How often should you conduct trauma screening with behavioral health clients? Nearly every agency will ask about trauma during the initial assessment. Often, the standard question goes something like, “have you ever experienced a traumatic event?” At best, we may ask more specifically about a history of physical, sexual or emotional abuse.
Of course those standard trauma questions are normally asked by a virtual stranger in one of the first appointments at an agency. Not surprisingly, we rarely get good information about trauma when clients start treatment.
When I first started asking existing clients about trauma in more detail, I was shocked by the number and severity of traumatic experiences reported. I checked their initial assessments and often found little evidence of reported trauma. When I started asking new clients the exact same questions, I was equally shocked at the lack of response.
So what’s the lesson? Screening for trauma at the initiation of treatment is not enough. Most clients aren’t willing to trust us with that type of information until they know we care and have the skills to help. Some may not even recognize events as traumatic until they’ve had some treatment and education.
I’ve had many clients tell me their childhood was “normal” only later to find out about awful accounts of abuse and neglect. I’ve also heard some say the beatings were “deserved” or that they “had it coming”. Again, the lesson is that we need to screen for trauma at intake and then follow-up at regular intervals for new information.
There are a variety of tools available for screening and assessment of trauma, probably many more than I’m familiar with. The one I’ve had the most experience with is the PTSD Checklist (PCL) that comes in a Military (PCL-M), Civilian (PCL-C) and Specific (PCL-S) version.
The PCL is not only useful as an initial screening instrument for PTSD, it is also used to track progress through treatment. It’s a 17-item, self report measure of the DSM-IV diagnostic criteria that’s pretty easy to administer and score. The National Center for PTSD is working on updated version for the DSM 5.
The Clinician Administered PTSD Scale (CAPS) is called the gold standard in PTSD assessment. It is a 30-item structured interview that also corresponds with the DSM-IV. It requires more clinical time than the PCL and like the PCL, is being revised for the DSM 5.
My primary complaint about instruments like the PCL and CAPS is that they only measure the diagnostic criteria of PTSD. Those of us who work in the trenches understand that trauma can manifest in any number of ways not necessarily reflected by the PTSD criteria.
The Trauma History Screen (THS) includes 13 self-report items with yes/no responses to specific questions about potentially traumatic events such as crimes, natural disasters, physical and sexual abuse. For any affirmative response, there are additional questions to determine the number of times the event occurred as well as additional details about the event.
Although not integrated into a standardized screening instrument, the 10 categories from the Adverse Childhood Experiences studies provide a valuable framework for assessing other life events. Witnessing domestic violence, an alcoholic or drug addicted parent, or having an incarcerated parent are just a few events that might be missed by most standard trauma screens.
This is where being trauma-informed plays such an important role in quality therapy. It’s critical to know what type of events can affect development and what signs to look for outside of the standard PTSD criteria.
In Oklahoma, the State Department of Mental Health and Substance Abuse Services is considering requiring some form of standardized trauma screening instrument at intake and then again at each service plan update. I’d love to hear from others regarding how frequently you screen for trauma and what techniques or instruments you are using with both adults and children.
7 thoughts on “Trauma Screening: Ask Early and Ask Often”
I totally agree, it does take an element of trust to share traumatic events from your life. Also, the reason for receiving the counseling
Has to be considered. Requesting
Help and having it court ordered makes a big difference. Interesting article keep me on the list
Of course I work a lot with court ordered people and it is certainly a challenge to develop the trust needed to actually engage in therapy…it’s not impossible but it is a challenge.
I also agree that this is an area requiring a trauma informed sensitivity. By that I mean that we need our attention completely open to the possibility so we may register/recognise subtle clues in the counselling sessions. It is difficult to put this as a generalisation as we can still miss it. I also agree that every peron’s responses are varied and do not necessarily fit into the diagnostic framework.
I am interested in how people understand anxiety and what triggers high levels. I find that a lot of people won’t admit to experiencing anxiety, usually based on the belief that it is a sign of a weakness such as a phobia, panics or OCD like behaviours. After I define anxiety then stressing and highlight the difference they may talk more openly about their experience.
In that discussion derealisation, dissociation may be alluded to. I am interested in the numbing and altered sensation. Each of these are suggestive of a more serious problem. I often ask how they feel about these events in a curious exploratory way. I reflect the motion that I observe and develop the connection.
Please realise that I don’t believe there is my value asking the person to relate their painful story. They will open it to discussion when thy have developed their trust in you. I have no expectation that they will tell at any time. I believe that all such discussions do is
re-traumatise the person. Remember the ethical principal of do no harm as it applies here.
I have seen some clients display tremendous relief from the process of discussing the events so I don’t think the discussion always causes re-traumatization. I really think it depends on the client. I also believe that avoidance is one of the things that keeps PTSD from resolving. I know prolonged exposure therapy has shown some promise but I’m personally not comfortable putting people through that process. Using CPT, the trauma recount can have a powerful cathartic effect but I’ve also used the CPT-C format for clients that didn’t seem appropriate for standard CPT. Again, I think it should be assessed on a case by case basis.
I agree to ask often! I usually get trauma history when I’m takin family info! Don’t think lengthy questionnaires are very helpful in the beginning! Most people want to check u out and tell their story!
As a state contracted provider, we have a number of “lengthy forms” that are required by the state. I was discussing with a group last week about how those forms, though well intended, have become so cumbersome that we don’t really use them as intended and only complete them because we have to. It’s a challenge that I’m sure all providers face when trying to meet documentation requirements of outside authorities.
At our facility we ask at preadmission and assessment about trauma and use all information collected to infer about any trauma, grief/loss, SI/HI, etc. I’m trying to help clinicians I supervise to think out of the box and think if a client reports growing up with a father diagnosed with Schizophrenia to think if that was unsettling or at times scary (traumatic). I feel we could do a better job at ensuring we assess again at treatment plan updates and plan to look at how to incorporate that better.
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