key: cord-0059535-lr58otkp authors: Mancini, Michael A. title: Trauma-Informed Behavioral Health Practice date: 2020-10-27 journal: Integrated Behavioral Health Practice DOI: 10.1007/978-3-030-59659-0_7 sha: e3c499e9f34b6db7f8dd1fb7af97cd948f966ac6 doc_id: 59535 cord_uid: lr58otkp The experience of trauma and toxic stress is common and can profoundly impact the health and behavioral health of survivors long after exposure. Survivors of trauma are at risk for a range of co-occurring conditions that can lead to high morbidity and premature mortality, making screening, assessment, and treatment of trauma in routine health and behavioral health settings a priority. In this chapter, I explore the impact of trauma and adverse childhood events (ACEs) on health and well-being. This chapter includes epidemiological data on the prevalence of trauma and post-traumatic stress disorder (PTSD), and how the experiences of ACEs impact health. A definition and overview of trauma-informed care (TIC) practices, policies, and procedures will be provided, and a range of common screening and assessment instruments will be reviewed. The signs and symptoms of post-traumatic stress disorder (PTSD), and an outline of trauma-informed and evidence-based strategies for assessing and treating trauma-impacted clients will also be provided that include prolonged exposure therapy, cognitive processing therapy (CPT), eye movement desensitization and reprocessing therapy (EMDR), and trauma-informed cognitive behavioral therapy (TF-CBT). .1 lists examples of traumatic events that impact health within several major domains. Examples of traumatic events are numerous and include experiencing war, famine and disease, interpersonal violence (e.g., physical abuse, rape, sexual abuse, extreme neglect, robbery, assault, kidnapping), accidents (e.g., motor vehicle, falls, heavy machinery), fire and explosions, and natural disasters (e.g., flood, earthquakes, hurricanes, tornados). While the DSM-5 requires traumatic events to be potentially life-threatening, events such as experiencing discrimination, learning that your spouse has been having an affair or wants a divorce, getting fired, loss of one's home, loss of an ability (e.g., eyesight, paralysis), or learning one has a chronic disease can be so lifeshattering and unexpected that they overwhelm our ability to cope. These events, too, can lead to significant trauma symptoms. Experiencing forms of interpersonal violence are more likely to lead to post-traumatic effects. For instance, complex traumatic stress is experiencing repeated, long-term interpersonal violence. Complex trauma is most often associated with the childhood experience of sexual or physical abuse and neglect in the home or in homes where there is intimate partner violence (NCTSN 2020) . The effects of traumatic experiences can be diverse and long-lasting. First and foremost, trauma, particularly interpersonal violence, disrupts the ability to form and maintain healthy relationships with other people. Trauma can lead to negative beliefs about the self, others, and the world that lead to a sense of personal helplessness, shame and worthlessness, fear and mistrust for others, and a sense of hopelessness for the future. Experiencing trauma can also lead to emotional dysregulation, Events Accidents, illness, and disasters Natural disaster (e.g., flood, hurricane, earthquake, tornado) Fire Transportation accident (e.g., car, boat) Other serious accident Exposure to environmental toxic substance Interpersonal violence Sexual assault Any unwanted/uncomfortable sexual experience Physical assault (e.g., being punched, slapped, kicked, threatened with a weapon) Captivity (e.g., being held/detained, held hostage, kidnapped) War, community violence, poverty 194 dissociation, negative effects on memory and concentration, and a reduction in the ability to cope with future stress and adversity. These effects can lead to depressed mood, anxiety, hypervigilance, and avoidant behaviors such as substance use and social withdrawal (SAMHSA 2014a, b). Adverse childhood events (ACEs) are defined as the experience of one or more negative or toxic life stressors that have been found to have long-ranging effects on health. Table 7 .2 lists examples of ACEs that impact health within several major domains. These experiences include physical, sexual, or emotional abuse; physical or emotional neglect; living in a household with a person who has a mental illness, substance use disorder, or who is in prison; parental divorce; and death of a caregiver, among other events. Some of these experiences are not considered lifethreatening as defined by the DSM-5; however, they exert a long-term negative impact on emotional and physical health (Burke-Harris 2018; Felitti and Anda 2010). freezing, substance use). Trauma memories serve a survival function and are designed to prevent a recurrence of trauma or death through increased vigilence, arousal, and avoidance. However, when these memories are triggered by cues in the environment and lead to distress when no danger exists or that is out of proportion to any potential danger, they can impair functioning and lead to the development of PTSD (APA 2013; Burke-Harris 2018; Van der Kolk 2015) . Traumatic events involving interpersonal violence, especially sexual violence, intimate partner violence, and community violence, are the most likely events to lead to PTSD and can have a long-term impact on the health and well-being of many of our clients (Goldstein et al. 2016) . For instance, PTSD is associated with higher rates of chronic diseases such as cardiovascular and cerebrovascular disease, cancer, hypertension, metabolic disease, and autoimmune diseases (Gradus et al. 2015; Howard et al. 2018; Husarewycz et al. 2014; Kessler et al. 1995; Remch et al. 2018; Song et al. 2018; Spitzer et al. 2009 ). Violence can also lead to higher rates of visible and invisible injuries such as traumatic brain injury (Halbauer et al. 2009 ). All of these factors can compromise health and impact the ability of people to take care of themselves, engage in preventative care, and adhere to treatment resulting in persistent morbidity, disability, and early mortality (Burke-Harris 2018; Felitti and Anda 2010; CDC 2020; Leeies et al. 2010; Perry and Szalavitz 2017 ; Van der Kolk 2015). The majority of people who experience a traumatic event do not develop PTSD. However, PTSD is a highly prevalent behavioral health condition in the community that is often comorbid with other behavioral health conditions (Goldstein et al. 2016 ). In the United States, nearly 70% of people experience a lifetime traumatic event. Lifetime prevalence rates of PTSD range from 6% to 8% nationally and 12-month rates for PTSD are nearly 5% (Goldstein et al. 2016; Kilpatrick et al. 2013) . Women experience higher PTSD prevalence rates than men and the potential of experiencing PTSD increases with increased exposure to traumatic events (Kilpatrick et al. 2013) . Over half of the general population (53%) will experience some form of interpersonal violence (58.6% of women and 47.1% of men). Almost a third of the general population (30%) and over 40% of women will experience a sexual assault. Over 40% of people and 45% of women will experience physical assault. Approximately half will experience a disaster, accident, or fire (Kilpatrick et al. 2013) . PTSD increases the odds of experiencing other behavioral health disorders including all anxiety disorders, major depressive disorders, substance use disorders, antisocial and borderline personality disorders. Persons with PTSD are 3 times more likely to have a co-occurring mood disorder, over 2.5 times more likely to have anxiety disorder, and 1.5 times more likely to have a substance use disorder (Goldstein et al. 2016) . Despite the prevalence of PTSD, only 60% of persons with the condition receive treatment with a 4.5-year delay, on average, between onset and treatment (Goldstein et al. 2016 ). Adverse childhood events (ACEs) are childhood experiences that are considered toxic or traumatic and can have a drastic impact on health (Felitti et al. 1998 ). The negative impact on health can develop regardless of whether a person develops full or even partial PTSD. These events are often silenced and buried in people's lives, but nonetheless have important health effects later in life. The ACE study, a large longitudinal study of over 17,000 middle-class, employed, college-educated people with good health insurance, found that experiencing any of the ten adverse childhood events mentioned below can have important health consequences later in life (Anda et al. 2006; Felitti et al. 1998; Whitfield et al. 2003) . Examples of these events include growing up in a household where the person experienced: (1) emotional abuse; (2) physical abuse; (3) sexual abuse; (4) emotional neglect; (5) physical neglect; (6) parental separation or divorces; (7) domestic violence; (8) a person with a substance use disorder or problem drinking; (9) a depressed, mentally ill, or suicidal family member; and (10) someone in the house that had gone to prison. ACEs were found to be very common with about two-thirds of the sample having experienced at least one ACE (and 87% of those had more than one), and one in eleven people having experienced six or more ACEs (Felitti and Anda 2010) . The impact of trauma on the brain and body can place people at risk for a range of negative behavioral, social, and physical health problems later in life (Anda et al. 2006; Whitfield et al. 2003) . For instance, childhood exposure to interpersonal violence led to increased rates of depression, substance use, and experiencing or perpetrating interpersonal violence in adulthood (Edwards et al. 2003; Whitfield et al. 2003) . A higher number of ACEs were also linked to higher rates of cancer (Brown et al. 2013) , COPD (Anda et al. 2008) , heart disease (Dong et al. 2004) , diabetes (Deschenes et al. 2018) , and autoimmune diseases such as rheumatoid arthritis (Dube et al. 2009 ). It is also important to note that the impact of ACEs on health occurs in a doseresponse relationship. Figure 7 .1 lists the dose response impact of ACEs on several health outcomes. For instance, four or more ACEs increased the risk for chronic obstructive pulmonary disease (COPD) by 390%, hepatitis by 240%, depression by 460%, and attempted suicide by an ominous 1220%. A person with an ACE score of 6 was 4600% more likely to be an IV drug user and 3100% (31-fold) to 5000% (50fold) more likely to attempt suicide than a person with 0 ACEs (Dube et al. 2001) . For every increase in ACE score, the risk for suicide attempts increased 60%. Experiencing any one of the ten identified ACEs increased suicide attempts 200-500% (2-5 fold) (Dube et al. 2001) . Experiencing any six ACEs shortened life expectancy by 20 years. Adverse childhood experiences disrupt neurological development through chronic activation of the stress response systems. This overactivation can lead to bio-psychosocial problems such as emotional dysregulation, hypervigilance, aggressive behavior, and low impulse control. These problems, in turn, can result in impairment in the ability to connect with other people and to the adoption of highrisk behaviors that can cause chronic comorbidity and early death (Burke-Harris 7.1 Chapter Overview 198 2018; Felitti et al. 1998; Van der Kolk 2015; Perry and Szalavitz 2017) . For instance, it was found that higher ACE scores were associated with a higher prevalence of unhealthy coping behaviors such as smoking (Anda et al. 1999) , alcohol and drug use Strine et al. 2012) , and obesity (Williamson et al. 2002) . However, when controlling for these behaviors, the impact of ACEs was still profound. This is due to the impact of chronic stress on the brain and nervous system. Major chronic unrelieved stress leads to overactivation of the hypothalamic pituitary adrenal axis (HPA axis), the release of pro-inflammatory chemicals, and the suppression of immune system functioning that can lead to many of these health and behavioral health problems. This means that the experience of ACEs can change the body and brain via the stress response system in such a profound way that the experience of these events by themselves can lead to high morbidity and mortality if left untreated (Burke-Harris 2018). Trauma-informed approaches are heavily influenced by the ecological systems framework discussed in Chap. 2, which views human development and behavior as the result of the dynamic relationships that exist between an individual and their environment (Bronfenbrenner 1979 (Bronfenbrenner , 2009 Bronfenbrenner and Morris 2007) . Wellbeing is impacted by the fit between the biopsychosocial needs of the individual, 199 and the resources and conditions available to them in their physical and social environments. Assessment and treatment should, therefore, focus on helping establish a good fit between individual characteristics (e.g., age, gender, culture, health and mental health, temperament and traits, education, and socioeconomic status, interpersonal relationships (e.g., social support, safety), and various social determinants of health (e.g., housing, income, neighborhood/community, and access to basic resources including health care). The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified four assumptions and six principles of trauma-informed care (TIC) (2014). These will be reviewed next. Trauma-informed care (TIC) is an approach to service delivery that fully recognizes the short-term and long-term impact of trauma on the health and well-being of service recipients, and responds with practices that promote safety, collaboration, trust, and empowerment (Elliott et al. 2005; Niolon et al. 2017; SAMHSA 2014a, b) . SAMHSA has identified four assumptions that define trauma-informed care for organizations and providers. Table 7 .3 lists the principles and practices of each of those assumptions. First, providers and organizations realize that trauma is prevalent in the lives of clients and that experiencing trauma exerts an impact on the health and well-being of client systems. Trauma sensitivity and awareness are integrated into all aspects of care, including screening and assessment, treatment, and follow-up care. A practice at the heart of trauma-informed care is asking the question What happened? What happened to this person? What happened to this family? What happened to this school? What happened to this community? Trauma awareness means positioning the behaviors of clients, families, organizations, and communities as reactions and attempts to adapt to the impact of traumatic stress. In other words, when providers practice TIC, they assume that trauma, experienced individually or collectively, and not traits inherent to the person or group, is the driving force behind behaviors that lead to negative health consequences. Framing behaviors in this way can diffuse judgmental feelings and responses by providers, reducing the risk of re-traumatization of the client (SAMHSA 2014a, b). Second, being aware and sensitive to the prevalence and impact of trauma requires providers and organizations to be able to recognize trauma in those they serve. This is accomplished through the routine deployment of trauma-informed screening and assessment procedures designed to identify the presence of PTSD or other health effects related to stress and trauma (SAMHSA 2014a, b) . Third, trauma-informed programs, organizations, and systems respond to trauma by integrating traumainformed services across all levels of care. Health and behavioral health settings that are trauma-informed have in place trained staff, policies, procedures, and practices designed to create a safe, welcoming environment and provide clients with access to effective treatments and services that address the multidimensional impact of trauma on individual, social, and environmental levels (SAMHSA 2014a, b). Lastly, trauma-informed providers, organizations, and systems resist practices that are toxic and re-traumatizing to clients and staff by creating practice environments that are safe, nurturing, and conducive to the development of well-being (SAMHSA 2014a, b) . These four assumptions represent the basic foundation underlying traumainformed care. Trauma-informed care is also guided by several practice principles that I will review in the next section. Trauma-informed care is guided by six overarching practice principles that are infused into all levels of care. First, TIC organizations are dedicated to the promotion of physical, emotional, psychological, and interpersonal safety of clients served by the organization and the staff providing those services. Second, TIC organizations ensure that all clinical and organizational decisions prioritize transparency and trust with providers and clients. Third, trauma-informed organizations rely on peer providers with lived experience of trauma to use their stories to engage clients in treatment, build trust and hope, and promote healing and recovery. Fourth, trauma-informed care is person-centered and prioritizes collaboration and Providers understand the signs and symptoms of trauma/PTSD and how trauma impacts the mind and body. Providers are trained to deploy routine and universal screening and assessment procedures and measures in a sensitive manner that ensures privacy and confidentiality. Respond Providers and programs effectively respond to trauma through training, policies, practices, and procedures. Trauma awareness is integrated throughout the setting. Programs strive to create trust by ensuring an environment that is welcoming, transparent, safe, and kind, and begins when the client walks through the door or calls to schedule an appointment. The program provides trauma services either on-site or through direct, formal partnerships with community providers. Providers and programs resist practices that could be re-traumatizing to clients. Through systematic procedures, providers routinely (re)-assess their practices, policies, and procedures to ensure they are trauma-sensitive in this regard. Based on SAMHSA (2014a) 7 Trauma-Informed Behavioral Health Practice 201 mutuality with clients. This means that service relationships are partnerships where power is shared. Fifth, TIC organizations place an emphasis on empowerment and choice. This means that services are designed to promote recovery, health, and healing, and that clients can choose from a range of options that are aligned with their preferences and needs. Providers rely on shared decision-making models during care planning and treatment to ensure that clients are able to make informed decisions about the course of their care every step of the way. Sixth, trauma-informed programs provide culturally-tailored services that are sensitive and responsive to multiple intersecting identities such as race, ethnicity, culture, language, gender identity, and sexual orientation. Providers are trained to recognize and address bias, and care is provided with recognition of historical trauma caused by racist, heterosexist, sexist, and patriarchal policies and practices. TIC organizations eliminate practices and policies that reinforce stereotypes and lead to biased care, and implement policies, practices, procedures, and structures designed to ensure care that is responsive, affirming, and inclusive to the needs of service recipients with multiple identities (SAMHSA 2014a, b). Trauma-informed organizations ensure that trauma-informed care practices are fully integrated into the systems, structures, policies, and procedures of the program (Mancini and Miner 2013) . Areas in which trauma-informed practices are integrated include intake procedures, staff training and professional development, screening and assessment procedures, policies regarding how to ensure safety and confidentiality of clients, hiring and retention policies of staff, physical space, monitoring and addressing compassion fatigue and burnout among staff, referral procedures, and continuous quality improvement initiatives. Programs also assess and address policies and practices that can be re-traumatizing such as the use of seclusion and restraints, power dynamics of provider-client relationships, lack of inclusive forms, lack of power over decision-making, being rushed through clinical appointments, physical touching and being placed in vulnerable positions, forced removal of clothing and invasive procedures, lack of privacy, and overly-personal questions. Trauma-informed practices utilize welcoming environments that are calm, affirming, and soothing. Providers take a holistic view of the client and engage in screening and assessment procedures for trauma in a safe, slow, and private manner. Providers utilize a collaborative approach offering clients choices among a range of holistic treatment options (e.g., group or individual counseling, yoga, nutrition, peer support, acupuncture, and meditation) offered on-site or through a warm referral process. The implementation of trauma-informed care covers a number of domains identified by the Substance Abuse and Mental Health Services Administration (SAMHSA 2014a, b) . First, trauma-informed care should be embraced by the highest levels of leadership. Peers with lived experience in trauma should be included in organizational decision-making processes, staff training, and the delivery and evaluation of services. Empowered champions for trauma-informed care should be positioned throughout the organization to increase acceptance and adoption of TIC practices. Second, TIC approaches should be part of the operations of the organization written specifically into all policy and procedure manuals and be a part of the organization's mission and vision. Third, the physical environment of the organization should be safe, welcoming, and collaborative. Fourth, TIC approaches should guide all decisions regarding organizational partnerships and collaborations. Referrals to outside services should only be to trauma-informed agencies and service sectors. Fifth, all providers receive continuous training in screening, assessment, and treatment services that are trauma-sensitive and culturally responsive. Sixth, trauma sensitivity is a consideration in hiring, supervision, and evaluation of all staff and leadership. Seventh, procedures are in place to ensure that staff have adequate access to selfcare strategies and resources. Last, trauma-informed care is integrated into records, billing, and monitoring systems (Mancini and Miner 2013 ; SAMHSA 2014a, b). A diagnosis of PTSD requires the persistent experience of symptoms related to the experience of a traumatic event for at least one month. There are four main clusters of PTSD symptoms: (1) intrusion/re-experiencing; (2) arousal/hypervigilance; (3) negative alternations in cognition and mood; and (4) avoidance. Figure 7 .2 lists the main symptoms for PTSD within each of these four clusters. Symptoms should be severe enough to cause significant distress and impairment in functioning (i.e., interpersonal relationships, employment, daily activities). The DSM-5 has a modified set of diagnostic criteria for children under the age of seven. For adults, adolescents, and children over the age of 6, the following criteria are required for a diagnosis of PTSD. Table 7 .4 lists the major diagnostic criteria for post-traumatic stress disorder. A traumatic event is defined as actual or threatened exposure to death, injury, or violence and can include direct experience, witnessing first-hand traumatic events experienced by others, being made aware of traumatic events that have happened to close persons, or being repeatedly exposed to the details of traumatic events experienced by others (APA 2013). Examples of traumatic events include: experiencing or witnessing interpersonal and community violence such as sexual assault, physical assault, assault with a weapon, combat or exposure to war, kidnapping or being detained, natural disasters, fire and explosions, serious accidents, life-threatening illness or injury, witnessing sudden violent death or serious injury, and witnessing intense human suffering (APA 2013; Blake et al. 1995) . The two most profound clusters of traumatic events that have the highest probability of leading to PTSD are experiencing sexual trauma and when traumatic events happen to close loved ones such as spouses, children, and parents. Experiencing sexual violence holds the highest likelihood of developing PTSD, with 33% of persons experiencing this form of violence developing PTSD. Thirty percent of persons who experience the sudden loss of a loved one or whose loved one experiences a life-threatening injury, illness, or trauma will go on to develop PTSD symptoms. Approximately 11-12% of persons experiencing or witnessing interpersonal and community-based violence or war may go on to develop PTSD (Kessler et al. 2014 ). One of the hallmarks of PTSD is the presence of intrusive thoughts and reexperiencing of the traumatic event. For a PTSD diagnosis, a person must experience at least one symptom from this cluster following a traumatic event (APA 2013). Intrusion symptoms can include prolonged, frequent, and vivid nightmares about the event; dissociative flashbacks where the person re-experiences the elements of the event as if it were happening again; and constant intrusive thoughts and memories of the event (e.g., can't stop thinking about it). Another important element of intrusion symptoms is cognitive, affective, or physiological reactions to cues or reminders of the event. For instance, a person who has experienced rape may have a psychological or physiological stress response if they smell the same or similar cologne as their attacker, leading to flashbacks, hypervigilance or nervousness, nausea, fear, sadness, or irritability that can interfere with functioning. It should be noted that the person may not be aware of what is happening or that this particular cue is significant, despite experiencing these emotional or physiological reactions (APA, 2013). Memories and reminders of the traumatic event are persistently distressing to persons with PTSD over time. A sign of PTSD is engaging in repeated efforts to avoid internal (e.g., distressing memories or feelings) or external reminders or cues associated with the event (e.g., places, people, or situations). This avoidance can result in maladaptive coping behaviors that can include alcohol and substance use, social withdrawal, and isolation. Avoidance behaviors can include either attempts to avoid unwanted memories of the event, or external triggers of the event such as people, place, things, and situations (APA, 2013). This cluster of symptoms was newly introduced to DSM-5 to capture the psychological distress and dysphoria that is a key feature of the trauma experience and PTSD. Persons with PTSD may experience a range of negative thoughts, feelings, and beliefs about the traumatic event. This cluster includes a wide range of symptoms associated with the traumatic event such as experiencing: (1) dissociative amnesia regarding the details of the event; (2) feelings of guilt, self-blame, shame, and negative self-concept due to the event; (3) negative emotions such as anhedonia, depressed mood, anxiety, and fear; and (4) detachment and feelings of numbness or the inability to experience positive emotions (APA, 2013). Persons with PTSD often experience a prolonged activation of the stress response system that can lead to high rates of health problems. Signs and symptoms of hyperarousal include irritability and anger, sleep disturbances, behavior that is reckless to self or others, increased vigilance for danger, and an exaggerated startle response (APA 2013). Universal screening and assessment for traumatic stress and PTSD in health and behavioral health settings is a key part of trauma-informed care. Effective screening and assessment for traumatic stress are rooted in safety, trust, respect, and compassion. Clients need to feel that they are in a safe place to disclose traumatic experiences and that their stories will be heard and validated. Clients also need to trust that their responses are confidential and must be made fully aware of any limitations to confidentiality or reporting requirements before being asked about trauma. Providers need to ensure that they ask about trauma in a private setting, utilize active listening skills, and show respect and compassion. Language interpreters should be independent professionals, rather than family or friends of the client. Persons who disclose trauma need to feel like it was a good idea to tell their story. Trauma assessment should also be ongoing as the relationship between provider and client develops over time. Initial screening for trauma should be in a sensitive way, and conversations about the impact of stress and trauma on health can signal to reluctant clients that they are in a safe place to discuss their trauma. Providers should provide education to clients about the role of trauma in health regardless of whether they disclose experiencing trauma. If they do disclose, providers should normalize the symptoms that often are associated with traumatic events. Positive screenings should lead to further assessment and access to trauma services provided onsite or a referral to outside behavioral health settings that specialize in trauma-focused care. Screening and assessment should include assessing for ACEs, traumatic events, and symptoms of PTSD. Table 7 .5 lists information about several common screening and assessment instruments for PTSD. Each of these instruments will be discussed in more detail in the sections that follow. The experience of adverse childhood events and traumatic events has been linked to a range of health issues. The experience of four or more adverse childhood events (ACEs) has been associated with higher rates of cancer, behavioral health issues Brief, 5-item screen for possible PTSD. Uses "yes" and "no" items that screen for intrusive thoughts, avoidance, hypervigilance, numbness or detachment, and guilt or self-blame. A "yes" to any three items indicates a positive screen. Prins et al. (2016) The PTSD checklist for DSM-5 (PCL-5) The PCL-5 is a 20-item self-report assessment checklist that corresponds to the 20 symptoms of the DSM-5 across four diagnostic symptom clusters: intrusion/re-experiencing, hyperarousal, negative alteration in cognition and mood, and avoidance. The PCL-5 scores can be summed and compared to a clinical cut-off to assess severity, or the scale can be used as a diagnostic instrument. Preliminary severity cut scores range from 28 to 37 depending on the population and setting. Weathers et al. (2013) Clinicianadministered PTSD scale for DSM-5 (CAPS-5) The CAPS-5 is a 20-item semi-structured clinical interview that measures PTSD diagnosis and also offers a severity score. It is considered the gold standard for research and clinical assessment of PTSD. The symptoms correspond to the 20 main PTSD symptoms in the DSM-5 across four clusters (intrusion, avoidance, arousal, and negative alterations in cognition and mood). Symptom frequency and severity are measured using a 5-point scale (0 = absent; 1 = mild/sub-threshold; 2 = moderate/threshold; 3 = severe/ markedly elevated; and 4 = extreme/incapacitated). In order to indicate the presence of clinical symptoms, a score of '2' or higher is required. Posttraumatic stress disorder symptoms scale interview for DSM-5 (PSSI-5) The PSSI-5 is a 24-item semi-structured interview schedule that assesses the presence of a traumatic event and measures the 20 DSM-5 symptoms for PTSD. Symptoms are assessed on a 5-point scale that measures frequency and severity ranging from 0 (not at all) to 4 (6 or more times a week/ severe). Scores of 1 or higher indicate the presence of symptoms. Scores can range from 0 to 80. The clinical cut-off score for a probable diagnosis of PTSD is 23. The PDS-5 is a 24-item self-report measure that assesses the presence of a traumatic event and measures the 20 DSM-5 symptoms for trauma. This measure is the self-report version of the PSSI-5 interview schedule. The clinical cut-off score for a probable diagnosis of PTSD is 28. Foa et al. (2016b) 7.4 Screening and Assessment for Traumatic Stress and PTSD 208 such as depression, heart disease, diabetes, and suicide, controlling for negative health behaviors and socioeconomic issues (Felitti et al. 1998 ). The original ACE questionnaire uses "yes" and "no" questions to assess whether clients have ever experienced any of the original ten ACEs, which included the experiences of intimate partner violence, emotional and physical abuse and neglect, sexual assault, divorce, having a person in the household who has been in jail, used alcohol or drugs, or had a mental illness. The concept of ACEs has been expanding to include items measuring peer victimization, peer rejection or isolation, and community violence (Cronholm et al. 2015) . This has led to the revised inventory of adverse childhood events (Finkelhor et al. 2015) . The addition of these items has increased the sensitivity of the original measure to predicting mental health issues. The addition of low SES has also increased predictive ability of the measure for health issues (Finkelhor et al. 2015) . Both versions of the scale can be found online and at the Centers for Disease Control and Prevention (CDC) website. A common screen for DSM-5 traumatic events is the Life Events Checklist (LEC-5) (Weathers et al. 2013a ). This checklist is part of two well-validated screening and assessment instruments: The PTSD Checklist for DSM-5 (PCL-5) (Weathers et al. 2013 ) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) (Blake et al. 1995) . The LEC was originally developed as part of the CAPS. The LEC-5 screens for 17 common traumatic experiences including: experiencing various forms of interpersonal violence (e.g., physical and sexual assault, kidnapping, war, being threatened), natural disasters, fire, accidents, and life-threatening medical conditions. The purpose of the LEC is to identify the experience of a potentially traumatic event and as a result, it does not have a specific score or scoring procedure. Primary Care Post-Traumatic Stress Disorder Screen for DSM-5 One of the most common screening tools in health settings for PTSD is the Primary Care-Post Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5) (Prins et al. 2016 ). This is a five-item "yes" and "no" screen that assesses whether a client has experienced significant symptoms associated with a traumatic event(s) in the past month. The symptoms assessed by the scale are: (1) experienced nightmares about the event(s) or unwanted thoughts about the event; (2) engaged in attempts to avoid situations or thoughts that serve as reminders of the event or had to try hard not to think about the event; (3) experienced hypervigilance such as being "on guard," watchful, or easily startled; (4) experienced a sense of being numb or detached from activities or environment; and (5) experienced a sense of guilt or was unable to stop blaming themselves or others for what happened or the effects of what happened. A positive screen is a "yes" to any three items and indicates the need for further assessment for PTSD. This instrument has shown excellent psychometric properties in primary care settings and good sensitivity (score of 3) and specificity with a cut score of 4 for maximum efficiency. The screen has shown good diagnostic accuracy and is very effective in routine settings (Prins et al. 2016 ). The scale is in the public domain and can be accessed at the National Center for PTSD in the US Department of Veterans Affairs. This screening instrument and others can lead to important clarifying conversations about trauma in the client's life. First, be sure to clarify whether the client experienced a traumatic event by asking the client to identify the event they feel has led to their symptoms. Be sure that the event is life-threatening. Experiencing troubling or stressful events that are not necessarily traumatic, but lead to depressed or anxious symptoms may be better classified as an adjustment disorder (APA, 2013). It is also important to ask how symptoms have interfered with work or interpersonal functioning. Lastly, it is important to assess whether any traumatic events the client identified are continuing to happen such as ongoing violence. Clients who disclose ongoing violence should be provided resources and referrals to legal and advocacy services, social services, behavioral health counseling and crisis response services, shelters, childcare services, and hotlines if safe to do so. If it is not safe to give the client brochures, providers should give them to the client verbally and offer the client the option to use the provider's office phone to make contact with referrals. Trauma-informed practice requires health settings that screen for trauma to offer services to survivors of violence on-site or through an active warm referral process. If the incident requires mandated reporting, consult with the client on how best to file the report in such a way that their safety is enhanced rather than diminished. The PTSD Checklist for DSM-5 (PCL-5) The PCL-5 is a 20-item checklist that corresponds to the 20 symptoms of the DSM-5 across four diagnostic symptom clusters: intrusion/re-experiencing, hyperarousal, negative alteration in cognition and mood, and avoidance (Weathers et al. 2013) . This measure uses the Life Events Checklist (LEC-5) to identify traumatic events. It is a self-report measure in which respondents identify how much distress each symptom has caused them in the past month on a 5-point scale that ranges from (0) not at all to (4) extremely. The PCL is easy to administer and score and has shown solid psychometric properties and diagnostic utility (Blevins et al. 2015; Bovin et al. 2016; Wortmann et al. 2016) . Like the PC-PTSD-5, this measure is in the public domain and can be accessed at the National Center for PTSD in the US Department of Veterans Affairs. The PCL-5 scores can be summed and compared to a clinical cut-off to assess severity or the scale can be used as a diagnostic instrument. Diagnosis of PTSD may be made if scores of 2 (Moderately) or higher are indicated on at least one intrusion symptom (Cluster B); one avoidance symptom (Cluster C); two arousal symptoms (Cluster D); and two negative alterations in cognition and mood symptoms (Cluster E). Preliminary Severity cut-off scores range from 28 to 37 depending on the 7.4 Screening and Assessment for Traumatic Stress and PTSD 210 population (military vs civilian), setting (medical clinic vs. VA), and reason for assessment. (Blevins et al. 2015) . The CAPS-5 is a 20-item semi-structured clinical interview that measures PTSD diagnosis and also offers a severity score (Weathers et al. 2018) . It is considered the gold standard for research and clinical assessment of PTSD. The symptoms correspond to the 20 main PTSD symptoms in the DSM-5 across four clusters (i.e., intrusion, avoidance, arousal, and negative alterations in cognition and mood). Symptom frequency and severity are measured using a 5-point scale (0 = absent; 1 = mild/sub-threshold; 2 = moderate/threshold; 3 = severe/markedly elevated; and 4 = extreme/incapacitated). In order to indicate the presence of clinical symptoms, a score of '2' or higher is required. Scoring for the CAPS-5 has been streamlined to combine frequency and intensity symptoms, and clinicians have a frequency and severity guideline that instruct them on how to score the scale. For instance, a score of 2 requires a minimum frequency of twice a month and a minimum intensity of "clearly present." A score of 3 requires a minimum frequency of twice a week and a minimum intensity of "pronounced." The CAPS-5 has shown good psychometric properties. It has good test-retest reliability (r = 0.78) and good internal consistency (0.88) for the severity score and showed good convergent validity with the PCL-5 (Weathers et al. 2013a, b) . The CAPS is more time-consuming and is a more complicated measure to implement and score than other self-reports measures. Clinical training is required to utilize the scale effectively. The CAPS can be obtained from the National Center for PTSD in the US Department of Veterans Affairs. It is not available in the public domain. The PSSI-5 is a 24-item semi-structured interview schedule that assesses the presence of a traumatic event and measures the 20 DSM-5 symptoms for PTSD (Foa et al. 2016a ). Symptoms measured are for the index traumatic event or the event that produces the most severe self-reported symptoms if multiple traumatic events have been experienced. The 20 symptoms correspond to the four DSM-5 symptoms clusters. Symptoms are assessed on a 5-point scale that measures frequency and severity ranging from 0 (not at all) to 4 (6 or more times a week/Severe). Scores of 1 or higher indicate the presence of symptoms. Scores can range from 0 to 80. Two items measure distress and interference with functioning, and a score of 2 or higher on either item is positive for clinical distress or interference in functioning. Two other items indicate duration of symptoms and delayed onset. Similar to DSM-5, a positive assessment requires the presence of one intrusion symptom, one avoidance symptom, two symptoms of negative cognition and mood, and two symptoms of arousal experienced for one or more months. The clinical cut-off score for a probable diagnosis of PTSD is 23, and the scale has shown excellent psychometric properties as a reliable and valid scale of PTSD. The sensitivity of the PSSI-5 is 0.82 and specificity is 0.71. The PSSI-5 showed good internal consistency (0.89) and test-retest reliability (r = 0.87) and showed good convergent validity with other measures of PTSD (Foa et al. 2016a ). However, as compared to the CAPS-5, the 29% false positive rate of the PSSI-5 might be due to a lower scoring threshold leading to the propensity for an increased risk of false positives (Weathers et al. 2013b ). This scale is not in the public domain and must be requested by the authors. The PDS-5 is a 24-item self-report measure that assesses the presence of a traumatic event and measures the 20 DSM-5 symptoms for trauma. This measure is the self-report version of the PSSI-5 interview schedule. The items measuring symptoms are the same as the PSSI-5 and utilize the same scoring anchors and thresholds. The clinical cut-off score for a probable diagnosis of PTSD is 28, and the scale has shown excellent psychometric properties with an internal consistency score of 0.95 and a test-retest reliability score of 0.90. The scale showed good convergent validity with the PSSI (r = 0.85) and the PCL-S (r = 0.90). The PDS-5 showed a 78% agreement with the PSSI and is a valid self-report scale of PTSD (Foa et al. 2016b ). This scale is not in the public domain and must be requested by the authors. Treatment guidelines for PTSD for behavioral health providers include a range of treatment and practices that have shown to be effective in addressing the impacts of trauma and PTSD in the population. Routine health and behavioral health settings are key places where PTSD intervention can occur. As mentioned previously, many people with PTSD do not receive treatment or deal with the symptoms of PTSD for many years before receiving treatment. Table 7 .6 lists the recommended guidelines for PTSD treatment drawn largely from the National Institute for Clinical Excellence (NICE). Specific guidelines to consider for treatment include the following: Clients These are important integrated treatment strategies to identify and address PTSD in routine health settings to help people avoid years of needless suffering. Trauma and IPV should be a part of normal and routine patient education. The role of trauma and health should be provided to all patients regardless of disclosure. Trauma-informed practices should be followed, which include assessing clients (especially children) separately from partners and caregivers. Primary care providers should ask clients about trauma symptoms and traumatic events in a sensitive and person-centered manner. Clients who screen positive for trauma should automatically have further assessment. For assessed clients who have PTSD or partial PTSD symptoms, care should be coordinated either within the team or through warm referral processes with trusted outside providers that specialize in trauma treatment for which there exist a formal referral arrangement. Providers should also consider the needs of families and caregivers, and assess and address practical and social support issues as they arise. 7 .5 Treatment Guidelines for PTSD (NICE Guidelines