Trauma-Informed Care: The Importance of Understanding the Incarcerated Women

Abstract

Numerous studies and research substantiate strong correlations between adverse childhood experience (ACE) scores and corrections. This study assessed the significance of trauma-informed care (TIC) in the recidivism rates of incarcerated women. A retrospective longitudinal survey was conducted. ACE scores were evaluated and documented through a self-reported survey. Seven years of Correctional Offender Management Profiling for Alternative Sanctions registry documentation was assessed. Descriptive statistics were utilized to define patients and evaluate patterns of recidivism after implementation of trauma-informed approaches to care. There is strong evidence associating lower recidivism rates for those who participate in TIC and trauma programs than for those who do not. This evidence supports further evaluation with a serious potential impact of reduction in recidivism and improved trajectories for incarcerated women and their families.

Introduction and Background

The first adverse childhood experiences (ACEs) study was completed in 1998 (Felitti et al., 1998). For 20 years evidence has continued to grow demonstrating the connection between childhood trauma and adverse impacts on life, including chronic disease, criminal activity, and even death. Cycles of abuse, neglect, and dysfunction continue and can often be predicted (Berlin et al., 2011). Stigma, lack of empathy, and fear further perpetuate these tragedies. Baglivio and Epps's (2016) prospective ACEs study included 17,421 highly educated and insured adults who reported 10 or more ACEs and their connection to chronic disease. The researchers also noted an increase in the prevalence of higher ACE scores in children who grew up in alcoholic homes and those involved in the juvenile justice system. As defined by Baglivio and Epps (2016), trajectories are patterns of growth over a lifetime, denoting behavior. Abuse occurring in childhood predicts substance abuse, risky sexual behaviors, aggression and violence, and criminal activity as well as mental health disparities (Berlin et al., 2011). According to the Centers for Disease Control and Prevention (2019), high ACE scores contribute to the potential for early death (see Supplementary Appendix SA1). Trauma is the exposure to an extraordinary experience that presents a physical or psychological threat to oneself or others and generates a reaction of helplessness and fear (American Psychiatric Association, 2013).

The stress experienced from repeated trauma can lead to long-term changes in physical and mental health. Stress interrupts the body's homeostasis adapting to internal and external stimuli to protect and defend. Frequent or ongoing stress responses can impact the body in the following ways: delay healing, complicate the body's response to vaccinations, and increase susceptibility to illness. The stress response and its relationship with constant cortisol exposure lead to compromised thyroid function, impaired cognition, and increased abdominal fat, which has strong associations for decreased cardiovascular health (Acabchuk et al., 2017). Relationships exist between trauma and chronic conditions (Baglivio & Epps, 2016).

For health care providers, the prioritizing of patients' mental and emotional well-being is supported by these correlations. The change begins with an emphasis that mental well-being is pursued with the same vigor that health care supports healthy blood pressure, vaccinations, and healthy lifestyle choices. Evaluating patients for anxiety, depression, and past traumas is as pertinent as familial history of cancer, diabetes, and hypertension.

Standardization of these assessments during a normal appointment may reduce the stigma of mental health disparities and lead to the treatment of underlying causes of patients' chronic conditions. Normalizing questions about anxiety, depression, and potential traumas may put patients at ease, leading to honest and open communication. Parrish et al. (2011) note that due to lack of access to mental health services as well as economic disadvantages, patients often seek the assistance for depression and anxiety with their primary care provider or with free clinics in their neighborhood.

Trauma-informed care (TIC) seeks to support the recognition of adverse childhood events as well as those experienced as adults. There are six decisive features in TIC: safety, trust, choices, collaboration, empowerment, and cultural and historical factors. It supports mindfulness, ownership, and forgiveness. TIC leads those treated to the identification of impactful events and empowers them to reclaim control of their lives emphasizing physical, psychological, and emotional safety. One gap that exists is the process in which traditional programs for trauma are provided; in some case trauma is not even recognized. Victims of trauma may feel lack of autonomy in these settings and feel triggered by the lack of control they experience; the correctional setting further perpetrates this reality. As noted by Withers (2017, para. 12), everyone should be “…making an effort to broaden our understanding of what people have been through in their lives, how these ‘preexisting conditions’ have affected their personalities, and what they need with that bigger picture in mind.” TIC programs and services offer collaboration, autonomy, and self-directed care resulting in improved outcomes and reduced stress for patients and providers (Trauma Informed Care Project, 2015).

Problem Statement

The United States currently leads the world in incarcerated individuals, with approximately 1 of every 100 adults being behind bars (Gjelsvik et al., 2014). There exist convincing associations between childhood trauma and incarceration (Reavis et al., 2013). These statistics should be alarming to health care professionals. Although society continues to evolve in addressing the stigma of mental illness, a significant gap in understanding remains. The identification of traumatic events and the prevention of future trauma are a moral imperative as the ability to cope with life events is vital to the making of successful transitions in society. There is clear evidence that management interventions that emphasize criminal rehabilitation devoid of TIC are preordained to fail (Reavis et al., 2013). Mounting concerns exist between incarceration and health disparities, not only for those incarcerated but also for their children (Gjelsvik et al., 2014). Children who experience ACEs are themselves at an increased risk for incarceration; because of this a change in focus is warranted. Although childhood trauma does not excuse criminal behavior, it may, in fact, explain it (Altintas & Bilici, 2018). In considering the impact parents and family figures have on young children, it stands to reason the cycles of violence and criminal activity would continue (Wooten, 2015). Children are led by example.

As many as 25% of adults with serious mental illness also have connections to the criminal justice system, and 30% of those with any mental illness perceive their mental health needs unmet even after treatment (Ali et al., 2018). The desired goal of rehabilitation before reentering society necessitates addressing what is below the surface, the things that providers cannot initially see. Health care in correctional settings can be challenging; there are security aspects that do not exist in most other health care venues. In that challenge, however, is an opportunity to help patients identify and cope with the adverse events that contribute to their crimes and change their self-perceptions for the better. In altering the perspective of patients who have experienced trauma and supporting their evolution in coping, the cycles of violence, substance abuse, and criminal behavior can be broken.

Furthermore, women involved in corrections experience a higher level of recidivism than their male peers. Researchers believe this is due to trauma occurring in childhood or ACEs, and this in combination with post-traumatic stress disorders, substance abuse, and mental health disorders further complicates successful release into the community (Vandiver et al., 2018). Complications such as these often precipitate devastating consequences for women such as the removal of their children, homelessness, and unemployment. When combined with substance abuse, ACEs in women predict successive criminal activity (Vandiver et al., 2018).

Recidivism is a significant reality of the criminal justice system. It speaks directly of the efficacy of rehabilitation and treatment an offender received. This study looks at the potential impact that TIC may have at reducing recidivism. There are many potential factors contributing to an offender's success, but can the tools TIC provide make a difference? Recidivism is defined as behavior that results in the rearrest or reconviction or a return to prison within 3 years after release (National Institute of Justice, n.d.). According to a 2014 report from the Bureau of Justice Statistics, of 404,638 prisoners released in 30 states in 2005, 56.7% were rearrested within 1 year of prison release, 67.8% within 3 years, and 76.6% within 5 years (Durose et al., 2014). Thus, it is evident: Most inmates are not prepared for a successful return to society. Risk factors of trauma and the cycle of criminal activity have strong connections to impaired decision making, damaged social relationships, addiction, and compromised physical well-being (Cotter et al., 2016). To reduce recidivism rates, improve the lives of those who have experienced trauma, and prevent the future cycle of victims, an innovative approach to treatment and care of those in correctional settings is crucial.

Need, Feasibility, and Significance

The strength of society, and the health of communities, is dependent on providers equipping patients with the necessary tools to succeed. For providers, understanding ACE scores may help aid diagnosis, treatment, and plan of care. How an individual adapts to and copes with life events is crucial to ultimate health outcomes.

The feasibility for change is attainable; learning to incorporate assessments and the implementation of TIC in a variety of settings from public schools to health care systems and correctional settings can lead to improved coping and empowerment for a better life (Bartlett et al., 2018). The potential TIC has to empower those who have experienced trauma to change their predicted trajectories and strengthen patients, communities, and families everywhere cannot be understated.

Objectives and Aims

According to the National Resource Center on Justice Involved Women (2016, para. 2), “Women are a fast-growing criminal justice population according to trends over the past 30 years. Since 1980, the number of women in U.S. prisons has increased by more than 700% and has outpaced men by more than 50%.” It is for this reason a study focused solely on women was conducted.

The objective of this study was to evaluate the potential impact TIC programs had on the recidivism rate of woman offenders. Women were selected from state-run prisons to participate in the trauma program based on the patient's desire to participate and personal goals. Programming was 6 months long; a group of 10 women started together and joined another group of 10 who were approximately halfway through their trauma program. The specialized unit in most cases had a total of 20 women at one time. These women learned to coexist, deal with their trauma, and build relationships. Therapy was individualized. Each person's course load was dependent on their goals and interests, with time for music therapy, cooking classes, and parenting class. All participants had personal therapies, group therapies, and classes. The facility where the study occurred employed several social workers, psychiatric associates, and supervisors with TIC training. The aim of this research was to assess whether the treatments and programming had long-term efficacy related to recidivism and the impact they have for those who have experienced trauma to change their predicted trajectories and strengthen patients, communities, and families.

Review of Literature

Through the systematic review of literature, a strong association has been suggested between the impact of adverse childhood events and criminal activity later in life. Although ACEs exist in nearly all lives, those with scores of five and above show the strongest affinity to corrections (Edalati et al., 2017). One of the clearest ACEs leading women to corrections, often for violent offenses, is sexual abuse; evidence suggests women who have experienced multiple traumatic events are predisposed to committing more serious offenses (Karatzias et al., 2018). In addition, evidence exists connecting elevated ACE scores to impulsivity, addiction, cycles of abuse, and adult revictimization (Cotter et al., 2016).

The importance of TIC and its potential for change is identified in multiple research studies (Karatzias et al., 2018). TIC has been shown to improve rapport between patients and providers, decrease health care costs, and improve outcomes for patients. TIC is an individualized focus and patient centered; it, therefore, contributes to increased patient buy-in and treatment compliance (Sederstrom, 2015). Recurring themes are apparent in studies of psychological trauma preceding incarcerations.

Trauma has become so pervasive that it is a public health crisis. Providers in social work, health care, psychology, and corrections find themselves with the insurmountable task of treating patients with trauma (Marvin & Volino Robinson, 2018). Increasing numbers of patients, lack of funding, and lack of preparation to treat further complicate this growing epidemic. Readiness for change and knowledge deficiency contribute to this growing tragedy. Patients and providers alike seek sustenance for change.

Researchers are recognizing the potential health risks for those with trauma, and believe that reducing recidivism through TIC is not only a possibility but also a responsibility to all providers, to heal the communities in which we live (Machtinger et al., 2015).

TIC is an example of an adaptive skill set used to deal with the impetuses of life, the past and the present factors impacting homeostasis. In supporting the growth, integrity, and future trajectories of those in corrections, TIC is a strong foundation for positive change. If beneficence is truly our focus, then our patients deserve a chance to learn from their trauma and their mistakes and build on the enlightenment that TIC provides. TIC therapies may include but are not limited to cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and brain spotting. These therapies aim to help the patient identify repressed memories (Substance Abuse and Mental Health Services Administration, 2014).

Method

Essential terms and phrases used in the search were TIC, recidivism, women, and ACE scores. The following databases were searched: CINAHL, MEDLINE, PsycINFO, and Science Reference Center. Since this research focused on women in correctional settings, the search focused on those demographic elements.

In addition, a retrospective study was conducted at a secure mental health treatment facility for inmates of the department of corrections. The study looked at 7 years of data related to a specialized TIC program, reviewing ACE scores, incarceration, and recidivism. ACE scores were collected for all but 15 who declined to answer as a part of the treatment process. Trauma programs included CBT training, thinking for a change, and EMDR. IRB approval was obtained from the University of Wisconsin Oshkosh and found to be exempt.

Results

This study, which occurred in a secure correctional mental health treatment facility in mideastern Wisconsin, found evidence that TIC did have a significant impact on the trajectories of patients who participated in programming. The program itself is specialized; the setup, location, and facility culture are patient centered. When the recidivism rate was evaluated for the patients who participated in this program compared with those of the state and the nation, recidivism rates were significantly lower. The correlations that exist in the reduction of recidivism support trauma-informed programs in all correctional settings.

Of the 237 participants studied, 121 women remained incarcerated at the time of the study, leaving 116 to evaluate. Of those released, only 11 had recidivated, meaning that exposure to TIC in this group had a 91% success rate. The impact of TIC cannot be underestimated. By reducing recidivism in the woman population, there is a strong probability of reducing trauma for their offspring. This small study shows potential for the reduction of recidivism with TIC support and teaching.

The ages of the women involved in this study varied from 21 to 69 years, with most in their 40s. It came as no surprise that of the ACE scores collected, only 45 of the 221 were under a score of 4. A score of 4 or higher elevates a person's risk for mental health disparities, chronic health conditions, and substance abuse, and is predictive of correctional system involvement as well as early death. The data gathered in this study support both the correlations and the need for further research about the positive implications TIC can have in the reduction of recidivism.

Of the 11 women who recidivated, 5 were Caucasian, 5 were Black, and 1 was American Indian. Specific statistics related to their socioeconomic status may have been addressed individually in therapy but was not documented, nor was their individual specific support system. These are contributors to success that could be further examined in future studies (see Table 1).

Table 1.

Study Participants

	Total participants, N = 237	Released women, N = 116	Incarcerated women, N = 121
ACEs reported	n	n	N
0	4	3	1
1–3	41	14	27
4–7	101	56	45
>7	75	34	41
Missing	16 cases; 6.75%	9 cases; 7.75%	7 cases; 5.78%
Age range (years)
18–24	4	2	2
25–40	106	47	59
≥41	127	67	60
Race
White	145	78	67
Black	60	25	35
Asian	2	1	1
Hispanic	14	4	10
American Indian	16	8	8
Number of incarcerations
1	151	65	86
2	45	23	22
3	15	12	3
4	9	7	2
5	6	3	3
6	7	3	4
7	2	2	0
8	1	1	0
9	1	0	1
Recidivated
White			5
Black			5
American Indian			1

ACEs = adverse childhood experiences.

Strengths and Weaknesses

The strengths of the study are the evidence of decreased recidivism in participants of trauma programming. Although the specific impacts of TIC will vary with everyone, this study has persuasive evidence that it is helpful when transitioning back to the community. In addition, there exists compelling evidence related to the correlations between high ACE scores leading to incarceration, with several large studies being done.

Potential weaknesses include that the study is small with no specificity of ACEs to individuals. The study was completed in the woman population only and there is no knowledge of specific treatments outside of the state of Wisconsin for comparison. Further considerations are the implications of race considering the overwhelming number of Caucasian women being treated for mental health disparities in corrections compared with their minority peers.

Support and understanding of TIC from communities and the buy-in can be difficult to attain. Society fears handouts, enablement, and excuses for existing outside societal norms. It may be difficult to relate to the social determinants that contribute to trauma because it forces each person to reflect how they contribute. Initial training may also be a concern; the time and money it takes would likely be saved in the long run. Housing inmates is expensive. Although training costs were not assessed with this study, the cost of training would likely pay for itself through reduction in housing those who recidivate.

Conclusion

Growing research suggests evidence supporting TIC as a necessity for all who enter corrections, potentially including those who receive probation only. Prevention is a major key to nursing treatment; in treating those in corrections and with high ACE scores, TIC may prevent further trauma, familial cycles, and repeated offenses. “Recovery cannot occur in isolation. It can take place only within the context of relationships characterized by the belief in persuasion rather than coercion, ideas rather than force, and mutuality rather than authoritarian control—precisely the beliefs that were shattered by the original traumatic experiences.” (Herman, 1992, p. 136).

Change is imperative with recidivism rates well >50% in society, suggesting current interventions are failing to rehabilitate offenders, contributing to further traumas, wasted time, and money (National Institute of Justice, 2008).

It is because of this, in the same way we personalize care plans for other health care issues, that providers should be committed to the recognition of the prevalence of trauma and the potential role it plays in a patient's overall well-being (SAMHSA, 2014). Current practices are not sustainable, realistic, or practical for nonmalevolent intent. Crowded correctional facilities, understaffing, and vicarious trauma further complicate this growing trend of ambivalence to the glaring truth. To heal our communities, we must identify the causative factors—in many if not all cases, trauma.

Although trauma is not the only factor contributing to recidivism, it stands to reason that learning coping strategies and mindfulness will improve the reintegration process. This is especially true if, as a community, we become more informed and offer more support and screenings in health care settings for trauma's impact. For this reason, it is evident that TIC should be further evaluated, recognizing the impact of trauma on a person's future in all health care and community resource settings.

Author Disclosure Statement

The author disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

The author received no financial support for the research, authorship, and/or publication of this article.

Supplementary Material

Supplementary Appendix SA1