Critical Review

British Journal of Occupational Therapy

2016, Vol. 79(4) 197–205

Occupational therapy in forensic psychiatry: ! The Author(s) 2015

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Recent developments in our understandings DOI: 10.1177/0308022615591018
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(2007–2013)

Danielle Hitch1, QK Hii2 and Ian Davey3

Abstract
Introduction: Occupational therapy in forensic settings has developed in recent decades, leading to an increasing amount of
research being conducted in this field. There have been two previous attempts to provide overviews of this body of evidence and
future directions for research; however, the rate of research has accelerated in recent years. This critical review addresses the
following question: what evidence has been published about occupational therapy in forensic psychiatry over the past 7 years?
Method: A mixed methods approach was adopted, with four databases and a search engine consulted (OTDBase, CINAHL, AMED,
PSYCHInfo, Google Scholar). The inclusion criteria were: (a) articles published in peer reviewed journals since 2007 and (b)
authored by at least one occupational therapist. Twenty-five studies were identified for review, and the four dimensions of
occupation – doing, being, becoming and belonging – were used to provide a theoretical context for the subsequent discussion.
Findings: The recent evidence base in forensic psychiatry focuses on doing and being, with fewer articles addressing becoming
and belonging.
Conclusion: This review has identified increasing numbers of studies about forensic occupational therapy, which may reflect
growth in both interest and the worldwide workforce.

Keywords
Mental health, criminal justice system, rehabilitation, offending

Received: 5 June 2014; accepted: 8 April 2015

three priorities: (1) the development of appropriate out-

Introduction
Forensic psychiatry is ‘the sector of mental health services
responsible for the assessment and treatment of mentally
ill offenders in the criminal justice system’ (O’Connell &
Farnworth, 2007: 184), and forensic occupational therapy
refers to the delivery of occupational therapy assessment
and interventions in such environments. Forensic occupa-
tional therapy originated in local, small scale initiatives in
secure and prison units during the 1980s (Farnworth et al.,
1987), and was also spurred on by the development of
regional secure units in the United Kingdom (UK)
during that decade (Chacksfield, 2007). Since then, occu-
pational therapists have become integral members of
multidisciplinary teams in treatment settings such as pris-
ons, secure hospitals and forensic community mental
health teams across the globe. Because of developments
in the treatment and rehabilitation of offenders with
mental health problems and service models, forensic occu-
pational therapy remains an evolving area of practice.
There have been two reviews addressing the evidence
base for forensic occupational therapy in the past decade.
Duncan et al. (2003) conducted a questionnaire survey to
identify research priorities for British occupational therap-
ists working in forensic practice. Their results highlighted
come measures; (2) the development of rigorous and
effective group work programmes; and (3) the develop-
ment of effective risk assessment tools. It further recog-
nised that there was a need to gather robust evidence for
practice, explore opportunities for multi-site research to be
conducted and share information with colleagues to pro-
mote collaboration. A literature review by O’Connell &
Farnworth (2007) found that much of the evidence sup-
porting the role of occupational therapy within forensic
psychiatry remained relatively weak, lacking both cur-
rency and methodological rigour. They support Duncan
et al.’s (2003) call for a co-ordinated and multi-site
1
Lecturer in Occupational Therapy, Deakin University, Australia
2
Occupational Therapist, Secure Mental Health Rehabilitation Unit, The Park
– Centre for Mental Health, Treatment, Research and Education, Australia
3
Chief Occupational Therapist, Forensicare, Victoria, Australia; Clinical
Associate, School of Health, Arts and Design, Swinburne University of
Technology, Australia
Corresponding author:
Dr Danielle Hitch, Lecturer in Occupational Therapy, School of Health and
Social Development, Deakin University Geelong Waterfront Campus,
1 Gheringhap Street, Geelong, Victoria 3220, Australia.
Email: dani.hitch@deakin.edu.au

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198
approach to conducting research, also suggesting the pur-
suit of international co-ordination.
These two reviews suggest that limited progress had
been made in developing the evidence base for forensic
psychiatry up until 2007, despite an overwhelming
acknowledgement of the need for this evidence to be gath-
ered, interpreted and disseminated. Given the time that
has elapsed since their publication, a fresh look at the
evidence available to forensic occupational therapists
was warranted. This review is intended to support and
complement the recently published practice guidelines
for occupation-focused practice in secure hospitals
(College of Occupational Therapists, 2012). Using the
model of human occupation as their theoretical frame-
work, these guidelines provide specific recommendations
for practice based on scientific research, theoretical evi-
dence and outcome measure research. While these guide-
lines are based on a somewhat bigger body of evidence
(n ¼ 34), only a third of these (n ¼ 11) are included in
this review and here they are analysed from a different
theoretical perspective. This review has also included evi-
dence regarding the practice of forensic occupational ther-
apy in the community, which has not traditionally been
the focus of much research to date.
The critical question guiding this review was ‘What
evidence has been published about occupational therapy
in forensic psychiatry over the past seven years (2007–
2013)?’ This review aims to provide occupational therap-
ists with an updated synthesis of the evidence available
to guide their practice, and to describe the overall char-
acter of the evidence base. This evidence will be reviewed
using the dimensions of occupation – doing, being,
becoming and belonging – as an organising structure.
The implications of these findings for practice in occu-
pational therapy in forensic psychiatry will then be dis-
cussed, and the article concludes with updated
recommendations for future research and evidence
generation.
Method
This review utilised the integrating theory, evidence and
action (ITEA) method, which was developed to meet the
need for synthesising the diverse range of knowledge avail-
able to occupational therapists. A full description of the
process underlying ITEA has been published in this jour-
nal (Hitch et al., 2014b), but we will provide a brief over-
view of the steps undertaken for this review.
The critical question (Step 1) guiding this review was
stated in the introduction. The four dimensions of occu-
pation – doing, being, becoming and belonging – were
chosen to provide a theoretical framework for this
review (Step 2), and are central concepts in both the occu-
pational perspective of health (Wilcock, 2006) and pan-
occupational paradigm (Hitch, 2014). The definition of
these terms has recently been updated as part of a crit-
ical analysis of this paradigm (Hitch et al., 2014a), and
these current understandings of the terms were used in
this review.
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British Journal of Occupational Therapy 79(4)
The inclusion criteria for this review were: (a) articles
published in peer reviewed journals since 1 January 2007;
(b) publication in English; and (c) authored by people
self-identifying as occupational therapists, consumers
of occupational therapy services and organisations self-
identifying as representing occupational therapy.
Excluding evidence published prior to 2007 ensures that
the articles included were current and that this review did
not repeat the work of the previous reviews on this topic
(Duncan et al., 2003; O’Connell & Farnworth, 2007).
Articles in languages other than English were also
excluded from this review. This is no indication of their
value or relevance, but reflected the linguistic skills of the
research team. Only one article was excluded as a result of
this criteria (Benz, 2009), so this is unlikely to have had a
major impact on the findings. Evidence not authored by at
least one occupational therapist, consumer or professional
organisation was also excluded, to ensure direct relevance
to the needs and concerns of occupational therapy.
Evidence that met the inclusion criteria were identified
through a search of four databases and a search engine –
OTDBase, CINAHL, AMED, PSYCHInfo and Google
Scholar. The search terms used in this review were rela-
tively broad, to improve the chances of identifying all
available evidence. The search terms were ‘occupational
therapy’ AND (‘mental health’ OR ‘psychiatry’) AND
‘forensic’. As shown in Figure 1, a process of screening
took place to assess eligibility against these inclusion cri-
teria, resulting in the final sample of studies.
The evidence was then classified into each dimension
(doing, being, becoming and belonging) according to
which was foregrounded or most evident in that study.
Qualitative studies were critiqued using the Rosalind
Franklin Qualitative Research Appraisal Instrument
(RF-QRA) (Henderson and Rheault, 2004), which evalu-
ates a study’s standards of trustworthiness, as measured
on a five point scale through credibility, transferability,
Records idenfied through
database searching
(n = 1043)
Records aer duplicates removed
(n = 1000)
Records screened Records excluded
(n = 1000) (n = 953)
Full-text arcles assessed Full-text arcles excluded,
for eligibility with reasons
(n = 47) (n = 22 did not meet
inclusion criteria)
Studies included in
synthesis
(n = 25)
Figure 1. PRISMA flow diagram of review (Moher et al., 2009).
Hitch et al.
Table 1. Qualitative and quantitative levels of evidence.
Levels of qualitative evidence
I: Affirmative responses to all 4 aspects of trustworthiness
II: Affirmative responses to 3 aspects of trustworthiness,
relevant problems noted in 1 aspect
III: Affirmative responses to 2 aspects of trustworthiness,
relevant problems noted in 2 aspects
IV: Affirmative responses to 1 aspect of trustworthiness,
relevant problems noted in 3 aspects
V: Relevant problems in all 4 aspects of trustworthiness
dependability and confirmability. Each piece of qualitative
evidence was subjected to key questions, and the scale
provides example strategies to highlight possible evidence.
If evidence exists that supports that element of trust-
worthiness, the study receives one point for that element
and a level of evidence is assigned. Quantitative evidence
was critiqued using a scale developed by the National
Health and Medical Research Council (2000). This scale
utilised a five level hierarchy based on the perceived rigour
of the quantitative method used, with systematic reviews
(and meta-analyses) at the top and expert opinion and case
studies at the bottom. Studies which used mixed methods
received two ratings – one for the quantitative component
and one for the qualitative component. Levels of evidence
were assigned according to the methodology used in the
study. As shown in Table 1, these systems of critique are
comparable to each other.
The evidence in this review was then consolidated and
correlated. Consolidation occurred when the evidence was
bought back together in the four dimensions of occupation
– doing, being, becoming and belonging. Correlation
occurred when instances of multiple forms of evidence
about the dimensions were identified. Finally, the analysis
progressed to comparison, where the evidence was evalu-
ated within the context of that dimension and other evi-
dence it had been grouped with. The analysed evidence
was formulated into a coherent statement, presenting the
outcomes of the consolidation, correlation and compari-
son processes in a prose statement of evidence. This state-
ment is reported in full in the results section of this article.
The final and most crucial step in the ITEA method is to
consider how the new knowledge arising from the review
can be transferred and utilised in practice. This is the sub-
ject of the discussion of the implications for practice raised
by our findings, to follow.
Findings and discussion
This review identified 25 articles relating to occupational
therapy in forensic psychiatry. The features of each article
are displayed below in Table 2. As shown in the table,
much of the evidence has originated in the UK (44%),
with the rest arising from Europe, the United States
(USA) and the Antipodes. Diverse evidence is available,
with sample sizes ranging according to the method used in
each study. Consumers have been the focus of the evidence
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199
Levels of quantitative evidence
I: Systematic reviews and meta-analysis
II: Randomised controlled trials
III: Controlled trials, cohort or case control studies
IV: Case series, post-test only, pre-test/post-test
V: Expert opinion, including literature/narrative reviews,
consensus statements, descriptive studies and
individual case studies
generated to date, as only two studies focused on occupa-
tional therapists or other staff.
The recent evidence base in occupational therapy in
forensic psychiatry focuses mostly on doing and being,
with fewer articles addressing becoming and belonging.
Quantitative studies were rated at the lower ends of the
hierarchy of evidence, while qualitative studies tended to
achieve higher ratings for quality. This is consistent with
an overall pattern found in the evidence base for occupa-
tional therapy in mental health (Hitch, 2014). British jour-
nals published almost half of the evidence, and research
from this country was also the most prevalent.
Findings
Doing. In reference to occupational therapy in forensic
psychiatry, doing refers to the performance of tasks and
activities that develop and occur in this setting, or the
performance of services for consumers.
Four of the articles reviewed provided an insight into
what clients in forensic settings do on a day-to-day basis
(Lindstedt et al., 2011; O’Connell et al., 2010; Rani and
Mulholland, 2014; Stewart and Craik, 2007). These studies
were undertaken in both inpatient and community set-
tings, and utilised surveys, self-report, time use diaries
and observation to capture data. Within both UK and
Australian inpatient environments, occupational engage-
ment was characterised by passive leisure and rest
(O’Connell et al., 2010; Stewart and Craik, 2007). In the
most recent study, only 61% of inpatients in an Irish
forensic setting were meeting a UK national standard of
25 hours of structured weekly activities (Rani and
Mulholland, 2014). This might be expected due to the
nature of the environment in these facilities; however,
similar findings have also been reported for people experi-
encing mental health problems who are not in the forensic
system (Eklund et al., 2009). While social participation
and occupational performance were found to improve in
the first year of contact with a Swedish forensic service
(Lindstedt et al., 2011), these clients were also noted to
continue to have ongoing challenges to participating in
their community due to mental health and psychosocial
issues.
Some positive findings were also made around the role
of choice and meaning in the doing of occupations in
forensic settings. Perceived competence, value and
200 British Journal of Occupational Therapy 79(4)

Table 2. Features of articles within this review.

Level of evidence

Reference Dimension Type of evidence Sample Location Quantitative Qualitative

Ardovino et al. (2010) Doing Pre–post 32 consumers USA IV

Bacon et al. (2012) Doing Mixed methods 2 consumers Australia V III
Colantonio et al. (2007) Being Descriptive 394 consumers Canada V
Cordingley and Ryan (2009) Doing Focus groups 8 occupational UK III
therapists
Craik et al. (2010) Doing Focus groups 26 consumers UK II
Dieleman and Duncan (2013) Belonging Case study 2494 online posts International V
Dolling and Day (2013) Doing Practice description 6 consumers UK OE OE
Dunn and Seymour (2008) Becoming Opinion piece Not applicable UK OE OE
Farnworth and Muñoz (2009) Becoming Literature review Not applicable Australia/USA OE OE
Fitzgerald (2011) Belonging Pre–post 43 consumers UK IV
Fitzgerald et al. (2012) Belonging Case study 1 family UK V
Heard et al. (2012) Doing Pre–post 19 consumers Canada IV
Kottorp et al. (2013) Being Descriptive 35 consumers Sweden V
Lin et al. (2009) Being Semi-structured 10 consumers Canada II
interviews
Lindstedt et al. (2011) Doing Longitudinal 36 consumers Sweden V
descriptive
Mason and Adler (2012) Being Semi-structured 11 consumers UK III
interviews
McQueen and Turner (2012) Being Semi-structured 10 consumers UK III
interviews
O’Connell et al. (2010) Doing Mixed methods 2 consumers Australia V III
Rani and Mulholland (2014) Doing Survey 93 consumers Ireland V
Smith et al. (2010) Doing Practice description Not applicable UK OE OE
Stelter and Whisner (2007) Being Practice description Not applicable USA OE OE
Stewart and Craik (2007) Doing Mixed methods 5 consumers UK V II
Tregoweth et al. (2012) Being Hermeneutic 8 consumers New Zealand II
Walker et al. (2013) Being Ethnography 21 staff and Australia II
consumers
Withers et al. (2012) Doing Service description Not applicable UK OE OE

OE: other evidence (non-scientific); UK: United Kingdom; USA: United States

enjoyment have been found to be related, with UK clients
more likely to enjoy occupations they have chosen
(Stewart and Craik, 2007). This literature review high-
lighted that occupational therapists have several tools at
their disposal to promote meaningful occupational
engagement, such as profession-specific assessments and
the ability to tailor intervention to individual occupational
needs (O’Connell et al., 2010).
Four interventions for clients in forensic psychiatry
have been investigated in the past 7 years. A US-based
leisure education intervention using resource modules in
a minimum security unit was described by Ardovino et al.
(2010). This intervention took a skill training approach,
with modules such as telephone and library use. A screen-
ing assessment performed pre- and post-intervention
assessed outcomes, and an improvement in the clients’
ability to participate in leisure activities was noted. It
appears this intervention was directed at people who
have been institutionalised for a long time, and its rele-
vance to other sections of the forensic population is
questionable.
Active leisure was the focus of an Australian study by
Bacon et al. (2012), who investigated the use of the Wii Fit
video game on an inpatient ward. Using an exploratory
case study design, the experiences of two clients were
assessed using interviews and an accelerometer. Wii Fit
use changed the clients’ attitudes to physical exer-
cise, which were found to be particularly positive if
staff also participated. However, there were some issues
with getting regular access to the equipment, and a
larger sample is needed before any broader conclusions
can be made.
Another intervention to make use of technology
involved a mechanical massage chair in a Canadian inpa-
tient unit (Heard et al., 2012). A standardised protocol
was adopted for the use of this chair, which was available
by appointment in a private area of the ward. Significant
reductions in stress levels were reported in a sample of 19
clients; however, the post-treatment scores were taken
immediately following the massage so the longer term
effects are not known. The discussion also indicates that
the authors see the chair’s main value to be immediate

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Hitch et al.
de-escalation within the ward environment, so research
into its impact on occupational performance is required.
Finally, in a descriptive article, Dolling and Day (2013)
outlined the formation of a relationship between a UK
medium secure forensic mental health service and a com-
munity arts project. A series of workshops were developed
between the two services, which ran for 10-week blocks
regularly over three years. Feedback from participants
was mostly positive, with clients experiencing the work-
shops in a positive manner and staff noting an improve-
ment in the clients’ mood and sense of achievement.
Two of the articles reviewed outlined the doing of ser-
vices for people in the UK forensic systems who are diag-
nosed with an intellectual disability and/or personality
disorder (Smith et al., 2010; Withers et al., 2012). While
this is a highly specialised area of practice, much of the
knowledge in this evidence is equally relevant to clients
without these additional diagnoses. For example, the qual-
ity of the working relationship between the multidisciplin-
ary team at a forensic service and a vocational provider
was highlighted as being crucial to the success of a work-
based learning programme (Smith et al., 2010). Similarly,
the quality of staff recruitment and training were found to
be important to the success of a specialist service for
people with intellectual disabilities and personality dis-
orders (Withers et al., 2012). A common theme to both
studies was the need to thoroughly assess individual needs,
and offer interventions tailored to and focused on their
particular occupational goals. This was supported at a
service level in both cases by an understanding of the effi-
cacy of an individualised approach, and the specialist
nature of the service.
Cordingley and Ryan (2009) studied the views of UK
occupational therapists working in forensic psychiatry
about risk assessment, using a focus group method
across three separate settings. There was some variation
in the way occupational therapists approach risk assess-
ment, although most acknowledged the need for funda-
mental information from their multidisciplinary team to
inform their own risk assessment. Harm to others was the
most often cited risk while engaging in occupations, and
the restrictions within many forensic environments were
part of the risk assessments therapists needed to perform.
A person, environment and occupational performance
framework was proposed to structure risk assessments,
but there remains little available evidence about risks asso-
ciated with occupations and client centred performance of
these assessments.
Recent understandings of doing in occupational ther-
apy in forensic psychiatry have mostly focused on clients.
Leisure and passive recreation remain a focus, although
there was also a study on an active leisure pursuit. Choice
can be challenging in forensic environments, but there is
recognition that engaging in activities which are personally
meaningful to clients does promote health and wellbeing.
Partnerships with other organisations (such as vocational
providers and art programmes) extended the choices avail-
able to clients in forensic facilities. To facilitate these
opportunities, occupational therapists are required to
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201
undertake complex risk assessments and the conducting
of these can have a profound impact on the subsequent
doing of the clients.
Being. In reference to occupational therapy in forensic
psychiatry, being refers to the lived experience of people
participating in this setting and the pre-existing capacities
that they bring to forensic psychiatry. Two types of evi-
dence around being in occupational therapy in forensic
psychiatry were generated in the past seven years: research
about the capacities and abilities of clients and accounts of
their lived experience. Two studies focused on the first
topic, and both found that clients of forensic services
tend to also experience cognitive problems (Colantonio
et al., 2007; Kottorp et al., 2013).
In a Canadian retrospective chart review, information
about clients’ history of traumatic brain injury, psychiatric
diagnoses, living circumstances and criminal offences were
analysed for associations (Colantonio et al., 2007). This
study found 23% of these clients had a history of trau-
matic brain injury, with people with alcohol/substance use
more likely to have this secondary diagnosis. The authors
recommend routine screening for a history of traumatic
brain injury as part of initial assessment. Processing
issues were prevalent in a Swedish study using the assess-
ment of motor and process skills (AMPS) to investigate
function in activities of daily living and self-awareness of
that function (Kottorp et al., 2013). Most of the clients
assessed were below the cut-off criteria for independent
living on this assessment, and awareness was significantly
related to both motor and process skills. Their compro-
mised motor and processing skills would likely have a
negative impact on their function post-discharge, which
the authors suggest is an area for occupational therapy
intervention.
Two articles focused on the lived experience of clients
within inpatient forensic facilities. Mason and Adler
(2012) interviewed male service users of a UK high secur-
ity hospital, while Craik et al. (2010) looked at a more
general population of people detained in UK forensic
units. Institutional factors such as the culture of wards
and risk management were identified in both studies, as
were opportunities for choice and decision-making.
Motivation also arose as a theme, with Mason and
Adler (2012) also finding that trust (on all sides) was fun-
damental to positive experiences of occupational engage-
ment in this setting.
The experience of moving back into the community was
the focus of two further studies, which investigated day
leaves from Australian inpatient units (Walker et al., 2013)
and the ongoing experience of living in the Canadian com-
munity (Lin et al., 2009). In the first, an ethnographic
approach was adopted to investigate community day
leaves, combining observations and semi-structured inter-
views. Staff and clients were found to have a similar under-
standing of the purpose of these leaves; however, the way
in which recovery was enacted varied between the two
groups. The authors advocate that recovery principles be
used to support beneficial experiences of activities of daily
202
living and reintegrating with communities. After this tran-
sition, the second study found there were four main
themes to the clients’ experiences. They remained aware
of the need to ‘do the right thing’ to avoid further contact
with the justice system, and also valued making connec-
tions with others. Similar to the finding around trust in
inpatient units, these participants also highlighted the
importance of freedom and responsibility, as means to
meeting the challenges of this new phase in their lives.
There were also three further articles which focused
specifically on clients’ being in regard to employment
and vocational rehabilitation. One study from the USA
in an occupational therapy sheltered workshop pro-
gramme focused on the development of self-responsibility
(Stelter and Whisner, 2007). Along with developing voca-
tional skills, this programme pursued a therapeutic agenda
based on the assumption that greater personal responsibil-
ity will reduce recidivism, and also promoted better social
skills. However, these findings were only based on the
therapists’ observations rather than direct data collection
from the clients.
Two articles used qualitative research methods to dir-
ectly access the client’s sense of being around employment.
Clients involved in work (paid or voluntary) or work prep-
aration reported valuing the opportunity to engage with
UK vocational activities as early as possible in their con-
tact with the services (McQueen and Turner, 2012). These
activities provided them with opportunities to experience
normality in their lives, take graded steps toward improv-
ing and connect with support to meet their goals. In a New
Zealand study of clients returning to work after a long
term admission (Tregoweth et al., 2012), the finding also
highlighted the opportunities that employment provides to
build skills and supportive relationships. Some of the chal-
lenges these participants faced included building stamina,
facing stigma, negotiating disclosure and the potential for
social isolation. Both studies provide recommendations
for the implementation of vocational services in forensic
settings, and promote a leadership role for occupational
therapy.
Becoming. In reference to occupational therapy in forensic
psychiatry, becoming refers to what both consumers and
occupational therapists hope to achieve from their work
together, both during admission to services and in the
future (Hitch et al., 2014a)
Two articles addressed becoming for these consumers,
with the first focusing on employment and vocational
rehabilitation (Dunn and Seymour, 2008). The ongoing
development of vocational services (and the associated
development of clients’ hopes and aspirations in this
area) is bolstered in the UK by both government policy
and the strategic plans of the College of Occupational
Therapists. However, at present, this area of research
and practice remains under-developed, and is therefore
in an early stage of its becoming.
A multinational analysis of the ways in which institu-
tions can fail to meet the needs of clients in forensic psych-
iatry explored the barriers for clients becoming in these
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British Journal of Occupational Therapy 79(4)
settings (Farnworth and Muñoz, 2009). The concepts of
occupational imbalance and deprivation, along with occu-
pational enrichment, are used to explore how these issues
impact on practice, which Wilcock (2006) identified as risk
factors for becoming. The authors concluded there was a
need to validate outcome measurements for use in forensic
psychiatry, and these are indeed essential if the impacts of
interventions on clients becoming are to be evaluated
effectively.
Belonging. In reference to occupational therapy in forensic
psychiatry, belonging refers to how consumers and occu-
pational therapists work and collaborate together to
ensure social inclusion and connectedness (Hitch et al.,
2014a), Two studies have investigated interventions
aimed at promoting belonging for clients of UK forensic
psychiatry services. Using the model of human occupation
screening tool (MOHOST), Fitzgerald (2011) found a sig-
nificant improvement in scores following participation in a
social inclusion programme which included community
integration. The programme was offered individually and
was tailored to each client’s goals. Family work is also
proposed to have a positive impact on clients’ belonging,
both within and outside of the family unit (Fitzgerald
et al., 2012). By reducing expressed emotion within
families, this intervention can reduce the risk of relapse
by bolstering the client’s access to support. While the
authors propose that occupational therapists can play a
role in the provision of family therapy, this would entail
further specialist training.
Finally, the belonging of international occupational
therapists was investigated in a study in an online discus-
sion group (Dieleman and Duncan, 2013). A review of 8
years of posts showed that clinicians from 20 countries
were accessing this group; however, activity in the group
had declined in recent years. The authors suggest this may
be due to the rise of alternative social media platforms as
places for networking. Advice seeking, networking, shar-
ing resources, service development, student learning and
clarifying the role of occupational therapy in forensic
psychiatry were all reasons for clinicians choosing to
belong to this group. Based only on posting content, this
study could not comment on participants’ views of their
belonging to this group.
Discussion
The current review has identified a growing number of
studies about forensic occupational therapy, which may
reflect both increasing interest and an increasing world-
wide workforce. In regard to doing, being, becoming
and belonging, the findings of several of the articles
reviewed indicate that occupational therapy services in
forensic psychiatry share the same core considerations of
service delivery as those in other mental health settings.
Passive leisure and rest are characteristic of inpatient
environments, both in secure and non-secure services.
The clinical profiles of clients are similar when considered
in terms of reasons behind reduced occupational
Hitch et al.
engagement and barriers to community discharge; factors
such as the ward or institutional culture, compromised
motor and process skills, cognitive problems, substance
misuse, positive and negative symptoms of mental illness,
stigma and the potential for social isolation.
Both settings also share the same factors that increase
and enhance occupational engagement; factors such as
choice, meaningful occupation, perceived competence,
value, enjoyment, trust between all stakeholders, freedom,
responsibility, and the development of close working rela-
tionships with community agencies (for example, arts and
vocational providers). Therefore, it follows that assess-
ments and outcome measures used by occupational ther-
apists in other settings can also be applied with similar
efficacy in forensic psychiatry. However, one additional
consideration must be considered in detail by forensic
occupational therapists: clinical risks. The area of clinical
risk assessment and risk management affects all service
providers and service users of forensic services, but is
not often addressed in this body of literature.
In the absence of a large evidence base originating from
their own discipline, forensic occupational therapists need
to adopt innovative approaches to ensure quality service
provision. These strategies might include dedicated time to
conduct small scale research, networking with inter-
national colleagues, collaborating with universities and
supervision of honours and masters students. This final
method can be particularly fruitful – an Australian foren-
sic occupational therapy service has participated in four
separate studies over the past 3 years, resulting in nine
manuscripts being prepared for peer reviewed journals (I
Davey, personal communication, 2014). If this method is
adopted by every occupational therapist in forensic ser-
vices, this would lead to increased generation of important
contributions to the evidence base for occupational ther-
apy practice in forensic psychiatry, and has the additional
advantage of clinician oversight and input through the
supervision of honours and masters students.
In regard to the previous reviews of evidence in this
area (Duncan et al., 2003; O’Connell & Farnworth,
2007), some of the developments called for have been rea-
lised. Three studies have focused on employment and
vocational rehabilitation, describing the development of
group work programmes in some settings. In regard to
qualitative studies, some of that which has been published
has been quite robust and the quantitative evidence cur-
rently available can provide the basis for studies of greater
complexity in the coming years. However, there have been
no occupational therapy specific studies which focused on
the development of outcome measures or risk assessment
tools. It may well be that those developed in other settings
(or already existing in forensic psychiatry) are suitable,
and there is no need to produce forensic-specific tools.
Indeed, it could be argued that using existing generic
tools would facilitate the consumers’ moves to non-
forensic services in future by providing continuity of infor-
mation. Another area which remains underdeveloped is
the call for multi-site or international collaborations.
There are many logistical considerations which can be
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203
barriers to this form of research, but these could be over-
come with sufficient interest and funding.
There are several limitations to this review, which limit
its generalisability and are important to acknowledge.
Firstly, the exclusion of authors who are not occupational
therapists may miss important and relevant evidence from
other disciplines. This exclusion criterion was also based
on the designations of authors as published in the articles
themselves, and we recognise that many occupational ther-
apists hold multiple professional identities (manager, aca-
demic etc.). While the intention was to highlight evidence
which has originated within the profession, this exclusion
criterion is not intended to imply the contributions of
other authors are not valid or relevant, and we would
encourage all forensic occupational therapists to search
broadly for evidence to support their practice. It is
encouraging to reflect that including all evidence (from
all authors) would likely uncover an evidence base which
would be too large to comprehensively review in a single
journal article.
The variable quality of the evidence available is also a
limitation in regard to its application to practice. As befits
an area which is still relatively early in development, many
of the studies were exploratory, and based on relatively
small samples of consumers. The character of the evidence
base is also influenced by the inherent nature of the set-
ting; relatively few mental health consumers are treated
within the forensic system, and there are serious ethical
challenges around obtaining informed consent and avoid-
ing coercion. Despite this, efforts should be made in the
future to consolidate our knowledge in this area, and con-
duct future inquiries to the highest possible standard. The
findings of such studies could then be generally applied
with far more confidence, and hopefully impact positively
on the lives of consumers.
Conclusion
The evidence base for occupational therapy in forensic
psychiatry has developed through an increase in both
study numbers and quality over the past 7 years. The
doing and being of consumers in these settings has been
the focus of much of this research, which is consistent with
the overall pattern found in the evidence base for occupa-
tional therapy in mental health. Indeed, a theme to emerge
from the review of this evidence was its continuity and
similarities with general evidence about mental health
occupational therapy. As a highly specialised area of prac-
tice, these links vastly increase what could be considered
the relevant evidence for this area of practice.
Future research about forensic occupational therapy
could greatly benefit from the combining of resources
and collaborative efforts. Such an approach could lead
to great sharing of knowledge and experience, along
with an increase in the quality of evidence available to
inform practice. Detention centres may also provide an
emerging area of practice to which forensic occupational
therapy could potentially make a valuable contribution.
The detention of refugees and asylum seekers is practised
204
in a number of countries around the world, and the
insights forensic occupational therapy has developed
within the criminal justice system could support the pre-
vention of occupational deprivation and occupational
injustice in these settings. Forensic occupational therapy
is now a clearly established area of practice, and the spe-
cialist knowledge of its practitioners is relevant to the
broader occupational community.
Key findings
. Evidence supporting forensic occupational therapy has
grown in recent years, and some qualitative studies are
methodologically rigorous
. The becoming and belonging of consumers in forensic
psychiatry remains under-researched
. Forensic occupational therapists need to seek opportu-
nities to contribute to the evidence base, particularly
through collaborations with academics and colleagues
What the study has added
This study had provided an update of the evidence base
for forensic mental health, and critiqued the evidence
available to clinicians.
Research ethics
Ethics approval was not required for this study.
Declaration of conflicting interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
References
Ardovino PS, Fahey J, Sprecher S, et al. (2010) An evaluation of
a leisure education intervention for adult male residents in a
state minimum-security forensic unit: Leisure resources mod-
ules. American Journal of Recreation Therapy 9(4): 31–37.
Bacon N, Farnworth L and Boyd R (2012) The use of the Wii Fit
in forensic mental health: Exercise for people at risk of obes-
ity. The British Journal of Occupational Therapy 75(2): 61–68.
Benz B (2009) Welchen Beitrag kann die Ergotherapie zum
Auftrag der forensischen Psychiatrie leisten? [What can occu-
pational therapy contribute to the assignment of forensic
psychiatry?]. Ergoscience 4(3): 107–116.
Chacksfield JD (2007) Forensic occupational therapy: Is it a
developing specialism? British Journal of Therapy and
Rehabilitation 4(7): 371–374.
Colantonio A, Stamenova V, Abramowitz C, et al. (2007) Brain
injury in a forensic psychiatry population. Brain Injury 21(13/
14): 1353–1360.
College of Occupational Therapists (2012) Occupational
Therapists’ use of Occupation-Focused Practice in Secure
Hospitals: Practice Guideline. London: College of
Occupational Therapists.
Cordingley K and Ryan S (2009) Occupational therapy risk
assessment in forensic mental health practice: An exploration.
British Journal of Occupational Therapy 72(12): 531–538.
Downloaded from bjo.sagepub.com at University of Newcastle on May 1, 2016
British Journal of Occupational Therapy 79(4)
Craik C, Bryant W, Ryan A, et al. (2010) A qualitative study of
service user experiences of occupation in forensic mental
health. Australian Occupational Therapy Journal 57(5):
339–344.
Dieleman C and Duncan EAS (2013) Investigating the purpose of
an online discussion group for health professionals: A case
example from forensic occupational therapy. BMC Health
Services Research 13(1): 253–260.
Dolling S and Day J (2013) How working with a community arts
project benefits service users. Mental Health Practice 16(8):
36–38.
Duncan EAS, Munro K and Nicol MM (2003) Research priori-
ties in forensic occupational therapy. British Journal of
Occupational Therapy 66(2): 55–64.
Dunn C and Seymour A (2008) Forensic psychiatry and voca-
tional rehabilitation: Where are we at? British Journal of
Occupational Therapy 71(10): 448–450.
Eklund M, Leufstadius C and Bejerholm U (2009) Time use
among people with psychiatric disabilities: Implications for
practice. Psychiatric Rehabilitation Journal 32(3): 177–191.
Farnworth L and Muñoz JP (2009) An occupational and
rehabilitation perspective for institutional practice.
Psychiatric Rehabilitation Journal 32(3): 192–198.
Farnworth L, Morgan S and Fernando B (1987) Prison-based
occupational therapy. Australian Occupational Therapy
Journal 34(2): 40–46.
Fitzgerald M (2011) An evaluation of the impact of a social
inclusion programme on occupational functioning for forensic
service users. British Journal of Occupational Therapy 74(10):
465–472.
Fitzgerald M, Ratcliffe G and Blythe C (2012) Family work in
occupational therapy: A case study from a forensic service.
British Journal of Occupational Therapy 75(3): 152–155.
Heard CP, Tetzlaff A, Fryer P, et al. (2012) Mechanical chair
massage and stress reduction in the seriously mentally ill con-
sumer: A preliminary investigation. Occupational Therapy in
Mental Health 28(2): 111–117.
Henderson R and Rheault W (2004) Appraising and incorporat-
ing qualitative research in evidence-based practice. Journal of
Physical Therapy Education 18(3): 35–40.
Hitch D (2014) Dynamic and diverse ways of knowing: A new
approach to evidence based practice for occupational therapy
in mental health. PhD Thesis, Deakin University, Geelong,
Australia.
Hitch D, Pepin G and Stagnitti K (2014a) In the footsteps of
Wilcock, part one: The evolution of doing, being, becoming
and belonging. Occupational Therapy in Health Care 28(3):
231–246.
Hitch D, Pepin G and Stagnitti K (2014b) The integrating theory,
evidence and action (ITEA) method: A procedure for helping
practitioners translate theory and research into action. British
Journal of Occupational Therapy 77(12): 592–600.
Kottorp A, Heuchemer B, Petersson Lie I, et al. (2013)
Evaluation of activities of daily living ability and awareness
among clients in a forensic psychiatry evaluation unit in
Sweden. British Journal of Occupational Therapy 76(1): 23–30.
Lin N, Kirsh B, Polatajko H, et al. (2009) The nature and mean-
ing of occupational engagement for forensic clients living in
the community. Journal of Occupational Science 16(2):
110–119.
Lindstedt H, Grann M and Soderlund A (2011) Mentally dis-
ordered offenders’ daily occupations after one year of forensic
care. Scandinavian Journal of Occupational Therapy 18(4):
302–311.
Mason K and Adler JR (2012) Group-work therapeutic engage-
ment in a high secure hospital: Male service user perspectives.
British Journal of Forensic Practice 14(2): 92–102.
Hitch et al.
McQueen JM and Turner J (2012) Exploring forensic mental
health service users’ views on work: An interpretative phe-
nomenological analysis. British Journal of Forensic Practice
14(3): 168–179.
Moher D, Liberati A, Tetzlaff J, et al. (2009) Preferred reporting
items for systematic reviews and meta-analyses: The PRISMA
statement. PLoS Med 6(7): e1000097.
National Health and Medical Research Council (2000) How To
Use The Evidence: Assessment And Application Of Scientific
Evidence. Canberra: Australian Government Printing Service.
O’Connell M and Farnworth L (2007) Occupational therapy in
forensic psychiatry: A review of the literature and a call for a
united and international response. British Journal of
Occupational Therapy 70(5): 184–191.
O’Connell M, Farnworth L and Hanson EC (2010) Time use in
forensic psychiatry: A naturalistic inquiry into two forensic
patients in Australia. The International Journal of Forensic
Mental Health 9(2): 101–109.
Rani S and Mulholland F (2014) An appraisal of service users’
structured activity requirements in an Irish forensic setting.
Journal of Psychiatric and Mental Health Nursing 21(5):
383–390.
Smith A, Petty M, Oughton L, et al. (2010) Establishing a work-
based learning programme: Vocational rehabilitation in a
Downloaded from bjo.sagepub.com at University of Newcastle on May 1, 2016
205
forensic learning disability setting. British Journal of
Occupational Therapy 73(9): 431–436.
Stelter L and Whisner SM (2007) Building responsibility for self
through meaningful roles: Occupational adaptation theory
applied in forensic psychiatry. Occupational Therapy in
Mental Health 23(1): 69–84.
Stewart P and Craik C (2007) Occupation, mental illness and
medium security: Exploring time-use in forensic regional
secure units. British Journal of Occupational Therapy 70(10):
416–425.
Tregoweth J, Walton JA and Reed K (2012) The experiences of
people who re-enter the workforce following discharge from a
forensic hospital. Journal of Vocational Rehabilitation 37(1):
49–62.
Walker A, Farnworth L and Lapinksi S (2013) A recovery per-
spective on community day leaves. Journal of Forensic
Practice 15(2): 109–118.
Wilcock A (2006) An Occupational Perspective of Health, 2nd ed.
Thorofare, NJ: SLACK Incorporated.
Withers P, Boulton N, Morrison J, et al. (2012) Occupational
therapy in a medium secure intellectual disability and person-
ality disorder service. Journal of Learning Disabilities &
Offending Behaviour 3(4): 206–218.