Introduction
Historically, in some traditions, work on trauma for those convicted of sexual crime was considered unhelpful; at the least a distraction and at worst deemed as providing an individual with an ‘exculpatory’ narrative to avoid taking responsibility. Recent thinking about the harm of feeling stigmatised as an offender and the potential healthy reasons for wanting to avoid shame have challenged this view, as has the increasing recognition that the motives for disclosure of abuse are not always about wanting to ‘dupe’ therapists. Indeed, the danger of replaying a damaging childhood trauma dynamic by repeating an episode of disbelief from caregivers is very real.
In spite of the historical reticence in relation to this kind of formulation, there have been a number of clinicians who have worked with trauma in this population. This chapter will attempt to outline the range of interventions used for working with trauma in people who have offended sexually and consider some of the learning points that have emerged. Most of the accounts reviewed are based on case studies, as the majority of interventions used for people who have offended sexually with histories of trauma have not been systematically evaluated. This is likely due to the fact that the range of possible kinds of presentation and associated formulations for this group are high; we are not talking about one homogenous group of people, in fact, quite the opposite. In evaluating this kind of work, practitioners tend to use more practice-driven epistemology, involving the use of case studies to evidence facets of the underlying treatment model as they either work or do not work in practice.
Dimaggio (2019) illustrates well some of the problems encountered when trying to apply evidence derived from larger cohort studies to individual cases. For example, high dropout rates leave questions unanswered about those who left treatment, making it difficult to ascertain whether your client will respond in the way described in the literature, or in the unknown ways of the dropout cases. Thus, a strength of the case study approach is that more detailed exploration of treatment non-responders can be undertaken and consequently there are more accounts of adverse outcomes in the literature. Considering the foregrounding of the question of mechanisms and indeed ethical implications of iatrogenesis in work with people who have offended sexually (e.g. Brooks-Gordon, Bilby, & Wells, 2006; Mews, Di Bella, & Purver, 2017) this offers a significant advantage. Case studies are also critical first steps paving the way for studies looking at efficacy in larger cohorts using more ‘robust’ designs.
The focus in this chapter will be on practitioners addressing the links between trauma and offending, but reference will also be made to addressing the links between trauma and responsivity issues (i.e. the concerns that individuals have that can get in the way of them responding to intervention initiatives).
Remediating the Neuropsychological Impacts of Trauma
There is a significant amount of evidence to suggest that traumatic childhood experiences impact significantly on the structural and functional development of the brain (e.g. Schore, 2009). Mills and Teeson (2019) argue that PTSD has been shown to be linked with changes in the cortico-limbic system; specifically, hyperactivity or hypoactivity of the amygdala, hypoactivity of the prefrontal cortex, and reduced volume of the hippocampus. These structures are involved in the mediation of stress responses, executive functioning, and memory, respectively. Dysregulation of these structures can ‘impair an individual’s ability to regulate intrusive trauma-related and craving-related thoughts and inhibit repetitive maladaptive behaviours…’ (Mills & Teeson, 2019, p. 183). Recognition of this has led to the development of interventions that aim to offset this impact. For example, in the UK prison service, current treatment programmes for individuals who have offended sexually use an ‘Enhanced Thinking Skills’ (ETS) intervention to do just this (A. Carter, personal communication, April 27, 2016). The intervention aims to develop the thinking skills that are conceptualised as being adversely impacted in the brain due to trauma.
Thinking Skills Training
By focusing on building skills in impulse control; flexible thinking; values and moral reasoning; interpersonal problem solving; social perspective taking and; critical reasoning, ETS aims to build cognitive skills that protect individuals from entering into relapse processes by increasing their capacity to self-regulate and problem solve. For example, individuals would develop the skill of staging and pacing thinking so that it is not done impulsively, to ensure problem solving is not rushed and unthinking. This requires suspension of critical thought to allow options to develop. These are then evaluated to see what their costs and benefits are before going on to make a choice. The impact of ETS on cognitive functioning is seen as both a responsivity factor (Andrews & Bonta, 2010) and a skill that needs to be strengthened in order to ensure that problem-solving skills remain intact when the individual is in a state of arousal or distress. This approach is also supported by the evidence that people who have offended sexually and completed the ETS course were 13% less likely to reoffend than those who did not (Travers, Mann, & Hollins, 2014).
Meditation Techniques
Jones (2020) indicated that trauma related changes in the propensity to shifts in states of consciousness (e.g. dissociation) are also linked with changes in the capacity and or willingness to think. These changes, it is argued, are mediated by trauma- and arousal-related alteration in brain functioning. Meditation practices, such as mindfulness and Yoga breathing techniques are suggested for addressing this (Jones, 2019).
Therapeutic Relationship Impacting on Brain Functioning
Reavis, Looman, Frabco, and Rojas (2013) wrote:
It is our belief that mediating variables between the adverse event and the criminal outcome are neurobiologic dysregulation and attachment pathology. There is now abundant empirical literature demonstrating the regulatory effect of social experiences, in early life, on neurodevelopment. It is our belief that treatment interventions that focus on the outcome variable (crime) without attempting to heal these neurobiologic wounds are destined to fail. To reduce criminal behavior one must go back to the past in treatment. Fortunately, evidence exists in support of both attachment-based interventions designed to normalize brain functioning and in the efficacy of psychoanalytic treatment, Shedler (2010). (pp. 47–48)
This idea that our social experiences and relationships impact potential ‘neurobiologic wounds’ is implicit in many interventions that focus on the therapeutic relationship as an instrument of change. Recognition of the scope and capacity for change associated with neuroplasticity entails a recognition of the bidirectional causal pathway between social and biological processes; relational experiences can both adversely and favourably impact on the brain. Creeden (2004) also highlights the impact of attachment on neuropsychological functioning and identifies attachment focussed interventions as a way of addressing this.
Cognitive Behavioural and Schema Focussed Interventions
Perhaps one of the first Cognitive Behavioural Therapy (CBT) based treatment accounts advocating the importance of linking trauma in the histories of people who have offended sexually was Saradjian (1996). Working with women who had offended sexually, Saradjian developed clear CBT formulations that focussed on the individual’s offending and almost always highlighted the critical role of attachment and trauma histories in their development. Intervention was then focussed on treatment targets emerging from these formulations, which almost inevitably meant that addressing trauma related difficulties was critical.
More recently, and working with men, Greenwald (2009) offers a generic CBT framework for working with people who have offended, including those who have offended sexually. The framework is based on research that indicates that in a high proportion of sexual offence cases (81%), the offence cycle was initiated by ‘situations triggering trauma-related helplessness, and to a lesser extent fear or horror’ (McMakin, LaFratta, & Litwin, 2000, p. 306). Greenwald (2009) has developed a ‘trauma informed offence cycle’ model that links trauma history to trauma trigger situations. The model explains that when trauma is triggered, this results in a cognitive and emotional response which the individual copes with using ‘quick-relief’ behaviour (e.g. sexual behaviour, substance and alcohol use, violence and self-harm). This process results in negative consequences which then ‘confirm lessons learned in the trauma history, thus increasing sensitivity to trigger situations’ (p. 308).
Greenwald (2009) argues that this population struggles to engage with therapy and often do not make significant progress following therapy. He suggests, based on clinical experience, that ‘many who attempt to face their traumatic memories only get upset, leading to acting out, negative consequences and then increased resistance to treatment. The treatment methods used are potentially harmful, generally inadequate, and, at best, consistently ineffective’ (p. 309). A salutary warning against unthinking work on trauma with this group. He makes the case for an initial stabilisation focus prior to working with trauma in order to prevent this kind of reaction. Creeden (2004) also identifies the importance of a phase-orientated approach common to a range of...