1. Working with women offenders
presenting with complex trauma needs
Dr Michelle Carr & Dr Susan Cooper
Consultant Forensic Psychologist
2. Aims of the presentation
Trauma and women offenders
3. Background
PTSD in women in general pop 3%> (McManus, 2007)
Woman are more likely to develop PTSD after a traumatic event (20.4%
women and 8.1% for men; Kessler et al 1995)
Rates of PTSD for women in prison have not been reported however are
assumed to be much higher (Ogloff, Cutajar, Mann & Mullen, 2012)
53% experienced emotional, physical or sexual abuse during childhood
50%> experienced domestic violence (Norman & Barron, 2011)
A history of abusive relationship experiences in childhood is evident in a
large number of both male and female offenders, but the specific nature of
these experiences may differ
This suggests a certain susceptibility to the development of PTSD and also
highlights that trauma in is a significant problem for women in prison
4. Complex Needs
Female offenders with a history of trauma and abuse
have overlapping problems with mental health; physical
health; victims/perpetrators of crime and self-harming
behaviour (Corston, 2007; Bloom, Owen & Covington,
2003; Covington, 2014)
Such factors can be relevant when trying to understand
their offending behaviour (Blanchette & Brown, 2006;
Chesney-Lind, 1997)
5. What is trauma?
Briere (2004) suggests that the definition was limited as it did not include
events that may not be life threatening but nevertheless may be extremely
distressing.
PTSD DSM- V definition: “ exposure to actual threatened death, serious
injury, or sexual violence”
Directly experiencing a traumatic event, witnessing a traumatic event, learning of a
traumatic event (violent/ accidental) or experiencing repeated or extreme exposure to
aversive details traumatic events.
Other symptoms include: intrusive, avoidance of stimuli, negative alterations in cognition
and mood associated with the trauma, alteration in arousal and reactivity.
“Complex” PTSD (Herman, 1992), although not appearing in DSM-IV, is
described in the clinical literature, and refers to complex outcomes that
arise from severe, prolonged, and repeated trauma, usually of an
interpersonal nature, such as child abuse or chronic spouse abuse.
6. Link between trauma and offending
Women in forensic
settings can present
with more
aggravating factors
than mitigating
factors. Which can
fall under the
following three
domains:
These three
interacting domains
can heavily influence
whether an individual
may be more
severely affected by
the traumatic events
and in what way.
A diagnostic framework
Bloom, 1997
7. Impact of trauma
A working study has found that multiple traumatisation
below the age of 26 years predicted development of
complex PTSD.
These early experiences can impact on mental health,
physical well being, personality difficulties and
ultimately an individual’s life trajectory.
But can trauma be a precursor to an individual taking a
pathway to offending?
9. Do we need to address trauma in women
offenders?
10. Therapist issues
Our own barriers to thinking about trauma (Chu, 1988)
Patient defends against intolerable experiences – therapist becomes
object of many confusing transferences – not good enough
Collusion with denial and access to services
Fabricate stories about good upbringing
Deny significance of abuse
Don’t mention the war
Why don’t we ask about trauma experiences and how these have
affected the individual’s life?
11. Effective therapy for CPTSD
The catalysts of trauma within this population are
varied and encompass complex issues such as
survivor/ perpetrator roles within their forensic history.
Need to work with victim and perpetrator …. Or risk of
working with ‘as if self’ ()
Issues can be felt in teams and organisations, for
example in the form of divides and blurred boundaries
Enmeshment
12. Effective therapies
Treatment programmes are often designed in such a
way that victims and perpetrators are treated as if two
distinct groups
Programmes for perpetrators of violence are often
designed for male offenders and seem to focus on the
offender taking responsibility for the offence and
empathising with the victim, which can be difficult when
there are complicated victim/perpetrator issues
13. Effective therapies
Is trauma treatment feasible in prison setting?
Covington (2014) argues for trauma-informed services,
emphasising safety, trustworthiness, choice, collaboration,
empowerment
Hooper (2003) has identified some trauma-focused interventions
that have been evaluated in prison settings, such as EMDR
(Colosetti and Thyer, 2000) and Traumatic Incident Reduction
(Valentine and Smith, 2001): however conclusions drawn from
these studies are limited because of small sample sizes and
methodological flaws.
TREM
EMDR / CBT RESEARCH/
DBT
14. Effective therapies
It might be difficult to fully understand a women’s
harmful behaviour without first understanding her own
experience of abuse. We would suggest that
interventions for this group of women offenders should
attend to offender’s experiences as a victim of
aggression as well as a perpetrator (also see
Covington, 2014)
Trauma work to include work on sexual abuse more
generally (see Ainscough C, Toon K, 2000)
15. Effective therapies
• Trauma treatments involving exposure techniques
appear to have the most support, but may not be
appropriate for those who have experienced prolonged
and severe trauma and in women with severe
personality disorder and multiple related problems
• A present-focused approach, focusing on psycho-
education, coping skills and anxiety management
recommended
16. Effective therapies
Trauma work necessitates creating a social and
physical environment that is trauma-informed (Blud,
2007; Covington, 2014)
Trauma work requires a ‘containing’ environment or
‘good enough’ holding (Winnicott, 1965) with limits to
dysfunctional behaviours
18. Understanding traumatic offences
Some (women) offenders can be traumatised by their
offender such as the murder of a partner or child (more
classic PTSD) and this would need to be addressed
This can manifest in psychological work
Avoidance
Overwhelming feelings of guilt/punishment (self-harm)
Hyperarousal
Anger and irritability
19. Further reading
Ainscough C, Toon K
(2000). Breaking Free Workbook
– Practical help for Survivors of Child
Sexual Abuse, Sheldon Press.
Blud, L. (2007). Literature review and
recommendations - treatment interventions dealing
with trauma: what will work with personality-
disordered women offenders? Unpublished.
Chu, J.A. (1988) Ten traps for therapists in the
treatment of trauma survivors. In In G. Adshead &
c. Jacob (2009). Personality Disorder: The
definitive reader. London: Jessica Kingsley
Publishers.
Hinweis der Redaktion
Apologies from Michelle.
Our abstract: The catalysts of trauma for women in secure services are varied and encompass complex issues linked to their forensic history. The need for interventions to reduce risk within forensic services is paramount and the extent to which this requires specific trauma intervention will be considered. This paper will also consider how some women offenders can be traumatised by their offences, and how this can manifest in psychological work and throughout therapy. Finally, the evidence base for trauma therapies with this population will be outlined.
Caveat rates of PTSD are generally under reported.
Rates for women in prison are much higher This number is much higher in offenders due to experienced significant (often multiple) interpersonal traumas in their life, such as childhood abuse, domestic violence, bereavement and loss.
In comparison to both the general population and male offenders, female offenders are more likely to have experienced victimisation that is violent and sexual over a prolonged period and involving numerous perpetrators (Blud, unpublished)
How this can affect adjustment to the prison environment and thus their presentation and ability to work with them therapeutically.
Islam- Zwart and Vik (2004) found that overall the experience of previous sexual assault, whether as a child or an adult, will have a negative impact on adjustment to a prison environment. Furthermore, Women with a history of both childhood and adult sexual assault reported lowest internal adjustment scores. Internal adjustment to an environment refers to coping strategies (i.e. cont substance misuse, self harming, poor emotion management, sleep hygiene, discomfort around prison officers and peers).
Slotboom et al., 2011. Furthermore the presence of child abuse and child victimization was found to be a predictor of serious prison misconducts; which has also been used as an outcome measurement in terms of adjustment to prison.
Unravelling the web of complexities in order to work with these women in the most effective possible way.
A question that often arises is the order or pathway of treatment for women in forensic setting. Do we need to focus on offending behaviour first or will this work be ineffective if trauma needs remain.
There is a pathways theory which examines the specific life course events that place women at risk for offending. It is based on the premise that criminal activity differs between men and women offenders primarily because of their paths to such activities also differ. Women's pathways to crime mainly include a history of abuse, economic marginality and a lack of resources to care for children (Belknap & Holsinger, 2006, Daly, 1992, 1994, Steffensmeier & Allan, 1998). Within this theory Covington would argue that trauma and addiction are extremely important for women to address if these facet have not been addressed then the likelihood of women remaining within the CJS is much higher.
Another theoretical framework is relational-cultural theory which contextualises women’s psychological development within their social relationships and interactions. Subsequently, a woman's substance abuse is also considered to be embedded in interpersonal relationships.
Also within the trauma literature it is widely reported that if trauma is not addressed early in the treatment pathway then other work will not be as effective, or longstanding.- need reference.
DSM Definition defines trauma as “threatened death or serious injury, or other threat to ones physical integrity” and lists a number of traumatic events including military combat, violent personal assault (sexual, physical attack, robbery, mugging) being kidnapped, being taken hostage, terrorist attack, torture, POW, man made disasters, being diagnosed with a life threatening illness, severe automobile disasters.
The chronic nature of the abuse results in somatic and dissociative difficulties and problems in identity, boundary awareness, interpersonal relations and affect regulation.
Clusters of symptoms observed in a range of personality disorders are similar to those observed in complex PTSD.
Women in prison are often perpetrators as well as victims of trauma and offending. With especially high levels of childhood trauma and abuse.
Childhood trauma is a risk factor for the development of later personality disorder (Weiler and Widom, 1996; Adshead, 2000). A disproportionate amount of women in forensic setting are diagnosed with one or more personality disorder. This is supported by Adshead (1994) who pointed out that personality disorder, in particular, borderline personality disorder, is often reported in female remand and convicted populations (e.g. Wilkins and Coid, 1991; Dolan and Mitchell, 1994).
Also PTSD is not a diagnosis commonly made within forensic populations. She suggests this may be because PTSD is generally associated with “victims” rather than “perpetrators”. However, Hooper (2003) cites research which suggests that PTSD may be significant in relation to female offending, through contributing to higher levels of distress and lower levels of self-restraint (Cauffman, Feldman, Waterman and Steiner, 1998), higher risk-taking, involving both drug and alcohol use and sexual risk-taking (Mullings, Marquart and Brewer, 2000) and attempts to relieve symptoms of PTSD via aggression (Adshead, 1994; Falshaw, Browne and Hollin, 1996).
Blooms notes that it is important to look for ‘disturbances’ in the three dimensions. Following this the Complex PTSD Dynamic Model (Busuttil, 2006) was developed. This CPTSD Dynamic model incorporated the element of being trapped in time, learned helplessness and adaptive over-coping.
Just to highlight the newer theories of trauma, PTSD sand CPTSD become more complex and this appears to be inline with the increased knowledge base and reflection of the people who present with these diagnoses.
Complex trauma is deemed to arise from sever, prolonged and repeated trauma usually of an interpersonal nature, such as child abuse or chronic spouse abuse. Generally individuals will have suffered the trauma under the age of 26, it may have affected attachments and may have also negatively impacted on early developmental stages.
Trauma is a fixed risk factor which has not been directly shown to be predictive of re-offending, but it may lead to outcomes such as shame and self-blame, problems with interpersonal relationships, anger, and the development of dysfunctional coping strategies, all of which may be mediating risk factors between trauma and offending
A study by Busutti & Turner (UK Trauma Group 2000 Discussion) postulated that adult victims of torture and incarceration (multiple traumas) are more likely to develop an Enduring Personality Change after catastrophic stress (ICD-10, 1992) and not straightforward PTSD or complex PTSD.
Kolk et al 1994, Field Trails Complex PTSD DSM-IV with adult survivors of CSA. These were the seven areas which could be affected. An individual may only be affacted in one or all of them.
Affect and Impulses: affected lability, anger/ aggression, self mutilation, suicidal preoccupation
2. Attention & Concentration: dissociation, amnesia, depersonalization
Self perception: helplessness, guilt & shame
Perception of perpetrator: idealization of the perp or feelings of vengance
Relationships with others: isolation, mistrust, victim role, victimization of others
Somatization: GIT, CVS, chronic pain, conversion etc
Systems of meaning: despair, hopelessness, major changes to previously witheld beliefs.
J. Herman who first described complex PTSD as Adult survivors of childhood sexual abuse + PTSD = Complex PTSD.
Notes that the individual may feel permanently damaged; they may sustain a loss of previously held beliefs, show social withdrawal, feel constantly threatened, show impaired relationships with others and show a change from the individuals previous personality characteristics.
See vignette
Trauma symptoms can be overlooked in forensic services or viewed as a secondary need
Do we do enough or do more?
Hollin and Palmer (2006) point to research which suggests that a history of abuse is not predictive of recidivism in either males or females (e.g Lowenkamp, Holsinger and Latessa, 2001).
Despite the evidence of a link between abuse and both personality disorder and offending in women, most of the studies attempting to identify risk factors for female offending do not consider the experience of trauma, such as abuse in childhood, to be a true criminogenic need (Blanchette and Brown, 2006).
While clearly not everyone who is abused in childhood goes on to offend or act out in violent ways, there is a subgroup of abused individuals who do act destructively towards themselves and others (Renn, 2004; Adshed and Bluglass, 2004; Ross and Pfafflin, 2004).
Hooper (2003) cites research which outlines a number of pathways from abuse to offending for women in particular: for example, running away from home to escape abuse may lead young women to be drawn into prostitution and/or drug use and hence develop criminal lifestyles, which in turn expose them to further victimisation (Lake, 1993; Belknap and Hosinger, 1998; Classen et al, 2005).
Abuse history and associated trauma should be addressed (Bland, 1999)
Direct risk factor vs indirect risk factor vs treatment interfering behaviour
Act out feelings of anger, sadism
The notion that female offenders are both victims and perpetrators of harm has important implications for treatment. Although at times it will be imperative to work with both modes of an individual balancing the timing or positioning in treatment. This is important as it is noted by eminent researchers and clinicians in the field of trauma that trauma should be one of the first things to be tackled within treatment. Whilst undertaking trauma work could be would allow the individual to easily shift into a victim mode. Then shifting this mode in order to work with the perpetrator within offence focussed work could potentially be very difficult.
Another difficulty one can come across in therapy is the notion of an ‘as if’ self (?). it relays a process in which the therapist thinks that the therapy is moving in the right direction but on reflection the process has not moved due to the clients resistance as they want to ‘prove’ they are ok or there is nothing that needs work or changing. The as if self or world can be a a defence or resistance against insight. When this is occurring a therapist could report lots of agreement between the therapist and the client however there is no ‘emotional learning’. The therapist will get little or no information about what the patient did hear or understand, the client may also grasp at wording that is unnecessary and secondary and will elaborate on these points- ignoring the important points. The client shifts the focus while accepting the therapists interpretation.
Some women can be traumatised by their offence of offending behaviour. This can lead to enmeshment in therapy and requires time, patience and understanding.
Staff teams can often reflect or parallel the family dynamics, as some of the women display few personal boundaries. Relationships with the women within the programme. Over involved in each others lives. Women with CPTSD and their attachment to the therapist and the difficulty they have in instilling these boundaries. Enmeshment with each other- offending against each other.
Additionally we have the impact of the women and their presentation on the team and within the organisation. Much research has focussed on the staff and teams working with personality disordered clientele, which as stated before, have higher levels of previous trauma. Often without appropriate supervision and support staff burnout rates can climb, therapeutic boundaries can be crossed and staff can be left feeling stuck with some team members fighting for one approach with others disagreeing and fighting for another type of approach. Reports from staff who work in environments geared for personality disorder, trauma and women report criticism from colleagues that they are ‘soft’, ‘too caring’ and the clients within these services are not challenged. Whereas Covington talks about working in a ‘smart’ not ‘soft’ way in that the services are trauma informed, staffed with individuals who want to be there.
There have been nine published studies in which complex PTSD symptoms were the target of treatment in adults. All studies were RCT’s (gold standard). All encompassed enhanced or phase based trauma treatment models. Phase based approaches were found to be superior when compared to exposure focussed treatment and skills focussed treatment.
Sequential or phase based treatments are recommended in which emotional stabilization and resource/ skill development occur before trauma memory processing.
Emotion regulation strategies particularly focussing on somatic experiences facilitates PTSD reduction (Hinton et al 2012 & Morina, Maier, Bryant, Knavelsrud, Wittmann et al 2012). Supported by the ACE study which reported strong links of early trauma and victimization and poor health outcomes and lower life expectancy (Felitti & Anda, 2010)
Individual therapies yielded larger effect sizes than group therapy.
Phase one: Stabilization and Skills Strengthening
To ensure that the priority of any mental health treatment, pattient safety has been achieved. Strengthen the individual capacities for emotional awareness and expression, increase positive self concept and address feelings of guilt and shame and increase interpersonal and social competencies. This improved functioning this hopes to build confidence and provides motivation and continuation in treatment.
Phase 2: Review and Reappraisal of Trauma Memories
Some form of review or re-experiencing of the traumatic events in a safe environment. Facilitate the reorganization and integration of the traumas into an autobiograohical memory in a way that yields a more positive, compassionate, coherent and continuous sense of self and relatedness to others. Generally this is done through the form of language however it can be supported by artwork, symbols or written word eg Narrative Exposure Therapy.
Phase 3: Consolidate the Gains
Applying skills to strengthen safe and supportive social networks and to build and enhance and family relationships. Plans for education, employment, recreation and social activities or meaningful hobbies should be considered and organized. It also includes proposed use of “booster” sessions to refresh skills or address a life challenge, an articulation of relapse prevention interventions, and identification of alternative mental health resources.
Covington talks of trauma informed staff- adjusting the behaviour of counsellors, staff and organizations to promote and support the use of positive coping skills by patients.
Trustworthiness – clarity, consistency, boundaries
Multimodal models of treatment are found to be most effective. What is meant by this is that the treatment attempts to tackle a myriad of factors simultaneously which women present with including trauma, substances and mental health difficulties.
Also promotion of healthy relationships are thought to be imperative (Saxena, Messina & Grella, 2014) would help to address the higher rates of CPTSD.
There remain concerns that trauma focussed interventions can trigger a relapse of substance misuse (Triffleman, Carroll & Kellogg, 1999; Pitman et al., 1991). It is often the case that other staff can become concerned when trauma and other interventions begin, they may observe a rise in self harm and behaviour which they find challenging. It is then the case sometimes that women can go through treatment without touching on their trauma or abuse histories. The women may then re enter the community and in order to cope with the underlying trauma may use substances to cope which can be detrimental to mental and physical well being.
TC’s which are a standard model of substance abuse treatment in prison in the USA were matched against individuals reciving gender responsive treatment based on the premises that I have been discussing and the outcomes show effective results in that those who received GRT in comparison with the TC. It was not as effective for women who have not experienced prior traumatic events.
Not just writing the report of the abuse/ trauma they have experienced. Building up trust with the individual that we are going to try and help.