16 Principles for Trauma Informed Assessment and Treatment
~ Promote Trauma awareness and understanding
~ Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences
~ View Trauma in the Context of Individuals’ Environments
~ Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics
~ Create a Safe Environment
~ Identify Recovery From Trauma as a Primary Goal
~ Support Control, Choice, and Autonomy
~ Create Collaborative Relationships and Participation Opportunities
~ Familiarize the Client With Trauma-Informed Services
~ Incorporate Universal Routine Screenings for Trauma
~ View Trauma Through a Sociocultural Lens
~ Use a Strengths-Focused Perspective: Promote Resilience
~ Foster Trauma-Resistant Skills
~ Demonstrate Organizational and Administrative Commitment to TIC
~ Develop Strategies To Address Secondary Trauma and Promote Self-Care
~ Provide Hope—Recovery Is Possible
~ The most important domains to screen among individuals with trauma histories include:
~ Trauma-related symptoms.
~ Depressive or dissociative or intrusive symptoms, sleep disturbances
~ Past and present mental disorders
~ Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat experiences).
~ Substance abuse.
~ Social support and coping styles.
~ Availability of resources.
~ Risks for self-harm, suicide, and violence.
~ Health screenings.
Advice About Screening
Discussing the occurrence or consequences of traumatic events can feel as unsafe and dangerous to the client as if the event were reoccurring. Don’t encourage avoidance of the topic or reinforce the belief that discussing trauma-related material is dangerous. Initial questions about trauma should be general and gradual. Ask all clients about any history of trauma; use a checklist to increase proper identification of such a history. By going over the answers with the client, you can gain a deep understanding of your client. Do not require clients to describe emotionally overwhelming traumatic events in detail. Focus assessment on how trauma symptoms affect clients’ current functioning. Talk about how you will use the findings to plan the client’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 have used in the past that have worked to relieve strong emotions. Finally, make sure the client is grounded and safe before leaving. Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment, what the client’s plan is for maintaining personal safety, and what the client’s plans are for the rest of the day.
~ Elicit only the information necessary for determining a history of trauma and the possible existence and extent of traumatic stress symptoms and related disorders.
~ Even if a client wants to tell his or her trauma story, it’s your job to serve as “gatekeeper” and preserve the client’s safety.
~ Your tone of voice when suggesting postponement of a discussion of trauma is very important. Avoid conveying the message, “I really don’t want to hear about it.”
~ Ask the client to state what he or she observes.
~ Guide the client through this exercise by using statements like, “You seem to feel very scared/angry right now. You’re probably feeling things related to what happened in the past. Now, you’re in a safe situation. Let’s try to stay in the present. Take a slow deep breath, relax your shoulders, put your feet on the floor; let’s talk about what day and time it is, notice what’s on the wall, etc. What else can you do to feel okay in your body right now?”
~ Help the client decrease the intensity of affect.
~ “Emotion dial”: Imagine turning down the volume of your emotions.
~ Clenching fists can move the energy of an emotion into fists, which the client can then release.
~ Guided imagery can be used to visualize a safe place.
~ Use strengths-based questions (e.g., “How did you survive?” or “What strengths did you possess to survive the trauma?”).
~ Distract the client from unbearable emotional states.
~ Have the client focus on the external environment (e.g., name red objects in the room, identify 5 things you see).
~ Ask the client to focus on recent and future events (e.g., “to do” list)
~ Help the client use self-talk to remind himself or herself of current safety.
~ Use distractions, such as counting, to return the focus to current reality.
~ Somatosensory techniques (toe-wiggling, touching a chair)
~ Ask the client to use breathing techniques.
~ Ask the client to inhale through the nose and exhale through the mouth.
~ Have the client place his or her hands on his or her abdomen and then watch the hands go up and down while the belly expands and contracts.
~ A history of trauma encompasses the experience of a potentially traumatic event, the person’s responses to it and the meanings attached to it.
Why Clients Fail To Report
~ Concern for safety (e.g., fearing more abuse for revealing the trauma)
~ Fear of being judged
~ Shame about victimization.
~ Reticence about talking with others in response to trauma.
~ Not recalling past trauma through dissociation, denial, or repression
~ Blockage of all trauma memory is rare among trauma survivors
~ Lack of trust in others
~ Not seeing a significant event as traumatic.
~ Feeling a reluctance to discuss something that might bring up uncomfortable feelings
~ Being tired of being interviewed or asked to fill out forms and may believe it doesn’t matter anyway.
Reasons Treatment Providers Avoid Screening For Trauma
~ A reluctance to inquire about traumatic events and symptoms because these questions are not a part of the counselor’s or program’s standard intake procedures.
~ Underestimation of the impact of trauma on clients’ physical and mental health.
~ A belief that treatment should focus solely on presenting symptoms rather than exploring the potential origins or aggravators of symptoms.
~ A lack of training and/or feelings of incompetence in effectively treating trauma-related problems
~ Not knowing how to respond therapeutically to a client’s report of trauma.
~ Fear that a probing trauma inquiry will be too disturbing to clients.
~ Not using common language with clients that will elicit a report of trauma (e.g., asking clients if they were abused as a child without describing what is meant by abuse).
~ Concern that if disorders are identified, clients will require treatment that the counselor or program does not feel capable of providing.
~ Insufficient time for assessment to explore trauma histories or symptoms.
~ Untreated trauma-related symptoms of the counselor, other staff members, and administrators.
Misdiagnosis and Underdiagnosis
It is important to use only validated instruments for screening and assessment. General instruments to evaluate mental disorders are not sufficiently sensitive to differentiate posttraumatic symptoms and can misclassify them as other disorders
Intrusive posttraumatic symptoms can show up on general measures as indicative of hallucinations or obsessions.
Dissociative symptoms can be interpreted as indicative of schizophrenia.
Trauma-based cognitive symptoms can be scored as evidence for paranoia or other delusional processes
Mood and anxiety disorders. Overlapping symptoms with such disorders as major depression, generalized anxiety disorder, and bipolar disorder can lead to misdiagnosis.
Attention deficit hyperactivity disorder (ADHD).
Impulsive behaviors and concentration problems can be diagnosed as ADHD rather than PTSD.
TO more effectively differentially diagnose, examine the function and triggers of the behaviors.
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(s).
~ How trauma-related symptoms are expressed (e.g., as somatic distress, level of emotionality, types of avoidant behavior).
~ Willingness to express distress or identify trauma with a behavioral health service provider and sense of safety in doing so.
~ Whether a specific pattern of behavior, emotional expression, or cognitive process is considered abnormal.
~ Willingness to seek treatment inside and outside of one’s own culture.
~ Response to treatment.
~ Treatment outcome.
Trauma impacts all aspects of life. It is important to create a safe space for assessment and to educate clients about what trauma is and how it might impact them. Trauma informed care is attentive to events which may have been experienced as traumatic and takes care not to retraumatize individuals.