From Punishment to Purpose: Occupational Therapy and Ethical Challenges in the Spanish Prison System

Abstract

Occupational therapy (OT) advocates for rehabilitation and social reintegration within prison systems, yet its integration must consider the ethical and institutional constraints of incarceration. This paper critically examines the Spanish penitentiary system to explore the tensions between the punitive logic of imprisonment and the rehabilitative values of OT. The aim is to assess whether the current institutional structure enables socio-health professionals—particularly occupational therapists—to act coherently with their humanistic and ethical principles. A detailed documentary review was conducted using the Triangular Method of Ontologically Grounded Personalism (Sgreccia), which integrates biological/situational, anthropological, and ethical dimensions. Legislative documents, institutional reports, and academic literature were systematically analyzed to identify ethical challenges affecting professional practice within Spanish prisons. Findings reveal a paradoxical reality: Spain maintains one of the lowest crime rates in the EU yet exhibits a high incarceration rate, reflecting a punitive penal culture. The prison population, mostly adult males convicted of property and public health offenses, experiences significant occupational deprivation, mental illness, and social vulnerability. Ethical dilemmas include dual loyalty, loss of autonomy, and institutional priorities that undermine person-centered rehabilitation. The study underscores profound ethical tensions limiting OT practice in prisons. Addressing these challenges requires institutional and professional transformation toward more participatory and dignity-centered correctional models. Future research should incorporate empirical and qualitative approaches to design ethical frameworks that promote occupational justice and sustainable reintegration.

1. Introduction

The contemporary prison system in Spain stands at a crossroads inherent to its very nature and purpose [1,2]. On the one hand, it retains its original objective of isolation as a form of punishment and coercive response to harm caused. On the other, it faces the more recent constitutional mandate—established in the 1978 Spanish Constitution (Article 25.2)—to orient its function toward re-education and social reintegration, as well as the creation of new opportunities for convicted individuals [3]. This duality between punishment and treatment cannot, by any means, be combined without generating ethical conflicts that particularly affect the practice of socio-health professions within this environment [4,5].

From a deep conviction in the need for ethical reflection and critical questioning of prison practices—both as strategies to improve reintegration processes of sentenced persons [6] and to build a correctional institution more consistent with the mission of socially rehabilitating those who inhabit it—arises the pressing need to respond to questions inherent in this conflict [7,8]. These include whether the current configuration of the prison institution truly promotes social reintegration, what the impact of imprisonment is on health, and whether socio-health professions can fully achieve their aims in this context. A fundamental premise in this consideration is to view human error and the capacity for change as elements inherent to human nature.

Within this complex framework, occupational therapy emerges as an emergent and humanistic socio-health discipline [9]. Its focus lies in enabling individuals to participate in meaningful occupations that promote health and well-being. Occupational therapy can be defined as a health profession that uses purposeful and meaningful activity to promote participation, autonomy, and well-being across diverse contexts. Within correctional settings, its role extends beyond individual rehabilitation to encompass the facilitation of occupational justice, the prevention of occupational deprivation, and the promotion of environments that support social reintegration. Occupational therapists working in prisons focus on restoring daily functioning, strengthening personal identity through meaningful occupations, and developing skills that enhance self-efficacy and social participation upon release. The paradigm of occupational therapy recognizes occupation not only as a therapeutic tool but as a constituent element of the human condition—fundamental to the construction of identity and the meaning of existence [10]. This situates the discipline in a relevant position to address the activity limitations and participation restrictions imposed by imprisonment. However, the disconnection between the reality of criminality in Spain and the disproportionate penal response, together with conditions such as overcrowding and the predominance of regimental over care-oriented approaches, raises serious doubts about the ethical coherence and sustainability of professional practice in this setting [11,12,13].

The Spanish prison context reveals that, although Spain has one of the lowest crime rates in the European Union [14], its incarceration rate remains notably higher than the European average [15]. This disparity suggests a comparatively more punitive criminal justice response than that of neighboring countries. The prison population is predominantly composed of adult males of Spanish nationality, with most inmates serving sentences for offenses against property and public health, such as drug trafficking, the illicit manufacture or distribution of controlled substances, and violations of health regulations related to public safety.

Persistent issues such as dual loyalty among professionals, power imbalances in therapeutic relationships, and the lack of person-centered practice are constant features of the prison environment [16]. The markedly higher prevalence of mental illness and substance dependence in prisons, combined with recidivism data, suggests that the institution may act as a substitute for other social and health services, yet without achieving the expected efficiency in rehabilitation [17]. Furthermore, the distorted public perception of crime and punishment—often shaped by mass media—hinders the adoption of policies grounded in reason and justice [18].

This study aims to critically analyze the Spanish prison system and the role played by socio-health professions—particularly occupational therapy—in promoting health, occupational performance, and social reintegration among individuals deprived of liberty. It seeks to examine the structural and social conditions of the prison institution, evaluate the impact of imprisonment on physical, mental, and occupational health, and assess the ethical coherence of professional interventions in this context. The analysis is framed within a perspective that recognizes occupational participation as a human right, and situates human dignity and the capacity for change as the foundations for rethinking prison practices and contributing to effective and just social reintegration.

2. Methods

The methodological approach adopted in this concept paper consisted of a detailed review of reference documentation. This process involved the systematic identification, selection, and analysis of national and international sources relevant to the intersection between occupational therapy, criminal justice, and public health. The review included legislation, institutional reports, academic publications, and policy documents published over the past two decades.

The selection of materials followed three main criteria: (1) direct relevance to the Spanish prison context or comparable European systems; (2) conceptual and theoretical contributions to the understanding of rehabilitation and social reintegration; and (3) recognition or citation within the academic or institutional literature. Once identified, the documents were analyzed to extract key themes and trends related to occupational therapy practice, the penal system’s orientation toward rehabilitation, and the evolution of public health frameworks within correctional settings.

The review process also entailed cross-referencing the information obtained from official databases, such as the Ministry of the Interior and the General Secretariat of Penitentiary Institutions, with findings from peer-reviewed journals and professional associations. This triangulation ensured the reliability and comprehensiveness of the analysis.

The structuring of information, its analysis, and the derivation of main conclusions were guided by the Triangular Method of Ontologically Grounded Personalism proposed by Sgreccia [19,20,21]. The ethical triangular method developed by Elio Sgreccia articulates three interdependent dimensions: (a) the objective consideration of scientific data in the case, (b) the anthropological reflection on the human person as a free, dignified, and relational being, and (c) the formulation of an ethical judgment grounded in the principles of ontologically founded personalism (

Table 1. Summary of the Triangular Method of Ontologically Grounded Personalism.

Vertex	Description
A: Biological Fact	Represents the object of analysis. In this study, it focused on deprivation of liberty and the situation of incarcerated individuals in Spain.
B: Anthropological Analysis	Examines the values and behaviors involved. For this study, it entailed analyzing the implications of deprivation of liberty on health and access to occupations, as well as identifying the paradigm of occupational therapy and its main occupational diagnoses applicable in prisons.
C: Bioethical Analysis	Examines ethical implications and derives conclusions for action.

). This approach enables a comprehensive evaluation of bioethical situations, ensuring that decisions respect the intrinsic dignity of the person and promote their integral good in complex settings such as healthcare, prisons, or social institutions.

In practical terms, the method comprises three main vertices:

Regarding information sources, the study consulted several types of resources:

• Statistical databases from official bodies, including the Secretaría General de Instituciones Penitenciarias, annual reports of the Ministerio del Interior, the Instituto Nacional de Estadística (INE), Eurostat, the United Nations, the Council of Europe, the European Parliament, and the World Health Organization (WHO).
• Spanish legislation, mainly through the Boletín Oficial del Estado (BOE).
• Specialized journals, such as the Revista Española de Sanidad Penitenciaria, Cuadernos de Bioética, and other publications in the fields of occupational therapy and related disciplines.
• Reference works, including doctoral theses, reports and studies by third-sector organizations, manuals, books, and seminal authors.

Priority was given to recent documentation (published within the last ten years), except for classic or foundational texts. The scope was limited primarily to Spain, referring to socio-politically comparable countries only when necessary for analysis. Access to information was carried out through databases such as Medline Plus, CINDOC-CSIC, PubMed, Tesis en Red, and Google Scholar.

3. Results

Understanding the Spanish prison reality and the role played within it by socio-health professions such as occupational therapy requires a deep and structured analysis. To this end, the Triangular Method of Ontologically Grounded Personalism proposed by Sgreccia [19,20,21] was applied. This framework enables an integrated and critical understanding by examining the biological/situational fact, the anthropological analysis, and the bioethical implications of the prison context (

Table 2. Application of the Triangular Method to the Spanish Prison Context.

Vertex	Description	Key Elements
A. Biological/Situational Fact (The Spanish Prison Reality)	Analysis of the prison context using empirical and epidemiological data, including inmate profiles, health conditions, and institutional functioning.	High incarceration rate despite low crime; predominance of property and public health offenses; high prevalence of substance dependence and mental disorders; overcrowding, psycho-emotional deterioration, premature mortality; deficiencies in the prison healthcare system; greater psychological impact on incarcerated women; limited socio-health research.
B. Anthropological Analysis (Human Dignity, Freedom, and Occupation)	Reflection on the human condition of persons deprived of liberty and their right to dignity, autonomy, and transformation through occupation.	The person does not lose dignity by offending; conditioned yet real freedom as the basis of responsibility; concepts of “total institution” (Goffman) and “prisonization” (Clemmer); occupational therapy as a promoter of autonomy, justice, and health; key ideas: occupational deprivation, occupational injustice, occupational apartheid.
C. Bioethical Analysis (Ethical Conflicts and Opportunities)	Ethical assessment of the legitimacy of the prison system and professional practice within it from a humanistic paradigm.	Questioned legitimacy—prison as a substitute for social and health services; professional double loyalty (control vs. care); power imbalance in the therapeutic relationship; limitations on the right to health; incongruence between prison and occupational therapy principles; low effectiveness of re-education and reintegration; disoccupation, inequality, and lack of a restorative approach.

).

3.1. Vertex A: The Biological/Situational Fact—The Spanish Prison Reality

The Spanish prison system faces a fundamental dichotomy: on the one hand, it fulfills the original punitive purpose of sentences; on the other, it bears the more recent constitutional mandate—articulated in the 1978 Spanish Constitution (Article 25.2)—to promote social reintegration and create new opportunities for convicted individuals [22,23]. This dual purpose produces bioethical conflicts that are the focus of this analysis [24].

As of June 2025 (latest available official statistics), the incarcerated population in Spain totaled 61,603 individuals, of whom 92.9% were men and 7.1% women. Among these, 49,995 were serving sentences, 10,501 were in pretrial detention, and 1570 were under other legal statuses. Most inmates are between 31 and 60 years old (43,371), with approximately 22% aged 18–30 and 5.5% over 60. In terms of nationality, 67.2% are Spanish and 32.8% are foreign nationals. The most common offenses leading to imprisonment are crimes against property and socioeconomic order (18,924) and offenses against public health (7786), mainly related to drug trafficking.

Paradoxically, Spain maintains one of the lowest crime rates in the European Union. According to official data published in 2022, Spain ranks third among the safest EU countries based on its homicide rate (0.69) compared to the EU-27 average (1.1). However, Spain’s prison population rate is 118 per 100,000 inhabitants (2023), seven points above the European average [25]. Moreover, historical data indicate a stable trend of low homicide rates over the past fifteen years (0.72 average), while incarceration rates remain consistently high [26].

This discrepancy evidences a disproportionate penal response, suggesting that prison policy is not always informed by empirical analysis of criminal behavior and that sentence severity does not necessarily correlate with crime prevention.

The health of incarcerated individuals is significantly affected. Between 70 and 80% of inmates are associated with drug use problems, and 63.5% reported having consumed drugs in the previous year while in prison. The prevalence of mental illness is up to five times higher than in the general Spanish population, reaching 84.4% according to official data published in 2022. Substance abuse and dependency disorders are the most common, followed by mood and psychotic disorders. Prisoners face a higher risk of premature death, with suicide being the third leading cause of mortality, at rates eight times higher than in the general population. Overcrowding, drug use, and infectious diseases such as HIV/AIDS and hepatitis remain persistent health problems. Imprisonment also produces significant psycho-emotional effects, including increased anxiety, diminished self-esteem and autonomy, and profound hopelessness.

Despite constitutional recognition of the right to health, prison healthcare remains secondary to regimental priorities, with chronic staff shortages, insufficient coordination with the National Health System, and limited resources [27]. Furthermore, institutional restrictions often hinder socio-health research, requiring official authorization for study publication. Incarcerated women experience particularly severe mental health deterioration and unmet needs, showing higher levels of anxiety and depression.

3.2. Vertex B: The Anthropological Analysis—Human Dignity, Freedom, and Occupation

Anthropological analysis within the prison context invites reflection on the human condition of those who offend. Inmates often experience depersonalization, being reduced to “numbers” rather than persons. Yet, human dignity is inherent and cannot be lost through criminal behavior [28,29]. Recognizing this dignity entails acknowledging the potential for personal transformation and the social responsibility to provide supportive conditions for that change.

Human freedom, though conditioned by biological, psychological, and social factors, is not entirely determined [30]. This conditional freedom remains sufficient for moral responsibility and for understanding punishment not only as retribution but also as an opportunity for rehabilitation [31]. For occupational therapy, which focuses on human doing and volition, this concept of conditional freedom is central.

Goffman’s notion of the “total institution” [32] and Clemmer’s concept of “prisonization” [33] describe prisons as environments that enforce uniform routines and erode individual identity. The process of prisonization involves social disconnection, identity loss, and adaptation to coercive structures, often leading to disempowerment and learned helplessness [34,35,36,37,38]. These processes drastically reduce autonomy and social participation, directly impacting the occupational repertoire of incarcerated individuals.

Within this context, occupational therapy emerges as a discipline aligned with health, well-being, human rights, and social justice. Its paradigm focuses on meaningful participation and the transformation of environments that restrict it. Core values include dignity, equality, service, solidarity, justice, beneficence, and non-maleficence [39,40,41].

Concepts such as occupational deprivation, occupational injustice, and occupational apartheid—defined as systemic restrictions on participation in meaningful occupations—are highly relevant to prison settings [23]. Due to limited access to purposeful activity and the lack of person-centered interventions, the prison environment exemplifies these occupational injustices.

3.3. Vertex C: The Bioethical Analysis—Conflicts and Opportunities

The Spanish prison institution presents significant bioethical challenges that restrict the effective practice of socio-health professions such as occupational therapy. One major issue concerns the legitimacy of imprisonment itself, as prisons frequently act as substitutes for underfunded social and health services [42]. Disproportionate sentencing, limited treatment individualization, and exposure to violent environments further compromise this legitimacy.

Professionals also face dual loyalty conflicts, torn between obligations to their patients and to institutional priorities of security and control [24,43]. This dynamic may result in coercive interventions and loss of therapeutic trust. The absence of multidisciplinary bioethics committees exacerbates the lack of ethical oversight in decision-making.

The power imbalance between staff and inmates is inherent to the regimental structure, hindering dialog, autonomy, and person-centered care. Prisoners often perceive themselves as continuously evaluated, fearing that any personal disclosure could have punitive consequences.

Access to healthcare remains restricted due to institutional scheduling, logistical challenges, and lack of coordination with external systems. Health, understood holistically as including living conditions, dignity, relationships, and social participation, is thus systematically undermined [44].

The prison’s custodial priorities directly conflict with the humanistic paradigm of occupational therapy, whose purpose is to enable autonomy and participation [23,39]. Assistance and rehabilitation remain nominal goals but are limited by staffing shortages, institutional mistrust, and the structural dominance of security imperatives.

Although re-education and reintegration are stated objectives, the conditions of imprisonment themselves—occupational deprivation, reduced autonomy, and perpetuation of inequality—undermine these aims. The focus on the offender rather than on community and victims contradicts occupational therapy’s commitment to the common good and its transformative social mission [45].

4. Discussion

The present analysis has examined the complex duality defining the Spanish prison system: its punitive function of isolation and punishment versus its constitutional mandate for re-education and social reintegration. This duality is not merely theoretical—it generates profound ethical conflicts that directly affect the practice of socio-health professions, including occupational therapy. Critical reflection is therefore essential to construct a prison institution that is more coherent with its mission of social recovery. The goal of this work was precisely to analyze whether the current system fosters reintegration, to assess its impact on health, and to determine whether socio-health professions—particularly occupational therapy—can fully achieve their objectives in this context.

The biological or situational reality of the Spanish prison system presents notable contradictions. Although Spain records one of the lowest crime rates in the European Union, its incarceration rate remains above the European average. Historical data confirm a persistent disconnection between the evolution of crime and the prison population. Some authors suggest that, for a fair and proportionate penal response, Spain would need to reduce its prison population by 50%, without any significant impact on crime rates [46].

The profile of the prison population—mainly adult Spanish men convicted of property and public health offenses—reveals that prison often functions as a “last human repository”, reflecting a collective failure to address broader social phenomena related to prior conditions of exclusion. The high prevalence of substance use disorders and mental illness within prisons supports this view, underscoring the need for greater investment in preventive and rehabilitative resources that the institution currently lacks or that depend on external collaboration with third-sector organizations. Consequently, it becomes necessary to establish an institutional framework that guarantees the effective exercise of socio-health professionals’ roles in rehabilitation processes.

The deficiencies of the prison healthcare system—including the dominance of regimental priorities over care, staff shortages, the absence of specific professional profiles in institutional structures, and weak coordination with the National Health System—constitute persistent barriers that limit the effective realization of the right to health. Research in this field is further hindered by institutional restrictions and a critical lack of specialized training and dissemination programs [27,47].

From an anthropological perspective, the analysis reaffirms that human dignity is inherent and cannot be forfeited by committing a crime. To deprive a person of their humanity based on their decisions or actions—however wrongful or harmful—constitutes an ethical violation and poses a serious risk to the rehabilitative mission of the prison and its professionals.

Within this scenario, occupational therapy emerges as a humanistic and transformative socio-health discipline, offering a complementary approach to existing interventions. Its paradigm is centered on enabling participation in meaningful occupations that promote health and well-being, recognizing occupation as an essential element of human identity, meaning, and belonging. However, occupational therapy is not formally recognized as a service within the Spanish prison system. As a result, occupational therapists are absent from official institutional staffing, and the management of occupation as a rehabilitative tool largely falls to mid-level technicians or “occupational monitors”, leading to limitations in scope, professionalization, and ethical quality [23,39,41].

The ethical evaluation identifies several critical bioethical conflicts that restrict the effective and coherent exercise of occupational therapy in prison settings:

• Questioned legitimacy: The prison often functions as a substitute for social and health services, encompassing individuals whose needs require specialized interventions outside the penal system. This dynamic compromises the institution’s bioethical legitimacy.
• Professional double loyalty: The dual assistance and forensic roles imposed on socio-health professionals compromise person-centered care, as decisions are frequently influenced by institutional security interests rather than therapeutic objectives [24,43].
• Power imbalance: Strict regimental structures grant disproportionate authority to staff, obstructing dialogical and trust-based relationships essential for rehabilitation. The lack of horizontal communication between inmates and professionals constitutes a major obstacle to reintegration-oriented interventions.
• Restrictions on the right to health: Despite constitutional recognition, access to healthcare remains limited by logistical, administrative, and coordination barriers. Health, in its broader sense—including dignified living conditions, opportunities, and occupational participation—is deeply compromised in prisons. Deprivation of liberty thus represents, in itself, a measure contrary to the comprehensive exercise of the right to health [44].
• Incongruence with occupational therapy principles: The institution’s emphasis on custody and containment conflicts with the humanistic paradigm of occupational therapy. Practicing within this environment generates serious ethical tension, demanding careful assessment and flexible adaptation of restrictions to ensure equitable access to meaningful and health-promoting occupations [23,39].
• Ineffectiveness of reintegration processes: Although recidivism cannot be attributed to a single factor, limited access to occupations, reduced autonomy, institutional detachment, and the reproduction of social inequality all negatively influence rehabilitation outcomes. Treatment programs are limited, disoccupation is pervasive, and the lack of individualized activity planning—often assigned to unqualified personnel—creates significant barriers [48].

Limitations

This study presents several methodological limitations inherent to its documentary and conceptual design. The analysis relied primarily on secondary data sources which, although systematically reviewed, cannot fully capture the lived experience and complexity of occupational engagement within prisons. The absence of empirical fieldwork limited the triangulation of findings and the inclusion of first-hand perspectives from incarcerated individuals, socio-health professionals, and institutional actors. As a result, the conclusions should be interpreted within the boundaries of a theoretical exploration that aims to identify ethical tensions rather than to measure outcomes or effectiveness.

Future research should therefore adopt qualitative and mixed-method approaches to reinforce the empirical foundation of this field. Incorporating interviews, participatory observation, and narrative methodologies would enable: (a) the recovery of first-hand accounts of occupational experience in prison; (b) a critical evaluation of the conditions of access to meaningful and health-promoting occupations; and (c) an assessment of the practical feasibility and ethical coherence of occupational therapy within coercive institutional contexts. Such empirical triangulation is essential to bridge the existing theoretical–practical gap in the ethical analysis of prison systems.

While this paper does not seek to outline institutional reforms or operational models for professional practice, it recognizes that the ethical tensions described here are inseparable from the structural characteristics of the Spanish penitentiary system. Spain’s prison network remains predominantly closed and centrally administered, with limited differentiation between custodial and rehabilitative regimes. Nonetheless, these very constraints reveal opportunities for transformation—both within the system and within the profession itself. For the prison institution, such change would entail a gradual shift toward more open, rehabilitative, and community-oriented models that align with the constitutional purpose of social reintegration. For occupational therapy, it calls for a reflective professional evolution capable of adapting its principles of autonomy, participation, and occupational justice to the realities of coercive contexts. The purpose of this work, therefore, is not prescriptive but generative: to illuminate the ethical implications of practice within restrictive environments while fostering critical reflection as a catalyst for institutional and professional change.

5. Conclusions and Implications

The analysis reveals that the professional practice of occupational therapy within Spanish prisons is marked by profound ethical tensions. Deprivation of liberty can be considered unjust insofar as it disproportionately affects vulnerable populations and perpetuates social exclusion. It is also inefficient, as it neither reduces crime nor effectively prevents recidivism, and it has limited capacity to repair the harm caused to victims and society. The persistent political trend toward penal hardening—combined with the media’s influence on public perceptions of crime—remains a source of concern and appears inconsistent with empirical evidence.

Although imprisonment may constitute a legitimate response in certain cases, its implementation must be carefully balanced to ensure that it serves as a period of effective, person-centered rehabilitative treatment. This requires an equitable allocation of resources that prioritize reintegration over control and security. The current institutional framework negatively impacts health and autonomy, exposing individuals to sustained occupational deprivation and dependency. Within this context, occupational therapy holds significant potential to contribute to rehabilitation by enabling engagement in meaningful occupations that promote health, well-being, and quality of life. However, serious bioethical limitations persist, including the absence of occupational therapists in official staffing structures, the erosion of personal autonomy caused by long-term incarceration, pervasive inactivity, the predominance of institutional priorities over therapeutic objectives, asymmetrical power relations, and the persistence of structural social inequalities.

These ethical incongruences should not lead to inaction but rather to an ethically conscious and critically reflective stance among occupational therapy professionals. Such a position entails recognizing the moral complexity of practice in coercive environments while advocating for systemic transformations that foster a more just, humane, and person-centered correctional model. Promoting this shift constitutes both a professional challenge and an ethical imperative for the advancement of an occupational therapy that remains socially engaged, committed to human rights, and consistent with its foundational values of autonomy, participation, and occupational justice.

Building upon these findings, three priority research directions are proposed: (1) longitudinal studies assessing the long-term impact of occupational therapy interventions focused on identity reconstruction, autonomy, and occupational justice, particularly in relation to inclusion indicators such as employability, social participation, and reduced recidivism; (2) qualitative analyses exploring inmates’ occupational narratives through intersectional perspectives—including gender, ethnicity, mental health, and age—to better understand how structural inequalities influence occupational opportunities; and (3) the collaborative design of ethical and practice-oriented protocols for socio-health professionals to address institutional dual loyalty, asymmetrical power dynamics, and the persistent tension between care and control.

Pursuing these lines of inquiry would not only mitigate current research constraints but also encourage a necessary paradigm shift in the way rehabilitation and punishment are conceived within correctional systems. Such work could help reposition occupational therapy as a discipline capable of contributing both to individual rehabilitation and to broader institutional reflection. By promoting the value of occupational dignity as an ethical and political cornerstone, future research and practice may inspire more humanistic, participatory, and rights-based approaches to incarceration—ones that recognize the inherent capacity for change and the collective responsibility to support reintegration through meaningful occupation.