Q&A: Occupational Therapy in Prisons with Heather Gilbert, OTD ‘23

Lecturer Heather Gilbert, OTD ‘23, describes the role OTs can play in supporting people in prison.
Heather Gilbert portrait

Heather Gilbert is a new lecturer and Tufts alum, specializing in mental health, acquired brain injury, and management. She has worked in a variety of settings, including as the director of rehabilitation at an inpatient forensic psychiatric facility for men who were detained or incarcerated, operated by the Massachusetts Department of Corrections.

  1. Describe your work in a prison setting. What types of challenges did your clients experience? 

I worked in a specialty psychiatric hospital that served individuals, primarily men, who were in the Department of Corrections custody. The individuals I served were experiencing a wide array of challenges. Many people had trauma histories that were impacting their daily behavior and how they experienced the world. Many were living with mental and behavioral health challenges such as mood disorders, personality disorders, psychotic disorders, brain injuries, or a dual diagnosis, which means they had both a mental health disorder and a substance use disorder. A large percentage of clients grew up in poverty and experienced discrimination, which can lead to mental and physical health challenges going untreated.

By virtue of being in a restrictive prison setting, my clients were experiencing what OTs call “occupational deprivation,” which is when people are prevented from being able to engage in necessary, normal life activities due to factors outside their control. In a prison, there is obviously limited access to things that may have been really important to clients on the outside. For example, they can’t see their family regularly; they’re not able to have much privacy; they can’t control what meals they eat; they have limited access to recreational activities and green space. They might not be able to engage in activities that help them manage stress, so you can imagine how being in such a setting could impact anyone’s mental health and ability to recover.

Prisons are not friendly, welcoming places. There’s a lot of hypervigilance among clients as well as staff. Depending on how long someone has been in prison, they run the risk of becoming institutionalized, which means becoming so accustomed to the atmosphere and rhythms of prison life that they lose the skills to independently direct their own life. Often, people who are incarcerated more long-term are not able to develop personally meaningful routines or make many decisions. Everything just becomes predetermined for them, which can negatively impact their ability to adapt to life when they reenter the community.

  1. How did you approach the work you did with your clients experiencing incarceration in terms of recovery from trauma and other mental health challenges?

What was important for me in those settings was to have a smile on my face and to engage in positive interactions with people, while maintaining professional boundaries. I used trauma-informed principles to create opportunities of choice for my clients. I really listened to them and tried to build that trust and rapport because trust is hope. I worked with a lot of clients who had been repeatedly let down their entire life. A number of them had been abandoned by their families and had experienced so many instances where trust had been broken. When I’m teaching Tufts OT students, I always emphasize how important it is to never make a promise to a client you can’t keep, because if something happens and you don’t show up like you had intended, trust can quickly erode.

In addition to providing one-on-one support, I ran a lot of groups because building relationships and finding commonality among clients is so meaningful to people in prison. My goal was always to make them feel like they were in a safe setting where they could share without judgment. I organized a lot of groups around creative expression; things like art, music, and movement. I worked on a collaborative mural project with a local university where a group of clients teamed up with college students to paint this beautiful mural we could all enjoy. I also piloted a “Seeds of Change” program where clients were able grow different plants and vegetables. And I supported a companion program where individuals who were doing well in the general population were paired with others who were really struggling. Those were such reciprocal relationships and helped give the person on both sides a sense of meaning, which is vital for recovery.

It’s important to focus on recovery in settings like this because most of the clients I saw were going to reenter the community and their well-being is certainly a public safety issue. They are going to be our neighbors someday, so we have to be thinking: What kind of care do we want them to receive? Do we want this to be a fully punitive experience, which will result in more mental health and social challenges for them? Or do we want to give them the support they need to have a greater sense of well-being, make better choices, and have the skills necessary to live healthy, productive lives once they’re released?

  1. How does the presence of OTs in a prison setting impact recidivism?

Occupational therapists can play an important role in reducing recidivism, though this is very much a new, emerging branch of OT. We have the potential to help people who are currently incarcerated as well as people who have been recently released. The first couple years after incarceration are a very vulnerable time for people for many different reasons. The Bureau of Justice lists statistics from 2018 that show 68% of formerly incarcerated people were reincarcerated after three years. And the statistics only get worse over time. 79% of formerly incarcerated people were reincarcerated after six years. So we're not being very successful in our rehabilitation efforts, if that is our goal.

OTs are very well equipped to support people reentering their communities. We are trained in supporting people to develop healthy routines, daily living skills, purpose, and meaning. We can help people to cultivate better social skills and relationships, manage their health, and secure housing and employment opportunities. Many formerly incarcerated individuals experience what OTs call “occupational marginalization,” which means not being able to make optimal choices due to socioeconomic status, stigma, or marginalization. It’s not being able to pursue the jobs you’re most interested in or live in the neighborhoods where you’d feel most safe. Many of my clients left our facility and returned to areas that are very unsafe; places where they are likely to fall back into old patterns that pose a risk to their recovery.

OTs have a role in helping people establish new positive patterns. We can be effective cheerleaders in that we’re trained to rally around people to empower them to improve their psychosocial, emotional, and financial well-being. More advocacy work needs to be done to get more of us into prisons and other criminal justice settings.

  1. For people interested in these topics, could you recommend books or other resources on prison populations and the role of OTs  in the criminal justice system?

There’s a podcast called Ear Hustle that I love and always recommend. It’s produced by two men who were incarcerated in the San Quentin Prison in California along with a local artist and it features interviews and stories of the people who are living in or have been released from the prison. In terms of occupational therapists working in prisons, I love the work of Jamie Muñoz, Lisa Jaegers, and their colleagues, who are conducting related research and are facilitating the Justice-Based OT Network.

Read more about Heather Gilbert, OTD ‘23, here.