The Importance of Assessing Invisible Wounds

It is a privilege to be invited to help those that struggle with the impact of past painful learning, and I feel honored to have the opportunity to be allowed to work with clients that have experienced the worst kinds of hurt in life. I am proud that much of my work with clients centers around addressing a variety of trauma histories, but I find that most of the time I am not the first therapist that they have worked with and when they come to me I find that these clients are often misdiagnosed. Accordingly, clients will embrace this misdiagnosis due to placing significant trust in therapists, in general, due to our title or education. I find that my clients will buy into what their therapist is telling them, so it is important that we are giving the most accurate diagnosis possible. I believe, as clinicians, we have to ensure we are properly assessing the symptoms that are present and explaining our treatment course to our traumatized clients as they must navigate those symptoms. In addition to thorough assessment and accurate diagnoses, I believe therapists need to be trained and prepared to educate clients and demonstrate effective skills. When we serve our clients well, they can heal from their past painful learning, so it is important to have the needed clinical skills and assessment tools to serve traumatized clients effectively.

Before anything can begin to happen clinically with our clients we must be prepared with proper training and an awareness of the unique aspects of treating traumatic stress. I have seen many children that are misdiagnosed with ADHD when they are in highly distressing environments; no one can properly focus when they feel a constant sense of fear about their safety so this is not always an appropriate diagnosis. I also have seen adults misdiagnosed with Bipolar Disorders but a history of trauma is at the root of their emotional disregulation. It is certainly possible for a person to have a dual mental health diagnosis but it is imperative that we are considering differential diagnostic questions to help make our assessment and rationale for the diagnosis more complete by reflecting on questions like “Does this diagnosis best account for the symptoms?” or “Does this connect the most closely to the appropriate course of treatment?”. How we assess and diagnose should be closely tied into how we are going to treat the client’s symptoms or if we should be referring that client out. As the professional we need to be aware of our own limitations and strengths and if treating a client with complexed trauma is not in our skill set we must serve that client well by connecting them to a practitioner that will be more suited to their needs. Many symptoms have overlap but the nuance of trauma needs to be highlighted in order to have positive outcomes for our clients.

Therapists can make use of appropriate screening questions and assessments in order to bring validity to a diagnosis or clarify any confusion. There are some aspects of diagnosis that are overt and will not require much deliberation but there are subtleties that may require some clarifying. Many trauma survivors are avoidant to the past painful learning that they have experienced so they may not be as open at first, they may not really see the events of the past as being that bad, or they may not want to talk to a therapist about that experience. As clinicians we have to be willing to move at the client’s pace in order to ensure the client has a sense of safety with the therapist. When a client feels they have a safe place to share they are more likely to disclose about past painful learning. I have learned to assess for neglect by asking if a client feels they have been properly nourished across the critical domains of the human experiences. Some clients that have survived chronic neglect may not be aware that they have experienced neglectful practices. I typically will ask “Do you feel you were properly supported emotionally, physically, and intellectually?”. I find assessing for neglect with this question tends to give the person a chance to reflect carefully on what has happened in their life and to appraise it for themselves. At that point I find I can sit back and ask some simple open ended questions and clarifying questions to build rapport and to further assess.

In addition, there are some very helpful assessments that I have found useful in starting a conversation with my clients about their trauma history. I find that using an assessment tool gives the client a concrete place to begin the discussion about the past and how it is impacting them currently. The Adverse Childhood Experiences (ACEs) assessment is not intended to render any specific diagnosis but it asks ten simple questions about past experiences that I have found give my clients a moment to think about how those experiences have formed them. I often give the ACEs to clients that have not drawn the connection from their past painful learning and their present disregulation and they typically have been told they have a mood disorder. Another assessment tool that I find helpful when clarifying a trauma diagnosis is the Dissociative Experience Scale (DES-II). Dissociation is something that many people do to an extent but in situations where it hinders functioning it is a symptom that is more commonly indicative of a trauma diagnosis. An elevated score on the DES-II can be helpful in differentiating between Generalized Anxiety, Post-Traumatic Stress Disorder, or even a Dissociative Disorder. In more extreme cases, the Multidimensional Inventory of Dissociation (MID) is an intensive assessment with over one hundred questions. The screener does require training to issue because of its indepth nature, but the amount of clinically significant data points it can provide is highly valuable. The assessment provides comparative analysis between the client’s responses and clients that met criteria for Post-Traumatic Stress, Dissociative Identity Disorder, Borderline Personality Disorder, Unspecified Dissociative Disorders, and the Non-dissociative control group. There are a host of other clinically appropriate assessment tools that can be helpful and it is important for therapists to utilize those tools to help clarify diagnosis and inform the course of treatment.

In order for clinicians to understand the subtle and overt signs of trauma we must begin undergoing constant continuing education and seek supervision. Training is a way to sharpen the tools in our clinical skill set and the sharper the tools the less it will weary the clinician. This is not to say serving a traumatized population is ever easy but it is much easier when the therapist is prepared with the needed tools to help. When therapists feel more competent to serve a client it increases our ability to act with greater effectiveness, and can serve as a protective factor from secondary traumatization and burn out. For the good of our clients and for the good of the clinical worker we have to invest in our skill set, but we must also know when it is best to refer. I have observed in the last three years as the profession has navigated the impact of the COVID-19 pandemic that some therapists struggle to hear the realities of what our clients face and it has been disheartening. I also think this brings to light that not every clinician needs to be a trauma expert or specialist in treating traumatic stress; it may be that kind of work would be harmful to the professional. As such, there should be no shame assigned to a professional, who is acting ethically, for admitting their limitations, but I do think all professionals should be trauma informed. A therapist that can recognize that they may not be the one to help a given client is an important insight but having the knowledge to see, even to a lesser extent, how trauma could be impacting the presentation of symptoms is a professional minimum.

How we engage in sessions with our clients that have a history of past painful learning can be the difference between serving them well or re-traumatizing them. Many of my clients reported feeling that they feel their experiences make it hard to feel understood or truly known, but I find that my being a trauma informed therapist allows me to accurately reflect and in some cases explain their reactions to triggers in a way they have not had someone do for them. The experience of being traumatized can be isolating as it is not one that is universally held. It is important to remember that the client’s experience of an incident, the physiology, and the selfappraisal are the core therapeutic issues and not just the event itself. We have all had bad days and we certainly have all experienced hurt but that is not the same as being traumatized. When people attempt to express solidarity with a traumatized person through the much more universal human experience of pain it can be invalidating; this is even more so true if that comes from the therapist. According to psychiatrist and researcher in the area of posttraumatic stress, Dr. Bessel Van Der Kolk, “Trauma can only be worked through when a secure bond is established with another person”. The therapist can become a safe place for that client to begin the difficult work of processing the lessons that were learned in past painful learning, but the therapist must model the self-regulation and communication that is needed to provide that safety. As I mentioned earlier, not every therapist needs to be a trauma specialist but all therapist must be trauma informed in order to engage traumatized clients even if it is just to refer them. The therapist having some specific trauma training can be extraordinarily helpful as it provides a framework for therapy and helps the therapist to provide an effective guide to the client on what to expect. To a person that has been traumatized, a surprise is often distressing so having a regulated trusted guide to explore their trauma will help reduce tension.

The therapist must have strong self-regulation skills and psycho-emotional boundaries in order to properly serve those with profound trauma histories. Having training in an evidencebased trauma therapy model is a major milestone; however, therapists must have the ability to regulate as they are working with the client. As a client begins to disclose their trauma history the clinicians reaction will either send the message “this person is not distressed by my story” or “they cannot handle this”. The metamessage that the therapist is listening, open, and compassionate opens the doors for therapy to become a meaningful experience to the client and that they have a free space to be open. The life experiences of trauma survivors are often difficult to listen to as they are heart wrenching. When a client discloses some of their trauma history to us, we are being invited into a truly sacred space in the life of that survivor. Unfortunately, the sacredness of that space is wrapped in suffering and painful learning about themself and the world around them. If we are invited into that space and we do not respond with a sense of compassion and respectful curiosity we may send the client, unintentionally, an invalidating response that leads to re-traumatization. When a client is re-traumatized by a therapist it can send the message that they cannot be helped because the helper was too scared to approach the pain the feel.

The impact of mental health trauma has been a topic that has gained growing awareness and prospective clients are coming to see a therapist to address their needs in growing number. Therapists must sharpen the skills needed to treat these issues in order to be effective. As clinicians we have an ethical and professional duty to be prepared to treat or refer any client that seeks us out for services. We must be able to help clients understand their symptoms and have some understanding as to what may be some of the best ways to go about offering help. In addition to being mindful of best practices we must also be aware of things to avoid in order to ensure that we do not retraumatize our clients. As we continue to seek out continuing education we should also be learning about the most appropriate screening tools to help better explain to our clients exactly what is happening to them. Lastly, therapists should model the skills we are teaching to our clients in order to not only demonstrate how effective those skills can be but to help facilitate a safe environment for the client to explore their past painful learning. Trauma therapy is a nuanced specialization within the mental health field and those that engage in treating trauma must be prepared for the challenges that come.

Written By: Eric Chatman, LMHC

Eric is a LMHC working in a community mentalhealth agency in central Florida. He hasexperience working with a variety of clients butspecializes in treating traumatic stress. He has training in a variety of evidence based tools for treating trauma. Hehopes to be of service to his clients and colleagues in an effort tospread awareness about the impact of traumatic stress disorders.