1. Working with women offenders
presenting with complex trauma needs
Dr Michelle Carr & Dr Susan Cooper
Consultant Forensic Psychologist

2. Aims of the presentation
Trauma and women offenders

3. Background
 PTSD in women in general pop 3%> (McManus, 2007)
 Woman are more likely to develop PTSD after a traumatic event (20.4%
women and 8.1% for men; Kessler et al 1995)
 Rates of PTSD for women in prison have not been reported however are
assumed to be much higher (Ogloff, Cutajar, Mann & Mullen, 2012)
 53% experienced emotional, physical or sexual abuse during childhood
 50%> experienced domestic violence (Norman & Barron, 2011)
 A history of abusive relationship experiences in childhood is evident in a
large number of both male and female offenders, but the specific nature of
these experiences may differ
 This suggests a certain susceptibility to the development of PTSD and also
highlights that trauma in is a significant problem for women in prison

4. Complex Needs
Female offenders with a history of trauma and abuse
have overlapping problems with mental health; physical
health; victims/perpetrators of crime and self-harming
behaviour (Corston, 2007; Bloom, Owen & Covington,
2003; Covington, 2014)
Such factors can be relevant when trying to understand
their offending behaviour (Blanchette & Brown, 2006;
Chesney-Lind, 1997)

5. What is trauma?
 Briere (2004) suggests that the definition was limited as it did not include
events that may not be life threatening but nevertheless may be extremely
distressing.
 PTSD DSM- V definition: “ exposure to actual threatened death, serious
injury, or sexual violence”
 Directly experiencing a traumatic event, witnessing a traumatic event, learning of a
traumatic event (violent/ accidental) or experiencing repeated or extreme exposure to
aversive details traumatic events.
 Other symptoms include: intrusive, avoidance of stimuli, negative alterations in cognition
and mood associated with the trauma, alteration in arousal and reactivity.
 “Complex” PTSD (Herman, 1992), although not appearing in DSM-IV, is
described in the clinical literature, and refers to complex outcomes that
arise from severe, prolonged, and repeated trauma, usually of an
interpersonal nature, such as child abuse or chronic spouse abuse.

6. Link between trauma and offending
Women in forensic
settings can present
with more
aggravating factors
than mitigating
factors. Which can
fall under the
following three
domains:
These three
interacting domains
can heavily influence
whether an individual
may be more
severely affected by
the traumatic events
and in what way.
A diagnostic framework
Bloom, 1997

7. Impact of trauma
A working study has found that multiple traumatisation
below the age of 26 years predicted development of
complex PTSD.
These early experiences can impact on mental health,
physical well being, personality difficulties and
ultimately an individual’s life trajectory.
But can trauma be a precursor to an individual taking a
pathway to offending?

8. Case vignette

9. Do we need to address trauma in women
offenders?

10. Therapist issues
Our own barriers to thinking about trauma (Chu, 1988)
 Patient defends against intolerable experiences – therapist becomes
object of many confusing transferences – not good enough
 Collusion with denial and access to services
Fabricate stories about good upbringing
Deny significance of abuse
Don’t mention the war
Why don’t we ask about trauma experiences and how these have
affected the individual’s life?

11. Effective therapy for CPTSD
The catalysts of trauma within this population are
varied and encompass complex issues such as
survivor/ perpetrator roles within their forensic history.
Need to work with victim and perpetrator …. Or risk of
working with ‘as if self’ ()
Issues can be felt in teams and organisations, for
example in the form of divides and blurred boundaries
Enmeshment

12. Effective therapies
Treatment programmes are often designed in such a
way that victims and perpetrators are treated as if two
distinct groups
Programmes for perpetrators of violence are often
designed for male offenders and seem to focus on the
offender taking responsibility for the offence and
empathising with the victim, which can be difficult when
there are complicated victim/perpetrator issues

13. Effective therapies
Is trauma treatment feasible in prison setting?
Covington (2014) argues for trauma-informed services,
emphasising safety, trustworthiness, choice, collaboration,
empowerment
Hooper (2003) has identified some trauma-focused interventions
that have been evaluated in prison settings, such as EMDR
(Colosetti and Thyer, 2000) and Traumatic Incident Reduction
(Valentine and Smith, 2001): however conclusions drawn from
these studies are limited because of small sample sizes and
methodological flaws.
TREM
EMDR / CBT RESEARCH/
DBT

14. Effective therapies
It might be difficult to fully understand a women’s
harmful behaviour without first understanding her own
experience of abuse. We would suggest that
interventions for this group of women offenders should
attend to offender’s experiences as a victim of
aggression as well as a perpetrator (also see
Covington, 2014)
Trauma work to include work on sexual abuse more
generally (see Ainscough C, Toon K, 2000)

15. Effective therapies
• Trauma treatments involving exposure techniques
appear to have the most support, but may not be
appropriate for those who have experienced prolonged
and severe trauma and in women with severe
personality disorder and multiple related problems
• A present-focused approach, focusing on psycho-
education, coping skills and anxiety management
recommended

16. Effective therapies
Trauma work necessitates creating a social and
physical environment that is trauma-informed (Blud,
2007; Covington, 2014)
Trauma work requires a ‘containing’ environment or
‘good enough’ holding (Winnicott, 1965) with limits to
dysfunctional behaviours

17. Effective therapies
Do women need to be stable prior to therapy?

18. Understanding traumatic offences
Some (women) offenders can be traumatised by their
offender such as the murder of a partner or child (more
classic PTSD) and this would need to be addressed
 This can manifest in psychological work
 Avoidance
 Overwhelming feelings of guilt/punishment (self-harm)
 Hyperarousal
 Anger and irritability

19. Further reading
Ainscough C, Toon K
(2000). Breaking Free Workbook
– Practical help for Survivors of Child
Sexual Abuse, Sheldon Press.
Blud, L. (2007). Literature review and
recommendations - treatment interventions dealing
with trauma: what will work with personality-
disordered women offenders? Unpublished.
Chu, J.A. (1988) Ten traps for therapists in the
treatment of trauma survivors. In In G. Adshead &
c. Jacob (2009). Personality Disorder: The
definitive reader. London: Jessica Kingsley
Publishers.