If anything distinguishes the therapeutic task in forensic services from other settings, it is the potential for people’s stories to shock and move us in powerful ways, sometimes even challenging the fabric of our understanding about what it means to be human. High secure hospitals, in their recent past – and still, in some forums – often have negative and potentially stigmatising associations, which enjoin references to risk and mental ill health in a frightening fusion of labels, perpetuating fears about ‘madness’ and ‘badness’ in fellow human beings.
Typically in the media, when a violent crime is committed, the headlines provide only the immediate outcome or impact. The public are told about the loss of life at the hands of someone suffering from a mental illness, or a vicious attack committed at random by someone with unmet mental health needs. What is less frequently reported is that childhood adversity often plays a causal role in the mental health problems1 that can directly relate to offending.
It is these themes and inequities that high security hospitals find themselves addressing. The therapeutic work of picking up the pieces post tragedy, with the goal of reducing future harm, involves safely looking back to traumas, known and hidden, in order to move on. The work is typically characterised by complexity, and unpacking layer upon layer of harm.
A quarter of a century ago, therapy in high security hospitals was not as accessible to all, even if there was some evidence that patients might benefit from it. In today’s National Health Service, accessibility is a prioritised value: this has changed the nature of the provision of psychological work with patients in high security settings, and the range of staff who might be involved in its provision. This article explores a framework within which we can deliver more timely therapeutic support in the most integrated and helpful way, in order to lower risk towards others in the future. Therapy provides a bridge into the internal world of the ‘offender patient’, who is also a person to whom things have happened. It offers a supervised opportunity for connection within a network of support for those whose needs have typically not been met, time and again, in their lives during and preceding their offending.
High security hospitals and their role
Broadmoor Hospital plays a role in the health service in the south of England, described by one patient as an ‘end of the road’ facility for those whose actions present grave and immediate risks to others. The site provides just over 200 beds for men whose complex mental health needs are thought to be functionally linked to serious interpersonal violence. Some patients are transferred from NHS mental health facilities because they have extra security needs, while others are transferred from prison because they have become mentally unwell and the prison cannot provide them with the right kind of care. There is also a small group who are sent by the courts to hospital as an alternative to custody in prison; these tend to be cases where it is clear that mental illness has played a major role in their violence towards others. There are only 700 high secure psychiatric beds in England and Wales. This is many less than 50 years ago, as a better understanding of the relationship between risk and mental illness has led to better service provision.
One important development is our understanding of how the experience of childhood adversity and trauma can be a risk factor for both mental disorder and violence in adulthood. Some prisons have been working to develop a new practice orientation called ‘trauma informed care’ (TIC), and Broadmoor Hospital and its sister sites in Liverpool and Nottinghamshire have been working towards operating as trauma-informed hospitals. As such, they are required to deliver care with sensitivity and awareness, safety and trustworthiness. When an individual is admitted to a high security hospital, the task for the therapeutic staff is to stabilise mental health, learn about what maintains safety for the individual and address the reasons for the dangerous behaviour that threatened public safety. The staff must get to know the person and their story, seek to understand the distress they may have encountered and perpetrated, and reduce the risks of re-enactment. The therapist maintains a professional frame of reference, yet also reacts to the out-of-the-ordinary disclosures in ways that are idiosyncratic, generating radical empathy. Being trauma informed is not about being ‘nicer’ to patients, but is a genuine attempt to prioritise trustworthiness and transparency, to reframe symptoms as understandable adaptations, and to work in partnership in a setting which is attuned to emotional and physical safety.
Can we safely open the 'can of worms'?
What are our fears about supporting those with offending histories to look back? ‘Don’t open that can of worms’ is a warning that arises often in mental health work. It invites us to attend to the litany of troubles we might discover if we take the lid off the tin with unknown contents. What if the worms are seen? What if they are allowed to wriggle? What if they go in search of solutions to their troubles? And who will be responsible for putting the lid of the can back on if things don’t go well?
This literary cliché encapsulates important fears. The warning may be a sensible and considered view, which indicates that the system is not ready to handle distress. We do not know what we will find, or whether we will have the resources (personal or professional) to cope with what we see. It therefore helps for staff of all disciplines to have had some training in what happens to the brain when exposed to a traumatic experience, whether it is a service user’s past, or the complex present for them and the staff. It is important to understand how our neurology, biology and anatomy change as an instinctual response to an overwhelming experience.
Two illustrations from forensic practice describe the complexity faced on a daily basis in a high-security (locked ward) environment. On a busy day, the nursing team is responsible for caring for a detained man with a history of childhood sexual abuse, assaults on staff and self-harm. He appears agitated following a psychology session. The ward staff experience something akin to anger at the injustice in the patient’s situation, and find themselves irritated with the colleague who has ‘just upset him’. Who will have to cope with any fall-out from the session? The answer is everyone: the patient, the 24-hour team around him and all the staff who walk alongside when distress is evident or enacted. The nurses ask at the next handover, ‘Should we be doing this? It’s making him upset!’
In another instance, on an intensive care ward, the ‘reducing restrictive practices’ team of nurses and healthcare facilitators attend to support a patient to come out of seclusion for some fresh air. The ward staff report that he is not in a good frame of mind. The team persuade him to work with them and walk to the garden area. He subsequently refuses to return to his room, and becomes specifically hostile to the ward-based team, one of whom is bitten during a struggle, resulting in restraint. Both teams experience emotional tension associated with the whole process.
The multidisciplinary infrastructure for trauma-informed care
What do we need to know to do this work safely in this environment? We must all understand and be as in tune as possible with what is perhaps happening for the patient. We must hold their wellbeing in mind. We must acknowledge the fact that many experiences in our services can also be re-traumatising (such as locked doors and enforcements). We need to be aware of the myriad of ways in which we have power over people when they feel most vulnerable (for example, the power to keep a door locked, rather than open it). We need to contain, remain calm and explain distress and the mind-body continuum. We have to communicate with everyone involved before, during and after we try to do something different. We have to keep a focus on empowerment for everyone (not only staff or only the patients, as this generates imbalances that can be unhealthy). We need to respond with sensitivity and care, and we need to stick at it, often for extended periods of time. To support the patient to move beyond the harmful impact of traumatic experience requires the support of the whole team in thinking in this way, and at least one trusted therapeutic alliance within which the past can be sensitively ‘held’.
Trauma enquiry in forensic services: working with body and mind
Research that has highlighted the lack of routine enquiry about people’s history of trauma tells us some important things about what responsible responding to the impact of trauma might look like in an informed mental health service.2 For clinicians to be concerned and interested in the experiences of the patient, and to be capable of validating and ‘bearing unbearable’ information at times, there must be relevant support and training. They must work in an integrated way with all members of the forensic clinical team. Training can assist them to ask about trauma with sensitivity, and then be prepared to stay in connection with the person to work out what they most need thereafter to cope with the physical impacts of states such as hyperarousal or dissociation. In forensic settings, multidisciplinary teams and supervisors must also be interested in the experience of clinical staff who undertake such enquiry; what is the impact on them of their alliance with the patient, and how might that influence safety in practice? Staff also need support to reflect on their own experiences of vicarious traumatisation while encountering the strong emotions of those for whom they are responsible. Similarly, those in rehabilitative roles require support to work alongside patients to rebuild confidence in their bodies and fitness, to support patients to participate in activities that regulate the mind, and to help ‘ground’ them through tension release.
For a system to be ‘trauma informed’, it assists if the survivor’s perspective is viewed as holistic, as unique, necessary and adaptive.3 This perspective can be obscured or overshadowed where there are also actions/activities linked to the perpetration of harm. Staff require a frame of reference for their experiences, and hopefully spaces in the workplace, including supervision and reflective practice, where this can be explored. Patients are often dealing with unprocessed sensations (such as flashbacks and disturbing memories) that result from unresolved harm; this can be difficult to witness when it is unrelenting, and inevitably converted into hostility and mistrust. Staff are not immune from reacting to this either.
Opening the can, together and with care
It is, of course, a reality that the human brain has both dangerous and callous propensities.4 There are times when it is absolutely right that we fear other people whose intention is to harm us; we cannot deny the seriousness of psychological disturbance that places others’ lives in danger.5 Even in cases where the intention of perpetrators may not even have been to harm, offending is always associated with a serious failure of accountability, and with actions that are deeply traumatising in their impact on others. Risk and mental states are dynamic phenomena, which require constant review and appraisal to minimise (tragic) oversights in everyday life, and subsequently, in the case of a detained patient, for the duration of their treatment and care.
Although detention and sentences are inevitably feared for their enduring impact on people, and often administered at times of acute vulnerability, the high secure hospitals themselves can represent containment: a solid holding place for patients whose needs are immediate and serious, assessed by the Care Quality Commission in the same way as other locations. The therapeutic task of the hospitals takes the recovery journey several steps further: can the risks that were once catastrophic in impact be reliably lowered to enable people to move on, to allow past harm to be accepted and sufficiently minimised – healed even – for the future?
Trauma-informed systems are distinguished by their acknowledgement of needs, the importance of asking (‘screening’) for trauma history; their understanding of the impact of trauma and the demands of survivor-hood; the capacity to differentiate power and control, and the structures to keep people safe in the present.6 From this foundation, working together, with teams supporting the body and the mind, long-term trusting relationships can become part of the journey of recovery and repair. Interventions cannot follow a ‘one-size-fits-all’ formula, as each individual will need to set the pace and nature of their journey for themselves. It has been said that letting go of the past is, in the end, the responsibility of each trauma survivor.7 In forensic settings, this can be one way of demonstrating and delivering accountability, where possible, for those who have been victimised, and who victimise others through serious harm.
Estelle Moore is Associate Professor in Forensic Psychology at Kingston University. She is also the Professional Lead for Psychological Services at West London Trust, and the Head of Psychology at Broadmoor Hospital. With a background in clinical and forensic psychology, she has trained and worked in the NHS since the early 1990s. Her research focus has been on how therapeutic alliances make a difference to outcomes, even for those living with multiple disadvantages, and whose actions have excluded them from living safely with others.
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