Abstract
The United States incarcerates more people than any other country, with nearly 7 million people involved in the carceral–criminal justice system to varying degrees (Kaeble & Cowhig, 2018). Mass incarceration disproportionately affects marginalized communities, such that 40% of incarcerated people are African American, despite only representing 13% of U.S. residents; in addition, rates of women entering the system are outpacing those of men (Minton & Zeng, 2016; Wagner & Sawyer, 2018). The median income for people before incarceration is less than $16,000 per year, indicating that many incarcerated people live in poverty and are unable to post bail for low-level crimes (Rabuy & Kopf, 2016). More than 95% of people in jails and prisons will be released at some point in their lifetime, at a rate of approximately 700,000 releases from state and federal prisons per year (West et al., 2011).
Impact of Incarceration
The cyclical manner of people being transferred from their community and then reintroduced to that community without sufficient support has a massive impact at individual, community, national, social, and economic levels (Brinkley-Rubinstein & Cloud, 2020; Morenoff & Harding, 2014). People face personal health, housing, and transportation issues; social challenges with family and friends; and barriers to accessing employment. In addition, effects of incarceration carry over long after a sentence has been served; people with a felony may be excluded from various types of social, financial, nutrition, housing, transportation, employment access or assistance, and civic participation (Morenoff & Harding, 2014). Considering the barriers encountered by those involved with the carceral system, the current rate of recidivism, defined as the return to prison after release, is not surprising. More than 50% of people released from prison are arrested within 1 yr of their release, and 67% are arrested within 3 yr (Durose et al., 2014).
Reentry Evidence
Although the trend is less than 20 yr old, increased use of reentry services has generally tended to decrease recidivism in programs with pre- and postrelease continuity of care (Jonson & Cullen, 2015). However, programs lacking treatment fidelity showed no significant effects, and meta-analysis findings were not promising (Berghuis, 2018). Documented limitations of reentry programming (e.g., lack of a clear theoretical model, no reintegration measure, criminogenic rather than strengths-based factors, and postrelease participation in jobs rather than quality employment) present opportunities for developing occupational therapy practice in these settings (Berghuis, 2018; Jonson & Cullen, 2015).
Outside of the criminology literature, one study described an occupational therapy–led, pre- and postrelease community reentry program in a county jail (N = 87). Among those who reentered the community (n = 59), the program achieved 98% reintegration (e.g., employed and remained in the community; n = 58) after 11 mo in the program (Eggers et al., 2006). The program addressed four domains: wellness, family and support, skills for living, and education and employment. The program posited that occupation-based assessment and preparation of clients may contribute to productive and meaningful societal roles and reintegration after jail release.
Occupational Deprivation: Influence on Individual and Community Health
Carceral settings contribute to community health issues among their residents and workforce, in part because of deprivation of occupations that are typically available in society. As defined by Wilcock (2006), occupational deprivation reflects environmental influences that prevent the person from “acquiring, using, or enjoying something” (p. 145). Within jail and prison settings, typically all spheres of daily life are standardized, structured, and supervised by staff for safety management, including eating, working, recreation, and sleeping (Seiter, 2017). This environment of occupational deprivation precludes the autonomy to participate in individually meaningful activities, thereby decreasing the person’s motivation and ability to participate skillfully (or optimally) in many activities (Jaegers et al., 2019). Occupational deprivation also results in the person’s decreased capacity for independent living, suggesting an influence on the rate of recidivism (Wilcock, 2006), although this hypothesis has not been empirically tested (Whiteford, 1997).
Wilcock (2006) argued that occupational deprivation for a prolonged period will not only have health consequences but also stunt a person’s well-being and ability to adapt and lead to low self-efficacy and decreased ability to manage time. As described in this context, occupational deprivation is a form of injustice that occurs because of factors outside of a person’s control, such as race, gender, economic status, and incarceration history (Townsend & Marval, 2013; Whiteford, 2000). Occupational justice tenets, however, promote the belief that people have the right to engage in occupations to sustain a healthy quality of life (Durocher et al., 2014).
Current occupational (e.g., justice-based occupational therapy [a network of scholars and practitioners]; Jaegers et al., in press) and social justice (e.g., John Jay Prisoner Reentry Institute’s policy advocacy) initiatives support carceral system reform and innovative programs and strategies for reducing incarceration and improving social and environmental conditions. Integrating humane, healthy, and rehabilitative operations through collaborative correctional culture has the potential to improve public safety outcomes (Ahalt et al., 2020). A shift away from punitive measures and highly structured environments with adherence to authority is recommended (Schlager, 2018). Approaches that apply risk assessment methods to a strengths-based approach are required for successful assimilation of people who have been incarcerated back into their communities (Schlager, 2018; Seiter, 2017).
Strengths-based approaches include building positive relationships between correctional workers and residents that emphasize collaboration, empowerment of residents using resiliency techniques, and community collaboration to recognize and value the contributions of the client postrelease (Schlager, 2018). Programs based in social services and cognitive–behavioral approaches have most commonly been used in reentry efforts (Berghuis, 2018). However, a gap in knowledge related to implementation practices exists in which how services can be delivered needs clear articulation (Taxman, 2018) to identify effective prevention, deflection, diversion, and transition intervention implementation methods.
Occupational Therapy Interventions in Carceral System Settings
Occupational science tenets regarding the establishment of functional roles, habits, and routines inform habilitation and rehabilitation approaches to sustain people as they return to society from incarceration settings. Moreover, they address a diverse array of contextually situated occupations, including those considered to be sanctioned and nonsanctioned “within dominant world views and societal groups” (Kiepek et al., 2019, p. 1). Community-based occupational therapy services in the United States have been expanding to include justice system settings such as jails, prisons, transitional programs, halfway houses, juvenile detention centers, and secured mental health hospitals (Eggers et al., 2006; Shea & Jackson, 2015). Occupational therapy practitioners have addressed community living skills, work and employment opportunities, interpersonal communication, stress management, coping strategies, and wellness skills (Muñoz et al., 2016).
Current Study: Occupational Therapy Transition and Integration Services
On the basis of occupational science and occupational therapy tenets, an interprofessional program model was conceptualized with occupational therapy at the core. Conceptualization of the occupational therapy component of the practice model is informed by the Person–Environment–Occupation–Performance model (Christiansen et al., 2014). This model depicts the transactional relationship between people and their occupational performance patterns and participation, occupational options, overall well-being, and health-related quality of life (Jaegers et al., 2019). For more than 30 yr, as a response to the deinstitutionalization of psychiatric patients in the 1970s, the interdisciplinary model Assertive Community Treatment (ACT) has been found to be a robust approach for interventions with community-dwelling people with mental health service needs (Drake & Deegan, 2008). This type of approach has been encouraged by public administration cross-sector leaders who promote broad integration of multiple metropolitan resources to address complex social problems (Bryson et al., 2006).
Not limited to psychiatric diagnoses, the Saint Louis University (SLU) Occupational Therapy Transition and Integration Services (OTTIS) were conceptualized from 2010 to 2014 with this model foremost. The interdisciplinary ACT model informed the design of interventions, emphasizing occupational science and occupational therapy concepts within our model. Program development began in 2015. By 2017, OTTIS functioned with a program advisor (emerita faculty focused on conceptualization), director (faculty member tasked with development and implementation), two licensed occupational therapy practitioners (one funded city position for prerelease client assessment, group, and individual interventions; one community-based position for postrelease services), Level II fieldwork students, student administrative staff, and resources provided by university partners (including law, business, career services, social work, nutrition and dietetics, and family and community medicine). Partnership building with a city’s Division of Corrections (DOC) short-term jail facility began in 2015 with a participatory study of correctional workplace health (Jaegers et al., 2020).
Conceptual Guide and Study Purpose
Little is known about the feasibility of implementing full-time OTTIS in an urban jail setting. To measure program efficacy in the future, we needed to establish the extent to which we were able to implement the intervention. Formative research informs the development of new interventions and can be guided conceptually by a logic model (Jaegers et al., 2014). In this study, we used the first stage of a logic model to guide the process evaluation for determining fidelity of the prerelease occupational therapy intervention by measuring the inputs (prerelease programming) and outputs (dose delivered, dose received, barriers and facilitators). Valuable guidance was also provided by structuring the process evaluation in a multilevel format. Social–ecological perspectives are commonly applied in community health research to address multiple levels of factors (e.g., individual, interpersonal, organizational, community, public policy) that may affect intervention implementation and health promotion (McLeroy et al., 1988). In this study, we used a social–ecological framework for organizing the barriers and facilitators that emerged as themes from our analysis.
The specific purpose of this study was to evaluate the implementation of the OTTIS program, which uses a pre- and postrelease model, in a Midwestern U.S. urban jail. The aims of this study were twofold: (1) to determine program fidelity—the extent to which the prerelease portion of the OTTIS program was implemented as intended—and (2) to examine the barriers and facilitators to OTTIS program implementation.
Method
Program Implementation
Through the SLU Transformative Justice Initiative (TJI) and the SLU Health Criminology Research Consortium, we seek to develop evidence-informed solutions to improve health promotion and health protection in justice systems. The SLU OTTIS program was developed through the collaborative efforts of coauthors Barney and Jaegers with community partners, occupational therapy practitioners, and university partners from 2014 through 2017 as a part of the TJI.
Recruitment
The goal for program recruitment was 8–10 participants per 8-wk cohort (five cohorts in total); the first four cohorts were intended for women, and the fifth cohort was designed for men and women (because of the facility’s request to begin services with men). People residing at the jail referred by internal case managers were invited to apply for admission to OTTIS but were excluded if they had a scheduled release date (to the community or a different DOC) within the subsequent 4 wk. All applicants expressed written or verbal interest and were interviewed by the OTTIS team, who provided an overview of the program, described expectations of participation, and screened applicants for interest and motivation (recruitment criteria) to participate in the program. Accepted participants were asked to sign a form saying that they agreed to follow the rules of the jail, attend and participate in sessions, and complete assignments. The OTTIS initial evaluation included an occupational profile, guided in part by a comprehensive intake form codeveloped with a community partner, and a variety of occupational and health assessments used to prioritize individualized goals for self-care, leisure, and productivity.
Intervention
The 8-wk prerelease portion of OTTIS was planned to occur 4 days per week for 2.5 hr each day. Daily sessions were designed to provide educational modules led by an occupational therapist to address participants’ needs on the basis of their initial evaluation. Each participant developed an individualized vision plan to set goals for education, employment, social networking, and leisure. Module topics included the exploration of occupations such as job seeking (e.g., resume writing, interview skills, skill assessment, career exploration), literacy (e.g., health, financial, reading, math, occupational), leisure skills, communication, emotional regulation, health, trauma, healthy relationships, community resources, and transition planning. Participants developed a detailed plan of action to complete immediately after their release, including making initial contact with the postrelease, community-based occupational therapist. Completion of the prerelease intervention was determined by the therapists’ assessment of the participant’s readiness and individual participation indicating that the participant was prepared to bridge to the community; some participants were able to attend a bridging ceremony to mark the occasion.
Implementation Evaluation: Design, Data Collection, and Data Analysis
In this study, we used a retrospective, mixed quantitative and qualitative descriptive design to evaluate the fidelity of the intended program. This study was approved by the SLU institutional review board. An intake list was used to track participants through referral, acceptance, completion of classes, transition, and community status. The prerelease occupational therapist completed session logs with five cohorts to document planned activities and actual events that occurred regarding attendance, homework completed, and session timing and duration. A research assistant compiled and analyzed session logs and weekly team meeting notes using descriptive statistics and in vivo coding to describe barriers and facilitators to carrying out the program.
Two independent raters coded data by barrier (appeared to contribute to difficulty or challenges in carrying out the intervention) or facilitator (appeared to contribute to promoting or making it easier to carry out the intervention) and then by social–ecological level (individual, interpersonal, institutional, public policy, occupational therapy procedures, university, and community) to perform thematic analysis. The two raters used consensus methods to agree on nonmatching codes. In addition, two meetings with four OTTIS team members (key informants) provided a review of the content presented in summarized thematic reports for group consensus on barriers and facilitators and to identify any additional content that was not originally identified within the data set.
Results
The following results describe the process evaluation and related barriers and facilitators to program implementation during the first 16 mo of the OTTIS program.
Recruitment and Participation
In our first five cohorts (January 2017–May 2018), 77 participants applied to the program, and 63 (82%) were accepted. Full and partial completion of the program is described in Table 1. The full 8-wk prerelease program was completed by 24 (38%) participants. Thirty-three (52%) participants were transferred to the community, were transferred to a state or local DOC, or were discontinued early and therefore did not fully complete the prerelease program. Postrelease community contact with OTTIS was initiated by all participants (n = 15) who completed the prerelease program and who were released to the community. Contact was also initiated by 7 more participants who remained at the jail or who transitioned to another DOC. In addition, 8 participants released to the community before completing the prerelease program initiated OTTIS contact. As of May 31, 2018, 30 participants (48%) were considered to be active community members (n = 14; contact within the past month), active jail or prison involved participants (n = 9), or on consult status (n = 7; remain in contact pre- or postrelease but require contact less than once per month).
Full and Partial Completion of the OTTIS Program (N = 63)
Note. DOC = Division of Corrections; OTTIS = Occupational Therapy Transition and Integration Services.
Program Implementation
Of 146 planned sessions within the prerelease program, 93% of sessions occurred (n = 136). The 2.5 hr of intended session duration was met during Cohort 3 but fell short with an average duration of 2.1 hr (range = 0.25–3.25 hr). Approximately one-half of classes began on time; Cohort 5 sessions started on time least often (18%), and Cohort 3 sessions starting on time most often (100%). Of the classes that began later than planned, the average late start was 19 min. Attendance average ranged from 73% (Cohort 1) to 96% (Cohort 3) and was 87% across all five cohorts. Average rate of completion of assigned homework for the first three cohorts was 92% and was not recorded for the last two cohorts because of time limitations.
Prerelease Barriers and Facilitators
Qualitative findings described the presence of both barriers and facilitators to program implementation categorized by social–ecological levels, including policy and community, individual, interpersonal, institutional, procedural, and university.
Policy Level
Perhaps the largest barrier to participation was related to the public policy or laws to hold people in jail before their sentencing and therefore to jail them without providing a release date or exit location. Participants were often released or transferred to another DOC location without prior notice and were unable to complete the prerelease program. There appeared to be a potential overuse of the jail for holding people with mental health conditions, who may have been candidates for treatment at a mental health facility.
Community Level
Similarly, the community-level barriers involved mental health services, substance abuse treatment, and housing shortages, which were the main challenges to supporting seamless postrelease transitions. Community partners, however, provided a wide variety of major supports to the program, including collaborative services in education, employment, substance overdose prevention, bail funding, and peer mentorship.
Individual Level
At the individual level, client participation was both a barrier and a facilitator to program implementation depending on the person’s active or inactive participation (e.g., attending sessions, completing homework, and active group discussion). In addition, untreated mental health diagnoses (e.g., mood and personality disorders) and unwanted behavior (e.g., fighting, which resulted in lockdowns) were identified as barriers in providing prerelease programming as intended. Interpersonal group dynamics were highlighted, such that trust between participants had to be earned over time, and conflicts within the cohort needed skilled interventions. Gaps in family support strained participation (e.g., how to bring family into the transition plan).
With regard to facilitators, peer mentorship was modeled by guest speakers and formed organically. Lived experience among peers (e.g., incarceration, parenthood, returning participant) assisted with developing within-group social networks that promoted attendance, participation, and discussion.
Institutional Level
At the institutional level, policies, communication, facility support, and the jail environment (physical and social) challenged daily operations. With limited access to written policies, jail staff often had varying understanding of participants’ transportation logistics, resulting in delayed or canceled sessions. Policies that did not allow men and women or those labeled “enemies” in the same space reduced the practice of intersectional collaboration and restorative communication. In addition, limited institutional capacity for health care (both mental and physical), such as medication provided on schedule, reduced participation for those who needed services and diverted practitioners’ resources and time away from programming.
The major facilitator at the institutional level was the city’s support to fund a full-time occupational therapy position and for the jail to allow OTTIS access to participants. As the program developed, OTTIS practitioners observed a culture shift within the facility displayed by more staff support (especially with bridging ceremony events), improved attitudes toward participant involvement, and active collaboration with occupational therapy.
Procedural Level
Procedural barriers existed within occupational therapy practice and OTTIS team capacity. A gap was identified in occupation-based assessments designed for pre- and postrelease occupational performance. Time and resources were used to review and trial various assessments across cohorts; this process continues. The intervention process was challenged by practitioner capacity to develop tailored intervention plans, manage documentation, and streamline communication within the team and among collaborators. Pre- and postrelease services were slightly disconnected, and utilization of resources was inconsistent; therefore, jail and community occupational therapy practitioner tasks were adjusted to integrate them across the transition stages.
Facilitating healthy occupations through advocacy within the jail, courts, and the community captured the attention of participants, practitioners, and a variety of professionals who offered their support. In addition, the intentional branding of the OTTIS program as a St. Louis community partner led to exposure in the local community, increasing program collaboration and visibility.
University Level
At the university level, SLU’s service-driven mission inspired by social justice guides OTTIS and has been an important facilitator of the implementation process. Having the university’s support to actively work toward social justice and criminal justice reform, we were able to more freely share our purpose and role with partners than if these subjects were not supported. Moreover, partnerships with university departments, such as business, career services, criminology and criminal justice, law, medicine, social work, and nutrition and dietetics complemented OTTIS goals.
Discussion
This formative research is the first study of its kind to evaluate the implementation of a jail-based occupational therapy transition program with people pre- and postrelease. The process evaluation demonstrated that it was feasible to deliver the OTTIS program in an urban jail setting for nearly 1.5 yr with five cohorts. However, prerelease attrition prevented many from completing the intervention. Many barriers and facilitators challenged and assisted program implementation at each social–ecological level. Transition and reentry programming is known to be difficult (Drawbridge et al., 2013), and solutions are needed to improve program implementation across disciplines (Taxman, 2018). This study confirms the need for innovative solutions to overcome programming barriers (e.g., referral process, jail system, program capacity, and community support) that may improve participant retention in pre- and postrelease transition programming.
Referrals and Community Transitions
Receipt of referrals by jail case managers and recruiting people into the program was a relatively smooth and efficient process. However, occupational therapy staff quickly learned that the largest barrier to participation was the unknown release date for jail residents, because most were being held before sentencing. This theme is common in other short-term facilities, and some programs have attempted to overcome obstacles through deflection in policing and methods such as reentry and mental health courts (DeMatteo et al., 2013). Efforts to address legal barriers to reentry have been described to reduce common civil legal issues such as child support, suspended driving privileges, and vocational licenses (Berger & Da Grossa, 2013).
In our project, we used an iterative feedback process to modify procedures, and we gained valuable input from the jail and the SLU law school by adding specific recruitment criteria based on felony class and referrals provided directly from attorneys and judges. By working with the courts, occupational therapy practitioners can communicate participant progress directly and increase chances for coordinated plans for postrelease. The prerelease phase was important in establishing rapport with OTTIS practitioners and in developing action plans for immediate use after release. The development of these prerelease relationships appeared to build trust and encourage postrelease engagement and collaborative transitions.
Jail System
Implementing programming within a jail presents challenges unique to these transient, relatively short-term settings. Achieving full duration of sessions and beginning on time were difficult because of inconsistent institutional policies, including lockdown, transport of women through areas dedicated to male residents, and communication about OTTIS activities to new jail staff. It was necessary to advocate on behalf of the participants, OTTIS staff, families, and collaborators to educate and work with jail representatives to widen staff views of allowable transition planning activities and people’s health needs (Kinner & Young, 2018), which is an area of need in the larger correctional population. Similar to other cities (Torrey et al., 2010), mental health treatment support was limited, exposing a gap in needed care for people in the jail. Jail staff acknowledged that they were performing their role administered by the city to serve and protect the community, and they were new to reentry programming and shaping their services during the same time that OTTIS was piloting this project. Therefore, jail and OTTIS staff continue to learn from one another and work together toward improving transition methods.
Program Capacity
With a service-driven mission, the program was guided by the university’s expectations for working for and with community members. However, the development of a new program and implementation within 16 mo proved to be a challenge, and occupational therapy staff continue to shape procedures, including job tasks, processes for recruitment, bridging pre- and postrelease, and streamlining assessments. Staff are condensing and shortening the program to address the high client turnover rate and are attempting to reduce prerelease attrition and therapists’ workloads. Currently, two occupational therapists manage the caseload with administrative, research, and grant writing support by faculty members. Adjunct support from fieldwork students, work study staff, professional volunteers, and university and community partners round out the full team. As with most community-based programs, limited funding poses a barrier to expanding services and building capacity for wider scale implementation; therefore, long-term sustainability solutions are continually sought.
Community Support
The facilitative factor with the most impact in this process was likely the support that OTTIS received through community and university partnerships. Occupational therapy staff recognize that problems of incarceration and reentry are far greater than one profession can remedy and that collaboration is required to work in this practice area. Although there are limitations in capacity for services, including housing, mental health, and substance abuse treatment, OTTIS staff were able to locate needed resources for participants through community and university providers.
Iterative Process
Evaluating program implementation was a valuable experience to learn about the intricacies of multilevel factors within and around jail-based work. With most programs, process evaluation is necessary to learn “how” from wins and losses and to continuously improve interventions. Using an iterative approach allowed OTTIS staff to identify barriers, problem solve, and restructure procedural components to maximize the reach of the program.
Implications for Occupational Therapy Practice
Occupational therapy in the U.S. carceral–criminal justice system is considered to be an emerging area of practice (Muñoz et al., 2016). Development of an evidence-driven model for occupational therapy practice in complex jail systems is critical for informing community transition and integration (reentry) services. This process evaluation provides evidence that implementation of an occupational therapy–based transition program in an urban jail is feasible. The results of this study inform the following implications for occupational therapy practice:
This formative research provides practical details to inform future programs and to assist practitioners with avoiding identified pitfalls and focusing on facilitators for successful implementation.
Collaboration with a variety of disciplines, resources, and key informants is required to integrate transition services within a jail setting.
Tracking simple metrics (e.g., session logs) to gauge program implementation is important and necessary to learn from the program, to make evidence-based changes, and to inform the impact evaluation.
Limitations and Future Research
The study provided an evaluation of one DOC program in an urban location; thus, results are not generalizable to other locations or types of justice settings. Occupational therapy staff were not able to control for the time of year, seasonal temperature, jail staff changes, and holidays that occurred differently for each cohort. Researchers in the current study had direct contact with program practitioners and participants. Although this interaction allows for a better understanding of the group experience, it may bias the interpretation of barriers and facilitators. The results of the current study infer that completion of prerelease programming may increase the likelihood of postrelease participation with community-based transition services. A future study will be conducted to analyze the fidelity of the postrelease program and to evaluate the impact of short-term, intermediate, and long-term outcomes on transformative changes for people who participate in OTTIS. A rigorous, large-scale study is needed to determine the effectiveness of such occupational therapy programming in justice settings.
Conclusion
This process evaluation study suggests that although a variety of barriers and facilitators exist in implementing a new community-based program, it is feasible to provide occupational therapy transition and integration (reentry) services in an urban jail setting. A future study will be conducted to evaluate the program’s impact on community transition.
Footnotes
Acknowledgments
We express deep gratitude to the participants in this project, the City of St. Louis Division of Corrections jail staff, community partners, university partners, and advisory board members for participating in and supporting this project. We appreciate the OTTIS team support provided by occupational science and occupational therapy students (including Serena Blank, Sabrina Nihsen, and Anna Paskvalich) and fieldwork students (including Morgan Clendening, Regan Clementi, and Maria Welding).