what might a counselor consider before asking a client to take a computer-administered inventory?

Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more half of respondents report a history of trauma, and the rates are even higher among clients with mental or substance use disorders. Furthermore, behavioral health problems, including substance apply and mental disorders, are more than difficult to care for if trauma-related symptoms and disorders aren't detected early and treated effectively (Part 3, Section i, of this Handling Comeback Protocol [TIP], available online, summarizes enquiry on the prevalence of trauma and its relationship with other behavioral health issues).

Not addressing traumatic stress symptoms, trauma-specific disorders, and other symptoms/disorders related to trauma can impede successful mental health and substance abuse handling. Unrecognized, unaddressed trauma symptoms tin can atomic number 82 to poor engagement in handling, premature termination, greater risk for relapse of psychological symptoms or substance use, and worse outcomes. Screening can as well prevent misdiagnosis and inappropriate treatment planning. People with histories of trauma often display symptoms that run into criteria for other disorders.

Without screening, clients' trauma histories and related symptoms often go undetected, leading providers to direct services toward symptoms and disorders that may only partially explain client screening for trauma history and trauma-related symptoms can help behavioral wellness practitioners identify individuals at risk of developing more than pervasive and astringent symptoms of traumatic stress. Screening, early identification, and intervention serves as a prevention strategy.

Screening to identify clients who have histories of trauma and experience trauma-related symptoms is a prevention strategy.

Trauma-Informed Care Framework in Behavioral Health Services—Screening and Assessment

The chapter begins with a give-and-take of screening and assessment concepts, with a item focus on trauma-informed screening. It then highlights specific factors that influence screening and assessment, including timing and environment. Barriers and challenges in providing trauma-informed screening are discussed, along with culturally specific screening and cess considerations and guidelines. Musical instrument selection, trauma-informed screening and assessment tools, and trauma-informed screening and assessment processes are reviewed as well. For a more research-oriented perspective on screening and assessment for traumatic stress disorders, please refer to the literature review provided in Role iii of this TIP, which is bachelor online.

Screening and Assessment

Screening

The first two steps in screening are to determine whether the person has a history of trauma and whether he or she has trauma-related symptoms. Screening mainly obtains answers to "yes" or "no" questions: "Has this customer experienced a trauma in the past?" and "Does this client at this time warrant farther cess regarding trauma-related symptoms?" If someone acknowledges a trauma history, then further screening is necessary to make up one's mind whether trauma-related symptoms are nowadays. Nonetheless, the presence of such symptoms does not necessarily say anything about their severity, nor does a positive screen betoken that a disorder actually exists. Positive screens only bespeak that cess or further evaluation is warranted, and negative screens do not necessarily mean that an private doesn't have symptoms that warrant intervention.

Screening is oft the commencement contact between the client and the treatment provider, and the customer forms his or her commencement impression of treatment during this intake procedure. Thus, how screening is conducted tin exist as important equally the actual information gathered, as it sets the tone of treatment and begins the relationship with the client.

Screening procedures should ever ascertain the steps to accept subsequently a positive or negative screening. That is, the screening procedure establishes precisely how to score responses to screening tools or questions and conspicuously defines what constitutes a positive score (called a "cut-off score") for a particular potential problem. The screening procedures detail the actions to have after a client scores in the positive range. Clinical supervision is helpful—and sometimes necessary—in judging how to go along.

Trauma-informed screening is an essential function of the intake evaluation and the treatment planning procedure, only it is not an finish in itself. Screening processes can be developed that let staff without advanced degrees or graduate-level training to conduct them, whereas assessments for trauma-related disorders require a mental health professional trained in assessment and evaluation processes. The most of import domains to screen amidst individuals with trauma histories include:

• Trauma-related symptoms.

• Depressive or dissociative symptoms, sleep disturbances, and intrusive experiences.

• By and present mental disorders, including typically trauma-related disorders (e.thousand., mood disorders).

• Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, agin childhood events, combat experiences).

• Substance abuse.

• Social back up and coping styles.

• Availability of resources.

• Risks for cocky-harm, suicide, and violence.

• Health screenings.

Assessment

When a customer screens positive for substance abuse, trauma-related symptoms, or mental disorders, the bureau or counselor should follow up with an cess. A positive screening calls for more action—an cess that determines and defines presenting struggles to develop an advisable handling program and to make an informed and collaborative determination near handling placement. Assessment determines the nature and extent of the customer's problems; it might require the client to answer to written questions, or it could involve a clinical interview by a mental health or substance abuse professional qualified to assess the customer and arrive at a diagnosis. A clinical assessment delves into a customer's past and cu r-hire experiences, psychosocial and cultural history, and assets and resources.

Cess protocols tin can crave more than a unmarried session to complete and should also use multiple avenues to obtain the necessary clinical information, including self-cess tools, past and present clinical and medical records, structured clinical interviews, assessment measures, and collateral information from pregnant others, other behavioral health professionals, and agencies. Qualifications for conducting assessments and clinical interviews are more rigorous than for screening. Avant-garde degrees, licensing or certification, and special training in administration, scoring, and interpretation of specific cess instruments and interviews are often required. Counselors must be familiar with (and obtain) the level of training required for any instruments they consider using.

Advice to Counselors: Screening and Assessing Clients

• Ask all clients virtually any possible history of trauma; use a checklist to increment proper identification of such a history (see the online Adverse Childhood Experiences Report Score Figurer [http://acestudy.org/ace_score] for specific questions nearly adverse babyhood experiences).

• Use only validated instruments for screening and assessment.

• Early in handling, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma.

• When clients screen positive, also screen for suicidal thoughts and behaviors (run across TIP fifty, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment; Centre for Substance Corruption Handling [CSAT], 2009a).

• Do non delay screening; do not look for a period of abstinence or stabilization of symptoms.

• Be aware that some clients will non brand the connection between trauma in their histories and their current patterns of beliefs (e.1000., alcohol and drug utilize and/or avoidant behavior).

• Do not require clients to depict emotionally overwhelming traumatic events in detail.

• Focus assessment on how trauma symptoms affect clients' current operation.

• Consider using paper-and-pencil instruments for screening and cess as well as self-report measures when appropriate; they are less threatening for some clients than a clinical interview.

• Talk near how yous will use the findings to plan the customer's treatment, and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment. It is helpful to explore the strategies clients accept used in the past that have worked to salve strong emotions (Fallot & Harris, 2001).

• At the end of the session, make sure the client is grounded and safety before leaving the interview room (Litz, Miller, Ruef, & McTeague, 2002). Readiness to go out tin exist assessed by checking on the degree to which the client is conscious of the current surroundings, what the client'due south plan is for maintaining personal safety, and what the client's plans are for the balance of the day.

For people with histories of traumatic life events who screen positive for possible trauma-related symptoms and disorders, thorough assessment gathers all relevant information necessary to understand the role of the trauma in their lives; appropriate treatment objectives, goals, planning, and placement; and whatsoever ongoing diagnostic and treatment considerations, including reevaluation or follow-up.

Overall, assessment may betoken symptoms that meet diagnostic criteria for a substance use or mental disorder or a milder form of symptomatology that doesn't attain a diagnostic level—or it may reveal that the positive screen was fake and that there is no significant cause for business organisation. Information from an assessment is used to plan the customer'due south treatment.

The plan tin include such domains every bit level of intendance, acute safety needs, diagnosis, inability, strengths and skills, support network, and cultural context. Assessments should reoccur throughout treatment. Ongoing cess during treatment tin provide valuable data by revealing further details of trauma history every bit clients' trust in staff members grows and by gauging clients' progress.

Timing of Screening and Assessment

Every bit a trauma-informed counselor, y'all need to offering psychoeducation and back up from the get-go of service provision; this begins with explaining screening and cess and with proper pacing of the initial intake and evaluation process. The client should understand the screening process, why the specific questions are important, and that he or she may choose to delay a response or to not respond a question at all. Discussing the occurrence or consequences of traumatic events can feel equally unsafe and dangerous to the client equally if the event were reoccurring. Information technology is important non to encourage abstention of the topic or reinforce the belief that discussing trauma-related fabric is dangerous, but exist sensitive when gathering information in the initial screening. Initial questions well-nigh trauma should be full general and gradual. Taking the fourth dimension to prepare and explain the screening and assessment procedure to the client gives him or her a greater sense of control and prophylactic over the assessment process.

Clients with substance use disorders

No screening or cess of trauma should occur when the client is under the influence of alcohol or drugs. Clients under the influence are more likely to give inaccurate information. Although information technology'southward likely that clients in an active phase of utilise (admitting non at the assessment itself ) or undergoing substance withdrawal can provide consistent data to obtain a valid screening and assessment, there is bereft data to know for sure. Some theorists country that no last assessment of trauma or posttraumatic stress disorder (PTSD) should occur during these early phases (Read, Bollinger, & Sharkansky, 2003), asserting that symptoms of withdrawal can mimic PTSD and thus result in overdiagnosis of PTSD and other trauma-related disorders. Alcohol or drugs can also cause memory impairment that clouds the client'southward history of trauma symptoms. Notwithstanding, Najavits (2004) and others note that underdiagnosis, not overdiagnosis, of trauma and PTSD has been a pregnant issue in the substance abuse field and thus claim that it is essential to obtain an initial assessment early on, which can afterwards be modified if needed (e.g., if the client'southward symptom pattern changes). Indeed, clinical observations suggest that assessments for both trauma and PTSD— fifty-fifty during agile apply or withdrawal—announced robust (Coffey, Schumacher, Brady, & Dansky, 2003). Although some PTSD symptoms and trauma memories can exist dampened or increased to a degree, their overall presence or absence, as assessed early on in treatment, appears accurate (Najavits, 2004).

Carry Assessments Throughout Handling

Ongoing assessments permit counselors:

• Track changes in the presence, frequency, and intensity of symptoms.

• Larn the relationships among the customer's trauma, presenting psychological symptoms, and substance abuse.

• Adjust diagnoses and treatment plans as needed.

• Select prevention strategies to avert more than pervasive traumatic stress symptoms.

The Setting for Trauma Screening and Cess

Advances in the evolution of uncomplicated, cursory, and public-domain screening tools mean that at least a basic screening for trauma tin can be done in well-nigh whatever setting. Not only tin clients be screened and assessed in behavioral health handling settings; they can besides be evaluated in the criminal justice system, educational settings, occupational settings, physicians' offices, hospital medical and trauma units, and emergency rooms. Wherever they occur, trauma-related screenings and subsequent assessments can reduce or eliminate wasted resource, relapses, and, ultimately, treatment failures among clients who accept histories of trauma, mental affliction, and/or substance use disorders.

Creating an effective screening and cess environs

You can profoundly enhance the success of treatment by paying careful attention to how yous approach the screening and assessment process. Take into business relationship the following points:

• Clarify for the client what to expect in the screening and assessment process . For example, tell the client that the screening and assessment phase focuses on identifying issues that might do good from treatment. Inform him or her that during the trauma screening and cess process, uncomfortable thoughts and feelings can arise. Provide reassurance that, if they exercise, you lot'll assist in dealing with this distress—merely likewise permit them know that, even with your assistance, some psychological and physical reactions to the interview may concluding for a few hours or mayhap as long equally a few days after the interview, and be sure to highlight the fact that such reactions are normal (Read et al., 2003).

• Approach the client in a affair-of-fact, yet supportive, manner. Such an approach helps create an atmosphere of trust, respect, acceptance, and thoughtfulness (Melnick & Bassuk, 2000). Doing then helps to normalize symptoms and experiences generated by the trauma; consider informing clients that such events are common simply can crusade continued emotional distress if they are not treated. Clients may also notice it helpful for you to explain the purpose of certain difficult questions. For example, y'all could say, "Many people have experienced troubling events every bit children, so some of my questions are about whether yous experienced any such events while growing up." Demonstrate kindness and directness in equal measure when screening/assessing clients (Najavits, 2004).

• Respect the customer'southward personal space . Cultural and ethnic factors vary greatly regarding the appropriate physical distance to maintain during the interview. You should respect the client's personal infinite, sitting neither too far from nor likewise close to the client; allow your observations of the client'south comfort level during the screening and assessment procedure guide the amount of distance. Clients with trauma may have particular sensitivity nigh their bodies, personal infinite, and boundaries.

• Accommodate tone and volume of spoken communication to suit the client's level of engagement and caste of condolement in the interview process. Strive to maintain a soothing, quiet demeanor. Be sensitive to how the client might hear what you have to say in response to personal disclosures. Clients who have been traumatized may be more reactive even to benign or well-intended questions.

• Provide culturally appropriate symbols of rubber in the physical environment. These include paintings, posters, pottery, and other room decorations that symbolize the safety of the surroundings to the client population. Avoid culturally inappropriate or insensitive items in the physical environment.

• Be aware of ane'south ain emotional responses to hearing clients' trauma histories . Hearing about clients' traumas may be very painful and can elicit stiff emotions. The client may interpret your reaction to his or her revelations every bit disinterest, disgust for the client's behavior, or another inaccurate interpretation. Information technology is of import for you to monitor your interactions and to bank check in with the client as necessary. You may as well feel emotionally drained to the indicate that it interferes with your ability to accurately heed to or appraise clients. This upshot of exposure to traumatic stories, known as secondary traumatization, can result in symptoms similar to those experienced by the client (e.g., nightmares, emotional numbing); if necessary, refer to a colleague for assessment (Valent, 2002). Secondary traumatization is addressed in greater detail in Function two, Chapter 2, of this TIP.

• Overcome linguistic barriers via an interpreter. Deciding when to add an interpreter requires careful judgment. The interpreter should be knowledgeable of behavioral health terminology, exist familiar with the concepts and purposes of the interview and handling programming, be unknown to the client, and be part of the treatment team. Avert asking family members or friends of the client to serve as interpreters.

• Elicit merely the information necessary for determining a history of trauma and the possible existence and extent of traumatic stress symptoms and related disorders. At that place is no need to probe deeply into the details of a client's traumatic experiences at this stage in the handling process. Given the lack of a therapeutic relationship in which to process the information safely, pursuing details of trauma can cause retraumatization or produce a level of response that neither you lot nor your client is prepared to handle. Even if a customer wants to tell his or her trauma story, it's your job to serve as "gatekeeper" and preserve the customer's safety. Your tone of voice when suggesting postponement of a discussion of trauma is very important. Avoid carrying the message, "I actually don't desire to hear about information technology." Examples of appropriate statements are:

  –

  "Your life experiences are very important, but at this early betoken in our work together, we should start with what's going on in your life currently rather than discussing past experiences in particular. If you feel that certain past experiences are having a big effect on your life now, it would exist helpful for us to discuss them as long as we focus on your safe and recovery right now."

  –

  "Talking nearly your by at this signal could arouse intense feelings—even more than than you might be aware of correct now. Later, if y'all choose to, you can talk with your counselor most how to work on exploring your by."

  –

  "Frequently, people who have a history of trauma want to motion quickly into the details of the trauma to gain relief. I understand this desire, simply my business concern for y'all at this moment is to assistance y'all plant a sense of condom and back up before moving into the traumatic experiences. We want to avoid retraumatization—meaning, we desire to establish resources that weren't available to you at the time of the trauma before delving into more than content."

• Requite the client as much personal control as possible during the assessment by:

  –

  Presenting a rationale for the interview and its stress-inducing potential, making clear that the client has the right to refuse to answer whatever and all questions.

  –

  Giving the client (where staffing permits) the selection of being interviewed past someone of the gender with which he or she is nigh comfortable.

  –

  Postponing the interview if necessary (Fallot & Harris, 2001).

• Use self-administered, written checklists rather than interviews when possible to assess trauma. Traumas can evoke shame, guilt, acrimony, or other intense feelings that tin can make it difficult for the client to report them aloud to an interviewer. Clients are more likely to report trauma when they utilise cocky-administered screening tools; however, these types of screening instruments but guide the side by side pace. Interviews should coincide with self-administered tools to create a sense of condom for the client (someone is nowadays as he or she completes the screening) and to follow upward with more indepth data gathering after a self-administered screening is complete. The Trauma History Questionnaire (THQ) is a self-administered tool (Greenish, 1996). It has been used successfully with clinical and nonclinical populations, including medical patients, women who have experienced domestic violence, and people with serious mental disease (Hooper, Stockton, Krupnick, & Green, 2011). Screening instruments (including the THQ) are included in Appendix D of this TIP.

• Interview the client if he or she has trouble reading or writing or is otherwise unable to complete a checklist . Clients who are likely to minimize their trauma when using a checklist (e.g., those who exhibit meaning symptoms of dissociation or repression) do good from a clinical interview. A trained interviewer can elicit information that a self-administered checklist does not capture. Overall, using both a cocky-administered questionnaire and an interview can assist attain greater clarity and context.

• Allow time for the client to become calm and oriented to the present if he or she has very intense emotional responses when recalling or acknowledging a trauma . At such times, avoid responding with such exclamations as "I don't know how you lot survived that!" (Bernstein, 2000). If the client has difficulty self-soothing, guide him or her through grounding techniques (Exhibit 1.4-1), which are particularly useful—maybe even disquisitional—to achieving a successful interview when a client has dissociated or is experiencing intense feelings in response to screening and/or interview questions.

• Avoid phrases that imply judgment about the trauma. For example, don't say to a client who survived Hurricane Katrina and lost family members, "It was God'due south will," or "It was her time to pass," or "It was meant to be." Do not make assumptions well-nigh what a person has experienced. Rather, mind supportively without imposing personal views on the client's experience.

• Provide feedback nearly the results of the screening . Keep in heed the client's vulnerability, power to access resource, strengths, and coping strategies. Present results in a synthesized manner, avoiding complicated, overly scientific jargon or explanations. Allow time to process client reactions during the feedback session. Respond customer questions and concerns in a direct, honest, and compassionate manner. Failure to evangelize feedback in this way tin can negatively bear upon clients' psychological condition and severely weaken the potential for developing a therapeutic alliance with the customer.

• Be aware of the possible legal implications of assessment. Data you assemble during the screening and assessment procedure can necessitate mandatory reporting to regime, even when the client does non want such information disclosed (Najavits, 2004). For example, yous tin be required to report a client'south experience of kid abuse fifty-fifty if information technology happened many years agone or the customer doesn't want the data reported. Other legal issues tin can be quite complex, such every bit confidentiality of records, pursuing a case against a trauma perpetrator and divulging information to third parties while however protecting the legal status of data used in prosecution, and child custody issues (Najavits, 2004). It's essential that you know the laws in your State, have an practiced legal consultant available, and admission clinical supervision.

Exhibit 1.4-1

Grounding Techniques. Grounding techniques are important skills for assessors and all other behavioral health service providers who interact with traumatized clients (e.g., nurses, security, administrators, clinicians). Fifty-fifty if y'all do not direct behave (more than...)

Barriers and Challenges to Trauma-Informed Screening and Cess

Barriers

It is not necessarily like shooting fish in a barrel or obvious to place an individual who has survived trauma without screening. Moreover, some clients may deny that they have encountered trauma and its effects fifty-fifty afterwards being screened or asked direct questions aimed at identifying the occurrence of traumatic events. The two main barriers to the evaluation of trauma and its related disorders in behavioral health settings are clients non reporting trauma and providers overlooking trauma and its furnishings.

Apropos the starting time main barrier, some events will be experienced as traumatic by one person but considered nontraumatic by another. A history of trauma encompasses non only the feel of a potentially traumatic event, merely also the person'south responses to it and the meanings he or she attaches to the event. Certain situations make it more probable that the client will not exist forthcoming about traumatic events or his or her responses to those events. Some clients might not have ever thought of a particular consequence or their response to it every bit traumatic and thus might not study or even recall the event. Some clients might feel a reluctance to talk over something that they sense might bring up uncomfortable feelings (especially with a advisor whom they've merely recently met). Clients may avoid openly discussing traumatic events or have difficulty recognizing or articulating their feel of trauma for other reasons, such as feelings of shame, guilt, or fearfulness of retribution by others associated with the event (eastward.thousand., in cases of interpersonal or domestic violence). Still others may deny their history because they are tired of being interviewed or asked to fill up out forms and may believe it doesn't matter anyway.

Common Reasons Why Some Providers Avoid Screening Clients for Trauma

Treatment providers may avoid screening for traumatic events and trauma-related symptoms due to:

• A reluctance to enquire well-nigh traumatic events and symptoms because these questions are not a part of the counselor's or plan's standard intake procedures.

• Underestimation of the impact of trauma on clients' physical and mental health.

• A conventionalities that treatment of substance corruption issues needs to occur first and exclusively, earlier treating other behavioral health disorders.

• A belief that treatment should focus solely on presenting symptoms rather than exploring the potential origins or aggravators of symptoms.

• Non knowing how to reply therapeutically to a client's report of trauma.

• Fear that a probing trauma inquiry will exist besides agonizing to clients.

• Non using mutual linguistic communication with clients that will arm-twist a report of trauma (eastward.g., request clients if they were abused equally a child without describing what is meant by abuse).

• Business organisation that if disorders are identified, clients will require treatment that the counselor or program does not experience capable of providing (Fallot & Harris, 2001).

• Bereft time for assessment to explore trauma histories or symptoms.

• Untreated trauma-related symptoms of the counselor, other staff members, and administrators.

A client may not report past trauma for many reasons, including:

• Concern for condom (e.chiliad., fearing more abuse past a perpetrator for revealing the trauma).

• Fear of being judged by service providers.

• Shame about victimization.

• Reticence about talking with others in response to trauma.

• Not recalling past trauma through dissociation, denial, or repression (although 18-carat blockage of all trauma memory is rare amongst trauma survivors; McNally, 2003).

• Lack of trust in others, including behavioral health service providers.

• Not seeing a significant event as traumatic.

Regarding the 2nd major barrier, counselors and other behavioral health service providers may lack awareness that trauma can significantly affect clients' presentations in treatment and functioning across major life areas, such as relationships and work. In addition, some counselors may believe that their part is to care for only the presenting psychological and/or substance abuse symptoms, and thus they may not be as sensitive to histories and effects of trauma. Other providers may believe that a customer should abstain from alcohol and drugs for an extended period before exploring trauma symptoms. Possibly you fear that addressing a clients' trauma history will only exacerbate symptoms and complicate treatment. Behavioral wellness service providers who hold biases may assume that a customer doesn't have a history of trauma and thus fail to ask the "right" questions, or they may exist uncomfortable with emotions that arise from listening to customer experiences and, every bit a result, redirect the screening or counseling focus.

Challenges

Sensation of acculturation and language

Acculturation levels can affect screening and assessment results. Therefore, indepth discussions may be a more than advisable style to gain an agreement of trauma from the customer's bespeak of view. During the intake, prior to trauma screening, determine the client's history of migration, if applicable, and principal language. Questions nearly the client's land of birth, length of time in this land, events or reasons for migration, and ethnic cocky-identification are also advisable at intake. Also be aware that even individuals who speak English well might accept trouble understanding the subtleties of questions on standard screening and assessment tools. It is non adequate to translate items just from English into another language; words, idioms, and examples frequently don't interpret directly into other languages and therefore need to be adapted. Screening and cess should be conducted in the client's preferred language by trained staff members who speak the language or by professional person translators familiar with treatment jargon.

Common Assessment Myths

Several common myths contribute to underassessment of trauma-related disorders (Najavits, 2004):

• Myth #1: Substance abuse itself is a trauma. However devastating substance abuse is, it does not meet the Diagnostic and Statistical Transmission of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), criteria for trauma per se. Yet, high-risk behaviors that are more than probable to occur during habit, such as interpersonal violence and self-harm, significantly increase the potential for traumatic injury.

• Myth #ii: Assessment of trauma is enough. Thorough cess is the best manner to identify the existence and extent of trauma-related problems. However, simply identifying trauma-related symptoms and disorders is just the beginning stride. Too needed are individualized handling protocols and activity to implement these protocols.

• Myth #3: It is best to wait until the customer has concluded substance apply and withdrawal to assess for PTSD. Inquiry does not provide a articulate answer to the controversial question of when to appraise for PTSD; nevertheless, Najavits (2004) and others annotation that underdiagnosis of trauma and PTSD has been more than significant in the substance abuse field than overdiagnosis. Clinical experience shows that the PTSD diagnosis is rather stable during substance use or withdrawal, but symptoms tin go more or less intense; retention damage from booze or drugs can also cloud the symptom picture. Thus, it is advisable to found a tentative diagnosis and and then reassess afterwards a period of abstinence, if possible.

Awareness of co-occurring diagnoses

A trauma-informed assessor looks for psychological symptoms that are associated with trauma or simply occur alongside information technology. Symptom screening involves questions about past or present mental disorder symptoms that may betoken the need for a full mental health assessment. A variety of screening tools are bachelor, including symptom checklists.

However, you should only apply symptom checklists when you lot need data about how your client is currently feeling; don't utilize them to screen for specific disorders. Responses will probable change from one administration of the checklist to the next.

Basic mental wellness screening tools are bachelor. For example, the Mental Health Screening Form-III screens for present or past symptoms of well-nigh mental disorders (Carroll & McGinley, 2001); it is available at no accuse from Project Render Foundation, Inc. and is likewise reproduced in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT, 2005c). Other screening tools, such as the Beck Depression Inventory II and the Brook Feet Inventory (Beck, Wright, Newman, & Liese, 1993), likewise screen broadly for mental and substance use disorders, likewise as for specific disorders often associated with trauma. For further screening data and resources on depression and suicide, see TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early on Recovery (CSAT, 2008), and TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Corruption Treatment (CSAT, 2009a).

For screening substance use disorders, run into TIP 11, Uncomplicated Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT, 1994); TIP 24, A Guide to Substance Corruption Services for Master Care Clinicians (CSAT, 1997a); TIP 31, Screening and Assessing Adolescents for Substance Utilize Disorders (CSAT, 1999c); TIP 42, Substance Abuse Handling for Persons With Co-Occurring Disorders (CSAT, 2005c); and TIP 51, Substance Corruption Treatment: Addressing the Specific Needs of Women (CSAT, 2009d).

A common dilemma in the assessment of trauma-related disorders is that certain trauma symptoms are as well symptoms of other disorders. Clients with histories of trauma typically present a variety of symptoms; thus, information technology is of import to determine the full scope of symptoms and/or disorders present to help improve treatment planning. Clients with trauma-related and substance use symptoms and disorders are at increased risk for additional Centrality I and/or Axis 2 mental disorders (Brady, Killeen, Saladin, Dansky, & Becker, 1994; Cottler, Nishith, & Compton, 2001). These symptoms need to be distinguished so that other presenting subclinical features or disorders do not go unidentified and untreated. To accomplish this, a comprehensive cess of the client's mental health is recommended.

Misdiagnosis and underdiagnosis

Many trauma survivors are either misdiagnosed (i.e., given diagnoses that are not accurate) or underdiagnosed (i.e., have one or more than diagnoses that have not been identified at all). Such diagnostic errors could consequence, in part, from the fact that many general instruments to evaluate mental disorders are not sufficiently sensitive to identify posttraumatic symptoms and tin misclassify them as other disorders, including personality disorders or psychoses. Intrusive posttraumatic symptoms, for example, can prove up on general measures as indicative of hallucinations or obsessions. Dissociative symptoms tin can be interpreted as indicative of schizophrenia. Trauma-based cognitive symptoms tin can be scored as evidence for paranoia or other delusional processes (Briere, 1997). Some of the near common misdiagnoses in clients with PTSD and substance abuse are:

• Mood and feet disorders. Overlapping symptoms with such disorders as major depression, generalized anxiety disorder, and bipolar disorder can pb to misdiagnosis.

• Borderline personality disorder. Historically, this has been more than frequently diagnosed than PTSD. Many of the symptoms, including a blueprint of intense interpersonal relationships, impulsivity, rapid and unpredictable mood swings, power struggles in the treatment environment, underlying anxiety and depressive symptoms, and transient, stress-related paranoid ideation or astringent dissociative symptoms overlap. The effect of this misdiagnosis on treatment can be especially negative; counselors ofttimes view clients with a deadline personality diagnosis equally difficult to treat and unresponsive to treatment.

• Antisocial personality disorder. For men and women who accept been traumatized in childhood, "acting out" behaviors, a lack of empathy and conscience, impulsivity, and self-centeredness tin can be functions of trauma and survival skills rather than true antisocial characteristics.

• Attending arrears hyperactivity disorder (ADHD). For children and adolescents, impulsive behaviors and concentration problems tin be diagnosed every bit ADHD rather than PTSD.

It is possible, however, for clients to legitimately have whatever of these disorders in add-on to trauma-related disorders. Given the overlap of posttraumatic symptoms with those of other disorders, a wide diversity of diagnoses often needs to be considered to avert misidentifying other disorders every bit PTSD and vice versa. A trained and experienced mental health professional will be required to counterbalance differential diagnoses. TIP 42 (CSAT, 2005c) explores issues related to differential diagnosis.

Cross-Cultural Screening and Assessment

Many trauma-related symptoms and disorders are culture specific, and a customer'south cultural background must be considered in screening and assessment (for review of assessment and cultural considerations when working with trauma, see Wilson & Tang, 2007). Behavioral health service providers must arroyo screening and assessment processes with the influences of culture, ethnicity, and race firmly in mind. Cultural factors, such as norms for expressing psychological distress, defining trauma, and seeking help in dealing with trauma, can affect:

• How traumas are experienced.

• The meaning assigned to the event(southward).

• How trauma-related symptoms are expressed (eastward.g., as somatic expressions of distress, level of emotionality, types of avoidant behavior).

• Willingness to express distress or identify trauma with a behavioral health service provider and sense of rubber in doing so.

• Whether a specific blueprint of behavior, emotional expression, or cognitive process is considered abnormal.

• Willingness to seek treatment within and outside of one's ain culture.

• Response to handling.

• Treatment outcome.

When selecting assessment instruments, counselors and administrators need to choose, whenever possible, instruments that are culturally advisable for the client. Instruments that have been normed for, adapted to, and tested on specific cultural and linguistic groups should exist used. Instruments that are not normed for the population are likely to contain cultural biases and produce misleading results. Subsequently, this can pb to misdiagnosis, overdiagnosis, inappropriate treatment plans, and ineffective interventions. Thus, it is important to interpret all exam results charily and to discuss the limitations of instruments with clients from diverse ethnic populations and cultures. For a review of cross-cultural screening and assessment considerations, refer to the planned TIP, Improving Cultural Competence (Substance Abuse and Mental Health Services Administration, planned c).

Civilization-Specific Stress Responses

Culture-jump concepts of distress exist that don't necessarily match diagnostic criteria. Culture-specific symptoms and syndromes tin can involve physical complaints, broad emotional reactions, or specific cognitive features. Many such syndromes are unique to a specific culture but can broaden to cultures that take similar beliefs or characteristics. Civilization-spring syndromes are typically treated by traditional medicine and are known throughout the culture. Cultural concepts of distress include:

• Ataques de nervios . Recognized in Latin America and among individuals of Latino descent, the master features of this syndrome include intense emotional upset (eastward.g., shouting, crying, trembling, dissociative or seizure-like episodes). It frequently occurs in response to a traumatic or stressful event in the family unit.

• Nervios . This is considered a common idiom of distress among Latinos; it includes a wide range of emotional distress symptoms including headaches, nervousness, tearfulness, stomach discomfort, difficulty sleeping, and dizziness. Symptoms can vary widely in intensity, as tin impairment from them. This frequently occurs in response to stressful or difficult life events.

• Susto . This term, pregnant "fear," refers to a concept found in Latin American cultures, just information technology is not recognized among Latinos from the Caribbean. Susto is attributed to a traumatic or frightening event that causes the soul to leave the trunk, thus resulting in disease and unhappiness; extreme cases may event in death. Symptoms include appetite or sleep disturbances, sadness, lack of motivation, low self-esteem, and somatic symptoms.

• Taijin kyofusho . Recognized in Nihon and amongst some American Japanese, this "interpersonal fear" syndrome is characterized by anxiety about and avoidance of interpersonal circumstances. The individual presents worry or a conviction that his or her appearance or social interactions are inadequate or offensive. Other cultures take like cultural descriptions or syndromes associated with social anxiety.

Sources: APA, 2013, pp. 833–837; Briere & Scott, 2006b.

Choosing Instruments

Numerous instruments screen for trauma history, point symptoms, appraise trauma-related and other mental disorders, and place related clinical phenomena, such equally dissociation. One instrument is unlikely to encounter all screening or assessment needs or to determine the existence and full extent of trauma symptoms and traumatic experiences. The following sections present full general considerations in selecting standardized instruments.

Purpose

Define your assessment needs. Do yous demand a standardized screening or assessment instrument for clinical purposes? Practice you lot need information on a specific aspect of trauma, such equally history, PTSD, or dissociation? Do you wish to make a formal diagnosis, such as PTSD? Do you demand to decide speedily whether a client has experienced a trauma? Do you want an cess that requires a clinician to administer information technology, or tin the client complete the instrument himself or herself? Does the instrument match the current and specific diagnostic criteria established in the DSM-5?

Population

Consider the population to be assessed (east.1000., women, children, adolescents, refugees, disaster survivors, survivors of physical or sexual violence, survivors of combat-related trauma, people whose native language is not English); some tools are appropriate only for certain populations. Is the assessment process developmentally and culturally appropriate for your client? Exhibit 1.four-2 lists considerations in choosing a screening or assessment musical instrument for trauma and/or PTSD.

Exhibit i.4-2

Fundamental Areas of Trauma Screening and Assessment. Key question: Did the client experience a trauma? Examples of measures: Life Stressor Checklist-Revised (Wolfe & Kimerling, 1997); Trauma History Questionnaire (Dark-green, 1996); Traumatic Life Events (more...)

Instrument Quality

An instrument should exist psychometrically acceptable in terms of sensitivity and specificity or reliability and validity as measured in several means under varying conditions. Published research offers data on an instrument'southward psychometric properties every bit well as its utility in both research and clinical settings. For farther information on a number of widely used trauma evaluation tools, see Appendix D and Antony, Orsillo, and Roemer's newspaper (2001).

The DSM-5 and Updates to Screening and Assessment Instruments

The recent publication of the DSM-5 (APA, 2013a) reflects changes to certain diagnostic criteria, which volition affect screening tools and criteria for trauma-related disorders. Criterion A2 (specific to traumatic stress disorders, acute stress, and posttraumatic stress disorders), included in the 4th edition (text revision) of the DSM (DSM-4-TR; APA, 2000a), has been eliminated; this criterion stated that the individual's response to the trauma needs to involve intense fear, helplessness, or horror. At that place are now four cluster symptoms, not iii: reexperiencing, avoidance, arousal, and persistent negative alterations in cognitions and mood. Changes to the DSM-five were made to symptoms inside each cluster. Thus, screening volition need modification to adjust to this alter (APA, 2012b).

Practical Problems

Is the instrument freely and readily available, or is there a fee? Is costly and extensive grooming required to administer information technology? Is the instrument too lengthy to exist used in the clinical setting? Is information technology hands administered and scored with accompanying manuals and/or other grooming materials? How will results exist presented to or used with the client? Is technical support available for difficulties in administration, scoring, or interpretation of results? Is special equipment required such every bit a microphone, a video camera, or a bear upon-screen figurer with audio?

Trauma-Informed Screening and Assessment

The post-obit sections focus on initial screening. For more information on screening and assessment tools, including structured interviews, see Showroom i.4-2. Screening is only as good as the actions taken afterward to address a positive screen (when clients acknowledge that they feel symptoms or accept encountered events highlighted inside the screening). Once a screening is consummate and a positive screen is acquired, the customer so needs referral for a more than indepth assessment to ensure development of an appropriate handling plan that matches his or her presenting bug.

Establish a History of Trauma

A person cannot take ASD, PTSD, or any trauma-related symptoms without experiencing trauma; therefore, it is necessary to inquire almost painful, difficult, or overwhelming past experiences. Initial information should be gathered in a style that is minimally intrusive notwithstanding clear. Brief questionnaires can exist less threatening to a client than face up-to-face interviews, simply interviews should be an integral function of whatever screening and assessment procedure.

If the client initially denies a history of trauma (or minimizes it), administrate the questionnaire later or delay additional trauma-related questions until the customer has perhaps developed more trust in the treatment setting and feels safer with the thoughts and emotions that might arise in discussing his or her trauma experiences.

The Stressful Life Experiences (SLE) screen (Exhibit 1.iv-3) is a checklist of traumas that too considers the client'south view of the bear upon of those events on life functioning. Using the SLE tin can foster the client–counselor relationship. By going over the answers with the client, you can gain a deep understanding of your client, and the customer receives a demonstration of your sensitivity and business for what the customer has experienced. The National Centre for PTSD Web site offers similar instruments (http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp).

Exhibit 1.iv-3

SLE Screening. Please fill up in the number that best represents how much the post-obit statements depict your experiences. You volition need to use two scales, 1 for how well the statement describes your experiences and one for how stressful you lot found this (more...)

In addition to broad screening tools that capture various traumatic experiences and symptoms, other screening tools, such as the Combat Exposure Scale (Keane et al., 1989) and the Intimate Partner Violence Screening Tool (Exhibit ane.4-4), focus on acknowledging a specific type of traumatic upshot.

Exhibit 1.iv-four

STaT Intimate Partner Violence Screening Tool. Accept you ever been in a relationship where your partner has pushed or Slapped you? Have you ever been in a relationship where your partner Threatened you with violence?

Screen for Trauma-Related Symptoms and Disorders in Clients With Histories of Trauma

This stride evaluates whether the customer's trauma resulted in subclinical or diagnosable disorders. The counselor can enquire such questions as, "Take you received any counseling or therapy? Have you ever been diagnosed or treated for a psychological disorder in the past? Have you ever been prescribed medications for your emotions in the by?" Screening is typically conducted past a wide variety of behavioral wellness service providers with different levels of preparation and teaching; however, all individuals who administrate screenings, regardless of instruction level and feel, should be enlightened of trauma-related symptoms, grounding techniques, ways of creating safety for the customer, proper methods for introducing screening tools, and the protocol to follow when a positive screen is obtained. (See Appendix D for information on specific instruments.) Exhibit 1.4-v is an instance of a screening instrument for trauma symptoms, the Primary Care PTSD (PC-PTSD) Screen. Electric current research (Prins et al., 2004) suggests that the optimal cutoff score for the PC-PTSD is 3. If sensitivity is of greater concern than efficiency, a cutoff score of 2 is recommended.

Showroom 1.iv-v

PC-PTSD Screen. In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you… Have had nightmares about it or thought about information technology when you did not want to?

Another musical instrument that can screen for traumatic stress symptoms is the iv-item self-report Bridge, summarized in Showroom 1.four-6, which is derived from the 17-item Davidson Trauma Scale (DTS). Span is an acronym for the four items the screening addresses: startle, physiological arousal, anger, and numbness. It was developed using a small, various sample of developed patients (N=243; 72 percent women; 17.four percentage African American; average age = 37 years) participating in several clinical studies, including a family study of rape trauma, combat veterans, and Hurricane Andrew survivors, among others.

Exhibit one.four-six

The Bridge. The SPAN instrument is a brief screening tool that asks clients to identify the trauma in their by that is near disturbing to them currently. It then poses four questions that ask clients to rate the frequency and severity with which they (more...)

The Bridge has a high diagnostic accuracy of 0.80 to 0.88, with sensitivity (pct of truthful positive instances) of 0.84 and specificity (percentage of true negative instances) of 0.91 (Meltzer-Brody, Churchill, & Davidson, 1999). SPAN scores correlated highly with the total DTS (r = 0.96) and other measures, such as the Impact of Events Scale (r = 0.85) and the Sheehan Disability Scale (r = 0.87).

The PTSD Checklist (Exhibit 1.four-7), adult by the National Center for PTSD, is in the public domain. Originally developed for combat veterans of the Vietnam and Western farsi Gulf Wars, it has since been validated on a diversity of noncombat traumas (Keane, Brief, Pratt, & Miller, 2007). When using the checklist, identify a specific trauma first and and then have the client answer questions in relation to that ane specific trauma.

Exhibit 1.4-7

The PTSD Checklist. Instructions to Client: Below is a list of bug and complaints that people sometimes have in response to stressful experiences. Delight read each one carefully and circle the number that indicates how much yous take been bothered (more...)

Other Screening and Resilience Measures

Forth with identifying the presence of trauma-related symptoms that warrant cess to decide the severity of symptoms as well as whether or not the individual possesses subclinical symptoms or has met criteria for a trauma-related disorder, clients should receive other screenings for symptoms associated with trauma (e.g., depression, suicidality). Information technology is important that screenings accost both external and internal resource (e.g., support systems, strengths, coping styles). Knowing the client'south strengths tin can significantly shape the handling planning process by allowing you to use strategies that accept already worked for the customer and incorporating strategies to build resilience (Exhibit i.iv-eight).

Exhibit one.4-8

Resilience Scales. A number of scales with good psychometric backdrop measure out resilience: Resilience Scale (Wagnild & Young, 1993)

Preliminary research shows comeback of individual resilience through treatment interventions in other populations (Lavretsky, Siddarth, & Irwin, 2010).

Screen for suicidality

All clients—particularly those who have experienced trauma—should exist screened for suicidality by asking, "In the by, have yous e'er had suicidal thoughts, had intention to commit suicide, or fabricated a suicide effort? Practice you lot take any of those feelings now? Have y'all had any such feelings recently?" Behavioral health service providers should receive training to screen for suicide. Additionally, clients with substance utilize disorders and a history of psychological trauma are at heightened risk for suicidal thoughts and behaviors; thus, screening for suicidality is indicated. See TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT, 2009a). For additional descriptions of screening processes for suicidality, see TIP 42 (CSAT, 2005c).

Last Note

Screenings are merely beneficial if there are follow-up procedures and resources for handling positive screens, such equally the ability to review results with and provide feedback to the private after the screening, sufficient resources to consummate a thorough assessment or to brand an appropriate referral for an assessment, treatment planning processes that tin easily comprise additional trauma-informed care objectives and goals, and availability and access to trauma-specific services that friction match the customer's needs. Screening is only the kickoff step!

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Source: https://www.ncbi.nlm.nih.gov/books/NBK207188/

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