PTSD diagnosis and evaluation -Case Description -Engagement -Target areas -Definitions -Measurement Strategy -Goals and Objectives -Interventions -Theories -Measurement Timeline -Results -Interpretations -Limitations -Agency -Ethics -Justice and Diversity -Policy -References

1. PTSD diagnosis &
evaluation
Muskaan Soni
University of West Florida
Department of Social Work
SOW 6548: Capstone
Prof. Erin King

2. Case
Description
33 year-old
female
LGBTQ+ (bisexual)
yoga instructor and part-time worker
history of childhood abuse - sexual assault,
domestic violence
brother died by suicide 3 years ago
abusive ex partners - caregiver of one of them
who was paralyzed
self-referred
seeking help for psychosocial symptoms
including communication issues, relationship
difficulties, stress, depression, and anxiety
Miley

3. Engagement
Mental Status Exam & Intake
Behavior - engaged and
cooperative; poor eye
contact
Affect - Constricted
Speech - Expansive,
pressured, hyperverbal
Appearance - clean,
well groomed
Orientation - oriented
to person, time and
place
Mood - anxious and
depressed
Appetite - decreased and
binging; health conscious
Judgement - good but
confused thoughts as
well as symptoms
Suicidality - none
Insight - lacks insight
but aware of need of
treatment
Sleep - unsatisfying
and middle insomnia
(can't stay asleep)
Homocidality - absent

4. Target areas -
"problems"
communication/relationship difficulties
emotional awareness and regulation
depression
anxiety
traumatic stress

5. THE "Problem"
First focusing on emotional regulation -
developing coping skills, sessions with partner,
appropriate assessment and building rapport
Identification
At 6-month treatment review, switching to
focus on traumatic experience after
discussing no changes in symptoms
Prioritization

6. Conceptual
definition
"the effect bad stuff from her past has on her ability to fully be herself today"
keeping it simple as well as relevant
increasing insight without re-traumatizing
client's self-determination

7. Operational Definition
"Individual trauma results from an event, series
of events, or set of circumstances that is
experienced by an individual as physically or
emotionally harmful or life threatening and
that has lasting adverse effects on the
individual’s functioning and mental, physical,
social, emotional, or spiritual well-being" (p.7)
SAMHSA (2014)
trauma responses - avoidance, disassociation,
hyper-arousal, re-experiencing, detachment,
upsetting memories, sleep, appetite (Conradi,
Wherry & Kisiel, 2011).
Holistic Functioning
emotional dysregulation - depression and
anxiety
Psychiatric symptoms

8. Measurement Strategy
Measures reliable and valid observable
outcomes across 19 domains including
ADL, traumatic stress, substance use,
family relationships, and more
(Schwartz, 1999) - observational
Functional Assessment
and Rating Sale (FARS)
9-item scale assesses for depression
symptoms over the last two weeks
(agency policy) - effective with clients
who are not ready for in depth trauma
assessment (Fallot & Harris, 2011)
self-report
Patient Health
Questionnaire (PHQ-9)
Generalized Anxiety
Disorder (GAD-7)
7 question brief self-report measuring
anxious symptoms over the past two
weeks (agency policy) - she has
enough insight into these symptoms
so opportunity for psychoeducation
self-report
agency policy - once every year
changing strategy to every month
clinician - verbal to help with psychoeducation

9. Objectives
reduce symptoms of detachment,
avoidance, and repression
Traumatic stress
reduce intensity, frequency and
duration of dpressive symptoms
Depression
reduce intensity, frequency and
duration of anxious symptoms
Anxiety
Goals
"I want to have more focus on the now and
become the person I am meant to be"
Client states:
1) traumatic experience
2) emotional regulation
Treatment plan

10. Intervention options
person centered as well as trauma-
informed, self-paced, possibility of
changing how client views self while also
respecting boundaries. Supports the natural
tendency of the person to move towards
"autonomous determination, expansion and
effectiveness, and constructive social
behavior" (Joseph, 2004, p. 103).
Trauma-Focussed Cognitive
Behavioral Therapy (TF-CBT)
more client centered but lacks trauma-
informed approaches. client alleges to be
competent in these techniques but when
assigned as homework it seems to be
ineffective. Needs a new approach that is
not closely related to her work/personal
life even thought I thought using this
would be a strengths-based approach
Mindfulness Based Stress
Reduction (MBSR)
brief, intense, more trauma-informed
than client centered. However, client's
behavioral status seemed
unpredictable and client was dealing
with active triggers at home.
Importance of a stabilization in early
stages of therapy (Sanderson, 2006);
client desired during intake
Eye Movement Desensitization
and Reprocessing (EMDR)

11. Trauma-
informed
practice
Person-
centered
theory
"Equipped with this self-belief and sense of control,
young people were able to successfully navigate the
difficulty of discussing trauma, a process that was so
fundamental to recovery and ultimately, responsible for
the transformative life changes described in future
outlook and self-perception” (Eastwood, 2021, p. 746).
A person with PTSD has a disorganized self-structure
who is trying to find themselves, grow, and cooperate
with others. Theory highlights that the client will be
motivated by their self-actualizing tendency to
appropriately reintegrate their story under a supportive
therapeutic environment (Joseph, 2004).

12. TF-CBT
Randomized clinical trials showed that trauma informed therapies were more
effective in reducing chronic PTSD symptoms than non-trauma focused therapies
(Bison et al., 2013)
ABC triangle (affect, behavior and cognition)
Three main stages of TF-CBT (Cohen & Mannarino, 2015)
Stabilization - psychoeducation, coping skills, emotional expression and
regulation, relaxation
Trauma Narration and Processing
Integration and Consolidation - gradual exposure, safety and future planning

13. Baseline (Intake)
"adjustment disorder"
Tx plan
review Final
"posttraumatic
stress disorder"
09/27/21 03/15/22 04/19/22
Measurement timeline

14. Evaluation Results

19. looking at symptoms holistically worked for client
increase sense of control over evaluation process (SAMHSA, 2014)
missed appointments, appropriateness of PCL-5
effect of current triggers and fear of re-traumatizing (SAMHSA, 2014)
important of emotional awareness/regulation before gradual exposure stage of TF-CBT
under-diagnosing vs. over-diagnosing
adjustment disorder at start did not allow us to do direct trauma work
correlation of change in strategy with change in scores (doesn't imply causation)
client was against pharmacological interventions
Interpretation

20. Limitations
Strengths
adaptable strategies
triangulation of results- self-reports
+observational data
good balance between person-
centered and trauma-informed
exposure
inconsistent measures
lack of individualization - all
measures were standardized
need for more agency provided
research on trauma screening and
evaluation

21. Agency evaluation
strict protocols that lack trauma-informed assessments and screening
a lot of screenings given at intake with little follow up
need for more frequent evaluation - once a year not enough
treatment plan review every six months
PTSD clients often irregular or stop services before that time
lack of policies around clinician boundaries
what if a client with extreme symptoms refuses psychiatric interventions
diagnosing down not always beneficial to clients with PTSD especially if they have
cooccurring illnesses like substance use issues (SAMHSA, 2014)
MSW interns ultimately are working with supervisor's clients so lack of
independent work

22. 30-year-old white Christian woman
hx of childhood sexual slavery, human trafficking, and domestic violence
flat affect, distorted cognitions, auditory and visual hallucinations in and out of in-
patient treatments, refuses psychiatric interventions including meds
client safety - high risk of self-harm and disassociation
chronic PTSD with depersonalization symptoms
as a clinician not feeling "intimidated" by client - personal history/boundaries
professional committment vs. competence (NASW, Code of Ethics, 2008)
Outcomes - deciding to step back to avoid counter-transference after consulting
my personal care team (professors, supervision, therapists); feeling affirmed in my
ability to say no in similar future cases
Ethics Case

23. Justice & Diversity Case
49-year old white transgender nonbinary pansexual
gender dysphoria diagnosis - client goal to determine gender affirming change process
personal background- as a member of LGBTQ+ intimately knowing the history of our
struggles with accessing health services (Lawlis et al., 2019)
real challenges this client is facing - transphobic physicians and work place, confusing
terminology/process, and unsupportive family
World Professional Organization for Transgender Health (WPOTH) recommends the
following to assess readiness (Coleman et al., 2012)
have a persistent and well-documented history of gender dysphoria,
the capacity to make an informed decision and consent to treatment
adult/age of majority in country
reasonably control medical and mental health concerns
Outcome - after developing a plan with client wrote a referal letter for physician

24. 40-year old black man from low-income background
ADHD and chronic PTSD
seeking referral letter for Supplemental Security Income or Social Security Disability Insurance
(SSI/SSDI)
history of early childhood domestic violence, sexual abuse, and substance use
faced incarceration multiple times as a juvenile and adult
lack of agency protocol for referral letters/release of information (ROI)
confusing request from the social security administration (SSA) with little instructions
early interventions like disability benefits for folks with history of mental illness provide easier
transition from jail to community (McCaultey & Samples, 2017)
SSI/SSDI benefits are automatically suspended once a person is sent to prison and if a person
received benefits before incarceration, they will most likely be required to reapply after release
(SSA, 2015)
Outcome - research into disability issues for incarcerated individuals; consolidating client
history across note-taking platforms; writing templates for ROIs for supervisor's future cases
Policy Case

25. Bisson J. I., Roberts, N. P., Andrew, M., Cooper, R., Lewis, C., & Bisson, J. I. (2013). Psychological therapies for chronic post‐traumatic stress disorder (PTSD) in adults. Cochrane Library, 2015(8),
CD003388–CD003388. https://doi.org/10.1002/14651858.CD003388.pub4
Cohen, J. A., & Mannarino, A. P., (2015). Trauma-focused Cognitive Behavior Therapy for Traumatized Children and Families. Child and Adolescent Psychiatric Clinics of North America. 24 (3): 557–570.
doi:10.1016/j.chc.2015.02.005.
Coleman et al. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7. The World Professional Organization for Transgender Health. URL:
www.wpath.org
Conradi, L., Wherry, J., & Kisiel, C. (2011). Linking Child Welfare and Mental Health Using Trauma-Informed Screening and Assessment Practices. Child Welfare, 90(6), 129–148.
Eastwood, O., Peters, W., Cohen, J., Murray, L., Rice, S., Alvarez-Jimenez, M., & Bendall, S. (2021). “Like a huge weight lifted off my shoulders”: Exploring young peoples’ experiences of treatment in a
pilot trial of trauma-focused cognitive behavioral therapy. Psychotherapy Research, 31(6), 737–751. https://doi.org/10.1080/10503307.2020.1851794
Fallot, R. D. & Harris, M. (2001). A trauma-informed approach to screening and assessment. In M. Harris & R. D. Fallot (Eds.), Using trauma theory to design service systems (pp. 23–31). San Francisco:
Jossey-Bass.
Joseph, S. (2004). Client-centred therapy, post-traumatic stress disorder and post-traumatic growth: Theoretical perspectives and practical implications. Psychology and Psychotherapy, 77(1), 101–
119. https://doi.org/10.1348/147608304322874281
Lawlis, S. M. Watson, K., Hawks, E. M., Lewis, A. L., Hester, L., Ostermeyer, B. K., & Middleman, A. B. (2019). Health Services for LGBTQ+ Patients. Psychiatric Annals, 49(10), 426–435.
https://doi.org/10.3928/00485713-20190910-01
National Association of Social Workers. (2008). Preamble to the code of ethics. Retrieved May 4, 2008, http://www.socialworkers.org/pubs/Code/code.asp
Sanderson, C. (2006). Working with Adult Survivors of Child Sexual Abuse. Counselling adult survivors of child sexual abuse (3rd ed.). J. Kingsley. 101-149
Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach (HHS publication no. (SMA) 14-4884). Rockville,
MD: Sub-stance Abuse and Mental Health Services Administration. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Schwartz, R. C. (1999). Reliability and validity of the Functional Assessment Rating Scale. Psychological Reports, 84, 389-391.
References

26. Thank you! Questions?