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"When you have got like twenty thousand thoughts in your head, that one little thing can just make it all go away": Trauma and non-suicidal self-injury in forensic settingsThis chapter explores the relationship between trauma and non-suicidal self-injury (NSSI) within forensic settings. In particular, it considers prevalence rates, pathways to NSSI, and the dual risk presented by those who engage in both NSSI and violence. The primary reference group for this chapter is those in the National High Secure Healthcare Service for Women (NHSHSW) and it considers responses within this setting to understand, manage, and reduce the occurrence of NSSI, considering the impact of these on both staff and patients. The chapter advocates Trauma-Informed treatment responses for this population, drawing on the Trauma and Self-Injury (TASI) service. Interwoven throughout the chapter are the lived experiences of patients, using the patients voice as part of the narrative.
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Early trauma, psychosis, and violent offendingPsychosis tends to be an experience that socially isolates the sufferer and generates fear and distance in others. This is likely intensified when this presentation is combined with offending. In this chapter, using case examples we describe the possible pathway to psychosis through trauma and the links to violence. We illustrate the function and method in “madness”, clear evidence for the need to understand, and make sense of, what is being communicated through delusional and/or psychotic experience, and the importance of looking beyond diagnostic frameworks. In doing so, we can explore the function of hypervigilance, the parallels with childhood experience, and the efforts to avoid further victimisation.
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Trauma, personality disorder, and offendingThis chapter provides an overview of the presence and relevance of childhood traumas in the histories of individuals who have been given a diagnosis of personality and offended. A summary of the impact of childhood traumas, adverse attachments, and adversity and the lack of relational security on individuals’ personality development is described in relation to the diagnostic traits for personality disorders and dynamic risk factors. A service user provides his narrative of the impact of childhood attachment adversity and traumas on his development, mental health, and offending and describes what has been significant in supporting his recovery journey so far. The significant overlap across these areas and the increasing recognition of the need to understand developmental antecedents of individuals’ mental health difficulties and offending are highlighted. Current psychological treatment approaches across forensic services, including those based on a developmental model, are briefly described and the application of Schema Therapy for individuals who have been given a diagnosis of personality disorder and offending is discussed. Overall, the importance of asking individuals what has happened to them and developing a shared understanding of the impact of what happened to them is considered fundamental to supporting development and risk reduction.
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Trauma and intellectual disabilityIndividuals with Intellectual Disabilities (ID) are exposed to higher rates of adverse experiences in childhood than those without ID. However, there is also an under-reporting of trauma-related disorders in this population, possibly attributed to communication deficits in those who experience it and diagnostic overshadowing. These issues are further compounded when exploring the role of trauma and offending in this population due to legal and social variations in what constitutes challenging versus criminal behaviour. This chapter looks to draw together our current understanding in this area, its implications for clinical practice, and provides a case example.
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Deafness and trauma: A journey to equitable trauma-informed careThis chapter explores the unique relationship between Deafness and trauma and emphasises the fundamental need for an equitable and inclusive trauma-informed care for Deaf people in forensic services. It describes the prevalence of trauma in the Deaf population, the trauma experience of many Deaf children and the unique characteristics of trauma experienced in the Deaf population. The chapter also offers key insights into the experience of being Deaf in the Criminal Justice System, highlighting that Deaf individuals are often vastly overrepresented (and often stuck) within it. The chapter explores in detail what is needed to achieve equity in trauma care for Deaf people in forensic services. The chapter aims to promote the importance of a resilience – and a strength – orientated approach to care that produces balance between retribution and rehabilitation, resilience and empowerment in a system that has re-traumatised Deaf people for too long. This chapter emphasises need for equality in research, strategy, delivery, and evaluation.
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From care to custody?This chapter explores the social care system’s role in trauma and adversity experienced by young people in care and the potential impact on the trajectory from care to custody. We include the unique perspectives of care-experienced individuals and highlight a need for more research that captures the voices of a marginalised population. Finally, we provide recommendations for practitioners and policy makers to embed trauma-informed care and identify bottom-up and top-down processes to ensure a more integrated, proactive, and compassionate system.
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Trauma and sexual offending: Causal mechanisms and change processesIn the past trauma has been as an area to be avoided in working with people who have offended sexually because it was seen as providing individuals with exculpatory narratives. In this chapter an alternative view to this will be examined. The chapter explores a range of pathways linking different kinds of experience of adversity, oppression, and trauma and sexual offending. The utility of making sense of the developmental context of offending in order to facilitate interventions and developing case formulations will be explored. A range of interventions that focus on different biological, psychological, and social, trauma-derived processes in the lives of people who have offended sexually are explored.
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Trauma, violence, and genderThere are marked differences between men and women in the overall frequency, severity, and type of offences that they commit. However, there is relatively little research into the reasons for these differences. This chapter examines the differences between men and women in the forms of early maltreatment and adversity they experience and its impact, how survivors and communities regard and respond differently to different forms of adversity in men and women, and how these factors can shape the responses of male and female survivors. This chapter uses the Power Threat Meaning Framework as a basis for exploring these factors and illustrates the ways in which the impact of adversity can be mediated by gender with the accounts of a female and a male forensic psychiatric patient.
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Trauma-informed forensic practiceTrauma-Informed Forensic Practice argues for placing trauma-informed practice and thinking at the heart of forensic services. It is written by forensic practitioners and service users from prison and forensic mental health, youth justice, and social care settings. It provides a compassionate theoretical framework for understanding the links between trauma and offending. It also gives practical guidance on working with issues that are particularly associated with a history of trauma in forensic settings, such as self-harm and substance use, as well as on working with groups who are particularly vulnerable to trauma, such as those with intellectual disabilities and military veterans. Finally, it considers organisational aspects of delivering trauma-informed care, not just for service users but for the staff who work in challenging and dangerous forensic environments. The book is the first of its kind to address such a broad range of issues and settings. It is aimed at forensic practitioners who wish to develop their own trauma-informed practice or trauma-responsive services. It also provides an accessible introduction to trauma-informed forensic practice for undergraduate and postgraduate students.
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Childhood maltreatment and its links to offendingThe link between childhood trauma and offending has been largely overlooked in forensic psychology. This chapter argues for the central importance of childhood trauma in understanding offending behaviour. However, it is not the presence of childhood trauma per se that is criminogenic, but rather patterns of childhood trauma that are chronic and pervasive, and that compromise the child’s sense of safety. This has profound impacts on a range of developmental processes including neuropsychological development, attachment, emotional and social development, and mental health. It is argued that the most important criminogenic needs can all be understood as resulting, at least in part, from childhood trauma. Effective correctional programmes therefore need to address these trauma-related developmental processes if they are to be effective.
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The future of trauma-informed forensic practiceIn this chapter a number of areas for further exploration and growth will be explored. While recognising the roles of trauma, adversity, and oppression in the development of offending behaviour and as impacting often disproportionately on the lives of people who have offended has been a significant breakthrough in recent years, this chapter will also examine some of the pitfalls in taking an unthinking approach to this area. Trauma-informed and responsive practice is at an early stage of its development and there are a range of opportunities for growth, innovative practice research and development. A number of growth points are suggested. Practitioner, organisational and national agendas for development and change are highlighted and explored.
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Trauma-informed risk assessment and intervention: Understanding the role of triggering contexts and offence-related altered states of consciousness (ORASC)Risk assessment and intervention has, historically, not made direct links between trauma-linked developmental psychological processes and dynamic risk. In this chapter two critical areas of consideration in risk assessment (safety planning) and intervention will be outlined, using an integrative framework pulling together evolutionary motivational, resource functional analytic, and good lives thinking. Specifically, the need for contextual resource provision in offence-related trauma-triggering situations is highlighted. In addition, the need to understand offence-related altered states of consciousness (ORASC), linked often with trauma-related altered states of consciousness (TRASC) will be proposed, as a significant component of risk and safety work with people who have offended. Practitioners need to attend to both areas to work in a trauma-informed way. Preventing re-traumatisation and trauma-triggering exposure to deprived or abusive contexts that increase the chances of offence-related solutions to resource losses or deprivations is a significant task for practitioners working with people who have offended. Understanding the ways in which felt agency and ORASC can change in contexts where trauma and related resource need processes are triggered is a significant component of this work.
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Trauma and offending in UK military veteransVeterans are the commonest occupational group in UK prisons. Understanding the possible links between UK military service and offending behaviour has been little researched. More recently greater acknowledgement of how military-related issues can have long-term implications has seen an increase in enquiry. This chapter considers psychological risk and protective factors associated with military service that may result in psychological trauma and pose as potential links to offending behaviour. It presents real-life experiences and discusses frequently reported psychological consequences of military service including PTSD, moral injury, transition. Consideration is given to the unique challenges Armed Forces personnel and their families face and how this can increase vulnerability to healthcare problems and additionally offending behaviour. Given is an overview of how current statutory, public, and charitable services are working with veterans and their families to develop apt and timely support.
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Trauma-informed care and culture change in an NHS forensic serviceThis chapter will describe the process of developing trauma-informed services, from strategic to operational, within a Forensic division. The information within this chapter is derived from a trauma-informed care pilot and takes you through the initial planning stage, engagement with stakeholders, and developing a framework to the final evaluation. It is an honest reflection on the trauma-related needs and concerns of staff and service users within the Forensic service and the strategy which aspired to attend to those. Based on five key pillars of trauma-informed care, this chapter will describe how each element plays a vital role in moving culture from “what’s wrong with you” to “what has happened to you”.
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Trauma, substance use, and offendingSubstance use and post-traumatic stress disorder are the two most prevalent Axis 1 disorders in the international prison population, but the boundary between being a victim or a perpetrator is often blurred because of exposure to violence, trauma, and substance use. Symptoms associated with trauma and substance use make these individuals one of the most challenging in the criminal justice system. Substance use and mental health issues have been estimated to be roughly 2–4 times greater among those with histories of childhood trauma. Women offenders report greater use of the most harmful drugs, and have higher rates of PTSD than male offenders. Racially minoritised individuals are less likely to use substances than their white counterparts and this is despite being at greater risk of drug use because they often live in disadvantaged and deprived areas. Treatment perspectives on trauma and substance use are discussed. This concludes by arguing that an integrated approach to treatment, consisting of formulating and targeting the interplay between trauma, substance use, and offending is indicated as being the most effective way forward. Finally, three personal narratives are included to illustrate the stories of individuals who have lived experience of the interconnection between trauma, substance use, and offending.
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Psychological and physical health impacts of forensic workplace traumaPurpose: Health-care professionals working in inpatient forensic mental health settings are exposed to a range of traumatic and distressing incidents with impacts discussed variously as “burnout”, “compassion fatigue”, “secondary trauma stress” and “vicarious traumatisation”. This study aims to explore the short- and long-term psychological and physical health effects of trauma exposure in the workplace for frontline staff in a forensic setting. Design/methodology/approach: Semi-structured interviews were conducted with 14 nursing staff members working in the male personality disorders care stream in a Medium Secure Hospital. Findings: Thematic analysis yielded five themes: categories of trauma; how well-being is impacted; ways of coping and managing; protective factors; and systemic factors, with sub-themes within each of the superordinate themes. Practical implications: The findings demonstrate that some staff members were affected both physically and psychologically as a result of trauma-focused work whereas other staff members were unaffected. The psychological and physical health effects were broadly short-term; however, long-term effects on staff member’s social networks and desensitisation to working conditions were observed. A broad range of coping methods were identified that supported staff member’s well-being, which included both individual and organisational factors. Staff member’s health is impacted by exposure to workplace trauma either directly or indirectly through exposure to material, and there is a greater need to support staff members after routine organisational provisions are complete. Staff should receive education and training on the possible health effects associated with exposure to potentially traumatic material and events. Originality/value: This research has further contributed to understanding the staff needs of nursing staff members working with the forensic personality disorder patients within a secure hospital setting. This research has identified the following service developments: the need for ongoing support particularly after organisational provisions are complete; further prospects to engage in psychological formulations; greater opportunities for informal supervision forums; staff training to understand the potential health impact associated with trauma-focused work; supervisors being appropriately trained and supported to elicit impacts of trauma-focused work on staff members; and additional opportunities to discuss well-being or monitor well-being.
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Helping with the pressures of the past: Service-user perspectives of the sensory approaches within the National High Secure Healthcare Service for WomenPurpose This paper aims to explore service-user perspectives of sensory approaches introduced and promoted by the trauma and self-injury service within the National High Secure Healthcare Service for Women (NHSHSW) at Rampton Hospital. Design/methodology/approach This cross-sectional descriptive study used a semi-structured questionnaire, which was devised for this evaluation and included both open and closed questions. The data collected were then analysed using descriptive statistics and thematic analysis. Findings The paper evaluates the current use of sensory approaches within the NHSHSW. Sensory approaches were widely used across the service, with essential oils being the most commonly used sensory approach. The use of sensory approaches can be understood according to the following three themes: independence, accessibility and self-regulation. The self-regulation theme contained three sub-themes as follows: safety-seeking, relaxation and reducing distress. The evaluation also highlighted barriers to using sensory approaches and sought service-user feedback as to how these may be overcome. Practical implications Participants’ feedback informed changes to practice, such as introducing sensory approaches to service-users earlier in their care pathway and increasing the accessibility of sensory items. These approaches may be of relevance to service provision in other forensic or inpatient settings. Originality/value This paper offers a unique contribution to the current literature with its focus on using sensory approaches to ameliorate trauma symptoms, in the context of a forensic setting.
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Development of the FORUM: a new patient and clinician reported outcome measure for forensic mental health servicesForensic mental health services provide care to people in secure psychiatric hospitals and via specialised community teams. Such services are typically low volume and high cost, often highly restrictive and average duration of inpatient care prior to discharge is long. Measuring outcomes of care is important to safeguard patients and the public, monitor progress, inform treatment plans and assist in service evaluation and planning. We describe the development in England of a new outcome measure for forensic mental health services. Patient interviews and multi-stakeholder focus groups were held to elicit key concepts. Thematic analysis was used to develop an outcomes framework. Fifteen patients participated in the interviews and 48 stakeholders in the focus groups. Six domains were identified in thematic analysis: 'about me, my quality of life, my health, my safety and risk, my life skills and my progress'. Sixty-two stakeholders participated in the first round of the Delphi process, and 49 completed round two. Eight of the top fifteen outcomes were shared between patients/carers and professionals. Based on these results, a new outcome measure, the FORensic oUtcome Measure (FORUM), was developed including both a patient reported and clinician reported measure. Further assessment of the FORUM's use to track patients' progress over time, and facilitate shared decision-making and care planning, is required.
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Uptake of COVID-19 vaccination in a medium secure psychiatric hospital populationPatients in medium secure hospitals may be at particularly increased risk of coronavirus disease 2019 (COVID-19) infection and complications. We undertook a service evaluation involving all current in-patients within a single, English medium secure hospital to describe the uptake of the COVID-19 vaccine among this population. Data regarding capacity to consent to the vaccine, acceptance/refusal of this (and reasons for refusal) and demographics was retrospectively collected from the patients' clinical records and analysed. In total, 85 patients (92.4% of eligible patients) had capacity to decide if they wanted the COVID-19 vaccine. Of these 68 (80.0%) consented and 17 (20.0%) declined to consent. A similar proportion of patients aged under and over 40 years old consented to have the vaccine. Those from a Black Asian minority ethnic background were more likely to decline the vaccine than White British patients. The reasons for capacitous refusal appeared similar to those seen in the general population.
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Audit of blood borne virus screening, referral, and hepatitis B vaccination in a high secure hospitalBlood borne virus (BBV) infections are a significant risk for patients and staff in secure settings. Hospital policy is that all newly admitted patients will be offered screening for hepatitis B & C and HIV. All admissions between 2016 and 2019 were audited for BBC screening and follow-up of positive results. 'Where appropriate', patients should be offered hepatitis B vaccination, and the offer/delivery of this was audited. Nearly all new admissions were screened for BBC in this period. The offer and provision of hepatitis B vaccination was inconsistent throughout the Hospital.
