D3 - CT

Briere, J. & Scott, C. (2025). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment(3rd ed.). Sage Publications. ISBN: 9781544333557. Chapter 3 ASSESSING TRAUMA AND POSTTRAUMATIC OUTCOMES: JOHN BRIERE, ERIN EADIE, & CATHERINE SCOTT Chapter 2 outlined the various symptoms, difficulties, and disorders that can arise from trauma exposure. The current chapter describes a number of ways in which these posttraumatic outcomes—and the events that produced them—can be assessed. We strongly encourage the use of empirically validated assessment instruments and structured diagnostic interviews. The reader is referred to Eadie and Briere (in press) for an extensive discussion on the use of trauma- relevant trauma measures. However, it is also true that most real-world clinical assessments occur in the context of less formal, relatively unstructured interchanges between the client and clinician during an intake session. Although more subjective, and thus potentially more prone to interpretative error, observation of client responses can yield important, sometimes unique, information that has direct implications for subsequent treatment. For this reason, we begin with the clinical interview and then move on to the application of more standardized methodologies. ASSESSMENT IN THE CLINICAL INTERVIEW Immediate Concerns Most of this chapter describes assessment approaches that allow the clinician to evaluate specific trauma-related symptoms or dysfunction. Such assessment is necessary to ensure that whatever interventions occur are best suited to the client’s specific needs. However, the evaluation of the client’s immediate level of safety, psychological stability, and readiness for further assessment and treatment is even more critical. Life Threat The first focus of assessment in any trauma-related situation is whether the client is in imminent danger of loss of life or bodily integrity or at risk of hurting others. This includes—in the case of immediate accident, disaster, or physical attack—assessment of whether the client is medically stable. In cases of ongoing interpersonal violence, it is also very important to determine whether the client is in danger of victimization from others in the near future. Most generally, the hierarchy of assessment is as follows:

1. Is there danger of imminent death (e.g., by bleeding, internal injuries, toxic or infectious agents) or immediate danger of loss of limb or other major physical functioning?

2. Is the client incapacitated (e.g., through intoxication, brain injury or delirium, severe psychosis) to the extent that they cannot attend to their own safety (e.g., wandering into streets or unable to access available food or shelter)?

3. Is the client acutely suicidal?

4. Is the client a danger to others (e.g., homicidal or making credible threats to harm someone), especially when means are available (e.g., a gun)?

5. Is the client’s immediate psychosocial environment unsafe (e.g., are they vulnerable to maltreatment or exploitation by others)?

When any of these issues are present, the first goal of trauma intervention is to ensure the physical safety of the client or others, often through referral or triage to emergency medical or psychiatric services, law enforcement, or social services. It is also important, whenever possible, to involve supportive and less affected family members, friends, or others who can assist the client in this process. Psychological Stability and Stress Tolerance A common clinical error is to immediately assess for psychological symptoms or disorders in a trauma survivor without first determining their overall level of psychological homeostasis. Individuals who have recently experienced a traumatic event, such as a rape or mass disaster, may still be in a state of crisis at the time of assessment—in some cases psychologically disorganized to the extent that they are unable to fully comprehend their current situation, let alone respond to a clinician’s inquiries or interventions. In such instances, as is true with some cases of debilitating longer term trauma impacts, psychological assessment may further challenge the survivor’s fragile equilibrium, and can lead to compromised assessment results (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). For this reason, the first step in the mental health evaluation of trauma victims should be to determine the individual’s relative level of psychological stability. When it appears that the client is overwhelmed or cognitively disorganized, stabilizing interventions (e.g., reassurance, psychological support, grounding exercises, or reduction in the level of environmental stimuli) should be provided before more detailed evaluation is pursued. In some cases, although the trauma survivor may appear superficially stable following a traumatic event, they may suddenly display extreme distress, intrusive thoughts or sensations, or outbursts of anger when faced with even superficial inquiry about the event. As described later in this chapter, these reactions are referred to as activation responses—intense, often intrusive, trauma-specific psychological states that are triggered by reminders of the traumatic event. Although some level of activation is normal—even desirable—during treatment, and most survivors in research studies do not report significant negative effects of trauma evaluation, per se (Carlson et al., 2003; Griffin et al., 2003), assessment-related activation may be psychologically challenging if the individual does not have sufficient capacities to internally regulate their distress. As a result, it is important to determine the extent to which trauma issues can be discussed with a given survivor without unduly “retraumatizing” them. When excessive activation is likely, it is usually preferable to at least temporarily defer significant questions about—or discussion of—traumatic material (Najavits, 2002; SAMHSA, 2014). The decision to avoid significant discussion of trauma with a trauma survivor should be made carefully, however, given the often-helpful effects of talking about traumatic memories and the sometimes- immediate need for assessment. Assessing Trauma Exposure

Once the clinician has determined that the client is safe and reasonably stable, the specifics of trauma exposure and response can be investigated. In many cases, the clinician begins by asking about the traumatic event or events, including the nature of the trauma and its characteristics (e.g., severity, duration, frequency, level of life threat). Because it is logical to start with events and then move on to outcomes, assessment of trauma exposure is presented here before the assessment of trauma effects. In some cases, however, the client’s emergent psychological state is obviously of greater initial concern than how they got that way. For example, except in some forensic situations, the evaluation of an acute rape victim often will focus more immediately on their emotional functioning and psychological symptoms than on the specifics of the assault itself. In other cases, however, especially when the trauma is further in the past and the client is not currently acutely distressed, it is reasonable to begin with a trauma history. Although one might assume that traumatized individuals easily disclose the events that bring them to therapy, this is not always the case. In fact, several studies indicate that trauma survivors are often reluctant to volunteer detailed (or any) information in this area unless directly asked, due to embarrassment, a desire to avoid reactivating traumatic memories, or the clinician’s own avoidance of such information (Agar & Read, 2002; SAMHSA, 2014). We recommend that each client, whatever the presenting complaint, be assessed for trauma history as part of a complete mental health evaluation. At what point in the assessment this occurs will vary according to the clinical situation. Often, as described previously, traumatized clients present with a chief complaint, such as depression, suicidality, generalized anxiety, or unexplained panic attacks, that does not obviously include the trauma. In such cases, it is advisable to explore with the individual the symptoms that bring them in for treatment before delving into the possibility of trauma exposure. This allows the client to develop an initial sense of trust and rapport with the evaluator, before answering what may be perceived as intrusive (if not irrelevant) questions about traumatic experiences. Many people, especially those who have never before been evaluated by a mental health professional, respond to questions about trauma history, particularly interpersonal victimization, with embarrassment and/or guardedness. It is not uncommon for clients to ask, “Why do you need to know that?” upon being queried about specifics of their trauma history. Victims of interpersonal violence who have been repeatedly hurt and betrayed by others may be especially reluctant to share intimate details with an evaluator who they have just met. Even those clients whose chief complaints are related to a particular acute or past traumatic event may balk at being asked other questions about their past. The victim of an earthquake who complains of acute anxiety, for example, may not want to answer questions about child abuse, feeling that such details are not relevant to their current situation. Likewise, the recent victim of a sexual assault may interpret questions about other sexual assaults and childhood sexual abuse as implicit criticism from the evaluator, or as a subtle message that they in some way “ask” to be victimized. Considering such concerns, general guidelines for assessment of trauma exposure include the following:

Establish an initial level of trust and rapport before assessing trauma

Spend some time at the beginning of the assessment interview exploring the client’s overt reason for presenting for clinical services, whatever it may be Ask questions in an empathic and nonjudgmental manner Become comfortable talking about details of sexual abuse and violence experiences with clients—victims of interpersonal traumas may be especially sensitive to nuances in the clinician’s voice and body language. For example, some clients may avoid reporting disturbing experiences if they believe that the clinician will be too upset by such material or will make negative judgments Use behavioral definitions. For example, a woman who was sexually assaulted and forced to perform oral sex on a man but was not vaginally penetrated may not believe that she was in fact raped. It is rarely sufficient to ask, “Were you ever raped?” Instead, a better question might be, “Did anyone ever do something sexual to you that you didn’t want, or make you do something sexual to them?” Remember that trauma is deeply personal and that the client may fear being stigmatized. During a trauma-focused interview, clients may disclose information that they have never told anyone before. The clinician should keep this possibility in mind and respond to such disclosures with visible support Be aware that disclosure of trauma history may bring up intense feelings, including shame, embarrassment, and anger. Clients may respond in a variety of ways—some may cry, others may become agitated and anxious, and some may withdraw. Still others may become irritable and even hostile toward the interviewer. In such contexts, gentle support and validation of the client’s feelings and reactions may be especially important Repeat assessments as necessary—some clients may not disclose certain trauma-related information at the initial evaluation, but may do so later, when they feel more comfortable with the clinician and the treatment process

Some evaluators find it helpful to preface questions about trauma exposure with an opening that frames assessment in a supportive and nonjudgmental context. Examples of such opening statements might include these:

“If it is okay with you, I’d like to ask you some questions about your past. These are questions that I ask every client/patient I see, so I can get a better sense of what [he/she/they] have been through.” “I’d like to ask you some questions about experiences you may have had in the past. If you feel uncomfortable at any time, please let me know. Okay?” “Sometimes people have experienced things in their pasts that affect how they are feeling now. If it is okay, I’d like to ask you some questions about things that may have happened to you.”

Other clinicians prefer to integrate assessment of trauma history into the flow of the initial interview. What follows are two examples of how this might be accomplished with different clients. These examples are not intended to provide an exhaustive list of potential trauma exposures; rather, they illustrate ways of approaching traumatic material in a nonthreatening and organic way in the context of a mental health evaluation.

For those clients who appear reluctant to discuss interpersonal information, a trauma history can be gathered at the same time as medical history is assessed. This formalizes the questioning and places it in the context of other, more routine questions that are generally experienced as both necessary and nonthreatening. The flow of questions in such a scenario might follow a pattern such as this:

– “Do you have any medical problems?” – “Are you in any physical discomfort right now?” – “What medications are you currently taking?” – “Do you have any allergies to medications?” – “Have you ever had any surgeries?” – “Have you ever been in a car accident? Were you injured? Did you receive medical attention?” – “Have you ever been in a disaster, like a fire, earthquake, or flood? Were you injured? Did you receive medical attention?” – “Have you ever had a head injury? Did you lose consciousness? Did you receive medical attention?” – “Have you ever witnessed a violent event, such as a shooting?” – “Have you ever been assaulted by anyone? How old were you? Were you injured? Did you receive any medical attention afterward?” – “Has anyone ever forced you to do something sexual against your will? Has anyone ever touched you sexually in a way that made you feel uncomfortable? Did you receive medical attention for this?” [Follow with childhood trauma exposure questions.]

For those patients who are willing to discuss their family and relationships, an alternative scenario for questioning might follow a different pattern:

– “Where did you grow up?” – “What was your childhood like?” – “Who did you grow up with?” – “When you were a child, what was home like?” – “Were both parents at home?” – “Did you witness any violence at home when you were a child?” – “How were you punished when you were a child?” – “When you were a child was anyone harmful or abusive to you in any way?” (In some cases, this question alone will prompt the client to report all of their childhood abuse experiences.) – “Did anyone ever do anything sexual to you when you were a child, or make you do something sexual to them?” [Follow with more detailed childhood trauma questions.] – “Have you ever been in a car accident? Were you injured? Did you receive any medical attention afterward?” – “As an adult, were you ever attacked by anyone? How old were you? Were you injured? Did you receive any medical attention afterward?” [Follow with other adult trauma questions.]

Given potential client reluctance in this area, and the likelihood that some traumas will be overlooked in an informal assessment interview, trauma assessment is probably best accomplished when the clinician refers to a predefined list of potential traumas during the evaluation interview and episodically thereafter. This structured approach ensures not only that trauma exposure will be formally assessed, but also that all relevant types of trauma will be explored. Included in Appendix 1 of this book is an instrument that can be used to evaluate the client’s life history of traumatic events: the Trauma Exposure Review (TER; Briere, 2023). This is a behaviorally anchored, semi-structured interview that allows the clinician to assess most major forms of trauma exposure that can also be administered as a self-report test. When used as an interview, the clinician should feel free to paraphrase the items of the TER in such a way that the process is supportive and nonstigmatizing, and to add any additional traumas that are relevant to the client’s situation. There are also a number of other instruments available in the psychological literature that the clinician may use to review a client’s trauma history, including the

Trauma History Questionnaire (Hooper et al., 2011) Psychological Maltreatment Review (PMR; Briere et al., 2012) Stressful Life Events Screening Questionnaire (Goodman et al., 1998) Trauma History Screen (Carlson et al., 2011) Life Events Checklist for DSM-5 (Weathers et al., 2013) Adverse Childhood Experiences Scale (ACES; Felitti et al., 1998) Complex Trauma Questionnaire (ComplexTQ; Vergano et al., 2015) Deployment Risk and Resilience Inventory-2 (DRRI-2; Vogt et al., 2013)

In addition, some psychological tests of traumatic stress include reviews of traumatic events, as described later in this chapter. ASSESSING THE SOCIOCULTURAL ENVIRONMENT An important element of any good trauma assessment is consideration of sociocultural and environmental factors that might impact the client’s experience of trauma and expression of its effects. In various familial, cultural, and historical contexts, an individual may be more or less likely to experience a traumatic event(s) and may interpret these experiences differently based on culture, environmental influences, and the effects of social discrimination (e.g., Mekawi et al., 2021). Information elicited by specific questions about the impact of sociocultural factors can provide much needed context to the rest of an assessment. Some of these questions, rephrased as needed, could continue from, or be integrated with, the previous series of questions on family and relationships.

– “When you were a child, how was it at home? Did you feel safe?” – “Was it ever dangerous outside of your home?” – “Did you ever feel like you were treated differently than other kids because of your race or sex, sexual orientation, or appearance?” – “Did kids make fun of you when you were young? What did they say? Were you ever bullied?”

– “Is/was it important in your family that you acted like a “regular” boy or girl or man or woman?” – “Did you attend any religious services growing up? Did you engage in any religious or spiritual practices at home? Do you now?” – “Where did your parents grow up?” (ask about each parent separately to get a more complete answer) – “Did your parents experience any stressful or traumatic events when they were young? Have any bad things happened to them as adults?”

Along with the example questions above, paraphrased as needed, the reader also may want to consider any immigration and immigration authority experiences relevant to the client as well as historical traumas impacting their family members or members of their cultural group (e.g., war, racism, genocide, honor killings, or enslavement). Also relevant to the process and interpretation of the assessment are any sociocultural influences on the client’s verbal and nonverbal communication. Some examples include the level of emotional expression that is typical or considered acceptable in the client’s culture, topics that are stigmatized or taboo and thus impact if and how they will be discussed, and gender-based rules impacting how a client may interact differently with a clinician of the same or other gender. A final set of considerations pertains to the client’s current, rather than historical, social environment. Clinicians should take care to assess and consider the level of safety or stressors in the client’s home and community environment, including the presence of community violence, social marginalization, children potentially at risk, and poverty. As discussed in Chapter 3, the current level or risk of violence in the client’s home is likely to impact their presentation during the assessment and the information they are willing to disclose. For example, a woman living in the context of ongoing partner abuse may be reluctant to share this fact with the clinician, lest that increase the level of danger she experiences. Beyond the immediate home environment, other issues pertaining to safety might include the following:

Current experiences of micro- or macro-aggressions based on race, gender, sexual orientation, or social class Risk or experience of sex or labor trafficking Membership in or affiliation with a gang History of incarcerations Harassment or maltreatment by law enforcement Perceived sense of safety within a health or mental health care environment

ASSESSING CURRENT AND PAST EXPOSURE TO DISCRIMINATION AND MALTREATMENT (SDM) As noted earlier, SDM has existed for centuries and is widely prevalent in North American culture (Harvard Public Health, 2018). Whether associated with life-threat (e.g., hate crimes, including violence against people of color or those identifying as LGBTQ+), or noncontact social maltreatment (e.g., taunts, shaming, nonphysical bullying), SDM has been associated with the broad range of adverse psychological outcomes described in Chapter 2. For this reason, past and

present exposure to SDM should be evaluated in the same ways as are more classically described traumatic events such as sexual assault or exposure to a disaster. As noted by the American Psychological Association (2022), clinicians “should be prepared to assess lifetime discrimination experiences, and to address an individual’s reactions to these experiences in a therapeutic manner” (p. 18). Although there are a number of SDM exposure measures in the literature, many have not been validated in clinical populations other than the Race-Related Stressor Scale (RRSS: Loo et al., 2001). Among these are

Schedule of Sexist Events (SSE; Klonoff & Landrine, 1995) Experiences of Discrimination (EOD; Krieger et al., 2005) Daily Heterosexist Experiences Questionnaire (DHEQ; Balsam et al., 2013) Social Discrimination and Maltreatment Scale (SDMS; Briere et al., 2024a)

Unfortunately, many SDM measures appear to have suboptimal psychometrics (Briere et al., 2024a) and may require further refinement before they can be used in clinical contexts. Included in Appendix 2 is the Social Discrimination and Maltreatment Scale—Short Form (SDMS-SF; Briere, 2023; Briere et al., in press), consisting of the 18 items and response options that best represent scores on the full SDMS (Briere et al., 2024a). Clinicians are free to use the SDMS or SDMS-SF in their trauma assessment battery. Notably, although this scale appears to be reliable and valid, it only evaluates exposure to sexism, racism, and cisheterosexism. Clinicians may choose to expand this measure to assess other forms of SDM, for example antisemitism, Islamophobia, or maltreatment based on body shape or size (see Briere et al., in press). EVALUATING THE EFFECTS OF TRAUMA For the purposes of this book, the effects of trauma can be divided into two categories: process responses, involving trauma effects that are readily determined during the interview, and symptom responses, involving the more classic markers or forms of psychological disturbance. Process Responses Considerable information may be gained by observing the traumatized client’s behavior during the clinical interview or therapy session. Because this form of assessment is based on the clinician’s perceptions, and thus is influenced by both clinical experience and personal subjectivity, data gathered in this manner are not always as valid as the results of standardized testing. On the other hand, the alert and perceptive evaluator often can discern things that are rarely, if ever, tapped by psychometric tests. Such information can be divided into four areas: activation responses, avoidance responses, emotional dysregulation, and relational difficulties. Activation responses. As described in Chapter 9, activation responses are the sudden emergence of posttraumatic emotions, memories, and/or cognitions in response to some sort of triggering stimulus. Some of these responses may be sensory reexperiencing of the traumatic event; in other cases, the response is less extreme, involving sudden emotional distress or anxiety. Although extreme activation is generally to be avoided, in most cases lower levels of such responses can

provide information regarding both severity of the client’s current posttraumatic stress and the degree to which their trauma memories can be readily activated by the external environment. Typically, the therapist’s intent is not to trigger activation, but rather to be alert to its emergence during the interview or during therapy. For example, the clinician interviewing a burn patient in their hospital room a week after a fire may watch carefully for changes in facial expression, tone of voice, verbal content, or even respirations when the patient is gently asked about their trauma experience. Or a child sexual abuse survivor may be observed for changes in emotion, body position, eye movement, or verbal syntax while they discuss a childhood molestation experience. When the trauma is relatively recent, a moderate level of activation is often a good sign, indicating that the client is not in a highly avoidant or numbed state and that their traumatic material is available for internal processing. Especially easily triggered and intensely experienced activation, however, may suggest more severe posttraumatic stress and indicate that unwanted intrusive symptoms can be triggered by a wide variety of stimuli in the environment. For example, immediate startle and panic in response to a moderately loud noise, like a door closing or a truck driving by, could suggest a state of hyperreactivity. In a similar vein, easily triggered activation in chronic traumatic states (e.g., tearfulness and distress in a combat veteran when discussing war experiences that occurred 30 years ago) may indicate inadequate processing, since, in the uncomplicated case, posttraumatic stress tends to resolve—or at least decrease—naturally over that time period. The attuned examiner or therapist may find that consistent attention to an individual’s emotional, verbal, and motor reactivity to trauma cues provides continuous information regarding (1) the level of posttraumatic stress the person is experiencing, and (2) the extent to which trauma reexperiencing is being blocked through dissociation or other avoidance responses. Information regarding the client’s level of posttraumatic activation not only can assist in diagnosis and assessment, but it may also indicate their expected level and type of response to the exposure component of trauma therapy. Avoidance responses. Observational assessment of avoidance in trauma survivors generally involves attention to both inferred underactivation—the relative absence of expected activation—and the visible presence of avoidance activities. In the former case, avoidance can be hypothesized when activation would be expected (e.g., in a recent sexual assault victim) but where little or no significant emotional reactivity is observed (e.g., describing the event in an especially detached or overly matter-of-fact manner). In the latter, the clinician is able to detect direct evidence of dissociation or substance use, or the client informs the clinician of effortful avoidance (e.g., no longer driving a car after a motor vehicle accident). Underactivation can occur as a result of a number of different defensive responses that are not, by themselves, visible, although their effects may be inferred. They include the following:

Emotional numbing. The client displays reduced emotional reactivity to trauma triggers as a result of severe posttraumatic stress (see Chapter 2). Intellectualization. The survivor tends to focus on facts and abstract analyses as a way to avoid or deflect upsetting thoughts, feelings, and memories related to a trauma.

Dissociative disengagement. The client engages in subtle cognitive-emotional separation or disengagement from potentially upsetting stimuli (e.g., by not understanding obvious questions or seeming somewhat distant interpersonally), but does so without exhibiting major signs of dissociation, per se. Thought suppression. The client cognitively blocks or suppresses emotionally upsetting thoughts or memories, often observable as sudden lapses in discourse or reports of inadequate memory. Denial. The client acknowledges the traumatic event but develops a theory or perspective that reduces the perceived threat or seriousness associated with the trauma. Anxiolysis without obvious intoxication. The client uses a psychoactive substance (e.g., alcohol or a benzodiazepine) prior to the session that is not evident during treatment or evaluation but that blocks anxious responses to trauma triggers.

Underactivation is often both difficult to identify and hard to pin down in terms of the specific mechanism involved. For example, when a trauma survivor presents as less upset than the circumstances might warrant (e.g., a calm and nontraumatized demeanor one day after involvement in a major automobile accident with fatalities), potential mechanisms include those listed as well as the possibility that the client is not engaging in avoidance at all, but, instead, is especially resilient to stress. Despite this uncertainty, the experienced trauma clinician learns to discriminate various types of defensive avoidance strategies from resilience, whether through increased sensitivity to subtle avoidance mechanisms or through a growing sense of when a posttraumatic response would logically occur. A less experienced assessor should be aware of the risk of misjudging underactivation as a sign of resilience or healthy coping and take steps to examine the evidence carefully. Explicit signs of avoidance, on the other hand, usually involve the use of mechanisms that are visible to the clinician or are expressed directly. Most typically, these include the following:

Visible dissociative symptoms. The client “spaces out,” demonstrates obvious fixity of gaze (e.g., the “thousand-mile stare”), moves in a disconnected manner, or occasionally seems to enter a different identity state. Self-reported dissociation. The client describes symptoms such as depersonalization (e.g., out-of-body experiences) or derealization (e.g., feeling like they are in a dream). Intoxication. The client comes to the session visibly intoxicated on drugs or alcohol. Effortful avoidance. The client describes behaviors consistent with the effortful avoidance cluster of PTSD symptoms, such as avoiding people, places, or situations that might trigger posttraumatic intrusions or distress. Effortful avoidance is also evidenced in the session by visible attempts to avoid discussing traumatic material. Missed sessions also may reflect effortful avoidance.

The excessive presence of emotional avoidance, in the evaluation or treatment session or elsewhere, typically signals a greater likelihood of posttraumatic stress (e.g., Jones & Ollendick, 2005), cognitive distortions (especially self-blame; Korem et al., 2023) an increased chance of chronicity (e.g., Muller et al., 2018), and potentially greater difficulties dealing with the exposure component of therapy (Zoellner et al., 2011). In addition, client reports of effortful avoidance may indicate specific areas in which the client is having especially intrusive experiences (e.g.,

avoidance of sexual activity because it triggers flashbacks to a sexual assault). Such information may allow the clinician to explore reliving PTSD symptoms that otherwise might not be identified or disclosed. It is important to reiterate, however, that avoidance is typically a coping response that the survivor uses to maintain psychological stability in the face of potentially destabilizing trauma memories and associated cognitive and emotional sequels (Korem et al., 2023). As a result, although such responses typically indicate traumatic stress, they are not necessarily maladaptive at the moment they occur—especially early in the recovery process. Emotional dysregulation. Some trauma survivors are prone to visible difficulties in emotional regulation. Emotional regulation refers to the individual’s relative capacity to tolerate painful internal states (emotional tolerance) and to internally reduce such distress without resorting to dissociation or other avoidance techniques (emotional modulation). Emotional regulation problems appear to arise from, among other phenomena, extreme and/or early trauma exposure and, as noted earlier, are associated with subsequent distress-avoidance symptoms such as substance abuse, dissociation, impulsivity, reactive aggression, suicidality, and self-injurious behavior (e.g., Briere et al., 2010; Gratz, 2003; van der Kolk et al., 2005). Individuals with reduced emotional regulation capacities may be less able to process traumatic memories in therapy without becoming overwhelmed by the associated painful emotions. The risk of overwhelming trauma survivors with too much therapeutic exposure is of sufficient concern that some clinicians (e.g., Cloitre et al., 2002; Ford et al., 2005) consider emotional dysregulation to be a central issue for this population. In other cases, typically when the trauma is less severe and occurs later in life, emotional regulation difficulties may be less relevant. In any case, a complete assessment of the trauma victim should include such issues so that the treating clinician can either address them in therapy (see Chapter 6) or be satisfied that otherwise effective therapy is unlikely to retraumatize the client. Problems with emotional regulation may be identified in the assessment or therapy session by any of the following signs: Mood swings that are not attributable to a bipolar or cyclothymic disorder Very short (e.g., measured in hours), yet symptomatically intense depressive episodes that seem to resolve spontaneously Sudden, extreme, emotional distress during the session, with apparent difficulty calming down or shifting to a more positive emotional state thereafter A tendency to act out, self-injure, become aggressive, make suicide attempts or gestures, or otherwise engage in sudden distress-reduction behaviors when upset or distressed Reports of long-term substance abuse or dependence Sudden dissociative responses in the context of strong emotionality Relational disturbance. Relational information is obtained in the interview by observing the client’s responses to the clinician and to the therapy environment. Such information can also be extracted from the content of client disclosures regarding important others in their life. In general, these responses signal underlying cognitive schemas, assumptions, and beliefs (as well as their associated affects) that the individual carries regarding important interpersonal figures and relationships.

Alertness to interpersonal danger. Because many trauma survivors have been hurt, betrayed, or otherwise maltreated in interpersonal relationships, they may respond to evaluation or treatment with hypervigilance to physical or emotional danger. In extreme cases, this response may take on nearly paranoid proportions: The recent victim of torture or rape may covertly examine the clinical setting for possible weapons, spy holes, or hiding places for other people; the refugee from a totalitarian state may scrutinize the clinical process for evidence of governmental collusion; the stalking or battering victim may voice fears that they were followed to the session or that the clinician is in communication with their perpetrator; and the war veteran may position themself for ready access to the nearest exit. Although such responses are not always part of the clinical presentation of trauma survivors, even those less severely affected may display signs of hyperalertness to potential aggression, boundary violation, unfair criticism, or other potential dangers. The client may question the evaluator or therapist regarding their intentions, the appropriateness or relevance of various assessment questions, and the intended use of the information gathered from the session. Sexual trauma and trafficking survivors may evidence special distrust of male interviewers, those with highly punitive parents may be hypersensitive to the possibility of negative evaluation by the clinician, and those exposed to micro- or macroaggressions may be especially vigilant or wary when interacting with dominant-group therapists. Although the presence of such preoccupations may indicate a specific sensitivity to evaluation and interactions with authority figures (Briere & Lanktree, 2012), the fact that danger schemas are easily triggered in the survivor may signal a generalized expectation of potential injury in interpersonal situations and is, most basically, a reflection of posttraumatic stress. Abandonment issues. Individuals with histories of childhood neglect, disattunement, or rejection may signal abandonment concerns or sensitivity to rejection during assessment and treatment—both by their description of significant others in their lives and by their responses to the clinician. There may be a preoccupation with themes of needing people or relationships (sometimes regardless of the valence or health of those connections), fears or expectations of abandonment or loss in relationships, or historical renditions that seem excessively characterized by being left or rejected. In the session, clients with abandonment preoccupation may become especially attached to the clinician, even over a very short period of time; they may be reluctant to allow termination of the interview and may seem especially “clingy” or dependent. On occasion, they may express anger or despair regarding the examiner’s perceived insufficient caring or support and the brevity of the evaluation or therapy session, or concern that the clinician is not sufficiently attuned to their emotional experience. Also common is the tendency for clinician unavailability (e.g., while on vacation or during personal emergencies) to trigger abandonment schema and produce anger or despondency. As might be expected, it is not always easy to detect abandonment fears in the evaluation interview or the first sessions of treatment—it may only be later in psychotherapy that the client’s underlying preoccupation with relationships and avoiding abandonment or rejection becomes clear. As noted in Chapter 10, however, such issues are highly relevant in work with those who were neglected or maltreated early in life. Not only do they represent potential sources of distress and conflict as the client encounters the constraints of the treatment process, but the

underlying dysfunctional schema they reflect are important targets for psychological intervention. Need for self-protection through interpersonal control. The experience of helplessness that arises from interpersonal victimization may lead to a later need for personal control in relation to others. Often, this manifests as an insistence on autonomy, a tendency to micromanage one’s interactions with others so that one’s own safety and self-determination are intact, and negative responses to control, perceived manipulation, or influence by other people. This interpersonal style may also manifest as difficulty with authority figures who, by definition, have some degree of implicit control over the trauma survivor. Those individuals with a high need for control may engage in behaviors that seek to maximize their own autonomy during interpersonal interactions—including those that take place in the evaluation or treatment session. For example, the trauma survivor may attempt to control the session by speaking in a continuous manner, thereby keeping the clinician from exerting verbal influence over the assessment or treatment process. In such instances, interruptions by the therapist may be ignored or may prompt irritation or anger. Similarly, the client may resist interview questions that lead away from whatever topic they are discussing, often viewing the clinician’s desire to gain historical or psychological information as an attempt to overtake the client’s agenda or autonomy. Such behaviors arise from a fear of being revictimized by others and often reflect underlying relational anxiety—a posttraumatic state that leads to interpersonal rigidity and sometimes an almost compulsive self-protectiveness. Signs of a need for interpersonal control should be viewed as potential evidence of a history of (1) highly controlling, intrusive, or abusive caretakers earlier in life; (2) early emotional neglect associated with a chaotic childhood environment; and/or (3) later trauma experiences that were especially characterized by extended helplessness, such as torture or forced confinement. The immediate implications of this interpersonal style are for the assessment process itself. It may be quite difficult to steer the control-focused survivor into domains that the clinician (but not the client) feels are important to evaluate and treat, including current symptomatology, prior history, and level of interpersonal functioning. Clinical experience suggests that the clinician will be most effective in this regard to the extent that they do not overly challenge the client’s need for interpersonal control, but rather works to reassure them—both verbally and nonverbally—of the benign intent of the clinical process. In some cases, this will require considerable patience on the part of the clinician. Symptom Responses Above and beyond the process signs of trauma response presented thus far, an obvious goal of trauma assessment is to determine the client’s current mental status and level of psychological functioning, and to inquire about the major symptoms known to be associated with trauma exposure. During a full psychological work-up, whether trauma focused or otherwise, the client should ideally be evaluated for the following issues or symptoms:

Altered consciousness or mental functioning (e.g., dementia, confusion, delirium, cognitive impairment, or other organic disturbance) Psychotic symptoms Self-injury Suicidal thoughts and behaviors Potential danger to others Mood disturbance (e.g., depression, anxiety, anger, bipolar disorder) Substance abuse or addiction Personality dysfunction Reduced ability to care for self

In combination with other information (e.g., from the client, significant others, and outside agencies or caregivers), these interview data provide the basis for diagnosis and an intervention plan in most clinical environments. However, when the presenting issue potentially includes posttraumatic disturbance, the classic mental status and symptom review is likely to miss important information. Individuals with significant trauma exposure—perhaps especially victims of violence—do not always disclose the full extent of their trauma history or their posttraumatic symptomatology unless directly asked, and thus require specific, concrete investigation in these areas. When there is a possibility of trauma-related disturbance, the assessment interview should also address as many (if not all) of the following additional components as is possible, many of which were outlined in the previous chapter:

Symptoms of posttraumatic stress Dissociative responses Sexual disturbance (especially in survivors of sexual abuse or assault) Trauma-related cognitive distortions Prolonged grief responses Distress-reduction activities Transient or chronic posttraumatic psychotic reactions Culture-specific trauma responses

This list may be more comprehensive than necessary for certain posttraumatic presentations (e.g., that of a motor vehicle accident survivor), although most of the components may be appropriate for chronic traumas (e.g., extended child abuse or torture). Some review of these symptoms is usually indicated in a comprehensive evaluation, even if it is followed by a more structured diagnostic interview. The assessment of the reexperiencing and dissociative symptoms associated with posttraumatic stress can be challenging, especially if the client has not described their symptoms to anyone before and views them as bizarre or even, perhaps, psychotic. Both reexperiencing and dissociation involve a change in level of consciousness and awareness of one’s surroundings, which can be difficult to put into words. Suggested interview approaches and questions in this area are presented next.

Posttraumatic nightmares. Some clients may not report nightmares that they only indirectly associate with the trauma in question—as a result, asking simply if they have nightmares about the event may not be sufficient. For example, a rape victim may not dream about the rape, but may have nightmares about being chased down a dark alley or about being attacked by animals or evil spirits. Clarifying questions may include these:

– “Do you have bad or frightening dreams?” – “What are your dreams about?” – “Do you ever dream about bad things that have happened to you?”

Flashbacks. Some clients will not know the meaning of the word flashback and may need a more descriptive explanation. More detailed questions include these:

– “Do you ever have visions of the [trauma] that flash or pop into your mind?” – “Do you ever see things in your mind that have happened to you?” – “Do you ever feel like the [trauma] is still happening to you?” – “Do you ever feel like you are reliving the [trauma]?” – “Do you ever hear the voice of the person who hurt you?” – “Do you ever hear the sound of the [gunshot/accident/war/other trauma]?”

Intrusive thoughts. Some clients report intrusive or ego-dystonic thoughts that intrude “out of nowhere” and are a major source of ongoing preoccupation. Questions that may assist in the exploration of such cognitive symptoms include these:

– “Do you think about the [trauma] a lot? All the time?” – “Do you have times when you can’t get the thought of the [trauma] out of your mind?” – “Does thinking about the [trauma] make it hard for you to concentrate on other things?” – [For those with associated insomnia] “When you can’t sleep at night, are there thoughts that keep you awake?”

Dissociation. Because dissociation is an internal process that may be difficult for the client to express to others, the clinician often can assist the clients by asking questions specific to the dissociative experience. Broken down by symptom type, these include the following, most of which overlap:

Depersonalization – “Do you ever feel like you are outside of your body?” – “Do you ever feel that you can’t recognize parts of your body, or that they change size or shape?” – “Do you ever feel like you are watching things that happen to you from outside of yourself?”

Derealization – “Do you ever feel like you are living in a dream or a movie?” – “Do you ever feel like people or things around you are not real?”

Fugue states

– “Have you ever found yourself somewhere far away and wondered how you got there?” – “Have you ever traveled a significant distance from home without realizing it?”

Cognitive-emotional disengagement – “Do you ‘space out’ while at work or at home and lose track of what you are doing?” – “Do other people tell you that you sometimes seem ‘a million miles away’ or ‘out of it’?”

Amnesia or missing time – “Are there important things in your life that you can’t remember very well or at all?” – “Do you ever have experiences where you ‘zone out’ for a few minutes and then find out that a much longer amount of time has passed?”

Identity alteration – “Do people ever say that sometimes you act like a different person or use a different name?” – “Do you ever feel like there are different people inside you?”

Psychosis in the Context of Posttraumatic Response Because dissociation and posttraumatic stress can sometimes involve reduced contact with—and altered perceptions of—the external environment, discriminating such responses from the symptoms of psychosis is not always easy. At times, the boundaries between posttraumatic reexperiencing and hallucinations; between reasonable posttraumatic fears, overvalued ideas, and paranoid delusions; and between anxiety-related cognitive fragmentation and frank thought disorganization may become blurred. In some cases, severe trauma-related dissociation may appear nearly indistinguishable from withdrawn, internally preoccupied psychotic states. Finally, research indicates that some psychotic presentations include dissociative and posttraumatic features (e.g., Renard et al., 2017), either because psychosis, posttraumatic stress, and dissociation share traumatic etiologies, or because psychosis is sufficiently threatening that it may traumatize and motivate dissociation as an avoidance strategy. Given this complexity, it is important to exercise caution before jumping to the conclusion that a trauma survivor is psychotic (Brand et al., 2019), or, for that matter, someone who exhibits disorganization and reduced responsiveness is necessarily dissociating—not the least because some treatments for psychotic disorders are not typically effective for posttraumatic stress, and the reverse. In some instances, the clinical presentation may be so ambiguous as to make a definitive determination impossible; in such cases, clients should be carefully followed in treatment with frequent reassessments. In differentiating psychosis from posttraumatic stress, the following, if present, may suggest a posttraumatic rather than psychotic process: Reexperiencing as opposed to hallucinations

– The content of the perceptions is trauma related (e.g., hearing the voice of the perpetrator or another sound associated with the trauma). Note, however, that a prior

trauma history can affect the content of bona fide psychotic hallucinations and delusions as well. – The perceptions occur in the context of a triggering experience or trauma-related anxiety. – The perceptions are not interactive: They do not, for example, “talk back” to the survivor. – The perceptions are not bizarre (e.g., of aliens or demons).

Posttraumatic expectations as opposed to delusions – The content of the ideas or fears is related to the traumatic event. – The client often is able to express an understanding that such ideas or fears are not reasonable (e.g., a woman who was sexually assaulted may fear all men and may not want to be alone with men due to fears of being further victimized, although she may be able to cognitively express that not every man is necessarily a rapist).

Trauma-induced fragmentation as opposed to loosened associations – The fragmentation or disorganization occurs only when the client is talking about upsetting or trauma-related subjects, and not throughout the client’s discourse. – The level of disorganization decreases as the client becomes less anxious.

Conversely, the following, if present, may suggest a psychotic rather than posttraumatic process: Hallucinations as opposed to reexperiencing

– At least some of the content of the perceptions is not trauma related (e.g., hearing the voices of others not involved in the trauma). – The perception is interactive, and/or the client is observed by others to be talking or laughing to themself.

Delusions as opposed to posttraumatic expectations – The content of the ideas/fears is not simply related to the traumatic event, but extends to other areas (e.g., a woman who was raped not only states that all men will potentially hurt her, but also believes that the CIA is wiretapping her home). Loosened associations as opposed to trauma-induced fragmentation – The cognitive slippage occurs throughout the client’s discourse, whether the client is anxious or not, and irrespective of the topic of conversation.

STRUCTURED INTERVIEWS Although an informal mental status examination and symptom review can reveal many forms of posttraumatic disturbance, the unstructured nature of such approaches often means that certain symptoms or syndromes may be overlooked or inadequately assessed. In fact, it is estimated that up to half of actual cases of PTSD are missed during unstructured clinical interviews (Zimmerman & Mattia, 1999). For this reason, some clinicians and most researchers use structured clinical measures when evaluating posttraumatic stress, especially PTSD. The most commonly used of these structured interviews are discussed next. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) The CAPS-5 (Weathers et al., 2013) is considered to be the gold standard of structured interviews for posttraumatic stress disorder. An update of the previous CAPS for DSM-IV (Blake

et al., 1995), it has several helpful features, including standard prompt questions and explicit, behaviorally anchored rating scales, and assesses severity of symptoms, ranging from “mild/subthreshold” to “extreme/incapacitating.” It generates both dichotomous and continuous scores for past week, past month, and worst month (lifetime) PTSD. In addition to the standard 20 PTSD items, the CAPS also contains items tapping posttraumatic impacts on social and occupational functioning, improvement in PTSD symptoms since a previous CAPS assessment, overall response validity, and overall PTSD severity, as well as items addressing guilt and dissociation. The CAPS-5 has been shown to be reliable and valid in several studies (e.g., Weathers et al, 2018). PTSD Symptom Scale Interviewer for DSM-5 (PSS-I-5) The PSS-I-5 (Foa, McLean, Zang, Zhong, Powers et al., 2016) is a semistructured interview updated from the original version to reflect DSM-5 diagnostic criteria. It consists of 20 symptom-based items and four items assessing distress and interference in daily life caused by reported symptoms, as well as symptom onset and duration. An index trauma is identified at the outset and symptoms resulting from this trauma are rated on a combined frequency/severity scale from 0 = “Not at all” to 4 = “6 or more times a week/severe.” The updated PSS-I-5 has been shown to be a valid and reliable tool for assessing PTSD diagnosis and severity (Foa, McLean, Zang, Zhong, Rauch et al., 2016). The Acute Stress Disorder Interview (ASDI) When the diagnostic issue is ASD, as opposed to PTSD, the clinician may find the DSM-IV ASDI (Bryant et al., 1998) useful. This interview consists of 19 items that evaluate dissociative, reexperiencing, effortful avoidance, and arousal symptoms. The ASDI has good reliability and validity and can be administered in a relatively short period of time (Bryant et al., 1998). Although the ASDI does not cover the DSM-5 version of ASD, the ASDI author has introduced an Acute Stress Disorder Structured Interview–5 (Bryant, 2016), which awaits psychometric validation (https://www.ptsd.va.gov/professional/treat/essentials/acute_stress_disorder.asp). The Structured Interview for Disorders of Extreme Stress—Revised (SIDES-R) The SIDES (Pelcovitz et al., 1997) was originally developed as a companion to existing interview-based rating scales for PTSD. The first edition of the SIDES measured current and lifetime indicators of disorders of extreme stress, not otherwise specified (DESNOS; van der Kolk et al., 2005)—an early version of what is now considered complex PTSD. The revised SIDES (Scoboria et al., 2008) contains five factor scales (demoralization, somatic dysregulation, anger dysregulation, risk/self-harm, and altered sexuality), and focuses on features of PTSD associated with early traumatic experiences, interpersonal trauma, and prolonged traumatic exposure. The revised SIDES does not assess for trauma exposure and items inquire about general symptoms, not those linked to a specific traumatic experience. The Semi-Structured Clinical Interview for Dissociative Symptoms and Disorders-Revised (SCID-D) The SCID-D (Steinberg, 1994, 2022) evaluates the existence and severity of five dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration. This interview provides diagnoses for the five major DSM-IV dissociative disorders along with acute stress disorder (although we recommend the ASDI for the latter). Also evaluated by the

SCID-D are “intra-interview dissociative cues,” such as alterations in demeanor, spontaneous age regression, and trancelike appearance, which are coded in a postinterview section. The is now a revised, DSM-5 version of the SCID-D (SCID-D-R; Steinberg, 2022), which, thus far, appears to have good psychometric characteristics and clinical utility (Mychailyszyn et al., 2021) PSYCHOLOGICAL TESTS In contrast to clinical interviews, structured or otherwise, most psychological tests are self- administered, in the sense that the client completes a paper inventory using a pencil or pen or completes the same inventory digitally using a computer or tablet. Standardized psychological tests have been normed on demographically representative samples of the general population, so that a specific score on such measures can be compared to what would be a “normal” value for that scale or test. We strongly recommend the use of such tests, since they provide objective, comparative data on psychological functioning (both trauma specific and general) in trauma survivors. A number of testing instruments are briefly described below. Not discussed are projective tests, although one (the Rorschach Ink Blot Test; Rorschach, 1981) can be helpful in the assessment of posttraumatic states (Armstrong & Kaser-Boyd, 2003). Please note that one of the authors (Briere) has developed several published psychological tests that evaluate trauma and its impacts, for which he receives royalties. Although every attempt has been made to objectively review these measures, we cannot, of course, rule out inadvertent bias. We suggest that the reader access independent reviews of these and other tests (e.g., https://www.nctsn.org/treatments-and-practices/screening-and-assessments/measure-reviews) whenever relevant. GENERIC TESTS A variety of standardized psychological measures can be used to assess generic (i.e., non– trauma-specific) psychological symptoms in adolescent and adult trauma survivors. Several of these assess anxiety, depression, somatization, psychosis, and other symptoms relevant to DSM- 5. Because posttraumatic distress often includes such symptoms, a good psychological test battery should include at least one generic measure in addition to more trauma-specific tests. Examples of often-used generic tests include the following:

Psychological Assessment Inventory (PAI; Morey, 2007) Minnesota Multiphasic Personality Inventory (MMPI-3; Ben-Porath & Tellegen, 2020; MMPI-2-RF; Ben-Porath & Tellegen, 2008; and MMPI-2; Butcher et al., 1989) Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A; Butcher et al., 1992) Millon Clinical Multiaxial Inventory, 4th edition (MCMI-IV; Millon et al., 2015) Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1983)

Each of these tests (especially the PAI and MCMI-IV) also provides information on the personality-level difficulties associated with the complex posttraumatic outcomes described in Chapter 2. In addition, three (the MMPI-2, PAI, and MCMI-IV) include PTSD scales—although these scales are typically only moderately effective in identifying actual cases (and noncases) of diagnosable posttraumatic stress disorder (Eadie & Briere, in press). Most major generic

instruments also include validity scales, used to detect client under- or overreporting of symptoms. Such scales can be helpful in identifying denial, exaggeration, and some cases of malingering. However, traumatized individuals—by virtue of the unusual quality of some posttraumatic symptoms—tend to score higher than others on negative impression (overreporting) scales (Merckelbach et al., 2017), even when not attempting to malinger or otherwise distort their responses (e.g., Jordan et al., 1992). TRAUMA-SPECIFIC TESTS Although generic tests can detect many of the more nonspecific symptoms associated with trauma, as well as other comorbid disorders that might be present, psychologists often use more specific tests when assessing posttraumatic stress, dissociation, and trauma-related self-capacity disturbance (Brand et al., 2016; Carlson, 1997; Eadie & Briere, in press). The most common of these instruments are presented below. Non-normed/nonstandardized tests are described only briefly, since measures without normative data cannot be easily interpreted relative to “normal”/less symptomatic individuals (Eadie & Briere, in press). For Posttraumatic Stress and Associated Symptoms Posttraumatic Stress Checklist for DSM-5 (PCL-5; Weathers et al., 2013). An update to the previous Posttraumatic Stress Disorder Checklist (PCL; Weathers et al., 1993), the PCL-5 is a 20-item self-report instrument that can be used to monitor posttraumatic symptoms over time and to assist in making a provisional diagnosis of PTSD. Although the PCL-5 has good psychometric qualities, the authors caution that it should not be used, alone, as a definitive diagnostic measure and recommend the CAPS-5 for this purpose. Posttraumatic Stress Diagnostic Scale (PDS-5). The PDS-5 (Foa, McLean, Zang, Zhong, Powers et al., 2016) is an updated version of the original PDS (Foa 1995). Similar to the PSS-I-5, it consists of 24 items assessing the severity of each of the 20 DSM-5 PTSD symptoms as well as four items examining the level of distress and interference caused by the symptoms as well as the onset and duration of symptoms. Two screening questions assess trauma history and identify an index trauma The PDS has good reliability and validity, and it provides a cutoff score for identification of probably PTSD diagnosis (Foa, McLean, Zang, Zhong, Powers et al., 2016). Detailed Assessment of Posttraumatic Stress (DAPS).1 The DAPS (Briere, 2001) yields a provisional DSM-IV PTSD diagnosis, and measures lifetime exposure to traumatic events; immediate emotional responses to a specified trauma; PTSD symptoms, and trauma-specific dissociation, suicidality, and substance abuse. A DSM-5 version (the DAPS-5) is in progress at the time of this writing (see Petri et al., 2020). Global Psychotrauma Screen (GPS). The GPS (Olff et al., 2020) is a brief self-report instrument that begins by identifying an index trauma and then asks about the presence of symptoms within the past month. Items do not map directly onto DSM-5 criteria, but instead include a range of posttraumatic symptoms such as sleep difficulties, self-injurious behavior, dissociation, and substance use in addition to symptoms of intrusion, avoidance, hypervigilance, and risk and protective factors. Versions of the GPS are available in 23 languages, several of which are accompanied by normative data.

Acute Stress Disorder Scale-5 (ASDS-5; Bryant, 2016; Bryant et al., 2000). The ASD-5 is a self-report measure that assesses 14 symptoms of traumatic stress that occur 3 days to 1 month following a trauma. First developed to meet DSM-IV ASD criteria (Bryant et al., 2000), it has been updated to tap DSM-5 criteria. Trauma Symptom Inventory-2 (TSI-2). The TSI-2 (Briere, 2011), a revision of the Trauma Symptom Inventory, is a standardized test of posttraumatic symptomatology experienced over the previous 6 months. Normed on a representative sample of the general population, the TSI-2 has two validity scales, 12 clinical scales, and four factor scales. Its clinical scales have been shown to have acceptable psychometric properties in various contexts (e.g., Filone & DeMatteo, 2017; Nilsson et al., 2017). For Complex PTSD As noted in Chapter 2, complex PTSD is a relatively new construct which includes not only symptoms of posttraumatic stress, but also emotional regulation difficulties, problems in relatedness, altered awareness, adversely affected beliefs, and somatization. As a result, any psychometric approach that taps this multidimensional presentation likely includes a combination of the measures described in this chapter. ITQ. Two instruments, however, specifically attempt to evaluate the full range of complex PTSD symptoms. The first, the SIDES interview, was described earlier in this chapter. The second is the International Trauma Questionnaire (ITQ; Cloitre et al., 2018; Hyland et al., 2018). A promising self-report instrument, the ITQ taps the core features of PTSD and complex PTSD. The final version was created and validated on a large community sample and a trauma‐exposed clinical sample. It consists of 12 easy-to-understand items, and demonstrates good psychometric qualities, including criterion validity for complex PTSD. For Emotional Regulation, Interpersonal Relatedness, and Identity Problems Trauma and Attachment Belief Scale (TABS). The TABS (Pearlman, 2003; formerly the Traumatic Stress Institute Belief Scale) is a normed and standardized instrument that measures disrupted cognitive schema and need states associated with complex trauma exposure. It evaluates disturbance in five areas: Safety, Trust, Esteem, Intimacy, and Control. There are reliable subscales for each of these domains, rated both for “self” and “other.” Inventory of Altered Self Capacities (IASC). The IASC (Briere, 2000) is a normed and standardized test of problems in the areas of relatedness, identity, and emotional regulation, and can be used to evaluate in detail the Disturbance of Self Organization (DSO) components of complex PTSD described in Chapter 2. The scales of the IASC assess the following domains: Interpersonal Conflicts, Idealization-Disillusionment, Abandonment Concerns, Identity Impairment, Susceptibility to Influence, Affect Dysregulation, and Tension Reduction Activities. For Distress Reduction Behaviors (DRBs)

As noted earlier, individuals who suffer from easily activated trauma or insecure attachment- level memories, especially in the context of diminished emotional regulation capacities, often engage in risky or otherwise problematic behaviors as a way to distract, soothe, or neutralize triggered distress. Tests that can facilitate the assessment of these responses include the following, although many are not yet standardized: Self-injury: Functional Assessment of Self-Mutilation (FASM; Lloyd et al., 1997) and the Deliberate Self-Harm Inventory (DSHI; Gratz, 2001), Risky or compulsive sexual behavior: Compulsive Sexual Behavior Inventory (CSBI; Miner et al., 2007), Sexual Compulsivity Scale (SCS; Kalichman & Rompa, 2001), and the Dysfunctional Sexual Behavior subscale of the TSI-2, Bingeing/purging: Binge Eating Scale (BES; Gormally et al., 1982) and the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994), Problem gambling: Brief Biosocial Gambling Screen (BBGS; Gebauer et al., 2010), Generalized involvement in distress reduction behavior: Posttrauma Risky Behaviors Questionnaire (PRBQ; Contractor et al., 2020) which assess the frequency of 14 risky behaviors over the past 30 days, and the Tension Reduction Behavior scale of the TSI-2. As well, Briere (2019) has developed several DRB-specific measures and worksheets which, although not standardized, allow assessment of the antecedent, types, and characteristics of distress reduction behaviors. These include the Review of Distress Reduction Behaviors (Rev- DRB), Trigger Review (TR), and Functions of Distress Reduction Behaviors (F-DRB). For Dissociation Although dissociation is a common result of childhood trauma and attachment disturbance, there are surprisingly few psychological tests available for its assessment (Brand et al., 2023). As a result, clinicians often have to rely on nonstandardized measures and interviews. Fortunately, some of these (e.g., the Dissociative Experiences Scale [DES]; M. Bernstein & Putnam, 1986) have been so widely used that quasi-norms can be derived from published studies. Dissociative Experiences Scale – II (DES-II). The 28-item DES-II (Carlson & Putnam, 1993) is the most often used of the dissociation measures, although, technically, it is not normed on the general population. It taps “disturbance in identity, memory, awareness, and cognitions and feelings of derealization or depersonalization or associated phenomena such as déjà vu and absorption” (E. M. Bernstein & Putnam, 1986, p. 729). Various recommended cut off scores are available in the literature. Notably, however, the DES-II has been criticized for both over- and underdiagnosing dissociative disorders (Brand et al., 2006; Ross, 2021). Dissociative Subtype of PTSD Scale (DSPS). The DSPS (Wolf et al., 2017) is a 15-item measure of lifetime and current dissociative symptoms. Items include symptoms from the dissociative subtype of PTSD, yielding three subscales: Derealization/Depersonalization, Loss of Awareness, and Psychogenic Amnesia. This instrument can be administered either as a self-report tool or a semi-structured interview. The DSPS has good psychometrics in samples of trauma-exposed veterans (Guetta et al., 2019; Wolf et al., 2017). Multiscale Dissociation Inventory (MDI: Briere, 2002a). The MDI is a 30-item, standardized and normed test of dissociative symptomatology, with six internally-consistent subscales: Disengagement, Depersonalization, Derealization, Memory Disturbance, Emotional Constriction, and Identity Dissociation, and a Total dissociation score. Commonly used in

dissociation research, this measure appears to have good reliability and various forms of validity (e.g., Jeffirs et al., 2023). Other Nonstandardized Tests A number of other instruments have been developed in research contexts that, as yet, are not fully standardized and normed. The most common and potentially most useful of these are the listed below: A number of other instruments have been developed in research contexts that, as yet, are not fully standardized and normed. The most common and potentially most useful of these are the listed below: Brief Inventory of Psychosocial Functioning (B-IPF; Kleiman et al., 2020) Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1996) Inventory of Psychosocial Functioning (IPF; Bovin et al., 2018) Brief Inventory of Psychosocial Functioning (B-IPF; Kleiman et al., 2020) Multidimensional Inventory of Dissociation (MID; Dell, 2006) Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999) Posttraumatic Maladaptive Beliefs Scale (PMBS; Vogt et al., 2012) Prolonged Grief Disorder (PG-13-Revised; Prigerson et al., 2021) Trauma-Related Cognitions Scale (TRCS; Valdez et al., 2021) Trauma Symptom Checklist-40 (TSC-40; Elliott & Briere, 1992) Some of these tests have been used in applied settings for years, and clinicians have developed cut-off scores for some in order to define normal versus clinical levels of distress. Others are widely used in research but are generally not recommended for clinical use (e.g., the TSC-40). When deciding which of these measures to apply in a given clinical situation, we recommend that the clinician also consider any fully standardized and validated test that might be better (or additionally) employed and consider any limitations of these tests that might constrain clinical interpretation. In general, psychometrically valid test interpretation (and modern psychological testing standards) requires that self-report clinical instruments demonstrate good internal consistency, convergent and discriminative validity, and statistical determination of symptom severity based on the relationship of a given score to the total distribution of scores in the general population (American Psychological Association, 2020b; Urbina, 2016). Health Status A trauma evaluation is not complete without an assessment regarding the client’s self-reported physical health status. At some point in the interview, the clinician (whether a medical or nonmedical practitioner) should ask if the client has any active medical conditions, whether they are in any current physical distress, and whether they take any medications (including over-the- counter medications, vitamins, and herbal supplements). This part of the interview is especially relevant for traumatized individuals, because, as described in Chapter 2, those with PTSD are at increased risk for physical health problems. In addition, some medical conditions (such as endocrine problems, pain, neurological disorders, and traumatic brain injury) can mimic or overlap with the symptoms of PTSD (Asmundson & Taylor, 2006; Kennedy et al., 2007). Given this complexity, and the fact that somatization is more common in traumatized individuals, the determination of which symptoms are due to actual medical illness (and require

medical intervention) often can be quite challenging. In health care settings that provide services to indigent, uninsured, or undocumented clients, or where, for various other reasons, clients have difficulty obtaining medical attention, concerns about medical care and complications may be especially relevant. In such instances, the mental health clinician may be the client’s primary point of contact with the health care system. We therefore recommend that therapists refer traumatized clients for full medical examinations and regular medical follow-ups. RECOMMENDATIONS FOR ASSESSMENT THROUGH TELEHEALTH PLATFORMS As noted in Chapter 13, the advent of the coronavirus in mid-2020 has required the use of remote therapeutic interventions, typically wherein the clinician interacts with the client via telephone, video device, or computer. This is also true of psychological assessment, which may easily be affected by constraints associated with the telehealth environment. Even when COVID-19 becomes less widespread and less dangerous there will no doubt be other viral pandemics in the future (Morens & Fauci, 2020), suggesting that teletherapy (as well as teleassessment) will continue to be an important aspect of trauma therapy going forward. Administration of tests and standardized interviews in a telehealth environment can differ in important ways from the context in which these assessment tools were normed and standardized. For example, a test inventory may have been standardized with the respondent sitting in a clinical room, reading the test items, and physically recording their responses on an answer sheet. In a telehealth context, this may vary such that administration is digital and the respondent completes the test on their personal computer – reading and recording their own responses. Or the assessment may vary more significantly with the clinician reading test items aloud, the client responding verbally, and the clinician then recording responses. These variations may alter the meaning of client’s responses and could make it more difficult to compare their results to existing normative data. Some considerations for ways to modify the assessment process to suit the telehealth context are included below. Nevertheless, there remain limitations, some of which may be yet unknown, when assessing a client in a context that differs from the standardization environment and from the typical in person context of providing services. Keeping in mind the clinical interview is the foundation of any good assessment, using interview-based assessment tools is especially advantageous in a telehealth context as the use of verbal question and answer over a video platform minimizes alterations from the standardized environment (Briere et al., 2020). When using psychological tests, we recommend tools that have been adapted to online or telehealth environments. Some test publishers have adapted their tests to an online environment where the client can logon and complete the test without the clinician’s involvement, thereby essentially satisfying standardization requirements. Of course, when tests are administered this way, issues of test security and confidentiality must be considered. Clinicians should provide directions to the client ahead of time, including instructions to complete the test in a private, secure location that is free from distractions and the input of others. Clinicians may also want to make themselves available to provide clarifications around test content, or to provide support if the client finds the test content to be upsetting or activating in any way. Finally, clinicians are responsible for the transmission and storage of test data in a secure and encrypted manner, and should refer to the APA (2017) Ethical Principles of

Psychologists and Code of Conduct and HIPAA requirements to ensure their practices are consistent with these guidelines. Unfortunately, many useful psychological tests and assessment tools are not interview based and have not been adapted for online administration. In such instances, the reader may consider administering written tests verbally with the clinician reading items and the client responding verbally. Because this is a deviation from the standardization environment for most tests, this alteration and any expected impact on interpretation should be documented in any written or verbal report. Finally, the clinician may choose to use tools without standardization or normative data, such as those listed in the Nonstandardized Tests section earlier in this chapter. As noted earlier, these tests could provide valuable information, but are limited by the lack of normative data for comparison and must be described as so in reports. Prior to and throughout the assessment process, the clinician is advised to plan and account for differences between telehealth and in person environments. Any changes to administration procedures should be thought through, done with care, and ideally rehearsed ahead of time to avoid the interference of technology glitches or other aspects of the new environment (American Psychological Association, 2020c; Briere, Lanktree et al., 2020). Similarly, it is the clinician’s role to remain mindful of their client’s access to technology and the level of technology literacy required to engage in the teleassessment process. Clients from a range of backgrounds may vary in their access to the internet, personal computers, private and secure spaces, and knowledge of technological procedures. Again, as noted, any alterations and modifications to standard procedures should be identified in the assessment report and feedback session, while noting any implications for test interpretation.