiting trial or a hearing for parole, probation, or bail revocation. -Some people can be confined in jails temporarily while they await transfer to a juvenile facility, a prison, or an immigration facility -Usually jail sentences are 1 year or less. It is important to consider that jails confine people shortly after arrest, a time when both stress levels and health and mental health-care needs are high -If a person with a mental illness is arrested, it is very possible that acute symptoms that may have contributed to poor behavior and led to his or her arrest are still present -Many U.S. jails are ill equipped to respond with mental health treatment or to manage issues that can include the need for seclusion or restraint, medication, and keeping the person, jail personnel, and other detainees safe Jails are high-volume facilities that serve as correctional distribution hubs filtering people to and from courts, community programs, and other correctional institutions while simultaneously confining many who have already been sentenced -This creates an environment where there is a steady stream of family members, visitors, and legal, social, and faith-based human service personnel moving in and out of jails, all of whom must adhere to visitation protocols and are subjected to security scrutiny and searches. -This constant movement of people offers more opportunity for social participation with a wider range of individuals than the typical prison context. The physical environment in jails varies, but most are structured so that minimum, medium, and maximum security-level inmates can be housed on different floors Jails are mandated to provide basic mental health screening, and some jails have beds designated for inmates with mental illness, but the availability of comprehensive mental health services in jails (e.g., crisis intervention, referral services, ability to segregate consumers) varies considerably

Community-based justice settings

may be federally contracted residential reentry centers where offenders are sent as an alternative to incarceration or placed just before or upon their release -They can also be residential or nonresidential community-based programs funded by a combination of state and local government and community nonprofit organizations that are funded by private and public foundations. Community-based correction settings can be a heterogeneous mix of programs developed to serve the needs of varied populations including but not limited to juveniles, adults, people with addictions, women, children of offenders, elders, sex offenders, and people who are at-risk for entering or returning to the criminal justice system or who are transitioning to the community after incarceration

Military BH issues

nearly one in four active duty service members exhibited signs of a mental health condition -The three most common diagnoses were PTSD, depression, and traumatic brain injury (TBI) -PTSD was 15 times higher in service members than in the civilian populations -Service members reported symptoms such as sleep issues, anger, nightmares, hypervigilance, and substance use, which are symptoms similar to those experienced by their civilian counterparts. -Additionally, these researchers reported rates of depression in service members that were five times higher than in the civilian population Service members often do not seek out appropriate mental health (MH) care for fear of feeling "weak" or unable to fulfill the duties of the military TBI care has been at the focus of military medicine in recent years -In many of these cases, the TBI is associated with a comorbidity such as PTSD or depression. Suicide and suicide ideation is an increasing concern for veterans and the providers who work with them -20 veterans die daily, on average, because of suicide

High security prisons

often house the most dangerous prisoners and have the most significant security features -In these settings, offenders can be confined for long periods of the day. -These facilities have the highest staff-to-inmate ratio of all prisons

Medium security prisons

provide more opportunity for movement, activity, and interaction among prisoners. -Inmates typically have access to a prison yard and exercise areas, libraries, showers, health-care services, and other facilities -can offer a variety of work-oriented and treatment programs -In some medium security prisons, offenders sleep in dormitories and have access to communal showers, toilets, and sinks

prisons

secure institutions that confine offenders who, in general, have been convicted of a felony and have been sentenced to at least 1 year of incarceration. Compared with jails, prisons are generally larger and more stable environments with much less movement in and out of the facility A primary objective of any prison facility is to confine the offender and protect the safety of the public, the prisoners, and the correctional staff In contrast to most people in jails, people in prison have often been in the criminal justice system longer, are more likely to experience geographic separation from their home communities, experience social and psychological adjustment related to longer incarceration, and can experience different post-release challenges Prisons are classified by their level of security. -The U.S. Federal Bureau of Prisons designates levels of security as high, medium, low, and minimum security according to the presence of various security features in the institution. -Security features include armed external patrols, security towers, fences and other security barriers, electronic detection devices, and staff-to-prisoner ratios -The majority of U.S. prisoners are housed in low or minimum security prisons (55%) and medium security prisons (30%) Prisons are mandated to provide a basic level of psychiatric service, including screening, assessment, referral, evaluation, intervention, and community reentry planning, but the frequency, quality, and availability of these services varies among institutions

drug court.

the individual voluntarily agrees to be diverted from confinement, is expected to receive treatment, must meet obligations of his or her sentence, often must submit to random drug testing, and always risks being returned to the traditional justice system if he or she fails to meet his or her obligations