Evaluating Trauma-Related Needs, Service Delivery and Outcomes

This document was developed by Julian Ford, PhD
(**ford@psychiatry.unhc.edu)** for the *Center for Women, Violence and
Trauma* to assist states in developing trauma evaluation plans for
mental health systems transformation. For further information, contact
the Center at **Women&ViolenceCenterDirector@abtassoc.com.**

### I. Background and Overview

Exposure to psychological trauma is prevalent in the community among
adults (Kessler et al., 1995), adolescents (Giaconia et al., 1995), and
children (Costello et al., 2002), and virtually universal among adults
receiving mental health (Mueser et al., 1998) or addiction recovery
(Triffleman, 1999) services in public sector systems. One in ten women
or girls and one in twenty men or boys in the community experience
**post- traumatic stress disorder** (**PTSD**; Kessler et al., 1995;
Saigh et al., 1999), but PTSD prevalence is estimated to be 40-50% or
higher among youths (Abram et al., 2004) and adults (Briere et al.,
1997) These rates do not include partial PTSD, nor do they recognize the
likelihood that many persons who experience a traumatic event then
develop significant functional and clinical impairments despite not
meeting the diagnostic criteria for PTSD (Briere, 1999; Nader, 1997;
Newman, 2002).

Moreover, most children and adults who experience trauma do not develop
PTSD (Kessler et al., 1995; Saigh, et. al., 1999), but unresolved
post-traumatic stress can lead to serious long-term problems in living
into and throughout adulthood (Briere, 1997). Adverse consequences
include, but are not limited to, **re-victimization, problems with
substance abuse, affective disorders, anxiety disorders, dissociative
disorders, eating disorders,** and **conduct disorders** (Briere, 1997;
Saigh, et. al., 1999).

These long-term post-traumatic dilemmas reflect four fundamental changes
that result from exposure to psychological trauma. Traumas are
experiences in which a person's **safety**, or that of key caregiver(s)
or significant others (e.g., children, siblings or friends), has been
compromised. Safety has both an objective (e.g., current or imminent
risk of physical or psychological harm) and subjective (e.g., sense of
personal safety and trust) dimension. Regaining objective safety is
crucial to recovery or healing after trauma, but even when this is
accomplished the second fundamental change often remains debilitating.

Surviving the physical danger or violation, and coping with the
emotional or spiritual shock and betrayal caused by psychological trauma
requires a complex set of adjustments in the body's central and
peripheral nervous systems (Bremner, Southwick, & Charney, 1999). In
trauma, survival takes precedence over **self-regulation**, and this can
result in biological and psychological reactivity which is
survival-oriented but which takes a profound toll on bodily health
(Boscarino, 1997; Ford et al., 2004) and psychological well-being (Ford,
1999; Herman, 1992) for years or even decades later.

When safety is uncertain (objectively or subjectively), and
self-regulation is disrupted, not only the individual but many or most
of her or his primary relationships and **social support** system are
vulnerable to the adverse effects of unresolved conflict and withdrawal.

The result often is one of many forms of social isolation which reduce
the person's access to the practical resources and the interpersonal
supports that are essential if a trauma survivor is to both recognize
within her/himself and restore or build the **personal strengths** and
capacities (e.g., self-esteem and self-efficacy; emotion regulation,
problem solving, and communication skills) needed in order to regain
safety, self-regulation, and involvement in supportive and productive
relationships.

### II. Evaluating Trauma-Informed Services

In order to achieve replicable trauma-informed services and to
demonstrate their outcomes, a plan for evaluation must include
assessment of: (1) the nature and extent of *past and current exposure
to psychological trauma and re-victimization*, (2) problems with *PTSD*
and *other psychosocial/psychiatric symptoms*, and (3) *current status*
and *needs* with respect to *safety, self-regulation, social support,*
and *personal strengths.* Both individual and provider interview
measures of services utilized and the provider-survivor "working
alliance" (such as those developed for the SAMHSA Women, Co-Occurring
Disorders, and Violence Study), and archival records (e.g., agency or
state computer databases), are needed to assess actual services
received.

**Multi-Perspective Assessment**. Multi-perspective assessment is
recommended in order to reduce the likelihood that unintended bias or
distortion will occur due to information based on any individual data
source. The perspective of the individual herself or himself is
important because other informants (e.g., family, teacher, treatment
provider, research observer) may focus on overt symptoms or needs while
ignoring more subjective symptoms or needs. However, other informants
are vital to identify needs, problems, and changes that may not be
evident to the individual herself or himself. There is no one "perfect"
measure for assessing trauma or post-traumatic sequelae. Measures vary
in their reliability, validity, sensitivity, specificity, and clinical
utility for different settings and populations. Time permitting, the use
of both self-report and interview-based assessments are recommended.
Additionally, both structured and semi-structured observational
assessments can provide ecologically valid behavior samples (Newman,
2002).

**Stages of Evaluation.** To maximize the benefits accrued by and the
safety of recipients, and the utility of trauma information for both
clinicians/case managers and policymakers/system evaluators, a staged
approach to collecting data and providing trauma-related education and
treatment is recommended. Although the exact stages and sequencing of
these trauma-related data collection and education/treatment activities
will differ based on feasibility and logistical factors in each
different system, project, or program, the phase-based model of complex
trauma services (Ford et al., in press) can serve as a guide for
trauma-sensitive implementation of trauma-related data collection and
services:

-   **Phase 1:** Ensure safety and stability, screen for past and
    current traumatic experiences and symptomatic difficulties without
    in-depth exploration, provide education about the effects of trauma
    in a non-stigmatizing, non-pathologizing, and user-friendly manner,
    and teach/strengthen basic self-regulation skills and social
    supports.

-   **Phase 2:** Assess past and current traumatic experiences and
    symptomatic and self-regulatory difficulties thoroughly with
    standardized replicable measures, provide education about the
    "traumagenic dynamics" (Finkelhor & Browne, 1986) and related
    alterations in core beliefs, self-regulatory strategies,
    interpersonal attachments, and spiritual/existential outlook
    (Herman, 1992) that begin as healthy self-protective reactions to
    trauma and can become persistent post-traumatic difficulties,
    provide a safe therapeutic environment in which the individual can
    disclose and gain more organized and self-regulated schemas or
    narratives for understanding current or past trauma-related
    experiences and problems in living, and teach/strengthen skills for
    complex self-regulation and interpersonal relatedness.

-   **Phase 3**: Monitor current stressful or traumatic experiences,
    symptoms, self-regulation, social support, and personal
    strengths/resources on an ongoing periodic basis.

**Evaluation Design**. As suggested in Phase 3 above, ongoing
longitudinal evaluation provides greater clarity concerning the timing,
nature, and potential sources of change than simpler traditional
pre-post evaluation designs. Data collection and temporal sampling
strategies that provide data suitable for longitudinal analyses (e.g.,
trajectory or growth curve modeling) and analytic plans that account for
change over time while adjusting for missing data (e.g., hierarchical
linear modeling, random effects regression) are optimal.

A blended qualitative (formative) and quantitative (confirmatory)
approach to evaluation is necessary in order to develop
screening/assessment and intervention questions and procedures that are
sensitive to the primary psychosocial, health, and socioeconomic needs
of the target population(s) and to differing norms and practices of
sub-populations of different gender, ethnocultural background,
developmental status and age, family structure, and type of
community/residential environment.

**Partnership Models**. Involvement of trauma survivors and service
recipients as full partners in evaluation is essential. The evaluation
team should formally include consumers/survivors/persons in recovery
(CSP) as integral staff and investigators in order to ensure that
evaluation is grounded in the experience of persons who have lived with
trauma and its effects. Hypotheses and logic models, methods and
measures for data collection, and approaches to services developed in
formative phases of the evaluation should reflect a balance of lived
experience and technical expertise, with CSPs often providing both types
of expertise. Data collection, analysis, and reporting and dissemination
equally should include CSPs as key contributing staff and investigators.

## III. Sample Measures 

**Trauma Exposure/History: Self-Report and Structured Interview (see
*[www.ncptsd.org](http://www.ncptsd.org/)[;
www.nctsnet.org]{.underline}*)**

-   *Childhood Trauma Questionnaire* (Bernstein, et. al., 1994)

-   *Traumatic Events Screening Inventory* (TESI; Ford et al., 2000)

-   *Life Stressor Checklist-Revised* (Wolfe & Kimerling, 1997)

**PTSD Symptoms; Self-Report and Structured Interview (see
*[www.ncptsd.org](http://www.ncptsd.org/)[;
www.nctsnet.org]{.underline}*[)]{.underline}**

-   *Clinician Administered PTSD Scale for Children and Adolescents*
    (CAPS-CA; Newman, 2002) and *Adults* (CAPS, Blake et al., 1995)

-   *PTSD Checklist* for adults (PCL-C; Blanchard et al., 1996) and
    parents (PCL-C/PR; Ford et al., 2000)

-   UCLA PTSD Reaction Index for Children (Steinberg et al., 2004)

-   PTSD Symptom Scale-Interview (Foa et al., 1993)

## Psychosocial and Psychiatric Symptoms: Self-Report and Structured Interview

-   *Trauma Symptom Inventory* (adults; TSI; Briere, 1996) and *Trauma
    Symptom Checklist for Children* (TSCC; Wolpaw, Ford, Newman &
    Briere, in press))--- Anxiety, Depression, Anger, Posttraumatic
    Stress, Dissociation and Sexual Concerns

-   *Diagnostic Interview for Children and Adolesce*nts -- Revised
    (DICA-R; Reich et. al., 1991)

-   *Diagnostic Interview Schedule* for adults (DIS; Helzer &
    Robins, 1988) and for children (DISC; Shaffer et. al., 1992)

-   *Schedule for Affective Disorders and Schizophrenia* *Present and
    Lifetime Version* () and *Kiddie* version for children and
    adolescents (K-SADS-PL; Kaufman, et. al., 1997)

-   *Structured Clinical Interview for DSM-IV* (SCID-P, SCID-II; First
    et al., 1996)

-   *Global Appraisal of Individual Needs* (GAIN; Dennis et al., in
    press)---substance abuse, legal and vocational issues, depression,
    anxiety, demographics (includes GPRA data categories)

##  Self-Regulation: Self-Report 

-   *Inventory of Interpersonal Problems-Short Form
    (IIP-32*[)]{.underline} (Barkham, Hardy & Startup, 1996)

-   *Post-Traumatic Cognitions Inventory* (PTCI*;* Foa et al., 1999).

-   *Generalized Expectancies for Negative Mood Regulation* (NMR;
    Cantanzaro & Mearns, 1990)

-   *Meta-Experience of Mood Scales (*Meta-Scales*;* Mayer & Stevens,
    1994)

-   *Positive Affect Negative Affect Scales* (PANAS; Watson, Clark, &
    Tellegen, 1988)

-   *Parenting Stress Index Short Form* (PSI; Abidin, 1995)

-   *Medical Outcomes Study Short Form-12* (SF=12; Gandek, B., Ware,
    J.E., Aaronson, N.K., Apolone, G., Bjorner, J.B., Brazier, J.E.,
    Bullinger, M., Kaasa, S., Leplege, A., Prieto, L., & Sullivan, M.
    (1998). Cross-validation of item selection and scoring for the SF-12
    Health Survey in nine countries: results from the IQOLA Project.
    International Quality of Life Assessment. *Journal of Clinical
    Epidemiology, 51*, 1171-1178.

## Social Support

-   *Crisis Support Scale (*CSS; Joseph, Andrews, Williams, & Yule,
    1992)

-   *Homeless Families Social Support Scale*
    ([www.samhsa.gov](http://www.samhsa.gov/); SAMHSA Matrix,
    Homelessness)

## Personal Strengths

-   *Hope Scale* (Snyder, 1996)

-   *Coping Orientation to Problems Experienced* (COPE, Carver, Scheier,
    & Weintraub, 1989)

-   Relationship Scales Questionnaire & Relationship Questionnaire
    (Griffin & Bartholomew, 1994)

IV\. References

Abidin, R.(1995). *Manual for the Parenting Stress Index.* Psychological
Assessment Resources, Inc.

Abram, K. M., Teplin, L. A., Charles, D. R., Longworth, S. McClelland,
G., & Dulcan, M. (2004). Posttraumatic stress disorder and trauma in
youth in juvenile detention. *Archives of General Psychiatry, 61,*
403-410.

Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M.,
Wenzel, K., Sapareta, E. & Ruggiero, J., (1994). Initial reliability and
validity of a new retrospective measure of child abuse and neglect.
*American Journal of Psychiatry, 151*, 1132-1136.

Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Charney, D.S.,
& Keane, T.M. (1995). *Clinician-Administered PTSD Scale for DSM-IV*.
Boston and West Haven, CT: National Center for Posttraumatic Stress
Disorder.

Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., Forneris, C. A.
(1996). Psychometric properties of the PTSD Checklist (PCL). *Behaviour
Research and Therapy*, 34, 669-673.

Boscarino, J. A. (1997). Diseases among men 20 years after exposure to
severe stress. [Psychosomatic Medicine, 59]{.underline}, 605-614.

Bremner, J., Southwick, S., & Charney, D. (1995). Etiology of
post-traumatic stress disorder. In M. Mazure (Ed.), *Does stress cause
mental illness?* (pp. 68-104). Philadelphia: Saunders.

Briere, J. (1997). Psychological assessment of child abuse effects in
adults. In J. P. Wilson and T. M. Keane (Eds.), *Assessing Psychological
Trauma and PTSD* (pp. 43-68). New York: Guilford Press.

Briere, J., Woo, R., McRae, B., Foltz, J., & Sitzman, R. (1997).
Lifetime victimization history, demographics, and clinical status in
female psychiatric emergency room patients. *Journal of Nervous and
Mental Disease, 185*, 95-101.

Costello, E. J., Erkanli, A., Fairbank, J. A., Angold, A. (2002). The
prevalence of potentially traumatic events in childhood and adolescence.
*Journal of Traumatic Stress, 15, (2)*, 99-112.

Dennis, M.L., Funk, R., Godley, S.H., Godley, M.D., & Waldron, H. (in
press). Cross validation of the alcohol use measures in the Global
Appraisal of Individual Needs (GAIN) and Timeline Followback (TLFB)
among adolescents in substance abuse treatment. *Addiction.*

Foa, E., Riggs, D., Dancu, C., & Rothbaum, B.(1993). Reliability and
validity of a brief instrument for assessing post-traumatic stress
disorder. *Journal of Traumatic Stress*, 6, 459-474.

First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1996).
*Structured Clinical Interview for Axis I DSM-IV Disorders - Patient
Edition (SCID-P).* New York: Biometrics Research Department New York
State Psychiatric Institute.

Foa, E.B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. (1999).
The Posttraumatic Cognitions Inventory (PCTI): Development and
validation. *Psychological Assessment, 11,* 303-314.

Ford, J. D. (1999). PTSD and disorders of extreme stress following war
zone military trauma: Comorbid but distinct syndromes? *Journal of
Consulting and Clinical Psychology*, *67,* 3-12*.*

Ford, J., Courtois, C., van der Hart, O., Nijenhuis, E., & Steele, K.
(in press). Treatment of complex post-traumatic self-dysregulation.
*Journal of Traumatic Stress.*

Ford, J. D., Racusin, R., Daviss, W. B., Reiser, J., Fleischer, A. &
Thomas, J. (2000). Child maltreatment, other trauma exposure, and
posttraumatic symptomatology among children with oppositional defiant
and attention deficit hyperactivity disorders. *Child Maltreatment, 5*,
205-217.

Ford, J. D., Schnurr, P., Friedman, M., Green, B., Adams, G., & Jex, S.
(2004). Posttraumatic stress disorder symptoms and physical health
outcomes fifty years after exposure to a toxic gas. *Journal of
Traumatic Stress, 17,* 185-194.

Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A.
K. & Cohen, E. (1995). Traumas and posttraumatic stress disorder in a
community population of older adolescents. *Journal of the American
Academy of Child and Adolescent Psychiatry, 34 (10)*, 1369-1380.

Griffin, D. W., & Bartholomew, K. (1994). The Metaphysics of
Measurement: The Case of Adult Attachment. In K. Bartholomew & D. P.
Perlman (Eds.), *Advances in Personal Relationships: Attachment
Processes in Adult Relationships (Vol. 5)*. London: Jessica Kingsley.

Helzer, J., & Robins, L. (1988). The diagnostic interview schedule.
*Social Psychiatry and Psychiatric Epidemiology, 23*, 6-16.

Joseph, S., Williams, R., & Yule W. (1992). Crisis support,
attributional style, coping style, and post-traumatic symptoms.
*Personality and Individual Differences, 13,* 1249-1251.

Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P.,
Williamson, D. & Ryan, N. (1997). Schedule for Affective Disorders and
Schizophrenia for School-Age Children-Present and Lifetime Version
(K-SADS-PL): Initial reliability and validity data. *Journal of the
American Academy of Child & Adolescent Psychiatry. 36(7)*, 980-988*.*

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B.
(1995). Posttraumatic stress disorder in the national comorbidity
survey. [Archives of General Psychiatry, 52]{.underline}, 1048-1060.

Mayer, J., & Stevens, A. (1994). An emerging understanding of the
reflective (meta-) experience of mood. *Journal of Research in
Personality, 28,* 351-374.

Mueser, K.T., Goodman, L.A., Trumbetta, S.L., Rosenberg, S., Osher, F.,
Vidaver, R., Auciello, P., & Foy, D.W. (1998). Trauma and posttraumatic
stress disorder in severe mental illness. *Journal of Consulting and
Clinical Psychology, 66*, 493-499.

Nader, K. O. (1997). Assessing traumatic experiences in children. In J.
P. Wilson and T. M. Keane (Eds.), *Assessing Psychological Trauma and
PTSD* (pp. 291-348). New York: Guilford Press.

Nader, K., Newman, E., Weathers, F. W., Kaloupek, D. G., Kriegler, J.,
Blake, D. & Pynoos, R. S. (1998). Clinician-Administered PTSD Scale for
children and adolescents (CAPS-CA). White River Junction, VT: National
Center for PTSD.

Newman, E. (2002). Assessment of PTSD and trauma exposure in
adolescents. *Journal of Aggression, Maltreatment & Trauma*, 6, 59-77.

Reich, W., Shayka, J. J. & Taibleson, C. (1991). Diagnostic Interview
for Children and Adolescents (DICA). St. Louis, MO: Washington
University.

Saigh, P. A., Yasik, A. E., Sack & W. H., Koplewicz, H. S. (1999).
Child-adolescent posttraumatic stress disorder: prevalence, risk
factors, and comorbidity. In P. A. Saigh and J. D. Bremner (Eds.),
*Posttraumatic Stress Disorder: A Comprehensive Text* (pp. 18-43).
Boston: Allyn and Bacon.

Shaffer, D., Fisher, P., Piacentini, J., Schwab-Stone, M. & Wicks, J.
(1992). The Diagnostic Interview Schedule for Children (DISC).
(Available from authors, Columbia NIMH DISC Training Center, Division of
Child and Adolescent Psychiatry-Unit 78, New York State Psychiatric
Institute, 722 West 168^th^ Street, New York, NY 10032).

Steinberg, A., Brymer, M., Decker, K., & Pynoos, R. (2004). The UCLA
PTSD Reaction Index. *Current Opinion in Psychiatry, 6,* 96-100.

Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and
validation of brief measures of Positive and Negative Affect: The PANAS
scales. *Journal of Personality and Social Psychology, 54,* 1063-1070.

Wolfe, J., & Kimerling, R. (1997). Gender issues in the assessment of
Posttraumatic Stress Disorder. In J. Wilson & T.M. Keane (Eds.),
*Assessing psychological trauma and PTSD* (pp. 192-238). New York:
Guilford.