Psychological trauma disorders

Meeting the challenge in primary care settings

by Tom Cloyd, MS, MA - Counselor / Psychotherapist - Bellingham, Washington (360) 920-1226 - email: tc (AT) tomcloyd.com (please read about content licensing)

Summary

Individuals with undiagnosed, untreated psychological trauma disorders present human service and health care providers with serious challenges to success. The first and most important step toward resolving this problem is to identify these individuals. This may be done using the simple screening procedure detailed here. The effort required is small, and the likely rewards large.

Undetected trauma disorders - a problem for all

Whenever a person experiences high levels of negative, unwanted feelings, psychological trauma occurs if they cannot adapt to the experience. People with such trauma do less well in virtually all situations than people without such a burden.

The consequences of psychological trauma have been noted for well over 100 years. For decades after the problem was first noted, professional response was undeveloped, erratic, and ineffectual. Clinical psychology's emergence as a major health care profession after the end of World War II, followed by the formal designation in the 1980s of enduring trauma-reaction disorders as Posttraumatic Stress Disorder (PTSD), produced a much-improved awareness of the problems of many groups who suffer high levels of psychological trauma:

• Viet Nam conflict veterans,
• Gulf War veterans,
• survivors of terrorist attacks,
• veterans of the Iraqi conflict, and
• survivors of multiple recent natural disasters which affect millions of people in the USA and elsewhere.

Victims of psychological trauma in a wide range of civilian environments are now better understood and responded too, as well, as a result of major changes in thinking and professional response which have occurred in the past two decades. Nevertheless, it remains true that large numbers of these individuals are never recognized and most are never treated.

All individuals who experience psychological trauma are at risk for possible long-lasting consequences. Trauma disorder victims simply do less well than they might in most areas of their lives, a problem extending to their work with us. This changes when the disorder is successfully treated. For that to happen, it first must be detected, and far too often it is not.

Affected individuals - early identification is crucial

Psychological trauma's enduring effects are not usually permanent, except in a distinct minority of cases. It is those individuals with whom we should be most concerned. When we suspect that trauma reactions are impacting our service recipients, we serve everyone's interests best by identifying at risk individuals, then identifying those in that group who do have a Posttraumatic Stress Disorder (PTSD). Intelligent treatment of trauma disorders will routinely produce real improvements in response to our services. Everyone wins, when this is the outcome.

Rapid screening - a workable solution

While assessment and treatment of Posttraumatic Stress Disorders is a job for a psychological trauma specialist, screening for them is reasonably simple. It can be done competently by a wide range of human services professionals.

The National Center for Post-Traumatic Stress Disorder (NCPTSD) of the US Department of Veterans Affairs (2) offers the PC-PTSD brief screening tool (8) for use in primary health care settings (it's a part of this kit - on a separate page). Containing only four self-response questions, it first verifies the prime qualifying antecedent of a trauma disorder - experience of a severely upsetting event, then assesses the most critical aspects of a person's response to that experience.

Use of this simple tool requires about 30-60 seconds of a service-recipient's time, and far less of a human service professional's time, unless a problem is found. Its use can dramatically improve detection of those individuals who truly need professional care. This simple tool is ideal for inclusion in a wide range of primary care and service settings.

How to use the PC-PTSD Screening Tool

• Give the screening tool to your service recipient - either during an office visit or as part of a pre-visit paper-work packet they receive. (1)
• Consider the screen positive if there are "yes" responses to any three items. (8)

Positive screening responses - how to manage them

Inform and explain

• Inform your service recipient of the finding and what it means - that it appears that they may be having a kind of serious stress reaction which should be looked into further. The screening tool is symptom focused, not traumatic-event focused, and you should be too. Avoid discussion of the traumatizing episode(s) if possible, as that can lead to immediate emotional difficulties yielding no positive result at all. (7)
• Clarify that "positive" on the screen means only that further investigation is warranted - not that a trauma disorder has been found. The screening tool alone cannot determine that.

• Making the evaluation of their responses a client/patient educational opportunity takes only seconds. Explain to your client/patient what the tool is looking for and why it matters. Some "talking points": (a) about 10% of the general population will suffer PTSD in their lifetime " (b) most are not getting treated due to not being identified or encouraged to seek treatment - and (c) untreated PTSD usually has serious consequences for physical health, as well as daily function.

• Since many people still have a negative view of getting mental health treatment, strive to "normalize" such treatment. It's usually fairly brief, not especially expensive (approximately the cost of a day in the hospital), and will most usually produce very significant relief. Avoiding treatment, however, will prolong suffering and may well lead to other disorders and increased health care treatment costs.

Confirm present safety of service recipient

If there are ANY positive responses on the screen, investigate the current situation of your service recipient.

• Are they at risk for further trauma? Are major stress challenges such as domestic violence, ongoing sexual abuse, or other threatening factors a part of their present life?
• Are they in active denial of any fairly obvious risk in their environment or life?

Your interview with them is critical, as it may be the only place where such problems are likely to be detected, and appropriate referrals made.

Screen for suicide risk, if appropriate

All service recipients who are positive on the screen should be checked for suicide risk. (3) You should briefly address...

• History of suicide-related thoughts and acts. ("Have you ever attempted to hurt yourself..." - address history of thoughts, acts, and treatment for acts, and the number of times each has occurred, as the presence of each indicates increased degrees of risk.)
• Mental health treatment history, including hospitalization. (Such history predicts increased likelihood of self harm.)
• Current substance use and abuse. (This impairs decision making, and can much increase risk of acting on suicidal impulses.)
• Recent losses. (Consider loss of health, friends, intimates or family members, housing, employment, or anything else they value.)
• Current thinking about suicide. (If present, ask about their having made any kind of plans.)

If you detect suicide risk, see note (5), below for appropriate response.

Make a written referral

Provide a written referral to a qualified mental health professional. Get an immediate release from the service recipient, so that you can share your knowledge of the service recipient with this professional. Explain...

• That you consider it important that you both find out whether or not they are experiencing a posttraumatic stress disorder;
• That such disorders are a normal reaction to overwhelming experiences;
• That you know that they are not crazy, but that professional treatment may be a very good idea for them;
• That treatment, if needed, will probably have a major positive effect on future mental and physical health, and on occupational success;
• That other individuals like them have successfully recovered from trauma-reaction disorders, so you expect that they can also, if one is found.

Gentle, empathetic, optimistic, persistent, and supportive engagement is the appropriate and productive intervention style to use at this point. It can work wonders.

Schedule follow up contact

Indicate your genuine interest and concern by scheduling a follow up contact - this could simply be a phone call in a few days, or could also be a few questions you make sure you ask your service recipient at their next scheduled contact. This is part of the safety net of support we must give trauma victims, and it can make a great difference in the degree of compliance we see with all kinds of response and treatment recommendations.

Children and adolescents - a special note

Evaluation of children and adolescents requires special attention. To help us work better with this population, consider the following:

• With a child or adolescent known to be a victim of recent emotional, physical, or sexual assault, our first concern (after emotional first-aid) should be to determine their present risk of further assault. Securing their ongoing safety must always be top priority.
• Girls 15 years and older, and boys 16 years and older, may possess significant emergent adult traits (their legal status varies from state to state). This emergent maturity can be helpful to all concerned, but when experiencing posttraumatic stress these adolescents will still benefit from, and probably need, the clear involvement and support of their parents during assessment and treatment.
• A troubled mind will usually produce troubling behavior, but the effect of disturbing events may not appear immediately. Watch for disturbance in interpersonal relations, school performance, personal habits, sleep and eating, among other areas. Some children may be particularly hard to assess casually, so be cautious about concluding that all is well. If there is no obvious reaction to disturbing events, continue to be observant for signs of disturbance as time passes.
• Low cost formal trauma disorder screening tools for children and adolescents are available. While informal assessment may be the only practical option in some settings, one should still consider using the "Child Report of Post-traumatic Symptoms (CROPS)" and the "Parent Report of Post-traumatic Symptoms (CROPS)". (6)
• Informal assessment of this population is best achieved by evaluating both history of disturbing events (including anything that might be seen by the child as abandonment or threat) and quality of function in present life. Information from both child and parents should be considered, since children usually know best what they're experiencing, while parents usually know best what actually happened. (4)
• Formal assessment of children and adolescents for posttraumatic stress disorders is most particularly a matter for a trauma treatment specialist. It's simply more difficult than assessment of an adult " and the costs of doing the job poorly are higher.

A final concern - You

Take time to realize your importance. "Realize", here, means two things:

• Understand your importance. As a primary care or service provider, you are one of the most critical people in the service network. You will typically have earlier "contact with more people in need than anyone else. In the system-wide effort to better detect and treat Posttraumatic Stress Disorders, your alertness to the problem of posttraumatic stress will often be the gateway to involvement of other professionals whose work can be critical to achieving good outcomes for all of us.
• Make real the fact of your importance by doing what needs to be done. It will often be true that others cannot act until you act. Do a few really right things, at the right time, and lives get changed. "Realize" your importance!

Professional support is available

If you have any questions or concerns about this screening process or anything else regarding psychological trauma and its detection and treatment, I invite contact by telephone - (360) 920-1226 - or email (see author credit at top of document). I consider this type of informal brief consultation to be time very well spent.

I also offer additional articles and client support materials, as well as a short list of excellent online support resources for professionals, at my website - http://tc.tomcloyd.com.

Notes

1. The NCPTSD-authored items in this kit are in the public domain - you may duplicate them as needed. The documents I have authored may also be duplicated as needed, as long as their author attribution and content is not altered in any way. (Contact me if you have questions.) All items may be downloaded from my professional website - http://tc.tomcloyd.com/.

2. The NCPTSD (National Center for Posttraumatic Stress Disorder) as an exceptional website at http://www.ncptsd.va.gov.

3. Be aware of these factors indicating seriously increased risk of suicide: male gender, middle age or older, active substance abuse, a mental health treatment history, a history of recent trauma or losses, or a history of recent self-harm attempts. Females do attempt suicide more, but males use much deadlier methods and have a much higher success rate.

4. Loeber, R., Green, S. M., & Lahey, B. B. (1990). Mental health professionals' perception of the utility of children, mothers, and teachers as informants on childhood psychopathology. Journal of Clinical Child Psychology, 19, 136-143.

5. Refer for an immediate suicide screen and intervention - by a mental health professional specializing in crisis and suicide intervention, if possible. If not, any mental health professional would be an acceptable alternative. Plan with your service recipient for a follow up call, to be made in the very near future (the same day is best). Confirm that your referral was acted upon. If you don't trust that this will happen, or if your service recipient has clear plans for self-harm, you have an active suicide risk on your hands, and must take appropriate action immediately to pass responsibility to a crisis specialist. Calling for police intervention is a common and appropriate response at this point.

6. The best available review of trauma assessment tools for children and adolescents is Greenwald's "Child Trauma Measures for Research and Practice" at http://www.childtrauma.com/mezpost.html. Details are also given there about obtaining the tools reviewed.

7. You, and they, should be advised that such matters are best taken up on with a qualified psychological trauma treatment specialist, who will know how to manage, contain, and minimize the effects of the emotional "flooding" and overwhelming reactions to memories and to real-world triggers which occur to many trauma victims. If such an response occurs with a service recipient, calmly comfort them, redirect their focus to other matters (a very effective intervention in many cases), and continue to offer support until they calm. The key to being emotionally helpful to a traumatized individual is maintaining your own emotional stability and compassion when in contact with them.

8. National Center for Posttraumatic Stress Disorder. "The Primary Care PTSD Screen (PC-PTSD)". Downloaded 2005-10-04 from http://www.ncptsd.va.gov/ncmain/ncdocs/assmnts/the_primary_care_ptsd_screen_pcptsd.html.