The importance of trauma-informed care

By Minne De Boeck (president NL-ATSA, criminologist University Forensic Centre, coordinator Stop it Now! Flanders), Floor Somers (intern University Forensic Centre) & Kasia Uzieblo

 

Approaching individuals who commit sexual crimes (ICSC) from a holistic perspective, can give insight in their trauma histories. While it is not possible to say that trauma caused a person to commit a sexual offense, there is growing evidence that certain types and the number of adverse childhood events (ACEs) are associated with different types of sexual crimes. Hence, it is important to gain insights into the impact of these traumatic experiences and - by doing so - to gain insight in the connection between past and present behavior.

 

On December 5, 2022, a symposium about the impact of trauma on ICSCs was organized by the University Forensic Centre (UFC) in Antwerp, Belgium. At the start of the symposium the chair, the criminologist of UFC, (Msc.) Minne De Boeck, explained the importance of trauma-informed care in ICSC, and described how the topic obtained more scientific attention thanks to strengths-based approach to offending behaviors. Nonetheless, she noted that there is still a lot of hesitation and reluctance in practice to pay attention to trauma in ICSCs. Possible reasons for this reluctance are a lack of knowledge about and training in trauma treatment, a fear of being manipulated by the client when focusing on the trauma, and a fear that these traumas would be used as ‘excuses’ or ‘justifications’ for their behavior.

 

The first presenter was, Dr. Melissa D. Grady, who received her M.S.W. and Ph.D. from Smith College School of Social Work. Her clinical experience includes clients who have experienced trauma, depression, anxiety, anger management problems as well as other mental health issues. In addition, she practices, writes about, and conducts research and trainings on ICSCs and evidence-based treatment. At the symposium, she discussed trauma, the connection with sexual offending, and possible treatment programs.

 

Trauma-informed care (TIC) shifts the focus from ‘what is wrong with you’ to ‘what happened to you’. Grady emphasizes that to understand trauma one needs to be person-centered, because every adverse event can be experienced differently in intensity. Small or large traumas cannot be universalized. Being left alone at the playground for 10 minutes can have an enormous impact on someone, while a car accident for another person can be less of a shock.  ACEs can have lasting effects on health, behaviors, and life potential. Research finds that 45,7% of male ICSCs have 4 or more ACEs comparing, whereas in the general population 9% experiences 4 or more ACEs. Thus, ICSCs are a very traumatized population. A higher ACE score not only elevates the chance of committing a sexual crime, it also increases the chance to commit more different types of crimes. A study of Melissa Grady and colleagues (2022) on the therapeutic needs of clients, suggests that the vast majority requests to discuss their traumatic past. Clients assert that there is a strong connection between their traumatic histories and their subsequent offending behavior. Some describe their offending as a repetition of their own past victimization. However, many clients also note that potential connections between trauma and offending are rarely discussed or acknowledged in treatment. This shows a big discrepancy between the clients’ needs and the focus of clinicians. The question arises how we - as clinicians - respond to such findings? Are we really exploring enough in therapy? Ms. Grady suggests questioning our own practices. A comment was made from the audience about trust issues these people face and therefore the unwillingness to speak openly about their traumas. Someone else mentioned not feeling comfortable or specialized enough to dig deeper into the traumas. It is therefore important that clinicians, working with ICSCs, have expertise in how to discuss trauma, how to treat in a trauma-informed way or that they know where to refer the client to.

 

The pressing question that remains: how do we make the connection? What are the theoretical links between ACEs and sexual offending? Trauma can cause deficits, followed by risk factors, criminogenic needs and eventually aggression in order to regulate and self-soothe. Sexual abuse predicts, for example, the development of criminogenic needs associated to sexual offence. To understand this process better, Ms. Grady refers to the importance of the attachment theory of John Bowlby. This theory focuses on the early relationship between caregiver and child. Based on this relationship, the child develops an internal working model - a blueprint on which the child bases his/her expectations about future relationships. The attachment behaviors in the internal working model continue to follow the same pattern in the future: ‘not nice to us, so not nice to them’. People with insecure attachments experience many struggles such as mental illness and deviant regulation of affect, cognition, and behavior. Ms. Grady stresses the need for programs that preventively analyze vulnerable children to interfere with this ‘prison pipeline’. In addition, she underlines the importance and impact of building (therapeutic) trust relationships in the guidance and treatment of ICSCs. Despite someone’s insecure basis, clinicians should have the capacity to make changes in these patterns and rebuild trust.

 

Is our program trauma informed and how do we implement this in our daily practice? Trauma-informed practitioners view trauma not as a discrete event, but as a set of experiences that deeply influence the person’s world view, narrative and identity. To consider whether your program is trauma-informed, you can consult the trauma-informed principles (TIP) Scale by Cris M. Sullivan and Lisa Goodman. To implement it in practice, there are different therapy modalities and models. A useful model discussed in the symposium, is SAMHSA’s 6 key principles of TIC, commonly used in the US. These principles are: safety, trustworthiness & transparency, peer support, collaboration & mutuality, empowerment & choice and cultural, historical and gender issues. Adopting a trauma-informed approach is not accomplished through any single particular technique or checklist. It requires constant attention, caring awareness, sensitivity, and possibly a cultural change at an organizational level. In addition to trauma-informed care, Ms. Grady mentioned trauma focused treatments, like Trauma-Focused Cognitive Behavioral Therapy, EMDR, Cognitive Processing Therapy and Exposure Therapy, all designed specifically to address the individual’s trauma and to target specific trauma symptoms and reactions associated with PTSD. These treatments extend beyond TIC and require specific training and expertise.

 

The second presenter was David Prescott (LICSW), the Director of the Safer Society Continuing Education Center. As a mental health practitioner for 38 years, he is best known for his work in the areas of understanding, assessing, and treating sexual violence and trauma. He discussed the implications of trauma research for professionals treating sexual offending behaviors and offered ideas for practitioners to employ from several different approaches. Mr. Prescott started with the three important elements of sexual offending treatment: risk, need and responsivity. It is important to match the level of services to the level of risk, target dynamic risk factors/criminogenic needs and use empirically supported approaches. Responsivity refers to the offender’s ability to learn from a rehabilitative intervention by providing cognitive behavioral treatment and modifying this intervention to the individual. There is general responsivity which refers to implementing theoretically relevant and evidence-based models for individual change, such as cognitive-behavioral and cognitive-social learning models. Specific responsivity can be regarded as a ‘fine tuning’ of the cognitive behavioral intervention. Mr. Prescott addressed that there is no method or model that fits everybody. Always take into account someone’s strengths, abilities, learning style, personality, motivation, and bio-social characteristics. This may raise questions like, ‘am I the therapist that this person can respond to?’ or ‘is this the program that this person can respond to?’.

 

Furthermore, Mr. Prescott indicated that clinicians could help these individuals find constructive ways of managing their emotions. It is the goal of (trauma-informed) treatment to teach people how to investigate every feeling they have, to help people live in the present. He recommends not only using CBT but also focusing on their physical reactions and impulses, by including for example yoga and several forms of meditation, like he does in his practice. Mr. Prescott also suggests the use of basic principles in TIC like motivational interviewing and feedback-informed treatment to get more effective.

 

We can conclude that there is no concrete nor universal answer (or method) to the pressing question: How can we put TIC into practice? It is the responsibility of all clinicians to help grow the empirical evidence and best practices. We need to explore more in depth what works and why it is working. Because we cannot get around the fact that working towards a concrete evidenced-based treatment for ICSCs implies including their trauma history.