by Dr. Julianne Ludlam
Do you have clients who you believe are struggling with traumatic backgrounds? Do you wonder if your clients’ past stressful experiences affect their present behaviors, whether or not they have psychiatric diagnoses or see their own pasts as relevant? If a client has a diagnosis, are you concerned that his or her trauma history was not taken into account? Alternatively, if a client comes to you with a clearly identified trauma, how is that client best assessed and treated? Trauma-informed evaluations can clarify these types of questions, and because they are empirically grounded, their detailed information about a client’s psychological functioning is likely to have probative value in legal proceedings (Evans & Hass, 2018).
The complex problem of trauma
Psychological trauma is often so devastating that it is difficult to imagine it could be neglected, ignored, or misdiagnosed. However, individuals with trauma histories can present in complex and confusing ways, from a straightforward case with a single stressor and clear symptoms, to a complex case with a lengthy history and hidden suffering (Evans & Hass, 2018). A client’s presentation can be complicated further when there are multiple traumatic experiences, co-occurring psychosocial problems, co-morbid disorders, or racial, cultural, and gender issues. The possibility of malingering in forensic evaluations also requires careful attention, particularly as rates of malingered Posttraumatic Stress Disorder (PTSD) vary widely and are considered imprecise (Young, 2017).
Many individuals have faced trauma in their lives, but diagnosable trauma-linked disorders like PTSD do not always follow a traumatic experience. Epidemiological studies show that approximately 70% of all adults have been exposed to at least one traumatic event in their lifetimes, making traumatic stressors fairly common (Young, 2017). However, specific disorders linked to trauma are much less common; traumatic reactions that rise to the level of a diagnosable disorder (like PTSD) occur in approximately 10% of cases (Young, 2017).
Higher rates of trauma and trauma-linked disorders are found in certain populations and circumstances, particularly in forensic settings involving issues such as child welfare, custody disputes, or criminal investigations. For example, approximately 90% of parents or caregivers involved in the child welfare system have histories of trauma exposure, including high rates of childhood abuse and neglect (National Child Traumatic Stress Network, 2017). With more trauma exposure, the rate of diagnosable trauma-related disorders increases. Groups disproportionately affected by poverty, discrimination, abuse, and other forms of adversity face rates of diagnosable trauma reactions greater than the broad, population-level statistic of 10%. For example, 30-45% of women who have experienced rape may meet criteria for PTSD (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), and men who have experienced combat have shown a rate of approximately 39% (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).
It's Not Always About PTSD
Although disorders like PTSD are considered synonymous with trauma, a history of trauma can lead to a variety of other psychological disorders and physical problems – issues that are not always considered unless a careful assessment is conducted.
As was abundantly shown in the Adverse Childhood Experiences (ACE) studies, there appears to be a direct link between childhood trauma and a myriad of negative outcomes (Felitti et al., 1998; Felitti et al., 2018; Gilbert et al., 2010). These negative outcomes include an increased risk for psychiatric conditions (including depression, anxiety disorders, bipolar disorder and schizophrenia, addictive disorders, eating disorders, dissociative disorders, and personality disorders) as well as chronic diseases and health problems (including chronic bronchitis, hepatitis, skeletal fractures, heart disease, cancer, and lung disease).
Adverse childhood experiences were also linked to problematic health-related behaviors starting in childhood and adolescence, including smoking, sexual activity, drug use, adolescent pregnancy, and suicide attempts.
The ACE Studies have demonstrated clear evidence of a dose-response model – the more adverse experiences, the higher the likelihood of negative outcomes (Felitti et al., 1998; Felitti et al., 2018; Edwards, Holden, Anda, & Felitti, 2003), and this direct relationship has been shown for all types of trauma (e.g., Follette, Polusney, Bechtle, & Naugle, 1996).
What Is Trauma-Informed Psychological Evaluation?
Trauma-informed psychological evaluations (also referred to as trauma-informed mental health assessments) can address the complexities of misdiagnosed or unrecognized trauma, disproportionate adverse experiences, and other possible psychological and physical impacts.
A trauma-informed evaluation is a comprehensive process conducted by a trained clinician to determine whether clinical symptoms related to traumatic stress are present and to characterize the severity of symptoms and impact on an individual’s functioning (Conradi, Wherry, & Kisiel, 2011; National Child Traumatic Stress Network, n.d.). Like all comprehensive psychological evaluations, multiple domains are assessed, including broader mental health symptoms, individual/family needs or difficulties, environmental or psychosocial issues, and resources and strengths, but there is an emphasis on trauma and developmental history and traumatic stress symptoms.
Like forensic psychological evaluations, multiple methods of data collection are employed, including clinical interviews, psychological testing, and behavioral observations, and data is typically gathered from multiple parties, including collateral contacts. When the goal is to attribute symptoms to a specific event, careful attention is given to the selection of measures and to the client’s recent and remote trauma history, particularly when symptoms are complex or pervasive (Briere & Spinazzola, 2005).
Test And Measures Used In Trauma-Informed Evaluations
The range of possible posttraumatic outcomes requires both broad and specific measures. Briere and Spinazzola (2005) recommend at least two broadband screening measures, such as the MMPI-2 and the Personality Assessment Inventory (PAI), and at least one measure for general trauma-related problems.
If a trauma-related disorder, such as PTSD or Acute Stress Disorder (ASD), is suspected based on the general trauma measure, a specific diagnostic test or structured interview for those conditions is also required. In addition, if other trauma-linked problems are noted, relevant measures should be included, such as those assessing dissociation, suicidality, and/or cognitive ability. In forensic settings in particular, malingering or exaggerated symptoms should also be assessed, and this may be accomplished by the careful selection of measures that include validity scales or with measures designed for that purpose.
Although there are many measures that assess trauma-related problems and disorders, some are more widely used due to their higher reliability and validity, and not all have been updated for DSM-5.
To determine the presence of general trauma-related problems, the Trauma Symptom Inventory 2 (TSI-2; Briere, 2011) is a 100-item questionnaire that includes ten clinical scales and three validity scales, has adaptations for children and adolescents, and is updated for DSM-5.
The TSI-2 is particularly useful in forensic evaluations due to the presence of validity scales that assist in identifying malingering (Christiansen & Vincent, 2012). For the specific assessment of PTSD and ASD, the combination of a screening measure combined with a structured clinical interview is recommended (Ford, Grasso, & Elhai, 2015).
Screening measures, such as the Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013a), the PTSD Check List for DSM-5 (PCL-5; Weathers, Litz et al., 2013), and the Stressful Life Events Screening Questionnaire (SLESQ; Goodman, Corcoran, Turner, Yuan, & Green, 1998), allow a clinician to quickly assess an individual’s past exposure to trauma and identify traumatic events that meet criteria for those specific disorders. If a qualifying traumatic event is identified, the screening is followed by a detailed structured interview.
For example, the LEC-5 is typically combined with the Clinician-Administered PTSD Scale (CAPS-5; Weathers et al., 2013b), a comprehensive and widely used PTSD interview that can evaluate current and lifetime PTSD. The CAPS-5 has been referred to as “the gold standard” for interview assessment of PTSD due to its level of detail, precise prompts, and impressive evidence of reliability and validity, and thus is often preferred in forensic contexts (Evans & Hass, 2018; Young, 2017). The CAPS-5 has several advantages, including the use of behaviorally based anchors for all ratings, which may improve assessment across cultures and ethnic groups.
Overall, the goals of a trauma-informed psychological evaluation are to obtain the most reliable and valid information about an individual’s past exposure to trauma and current symptomatology, and to determine how their past traumatic experiences may be linked to their present health and functioning and intertwined with symptoms of other psychiatric or medical conditions. Trauma-informed evaluations can be a valuable resource for attorneys and courts working to provide fair, effective representation for clients with a history of suffering.
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