Trauma Assessment

In assessing trauma, one must distinguish between two meanings of the word trauma. Considerable confusion is created because the same word carries two different meanings. For example, take witnessing and facing the risk of death and serious injury in a combat situation. When we use the term combat trauma, it can refer either to the event itself, or to the adverse psychological consequences of that event on a particular individual. Research evidence clearly indicates that exposure to a particular type of traumatic event, such as combat, does not have lasting traumatic sequelae for all individuals who experience it; actually, for most types of traumatic events, the majority of exposed individuals will not manifest posttraumatic stress disorder (PTSD) or any other ongoing disabling psychological effects.

Furthermore, although PTSD is the disorder most people think of in connection with exposure to a traumatic event, a wide range of syndromes can arise in response to the experience of trauma (see the entries on “Complex Trauma;” “Dissociation;” and “Posttraumatic Stress Disorder, Comorbidity”). For this reason, it is critical to distinguish these two meanings of the word and to assess for trauma in both senses. This requires that the evaluator keep in mind that a particular examinee may have encountered a number of different traumatic events, possibly of various types (e.g., child abuse, criminal assault, natural disaster) at various points in the life cycle. Although the examinee may identify a particular traumatic event or related series of events as the cause of his or her psychological difficulties (often referred to as the index trauma), other traumatic experiences that preceded or occurred subsequent to the index event may be even more strongly related to the clinical picture or, at the least, likely compound the impact of the index trauma. Examinees will sometimes reveal certain traumatic events while intentionally failing to report even more disturbing ones that they find too distressing to discuss.

Although formal instruments can assess for the presence and severity of traumatic events in the client's history—such as the Childhood Abuse and Trauma Scale (CATS); Childhood Trauma Questionnaire (CTQ); Sexual Abuse Exposure Questionnaire (SAEQ), to assess for a history of child abuse; and Conflict Tactics Scale (CTS), to assess for the presence of domestic violence—in most instances they should not be considered substitutes for a thorough clinical interview. Instruments such as these may alert the examiner to a history of traumatic events and be useful for research purposes, but only a careful, sensitive interview is likely to produce an in-depth picture of the nature of these experiences and their impact on the examinee. Obtaining an accurate and detailed account of an examinee's trauma history requires taking the time and patience to earn his or her trust and gather the relevant information without alienating or overwhelming the examinee. Consequently, a clear picture of how the examinee's trauma history affects current psychosocial dysfunction, especially when repeated and multiple varieties of traumas occurred, may take time.

Because of the wide range of psychological problems other than or in addition to PTSD that can be related to confrontation with a traumatic event (including major depression, complex PTSD, dissociative disorders, substance abuse, and personality [Page 706]disorders), the examiner must cast a wide net to sufficiently explore the possible impact of any traumatic events reported by the examinee. A full trauma assessment, therefore, should include comprehensive investigation of symptomatology and a complete mental status examination to adequately survey the examinee's possible difficulties. However, factors other than trauma may be responsible for some of any psychological symptoms the examinee exhibits. There is a tendency to assume, once a history of trauma is identified, that any and all psychological problems presented are trauma related.

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