How useful is the concept of trauma-informed practice in prisons?

There is a high prevalence of trauma exposure within custodial settings and the wider criminal justice system (CJS). ¹ This trauma exposure is associated with a range of complex mental health conditions, along with attention deficit hyperactivity disorder (ADHD), substance misuse, personality disorder, physical health conditions, and increased risk of violent and re-offending behaviour.^1,2

Accordingly, there is increasing interest in trauma-informed practice (TIP) in custodial and justice settings, and many examples of TIP have been implemented in these settings internationally to improve the health and wellbeing of people who have experienced trauma.^3,4 TIP is increasingly being included within policy, and substantial resources are being invested in the approach, often with the aim of reducing reoffending. ⁵ Therefore, the need for effective measurement and evaluation of the clinical and cost effectiveness of TIP has become a pressing issue. ⁶ However, despite this apparent momentum, the impact of TIP within prisons and the CJS remains unclear, and important questions remain about its components, how it is defined and implemented, and how it is assessed and measured at staff, programme, organisational and systems levels.^7,8

Some authors have described the challenges of evaluating TIP within these settings and have queried whether TIP can be effectively measured at all. ⁹ Studies highlight that, despite the widely accepted concept and general principles of TIP, the specific components are operationalised in different ways, and often used interchangeably to refer to any programme that is designed to support people experiencing trauma.^10,11,12

A further challenge with defining and measuring TIP within custodial settings, as well as within other settings, is that several different but related concepts have also been widely adopted. These include Enabling Environments and Psychologically Informed Planned Environments, as well as the Royal College of Psychiatrists (RCPsych) Standards for Prison Services, and UK policy that prioritises rehabilitation.^13–15 All of these approaches cover broadly similar areas in that they define principles of good practice within domains of environment, leadership, patient care, access to meaningful activities and rehabilitation. An important distinction between these approaches and TIP is that these other approaches are ‘universal’ – that is, although they share many of the principles and values of TIP, they often do not have an explicit trauma focus.

It is currently unclear as to whether trauma-informed programmes lead to improved outcomes compared to these related concepts. It is also unclear whether evaluation tools are able to differentiate between these different concepts, given the considerable overlap between measured domains. ¹⁶ Furthermore, some research suggests that these alternative, more universal concepts, may be more understandable and acceptable to staff and policy makers. ¹⁷ Consistent with this, Auty et al. ¹⁸ found that the delivery of true TIP does not necessarily coincide with the adoption of the label. They argued that, conversely, within prisons that had adopted and implemented TIP, these benefits were often not realised by the people living within the prisons. They suggest that using different language, and focusing on concepts that are already familiar to staff, such as ‘respect’, ‘safety’ and ‘fairness’ may offer a better fit between aspirations and reality, and may help to operationalise TIP. ¹⁸ This suggests that TIP may be, at least in part, an extension and development of ‘good prison practice.’ ¹⁹

In addition, there is a broad continuum of trauma-informed approaches that include specific interventions delivered by staff, and the broader multi-level programmes across an organisation or a system, which address the population health consequences of trauma.^5,20–22 Consistent with this, within custodial and justice settings the effects of trauma can be seen in behavioural, emotional and relational sequelae, and are managed across the whole estate, with frontline officers often having the most intensive role in managing the impact of trauma within the prison. ⁶

There is therefore growing awareness that psychological and mental health interventions must sit within whole-organisational approaches, which address environmental factors such as overcrowding, poor conditions and understaffing. ⁶ Hanson and Lang found that the most commonly implemented components of TIP were those that were not considered unique to TIP at all, such as positive, safe physical environments, services that were strengths-based and promoted positive development, and inter-agency collaboration/coordination. ⁸ This is consistent with the developing consensus that responding to trauma within the CJS necessitates a broader social and policy approach, which includes dealing with the social determinants of crime, considering liaison and diversion away from the CJS,strategies for reintegration into the community, and effective approaches to rehabilitation. ²³

Within this broad social and policy context, the challenges of defining the components of TIP are clear. From an evaluation perspective, it is far more complex and difficult to show progress at these levels, than with trauma-specific treatments, which generally have person-level outcomes relating to symptom reduction, are well-established, and can be measured within clinical practice, as well as evaluated within research methodologies. ³ Conversely, when evaluating broader organisational and systems change, and moving across the socio-ecological levels from individual practice and interventions, to organisational approaches, and to systemic and community approaches, it becomes progressively harder to demonstrate change.^24,25

It is more difficult to show which outcomes can be attributed to the intervention, and which components have contributed to these outcomes, as well as the mechanisms of change. ²⁶ There are many more possible outcomes to measure, with a wide range of factors that can impact the change process, and multiple components and interventions. In addition, change processes tend to be longer-term, requiring a long-term approach to evaluation, underpinned by sustained funding. Within the field of TIP, there is a tendency to bring individual-level research thinking to more complex, systems-level problems. ²⁷

Clinical research that is focused on individuals, such as intervention-led research and randomised controlled trials, and the use of outcome measures, tends to assume uniformity across populations. In other words, if an intervention is effective, it will also likely work with similar individuals in ways that are broadly the same. But with systems-level change, the unit of change (the whole system) is complex and non-linear. Therefore, evaluation strategies must include implementation science and realist evaluations, which aim to determine how change can occur within complex and interrelated systems. ²⁸

Although individual-level diagnostic and screening instruments, and outcome and patient-experience measures, have been well researched and developed, systems-based measures of TIP have been under-researched, with widespread methodological issues evident.^29,30 Within studies of TIP, it remains unclear whether the trauma-informed intervention has actually led to improved outcomes for service users, staff or the organisation as a whole.^21,22 Although there is growing evidence that TIP initiatives can act to improve service quality, there is limited empirical evidence that TIP improves the lives of people who have survived trauma. These findings become even less robust when models are translated into complex interacting systems, such as health services operating within justice systems.

Conversely, there is evidence that people living in prisons often do not experience the hoped-for outcomes of TIP.^17,18 Studies that have explored lived-experience perspectives also suggest that both staff and people in prison have reservations about whether prisons can be truly trauma-informed. ³¹ There are many organisational factors within prisons and the wider justice system that make change more difficult, including environmental factors such as overcrowding and poor conditions, an increase in prisoners on remand, and exposure to bullying, drug use, violent behaviour and suicide. ³²

Consistent with the findings of Hanson and Lang, ⁸ research also suggests that ‘universal’ factors such as safe physical environments, services that are strengths-based and promote self-development, access to meaningful activities and effective rehabilitation pathways, are seen as most impactful by staff and prisoners.^31,33,34 In addition, the development of effective pathways for the treatment of complex and co-occurring mental health, physical health and neurodevelopmental conditions is seen as a priority. ³⁵ Together, these findings suggest that the goal of providing trauma-informed and responsive care is still far from being realised, and that the focus of change should instead, first of all, be on resources, prison practices and culture.^31,36

Future research priorities include increased focus on service users’ perceptions and views of TIP, and the mechanisms through which changes in staff knowledge and attitudes lead to these client outcomes. ¹⁶ Further research on the extent to which trauma-informed concepts can be differentiated from, or extend, universal, related concepts, and the extent to which they lead to improved outcomes, will also be key for the adoption of policy initiatives. Research demonstrates that staff and people in prison believe that the most important aspect of TIP is relational change, and this finding is consistent with the theoretical basis of most TIP models. ³⁷ Therefore, it is possible that implementation and evaluation that centres attachment and relational practice within organisations will lead to a greater impact. ¹⁸

We argue that investment within the prison system, addressing overcrowding, understaffing and staff conditions, physical environments and exposure to drugs, violence and bullying, should be addressed as a priority. These aims are not dissimilar to the aims of the Offender Personality Disorder Pathway (OPDP), the Quality Network for Prison Mental Health Services (QNPMHS), and a variety of initiatives that have been tried.^15,38 Perhaps, in the end, we are all addressing the same issues but in different ways, and we are more likely to affect change with a systemic approach that reduces the effect of adverse environments and institutional approaches.

It is unclear both whether these reforms can be usefully conceptualised as, or differentiated from, ‘trauma-informed practice’, and the extent to which TIP can be effectively implemented without broader prison reform. Therefore, although the concept of TIP is theoretically sound and driven by an imperative to respond to the needs of a highly traumatised population, there is still a long way to go before we can be sure that it is a useful concept within prisons and the wider justice system. ³⁹