Making Sense of Offense-Related Trauma: Exploring Two Patients’ Lived Experience

Offense-Related Trauma

Trauma is a concept usually associated with victims of offenses. However, there is evidence it can be as a result of an individuals’ own actions. Such responses have been reported amongst police officers and military personal (MacNair, 2002; Manolias & Hyatt-Williams, 1993). A growing body of research has shown evidence of this amongst offenders, coining the phrase “offense-related trauma,” which describes a phenomenon whereby individuals who have committed violent or impulsive offenses develop a trauma reaction (e.g., Gray et al., 2003; Kruppa et al., 1995; Pollock, 2000). While the majority of research into offense-related trauma has focused on homicide (Harry & Resnick, 1986; Papanastassiou et al., 2004; Pollock, 1999; Rogers et al., 2000), some have argued that violent offenses of any kind can lead to psychological trauma for the perpetrator (Payne et al., 2008).

Prevalence of Offense-Related Trauma

The majority of research into offense-related trauma has focused on determining the prevalence of this condition in different offender populations. Prevalence rates have been found to range from 15% (Collins & Bailey, 1990) to 32% (Steiner et al., 1997) in prison populations. However, in samples of forensic patients in secure hospital settings, the prevalence is reported to be much higher, with rates between 33% and 64% (Crisford et al., 2008; Gray et al., 2003; Papanastassiou et al., 2004; Spitzer et al., 2010).

Symptoms of Offense-Related Trauma

Symptoms of offense-related trauma have been reported to present as similar to other psychological trauma and include recurrent and intrusive memories of the offense, nightmares, flashbacks, guilt, intrusive thoughts, hyper-arousal, and avoidance of offense-related stimuli (Harry & Resnick, 1986; Pollock, 2000). Further, higher levels of trauma symptoms have been found to correlate with increased occurrences of shame cognitions (Buchman-Wildbaum et al., 2021) and it has been hypothesized that shame and guilt may impede emotional processing and therefore exacerbate and perpetuate symptoms of PTSD (Crisford et al., 2008). Trauma symptomatology, if left untreated, can have adverse life-long consequences (Gray et al., 2003; Kruppa et al., 1995).

Individual Characteristics of Offense-Related Trauma

Meichenbaum’s (1996) Narrative Theory of Traumatic Events hypothesizes that trauma occurs after an event that is unforeseeable, unpredictable, and uncontrollable. In line with this, Pollock (1999) suggests that offense-related trauma is more likely to affect those with no prior history of violence and whose offense is reactive and not premeditated in nature. Further, Pollock maintains that individuals who view themselves as having high moral standards and who hold prosocial views experience an intrapersonal challenge of the self when they commit homicide, showing a loss of control, self blame, and culpability, all of which are natural consequences, but can lead to a complicated bereavement reaction. Pollock suggests that these individuals may therefore be more likely to suffer from emotional disorders following the offense.

Intervention for Offense-Related Trauma

Research suggests that PTSD symptoms within forensic patients may act as a stressor, exacerbating co-morbid psychiatric illness and contribute to poor treatment response and relapse (Gray et al., 2003). Unfortunately, trauma symptoms are not always identified and consequently remain untreated. Untreated offense-related trauma symptoms may prevent an individual from fully engaging or benefitting from offense-related treatments until they have received an intervention focused on resolving their trauma symptoms. Consequently, an individual’s future risk of violence towards themselves or others, and therefore risk of re-offending, may remain until trauma resolution has been achieved (Clark et al., 2014; Pollock, 2000), therefore making any offense related treatments offered before trauma resolution redundant.

Gray et al. (2003) highlights how intervention for forensic patients focuses on offending behavior, targeting victim empathy, the perpetrator taking responsibility for their actions, and in-depth discussions about factors leading up to and surrounding the offense. This focus potentially increases an offender’s likelihood of developing offense-related trauma, either by developing an understanding that the offense was unjustified, acknowledging feelings of shame and guilt (Gray et al., 2003), or re-traumatizing offenders through talking about their offending (Rogers et al., 2000), which in turn may act as a trigger and potentially heighten the immediate risk of reoffending (Clark et al., 2014; Pollock, 2000).

Pollock (2000) maintains that trauma-focused intervention should be available to perpetrators. Researchers have argued that all offenders should be screened for offense-related trauma prior to engaging in offending behavior programs, and if present, offense-based interventions should be suspended until trauma resolution has been reached (Clark et al., 2014).

Experiences of Offense-Related Trauma

To date, offense-related trauma has not been investigated through a qualitative methodological lens. This research proposes to further examine offense-related trauma and how forensic patients cope with this in a hospital setting before, during, and after receiving an offense-related trauma intervention.

Ethics

This study received ethical approval from the National Research Ethics Service Committee London - Dulwich (REC ref 12/LO/0223).

Participants

Participants were recruited from one medium secure forensic hospital in the United Kingdom where patients are detained under the Mental Health Act (1983). For inclusion in this study, participants were required to have had experience of offense-related trauma, an established diagnosis of PTSD as per the DSM 5, and to have received a trauma-focused intervention related to their offending. Only two patients were identified as suitable for participation in this study. These potential participants were discussed with treating clinicians before being approached to take part. Both agreed and consented to take part in the study, one male (Richard, aged 52) and one female (Tina, aged 41)—names have been changed to maintain anonymity. Both participants had a diagnosis of borderline personality disorder and were detained for the offense of manslaughter. As per the inclusion criteria, both participants had completed a trauma intervention for offense-related trauma (eye movement desensitization reprocessing or EMDR), had reached an adaptive resolution and no longer reached the criteria for PTSD as measured by the Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1997).

Procedure

The participants’ clinical teams were consulted in regards to capacity and suitability to take part in the research, prior to recruitment. A member of the research team approached participants to discuss the research and provide an information sheet. Once agreeing to take part in the study, participants gave written consent; their understanding was verified by the researcher prior to commencing interviews.

Face to face semi-structured interviews were conducted by a member of the research team. Interviews were audio recorded. The interview schedule was developed from questions raised by literature review and is presented in Table 1. Interviews lasted between 1–2 hours.

Analysis

Interviews were transcribed and analysed using Smith et al. (2009) version of Interpretative Phenomenological Analysis (IPA). IPA has a primary aim of understanding an individual’s lived experience by exploring how they make sense of it (Smith & Osborn, 2003) and so is useful for research examining the lived experience of offense-related trauma. The analysis was broken down into three stages. First, listening to the audio–recordings and reading through the transcripts numerous times to become familiar with the data and ensure accurate interpretation of the context. Second, establishing initial exploratory comments and highlighting quotations of interest. Comments focused specifically on the descriptions, linguistics, and concepts presented within the data. Finally, emergent themes from the initial interpretations were identified and developed using psychological concepts, phrases, and patterns across the two transcripts were identified, examined, and developed further. Underlying connections across the emergent themes were then established and super-ordinate themes identified alongside the subthemes. The researcher interacted with the data by making exploratory comments and interpretations in each of the analytical stages to ensure that the original context and content of what each participant said was preserved.

Validity of the research was ensured by: (1) Transcripts were read by another author to check the analysis and ensure subthemes and super-ordinate themes reflected the data extracts. Discussion, further exploration, and reflection between authors included consideration of further themes, overlapping of themes, and an agreement of themes. (2) Following data analysis, the research results were presented to participants to ensure that the themes developed reflected the participant’s experience. Participants agreed with themes presented.

A member of the research team, familiar with the chosen methodology but independent from this specific research, was also utilized as a second rater, to ensure reliability and check the analysis was accurate in order to reduce subjectivity. Themes presented were considered reflective of the data collected.

The Right

For Tina, there was a sense that she had broken her own moral code by committing the offense and was experiencing maladaptive shame. She described a feeling of unworthiness to grieve because of her role in the death, which in turn, as she saw it, prevented the “prescribed” response to losing a loved one:

This shame and sense of anger towards herself that she described appeared to impact on her willingness to be helped, and the sense that she deserved to remain stagnant in her care pathway was evident at an intrapersonal level:

For Richard the right to move forward revealed itself as an external facet, whereby he described a sense that his right to be heard was no longer permitted, and he should remain submissive to those he perceived as potentially judgemental:

Punishment

There was a sense from the narratives that the role of punishment was crucial in the participant’s journeys with regards to the self-punitive guilt experienced by participants. There appeared a great deal of weight given to the concept of suffering for their actions, and a sense that the level of perceived punishment must be dictated from within – not from interpersonal agents. There was a sense that punishment was experienced by participants as one aspect in the journey they had control over. Tina spoke of seeking the hardest route to redemption by prolonging her sentence and thereby avoiding the “easy option.” For Richard, this revealed itself by forcing himself to feel uncomfortable by attending the most challenging groups:

Providing that they had appeased their own sense of shame within person-centered individual therapy, in the process of suffering, participant’s narratives gave the sense that this type of punishment had a finite quality. Tina described a conscious decision whereby punishment transformed from her captor to her releaser:

Never-Ending

Participants described trauma resolution as a discrete process following trauma-focused treatment, EMDR. For Tina, there was a sense that the acute reminder of her actions came to an abrupt and surprising end, as she described the first time she found herself holding an instrument that she had avoided for so long:

Richard described learning how to adapt, by placing it safely in the past in order to move forward. Richard is not repressing or dissociating from the memories, he is processing them within treatment. He uses a metaphor of a cabinet; he can recall these memories at any time by opening it, however he is not reliving it everyday anymore like other unprocessed traumas:

However, participants also described chronic feelings of remorse, remaining as background noise and integral to their new sense of self. Narratives gave the impression that participants had reached a state of acceptance, acknowledging that things could not be changed. Tina acknowledged that whilst her EMDR treatment may be completed, her life going forward would forever be shaped by her actions:

Victim vs. Perpetrator

Participants described conflicting emotions when trying to understand their offense; this suggested there was a sense of cognitive dissonance experienced, with participants feeling torn and uncertain of their identity. Tina described living with two incompatible views of herself – perpetrator and victim. These two identities appeared to present themselves interchangeably throughout the narrative. She indicated needing to acknowledge and accept these two roles in order to reach reintegration of the whole self; however, as the following account described, this was only possible if she separated herself from her actions, akin to a dissociated state:

Participants’ accounts gave the impression that previous victimisation continued to impact on their current sense of self. For Tina, she alluded to a sense of feeling trapped, knowing that her offense had occurred within the context of an abusive relationship, but internally fearful that sharing this would be interpreted as her minimization which in turn may invite negativity from others:

Living in the Minds of Others

Throughout both accounts, participants described experiencing opinion and judgement from others. These perceived interpersonal views appeared to have impacted on participants’ own intrapersonal sense of self, serving to strengthen, mirror, and reinforce their own self-criticism and negativity. Tina described transference of encompassing others’ views as her own, believing that this was proof that the fears she had about herself were true:

As Tina progressed in her recovery, she described an intrapersonal shift that appeared akin to reconciliation, evidenced by her developing compassion for herself. This was accompanied by a reduction in feelings of destruction towards herself. This gave the impression that there was a point of realisation that she could in fact separate herself from her actions. However, and despite this, as the following quote highlights, her ability to separate remained fragile and was easily threatened by interpersonal agents:

Richard described experiencing a varied response from others, which he appeared to internalize, ultimately leaving him feeling confused and uncertain about how he lived in the minds of others, “I thought I was a bad person.” Richard described a sense of projective identification in how he perceived, others viewed him:

Feeling the Shame

Narratives within this subtheme described the role of shame on the participants’ views of themselves. There was a sense that maladaptive shame was not only present subsequent to the offense, but seeped into other areas of their recovery. For Tina, she described feeling shame with regards to her role in her daughter’s schemas and how she may now interpret the world and others:

Evident in both accounts was the impression that shame was experienced within offense-focused treatment (EMDR). Tina described disclosing to others an offense which she considered the most severe and therefore opening herself up to further judgement from others. Tina described a sense of feeling coerced to do this to demonstrate remorse and take responsibility in order to appear rehabilitated; however, she described that this process “un-did” any internal reconciliation she had already achieved:

Throughout Richard’s narrative, he described how his progress in treatment was strongly influenced by the shame he felt:

There was a sense that he survived by blocking his shame, keeping his true feelings buried and hidden from others. He denied the need for support and gave the impression of wanting to show the world that he was coping. There was a sense that shame would be interpreted as a weakness by others and he appeared to believe that showing power, “a bravado thing” and strength in other ways, would compensate for this:

The Role of Trauma Intervention on the Self

Participants described talking about the offense as difficult and at times re-traumatizing: “it’s a distressing thing to talk about” (Tina). There was a sense of generic offense treatments being negative and unhelpful: “brought up a lot of anxiety” (Richard). Throughout both narratives, participants described powerlessness towards the prescribed care pathway, experiencing this as punishing: “it was a case of ‘you have to do this’” (Tina)

Trauma-focused intervention (EMDR) on the other hand was associated with feelings of safety and containment:

Tina’s sense of control appeared to develop with treatment she perceived as less judgemental and more collaborative. She felt as though she was listened to and as a result was more hopeful: “I felt like we were working together, all of us.” There was a sense it allowed her to consider how her own recovery may look: “it can help you live with it,” and that it allowed and supported her to reintegrate those different parts of herself that she struggled with. She described that EMDR would “not just talk about what I had done. To actually think of it as a whole treatment”, helping her to feel less fragmented.

For Richard, his perceived safety within EMDR intervention allowed him to open up and trust others with what he had feared to share for so long. He trusted that his psychologist would be able to contain what he shared and not reject him as he had feared in other treatments:

The narratives appear to conclude that recovery for participants came when they were supported and allowed to see themselves as different from their actions. There was a sense that EMDR encouraged participants to become more mindful of their situation and as a result were able to notice distinct and welcome changes in their own sense of self: