Assessment & Measurement

Assessing a client, especially one who has experienced trauma, can be challenging. You are looking at the whole person, in their environment, biological health, psychological health, socio-cultural aspects of their lives, spiritual aspects, strengths, challenges, protective factors, family constellation, etc. It can all be a bit overwhelming trying to ask as much as you need to during an initial assessment. The good thing is: assessment is ongoing. We don't need to cover everything all at once. While it's good to get a history, create a map of the clients micro/mezzo/exo/macro systems, determine what brought them in, and what your next steps will be, you will be uncovering aspects of all of this throughout your time with the client so I try not to be overly-concerned if we don't get to say, their spiritual life before the end of their first session. I will always be performing assessment and can cover that the next time we meet.

Some of the tools I've really liked using are listed below.

The SAMHSA Trauma-Informed Care in Behavioral Health Services Tip 57 protocol is a great starting point for my assessments. Prior to reading this protocol I hadn't been screening for trauma across the board, only as I saw indicators in intake paperwork. I used to think about trauma very differently than I do now. I used to think it was less common, when in fact it is very common (as we learned from our ACES work, 60% of people have at least one adverse childhood experience). And so, I changed my lens to a trauma-informed approach to care. I really like this Treatment Improvement Protocol (or TIP), provides great tools for how to screen and assess clients for trauma, how to pace the evaluation process, and tips for helping the client feel comfortable talking about potentially very uncomfortable topics. It includes grounding techniques to help deescalate if a client begins to get hyper-aroused (which I have used with clients and found very effective). It discusses some challenges to trauma informed care, including culture and language issues and considers how to screen clients using a cultural humility app

roach. It also includes from specific standardized measurement tools to use during screening, a few of which I've used directly with clients and found them to be quite straight-forward and helpful.

The Stressful Life Experiences Screening Tool (SLE) is 20 questions about exposure to everything from natural disasters to sexual abuse. It uses Likert-scaling to provide the level of stressfulness to the client and gives us a snapshot of what kinds of trauma they've encountered and helps us assess post-traumatic stress. It can be used to get a baseline of their post-traumatic stress and then ongoing periodically to determine if the effect of the traumatic stress is lessening over time with treatment. Similarly the Adverse Childhood Experiences (ACEs) questionnaire give us a score that we know translates to psychological & physiological issues far into adulthood (not shown). In both cases I like the length of the screening tools, but wonder if clients may be put off by how direct the questions are. In some cases there may be people who find simply answering these very intimate questions difficult to do. I would not use them during initial assessment. I'd want to get a feel for the client first and then, depending on their reactions to the Comprehensive Clinical Assessment (CCA) I would determine if I needed to build up some rapport with the client before asking some of these questions.

The Trauma History Questionnaire (THQ) is a good assessment tool for determining exposure to traumatic events. What I like about it is it doesn't just ask 'did you experience these things' but how many times and at what ages. While we wouldn't use all of these tools, we would determine which one, maybe two would be most relevant, it's good to have several different options to tailor the tool and approach to the client.

Assessing positive attributes is also beneficial with clients. The Resilience Scale (also for Adults, not shown) is a good tool to determine how a client sees their protective factors. It's been shown to be a valid and reliable method of self-reporting (Hjemdal, et al, 2011). I really love drawing the client's attentions to their strengths. It can be a reminder that they have skills already that can help them cope with their trauma. I would use this in tandem with one of the trauma screeners to show clients that, while they may have a high level of post-traumatic stress due to experienced events, they also may have skills they don't realize could be beneficial to ongoing treatment and management of traumatic stress symptoms and together those two tools could guide our future treatment.