Professional Perceptions of Trauma-Informed Care in Forensic Settings

International Journal of Forensic Mental Health | 2024, 1–13.

Trauma-Informed Care Practices in a Forensic Setting: Exploring Health Care Professionals’ Perceptions and Experiences

The prevalence of trauma within secure forensic populations is widely acknowledged, yet the implementation of trauma-informed care (TIC) in secure forensic settings (SFS) remains in its infancy. This qualitative study delves into the perceptions and experiences of healthcare professionals (HCPs) adopting a TIC framework in SFS, examining associated barriers and facilitators. 15 participants engaged in semi-structured interviews, and the results underwent thematic analysis, yielding five overarching themes and 15 sub-themes. The themes identified include: 1) understanding the TIC experience in SFS, 2) organizational and personal barriers in TIC implementation, 3) facilitators and reflections on TIC benefits, 4) barriers to specific TIC practices, and 5) practical recommendations. Participants emphasized the prevalent nature of trauma in SFS and underscored the perceived advantages of creating spaces for reflection and emotional well-being. Interviewees explored the impact of organizational culture, the demands of frontline roles, and training accessibility. Practice implications highlight the need to involve key stakeholders (staff and SUs) in decision-making and in assessing the feasibility of implementing TIC. SFS should prioritize TIC by addressing training needs, allocating time for TIC in supervision, providing specialist support for trauma-informed clinical work, and ensuring dedicated spaces for reflection. While the study highlights the power of incorporating HCP perspectives, limitations arise from findings drawn from a single forensic service, emphasizing the importance of further replication. This research contributes valuable insights into advancing trauma-informed care practices within secure forensic settings.

trauma-informed care, secure forensic setting, qualitative, staff perceptions

Understanding trauma and vicarious trauma and implementing trauma-informed care (TIC) is critical in secure forensic settings. “Trauma may be the outcome of ‘an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotion, or spiritual well-being’” (p.1).  Health-care professionals (HCPs) and service users (SUs) experience what is known as “vicarious trauma,” which is the experience of PTSD-like symptoms due to the intense distress or violence they witness in secure forensic settings (SFS).  Trauma in forensic populations is more elevated than in the general population, and this elevated stress increases the risk of violent behavior HCPs experience. 

This study focuses on the framework of TIC and how its principles of “safety, trustworthiness and transparency, peer-support and mutual self-help, collaboration and mutuality, and empowerment, voice, and choice”  can improve collaboration and staff satisfaction within correctional and mental health settings (p. 2). The current research aims to highlight the benefits of empowerment and compassion in implementing TIC in forensic settings while acknowledging how a lack of training, funding, and time constraints can hinder HCPs' recovery from the elevated burnout and compassion fatigue they experience in the workplace. Although our understanding is still relatively limited, prior research has suggested that TIC approaches in the workplace can lead to greater treatment engagement and coordination among staff. Fortunately, there is a “growing interest” in implementing TIC, which has reduced the risk of vicarious traumatization in providers and re-victimization or re-triggering of trauma in trauma survivors.

Implementing TIC in SFS benefits providers and patients, yet it can still bring its own challenges. This study recruited 17 HCPs and gave 30-minute to 1-hour interviews between April and June 2021. Two participants were excluded due to the poor audio quality of the interview recording, making the final sample N=15. 

Coding the transcripts revealed five significant themes regarding TIC implementation in SFS: 

• Understanding the experiences of patients’ trauma
• Identifying organizational and personal barriers to TIC
• Barriers to TIC implementation
• Facilitators/Reflection
• Practical recommendations on how HCPs and SUs can be more involved in decision-making with enhanced specialization and training. 

The thematic analysis aimed to give a more advanced view of HCPs’ perception of trauma. Therefore, the authors identified 15 subtypes within these five themes, including these professionals addressing how prevalent trauma is in their settings, feelings the SFS itself can be a re-traumatizing environment, and believing that acknowledging and prioritizing the treatment of trauma should be at the forefront of any forensic work. 

The findings from this study highlight the distinct challenges and necessities of TIC within SFS. Findings underscore the frequent neglect of complex, chronic trauma (Type II) compared to acute, single-event trauma (Type I), which has significant implications given the severe mental health issues observed in SFS. Additionally, the study notes an organizational culture within SFS that might be seen as punitive or resistant to vulnerability, characterized by a “macho” demeanor and restrictive practices. This culture not only contradicts TIC principles, which advocate for empathy, collaboration, and empowerment but also contributes to staff burnout and a lack of engagement with reflective practices essential for trauma care.

The research further identifies challenges frontline staff face, such as emotional desensitization and reliance on survival strategies, which are exacerbated by high workloads and insufficient support for reflective practice. There is a recognition of the need for building rapport and adopting individualized, culturally sensitive approaches to trauma care to ensure the safety and trust of trauma survivors. These approaches aim to address and potentially repair the harm from past unsafe or betraying environments. The findings advocate for integrating cultural sensitivity and reflection on biases into all phases of TIC assessment, formulation, and rehabilitation.

Trauma-Informed Care as a Top-Down Flow: 

Using direct quotes from interview transcripts, numerous HCPs offered concrete suggestions for enhancing sustainability in SFS. From these suggestions, three key themes emerged: the need for adequate training, the need for appropriate supervision, and the need for designated spaces for reflection. These themes were highlighted within the broader recommendations for practical applications of the study's findings.:

“1. Involve trauma specialists and experts by experience in the co-production and delivery of training in line with the TIC principle of peer support.

2. Managers should collaboratively explore the individual training and support needs of frontline staff, from the onset of staff’s induction. Effective orientation programmes have previously included topics such as trauma, substance misuse, peer support and empowerment, and therapeutic safety and boundaries. Staff capacity to attend training should be evaluated and opportunities created, and feedback should be sought on the accessibility and benefits of training. This would also support staff retention in SFS, creating more sustainable working environments.

3. Establish space to think about trauma in daily processes relevant to general MH settings (team meetings, ward rounds, supervision) and offer 1:1 psychological support when relevant to staff members.

4. Review and continuously evaluate the processes and policies specific to SFS (seclusion, seclusion reviews, CCTV, patient restriction) to ensure their implementation in a manner that promotes respect, fairness and dignity.

5. Establish protected spaces with dedicated time and specialist external facilitation to discuss working with trauma and complexity. An emphasis should be placed on the confidential and non-judgmental nature of these spaces (p. 10)."

Self-reflection: “Ten participants across disciplines described that self-reflection is necessary to support patients from a trauma-informed perspective, including exploring individual biases and triggers, but also allowing alternative view-points and improving their practice through supervision” (p. 7).

The below quotes given by interviewed HCPs provide direct input to researchers and clinicians to aid in preparing themself for the evaluation of their biases, reactions, and judgment before supporting their patients in SFS:

“‘But before dealing with that, I  have to  deal with myself first, the  impact on  me, and  then from there, I can help my team, I can help my patient.’ 

‘I  have my own biases and judgment that I  bring into my work and its good practice to reflect and maybe think of a different approach’” (p. 7).

As always, please join the discussion below if you have thoughts or comments to add!

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