Mastering Trauma-Informed Screening and Assessment | Counselor CEUs

You. I'd like to welcome everybody to today's presentation on trauma informed screening and assessment. I'm your host, Dr. Donnelly Snipes. In this CEU presentation, we are going to discuss why screening is important and why screening must be trauma informed, even if you're not screening for trauma. Imagine that. Okay. We'll learn about three types of prevention. Define trauma, traumatic injury, PTSD and cptsd. Discuss the preventative impact of screening and assessment for adverse childhood experiences, trauma mental health issues and addictions. Review effective screening practices and the 16 principles of trauma informed care. So batten down the hatches. Let's get moving. Why do we do trauma informed screening? Well, basically, trauma informed screening recognizes that trauma is at the heart of, is at the core of what causes a lot of mental health, addictive and behavioral health, and physical health problems. So if we're screening, we need to be able to understand what part of this might be caused by trauma. Hypothyroid, for example. If you're screening somebody for hypothyroid, they may have symptoms of depression and fatigue and dry skin and they may be able to, you know, knock off a lot of those symptoms. And yes, they are hypothyroid, but what caused the hypothyroid? And we know that adverse childhood experiences, ongoing extreme stress and or trauma can contribute to a dysregulation of the nervous system and the development of hypothyroid, especially, especially autoimmune hypothyroid. So by screening for that, we can recognize, yes, we can treat the hypothyroid with certain medications. But let's also address this underlying issue that is keeping the stress response and the nervous system out of balance and exacerbating this problem. It's important, just like we've talked about in other videos, if a clinician, a counselor is screening for depression, well, there are a lot of symptoms of depression, but we also need to recognize that there are physical causes of depression as well. We need to examine gonadal hormones, we need to examine thyroid, we need to examine nutrition and sleep and, you know, a host of other things that may be contributing to the person's depressive symptoms. If we don't address those, then they're only going to probably see partial recovery from their current condition. We have to address all of the problems that are going on. It's like taking your car to the, to the mechanic and getting the oil changed. And maybe you do it religiously like you're supposed to every 3, 000 miles. That's wonderful. But if you're not also using good gas and rotating your tires and doing the other kind of maintenance things that you're supposed to do that I trust my mechanic to do, then the car is not going to last as long. You have to address all of the things to keep that car running, just like you have to address all of the issues to keep the body factory running. The lifetime prevalence of any potential trauma is about 81%. Wow. And most people obviously have experienced some kind of trauma. The lifetime prevalence of diagnosed PD PTSD is 8.3%. Now why do I say diagnosed? Well, let's think trauma informed screening. If somebody has gone through trauma and they've developed symptoms of ptsd, but we're not considering trauma as a causative factor, then we may attribute their difficulty concentrating, their irritability and some of those symptoms with ADHD or anxiety or something else. So we really need to consider, is this a trauma related problem? The prevalence of CPTSD or complex post traumatic stress disorder in 11 to 19 year olds. So your adolescence is 3.4%. And the prevalence of adverse childhood experiences is 61.55%. With people report at least one and about a quarter of people, 25% reported three or more adverse childhood experiences. We know that when you get over four ad first childhood experiences, there is a much higher likelihood of stress related physical and mental health issues. Trauma is associated with the development of a range of disorders, including autoimmune disorders, polycystic ovarian syndrome, gonadal hormones, cardiovascular diseases, addictive substance, addictions to substances or behaviors, mood disorders, personality disorders, suicide attempts and impaired educational performance, to name a few. Now, we could go down the list and I'd be here for hours. But it's important to understand that trauma does not just impact somebody's emotions or the way they think. It impacts their whole body. It impacts them physically, interpersonally, emotionally, cognitively, environmentally and spiritually. Given the prevalence of trauma and the diversity of associated issues, we can confidently say a trauma informed approach may prevent re victimization. If we just assume, and I know what they say about assuming, but we're going to do it anyway. If we go ahead and assume that the majority of people coming into our office, whether you're a doctor, a nurse or a clinic counselor, have experienced trauma, how will that change our approach? How will that change our environment? How will that make us more sensitive to the environment? In many hospitals it's always been, and in many behavioral health centers it is has started to be over the past eight to 10 years where you go through multiple doors and they lock behind you and the clinician has to swipe in with their special card to get in. And for people who have been trapped in some way that's traumatizing, just hearing that click behind them can make their, their stomach kind of jump up a little bit. We need to be sensitive to that. We have probably started to ignore it. We desensitize to it because we do it every day and we have the car that swipes us in and out. But for the people who don't have that, it just reminds them that they are in a place where they're not in total control. So if we have a trauma informed approach, we can start out from the minute somebody contacts our agency there they call in, to when they walk in the lobby, to when they're called back to when they're in your office. We can pay attention to the environment, we can pay attention to the surroundings, we can pay attention to our approach to make sure we are doing as much as we can to help people feel safe and empowered. When we answer the phone, we don't act like they're bothering us. We say, oh my gosh, let me help you. We recognize that if they're calling in for a mental health appointment, they're probably not in a good space. And instead of getting irritable with them because they're slow processing or they're crying or they seem to be needy, well, you know, those are the symptoms that are bringing them to treatment. So we acknowledge it and we again try to help them feel like we hear where they're coming from and we want to help. So that begins with the first call. When they walk into your office, when they're in the lobby, what things in the lobby might make them feel unsafe or powerless? What things in the lobby might make them feel unwelcome? Example, if you have a ch child and you walk into a. A lobby and it's all everything there is for adults, the child doesn't have anything to do and the parent may not know, you know, what do I do with my child? You know, feels stressful and uncomfortable. Well, if the parent has experience with abuse, even verbal abuse, when the child is noisy, or maybe they got in trouble when they were noisy and they walk into this environment and all of a sudden it's like, oh my gosh, there's nothing for my kid to do. And if, if he makes noise, we're going to get in trouble. And oh my gosh, you know, they start stressing out and spiraling when we Call people back, acknowledging them, not just looking at the board and saying, okay, patient number 643, come on back. And then not looking at them, just turning and follow me. That's not welcoming at best. You know, we want to talk to them and pretend like you're a. Whatever they call the person who seats people at restaurants. I can't even think right now, but hostess or a host. When you bring people back, you're welcoming them into your organization when you have them sit down. I hate it when I get stuck in a doctor's office and they call me back after, you know, forever. And then they put me in this little room and I'm sitting there twiddling my thumbs for 20, 30 minutes or more. It's disrespectful, number one. But number two, I don't know what's going on. And so we want to pay attention to helping people feel empowered and acknowledged and respected and all those things that are essential for people to feel safe. A trauma informed approach provides early identification for prevention of additional related issues. If we recognize that, let's be optimistic and say we recognize early on that Junior experienced trauma of some sort, maybe, you know, parent or step parent was abusive, whatever. Junior has experienced adverse childhood experiences, we recognize that early on, well, that if that goes untreated, Junior may develop autoimmune issues, may develop behavioral issues, have difficulty functioning in school, may develop depression, anxiety, addiction. You know, there's a whole lot of things that can happen when Junior. When Junior's trauma isn't addressed, and Junior goes through life feeling unsafe and powerless. So with trauma informed screening, by asking, what are these behaviors communicating and could these behaviors have developed as a way of surviving trauma? It helps us identify potential unknown causes early so we can intervene and prevent those other issues from becoming true. We can improve treatment outcomes by addressing the underlying causes of symptoms. If somebody is having difficulty with concentration and attention because they're hyper vigilant and they're not sleeping well, well, those are two symptoms of ptsd. If those symptoms are being caused by trauma because the person feels unsafe, then we need to help them feel safe so they can get adequate sleep and they can learn how to not be hyper vigilant in every situation so they can concentrate. But that's a long process. It's not something we just say, hey, here's a magic trick that you do and all of a sudden you'll be able to focus. No, it's a process, but we are addressing the underlying causes. If you don't fix the body, it's going to be hard to create lasting changes in the mind. We've got to fix the nervous system and heal the body. It helps us improve treatment outcomes by recognizing the function of symptoms to prevent pathologizing. So you have somebody who dysregulates, and that is one of those hallmark symptoms that makes a lot of clinicians feel very powerless. And well, think about the person who's dysregulating. Think about how powerless they feel. And that dysregulation comes from years of stress, years of trauma, whether it's a lot of little T's or one big T, don't matter. Years of feeling unsafe and powerless, which has led to the stress response, the HPA axis, becoming dysregulated. When that happens, the person conserves their energy most of the time. So they feel flat. They're not going to feel excited. They're probably not going to get irritable. They just, they ain't got the energy or the resources right now. They're just, they're holding on because they don't feel safe. And they're constantly spending all their energy just scanning the environment, being hyper vigilant. But when they do get triggered, there's a tsunami of stress chemicals that flood their brain and flood their body. So they go from flat to furious or frantic like that. Well, it makes sense when you start understanding it's not just the person. Quote, and I don't like this term, but I'm going to say it don't like overreacting. That's not what's going on. Yes, their body is reacting with an, probably an excessive stress response compared to what is needed. But that is how they're wired. That's how their stress response system responds. Right now it's either nothing or anything, Everything. And helping people understand that instead of pathologizing it and saying, oh, you're overreacting to everything. No, you're not. You are reacting the only way your nervous system knows how right now. And in order to address that, we need to figure out how we can reduce your stress so we can start helping your nervous system heal. And it assists providers, mental health, medical, clergy, even teachers in creating environments that promote a sense of safety and recovery. In this classroom, for example, for any of you who are teachers looking around at the environment and saying what in this environment might feel stressful to a child, My son, when he was in first grade, he, he has ADHD in a big way, but he's always wanted to please people. You know, he, he's always wanted to do Right. He doesn't like getting in trouble. And the. The stoplight system that they had in first grade stressed him out to no end because he had all he could do to keep it together and manage his ADHD symptoms in the classroom without having to worry about getting in trouble. And, you know, we tried to talk to him, and we're like, if you, you know, make a mistake and you go to yellow, you know, okay, let's learn from it. Not a big deal. We tried to help him reconceptualize it as not a big thing, but it was something that he couldn't get out of his head. And it wasn't that he had been traumatized and yelled at before and gone on yellow. You know, he never had gotten to yellow, but he had seen other kids get on yellow and get in trouble, and that was scary to him. He didn't want to get yelled at. He didn't want to get in trouble or sent to the principal's office. So he didn't feel safe with that particular system. And we can back off or back away from that a little bit more and go, okay, well, why didn't he feel safe? Well, because he was having a hard time controlling his own behaviors. And this was before he was on medication, so he was just, you know, holding on with dear life to try to prevent himself from blurting or getting up and moving around or doing those things that kids with ADHD do. We want to help break the intergenerational cycle of illness through trauma, informed screening. We can destigmatize, depathologize, whatever word you want to use, a lot of the symptoms that people are experiencing, and help them understand how those symptoms make sense. You're not crazy. These symptoms develop to help you survive the only way you could during a really stressful or traumatic time. Many times we see people in the present who have trauma, who are exposed to adverse childhood experiences like mental illness in the home, addiction in the home, abandonment, neglect, those things. When they've experienced those, we can often look back at caregivers. Caregivers experience those, and caregivers are living in a state of perpetual, unresolved trauma. So, you know, they're learning what they live, and then they're teaching what they've learned to the next generation. So we can break this intergenerational cycle. We can help people recognize some of the things that may be contributing to hypertension in their family besides eating too much, you know, bad foods. Three types of prevention. Primary prevention. You never had the problem in the first place. Example, major depression. Some people go through life and they never have a major depressive episode. Hallelujah. Addiction, chronic pain, diabetes, and adverse childhood experiences. These are all, well, at least type 2. But diabetes, these are all things that it is possible to prevent. So people never actually develop these symptoms of these issues. And part of that comes through education and early screening, early intervention, screening children when they are, you know, in elementary school for things that might be contributing to depression, like lack of sleep, poor nutrition, chaos in their household, anything that might require them to use a lot of energy, keep them from sleeping well, or lead them to feel hopeless and helpless. We can start addressing those. Because sometimes depending on depression is initially caused by the way a child thinks and perceives the world. Sometimes major depression is initially caused by a lack of sleep and, and, or poor nutrition. But ultimately that's the initial cause. Ultimately, all of the pieces of the person's life start becoming affected. Their physical health, their interpersonal relationships, their emojis emotions, their cognitions, the way they think and perceive the world, their environment, and their sense of connectedness and spirituality. Addiction, you know, we know people. I know there are people out there who haven't ever developed an addiction. And when I, I'm using that big umbrella right now, that includes everything from behavioral addictions to chemical addictions, including smoking. Okay, okay, so there's a lot of people out there with addictions, but there are people out there who never develop them. Chronic pain. Not everybody develops chronic pain. Now, some people have an injury, and by virtue of that injury, they develop chronic pain. But other people, their chronic pain is caused by autoimmune issues. And those autoimmune issues didn't necessarily need to develop. You know, autoimmune issues usually develop in response to an extreme stressor. Not always. Sometimes it's a virus or something else. Diabetes type 2 is partially autoimmune in nature, but it's also exacerbated by stress. When we are stressed a lot, it impacts our blood sugar levels because when we're stressed, our body releases blood sugar to give us energy to fight or flee. So if your body's constantly dumping blood sugar, your blood sugar numbers are going to go high. And then adverse childhood experience experiences. As I mentioned, if we educate people what aces are, if we educate people about how to manage the those issues in their household so they aren't adverse childhood experiences, then we can help prevent the problem. For example, neglect in, of children in, in their home can result, usually results when the parents have an addiction or mental health issue that is consuming Them, they are barely functioning on their own. So they have a hard time functioning and parenting that child. They have a hard time dealing with their own stuff, let alone the kids stuff. We can help people understand this. When addictions and mental health issues are being addressed and are being managed by the person, then they don't have that negative impact. Then the caregiver can pay attention to the child. So. So what we're talking about is helping people recognize the importance of managing their addictive and mental health issues, of managing their attention, of managing their time. Secondary prevention is preventing the problem from getting worse. Okay, somebody develops major depressive disorder or an addiction or chronic pain or diabetes, all right, it's there, it happened. Now we can nip it in the bud. Just like when you get a cold, you start feeling a scratchy throat and your nose starts running, you're like, it might be an allergy, it could be a cold. Do I just wait it out and see if I develop pneumonia? Or do I notice these symptoms and take action to prevent it from getting worse? And we can help people with this. When they present in clinic, we can help them identify what makes it worse, what makes it better. Okay, how can we help you keep it from getting worse? We're not going to solve the problem in today's session or even next week's session, but how can we help you keep it from getting worse and gradually help you get better? Tertiary prevents additional problems caused by the primary problem. So if somebody has trauma, we want them to. We want to help prevent them from also developing depression and addiction. If somebody has adverse childhood experiences, we want to help them cope with that and prevent them from developing PTSD or autoimmune issues. If somebody has trauma, we want to help them cope with that, for example, and so they don't get develop chronic pain conditions or diabetes or pcos. So we can address the current issue so it doesn't start sending out its little tentacles into other systems of the body and causing other physical and mental health issues. So how do we prevent. Through screening. Now remember, screening is something that anybody can do. The pharmacist can do it. Teachers can do it, pastors can do it. You don't have to be a licensed clinician to screen. Screening is not diagnosing. Screening is determining whether there's a need for further examination. So when we screen, what we're looking for, looking for is, you know, asking people, does someone in your household have mental health issues? Or screening? You can even do this through observation. Children, for example, who are coming to school and it doesn't look like they've bathed in a couple of days. Maybe they don't have any food in their lunchbox or you know, things that might indicate that there might be neglect going on. Now it could be the kid decided to go play rough and tumble with somebody before they got on the bus and they didn't like their lunch so they threw it away before they got to school. I don't know. We don't want to assume based on a couple of observations, but screening tells us. Hm, there might be something we want to look into here. We can screen for trauma, both physical history of physical trauma, like physical abuse, or even car accidents that might cause traumatic brain injury and psychological trauma. We want to screen for mental health issues. There are very easy screening tools that we can use. For example, with depression, we can just ask somebody, you know, for the last six months, more days than not, have you felt depressed or unhappy? And if they say yes, well, you've screened for depression. Now that's not the most accurate screening tool. There are better ones out there like the Beck Depression Inventory. But if you're just looking for something that is easy to do, sort of on the fly, if you're a pastor or a teacher or you're working at a community health there, then having something that has two or three simple questions is really helpful. We screen for diabetes by asking people about whether they've suddenly had just an unquenchable thirst and an insatiable hunger. And you know, we start asking them. There are a few questions we can ask. It doesn't mean they have diabetes, could mean a lot of different things or nothing at all. But it gives us an indication about what might be going on. We can screen for addictions. Do you use something to help you cope with pain? Are you using it more than intended, Spending more time than intended, using it or recovering from it? Are you using it in a way that it's causing you to give up or ignore important things in your life? And if the answer is yes, then there's a good chance that the some somebody may be developing a substance use disorder or an addictive disorder, sleep disorders with apnea. We can ask them, does your family say that you snore and it sounds like you're peeling the paint off the walls? Okay, well that's a screening question right there. And if the answer is yes, then they may need to be screened for apnea. You know, a follow on question would be do you, when you wake up from sleep, do you feel rested and energetic or do you Regularly have to lay down and take naps, or just. You live on caffeine all day long. We can scream for pain and for nutrient deficiencies. Now, this is one that only a doctor can screen for because it has to be done through a blood test. But doctors can screen for vitamin D deficiencies, iron, thyroid issues, or gonadal hormone issues, either too much or too little. That is really helpful. And I emphasize with my patients that, yes, you may be presenting with mood symptoms or cognitive symptoms like difficulty concentrating, you know, brain fog. And there are a lot of things that could cause that. But let's rule out any physical things, anything that's going on in that factory that may be keeping your body from and your brain from functioning optimally. And because those things can often be addressed pretty easily by doctors. Trauma is an event that's experienced by the person as horrific and causes a feeling of being unsafe and powerless. What is traumatic differs based on individual characteristics. What's traumatic for you may not be traumatic for me, and vice versa, based on my history and who I am and all those things. What's traumatic for me may not be traumatic for you. And I wouldn't put it up in the cat category of trauma by any means, but I've used this example before, and I'll use it again. ASPCA commercials hate those things. It just breaks my heart to see those commercials. My husband, he sees them and he's just like, oh, that's another stupid commercial. I have to look away because it upsets me to see those little animals struggling. So people have different reactions to different things. Abandonment and neglect causes trauma in most people, especially in childhood victimization. Now, what is considered victimization differs between people. A car accident. Some people may have a car accident, walk away and go, glad I walked away from that one. Somebody else may have that same car accident and be terrified to get back in the car, feel completely powerless and unsafe in the car. Having a heart attack, that's really scary. And that's traumatic not only for the person having it, but the people around them. Because it's sudden, it's unexpected, and, yeah, you're kind of powerless at that moment. Natural disasters and pandemics are other examples of things that can cause trauma. Now, we can experience these things. We can experience traumas, and we can cope with them. We can assimilate and accommodate them and, you know, work them into our understanding of the world. But when we don't, when that trauma is just hanging out there and we're like, I don't know what to do. With this, I, I don't know how to feel safe after this event happened, then that starts to cause traumatic injury. And this is traumatic injury is when the experience of that trauma causes physical or mental health injuries or both. PTSD is an exposure to an extremely threatening or horrific event or series of events resulting in re experiencing avoidance of thoughts and memories of the event, persistent perceptions of high heightened current threat, which lasts for more than four weeks and causes significant impairment in personal, family, educational or occupational functioning. So if somebody has a heightened sense of threat, but it's not causing them any problems and they don't see a problem with it, then they wouldn't meet that criteria. But the behaviors in PTSD re experiencing the event. That's your brain saying, hey, we got this hanging out here. We don't know what to do with it. And you need to figure out how, when this thing happens again or if it happens again, how you're going to stay safe. We've got to file it somewhere. Avoidance of thoughts and memories of the event is saying, I don't want to remember it. Your brain's going, you're going to remember it. And you're going, I don't want to remember it because I still don't know how to feel safe and I don't like feeling unsafe. And since you've got that undercurrent of I know there are instances out there where I am not going to feel safe and I don't know how to stay safe, then you're going to be feeling unsafe. You're going to have a high heightened current threat response and you're going to be hypervigilant. CPTSD involves exposure to the event or series of events of extremely horrific nature, most commonly prolonged or repetitive. Now, this is the unique part about CPTSD from which escape is difficult or impossible. CPTSD is a ongoing sort of thing. It can be multiple instances or it can be sort of a daily ongoing fear. Complex PTSD requires all the diagnostic criteria for PTSD to be met. In addition, complex PTSD is characterized by severe and persistent problems in affect regulation. So people with CPTSD emotionally disregulate. Oh, my gosh. Maybe it's not borderline personality. They have beliefs about themselves as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event. Now, if their entire childhood was one of neglect, there's not a particular event they can point to to go, oh, that made me feel worthless. But that entire childhood taught that child that they're not lovable. And it's whatever was going on with the parents was their fault. So they have this deep seated shame and guilt and sense of failure because they weren't loved the way they deserve to be loved. And they have difficulty sustaining relationships and in feeling close to others, which cause significant impairment in multiple areas of functioning. So again in cptsd, just like in borderline Personality, we see relationships that are often intense and unstable where people may cling and then reject. Now sometimes people with PTSD develop more of an avoidant attachment style, so it's they keep keep a distance. But it is important to recognize that that trauma from whenever it was is keeping them feeling unsafe and keeping them believing that other people are unsafe. Therefore, the reason they're distancing themselves is to stay safe. I can't let you in because you'll hurt me. Additional Diagnoses When CPTSD is diagnosed, additional diagnoses should only be made if the symptoms are not fully accounted for by CPTSD and all diagnostic requirements for each disorder are met. Very often people with CPTSD are misdiagnosed as having ADHD or borderline personality, for example. Screening is a brief evaluation to determine if there might be a need for further evaluation. The CAGE is one screening tool that we use for substances. Have you tried to cut down and failed? Do you feel annoyed when people ask you about it? Do you feel guilty about your use? And do you need to have an eye opener? Do you need to use first thing any order to get your day started? Now the eye opener isn't quite the same when we're talking about behavioral addictions, but it isn't. There is something to it because people who are addicted, when they wake up in the morning, their dopamine levels are are all out of whack and they may need to do something to bump up that dopamine in order to even get kick started in the morning. Other examples Breast self exams Diabetes screenings. These are all screenings that can be done by the individual, by healthcare practitioners, and don't need to necessarily be done by a doctor. Individuals can do self screening. There are self screening instruments on the Internet. We can tell people how to do a self screening. We can provide them the three or four questions to ask themselves through public service announcements or ads. We can print on receipts. And they've started doing this. I can't remember what town I was in recently, but they had actually started doing this on some receipts. At the bottom of the receipt there was a blurb that described the symptoms of depression. I was like how awesome is that Because I look at my receipts usually to see, make sure I got charged the right thing and see if there's any coupons. But if people are looking at their receipts, then they're at least seeing that and they're not having to ask for it. Because some people still feel like mental illnesses, mental health issues are shameful, which all they do is represent an illness in the body, a dysfunction in the stress system. Medical personnel, including CNAs can do screening. Mental health personnel, clergy, teachers, social service workers. And what I mean by that is people who work at the office where the EBT cards, where the and and TANF benefits are just distributed. So we're not talking about social workers, we're talking about people who work in social service and corrections officers. Hallelujah. If corrections officers were more sensitive to the traumas that most of the people in jail have experienced and how their behaviors are reactions to, to a history of trauma, then the approach in the jails would be very different. In creating an effective screening and assessment environment, we want to clear, clarify for the person what to expect in the process. Not just sit them down and go, okay, we're going to, I'm going to ask you some questions and start rattling stuff off. Let them know, I'm going to ask you some questions. And in order to determine if there are, if you are having any symptoms of X, Y and Z, you don't have to answer questions that you don't feel comfortable answering and you can stop at any time that's trauma informed. I'm giving the power back to the client. I'm saying I'm going to ask the questions, but you can tell me none of my business if you're not comfortable answering that right now. Approach the client in a matter of fact yet supportive manner. When you're asking about substance use, for example, instead of being like how much do you drink? Just all right, how many drinks do you have each week? Saying that is almost assuming the person drinks, which is much less stigmatizing than going, do you drink? Especially in certain environments. I know around here in Tennessee a lot of the doctor's offices actually have a very overt Christian presence with Christian music playing on the loudspeakers, with Christian literature with little Bibles around. So when people are asked about their substance use or something, I can imagine it may feel uncomfortable saying, yeah, you know, I drink about a six pack a day, that it's going to encourage minimization. So just be matter of fact, how many drinks do you have? Respect the client's personal space. If they don't want to shake hands. If they don't want to get too close, that's fine. Let them choose where to sit in the room. You know, obviously not behind your desk, but if they don't want to sit on the exam table, cool. Let them sit in the little chair next to the exam table until they absolutely have to get up there. Provide culturally appropriate symbols of safety in the physical environment, whatever that means for the cultures and the communities that you serve. Be aware of one's own emotional responses to hearing clients trauma histories. Pay attention to those nonverbals because they're hypervigilant to them. If they tell you something and you go, oh, they're gonna feel like, I'm embarrassed now or I'm ashamed. Make sure that you are going into this expecting what. What I do. I go in expecting to hear the absolute worst and think there's nothing they can share with me that's gonna shock me. And after a quarter century, I can say that that's probably true. I've heard a lot of things, but it's important for me to be supportive and not have any hint of judgmentalism, if that's a word on my face. When they are telling me about their trauma history, you know, we talk about it in a way that feels comfortable for them, and I am accepting and receptive to what's going on. It's important for doctors and dentists, but especially doctors, to start becoming more trauma informed, being aware that clients may have trauma histories. So don't go in just, you know, pulling up their shirt to listen to their heart or poking and prodding and stuff, without being sensitive to the fact that that might be triggering to them and overcome any linguistic barriers via an interpreter. I also should add to this, if the client wants to have somebody in the room with them, if they have a support person that they've brought with them, you know, that can also help them feel safer and more empowered. Elicit only the information necessary for determining a history of trauma and the possible existence and extent of the traumatic stress symptoms and related disorders. We're not asking about the details. It's not safe. When somebody has experienced a trauma and they've kind of locked it up somewhere, we don't want to open Pandora's box in the screening or assessment. All I want to know is, do you have a history of this? If you even feel comfortable telling me that, and, you know, if so, let's. Let's talk about what symptoms you might be having. You know, I'm not trying to tie them back. I'm not trying to create connections for the person right yet. I'm just trying to get some information. Even if the client wants to tell their story. It's your job as a gatekeeper to slow, slow things down to preserve the client's safety. I want to hear about what's happened to you. I want to help you work through it. However, I, I'm afraid that if we start going too deep into this right now, before we've developed some safety skills, that it might feel re traumatizing or it might feel even more unsafe to you. So, you know, let's talk about, you know, when we might start delving into that because sometimes clients just really want to deal with it and that's fine. But I want to do some, lay some groundwork first. So I know that not only in session, but, but between sessions they are going to feel safe and they're not going to be re triggered and spiral. Your tone of voice when suggesting postponement of the discussion of trauma is very important. Avoid conveying the message, I don't want to hear about it. You want. Again, I really want to hear what you have to say. And I really think we can do some great work working through this. I don't think it's safe to go, you know, do a deep dive into this yet. So let's make a plan and by, by providing an alternative, not just shutting them down and going, we'll talk about it at some point, but by making a plan. Then the person feels heard and validated. Give the person as much personal control as possible by presenting a rationale for the interview and making clear that they, the person, has the right to refuse to answer any questions. Give the person the option of being interviewed by someone of the gender with which they are most comfortable. If they were abused by a female person and you happen to be a female person, then they may not feel comfortable talking to you even if they are also female. And a lot of times there is the false belief that, that women feel safer talking to women and men feel safer talking to men. And that just ain't right. That just ain't it. Sometimes it's very different based on the person's experiences and their upbringing. So we want to make sure to ask them who. If there are characteristics of a clinician that would make them feel most comfortable. If you're in private practice and they've come to you, then obviously we're going to make the assumption that they feel comfortable talking to you and postpone the interview if necessary. If the Person starts getting too agitated and they say, I just, I can't do this right now. All right, we'll finish it next time or we'll finish it later. Use self administered written checklists rather than interviews when possible to assess trauma. People are a whole lot more honest on pad and paper and than they are having to look you in the face and say, this happened to me. Allow time for the client to be calm and oriented to the present. If they have a very intense emotional response when recalling or even acknowledging trauma. If you ask that question and they become upset or even dysregulated, we need to allow them to get regrounded before we go on. Don't just say, okay, well, let's switch gears. Let's just push that aside for a moment and pretend it didn't happen. It's our job to help them feel safe. Avoid phrases that imply judgment about or minimize the experience of the trauma. For example, don't say to a client who just survived a natural disaster and lost family members, it was God's will, or it was her time to pass or it was meant to be or any of those other trite phrases and that make someone potentially feel like life is a crapshoot. I have no control over anything. Provide feedback about the results of the screening to the person. Keep in mind the client's vulnerability, ability to access resources, strengths and coping strategies. If they have something going on and you're going to make a referral, make sure that you're making an appropriate referral and don't give them more than they can process at that sitting. You know, you don't need to do a deep dive into all the explanations, just that it seems like you may be struggling with depression or addiction. And I think this might be a good resource for you. And this is why. Be aware of possible legal implications of assessment. Information gathered can necessitate mandatory reporting to authorities even when the client does not want the information disclosed. So when we are doing an assessment or even a screening, it's important to make sure people understand their rights and confidentiality, especially if you're a mandatory reporter. But it's important to also recognize that people in safety sensitive positions like air traffic controllers, law enforcement, fire rescue, people who drive big equipment, they are potentially lawyers, clinicians, they are potentially, I hate to say at risk, but at risk when they do an assessment because that assessment can be subpoenaed under certain circumstances. Now, it doesn't usually happen, but it is important to understand that some people will be very guarded because they're afraid how it's going to impact their career. The military, it's another one. Explain screening and assessment and if appropriate, pacing of the initial intake and evaluation process. All right, Nice to meet you, Jane. We're going to spend about the next hour doing these things and this is why offer psychoeducation and support from the outset. If you're screening somebody for addiction or mental health disorders, make sure that you've got handouts for them so they or a website you can send them to that's easy to understand so they can get easily digestible information about the conditions and the fact that any symptom can potentially have a variety of causes, risk factors and prevention tools. So chronic pain, for example, can have a variety of causes, hormone imbalances, hypothyroid can have a variety of causes and we need to be able to get curious and explore what is causing those. We need to reassure the person that they have control and do not have to answer questions and can stop the screening at any time and provide informed consent about the purpose of the screening, who will have access to the information and how it will be used. If you're documenting the screening at all, then you must make sure that the client does an informed consent. We can screen for depressive, dissociative or intrusive symptoms, sleep disturbances, past and present mental health symptoms, substance abuse, their social support and coping styles, availability of resources including safe housing, nutrition and medical care and their ability to access health screenings. So we want to screen the whole person ideally. But all of these screening areas can be associated with with trauma in any screening. Include questions about a history of trauma and use a checklist to increase proper identification. You can see the online Adverse Childhood Experiences Study score calculator for specific questions about ACEs. Discussing the occurrence or consequence of traumatic events can feel very unsafe and dangerous to the client as if the event were recurring. Initial questions about the trauma should be general and gradual, provide support and empowerment. Don't encourage avoidance of the topic or reinforce the belief that discussing trauma related material is dangerous. So we want to help them understand that discussing it under the right circumstances will help you feel empowered by but we need to build up to it. Just like you wouldn't lift a 50 pound weight the first day in the gym, you're going to need to develop your your strengths and your skills in order to revisit something that you know was extremely traumatic and you've already shown immense strength because you survived. By going over the answers to the screening with the client, you can gain insight into the potential function of the behaviors and issues underlying the symptoms. We also want to examine the temporal relationship of the trauma to the symptoms. Did the symptoms develop before the trauma or did all these symptoms develop after the trauma? Now, in the case of CPTSD and ongoing trauma, which symptoms developed first? And let's look at how they sort of built on each other. Don't require people to describe emotionally overwhelming traumatic events in detail. Focus the assessment on trauma specific symptoms and how they affect the client's current functioning. This is going on. It impacts you this way. All right, let's figure out how to mitigate that. When clients screen positive for trauma, also screen for suicidal thoughts and behaviors. And after the screening, reiterate how you will use the findings to make referrals and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment, I. E. Getting them to a counselor Today, if you're seeing the person for medical, addiction or criminal justice related reasons, screen for a history of exposure to trauma and for psychological symptoms and mental disorders related to trauma. And be aware that some clients will not make the connection between trauma in their histories and their current behaviors. They just they don't see the connection or may not recognize what they experienced as trauma because it's everything they've always known. Make sure that the client is grounded and safe before leaving. Readiness to leave can be assessed by checking on the degree to which the person is conscious of the current environment, what their plan is for maintaining personal safety, and what their plans are for the rest of the day. It's helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions. Grounding techniques include asking the client to describe what they observe. Help them decrease the intensity of the affect, using an emotion dial, for example, or clenching their fists and then releasing it in order to release the intensity of the emotion. Through their fingers or guided imagery, help them distract from unbearable emotional states, temporarily help them tolerate that distress. Use breathing techniques like square breathing to help them trigger that vagus nerve and the relaxation response. Ongoing screening and assessment lets providers track changes in the presence, frequency, and intensity of symptoms. Learn the relationships among the client's trauma presenting symptoms and substance use. Adjust diagnoses and treatment plans as needed, and select prevention strategies to avoid more pervasive traumatic stress symptoms. So we don't just screen one and done. We want to keep screening because as the client changes, their risk factors may change. It's not necessarily easy or obvious to identify an individual who survived trauma without A screening, a history of trauma, encompasses the experience of a potentially traumatic event, the person's response to it, and the meanings they attach to it. So it's not just the event, but it's their response to it and how they understand it. Some clients may deny that they've encountered trauma and its effects even after being screened. Okay, let's not take their power away and argue with them about it. Two main barriers to the evaluation of trauma and its related issues are us as providers overlooking trauma and its effects and assuming that it's something else and clients just not reporting trauma. Sometimes clients fail to report because they don't consider what they experience traumatic. They're afraid for their safety if they report. They fear being judged. They may feel ashamed that they were victimized. They may be reticent about talking with others in response to the trauma they've just learned to keep quiet. And they may not recall the past trauma through dissociation, denial, or repression. Now, it's important to recognize that blockage of all trauma memory is rare among trauma survivors. They may have glimpses, but they may not remember the whole thing. They may also not trust you, which if you've just met them, I don't blame them. You know, we're, they don't know us from Adam's house cat. There may be a feeling of, of reluctance to discuss something that might bring up uncomfortable feelings. Or they may be tired of being interviewed or asked to fill out forms and don't think it matters anyway. We avoid screening for trauma because those questions are not part of our program or standard intake procedures. We may underestimate the impact of trauma on the symptoms. We may believe that the treatment should focus solely on presenting symptoms rather than exploring the potential origins or aggravators of the symptoms. We may lack training or feel incompetent in effectively treating trauma related problems, or not know how to respond therapeutically to clients reports of trauma. We may fear that probing trauma will be too disturbing for clients, which is why you pace it according to their let them set the pace, not using common language with clients that will elicit a report of trauma. We may have concern that if disorders are identified, the clients will require treatment that our program doesn't provide. So oh my gosh, we're going to have to refer out, okay, do that. You know, don't worry about the dollar signs, worry about the client. They may feel that there's insufficient time for assessment to explore trauma histories and symptoms, or clinicians may have untreated trauma related symptoms themselves and not want to Go there. General instruments used to evaluate mental disorders are not sufficiently sensitive to differentiate post traumatic symptoms from other disorders. Intrusive post traumatic symptoms can show up on general measures as indicative of hallucinations or obsessions. Dissociative symptoms can be interpreted as indicative of schizophrenia instead of a trauma response. And trauma based cognitive symptoms like negativity can be scored as evidence for paranoia or other delusional processes. Overlapping symptoms with mood and anxiety disorders can also lead to misdiagnosis. We want to pay attention when we're diagnosing ADHD or borderline personality disorder that a lot of the symptoms in these disorders also overlap with PTSD and figure out whether we're dealing with PTSD or CPTSD or these disorders. Same thing is true. I know you don't want to hear it for antisocial personality. When you look at the behaviors of personality disorders that and given that they have to start being evidenced in early adolescence, you can see that a lot of times those behaviors are developed to survive really chaotic environments. Cultural factors such as norms for expressing psychological distress, defining trauma and seeking help can affect how trauma is experienced, the meaning assigned to events, how trauma related symptoms are expressed, whether they're emotional or physical, the level of emotionality, the willingness to express distress or identify trauma to providers. Some cultures say that's a no no whether a specific pattern of behavior, emotional expression or cognitive processes is considered abnormal. Different cultures have different ways of reacting and the willingness to seek treatment inside and outside of one's own culture is partly determined by one's culture. Screening and assessment Incorporate universal routine trauma informed screenings for mood disorders, pain, sleep disorders, physiological imbalances as well as trauma. We need to assess the whole biopsychosocial person. We need to familiarize the client with trauma, informed services and the impact of trauma, and create an environment that's supportive of control, collaboration, choice and autonomy to minimize the risks of retraumatization or replicating prior trauma dynamics. Are there any questions?