U.S. Navy Photo by Photo by Petty Officer 2nd Class Justin Woods

Felisha Garcia, Psy.D., Olivia Bentley, Ph.D., LPCC-S, Lt. Cmdr. Dierdra Oretade-Branch, DSW, LCSW, BCD, U.S. Public Health Service
June 11, 2024

How do you help someone who has been through trauma? What if they have suffered from multiple traumas? Clinicians often find themselves overwhelmed when deciding how to help a patient navigate the impact of trauma — especially when dealing with compounded traumas and comorbid conditions. Trauma screening and assessment can help to identify ongoing safety issues like intimate partner violence. Oftentimes, patients do not realize that their unhealthy relationships are traumatic. Where do you start? Which trauma do you address first?

Let’s starts with the basics. Establishing a positive rapport with healthy boundaries sets the foundation for a safe and supportive environment for your patient.¹ Take the time to review an informed consent that covers personalizing treatment, going at a pace comfortable for the patient, and limits of confidentiality. These are the building blocks necessary to enhance the trust of the therapeutic alliance.¹ Once this foundation of care is set, then the vulnerable work can begin.

Next, let’s look at what is going on. Trauma is multifaceted and every patient responds to it differently, so it is important to learn their specific issues and symptoms. To help assess trauma history and impact, several evidence-based screenings and interviews for posttraumatic stress disorder are recommended by the Department of Veterans Affairs and Department of Defense such as the Primary Care PTSD Screen for DSM-5, the Clinician-Administered PTSD Scale, and the PTSD Symptom Scale-Interview Version.² The PTSD Checklist for DSM-5 and the Clinician-Administered PTSD Scale are assessment tools that can assist with detecting changes in symptom severity over time. Ongoing assessment can help inform adaptation of your treatment plan based on your patient’s needs.²

Now that we know what is going on, let’s treat it. There are many approaches to treatment, but evidenced-based, manualized and trauma-focused therapy in an individual therapy format appears most effective for treating posttraumatic stress disorder.² These manualized PTSD treatments may include: Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing, Prolonged Exposure, Ehlers’ Cognitive Therapy for PTSD, Present-Centered Therapy and Written Exposure Therapy.² It is important to note that pharmacotherapy, specifically Paroxetine, Sertraline, or Venlafaxine, have also shown to be effective for the treatment of PTSD.²

Clinicians are also working to adapt evidence-based, trauma-focused treatments to better address effective interventions based on specific type of trauma that the patient has experienced. For instance, in relationships involving IPV, safety and control are major concerns which may create hurdles to engaging in and/or completing treatment. In a pilot study of women survivors of IPV, Galovski et al., found that condensing Cognitive Processing Therapy into five days was a helpful and potentially effective option for women who had very little time to safely access the traditional, more lengthy complete treatment delivery schedule.³ Also, adjunct treatments, such as mindfulness training and trauma-sensitive yoga, appear to be effective in combination with evidence-based, manualized and trauma-focused therapy.^2,4,5

For the treatment of Acute Stress Disorder, trauma-focused cognitive-behavioral therapy appears to be effective.² The military developed a distinct concept (not the same as ASD) related to responses to stressors from combat situations, the combat and operational stress reaction.⁶ The DOD Instruction 6490.05 (3) defines COSR as “physical, emotional, cognitive, or behavioral reactions, adverse consequences, or psychological injuries of service members who have been exposed to stressful or traumatic events in combat or military operations.”⁶ Take time to familiarize yourself with the COSR concept so you can meet the unique needs of service members who are experiencing it. Also remember that as much as it is important to treat the military member, we must not forget that families are also likely to be impacted by the traumatic experiences of their service member. Trauma-focused cognitive–behavioral therapy may be effective for treating military children exposed to maltreatment, IPV and grief.⁷

It is truly an honor to be chosen by a patient to help them process their traumatic experiences, and to witness their work towards healing. Trauma treatment can feel daunting for both the patient and clinician; however, it can also be a beautiful journey of strength.

Free Assessment Tools

Primary Care PTSD Screen for DSM-5^2,8

• Form: https://www.ptsd.va.gov/professional/assessment/documents/pc-ptsd5-screen.pdf
• Scoring information: https://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp

Clinician Administered PTSD Scale^2,9

• Form: https://www.ptsd.va.gov/professional/assessment/ncptsd-instrument-request-form.asp
• Scoring information: https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp

PTSD Symptom Scale-Interview Version^2,10

• Request the form and scoring information from the author directly: foa@pennmedicine.upenn.edu.

PTSD Checklist for DSM-5^2,11

• Form and Scoring information: https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

Want this information in an easy to access manner? See the PTSD clinical support tools and PTSD Assessment Tools.

References

1. Portnoy, G.A., Colon, R., Gross, G.M., Adams, L.J., Bastian, L.A., & Iverson, K.M. (2020). Patient and provider barriers, facilitators, and implementation preferences of intimate partner violence perpetration screening. BMC Health Services Research 20, 746. https://doi.org/10.1186/s12913-020-05595-7
2. Veterans Affairs and Department of Defense. (2023). VA/DOD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. (Version 4.0). https://www.healthquality.va.gov/guidelines/MH/ptsd/
3. Galovski, T. E., Werner, K. B., Weaver, T. L., Morris, K. L., Dondanville, K. A., Nanney, J., Wamser-Nanney, R., McGlinchey, G., Fortier, C. B., & Iverson, K. M. (2022). Massed cognitive processing therapy for posttraumatic stress disorder in women survivors of intimate partner violence. Psychological Trauma: Theory, Research, Practice, and Policy, 14(5), 769–779. https://doi.org/10.1037/tra0001100
4. Gallegos, A. M., Heffner, K. L., Cerulli, C., Luck, P., McGuinness, S., & Pigeon, W. R. (2020). Effects of mindfulness training on posttraumatic stress symptoms from a community-based pilot clinical trial among survivors of intimate partner violence. Psychological Trauma: Theory, Research, Practice, and Policy, 12(8), 859–868. https://doi.org/10.1037/tra0000975
5. Nguyen-Feng, V. N., Morrissette, J., Lewis-Dmello, A., Michel, H., Anders, D., Wagner, C., & Clark, C. J. (2019). Trauma-sensitive yoga as an adjunctive mental health treatment for survivors of intimate partner violence: A qualitative examination. Spirituality in Clinical Practice, 6(1), 27–43. https://doi.org/10.1037/scp0000177
6. Department of Defense. (2011, November 22). Maintenance of psychological health in military operations (DOD Instruction 6490.05). https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/649005p.pdf
7. Ridings, L. E., Moreland, A. D., & Petty, K. H. (2019). Implementing trauma-focused CBT for children of veterans in the VA: Providing comprehensive services to veterans and their families. Psychological Services, 16(1), 75–84. https://doi.org/10.1037/ser0000278
8. Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G, Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). Primary care PTSD screen for DSM-5 (PC-PTSD-5). National Center for PTSD. https://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp
9. Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The clinician-administered PTSD scale for DSM-5 (CAPS-5). National Center for PTSD. https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp
10. Foa, E. B., McLean, C. P., Zang, Y., Zong, J., Rauch, S., Porter, K., Knowles, K., Powers, M. B. & Kauffman, B. (2016). Psychometric properties of the Posttraumatic Stress Disorder Symptoms Scale Interview for DSM-5 (PSSI-5). Psychological Assessment, 28(10), 1159–1165. https://doi.org/10.1037/pas0000259
11. Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

Biographies

Dr. Felisha Garcia is a licensed clinical psychologist and contracted subject matter expert for the Defense Health Agency, Psychological Health of Center Excellence. She specializes in forensic psychology with extensive experience in the treatment of trauma.

Dr. Olivia Bentley is a licensed professional clinical counselor and contracted subject matter expert at the PHCoE who specializes in trauma-informed care.

Dr. Dierdra Oretade-Branch is a board certified clinical social worker and Lieutenant Commander in the Commissioned Corps of the United States Public Health Service. She is a subject matter expert at PHCoE and specializes in military and forensic social work within the civilian, veteran, and active-duty service member populations.