Preparing
compassionate,
trauma informed
Trauma Assessment and Treatment
Planning in Counseling Practice:
Using Formal and Informal Tools
New Jersey Counseling Association Conference
May 5, 2017
Jane Webber PhD, LPC, ACS, DRCC
Session Description
•
The majority of individuals have experienced
some form of trauma. Counselors may have
an intuitive sense about a client’s trauma
history but inadvertently miss cues leading to
misdiagnosis or re-traumatization. We present
formal trauma assessments, as well as
informal case history and intake questions to
illuminate a client’s trauma history and
promote appropriate treatment planning.
Cases are presented and common mistakes in
trauma assessment and treatment are
Trauma Informed Counseling
•
Is not a specialization…
•
Approaches clients using universal
precautions
•
Means every counselor should be trained
in trauma informed techniques
•
Means that everyone in this room works
with
traumatized
clients
•
Means understanding that the basis of all
emotional distress is the autonomic
Trauma Informed Counseling
•
Trauma phobic
•
Trauma aware
•
Trauma competent (Gentry, 2013)
•
Universal screening for trauma
Trauma Screening:
Why and Why Not
•
The majority reports one or more traumatic events
•
Most individuals in court or social services have trauma
history
•
Trauma and substance abuse
•
Identify and treat early
•
When trauma screening is not addressed: poor
engagement, premature termination, higher risk for
relapse (Psych symptoms or substance use), suicide
attempt, more serious disorders
•
Example, Viewing a video of a counselor and an 8
thgrade girl
•
Counseling since 4
thgrade, SOS same old stuff,
TRAUMA EVENT:
Did the client experience a trauma?
Identifies events (assault, rape, accidents); establishes
trauma history
Evaluates other trauma related symptoms (horror,
helplessness, fear
•
Life Stressor Checklist-R.
•
Trauma History Questionnaire (THQ)
self-administered
•
Trauma Life Event Questionnaire
•
Stressful Life Experiences (SLE)
Going over answers develops therapeutic
relationship
Informal Self-Expressive Assessments
Life time line
+
_________________________________________
-TRAUMA HISTORY: Did trauma history
lead to diagnosable or subclinical
disorders?
•
Have you ever 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
ADVERSE CHILDHOOD EXPERIENCES
ACE STUDY
•
17,337 people studied by
Kaiser-CDC 1995-1997
•
Results show traumatic
experiences in childhood have an
impact on longevity & diseases
•
The cause – emotional
Finding Your ACE Score
While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often or very oftenSwear at you, insult you, put you down, or humiliate you? or
Act in a way that made you afraid that you might be physically hurt? If yes enter 1 ____
2. Did a parent or other adult in the household often or very oftenPush, grab, slap, or throw something at you? or
Ever hit you so hard that you had marks or were injured? If yes enter 1 ____
3. Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? or
Attempt or actually have oral, anal, or vaginal intercourse with you? If yes enter 1 ____
4. Did you often or very often feel that no one in your family loved you or thought you were important or special? or
Your family didn’t look out for each other, feel close to each other, or support each other? If yes enter 1 ____
5. Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? If yes enter 1 ____
6. Were your parents ever separated or divorced? If yes enter 1 ____
7. Was your mother or stepmother: often or very often pushed, grabbed, slapped, or had something thrown at her? or
Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? If yes enter 1 ____
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
If yes enter 1 ____
9. Was a household member depressed or mentally ill, or did a household member attempt suicide? If yes enter 1 ____
10. Did a household member go to prison? If yes enter 1 ____
ASD and PTSD:
Does the Client Meet Criteria?
DSM4 TR A2 eliminated- response needed intense fear, helplessness or horror
DSM 5. Re-experiencing, Avoidance. Arousal. Persistent negative alterations in cognitions and mood
• Clinician -Administered PTSD Scale(CAPS)
Interview
• Modified PTSD Symptom Scale. Self –report • PTSD Checklist. Public Domain Self report
• Stanford Acute Stress Reaction Questionnaire Self report • Primary Care-PTSD (PC-PTSD) Screen
OTHER TRAUMA-RELATED SYMPTOMS:
Does client have other symptoms related to
trauma?
• Depressive, self harm, dissociation, sexuality,
relationship, distrust
• Gauge levels of symptoms, useful, broader • Beck Depression Inventory
• Dissociation Experiences Scale • Impact of Events Scale
• Trauma Symptom Inventory
Misdiagnosis and Mistreatment:
Is It PTSD or…
•
ADHD ?
•
Bipolar?
•
Generalized Anxiety Disorder?
•
Autism spectrum?
SCREENING
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Screener must like trauma-affected
individuals (Must Like Dogs)
•
Screening—first step in
COLLATERAL INFORMATION
•
Self-assessment
•
Records (clinical, medical, VA, discharge,
hospitalization)
•
Structured interview
•
Assessment instruments
•
Collateral information (parents, partners,
etc.)
•
Other mental health
QUESTIONS FOR QUICK
ASSESSMENT OR SCREENING
• Traumatic events
• Positive traumatic symptoms
• Role of trauma in client’s life
• Sub threshold symptoms/false positives
BEST PRACTICES FOR SCREENING
1.
Ask all clients about any possible history of
trauma–Use a checklist
2.
Use only validated instruments
3.
Screen all clients with exposure to traumatic events
for psychological symptoms and trauma related
disorders (Triggers, Avoidance , Stigma,
Understanding)
BEST PRACTICES FOR SCREENING
5. Do not delay screening!
6. Some clients will not make connection between trauma in history and current patterns of behavior e.g. substance
abuse
7. DO NOT REQUIRE clients to describe emotionally overwhelming traumatic events in detail.
9.
Consider paper & pencil instruments &
self-report—less threatening than interview
10.
Talk about how you will use findings to plan
treatment, discuss any immediate actions
necessary, review strategies that worked in the
past to relieve strong emotions
11.
At the end, make sure client is grounded and
safe before leaving room, e.g. conscious of
current environment, plan for maintaining
personal safety, plans for the day (TIP 57)\
National Center for PTSD
PsySTART IN DISASTER RESPONSE
•
Purple
.
Marking the purple level at the
top of the list indicates an immediate
crisis intervention is required, as the
disaster affected individual has
PsySTART Red
•
Red
12 red factors indicate immediate
intervention and high risk for crisis and
long-term mental health issues. Risk factors
are:
(1
) felt or expressed extreme panic?
PsySTART RED (continued)
5) death of immediate family member?
(6) death of friend or peer?
(7) death of pet?
(8) significant disaster related illness or physical
injury of self or family member?
9) trapped or delayed evacuation?
(10) home not livable due to disaster?
(11) family member currently missing or
unaccounted for?
PSYSTART Yellow
Yellow.
6 yellow moderate risk factors in the next level: 2
factors are personal and family related, 2 factors are
related to contamination. At this level, a referral to a
provider may be warranted.
The personal factors are:
(1) family members separated unaware of their
status/location?
(2) prior history of mental health care?
Indicators of contamination at the moderate level of risk
are:
(3) confirmed exposure contamination to agent?
(4) de-contaminated?
PsySTART Green
•
Green.
The lowest level of the chart
indicates
no triage factors observed.
This
means there is minimal risk for crisis and for
long-term mental health issues. Marking this
level also assures that the form is completed
even when no risk factors are observed.
Schreiber, 2009–2016. Indicators reprinted
with permission.
•
Friendly conversation, not an interrogation
•
Less than 15 minutes
GROUNDING
1. PERSONAL OBSERVING
You seem to feel very 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 an time it is, Notice what’s on the wall….
What else can you do to feel okay in your body right now. 2. Wiggle toe, Touch chair, Blink
• After a frightening experience, you can find sometimes yourself
overwhelmed with emotions or unable to stop thinking about or
imagining what happened. You can use a method called ‘grounding’ to feel less overwhelmed. Grounding works by turning your attention from your thoughts back to the outside world. Here’s what you do. Sit in a comfortable position with your legs and arms uncrossed. Breathe in and out slowly.
• Look around you and name five non-distressing objects that you can
see. For example, you could say “I see the floor, I see a shoe, I see a table, I see a chair, I see a person.” Breathe in and out slowly.
• Next, name five non-distressing sounds that you can hear. For
example, “I hear a woman talking, I hear myself breathing, I hear someone typing, and I hear a door closing. I hear a cell phone ringing.” Breathe in and out slowly.
• Next, name five non-distressing things that you can feel. For example,
TRAUMA INFORMED ASSESSMENT
ENVIRONMENT: CALM & STEADY
Keep calm: explain what to expect. Uncomfortable thoughts and feelings can arise. Reassure you will assist in dealing with the distress. Inform that some reactions may last a few hours or days and these are normal.
Approach the client in a matter-of-fact, yet supportive manner to create trust and acceptance & normalize
symptoms and experiences. Can cause continued distress if not treated.
Explain purpose of difficult questions: Many people have experienced troubling evens as children, so some of my questions are about whether you experienced any such events while growing up.
TRAUMA INFORMED ASSESSMENT
ENVIRONMENT
• Respect client’s space. Observe comfort level and adjust distance. • Clients with trauma may have particular sensitivity about their
body, space, and boundaries.
• Adjust tone and volume to suite level of engagement and degree of
comfort. Consider your response to personal disclosure.
Traumatized clients may be more reactive even to benign questions.
• Do not dig. Elicit only info necessary for determining. History of
trauma and the possible existence and extent of traumatic stress symptoms and related disorder.
• You do not have a therapeutic relationship to process information
CULTURALLY COMPETENT TRAUMA
ASSESSMENT
Provide culturally appropriate symbols of safety in the environment. Avoid inappropriate or insensitive items.
Overcome linguistic barriers with a translator; not known to client, e.g. family
How traumas are experienced meaning assigned to events, somatic expressions of distress, emotionality, normal vs. abnormal
Be aware of your own emotional responses to hearing clients’ trauma history. Client may misinterpret your reaction as disinterest, disgust, shock, Monitor your reactions. Check in with the client.
MOVING TO TRAUMA PROCESSING
TOO FAST
Your life experiences are very important, but at this early
point in our work together, we should start with what’s
going on in your life currently rather than discussing past
experiences in detail. If you feel that certain past experiences
are having a big effect on your life now, it would be helpful
for us to discuss them as long as we focus on your safety
now.
MOVING TO TRAUM PROCESSING
TOO FAST
Often, people who have a history of trauma want
to move quickly into the details of the training to
gain relief. I understand this desire, but my
concern for you at the moment is to help you
establish a sense of safety and support before
moving into the traumatic experiences. We
want to avoid retraumatization, that means we
want to establish resources that weren’t
BEST TRAUMA INFORMED
PRACTICES
Give the client as much personal control as possible during assessment.
Option for interviewer of the gender client is comfortable with.
Present a rationale for the interview and its stress-inducing potential, making, making it clear that the client has the right to refuse to answer any and all questions.
Postpone interview if necessary.
Under-diagnosis of PTSD in substance abuse field
BEST TRAUMA INFORMED
PRACTICES
Use self-administered written checklists instead of interviews. Trauma can evoke shame, guilt, anger, or other intense feelings. Trouble self-soothing: guide through grounding; very useful with dissociation or intense feelings
Caveat: avoid exclamations, e.g. I don’t know how you survived that.
More likely to report trauma than when interviewed out loud. The Trauma History Questionnaire (THQ).
Interview client who has difficult with reading or writing can’t complete checklist.
Clients with dissociation and repression should be interviewed to elicit other info.
BEST TRAUMA INFORMED
PRACTICES
• Provide feedback about results.
• Keep in mind the client’s vulnerability, resources, coping
strategies
• Keep it simple, direct, compassionate, honest.
• Allow time for client to become calm and oriented to the present • Is he/she has very intense emotional responses when recalling or
acknowledging trauma
• Allow time to process reactions Avoid phrases that imply
judgments, e.g. It was her time to pass. It was meant to be. It was God’s will.
• Listen supportively. Do not impose your personal views.
• Do not make assumptions about what the person experienced. • Information may require mandatory reporting. e.g. report child
abuse that happened years ago; cases against perpetrators.
MISDIAGNOSIS & UNDERDIAGNOSIS
• Many mental health instruments not sensitive to identify
PTSD or misclassify
• e.g. Intrusive PTSD symptoms -- indicative of
hallucinations or obsessions
• Dissociative symptoms---schizophrenia
• Trauma-based cognitive symptoms—paranoia or
delusions
• MDD, GAD, BD, BPD
• BPD: more diagnosed than PTSD, impulsivity, rapid
unpredictable mood swings, power struggles in
MISDIAGNOSIS
Trauma & survival skills ---Antisocial
personality disorder: Traumatized as child,
acting out, lack of empathy& conscience,
impulsivity, self-centeredness,
Impulsivity, concentration problems in
children & adolescents PTSD –ADHD
TIP 42 Substance Abuse Treatment for Persons
With Co-Occurring Disorders (differential
PTSD is associated with
increased rates of:
•
Agoraphobia
•
Social Phobia
•
Panic Disorder
•
Specific Phobia
•
Bipolar Disorder
•
Major Depressive
Disorder
•
Generalized Anxiety
Disorder
•
Substance-Related
Disorders
Building & Maintaining
THERAPEUTIC RELATIONSHIP
Relaxation/ Self-Regulation
Constructing & Sharing NARRATIVES
CULTURE SPECIFIC STRESS
RESPONSES
Ataques de nervios: intense emotional upset often in
response to trauma or stressful event in family; shout,
cry, tremble, dissociative, seizure-like episodes
Nervios: Emotional distress: headache, nervousness,
tearfulness, stomach discomfort, sleep issues, dizzy,
often in response to stressful life events
Sustos: “fright”,traumatic or frightening event, soul
leaves the body,
Appetite, sleep, sadness, lack of motivation, somatic
Taijin kyofusho: “interpersonal fear” syndrome,
BARRIERS TO TRAUMA ASSESSMENT
1.
Counselors overlook trauma and its effects.
Fear that we could increased problems, biased,
uncomfortable with such intense emotions/stories
2. Clients not reporting trauma or denying even with
direct questions.
Concern for safety, Fear of being judged, Shame
Reluctance/reticence about disclosing
CHALLENGES IN TRAUMA
ASSESSMENT
History of migration, refugees, accultural level, ethnic self identification, country
Use preferred language
Nuances of language on assessments, difficulty translating words directly into another language
Use checklist only for information about what the client is currently feeling
Note: Responses likely to change from one administration to the next.
ASSESSING YOURSELF
•
SUD= 0 – 10
•
Subjective Units of
Distress (discomfort)
BASIC MENTAL HEALTH SCREENING
TOOLS
• Mental Health Screening Form –III. (screens for
present/past symptoms of most mental disorder), in TIP 42 Substance Abuse Treatment for Persons With
Co-Occurring Disorders. Or free from Project Return Foundation
• Beck Depression Inventory II Beck Anxiety Inventory • TIP 48, Managing Depressive Symptoms in Substance
Abuse Clients During Early Recovery
• TIP 50, Addressing Suicidal Thoughts and Behaviors in
Substance Abuse Treatment
• TIP 11 Simple Screening Instruments for Outreach for
Alcohol and Other Drug Abuse and Infectious Diseases
• TIP 24 A Guide to Substance Abuse Services for Primary
DECREASE INTENSITY OF
AFFECT QUICKLY
Emotion Dial
Imagine turning
down the
Volume on your
emotions
Clenching Fists
Move energy of
the emotions into
fists and then
•
Steam
through
DISTRACTION
•
Breathe in
through nose,
out through
mouth
•
Hands on
abdomen
•
Strengths-Based
Questions
•
How did you
survive?
•
What strengths do
COUNSELOR’S SELF-ASSESSMENT
•
Refer to trauma specialist
•
Avoid follow up
•
Change topic
•
Secondary traumatic stress
•
Compassion Fatigue
ABOUTFACE
Inaccurate Perceptions
•
Veteran experiences IED
exploded with diesel fuel
smells & fire
•
Amygdala now
hypersensitive to olfactory
memory (e.g., diesel fuel
smell)
•
Non-threatening situations
such as a gas station results in
dysregulation (e.g.,
Traumatic Memory Talk Therapy
•
Conscious
•
Linear
•
Time-based
memory
•
Verbal recall
•
Speak the
unspeakable?
•
Present tense
•
Visceral (body)
•
Old brain
•
Non-narrative
•
Repeated until
Bilateral Stimulation
•
Thigh tapping
•
Foot tapping
•
Hug yourself…
•
Tap your shoulders
•
Someone else taps your shoulders
•
Windshield wipers
•
Walking
TECHNIQUES
•
Tongue touch
•
Stress ball squeezing (2 hands)
•
Steam irons
•
Tapping (thigh, foot,
shoulders)
•
Eraser
Self-Regulation
Nonanxious Presence vs Chronically Anxious Presence
Keep your body relaxed in the presence of a perceived stressor. Wolpe 1954, 1958
