A Subpopulation Within a Subpopulation: Working with Women in Forensic Settings

Anna Motz, Oxford Health NHS Foundation Trust, Family Assessment and Safeguarding Service, Oxford, UK

Women’s pathways into forensic settings differ from men’s. In particular, women in forensic settings, whether in prison, hospital, or the community frequently share histories of multiple trauma and attachment disturbances, often leading to profound difficulties in relating to others, despite a wish to do so. Consequently, effective engagement with such women requires gender-sensitive techniques, both in assessment and treatment. They are likely to view authority figures with suspicion and to be wary of engaging in a clinical interview whether for risk assessment, evaluation for a court report or another psychological issue, including treatment viability. They may have told their stories countless times before, and yet feel that they have never been heard, or seen. Communication is often indirect, rather than verbal, as the women may express their distress through behavioral disturbance including severe self-harm, aggression, and verbal assaults. This can challenge and confuse practitioners, and may also disguise a wish for care and emotional contact. This article explores the question of how to elicit trust and cooperation within the clinical interview and identify effective techniques for establishing therapeutic rapport. It focuses both on the experience of the clinicians, including their countertransference feelings, and the experience of the women being interviewed.

Countertransference, Communication, Engagement, Gender-Sensitive, Trauma

“It is clear that the assessment and treatment of women, both in the criminal justice and the forensic mental health systems, has all too often been either gender-blind or gender-biased, and that this has created services in which women’s traumatic histories, risk profiles, and psychological needs can be overlooked…In addition, the perception of female dangerousness may be heightened by the vilification of women who commit violent crimes, as these offenses are unusual – most crimes committed by women are nonviolent…Alongside the development of gender-sensitive assessment measures…it is important to attend to particular process issues in the effective clinical interviewing of females within forensic settings” (p.21-22).

“Alongside higher rates of personality disorder compared to the general population, the women in forensic settings frequently share histories of multiple trauma and attachment disturbances, creating profound difficulties in relating to others, despite a wish to do so. The rates of adverse childhood experiences are high in this population…As the women seen within these settings have often had multiple experiences of betrayal and misunderstanding by those in authority, starting with their parents, or carers, they are likely to be wary of engaging in a clinical interview…The women’s feelings toward early carers can be transferred onto interviewing clinicians, with powerful results; sensitive interviewers can anticipate and modify this…When interviewing women in these settings it will be important to address those areas that link directly to their offending and which distinguish them most significantly from male offenders, particularly their histories of trauma, mental health, and substance misuse” (p.22-23).

“It will be essential to be clear that the remit of the interview is not to offer therapeutic intervention oneself, but that it would be possible to direct her to a therapist thereafter, so that any details she wants to keep confidential should not be disclosed. Although she may hear this and understand it rationally, it is inevitable that the interview will generate a degree of emotional engagement with you, and transference feelings, so it is essential to proceed with sensitivity and care. While this is not therapy per se, the disclosure of intimate details to a female interviewer eliciting trust will invite some transference and it is crucial that [the client] not be left feeling exposed and unprotected, so you will need to keep her defenses intact. This means checking how she is feeling at regular points in the interview, reminding her of the limits of your role, and that you will be considering with her whether future work of a therapeutic interview is indicated, and if she wants to engage” (p.30).

“It is ethically and professionally essential to inform the woman at the outset that there are strict limits on confidentiality in the interview, as its purpose is to prepare a report for the Court, or to advise the multidisciplinary team about therapeutic and risk considerations. If she has not been made aware of the limits of confidentiality and the report or its findings are subsequently shared, she may, understandably, feel betrayed, and angry. She should always be asked if she gives consent to be evaluated, and, where possible, written indication of consent obtained” (p.32).

“…While asking questions and inviting discussion, you should also observe non-verbal behavior closely. Any points of heightened arousal or disturbance in the interview itself, including tears, expressions of anger, or attempts to leave the room can be seen as cues to slow down the interview process, pause, and then return to explore what happened just at the point where the arousal level increased. This may be the woman’s unconscious attempt to stop the interview, but if you are skilled and aware of this, you can see it as a useful piece of data, and explore it…When interviewing women with whom one has a strong identification, for example, someone close to one’s own age, or with a similar background, it is essential to maintain a professional stance, use supervision to consider the possibility of enactments and ensure appropriate boundaries are maintained” (p.32).

“There may be some sensitive cultural issues with some BAME (Black, Asian, Minority Ethnic) women, including their fear of being viewed primarily through the lens of race and seen as ‘other’ dangerous, and alien. Some BAME women with previous experience of harsh treatment by those in authority may expect that this will recur in the interview and this can impact on engagement. It is particularly important for the interviewer to bear this in mind, and to allow time and space for therapeutic rapport to develop. If the interviewer is from a BAME background they may face prejudice from women they assess…and feel under attack. This can lead to powerful countertransference reactions and requires close supervision and self-reflection. When assessing a BAME woman for risk, care should be taken to reflect on one’s own, sometimes unconscious, prejudices, and assumptions” (p.32).

“Interviewing women who have committed sexual crimes will create particular challenges for practitioners; beware of…your own excitement as you ask for details that may not be necessary…It will help engagement if you bear in mind that victim and perpetrator often coexist in the same woman. As there is far less research available generally on female sex offenders than males, a rich clinical interview is essential to enable comprehensive formulation and risk assessment of a female perpetrator” (p.33).

“While women within forensic mental health settings present particular challenges for clinicians, with persistence, patience, and sensitivity, these can often be overcome…It is essential that the interviewer manages their intense countertransference responses to the women, bearing the coexistence of victim and perpetrator in mind to resist being drawn into either a punitive role or an overly sympathetic one…the interviewer has the difficult task of remaining still, thoughtful and empathic ‘in the eye of the storm’ to glean sensitive and rich information about the woman, and determine appropriate pathways for her within forensic mental health and criminal justice systems” (p.33).

“…While it [effective clinical interviewing] is a means to achieving important clinical information it is also an important encounter in itself, and can offer the woman a valuable experience of containment. One must be mindful, however, that such an encounter, if helpful, can also awaken needs for further contact in a woman who is starved for such containment and understanding. A responsible practitioner should keep in mind that assessment might reveal the client’s receptivity and need for therapeutic work, and also alert her, and those around her, to the possibility that she might feel stirred up after the interview ends. Communication is often indirect, rather than verbal as the women may express their distress through behavioral disturbance including severe self-harm, aggression, and verbal assaults that challenges and confuses workers, disguising a wish for care and emotional contact” (p.23).

“It may be helpful for you to identify the specific way that the experience appears to have impacted on her and to reflect this back to her verbally at the end of the assessment rather than leaving her to read it in your report. A clear summary, delivered in person, can leave her with a sense of having been heard and understood…Offering her with a formulation of sorts can be helpful in containment, but should not be offered prematurely as this may interfere with how she presents herself in the situation, and could be seen as leading her in a particular direction” (p.30).

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