Life After Incarceration: Transition and Reentry (LAITR)
A Pilot Program

METHODS

This pilot included five residents of the CSC, ages 21-47. To be eligible for this study, participants were required to be around their eighth week of residency in the CSC as this begins the “community reentry” phase of DOC’s programming. The second population involved in this study were staff including the CSC District Administrator, the CSC Unit Supervisor, the Institutional Activities Coordinator and POs of the participants in this study. This study was implemented over a 16-week period. Participants were referred to the occupational therapist by the CSC Unit Supervisor as they approached or surpassed their eighth-week in the CSC. After consent, the participants completed the pre-test battery including a demographic survey and the seven measures listed below.

Measures Administered

• PROMIS-43 Profile v2.0: Physical function, anxiety, depression, fatigue, sleep disturbance, ability to participate in social roles and activities and pain

• PROMIS Bank v2. -Social Isolation: Feelings of social isolation

• PROMIS Self-Efficacy for Managing Daily Activities v1.0: Self-efficacy managing daily activities

• PROMIS Self-Efficacy for Managing Emotions-short form 4a: Self-efficacy managing emotions

• PROMIS General Self-Efficacy- short form 4a: General self-efficacy

• VI-SPDAT: Risk of homelessness

• ACS: Engagement in activities (76 activities; do now, do less, want to do, given up, or never did)

On the second visit, the therapist conducted a standard behavioral mental health occupational therapy interview and the secondary ACS follow-up leading the therapist and participant to establish client-centered goals for this pilot. Participants then met with the occupational therapist 1-2x a week for 1:1 intervention for 12 weeks inside and outside of the CSC focusing on building the skills needed to meet their identified goals. The occupational therapist additionally worked with MO DOC staff in the CSC to expand upon programming to include weekly recreational groups and other semi-structured groups within and outside of the CSC. Group development and interventions were stunted by COVID-19. At the end of the pilot study, the PROMIS measures and secondary ACS questionnaire were re-administered to participants over the phone. On average, there were 12.14 weeks between pre and post-test data collection. Additionally, participants were asked the following questions in an exit interview: 1. Were there any benefits to your participation in this study (If yes, what?)? 2. Do you have any concerns you wish for us to address? 3. Do you have any suggestions? 4. What did you like about your time spent in the CSC? 5.What do you think could be better or what do you wish you had more of while in the CSC? 

The therapist also conducted seven semi-structured exit interviews with the staff sample. The staff exit interview questions were developed with key areas in mind to elicit information regarding staff perceptions of the feasibility of this program (Bowen et al., 2009). Questions included: 1. Please describe your overall impression of the occupational therapy pilot program. 2. What, if any, differences have you seen in your clients (or any clients) after receiving the occupational therapy (acceptability, demand, practicality)? 3. Do you see benefits in an occupation therapy program becoming a permanent service for this population? Why or why not (acceptability, demand, practicality, integration, expansion, implementation)? 4. Do you think this program can be effective in helping DOC meet goals of reducing risk for recidivism and addressing criminogenic needs? Why or why not (demand, practicality, integration, expansion)? 5. Was the service provided a barrier to your work or DOC’s work as a whole (i.e. time required, effort required on your end, feasibility of this program long term) (implementation, practicality, integration)? 6. In your opinion, what do offenders need more of here at the CSC? 7. Other suggestions, remarks or questions.

Patient-Reported Outcomes Measurement Information System (PROMIS) conversion charts, scoring manuals and online scoring services were used to obtain T-scores for the PROMIS measures. The VI-SPDAT was scored as indicated by the scoring instructions on the survey itself. The ACS follow-up was scored via self-report responses for how fully the participant engaged in the particular activity and how satisfied they were with their performance on Likert-scales ranging from 0 (not participating or not satisfied) to 5 (fully participating or very satisfied). Qualitative data was collected via audio-recorder and transcribed verbatim or completed via word document for four staff members. A qualitative data analysis software, NVivo, was used to analyze and thematically code both the participants’ exit interviews as well as the staff’s exit interviews. Participants’ notes were analyzed to determine the themes amongst goals as well as the percentage of goals met.

RESULTS

Participants averaged four diagnoses per person with the most common being ADHD, bipolar and depression. Scores on the VI-SPDAT indicated housing insecurity with this sample. Pre and post-intervention data on PROMIS measures demonstrated significant positive changes in: self-efficacy for managing emotions, general self-efficacy, and reduction of anxiety and sleep disturbances symptoms after participation in this program. Moderate positive changes were seen in reduced feelings of social isolation after participating in this study. Of the activities participants wanted to engage in more, participants reported increased participation and/or satisfaction after treatment for 15/22 activities, participants remained at the same level of participation and satisfaction for 3/22 activities, 1/22 activities demonstrated decreased participation and/or satisfaction and 3/22 activities included activities that changed (such as applying for school) or plans that are halted due to COVID-19 such as traveling. Of a total of 31 goals set between the therapist and each resident, 54.8% were met, 29% were in progress/partially met, 9.7% were unmet and 6.5% were requested by the participants to be put on hold. Goals included: completing job applications, obtaining housing, maintaining sobriety, increasing leisure participation, identifying and using healthy coping strategies, exploring schooling opportunities, increasing physical activity, managing medications, creating a budget, meal preparation, creating and meeting SMART goals, engaging in computer tasks without destructive behaviors, routine planning, reducing smoking frequency, completing computer social activities, maintaining clean living environment in the CSC, seeking services via technology, reading/writing tasks weekly to increase literacy and opening a checking account.

There were four themes developed from the qualitative exit interviews with the residents:

      Benefits of getting out of the CSC: Four of the five participants reported how one benefit to the pilot program was that they were able to get out of the CSC for some activities. Participants proceeded to report that getting out of the CSC more frequently for recreational activities, smoke breaks, free time and other activities is one way their time spent there may have been better. One participant even suggested it would help build rapport with residents, allowing them to open up in a different setting.

      Gaining life skills: When asked about benefits of this pilot program, all participants reported that it was helpful to them in various ways. Participants named a number of daily life skills that they learned with the therapist such as medication management, taxes, reading, organization, job searching, technology use, personal growth and goal accomplishment.

      Accountability and structure: The main benefit of the participants’ time in the CSC in general (not specific to this pilot program) was reported to be that it held them accountable, provided structure and gave them time to get themselves together prior to reentering the community.

      Client-centered support: Participants reported on their perceptions of the differences in support from the therapist compared to staff. One participant shared that he felt the therapist was the only person he could really talk to and that staff members only view residents as criminals and do not listen to them.

There were also four themes developed from the qualitative exit interviews with staff:

      Initial hesitancy transformed into increased engagement and behavior: This sample reported both resident and staff’s initial hesitancy participating in this pilot, however admitted positive end results such as increased engagement in PO and CSC programming, improved resident behavior, and overall acceptance of the program from both sample groups. Additionally, staff commented on specific improvements in their clients’ behaviors and overall engagement

      Benefits of separation of roles: Staff reported on how beneficial it was to have someone outside of DOC working with clients as there was a different level of comfort, quicker rapport building and trust thus leading to quicker results with the therapist as the goal was to work on clients’ life-skill goals rather than focused on compliance with the law.

      Clients lacking life skills: The term “life skills” and the lack thereof within this population was a strong theme that each staff member commented on. Staff gave examples of basic skills clients lack and how this program helped to address those needs.

      Asset to the probation and parole team: Despite initial hesitation reported earlier, staff reported on how the therapist proved to be an asset, rather than a barrier, to the team. When asked about barriers to implementation of this program, the response was that the biggest barrier was the therapist’s limited availability. Staff felt that the therapist was able to save them time and effort, opening them up to work on other tasks or with other individuals who needed their attention. In addition to time savings and collaborative benefits reported, one staff member reported a change in staff mentality, broadening their view in multiple ways.

CONCLUSION

This pilot program highlighted the high demand as well as the program’s fit to meet that demand for occupational therapy for JII. Results revealed that within the short-period of time, significant positive changes in self-efficacy, self-efficacy for managing emotions, anxiety, and sleep disturbances with moderate positive changes in reduced feelings of social isolation we seen in JII after participating in this study. Based on participant and staff results of this study, this program is not only a feasible program but has potential to expand further based on the needs. The JII sample in this study demonstrated difficulty setting attainable goals, difficulty with other cognitive tasks such as organization and attention and lacked many life skills that many people take for granted; all skills that this program addressed. This pilot program led participants to change their typical habits which demonstrated their progress and surprised staff members who have worked with the same individuals for years without promising change. These skills are extraordinarily essential for the population’s successful reentry to the community, maintained sobriety and prevention of recidivism.