The complexity of 'complex' trauma

Forensic psychologists have been aware for many years that the people we seek to help tend to come from economically deprived areas. Offending behaviour is often rooted in violent, marginalised and socially disadvantaged backgrounds. Life circumstances can breed complex systems of psychological trauma, in which maladaptive, disabling and self-destructive coping strategies occur. It's our duty as applied psychologists to recognise social, familial and systemic factors – could trauma informed practice also be the key to switching our focus from the individual within an isolated context?

Indeed, the Power Threat Meaning Framework (PTMF) released by the British Psychological Society's Division of Clinical Psychology has resonated with many practitioners in the forensic arena; not least because of its wider interpretation of how 'adversity' impacts on the individual. Theirs is a broader interpretation of interpersonal trauma, encompassing not only the 'event'(s) based on threats to life, serious injury, or sexual violence that tend to appear in diagnostic frameworks. A more chronic set of adverse circumstances comes into play – including, for example, unemployment, homelessness, neglect and other forms of social and interpersonal disadvantage.

Yet within forensic psychology, the debate that has hamstrung us for a generation is whether interpersonal trauma is even a predictor of offending; might it be a mere correlate? As numerous studies have indicated, the overwhelming prevalence of interpersonal violence and trauma for both incarcerated men and women is hard to miss. Yet the question of whether we should be putting our energies into this area, and precisely how to respond to client's histories of complex and multiple trauma, has persisted. This has been largely due to the highly influential What Worksliterature of the 1980s and onwards, as well as the resultant Risk-Need-Responsivity (RNR) model that did not consider 'personal distress' as a predictor of offending (Andrews & Bonta, 2016). Indeed, interpersonal trauma, when thought of, has been largely considered an issue mostly relevant to female offenders. 

In recent years, however, prominent voices have called into question the RNR model as being both 'conceptually thin' and one that fails to adequately capture the range of goals, motivations and psychopathologies that forensic psychologist need to focus on (Ward & Carter, 2019). An increasing recognition of the prevalence data for interpersonal trauma in forensic populations, particularly in terms of adverse childhood experiences (ACEs), has led to compelling arguments from a range of concerned voices (Scottish Government, 2018). These voices have highlighted that interpersonal trauma needs to be more competently accounted for within offender rehabilitation. Such work has been taking place in female prisons over the last decade, as well as in the focus that Therapeutic Communities have brought to the work of offender rehabilitation. 

Interpersonal and complex

However, a greater understanding of the actual mechanisms that underpin the complexity of interpersonal trauma is still required. This is particularly with respect to behaviours that are illustrative of the anger, perceived betrayal, lack of connectedness and shame that are core components of such experiences. Offending is so often interpersonal, and the disorganised attachment styles that may predispose, precipitate and perpetuate such behaviours are an important concern within a trauma informed approach (Velotti et al., 2018).

Post-traumatic stress disorder (PSTD) is an interesting case in point here. Within the 11th revision of the World Health Organization's diagnostic manual, the International Classification of Diseases, published in 2018, complex post-traumatic stress disorder (CPTSD) is seen as a 'distinct sibling' condition to PTSD. This distinction is based on an individual demonstrating disturbances in self-organisation (DSO). These additional symptom clusters involve affective dysregulation, negative self-concept, and disturbances in relationships. 

If we are to view the world through this diagnostic lens, then we could easily conclude that psychologists working in forensic settings will of course regularly work with DSO 'symptoms'. For example, the 'motivations' for violent offending, whether by men involved with anti-social peers and other 'ego driven' concerns or by women in relational contexts, could be defined as DSO symptoms. Perhaps one of the priorities for forensic practitioners is therefore to alleviate such symptoms. 

Take negative self-concepts such as shame. Shame involves persistent beliefs about oneself as being diminished, defeated or worthless – particularly in respect to not preventing or overcoming adverse life experiences. This is relevant to survivors and to offenders whose harmful behaviours maybe rooted in fragile levels of self-esteem, as well as self-attacking thoughts and the avoidance of painful emotional experiences. Helping to construct more positive and secure self-identities, alongside more socially adjusted self-soothing responses, may have enormous benefits for many offenders. This in turn has led to an interest by forensic practitioners into how compassion-focused strategies could help address the complex systems that drive negative interpersonal responses. 

Does it work?

Importing community-based trauma practices into prison settings may have had some success, but arguably the evidence base is limited. In our recent meta-analysis of group-based interventions only a limited number of the included randomised control trials were based in prison settings (Mahoney et al., 2019). These underpowered studies either had serious methodological issues or struggled to demonstrate robust levels of efficacy. There's often a lack of consideration of co-occurring issues and interventions, such as substance misuse. And it's unclear whether trauma memory processing (TMP) therapies such as Prolonged Exposure and Cognitive Processing Therapy are necessarily more efficacious than 'non-trauma focused' compassionate interventions (Hoge & Chard, 2018).

To add to this uncertainty, the effectiveness of the traditional 'phase based' model, on which most trauma interventions have been based, has been questioned (de Jongh et al, 2016). Perhaps the reason why this treatment model has been so popular is that 'phase 1' brief psychoeducational interventions have been considered easier to deliver and avoid re-traumatising unprepared clients. On the other hand, processing trauma memories – otherwise known as 'phase 2' interventions – is often regarded as a highly skilled, complicated and potentially risky endeavour. However, delaying or even avoiding processing trauma memories may keep survivors stuck in the very situation they are seeking help for. 

In a recent RCT conducted with prison service colleagues we investigated the efficacy of a widely delivered psychoeducational intervention with female offenders. Our analysis ultimately led us to question the effectiveness of such an approach. Whilst the results need to be further explored we also found increases in Depression and decreases in Non-Acceptance. Arguably participants' 'therapeutic journey' can, at least initially, be intense and emotionally stressful (Herman, 1992). But given the current weight of evidence, forensic practitioners need to think carefully about the expected and indeed intended therapeutic outcomes from brief generic trauma informed interventions.  

No 'one size fits all'

Offender populations are complex, and perhaps simply importing interventions designed for community settings needs greater consideration. Interventions also need to be more responsive to factors that lead some survivors of abuse to harm others. For example, there is a range of evidence highlighting the impact that chronic levels of trauma can have on the brain's architecture (Haller, 2018). This impact on neurological structures can be evident for survivors who subsequently commit violent offences. This has particular implications in terms of the assessment and treatment of survivors where offences, sometimes involving extreme levels of violence, are often assumed linked to dissociative states. However, as any competent practitioner will be aware, there is no one-size fits all trauma-based formulation that leads to offending or indeed to any other problematic behaviour. 

A number of authors, in their work with young people in the justice system, have sought to develop trauma informed paradigms that account for a range of factors such as personality, temperament and interpersonal expectations (Kerig, 2019). Yet the offending behaviour committed by adults – and particularly adult male offenders – is rarely given such consideration particularly where RNR is the central treatment approach. Forensic psychologists, for example, regularly help offenders with rejection sensitivity, attachment-based difficulties and cognitive styles such as rumination that ultimately arise out of adversity and interpersonal trauma. Indeed, addressing early maladaptive schemas, involving 'Disconnection', 'Impaired Autonomy', 'Vulnerable to Harm', are relevant endeavours for both trauma and offending treatments. We need to understand both the aetiology and therapeutic responsivity of client's needs. Indeed, a synergistic approach is also important in avoiding a simplistic paradigm that erroneously equates a linear approach between complex trauma with offending.

Developing an integrative and distinct branch of forensic informed trauma practice could help us account for this complexity. This includes some of the specific coping mechanisms evident in clients' offending that need more careful understanding and addressing. For example, appetitive aggression, or the experiencing of 'violence-related enjoyment', is one such way offenders may diffuse their DSO-based suffering. Of course, any relief is only temporary and the initial excitement from interpersonal dynamics involving power and control has to be repeated. As Hemeneu et al. (2013) noted, those high in appetitive aggression are more likely to align themselves to peers who support such coping strategies and reintegration attempts are likely to be harder. Other compensatory mechanisms as well as the interplay of personality, cultural and sub-cultural norms have all been seen as making important contributions to influencing the trajectory from abusive and 'adverse' life situations to offending. Such considerations again emphasise the particular importance of developing an appropriate forensic understanding of interpersonal trauma both in its formulation and treatment.

The other important implication in terms of considering the wider expression of traumatic distress within forensic settings is the devastation caused by self-directed harm, often seen in such extreme levels in prisons and forensic mental health units. Tackling extreme self-mutilation, the constant use of ligatures, reckless misuse of substances and other forms of suicidal behaviours are deeply challenging and complex concerns. The ideas, theories and the overall therapeutic 'language' provided by a trauma informed approach can ultimately help to get disciplines talking in a way that can begin to make a difference. 

The important work being undertaken by those in the vanguard of practice has been to recognise that this existing trauma knowledge base needs translating to the forensic and prison context if these benefits and gains are to be realised (Jones, 2018). All of this can be incredibly difficult to achieve and to sustain, given pressures on staffing and changes in the sentencing, political and social context. Unfortunately, increased prison numbers and fewer resources – as have been seen in the UK recently – will always be a lethal combination.

Time to make real change

This is an exciting time in forensic psychology. Internationally, a greater awareness of complex interpersonal trauma is presenting an opportunity to develop a more comprehensive and integrated model of forensic practice. To date, most offenders, including male offenders and those presenting with chronic and persistently challenging behaviours, have not been the focus of well-developed trauma informed interventions. Ensuring that they are could make a substantive difference to their lives and to the effectiveness of the criminal justice system. 

Whilst there are highly skilled and experienced forensic practitioners working in a trauma informed context, their work is often with specialist populations. Much of this highly skilled case work may not get the recognition or empirical analysis it deserves. It needs to become the standard. This requires a greater focus on interpersonal trauma, at all levels of training and practitioner development.

However, there is much work to do. There is limited evidence regarding the effectiveness of implementing community-based trauma informed or focused interventions in forensic settings. Similarly, many existing trauma interventions and treatment protocols are also being challenged. It is also important for forensic and correctional services to go beyond simply having trauma informed policy statements that nod to these important concerns. Well-established treatment protocols such as Compassion Focused Therapy may be particularly useful in developing a coherent forensic and correctional informed trauma practice that accounts for important shame-based behaviours. 

It is also useful to adopt a wider understanding of 'trauma' to include the impact of poverty and social injustice. The consequences of inequality, disparity in wealth, and lack of hope have been reflected in declining life expectancies amongst certain demographics. These 'deaths of despair', recently noticeable in the USA as well as potentially the UK, present a challenging set of circumstances for forensic psychologists to work with. We need to step up, in developing innovative and comprehensive models and practices which takes of account these complex and often contextually driven behaviours. It's time to make real change to the lives of the individuals that we work with. 

- Dr Adam Mahoney is in the Psychology Department, Glasgow Caledonian University.

References 

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Scottish Government (2018). What have ACEs got to do with Justice? Retrieved from: https://www.gov.scot/publications/understanding-childhood-adversity-resilience-crime/

Johnstone, L. & Boyle, M.  (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society.

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