Psychosocial and Trauma Assessment
Comprehensive Diagnostic Evaluations at J. Flowers Health Institute
The information presented on this page is an overview of the average evaluation of this nature and is offered here as a resource. At J. Flowers Health Institute, our evaluations are customized and tailored to the individual’s needs. We specialize in providing truly comprehensive health and wellness evaluations and a workable plan for future health to those who want to improve their quality of life.
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What is a Psychosocial and Trauma Assessment?
Table of Contents
According to an article from the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 50% of those receiving behavioral health help (such as in therapy) have a history of trauma.1
Therapists estimate this number is higher for those who have a history of mental health disorders and struggle with substance abuse.
A psychosocial and trauma assessment is a comprehensive questionnaire that medical professionals ask a person seeking treatment for substance abuse or other conditions. It is a start-to-finish questionnaire about a person’s health, past experiences, and overall sense of well-being.
As little as 10 years ago, doctors thought it was best to treat substance abuse and mental health disorders separately. Today, research shows that to treat one condition (such as substance abuse), the other condition must also be addressed (such as how the underlying trauma affected a person).1
This is why doctors may assess for trauma. If a doctor can recognize that a person has a history of trauma, they can better plan an approach for treatment.1
Determining State of Mind with a Psychosocial Assessment
How a doctor approaches screening a person during a psychosocial and trauma assessment is just as important as the questions they ask. People who’ve experienced trauma have been through a lot. They have survived life-changing events, but they may not immediately connect their past trauma with their current behavioral health issues.
There is no “perfect” time to screen a person for trauma. A person may never be in the perfect mindset to talk. That’s why it’s important that a doctor helps a person understand why they are asking the questions they do and how they may help the person later.1
However, SAMHSA does caution against screening someone when they are under the influence of drugs or alcohol, simply because the information is less likely to be accurate.1
If a person seems very uncomfortable answering questions, a good alternative is to give them a paper questionnaire that they can read and check off answers without having to answer out loud. This can prove very helpful for some people.1
Determining Readiness for Treatment
A person’s readiness for treatment can affect them from the beginning as they may be less inclined to answer questions about their lives if they went into treatment unwillingly or aren’t ready to change. Lacking motivation or showing unwillingness for treatment is common. A medical professional may have to change their approach to help a person develop their motivation before pursuing further treatment courses.
Key Components of Psychosocial Assessments
Psychosocial assessments can take some time to complete on both the part of the interviewer and the person answering the questions. Sometimes, a person may have to answer the questions over the course of several visits before a doctor can complete a full-scale psychosocial assessment. This is because the assessment can sometimes feel exhausting on the part of the person being interviewed. Because the interviewer wants to get the best responses to their questions, they may find that splitting the questions across several sessions can help to get the most effective answers.
Below is a break-out of the most common components of a psychosocial assessment. These may vary based on the facility where a person works or the type of treatment program.
Identifying the Chief Complaint
A medical professional asks the client, in their own words, why they are here today. Often, a person’s impressions of why they are at a treatment facility or doctor’s appointment may be very different from a medical professional’s impression as to why they are there.
Get a Patient's History During a Psychosocial Assessment
History of the Presenting Illness
A medical professional will ask questions about the client's history. If substance abuse seems to be an underlying condition, a doctor may ask about when the person started using a particular substance or substances, how much they use, and how often they use it. The doctor may also ask the patient to describe a time when they felt they had hit rock bottom, and they may ask if the patient has sought treatment before or if they've made any personal attempts to recover from their addiction.
Psychiatric History
A medical professional will ask the patient if a doctor has ever diagnosed them with a mental illness. They may ask them in their own words what medical condition they've been diagnosed with or if they have any medical conditions a doctor has prescribed medications for.
During this portion of the assessment, it's vital for the medical professional to consider if a person has suicidal thoughts or behaviors, such as cutting or making a plan for self-harm.1
Medical History
A person's past medical history is important in deciding what kinds of treatments they may need. If a person has multiple complicated medical issues (like heart or lung problems or diabetes), they may require a different level of care while they treat the conditions they are at the facility for. Also, the National Institute of Mental Health has identified that people who have chronic medical conditions are more likely to experience mental illness.
Medication List
A medical professional should review a person's list of medications to determine if any medicines could be causing or contributing to their symptoms. It's also important to ask if a person is taking more of the medication than prescribed or is taking the medicines differently than prescribed. Finally, it's important to ask the patient what they believe they are taking a specific medication for.
Family/Social History
Questions for this section may focus on where a person was born and raised, as this can give clues into a person's cultural beliefs or how they were raised. Other questions may be about the person's family of origin, as well as about their current relationships, number of children, and available social support network. This information could help identify the support a person may have for treatment in the future.
Occupational History
Where a person works currently or has worked in the past can provide cues as to the types of stress or work-related concerns a person may have. Example questions include:
- Do you like your current job?
- Do you get along well with your co-workers?
- Have you ever lost your job?
- How many jobs have you had in the last five years?
Educational History
Educational history questions may include asking about the highest grade a person has completed, as well as the schools a person may have attended in the past. A key question could be about whether or not a person has ever had discipline problems at school, such as always being in trouble or having to perform remedial education.
Legal History
Knowing a person's previous problems with the law can convey the extent to which they've had problems with their substance abuse or behavioral health in general.
Developmental History
A medical professional will ask about a person's childhood history. Examples include how a person would describe their childhood, what they were like as a child, and whether or not they had any traumatic experiences in their childhood that may still affect them now.
Assess Factors That May Affect Recovery
Spiritual Assessment
A medical professional can ask if a person identifies with any religious background and if they regularly attend religious services. A doctor may ask what role spirituality plays in a person's life.
Cultural Assessment
Some of the earlier questions may help to inform the cultural portion of the assessment (such as where a person was born and raised). However, a medical professional may ask how a person's cultural background affects them, including how their culture may view substance abuse.
Financial Assessment
A medical professional can ask if a person feels secure in their finances or if they are struggling financially. Other questions could include, "Do you frequently worry about your finances?" and "Have you ever stolen or engaged in other illegal acts to help your finances?"
Violence Risk Assessment
A medical professional will ask questions that may include the following:
- in the past month/year, have you been physically hit, kicked, or punched by another person?
- Do you have anyone in your life who threatens you with physical harm?
- Have you ever been forced to have sexual contact with a person (even if it is your spouse or significant other) when it was unwanted?
- Have you ever been abused emotionally or physically by another person?
Make Determinations During a Psychosocial Assessment
Determining Alcohol and Drug Use
In this part of a psychosocial assessment, a medical professional emphasizes to the patient the importance of being as honest as possible when it comes to their history of drug and alcohol abuse. The medical professional may ask questions about how much a person is drinking or using drugs each day and how the person feels about their substance abuse. Other questions may be about how often a person uses the drug or alcohol and how much a person may have used in the past.
Determining Coping Skills
A lack of positive coping skills can be a trigger for substance abuse and other health problems. A medical professional could ask the patient a question like "How do you cope with stress in your life?"
Determining Interests and Abilities
When a person struggles with addiction, they often stop doing things they used to enjoy in favor of using drugs or alcohol. However, it's important to explore the hobbies a person used to have or things they would enjoy doing. This can help guide later treatment decisions. Examples of questions include:2
- What hobbies do you have?
- What would you say you are good at?
- What makes you happy?
Mental Status Examination
The mental status examination during a psychosocial assessment has several different aspects to consider. Usually, this will appear on the medical professional's chart as check-boxes for quick assessment purposes. Examples of factors to observe during the mental status examination include:
- Orientation
- Appearance
- Behavior
- Speech
- Mood
- Attitude
- Presence of hallucinations, delusions, or strange thoughts
How Psychosocial Assessments Benefit Treatment
A psychosocial assessment is a comprehensive document that examines multiple aspects of a person’s life. A medical professional must consider each aspect of a person’s response when recommending treatments.
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Types of Trauma Assessments
There are a variety of tests that a therapist or doctor can administer to help identify if a person has past experiences with trauma:
Childhood Attachment and Relational Trauma Screen (CARTS)
The CARTS screening tool is a reasonably new questionnaire that asks about a person’s relationships with key people in their lives when growing up.3
Examples could include a person’s parents, siblings, aunts/uncles, and other key caregivers as they grew up.
Global Psychotrauma Screen (GPS)
The Global Psychotrauma Screen is a questionnaire that consists of 22 items that have yes or no answers. The questionnaire is available in 18 languages and covers a variety of different potential conditions related to trauma, including post-traumatic stress disorder, anxiety, depression, problems sleeping, substance abuse, childhood trauma, and more.4
Clinician-Administered PTSD Scale (CAPS)
The Clinician-Administered PTSD Scale is a 30-item questionnaire that takes place in the setting of a structured interview. This means a therapist will ask a person the questions and consider their responses when making a diagnosis.5
The questions are taken from the Diagnostic and Statistical Manual of Mental Disorders-V(DSM-5) guidelines for diagnosing post-traumatic stress disorder. A doctor will rate a person’s responses by severity and provide them with an overall score indicating how severe their PTSD may be. An example of a question to include would be, “In the past month, have you had any unwanted memories of (the event) while you were awake, not counting dreams?”6
How Trauma Assessments Benefit Treatment
Trauma assessments are important for mental health professionals because they are a standardized way of establishing if a person has a history of trauma and rating the degree to which it affects the person. This helps a person get treatments across a variety of specialties. Having standard assessments ensures a person living on the West Coast is diagnosed in the same manner as a person who lives on the East Coast, for example. A doctor can then review a person’s results with other doctors or medical professionals to determine what treatments may be the best options for that person.
If a therapist does not address trauma history in a person’s past, the likelihood that their treatment will be successful decreases. Failing to address trauma symptoms can lead to the following unwanted side effects:
- Poor engagement in treatment
- Early termination of rehabilitation treatment
- Greater risk for relapse
- Worse clinical outcomes
Sometimes, a person’s medical condition can mimic another condition (such as depression, borderline personality disorder, or anti-social personality disorder) when the real underlying cause is related to trauma in their past. To get to the root of a problem, it is important for a doctor to screen for trauma.
Resources
- https://www.ncbi.nlm.nih.gov/books/NBK207188/
- https://ceufast.com/course-resources/example-of-a-psychosocial-assessment.pdf
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622711/
- https://istss.org/clinical-resources/assessing-trauma/gps
- https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp
- https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/index.shtml
