Download A Review of Two Instruments and Clinical Recommendations

Running Head: TRAUMA ASSESSMENTS
Assessing Trauma History and Trauma-Related Symptomology:
A Review of Two Instruments and Clinical Recommendations
Rachel Berry
Wake Forest University
1
2
TRAUMA ASSESSMENTS
Abstract
This paper compares two instruments for assessing trauma in mental health settings. These
assessment tools are the Trauma Symptom Inventory, created by John Briere, and the Trauma
Assessment Inventories, created by Edward Kubany. The Trauma Assessment Inventories
includes three assessment tools used in conjunction with one another: the Traumatic Life Events
Questionnaire, the Post-Traumatic Stress Disorder Screening and Diagnostic Scale, and the
Trauma-Related Guilt Inventory. Descriptions of the assessments including strengths,
weaknesses, and psychometric properties are provided. Finally, the paper provides
recommendations for trauma-informed assessment practices for counselors.
3
TRAUMA ASSESSMENTS
Assessing Trauma History and Trauma-Related Symptomology
Introduction
The National Center for Trauma-Informed Care (NCTIC), a division of the Substance
Abuse and Mental Health Services Administration (SAMHSA), states that while exact estimates
differ, the majority of clients of mental health services have experienced trauma (SAMHSA,
n.d.). James and Gilliland (2013) define psychic trauma as “a process initiated by an event that
confronts an individual with an acute, overwhelming threat”(p.149). Studies such as the Adverse
Childhood Experiences Study (ACES) have drawn attention to the range of traumatic
experiences many people experience in childhood that may lead to trauma symptoms (CDC,
2010). The 2009 ACE study found that 59.4% of study participants reported at least one ACE,
with 8.7% reporting five or more (CDC, 2010). Afifi et al. (2008) found that certain adverse
childhood events such as witnessing domestic violence and being the recipient of physical or
sexual abuse correlate with adult psychiatric disturbances and suicidal ideation. In addition to
childhood traumatic events, many adults also experience trauma in the form of automobile
accidents, intimate partner violence, rape, natural disasters, and combat, to name a few. A
diagnosis of Posttraumatic Stress Disorder (PTSD) or Acute Stress Disorder (ASD) requires the
presence of a traumatic stressor, but other physical and mental health disorders such as mood,
anxiety, substance abuse, and personality disorders may also be precipitated or exacerbated by
trauma. Given the high number of individuals who report traumatic experiences as well as the
correlation between trauma and mental health issues, assessing for trauma is an important issue
for clinical mental health counselors regardless of setting. This paper compares two formal
assessment tools counselors can use with adult clients to assess for history of trauma, current
trauma symptoms, and adverse mental health consequences that may be related to trauma.
TRAUMA ASSESSMENTS
4
Finally, the paper provides trauma-informed care recommendations pertaining to administering
trauma assessments to clients.
Briere’s Trauma Symptom Inventory
The Trauma Symptom Inventory (TSI) was created by John Briere and last revised in
1995 (Briere, 1995). John Briere developed the TSI based on a previous assessment tool called
the Trauma Symptom Checklist, which he had written with Marsha Runtz several years prior
(Gebart-Eaglemont, 1996). The TSI is a self-report instrument that assesses for symptoms in the
ten trauma-related domains of anxious arousal (feeling tense or jittery), depression (feeling sad
or hopeless), anger/irritability (evidenced by thoughts and behaviors), intrusive experiences
(such as flashbacks or nightmares), defensive avoidance, dissociation (including
depersonalization, derealization, and feelings of numbness), sexual concerns (physical or
cognitive), dysfunctional sexual behavior (promiscuity, risky sexual behaviors), impaired selfreference (related to identity and self-esteem), and tension reduction behavior (such as self-harm
and manipulation; Gebart-Eaglemont, 1996). The client assigns a number from one to four for
each of 100 items based on frequency of symptom occurrence in the past six months. The test is
administered using paper and pencil and takes approximately twenty minutes to complete. It is
written at a middle school reading level.
Strengths of the TSI include relative ease and speed of administration and scoring
(Gebart-Eaglemont, 1996). At twenty minutes in length, it could be incorporated into a 1-2 hour
intake session (Fernandez, 1996). The questions are written at a middle school reading level, so
many adults will be able to understand the questions. The TSI is administered using paper and
pencil, so it is suited to a wide range of adults regardless of computer skills. In addition to userfriendliness on the part of the client, the TSI is also straightforward for counselors to administer
TRAUMA ASSESSMENTS
5
and score. The package of materials available to mental health professionals comes with a
manual, reusable item-booklet, answer sheet, and profile forms (Gebart-Eaglemont, 1996). The
manual provides information on psychometrics and norming as well as straightforward
instructions on interpreting the results.
The test’s creator, John Briere, subjected the test questions to rigorous psychometric
refinement (Fernandez, 1996). It was normed using both normal and clinical samples (GebartEaglemont, 1996). Built into the test is a validity scale to determine if the client may be overreporting, underreporting, or providing conflicting answers (Fernandez, 1996). Three studies
assessed the internal consistency reliability of the TSI and found it to be between .84-.87
(Fernandez, 1996). The ten clinical scales correlate significantly with each other, according to
Fernandez (1996). However, Gebart-Eaglemont (1996) questions the discriminant validity due to
the overlap with symptoms of personality disorders, particularly Borderline Personality Disorder.
Fernandez (1996) notes that the TSI has concurrent validity with other measures such as the
Brief Symptom Inventory and the PTSD scale of the Symptom Checklist-90-Revised. Fernandez
(1996) suggests that based on its psychometrics and test construction process, the TSI is among
the strongest tools available to assess trauma symptoms.
An important feature missing from the TSI is questions to assess what may have triggered
trauma symptoms (Fernandez, 1996). Therefore, its diagnostic utility is limited. Counselors
should combine administration of the TSI with a clinical interview to gather bio-psycho-social
and historical information about the client, particularly if the intent is to determine whether the
client meets criteria for PTSD or ASD. When combined with client report of a traumatic event,
the predictive diagnostic accuracy of the TSI is 96% true-positive and 91% true-negative
(Fernandez, 1996). This predictive accuracy means that while the test should not be used
TRAUMA ASSESSMENTS
6
singularly to diagnoses PTSD, ASD, or any other mental health condition, it can provide
valuable information to inform diagnosis. The TSI could also be improved by providing duration
and intensity scales for symptoms (Fernandez, 1996). This would increase the test’s complexity
and administration time, however, potentially decreasing its clinical utility.
An additional concern reviewers noted about the TSI pertains to evidence that the
domains measured may be more applicable to females (Gebart-Eaglemont, 1996). When
administered in addition to two other instruments that measure the impact of trauma, the Impact
of Event Scale and the Brief Symptom Inventory, the TSI only added a significant amount of
variance for female subjects. Potentially contributing to the gender differences in results is the
inclusion of clinical scales for sexual concerns and dysfunctional sexual behavior (Fernandez,
1996). While many clients who have experienced sexual trauma report symptoms in these
domains, these scales likely have little relevance for other types of trauma (physical violence,
witnessing a natural disaster, combat, etc.). As men are less likely to be victims of sexual
violence, men’s overall TSI scores may skew lower due to low scores in these two categories.
Indeed, women’s average TSI scores are higher than men’s, which may be accounted for by
higher scores on these clinical scales.
Bahraini et al. (2009) argue that formal psychometric measures such as the TSI are
particularly important when the client may have comorbid conditions. Comorbid mental health
conditions such as substance abuse, depression, and panic disorder may occur with PTSD or
other trauma-related disorders. Finding instruments that can distinguish trauma symptoms from
other symptoms is critical for treatment planning. Bahraini et al. (2009) found that the TSI has
utility with combat veterans who may have co-occurring PTSD and traumatic brain injury (TBI).
Among the military personnel returning from Iraq, Afghanistan, and other combat zones in the
TRAUMA ASSESSMENTS
7
past decade, many may have symptoms of both PTSD and TBI. These symptoms can be hard to
distinguish from one another, and there is some concern about the attribution of symptoms to the
proper cause.
Kubany’s Trauma Assessment Inventories
The Trauma Assessment Inventories are a package of three assessments to be used in
conjunction with one another: the Traumatic Life Events Questionnaire (TLEQ), PTSD
Screening and Diagnostic Scale (PSDS), and the Trauma-Related Guilt Inventory (TRGI;
Donnelly & Donnelly, 2004). The TLEQ and PSDS are screening tools, while the TRGI is used
in conjunction with cognitive therapy for trauma. This paper focuses on the TLEQ and PSDS,
tools a counselor could use in conjunction with a clinical interview to assess for trauma history
and trauma symptom severity during an intake session.
The TLEQ consists of twenty-four self-report items (Sheperis & Heiselt, 2004). The first
group of questions assesses client history of twenty-one traumatic life events, asking if and how
frequently the client experienced the events. If the client responds affirmatively to any of the
questions about traumatic life events, they then report feelings such as fear, horror, or
helplessness they have experienced as a result of the traumatic event(s). The final question asks
the respondent which event was most distressing. Clients with at least a sixth grade reading level
can complete the TLEQ on the computer or by hand. Administration takes approximately fifteen
minutes.
If a client reports trauma history based on the TLEQ or another form of assessment, the
counselor may administer the PSDS to obtain further information about the trauma-inducing
event or events (Sheperis & Heiselt, 2004). The PSDS, developed from the Distressing Event
Questionaire, consists of thirty-eight questions based on the criteria for PTSD in the Diagnostic
TRAUMA ASSESSMENTS
8
and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994).
Clients report symptom severity within the past thirty days using a five-point Likert scale
(Sheperis & Heiselt, 2004). In addition to symptom severity, clients are asked about the duration
of symptoms. This assessment is self-report, can be completed on the computer or with paper
and pencil, and is designed for adult clients at or above an eight-grade reading level. The TLEQ
and PSDS do not provide standardized scores based on normed samples, rather they provide
descriptive information for counselor and client to start a conversation about the client’s
experiences with trauma.
Edward Kubany, a researcher and clinician who focuses on PTSD in veterans, created the
Trauma Assessment Inventories. Kubany (2004) developed the Trauma Assessment Inventories
using information from previous studies, other trauma instruments, trauma counselor
suggestions, and semi-structured interviews with victims of trauma (Donnelly & Donnelly,
2004). For the TLEQ and PSDS, a panel of clinicians who specialize in working with trauma
survivors reviewed the questions to assure content validity (Sheperis & Heiselt, 2004).
One strength of the TLEQ and PSDS, as compared to the TSI, is the apparent lack of
gender bias. The TLEQ and PSDS were tested on a wide variety of samples, including combat
veterans, male and female substance abuse clients, college students, and female survivors of
domestic violence (Kubany et al., 2000). By administering the instruments to a range of
homogenous and heterogeneous samples, the tests’ creator increased the instrument’s validity
across populations. However, the samples were small in size, and further research would increase
the reliability.
The TLEQ and PSDS do not result in formal scores but rather descriptive information,
which can be considered a strength or a weakness. Normed quantitative scores could provide an
TRAUMA ASSESSMENTS
9
objective measure of traumatic experiences and trauma-related symptoms of distress, which
could help clinicians prioritize client needs. This could be helpful in today’s mental health
settings, in which triage systems may be used to determine the most efficient use of agency
resources. However, descriptive scores allow mental health care to remain person-centered and
nonjudgmental by refraining from comparing one client to another. Particular advantages of the
TLEQ and PSDS over the TSI also include the addition of identifying traumatic events as well as
scales for duration, frequency, and severity.
When compared to the Structured Clinical Interview for DSM-IV (SCID), the TLEQ
prompted respondents to report a greater number of traumatic events (Pierce, Burke, Stoller,
Neufeld, & Brooner, 2009). The TLEQ also proved more comprehensive than the SCID in terms
of the types of traumatic events respondents reported. The greater sensitivity and
comprehensiveness of the TLEQ resulted in more respondents receiving a diagnosis of PTSD
(33% as compared to 24% with the SCID). This research indicates that the TLEQ is a clinically
useful instrument in assessing for trauma.
The Trauma Assessment Inventories are intended for use in conjunction with one
another, which increases clinical utility. Not only can the counselor assess for traumatic
experiences and trauma-related symptomology using the TLEQ and PSDS, the counselor can
then incorporate responses from the TRGI into treatment planning (Donnelly & Donnelly, 2004).
The TRGI is part of a cognitive therapy to address trauma response. All three instruments were
created by a clinician who is both researcher and practitioner, which likely speaks favorably to
the instruments’ utility in clinical settings.
Trauma-Informed Assessment Considerations
TRAUMA ASSESSMENTS
10
Trauma-informed services have become more prominent in mental health settings in
recent years. Research indicates that trauma-informed treatment approaches reduce substancerelated issues as well as mental health symptoms, including trauma-related symptoms
(Weissbecker & Clark, 2007). Cohen, Berliner, and Mannarino (2010) recommend assessing for
trauma early in the treatment process, particularly when working with children. In fact, assessing
for trauma in children and adults can empower clients because it counteracts the overt and covert
orders victims often hear to stay silent regarding their abuse (Elliott, Bjelejac, Fallot, Markoff, &
Reed, 2005). Assessing for trauma early in the counseling relationship communicates to the
client that their experiences are valid and will be taken seriously by the counselor.
Several principles of trauma-informed services can guide counselors when serving
traumatized clients and reduce the risk of retraumatization (Elliott et al., 2005). Elliott et al.
(2005) suggest the acronym “RICH”, which stands for respect, information, connection, and
hope. The counselor should instill hope, respect the client, try to form a genuine connection with
the client, and provide helpful information. The clinician should support the client’s autonomy,
help the client feel safe, and attempt to create an atmosphere where the client can transform from
powerless victim to empowered survivor. During assessment, the counselor can incorporate these
principles by establishing a therapeutic relationship based on trust and empathy, carefully
explaining the purpose of the trauma assessment, recognizing and responding empathically if an
instrument triggers the client to experience overwhelming sensations or emotions, and process
the assessment collaboratively (Whiston, 2013; Elliott et al., 2005). Indeed, collaborative
assessment interpretation can increase a client’s likelihood of returning for additional counseling
(Whiston, 2013).
11
TRAUMA ASSESSMENTS
Although semi-structured interviews are preferable to self-report instruments, the latter
can be administered in a more time-efficient manner (Cohen, Berliner, and Mannarino, 2010). In
today’s mental health settings, counselors must balanced client-centered concerns within the
organizational constraints of the organization. Assessment tools such as the Trauma Symptom
Inventory and Trauma Assessment Inventories (TLEQ and PSDS) are time-efficient and
psychometrically sound instruments that can help counselors assess for trauma history and
symptomology in the early stages of counseling. This in turn will help counselors to provide
appropriate, sensitive, and helpful care to mental health clients.
Conclusion
Given the prevalence of trauma history among consumers of mental health services,
counselors should incorporate trauma assessments early in treatment. Two tools available to
assess trauma are the Trauma Symptom Inventory and Trauma Assessment Inventories. These
are psychometrically sound tools that can be administered in a time-efficient manner to clients
with a wide variety of experiences and abilities. While assessing for trauma, counselors must
strive to avoid retraumatization and create an atmosphere of trust, collaboration, and healing.
12
TRAUMA ASSESSMENTS
References
Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.G., Stein, M.B., & Sareen, J. (2008).
Population attributable fractions of psychiatric disorders and suicide ideation and
attempts associated with adverse childhood experiences. American Journal of Public
Health, 98(5), 946-952. doi:10.2105/AJPH.2007.120253
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Bahraini, N.H., Brenner, L.A., Harwood, J.E.F., Homaifar, B.Y., Ladley-O’Brien, S.E., Filley,
C.M., … Adler, L.A. (2009). Utility of the Trauma Symptom Inventory for the
assessment of post-traumatic stress symptoms in veterans with a history of psychological
trauma and/or brain injury. Military Medicine, 174, 1005-1009.
Center for Disease Control & Prevention. (2010). Adverse childhood experiences reported by
adults – Five states. 2009. Morbidity and Mortality Weekly Report, 59(49), 1609-1613.
Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm
Cohen, J.A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with cooccurring trauma and behavior problems. Child Abuse & Neglect, 34, 215-224.
Donnelly, J.P., & Donnelly, K. (2004). [Review of Trauma Assessment Inventories]. In The
fourteenth mental measurements yearbook. Available from http://www.unl.edu/buros/
Elliott, D.E., Bjelejac, P., Fallot, R.D., Markoff, L.S., & Reed, B.G. (2005). Trauma-informed or
trauma denied: Principles and implementation of trauma-informed services for women.
Journal of Community Psychology, 33(4), 461-477. Doi: 10.1002/jcop.20063
Fernandez, E. (1996). [Review of Trauma Symptom Inventory.] In The fourteenth mental
measurements yearbook. Available from http://www.unl.edu/buros/
TRAUMA ASSESSMENTS
13
Gebart-Eaglemont, J. (1996). [Review of Trauma Symptom Inventory.] In The fourteenth mental
measurements yearbook. Available from http://www.unl.edu/buros/
James, R.K., & Gilliland, B.E. (2013). Crisis intervention strategies (7th ed.). Belmont, CA:
Brooks/Cole, Cengage Learning.
Kubany, E.W., Liesen, M.B., Kaplan, A.S., Watson, S.B., Haynes, S.N., Burns, K., & Owens,
J.A. (2000). Development and preliminary validation of a brief broad-spectrum measure
of trauma exposure: The Traumatic Life Events Questionnaire. Psychological
Assessment, 12(2), 210-224. Doi: 10.1037/1040-3590.12.2.210
Pierce, J.M., Burke, C.K., Stoller, K.B., Neufeld, K.J., & Brooner, R.K. (2009). Assessing
traumatic event exposure: Comparing the Traumatic Life Events Questionnaire to the
Structured Clinical Interview for DSM-IV. Psychological Assessment, 21(2), 210-218.
Doi: 10.1037/a0015578
Sheperis, C.J., & Heiselt, A.K. (2004). [Review of Trauma Assessment Inventories]. In The
fourteenth mental measurements yearbook. Available from http://www.unl.edu/buros/
Substance Abuse and Mental Health Services Administration. (n.d.). Welcome to the National
Center for Trauma-Informed Care. Retrieved from http://www.samhsa.gov/nctic/
Trauma Assessment Inventories. (2004). In The fourteenth mental measurements yearbook.
Available from http://buros.unl.edu/buros/
Trauma Symptom Inventory. (1995). In The fourteenth mental measurements yearbook.
Available from http://buros.unl.edu/buros/
Weissbecker, I., & Clark, C. (2007). The impact of violence and abuse on women’s physical
health: Can trauma-informed treatment make a difference? Journal of Community
Psychology, 35(7), 909-923. Doi: 10.1002/jcop.20189
TRAUMA ASSESSMENTS
14
Whiston, S.C. (2013). Principles and applications of assessment in counseling (4th ed.). Belmont,
CA: Brooks/Cole, Cengage Learning.