Being Humane in Inhumane Places: A Collection of Papers about Trauma-Informed Forensic Practice

Abstract

This paper introduces the special issue of the journal on trauma-informed care in forensic settings. We consider the contributions of each of the papers, followed by a discussion of the complexities of work in this area. We conclude by proposing three general principles that can be used to guide the ongoing development of trauma-informed forensic practice.

There are many ways in which trauma-informed care has been delivered in forensic settings, but we are not always clear about what it means to be ‘trauma informed’ in forensic settings. Genuine questions arise about how to implement the principles of trauma-informed practice and how to determine the extent to which implementation efforts have been successful. What is the end point? What are we really trying to do when we make something trauma-informed? Is it being nicer to people? Is it allowing people to leave early? Providing tea and biscuits or a square patch of lawn and some soft furnishings and plant pots? It seems that local services are largely left to their own devices when deciding what trauma-informed practice should actually look and, in different ways, each of the papers in this special issue can help us to better understand just what it means to aspire to being trauma-informed in settings and services that are known for their lack of humanity and capacity to create more trauma.

The desire to work in ways that are more ‘trauma-informed’ is now shared in forensic services around the world. In this special issue alone, there are contributions from teams in the United Kingdom (Kelman et al., 2024; Seitanidou et al., 2024), in Europe (Dekkers & Keulen-de Vos, 2024), the USA (Krider et al., 2024; Stinson et al., 2024), and Australia (Hamilton et al., 2024), as well as those that present evidence and practice approaches that have global relevance (Davies & Jones, 2024; Jeffery et al., 2024; Liddle et al., 2024; Simjouw et al., 2024). The papers also cut across a range of different service settings, addressing key issues for children and young people (Hamilton et al. 2024; Simjouw et al., 2024) and for justice-involved women (Kelman et al., 2024) and men (Dekkers & Keulen-de Vos, 2024; Jeffery et al., 2024). In addition, several of the contributions speak to the importance of understanding the differences and similarities that exist within and between particular groups of people in receipt of forensic services (Dekkers & Keulen-de Vos, 2024; Hamilton et al., 2024; Jeffery et al., 2024). They offer insight into the prevalence of trauma and its associations with self-harm and acts of violence (Jeffery et al., 2024; Liddle et al., 2024), as well as identifying new opportunities for treatment (Stinson et al., 2024) and documenting progress in workforce development (Davies & Jones, 2024; Kelman et al., 2024; Krider et al., 2024; Seitanidou et al., 2024; Simjouw et al., 2024) and creating the professional, organisational, and structural changes that are required to realise, recognise, respond, and resist trauma and re-traumatisation. However, the most consistent message from this special issue is not only that the experience of trauma is very common in all forensic services but that it can also be expected to have profound and long-lasting impacts that are of direct relevance to the way in which people are expected to or able to engage with services. The case for thinking more about the impact of trauma in forensic populations is, in our view, simply compelling.

The complexities of trauma and trauma-informed care

As we were discussing the (excellent) submissions, we were mindful of some of the complexities that arise in efforts to work in a trauma-informed way and some of the barriers and challenges that often occur. The papers in this special issue speak to many of these, including the need for clear thinking about language, about the causal relationships between adversity, maltreatment and disadvantage, about the experience of trauma and its subsequent expression, and of the need to avoid ‘one size fits all’ responses:

Terminology

The term ‘trauma-informed’ is one that remains loosely defined, hard to operationalise and, at times, poorly understood. The papers in this special issue help to unpack some of the terminology that has the potential to create uncertainty and confusion. It is possible, for example, to differentiate between trauma-informed care (TIC) as activity at a service level whilst trauma-informed practice typically concerns the work of individual practitioners. We also learn about the difference between practice that is trauma-specific (interventions designed to address trauma and related symptoms), that which is trauma-informed (when staff are trained to understand about trauma and its impact), and/or trauma-responsive (where organisations and services create a positive environment and have implemented, or amended, policies and practices to minimise the chance of re-traumatision) (Davies & Jones, 2024; Seitanidou et al., 2024). There is a need to appreciate the importance of distinguishing between trauma as a reaction to an event rather than as exposure to an event (Davies & Jones, 2024; Hamilton et al., 2024), as well as the differences between Type I trauma that relates to single discrete traumatic incidents, and Type II trauma that is characterised by repeated exposure to events (Seitanidou et al., 2024). There are also key issues to consider concerning the cumulative impact of chronic adversity and exposure to a series of traumatic events and poly-victimisation and the impacts of inter- and trans-generational trauma (Jeffery et al., 2024; Liddle et al., 2024). New terminology is also proposed (Davies & Jones, 2024), such as organisational trauma-informed consultation (to review approaches and responses to service need and delivery with an external consultant) and proactive trauma containment (a structure and culture that is responsive to the experience of all who live, work, or access the service). It is important to be clear about which aspects of trauma-informed practice we are focussing on in our efforts to work more effectively with justice-involved people.

Causality

There are important messages in this special issue about the dangers of assuming that simple linear pathways exist between the experience of trauma and the reasons why a person is in receipt of a forensic service. For example, how important it is not to subscribe to the ‘sexual abused—sexual abuser’ hypothesis (Dekkers & Keulen-de Vos, 2024) and to recognise that some while people will externalise their responses to trauma, others will internalise them (Hamilton et al., 2024).

Targeting

As Dekkers and Keulen-de Vos (2024) succinctly note “trauma histories are too often ignored or simply overlooked” in forensic services. There is an overwhelming need for forensic services to recognise the trauma histories and experiences of people in their services and to provide care. This does not, of course, necessarily mean providing universal treatment—a key finding from Kelman et al. (2024)’s work with women in prison was that none of the people interviewed felt that they required specific attention to their trauma.

The ‘victim’s’/survivor’s ask

Herman (2023) sought out the voices of people who had been offended against, addressing what they think should happen with people who have perpetrated offences. She proposes that a trauma-informed criminal justice system needs to focus on reparation, restorative justice, and restitution as well as offering a real attempt at rehabilitation – despite uncertainty about the impact of programs and services that are currently available. The importance of honouring the ‘victim’/survivor perspective is underscored when we acknowledge the victimisation experiences of people who have perpetrated offences; together they cry out for this kind of approach to be woven in to criminal justice systems.

We were also reminded about the need to remember that trauma is disproportionally experienced by the most vulnerable and marginalised in society (Davies & Jones, 2024), as well as about the various forms of abuse and household adversity that are assessed in the ACEs checklist and can also result in traumatic experiences (Dekkers & Keulen-de Vos, 2024; Hamilton et al., 2024).

Some bigger picture issues: Bias, friendly fire, and catch 22s

Most of the submissions that were received for the special issues were quite concrete pieces of research. Somewhat surprisingly we had no submissions that focussed on some of the ‘bigger picture’ issues. These include how we might conceptualise this kind of practice in the forensic setting, the ethical practices that inevitably arise, and/or how to engage with the limited evidence-base to support arguments that delivering trauma-informed care (TIC) and trauma-informed practice (TIP) will lead to better outcomes for individuals, services, and the wider community. These are all areas that the field needs to address, as trauma-informed practice develops and matures.

Too often, perhaps we rush headlong into service improvements before we have developed the theoretical and methodological frameworks needed to collect the evidence required to design and implement transformative services and interventions. While we should celebrate the considerable progress that has been made, there is much work to be done if forensic services are to be genuinely trauma-informed. For example, it would be remiss not to draw attention to the biases and prejudice that limits our capacity to recognise or ‘accept’ trauma in justice-involved people. For example, the trauma histories of adult males who have committed a sexual offence are still often overlooked by service providers (and funders) and, perhaps most importantly, the recounting of a trauma history is sometimes still seen as evidence of an individual’s attempts to justify or minimise their offending. This is problematic since a body of forensic research, particularly involving those with a sexual offence conviction, has demonstrated the relationship between cognitive ‘distortions’ and a lack of empathy (e.g., McCrady et al., 2008). And we do not have to look far to find evidence across a range of psychological fields that a lack of empathy can be caused by exposure to trauma (e.g., Beck et al., 2009; Regehr et al., 2002). Even the presence of cognitive distortions tells us that the person understands that they have done something wrong, that they may be experiencing shame, and reflects the normal process of making excuses. And the explanation for this may well have relevance in the individual’s trajectory towards offending, with unprocessed trauma at the core. Thus, overlooking or discounting people’s traumas may well undermine any efforts to help them.

Another way in which bias may arise is through the ways in which trauma is experienced and expressed. It is much easier, perhaps, for professionals to accept the presentation of trauma when it involves flashbacks, nightmares, and/or physical symptoms - such as feeling sick or being in pain. However, when trauma is expressed in terms of violence or aggression it can be less easy to maintain sympathy - especially in circumstances where our personal safety is threatened. Furthermore, certain types of traumatic experiences may be perceived as more worthy of treatment than others. Here, we are thinking of trauma that relates to both the pains of imprisonment (Sykes, 1958) and/or to what has been termed ‘perpetration-induced trauma’ (McNair, 2002) which is rarely addressed directly in treatment programs. In the latter case, the need for someone to repeatedly detail ‘what happened’ when they committed their index offence can easily retraumatise. There is also often little recognition of the traumatic impact of being required to disclose personal information in everyday life (e.g., taking out insurance, going to a General Practitioner, renting a house) and the reactions that ensue. This is despite extensive and long-standing evidence on the negative impact of reintegrative shaming (Braithwaite, 1989). The potential for causing further trauma here is considerable.

When people are just being seen through a trauma lens, they can feel as if significant aspects of their selves have been diminished; everything comes to be seen as sequalae of trauma. WrenAves (2022) captures this well in a blog account describing the experience of mental health services:

“Over the years, as I shared more and more of my traumatic experiences, more and more of me was erased. I couldn’t move or breathe without being told I was doing so because of my trauma. It hurt, to be so completely defined by the most terrible moments of my life, especially when my attributes, the things I was proud of; my drive, my passion for justice, my loyalty, my compassion, were also considered traumatic instalments. As if the people who took so much from me, who I had fought to be free of, had actually created me. I got stuck on this in therapy. I was merely a product of abuse, nothing was attributable to me, even my good parts were theirs. My strengths, my quirks, my unique ways of being were just my reactions to trauma”.

This account reminds us that a modest and moderate approach to treating people with trauma is sometimes needed. We need to be much more aware of the dangers of working in ways that are iatrogenic - even when our intentions are good (so called ‘friendly fire’).

The ‘catch 22’ of forensic trauma relates to the understanding that when people feel safe in secure settings, they will feel able to disclose more of their trauma histories. However, by sharing their trauma, scores on assessment tools (such as ACEs or symptom checklists) will increase and this will often mean that they will then be required to have more treatment and/or be seen as being at higher risk. The result may be that they are required to stay longer in secure services which, in themselves, are likely to increase trauma (Morgan & Shannon, 2019; Sykes, 1958). It is important to think carefully about how the deprivation of freedom is a harm inflicted; incarceration not only triggers memories of historical restriction and coercion inflicted in both the contexts of abuse but is also de novo harmful. It is a new experience of abuse, especially when any form of rebellion or efforts to attain freedom are viewed as subversive or evidence of ‘non-compliance’. Furthermore, we know relatively little about the process described by Crewe (2024) as ‘sedative coping’ - adapting to the trauma of incarceration by becoming ‘emotionless’ or numb (see also Jamieson & Grounds, 2005). As Jones (2020) has suggested, it is important to consider the process of grieving about the loss of liberty as this provides an important backdrop to any therapeutic work in custodial contexts. We could perhaps be doing more to assess people’s response to custody and working to minimise the aggravating impacts of incarceration. In this sense then, trauma-informed practice extends far beyond restricting the use of more obviously traumatising practices, such as strip searching, removing people from family, violence, institutional abuse, and overcrowding (see Stein et al., 2016 for an account of the construct of ‘ongoing traumatic stress’ and Lambie & Randell 2013 on the traumatic impact of incarceration).

For some people of course, the accumulation of trauma will have begun long before their actions brought them into contact with the criminal justice system. Discriminatory police practices, such as increased rates of stop and searches, unnecessary aggression, and greater use of force, have been reported across many European countries, the US, Canada (see, for example, Briere & Runtz, 2024; Plumecke et al., 2023). It is worth noting here a 22 year follow up to the Macpherson (1999) Report, itself an investigation of police failings after the murder of a young black boy, Stephen Lawrence in 1993. The follow up inquiry reported “persistent, deep rooted and unjustified racial disparities in key areas including a confidence gap for communities, lack of progress on recruitment, problems in misconduct proceedings and unjustified racial disparities in stop and search” (House of Commons Home Affairs Committee, 2021, np). For some people, a traumatic response to the criminal justice system has already been established long before the individual has done anything to merit attention from any criminal justice agents and this is too often overlooked by mental health professionals.

Three principles for practice?

It is much harder than we might expect to make a fresh start, to go back to the beginning, and describe what trauma-informed practice might have to look like in a forensic service. The most common approach to trauma informed work in a forensic setting is to simply acknowledge and offset the negative impacts of trauma on mental health. In essence, our focus has been on: (a) working with trauma as a way of ‘healing’ mental distress; together with (b) preventing the trauma experiences driving these difficulties from being triggered and thereby having a harmful impact on the individual, while also (c) preventing ongoing exposure to trauma in the forensic or custodial setting. These are all clearly important. However, when we consider how forensic settings themselves are likely to cause and reactivate trauma, we think it is helpful to set down some broad principles for the provision of trauma-informed care:

First Principle: Do no further harm

Doing no harm is the foundation of any ethical approach to human and health service delivery. In the context of trauma-informed practice we think this could involve attending to the following:

Understanding the threat of making progress, given that progression within the system (e.g. from a high secure hospital to a medium secure hospital) else people are going the wrong way! Greater awareness is needed that some people may be too ashamed of their behaviour to move on and/or that processing perpetration-induced trauma may be required to avoid taking one step forward and four steps backwards.

Disadvantage and power are key concepts in any effort to implement trauma-informed practice. In forensic services, professionals exert considerable power in decision making, whether this be about security classifications in prison, how risk and protective factors are weighted, which interventions are needed and when, early release and discharge, making and interpreting licence conditions, or recall decisions. These important tasks all need to be carried out properly, and by people who have the expertise and character to do so without fear or favour. And so it becomes important to consider when and how we might risk being complicit with a system that strips all power away from an individual and when we can – and should - give some power or control back to individuals.

Promoting trust. The foundation of any effort to help people change is what is sometimes referred to as ‘epistemic trust’. This is a person’s willingness to judge new knowledge, gained from others, as trustworthy and relevant, and therefore as worth using in their lives (see Fonagy et al., 2024; Kampling et al., 2022; Talia et al., 2021). Without epistemic trust, the individual experiences an inability to modify current representations (e.g., beliefs, schemas) in the face of new knowledge. It is not just an experience of working with somebody who commits to being truthful and open, but also the experience of consistency and an attentive other who is there with you. This is the crux of what in the ‘Risk Need Responsivity’ (Andrews & Bonta, 2010) literature is described as responsivity. This refers to those factors that the individual presents with that enable or prevent them from engaging. Epistemic mistrust may result when there is no trust in others due to betrayal or systemic lack of transparency, use of mixed messages, undermining of a sense of ‘what is true’, betrayal, and prohibitions on acknowledging the truth.

Awareness of the lack of restorative justice is important to ‘doing no harm’ when we view the experience of trauma as a form of injustice. In addition to the actual trauma experience, the injustice involved is often profound and plays out in a pervasive sense of mistrust, anger, or vengefulness. There is also the injustice of not being believed, or, worse still, of being accused of telling lies that match the broader-brush defamation that go with being labelled as a ‘criminal’ or as ‘bad’. Not being trauma informed is, then, to withhold a critical psychological human right - the right to be understood and to belong to a culture and context that acknowledges the impact of developmental experiences and tries to make sense of what has happened. For those who have experienced repeated injustice – primarily as victims of crimes that have not been reported or responded to by society – there is a profound need for restorative action. Just as there is a need for the individual to take restorative action for their own crime, there is a need for society to make amends with them for crimes committed against them.

Second principle: Offer people care

Our second principle is more practical. It concerns the need to behave and interact in ways that express compassion and humanity towards those who we work with. To be kind.

Person-centred language is an important aspect of this. We should aim for language that is accurate and does not obscure the person. We should not need to speak or write about ‘humanising’ people with criminal convictions (since people with convictions are already human). We should not use language that is dehumanising (see Winder et al., 2021). Terms that conflate a person with an act (e.g., ‘rapist’, or ‘murderer’) should be avoided, as should language that aligns the current identity of a person with their historical actions, namely ‘offender’, ‘perpetrator’, ‘ex-offender’, or ‘ex-prisoner’. We should avoid terms that suggest membership of a homogeneous group that is defined and stigmatised on the basis of criminal behaviour that may have taken place once, infrequently, and/or many years in the past (e.g., ‘sex offender’). And we need to recognise that people with a criminal conviction and those in our prisons and hospitals are part of society; not separate or separated from it. The use of person-centred language is not necessarily a quick fix, but over repeated use and, with time, the shift in identity that results can have a substantive impact on everyone. It is something we can all do, and that has no associated cost.

Explaining trauma responses to people and how these link to their offending is surely a basic right for each person who has offended. We can focus our efforts on helping people to make sense of their predicaments and to situate themselves differently in and against the spotlight of judgemental thinking and blaming that they may have experienced throughout their lives.

Triggering deterioration unwittingly can occur through attempts to elicit trauma narratives in an unstructured, insensitive way. This can result in people being overwhelmed which in itself can precipitate problematic coping strategies, including violence. A seemingly prurient or voyeuristic professional interest in trauma can also be very harmful. Specialist training (as slightly different ideas) is needed about the importance of not talking and/or allowing people to forget and hide (dissociate) their past.

Moving away from exposure-based ways of working, given the lack of evidence about its effects on symptom reduction and an awareness that common psychotherapy factors may facilitate patient self-directed exposure outside of the therapy context (Rubenstein et al., 2024). This is to say that we do not always need to hear the stories in therapies. What we need to do is to expose people to good positive relationships, to offer ‘disparity’ (Briere, 2019) and to not behave in the harmful ways that people have come to expect. In short, treating people with humanity.

Remembering that not everything is pathological and to consider standard or ‘normal’ human ways of dealing with difficult situations. For example, if someone is in ‘denial’ about a sexual offence, we may instinctively assume that they are at greater risk of reoffending (they are not). Denial is a completely normal process that everyone uses when they feel embarrassed or ashamed; it is a self-soothing strategy that we all resort to at times, rather than an indicator of something problematic.

Sharing power. In an experimental study conducted decades ago, Langer and Rodin (1976) highlighted the wellbeing improvements that resulted from offering residents the freedom to make a few small choices in a nursing home for older people. The inclusion of people with lived experience of imprisonment to interview staff for a therapeutic wing (Prison Officers Association, 2022) or decisions about categorisation and progression (see Nethercott, 2019) are examples of how it is to share power in forensic settings. We can reflect on ways that we can offer power back to people, whether by being more transparent about our decision-making, or by moving some of the responsibility for decision-making onto them (as is done most effectively in therapeutic communities, such as His Majesty’s Prison, Grendon Underwood in the United Kingdom).

Avoid splitting. The term ‘splitting’ is sometimes used in forensic mental health settings when staff members have very different perceptions about a patient. Those arguing ‘on behalf of’ the patient may be told that the patient is very good at ‘splitting’ (i.e., dividing the staff group) with the implication that the ‘nice’ staff are somehow being conned. Watts (2024) challenges this concept by arguing that splitting serves the purpose of preventing the person from accessing staff who they do not feel epistemic trust with. The notion that we attach better to some people than others is obviously not a novel one, but in the forensic arena it is often characterised as a negative and intentional act of manipulation, rather than being seen as a positive (i.e., that the patient can relate well to some members of staff).

Provide resources, or more specifically, the time to listen empathically and the space for this listening to occur. Protected spaces, time to stop and think, where people are allowed to feel safe, and cultures where safe spaces are valued can all be viewed as ‘the soil’ in which trauma-informed practice can grow and develop. Forensic settings are, however, not noted for their abundance of resources. Investing in them is not a vote winner and goes against the overt or covert agendas of retribution that follow people who have offended in such pernicious ways.

Evaluation, evaluation, evaluation is key to progress, and we all have a role to play in establishing a robust evidence base for our work. For every element of trauma-informed care, practice, or service, we need to know if it works, how well it works, and who it works best for (and who it doesn’t). In this special issue, every one of the papers helps us to develop thinking and practice in this area.

Third principle: Look after staff

Central to the success of trauma-informed forensic practice is the development of capability and capacity across the organisation and the workforce.

All staff need to be trauma-informed, noting here that good security can only be attained when staff are informed about trauma and its role in relationships and behaviour. We need more training to help staff understand some of the impacts of trauma, such as the episodic fear and hatred of authority, the need to be secretive and to lie, and how some people react in certain situations (e.g., being restrained) as if they are back at the scene of their abuse and reliving it. Staff in any forensic setting also have a right to know that, when somebody is accusing them of being unkind or cruel it may be because something has reminded them of trauma inflicted by others - and in that instant they are seen by the individual as the same as their abuser and the response is as if this is the case.

Prevent burnout. Despite a broad recognition that working in the criminal justice system can be stressful, relatively little is known about how this translates into burnout and trauma. It is here that an understanding of what is called ‘secondary traumatic stress’ and ‘vicarious trauma’ can be helpful. These are both terms that refer to the indirect impacts of forensic work (Rauvola et al., 2019). While there has been some focus on the impact of specific types of stressors, such as being exposed to child exploitation material or audio-visual evidence of violent crimes vicarious trauma is more likely to occur in response to chronic and repeated exposure to a broad range of offending behaviours or victimisation. The manifestations of vicarious trauma are the same for mental health staff and criminal justice practitioners as they are for victims of crime and people who have experienced other types of adversity (see McLachlan, 2024). They include psychological distress, avoidance behaviours, hypervigilance, irritability, and poor emotional regulation (Duran & Woodhams, 2022)^.and it is important that we care for all of those who work in forensic services if a trauma-informed approach is to be successfully implemented. The finding that, in some forensic settings, the incidence of trauma in the backgrounds of staff, is higher than the population at large (Carlisle & McGuire, 2020) makes this work even more important.

Conclusion

In this introduction to the special issue, we started to map out three principles for trauma-informed care and practice that can build on the contributions of each of the papers. These principles are obviously preliminary and will require refining and expanding over time, but our hope here is to simply illustrate how the learnings from this collection of papers might be used to develop robust frameworks for practice that embody what it means to work in a trauma-informed way in a forensic setting. What emerges, for us at least, is that forensic trauma-informed practice must deal with the contradiction that is inherent in the invitation to ‘trust me even though I am part of a system that is punishing you and that doesn’t understand you’.

There are clearly pockets of very good practice out there, but more work is needed to articulate what is required to provide services that are truly humane. Our closing message is, however, that not only do we - as those who work in forensic services - need to demonstrate compassion towards those in our care, but that society also needs to take on the responsibility of making space to welcome those with criminal convictions. The ‘penal fire’ (Scott, 2024) that is aroused in the public mind by the media and that is so often stoked by social media, means that practitioners will need to be activists in this arena—to at least try to change society by using the unique privilege they have of holding the narratives about trauma that society just doesn’t hear. The messaging here is clear, investing in and valuing the humanity of the people who find themselves in prisons or secure hospitals is a critical task if we are to try and bring about change. If hurt people hurt people, then valued and nurtured people value and nurture people.