Trauma in Female Forensic Psychiatric Patients: A Mixed-Method Study into the Clinical Practice of Trauma-Focused Treatment

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

- The introduction is dense with information and should be moved on "discussion" or "results"

- Conclusions should be expanded

- tables and chart should be optimized

- the language should be simplified

- the self- report subministration could create some bias

- some references are incomplete

- the lack of follows up endanger the research robustness

Comments on the Quality of English Language

- The introduction is dense with information and should be moved on "discussion" or "results"

- Conclusions should be expanded

- tables and chart should be optimized

- the language should be simplified

- the self- report subministration could create some bias

- some references are incomplete

- the lack of follows up endanger the research robustness

Author Response

Reviewer 1

The introduction is dense with information and should be moved on "discussion" or "results"

We substantially rewrote the Introduction; parts were deleted and / or moved to the Discussion.

- Conclusions should be expanded

- tables and chart should be optimized

- the language should be simplified

We have carefully read our manuscript again and expanded conclusions where possible, optimized tables and simplified the language. We would like to emphasize that we used the format received by  Social Sciences for the whole manuscript including the tables, hence, we assume that this is the correct lay out.

- the self- report subministration could create some bias

We acknowledge that self-reporting in surveys can introduce bias such as socially desirable responses. To address this, we have incorporated interviews into our mixed-method study. Additionally, we have discussed the potential biases in the limitations section of the Discussion.

- some references are incomplete

We carefully revised the references and corrected where needed.

- the lack of follows up endanger the research robustness

We are unsure what specific follow-up you are referring to. Our study did not examine effectiveness; rather, it mapped the knowledge and experiences of professionals and patients with trauma treatment. However, we agree that follow-up studies would be valuable, especially after implementing more trauma-informed care or trauma treatment interventions. However, this was not the case in the current study.

 

Comments on the Quality of English Language

Transitions, redundancy, and work comprehensiveness are needed.  

We have carefully revised our manuscript and also included advice from a native English speaker.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this interesting study focussed on a very vulnerable and inaccessible population.

The introduction is informative and methods clearly described. Very succinct description of the coding process, which appears to have been comprehensive and thorough. Consideration for participants is apparent.

Minor language edits suggested:

Lines 76-78 repeat lines 74-75. Suggest keep the former, erase the latter. 

 

117-118 aimed at gaining more.i sight...

 

Suggest say 'that aims to gain insight into the challenges of female forensic  patient care, and to develop...

120-21, simplify the sentence

The research design consisted of....

Line 123

Delete 'The inclusion criteria for'

Line 127 'who were all working...

 

Line 132-33  

The numeral 1 should be in word form.

Non-binary is a gender not a sex. Perhaps use the language 'participants identified as non-binary'

123-4

Suggest simplified language:

'People over 18 years of age working in mixed gender forensic mental health care were recruited by snowball sampling.'

126

who were working 

129-131

Unclear whether the online platforms were social media based or a separate professional platform:

via an online platform as well as social media

OR

Via online platforms such as..

 

The words 'filled out' are cumbersome- two examples

Filled out email addresses : 'provided email adresses'

Filled out the survey: 'completed the survey'

 

306

'sometimes' should be 'someone'

 

319-26

Attention consistent formatting of quotes.

 

442  query if a better translation (I presume original transcript was in Dutch ) 'men carry on more easily'

 

Other comments:

Did any interview participants cease the interview or did they all complete?

233

Were the participants who endorsed focussing on the offender status practitioners or patients male or female? If practitioners, were they clincians or other therapists? Perhaps not relevant as its too small a number to glean meaning, nevertheless it would be interesting to know.

 

The apparent lack of opportunities to dwvelop or recognise coping skills could potentially be a recommendation, related to strengths based approaches and actively supporting post traumatic growth. 

 

The recommendations for awareness, professional develoment, diversifying options for trauma treatment, sooner and with more emphasis on gender-responsive strategies are all supported by the findings.

 

*End of suggestions.*

 

 

 

 

Author Response

Reviewer 2

Thank you for the opportunity to review this interesting study focussed on a very vulnerable and inaccessible population.

The introduction is informative and methods clearly described. Very succinct description of the coding process, which appears to have been comprehensive and thorough. Consideration for participants is apparent.

Minor language edits suggested:

Lines 76-78 repeat lines 74-75. Suggest keep the former, erase the latter. 

 117-118 aimed at gaining more.i sight...

 Suggest say 'that aims to gain insight into the challenges of female forensic  patient care, and to develop...

120-21, simplify the sentence

The research design consisted of....

Line 123

Delete 'The inclusion criteria for'

Line 127 'who were all working...

 Line 132-33  

The numeral 1 should be in word form.

Non-binary is a gender not a sex. Perhaps use the language 'participants identified as non-binary'

123-4

Suggest simplified language:

'People over 18 years of age working in mixed gender forensic mental health care were recruited by snowball sampling.'

126

who were working 

129-131

Unclear whether the online platforms were social media based or a separate professional platform:

via an online platform as well as social media

OR

Via online platforms such as..

 The words 'filled out' are cumbersome- two examples

Filled out email addresses : 'provided email adresses'

Filled out the survey: 'completed the survey'

 306

'sometimes' should be 'someone'

 319-26

Attention consistent formatting of quotes.

Thank you, we changed this according to the author guidelines of Social Sciences.

 442  query if a better translation (I presume original transcript was in Dutch ) 'men carry on more easily'

Thank you for all these suggestions, we incorporated all of them in the text.

Other comments:

Did any interview participants cease the interview or did they all complete? 233

All the participants completed the interview, we added this information in the Method section.

Were the participants who endorsed focussing on the offender status practitioners or patients male or female? If practitioners, were they clincians or other therapists? Perhaps not relevant as its too small a number to glean meaning, nevertheless it would be interesting to know.

This is an interesting point. We examined our data but did not observe a clear pattern. Due to the small sample size and the potential for participant identification, which would violate privacy, we did not include this in our manuscript.  

The apparent lack of opportunities to dwvelop or recognise coping skills could potentially be a recommendation, related to strengths based approaches and actively supporting post traumatic growth. 

Thank you for this interesting suggestion, we included this in the Discussion part.

 The recommendations for awareness, professional develoment, diversifying options for trauma treatment, sooner and with more emphasis on gender-responsive strategies are all supported by the findings.

 

Comments on the Quality of English Language

Transitions, redundancy, and work comprehensiveness are needed.  

We have carefully revised our manuscript and also included advice from a native English speaker.

Reviewer 3 Report

Comments and Suggestions for Authors

The first paragraph is excessively long, somewhat redundant, and contains repeated terms, which detract from its clarity. It is challenging to identify the main points, as the argument lacks focus and coherence. The opening sentence, which should set the tone and guide the paragraph, becomes overshadowed and disconnected, particularly from line 33 onward.

In line 43, the authors prematurely present results without first addressing the gaps or key research questions. This placement is inappropriate, as these elements should belong to the results section. Additionally, the mention of “personality disorders” appears out of context, as it is neither clearly introduced nor adequately developed.

A similar issue arises in the second paragraph. The discussion transitions from post-trauma experiences to pre-trauma experiences in a manner that feels disjointed. It would be more effective to begin the paragraph with a strong key sentence that encapsulates its central theme, ensuring the reader is engaged and can follow the logical progression.

The opening sentence of the third paragraph would be better suited as the concluding sentence of the second paragraph. Starting the third paragraph with a discussion on treatment and care would provide better structure.

A critical issue in the third paragraph is the ambiguous role of men. The inclusion of gender appears either as filler text or an underdeveloped central theme. If the former, the discussion should be delayed or better integrated. If the latter, it should be removed unless it is directly relevant and substantiated.

In the middle of the third paragraph, there is a heavy focus on self-esteem, but this abruptly transitions into social support without a clear or informative link. The lack of a proper transition and the absence of a cohesive narrative hinder the reader's understanding.

By the end of the introduction and section 1.2, the purpose of the scattered topics remains unclear. The role of men, women, and gender, particularly when the title targets “female” subjects, lacks explicit connection and relevance. Lines 108–109 introduce factors the authors aim to explore, but these factors were not clearly delineated earlier. For instance, the authors query whether professionals recognize gender differences in line 106, but this issue is neither identified as a gap nor a research problem in the introduction.

The mention of “gender-responsive factors” in line 109 should be a central theme but is poorly established. Although referenced in disparate parts of the manuscript, it lacks a cohesive framework.

Section 2.1 raises several methodological concerns. How were the participants for the interview selected? What criteria were used for inclusion and exclusion? Between sections 2.1 and 2.2, the term “survey” is used, but its details, including its name and purpose, are not adequately explained. The phrase “affiliation with the topic(s)” is vague and requires clarification. Similarly, the statement about “15 consensus meetings... the codes” is unclear. How was it determined that saturation had been reached?

Upon reaching the results section, the survey’s specifics—such as scoring methods, main scales, and subscales—remain ambiguous. These details should be presented in the methodology or supplemental materials.

Additionally, the discrepancy between the findings is that 250 participants (84.7%) believe gender plays an equal role in treatment effectiveness, and the 60.5% who emphasize gender differences need reconciliation. This inconsistency undermines the argument about the role of gender and its relevance.

Reflecting on the manuscript holistically, several key issues arise:

1. Does the introduction provide a solid and comprehensive background, outlining the topic, research gaps, and relevance? Unfortunately, no.
2. Does the methodology and procedure section provide sufficient clarity to enable the reader to understand and evaluate the results? Again, no.

Given these shortcomings, the authors should revisit and revise their work before proceeding further. The manuscript contains numerous gaps that render its conclusions unaligned. For example, the explanation of trauma is inadequate. A comprehensive and well-defined scope of trauma and its conceptualization is essential. Similarly, the concept of gender remains unclear—whether it pertains to biological sex or broader sociocultural constructs. This lack of definition, as seen from lines 630 onward, introduces further limitations to the study’s validity and coherence.

 

Comments on the Quality of English Language

Transitions, redundancy, and work comprehensiveness are needed.  

Author Response

Reviewer 3

The first paragraph is excessively long, somewhat redundant, and contains repeated terms, which detract from its clarity. It is challenging to identify the main points, as the argument lacks focus and coherence. The opening sentence, which should set the tone and guide the paragraph, becomes overshadowed and disconnected, particularly from line 33 onward.

Thank you for these comments, we agree and substantially rewrote the Introduction. Several sentences were deleted, as they were not relevant for the present study and may confuse readers.

In line 43, the authors prematurely present results without first addressing the gaps or key research questions. This placement is inappropriate, as these elements should belong to the results section. Additionally, the mention of “personality disorders” appears out of context, as it is neither clearly introduced nor adequately developed.

We deleted some parts (about the personality disorders) and more clearly addressed the gaps in the literature.

A similar issue arises in the second paragraph. The discussion transitions from post-trauma experiences to pre-trauma experiences in a manner that feels disjointed. It would be more effective to begin the paragraph with a strong key sentence that encapsulates its central theme, ensuring the reader is engaged and can follow the logical progression.

We have substantially rewritten this paragraph.

The opening sentence of the third paragraph would be better suited as the concluding sentence of the second paragraph. Starting the third paragraph with a discussion on treatment and care would provide better structure.

Thank you for this suggestion, we changed this accordingly.

A critical issue in the third paragraph is the ambiguous role of men. The inclusion of gender appears either as filler text or an underdeveloped central theme. If the former, the discussion should be delayed or better integrated. If the latter, it should be removed unless it is directly relevant and substantiated.

We agree, we discuss this issue also in the Discussion part with some more literature, so we deleted the information in the Introduction.

In the middle of the third paragraph, there is a heavy focus on self-esteem, but this abruptly transitions into social support without a clear or informative link. The lack of a proper transition and the absence of a cohesive narrative hinder the reader's understanding.

We agree, we rewrote this paragraph and included more information and more structure discussing the four factors that have been found to be of particular importance for justice-involved women.

By the end of the introduction and section 1.2, the purpose of the scattered topics remains unclear. The role of men, women, and gender, particularly when the title targets “female” subjects, lacks explicit connection and relevance. Lines 108–109 introduce factors the authors aim to explore, but these factors were not clearly delineated earlier. For instance, the authors query whether professionals recognize gender differences in line 106, but this issue is neither identified as a gap nor a research problem in the introduction.

The mention of “gender-responsive factors” in line 109 should be a central theme but is poorly established. Although referenced in disparate parts of the manuscript, it lacks a cohesive framework.

We have tried to describe this more clearly and in a more structured way. However, we should acknowledge that the literature is still limited and there is no consensus yet or a clear framework available.

Section 2.1 raises several methodological concerns. How were the participants for the interview selected? What criteria were used for inclusion and exclusion? Between sections 2.1 and 2.2, the term “survey” is used, but its details, including its name and purpose, are not adequately explained. The phrase “affiliation with the topic(s)” is vague and requires clarification. Similarly, the statement about “15 consensus meetings... the codes” is unclear. How was it determined that saturation had been reached?

Several of these aspects are described in section 2.2 Materials (the survey) and 2.3 Procedure. We understand the confusion, therefore, we decided to change the order and start with Procedure, then subsequently Materials and Participants. We hope this clarifies the methodology.

Furthermore, we explained some more details in the text, like the name and goal of the survey.  

No selection criteria were used; all professionals and patients were welcome to share their experiences. We explained some more about the recruitment process:

For the professionals, we used a purposive cell sampling strategy. Professionals were initially recruited via the online survey where they could leave their names and email addresses in a separate part of the survey if they wanted to participate in the interviews. It was important to have a representative group of professionals for the interviews. Therefore, we selected professionals from various settings and professions from this list, such as sociotherapists, psychotherapists, social workers, vocational therapists, and psychiatric nurses. Next to these professionals, we recruited some professionals whose profession was missing from the list, for example, a psychiatrist.

 

Forensic psychiatric patients were recruited via treatment staff from two of the participating forensic hospitals. It was important that patients were willing and fit enough to participate and they were informed that they could stop the interview at any point, without any reason or consequences for their treatment. Also, it was explained to them that participation would not impact their treatment. It should be noted that all researchers worked in the forensic hospital and remained in close contact with the treatment team to ensure if patients were fit and stable enough, also after the interview. All patients gave their informed consent and agreed to voice record the interview, and verbatim transcripts were made for all interviews.

Saturation was reached when no new themes emerged from the data. This is in accordance with the literature; saturation is usually expected to be achieved with a sample size between eight to fifteen participants (Hill et al., 1997).

Upon reaching the results section, the survey’s specifics—such as scoring methods, main scales, and subscales—remain ambiguous. These details should be presented in the methodology or supplemental materials.

We have added some more details and refer to the full study project for a more elaborate explanation of the survey.

Additionally, the discrepancy between the findings is that 250 participants (84.7%) believe gender plays an equal role in treatment effectiveness, and the 60.5% who emphasize gender differences need reconciliation. This inconsistency undermines the argument about the role of gender and its relevance.

We believe these are distinct aspects. The first statement addresses whether trauma-focused treatment is equally effective for females and males, with 84.7% agreeing that it is. The 60.5% figure pertains to a knowledge question, where 60.5% of participants correctly identified the higher prevalence of trauma in women. However, this does not relate to the effectiveness of treatment.

Reflecting on the manuscript holistically, several key issues arise:

1. Does the introduction provide a solid and comprehensive background, outlining the topic, research gaps, and relevance? Unfortunately, no.
2. Does the methodology and procedure section provide sufficient clarity to enable the reader to understand and evaluate the results? Again, no.

Given these shortcomings, the authors should revisit and revise their work before proceeding further. The manuscript contains numerous gaps that render its conclusions unaligned. For example, the explanation of trauma is inadequate. A comprehensive and well-defined scope of trauma and its conceptualization is essential. Similarly, the concept of gender remains unclear—whether it pertains to biological sex or broader sociocultural constructs. This lack of definition, as seen from lines 630 onward, introduces further limitations to the study’s validity and coherence.

We have included definitions of trauma and gender in the text. Given the length of the manuscript, we chose to discuss them only briefly and refer the interested reader to more elaborate discussions about definitions.

Trauma is defined as an event or circumstance resulting in physical harm, emotional harm, and/or life-threatening harm (SAMSHA, 2024).

SAMHSA (2024). Trauma and violence. https://www.samhsa.gov/trauma-violence

It is important to define the terms sex, gender, gender-sensitive and gender-responsive. The term sex refers to the biological aspects of being female or male whereas the term gender includes psychological, social, and cultural aspects associated with the biological aspects (see for a discussion Javdani et al., 2011).

 

Javdani, S., Sadeh, N., & Verona, E. (2011). Expanding our lens: Female pathways to antisocial behavior in adolescence and adulthood. Clinical Psychology Review, 31, 1324-1348. doi:10.1016/j.cpr.2011.09.002

 

Comments on the Quality of English Language

Transitions, redundancy, and work comprehensiveness are needed.  

We have carefully revised our manuscript and also included advice from a native English speaker.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

A well written paper. Due to the theoretical and cultural complexity of this topic it should be empowered with some gender psychology contributions which could highlitgh this one. The sample should be balanced and analyzed with more powerful methodology and instruments.

Author Response

A well written paper. Due to the theoretical and cultural complexity of this topic it should be empowered with some gender psychology contributions which could highlitgh this one. The sample should be balanced and analyzed with more powerful methodology and instruments.

 

We fully agree that integrating insights from gender psychology could significantly enrich the work, particularly given the theoretical and cultural complexity of the topic. We incorporated some more information in the Introduction, however, given the number of words, however, we decided not to include much more new literature, but emphasize some gender psychology contributations that were already in our manuscript, like the work of Miranda Olff, 2017. We included one more general reference (Pantalone et al. 2020).

We appreciate your comments regarding the sample and analytical methods. However, at this moment, it is not possible to make changes, we emphasized the limitations of our study some more in the Discussion part.

Reviewer 3 Report

Comments and Suggestions for Authors

dear authors, 
Thank you for edits; they look fine to me for now

Author Response

Thank you.