If you’re a therapist, it’s likely that one or more of your clients has a history of trauma. Some studies suggest that about half of all people have experienced at least one trauma in their lives. Do you know which of your clients have experienced trauma and how it might be affecting their care?
It's easy for therapeutic progress to stagnate when trauma goes unnoticed or untreated. That’s why properly screening and treating clients with a history of trauma is imperative for any clinician who wants to see their clients getting better. Measurement-based care (MBC) can help clinicians skillfully identify and respond to PTSD and related trauma experiences in their clients. We sat down with an expert, Dr. Sacha McBain, to help us understand how.
Dr. McBain is an integrated trauma specialist who works in the trauma unit of a level-one trauma hospital. She sees clients who have experienced life-threatening injuries both in the hospital and as an outpatient clinician. Her position is embedded within the hospital system, enabling her to offer immediate, front-line interventions for PTSD and continuing support after discharge.
Screening and Treating Trauma with MBC
The way trauma experts like Dr. McBain and her colleagues view and treat trauma has changed as a result of measurement-based care.
“For trauma specialists like myself in integrated care settings,” Dr. McBain explained, “routine screening and outcome measurement really impacts access to and engagement in trauma-focused care. We're able to catch people earlier on in their trajectory of trauma recovery and connect them with services that they may never otherwise access. There's been a lot of benefits to using screening and measurement in order to get people connected with the services that they need.”
Dr. McBain explains that these benefits apply to any mental health clinician whose clients may have trauma.
“With measurement-based care, we are more able to easily identify that traumatic stress symptoms are a component of somebody's presentation, whether it's when they show up in a medical setting or whether they're showing up in an outpatient setting. Understanding what's truly driving symptoms through screening and measurement increases the quality of engagement and overall care recommendations.”
In addition to identifying trauma, Dr. McBain has seen outcome measurements improve patient engagement.
“In terms of outcome measurement, your patients are more engaged because they understand that what you're doing together is helping them to feel better, not just within themselves but tangibly. They’re able to see changes in scores, and clinicians are able to tailor treatment to pinpoint the items that are staying elevated and not changing when engaged in trauma-focused treatments. It's a really great approach to identify the problem, and then also to make sure that we're really targeting and tailoring our interventions to solve the problem at hand.”
Using data to improve the treatment of PTSD makes sense for someone like Dr. McBain, who works alongside medical professionals regularly. In fact, it’s an analogy she often uses with her outpatient clients.
“One of the things that I always talk with my patients about is that when you go to your primary care doctor, if you're going to address high blood pressure, and they're not measuring your blood pressure you're going to be really concerned. You’d start asking, what is this person doing? Is this working? Is this helpful for me? You might feel changes in your body, but having that measurement to show that your blood pressure is changing is really valuable. The same is true with our mental health. When we're engaging in the really difficult process of a trauma-focused treatment, it’s important to have these measures to show you that you're making progress. And it's helpful to know that we're both checking in on the same things and that we have a shared language and a shared way to talk about the ways in which your symptoms are changing and how you're improving.”
Implementing MBC for Trauma
If you want to get the most out of MBC, you should be screening every client for exposure to trauma, says Dr. McBain. However, trauma screening measures are not the only ones that can make a difference when you are dealing with trauma.
“I use the Injured Trauma Survivor Screen, which is a predictive risk screen to assess for post-injury PTSD and depression. In terms of supplemental measures and what I use with my outpatients, I routinely use the PTSD checklist (PCL-5), which is a standard measure of PTSD symptoms. I use the PHQ-9 for depression. I will occasionally use the DES-II, which is a dissociation scale, as needed based on the client's presentation. I also use the Posttraumatic Growth Inventory as a way to integrate a strengths-based approach when indicated.”
Dr. McBain encourages clinicians to view the measures themselves as a potentially powerful therapeutic tool.
“I do a lot of early intervention with people who are just starting to understand what they're going through and are navigating the early stages of PTSD. And when I do a trauma interview with somebody, we go through the questions together, and a lot of people describe how validating and insightful it is to see the symptoms of PTSD. They might see that there's an item that literally says “blaming myself”. And the idea that it might be part of their diagnosis and not a reality that this is truly their fault can be really, really validating for people. And I've had that happen multiple times, where clients go, “Wow, I never realized that my irritability wasn't that I'm a bad parent. It was that I'm dealing with a trauma-related disorder. Clinicians should make this a therapeutic tool where they sit down and intentionally talk through the different symptom clusters and how they show up, and why they're showing up. It can be a really formative and healing experience in and of itself.”
Therapists should also set the expectation early that measurements will be a regular part of the therapeutic process, suggests Dr. McBain.
“The best implementation of measurement-based care is when the patient has the expectation that this [the measuring] is happening every week or whatever standard you set (bi-weekly, monthly) When they are doing it either before the visit, or during the beginning of the visit, and you’re using that to help set the agenda of your session. My patients will bring them to me or they'll send them online before we start the visit. And I'll say “Based on your total, your score came down five points this week. Does that match your experience? How does that map onto what's been going on for you? Where did you notice that symptoms are feeling increased this week or decreased? So being really explicit and transparent and talking about the items, and then bringing that into the conversation in the session is the best implementation of measurement-based care.”
Trauma-Specific MBC Considerations
Any clinician knows that dealing with trauma has its own set of rules. Dr. McBain has a few tips for what clinicians should know when they’re utilizing outcome measurements with trauma clients.
First, she emphasizes that when trauma is involved, scores frequently rise before they fall.
“One thing that I always try to do when we're doing trauma-focused work is talk about how avoidance symptoms can be high. We can actually use the measure to show that - “Notice how you endorsed ‘extremely’? You’re avoiding thinking about it and you're avoiding things that remind you of what happened. We know that avoidance is a core piece of PTSD, so as we start talking about it and we start facing it a little bit directly, you might actually notice that your symptoms increase. It's not uncommon for us to see that on these measures, the symptoms go up a little bit before they come down. That's a common pattern - you'll get a baseline score, and then you'll notice, after you start doing trauma-focused work, an increase in the re-experiencing symptoms. Or you'll see an increase in avoidance symptoms. And then as you do the work, you see a peak and followed by a drop that comes down.”
This insight is especially important for leadership and executives to keep in mind as they are understanding how to evaluate the quality or effectiveness of their services. Symptoms of trauma don't always change linearly. People in leadership may be looking for steep and sustained drops in scores, but this expectation reflects an unrealistic expectation of how trauma recovery occurs. Clinicians should also be mindful that for clients with PTSD, the list of symptoms questions may be overwhelming in itself. For such clients, Dr. McBain offered some guidance.
“We don't want people to be distressed and uncomfortable without them understanding the rationale for why we're doing it. Make sure that clients have a deep understanding of the rationale and see if that helps to alleviate some distress around it. But it won't for everybody. So we come back to our foundation of why we’re pursuing this. We assess how often we have to do it in order for it to be effective. And we might initially add some kind of guidance around how we're executing it, like having the client sit in the therapy room and fill it out silently while the clinician is present or we might talk through it as we go through, or use an abbreviated version, or complete it every two weeks instead of every week to start.
It just depends on your relationship with your client and the expectations around the treatment that you're doing. Don’t get into a battle over doing the assessment, because then you're just getting in the way of the work that you need to do. Prioritize their psychological safety without colluding with their avoidance around it. Ask, ‘What skills can we put in place? How can we help you learn to manage distress around answering these questions? How can we set up structures around them so that you feel like you have a good rationale and motivation to complete some of these measures?’”
Trauma Treatment and MBC just make sense
According to Dr. McBain, utilizing the data provided by MBC often helps provide a sense of direction that trauma clients need during a chaotic experience.
“Structure can be really valuable for patients and clinicians. We have really complex lives and when somebody comes in and they have something that they want to work on, it's not just that thing. There are all of the other things that are happening. There’s the situation of the week. And then there’s the longstanding crisis that we're dealing with. This work can be really complex and tricky and diffuse, and having a structure around how we're measuring can really be a guiding light for clinicians. It can help clients to know that we're doing the work that we need to do to help them feel better and live their best life.”
It’s impossible to work in mental health for any length of time without encountering clients who are influenced by trauma. But the complexities that trauma brings to a case can limit the effectiveness of therapeutic interventions. Therapists who fail to identify and consider trauma often find themselves frustrated in their attempts to help their clients. But by implementing measurement-based care, trauma can be identified and addressed as proactively as possible, allowing therapists and clients to focus on building healthier and more fulfilling lives.
If you’re ready to improve your practice’s trauma identification and treatment capabilities, Blueprint can help. Contact us today to find out how seamless and intuitive trauma screening and outcome measurement can be.