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Trauma Assessment for Women Receiving Mental Health Services

The National Institute of Mental Health states that in any given year 25% of adults in the United States are diagnosable for one or more mental disorders. Of that 25%, 6% meet the criteria for severe mental illness. Women are not more likely to meet the criteria for a diagnosis however; women are more likely to enter into treatment (either inpatient, outpatient, or prescription drugs) to help alleviate the symptoms of their mental distress. Women are 50% more likely than men to be diagnosed with a mood disorder, 60% more likely to be diagnosed with an anxiety disorder, and 70% more likely to be diagnosed with depression than men. As mental health professionals it is vital that we understand how trauma affects the mental health of the women that we are providing service for.

Women are more likely to be traumatized in their interpersonal relationships than men. Women are more likely to be physically and sexually assaulted by someone they know. In the general population between 17 and 35% of women report a history of physical or sexual abuse, whereas in mental health setting that statistic rises to 35-50% (van der Kolk et al., 2005). These statistics again increase when taking into consideration women with co-occurring disorders: 48% of women with a co-occurring disorder in community samples report histories of interpersonal trauma and 90% of women with co-occurring disorders in inpatient settings report interpersonal trauma (Becker et al., 2005).

Symptoms of trauma can be manifested in ways that may not meet the criteria for Post-Traumatic Stress Disorder (PTSD), often times women experience depression and anxiety in response to trauma. In part this may be due to the definition of traumatic events according to the DSM-IV-TR, which states that a traumatic event is one in which an individual experiences the threat of death or serious injury and emotional response of fear, helplessness, or horror at the time of the event. A stressful life event often constitutes the normal fluctuations of life such as divorce, loss, serious illness, or expected death of a loved one, which an individual may experience as traumatic. All of the aforementioned life events require and individual to cope and adapt which of course can bring about psychological changes. When dealing with a traumatic event the difference often becomes the individual’s adaptive capacities to be overwhelmed which leaves the individual unable to cope effectively.

Research has shown the link between child abuse and severe mental illness as well as the link between child abuse and PTSD (Frueh et al., 2009; Read 1997; Read et al., 2005; Mueser et al., 2001; Herder & Redner, 1991). Severe Mental Illness (SMI) is defined as: Schizophrenia, a Schizophrenia Spectrum Disorder, Bipolar Disorder, or Treatment Resistant Depression. Recent research has shown that the symptoms of PTSD can be very similar if not identical to the symptoms of SMI (Herder & Redner, 1991; Mueser et al., 2002). Lifetime rates of interpersonal violence range between 43 and 97% in women with SMI who seek treatment (Cusak, Morrissey, & Ellis, 2007).

In the past fifteen years researchers have taken an interest in the effects of trauma on SMI. Studies have found repeatedly and consistently that individuals diagnosed with SMI are far more likely to have suffered a trauma than those individuals in the general population (Read, 1997; Frueh et al.,2009; Herder & Redner, 1991; Mueser et al.2002; Mueser et al. 2001; Read et al. 2005). Individuals diagnosed with a SMI are far more likely to be the survivors of physical abuse, sexual abuse, or both physical and sexual abuse (ibid). Most often this abuse occurred before the age of 18. These individuals are also more susceptible to being further victimized in their adult lives (Mueser et al. 2002).

Historically when researchers would study the long-term effects of child abuse, they did not to include individuals diagnosed with SMI, especially individuals with some form of psychosis (Read, 1997; Read et al. 2005). However, recent research studies indicated that individuals diagnosed with a psychotic disorder have the highest rates of child abuse. This population tended not to be studied as it was thought that due to their symptoms of psychosis, they would not be reliable reporters (ibid). However, the inter-rater reliability for this population was the same for the general population when asked the same questions (Read et al. 2005; Mueser et al. 2001). Often, once it was found that a patient suffers from any form of psychosis, they were not included in child abuse studies (Read 1997; Herder & Redner, 1991; Mueser et al. 2001). This type of research practice obviously distorts the data of the long-term effects of child abuse. Unfortunately, it was not until 2004 that large scale research studies started to address the issue of child abuse and psychosis (Read et al. 2005).

Studies have also shown that in patient charts, abuse is not regularly assessed or documented. In one study charts were reviewed to determine if a child abuse history was documented. The patients were then interviewed to determine if they were victims of child abuse. It was found that only 14% of the charts had documented child abuse, but 70% of the patients interviewed reported having been the victims of child abuse (Read, 1997). Due to the aforementioned data regarding the relationship between child abuse and SMI, researchers began to look at the prevalence of PTSD in individuals diagnosed with SMIs (Mueser et al., 2002; Mueser et al., 2001; Frueh et al., 2009). Research show that there is a co-morbidity of PTSD and SMI ranging between 29% and 43% (ibid). The prevalence of PTSD in the general population is about 10% (ibid).

In 2009 a study was conducted to determine whether SMI patients in a multi-site community mental health clinic met the criteria for PTSD. The study found that 98% of the patients diagnosed with a SMI had a history of trauma; 42% when assessed met the criteria for PTSD (Frueh et al., 2009). The researchers then reviewed the patient’s charts to determine how many of the patients had a diagnosis of PTSD. Only 2% of the appropriate patient charts documented a diagnosis of PTSD (ibid). This indicates that clients who meet the criteria for PTSD are not being treated for PTSD, which is obviously problematic. The study also found that most mental health clinicians do not treat the symptoms of PTSD, rather just the symptoms of the SMIs. This is problematic, in that PTSD remains largely untreated and undiagnosed in the SMI population (ibid). It would be like a person having a diagnosis of diabetes and emphysema, and only treating the emphysema.

The Women, Co-Occurring Disorders, and Violence Study (WCDVS) was a large government funded study that aimed to determine the effectiveness of integrated and trauma informed services for women with Co-Occurring Disorders (McHugo et.al, 2005). The data that was gathered from this study has been tremendous leading to many others to examine the data and thus provided the mental health world with important information that can help to facilitate proper mental health treatment to women who have been affected by trauma and stressful life events.

One of the invaluable tools that was gained from the WCDVS was a modified assessment tool that mental health professionals can utilize when assessing clients for trauma and stressful life events. The WCDVS used a modified version of the Life Stressor Checklist Revised (LSC-R) during the study to evaluate a woman’s trauma and stress exposure. The LSC-R and the WCDVS version of the LCS-R does not assess for symptoms of trauma or stress rather it asks questions regarding a person’s exposure to trauma and stress that the mental health professional can take into consideration when working with the client in determining how these events currently fit into the woman’s mental health (McHugo et. al, 2005).

As the statistics show, women are more likely to be victims of both physical and sexual abuse often beginning before the age of 18. Once victimized women are more likely to be re-victimized especially if they have a mental health diagnosis. The research is very clear that these aforementioned forms of trauma have a high correlation with substance abuse and mental health issues. It is clear that in mental health service provision of women, trauma needs to be taken into consideration. It is important for women to be assessed for trauma in order to accurately and appropriately diagnose and thus provide appropriate treatment. The research also shows that women can tolerate a sensitive assessment such as the LSC-R which will enable mental health practitioners to be better informed of a woman’s trauma history which may help to understand a woman’s symptoms. As mental health professionals we can treat the symptoms that women present with, but we need to ask ourselves: Are we treating the cause?

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