Fresh thinking on trauma assessment

According to a large-scale international survey of more than 68,000 people, around 70% of people have experienced at least one trauma in their lives, and 31% have been exposed to four or more traumatic events (Benjet, C., et al., Psychological Medicine, Vol. 46, No. 2, 2016opens in new window). Furthermore, those most impacted by trauma tend to be among the most vulnerable financially, socially, and otherwise (Ravi, M., et al., Mental Health Science, Vol. 1, No. 4, 2023opens in new window).

The high rate of trauma exposure suggests that many or most of those who enter therapy or otherwise work with a psychologist have faced one or more traumatic life events, said Charles Benincasa, PsyD, a clinical and trauma psychologist based in Everett, Washington, and a member of the APA Task Force on the Assessment of Trauma. But surprisingly, most graduate programs lack specific training in the assessment and diagnosis of trauma, particularly of complex presentations. Training often focuses solely on discussing trauma within the context of trauma-related diagnoses rather than recognizing trauma as a possible cause or complicating factor in a person’s mental health presentation, he said.

Yet “if these factors are not included as part of the standard of assessment, we can miss really important aspects of understanding the experiences that people are coming to us with,” Benincasa said.

To help fill this gap, he and other members of the trauma assessment task force developed the 2025 APA Guidelines for Psychologists in the Assessment of Psychological Trauma in Adultsopens in new window, approved by APA’s Council of Representatives in August. The document provides direction for gaining competency in trauma assessment, highlights important research developments in the area, and points to areas still in need of deeper understanding and further attention, including more research on trauma types and symptoms and better instruments to gauge the many types of trauma that people experience, said Tyson Bailey, PsyD, cochair of the assessment task force and a clinical and forensic psychologist and trauma specialist in Everett, Washington.

“We have come a really long way in understanding how to properly understand and assess trauma,” he said, “and we have a very, very long way to go. We hope these guidelines encourage people to use the knowledge we have and continue to grow the literature on recognizing the broad effects of trauma, because trauma and adversity are common and are disproportionately felt by people who are already marginalized.”

In general, the aim of the guidelines is to help the field better understand the central role that trauma might play in some patient experiences and, in a related vein, the wide variation in trauma reactions that are not covered by traditional diagnoses, Bailey added. For example, while the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) recognizes several trauma-related diagnoses, it does not recognize complex trauma—trauma resulting from repeated, prolonged exposure to stressors, particularly interpersonal ones, though the World Health Organization’s International Classification of Diseases, or ICD-11, does (see March 2025 Monitor article on treating complex trauma).

To get at these core ideas, the task force organized the guidelines around three themes: knowledge—what psychologists need to know about the possible role that trauma plays in mental and physical health presentations and the instruments used to treat it; content—what psychologists should be looking to assess when they use available assessment techniques and measures; and process—the way psychologists should interact with clients when conducting assessments.

In the knowledge domain, the guidelines underscore the importance of viewing trauma exposure as a possible root cause of common presenting problems such as depression, anxiety, insomnia, relationship problems, and, in more extreme cases, dissociation and even psychosis, said Paul Frewen, PhD, an associate professor of psychiatry and psychology at Western University in London, Ontario, and a member of the trauma assessment task force.

In many cases, trauma does not cause long-term ill effects—most people recover naturally from single-incident traumas, with about 40% recovering within a year, according to the World Health Organization. However, the fact that trauma is so common, coupled with research showing high correlations between more complex trauma and mental and physical problems, means that “trauma history is essentially a risk factor for any mental health diagnosis that one could have,” Frewen said. For example, a study of 9,000 adults found that those who had experienced four or more adverse events in childhood, such as ongoing neglect or abuse, were 4 to 12 times more likely to be suicidal, depressed, and to misuse substances than those without a trauma history (Felitti, V. J., et al., American Journal of Preventive Medicine, reprint, Vol. 56, No. 6, 2019opens in new window). Other studies show that the greater the number of adverse childhood events one has experienced, the greater the risk of developing physical, psychosocial, neurobiological, and functional problems (Madigan, S., et al., World Psychiatry, Vol. 22, No. 3, 2023opens in new window).

Integral to this expanded understanding is knowing that the person themselves may not know that trauma is at the base of their symptoms, Frewen added. A patient might enter therapy seeking help for symptoms like insomnia, mood instability, or relationship problems, for instance, “but not necessarily recognize that those symptoms tie to traumatic life events that they have experienced recently, at some point earlier in their life, or throughout their life,” he said. “It’s important for psychologists to be mindful of these possibilities.”

Considering trauma in this wider context also means opening the door to diagnoses and understandings that go beyond post-traumatic stress disorder (PTSD), said Constance Dalenberg, PhD, director of the Trauma Research Institute and distinguished professor at Alliant International University, both in San Diego, and a member of the APA task force. Although much has been learned about trauma since PTSD entered the DSM-3 in 1980, PTSD remains the go-to gauge for whether a traumatic reaction exists or not.

“People think that if you do or don’t have PTSD, it has implications for whether you were or were not traumatized,” she said. “But PTSD is only one way a person can react to trauma, and if you do have a trauma reaction, most of the time it is not PTSD.”

Instead, it behooves psychologists to consider and assess more broadly how trauma might manifest in a person above and beyond traditional diagnoses, Dalenberg noted. Assessors should stay alert to potential emotional, cognitive, behavioral, and interpersonal effects of trauma, such as general anxiety and depression, changes in cognition, such as problems with logic and processing speed, and changes in level of trust.

Looking beyond diagnostic boxes and using different kinds of instruments provides a wider and more humane lens on how trauma can affect people, Dalenberg added. An example is assessing a person’s belief system after they have experienced an interpersonal trauma. If the measure reveals that the person now trusts people less and sees the world as a more dangerous and unfriendly place, “that might not mean that the person has PTSD,” she said, “but it might mean they’ll have a much more damaged life because of that change.”

In terms of testing itself, task force members recommend using a range of empirically validated interviews and questionnaires to get at a person’s trauma history and its current manifestations. Reactions and symptoms to screen for include PTSD, anxiety, dissociation, depression, grief, substance misuse, anger and aggression, emotional dysregulation, cognitive changes, and changes in belief systems. It is also important to gather information on the type, frequency, and recency of the trauma—factors often missing from standard assessment instruments.

Dalenberg recommends beginning an assessment with a general psychosocial interview that weaves trauma-related questions throughout, then gradually moving to more specific tools that further explore what the broad assessment has suggested. For instance, the Trauma Symptom Inventory-2opens in new window can help assess a wide range of short- and long-term psychological effects of trauma, including PTSD, dissociation, somatization, attachment issues, and self-harm.

Good assessment also requires using instruments and other tools thoughtfully and using one’s clinical judgment and understanding in interpreting them, Bailey added. The challenge is to synthesize the information you have—for example from interviews, assessment measures, records, and collateral sources—in ways that accurately capture a person’s experience. A good trauma assessor “has a firm and grounded understanding of what the tools are and what they can and can’t tell you,” he said, and also does their own work in making an informed assessment.

As an example, if an interviewer merely asks a person if they have ever been raped or sexually assaulted, it often leads to underreporting because the person does not necessarily use those words to describe their experiences, Frewen explained. A more useful approach is using validated instruments that ask specific questions about whether a person has ever experienced certain behaviors from others.

“It’s much better to ask behavioral-type questions about whether a certain type of event has specifically happened, as opposed to asking questions in global terms that people can interpret in different ways,” he said.

In the forensic context, it is important to carefully weigh client responses on validity measures that assess the possibility that a person is feigning or exaggerating symptoms, Frewen added. While such measures are often used in this context because people may overplay symptoms to avoid legal consequences or to gain benefits, the scores need to be interpreted carefully for trauma survivors, he said.

That is because while people may feign extreme reactions that are known to be rare in the general population—for example, anger displays, dramatic somatic complaints, or self-destructive actions—a person who has been traumatized through ongoing abuse, coercive control, or combat may actually experience these reactions. So to make an accurate determination, assessors should also include data from other instruments and the person themself, Frewen said. Also important to keep in mind is the continued reality that people still often do not believe those who say they have been raped, he added.

Social support is likewise a vital area to assess because research shows that support systems can be immensely valuable in helping people cope with and overcome traumatic experiences (Calhoun, C. D., et al., Psychiatric Quarterly, Vol. 93, No. 4, 2022opens in new window). Benincasa recommends using questionnaires that ask about a person’s level of support from family, other relationships, community, work, health care providers, and other sources. Psychological First Aid, an evidence-based approach to helping people after a crisis or trauma, recognizes this reality by helping to match people with resources aimed at reducing the odds that they will develop a sustained traumatic response over time, he noted.

Culture, language, and ethnicity are also key items to consider in trauma assessments, said Dalenberg. While the way that people process trauma in the body and emotions is probably universal, “different cultures understand bodily reactions and emotions in different ways and use different mechanisms and metaphors to describe them,” she said. “So how I interpret the changes that are happening within me will differ depending on my culture, and my secondary reactions to those changes will differ as well.”

In the case of immigrants who have come to this country to escape difficult conditions, psychologists should consider that many have never had a time in life when they have not faced traumatic stressors. It is important to think about how ongoing political persecution, loss of one’s home, war, migration, and resettlement can impact individuals, the guidelines note.

That said, current tools and methodologies for dealing with some of these issues are still very underdeveloped, said Bailey. In cases of language and cultural differences, using translated measures, a personal interview, and/or a professional translator are likely to be more helpful than current assessment instruments, he said.

“We hope that these guidelines spur the development of tools that are more robust and that address post-traumatic reactions more broadly, rather than focusing on one particular diagnosis,” he said.

In terms of process, psychologists need to be aware of the human dynamics occurring during the assessment itself—in particular, what the person being assessed might be experiencing internally and in relation to the assessor, according to the guidelines. For example, external factors such as skin color, gender, age, or appearance might inadvertently make it difficult for a person to trust or disclose information to you, Benincasa noted.

For example, he evaluates many people who have experienced interpersonal violence, and he recognizes that as a large-statured, bald, white man, “there’s a high likelihood that I might look like the person that my client is most afraid of,” he said. If the person does make that association, it can lead to an involuntary activation of their nervous system and make it harder for them to answer assessment questions accurately. In cognitive or neuropsychological testing, research shows that such nervous system activation makes it harder to complete tasks with high cognitive demand “because there is the distraction of the associations that are going on and of what’s happening in the nervous system,” Benincasa said.

Also important to keep in mind is that the person is probably experiencing post-traumatic symptoms during the assessment itself, and to think about timing one’s questions and level of detail accordingly. If a person seems to be having difficulty with the process, encourage them to take a break and do brief breathing or grounding exercises, Frewen advises.

Sometimes, no matter how hard one works to create a trusting relationship with the person being assessed, there are times a patient simply cannot overcome internal obstacles to working with you, Benincasa added. If that is the case and future therapy or work is needed, help the person find a better match, he said. If that is not possible in the time allowed or for other reasons, use your clinical skills to discuss those issues and try to work through them with the person, he said.

Finally, if an assessment determines that the person needs additional therapy, act expediently, Frewen said. “It’s not a great help just to identify a problem without offering a solution,” he said. “We’ve got to be ready to provide care if the person needs it.”

Gaining the right tools and knowledge can open the door to helping people heal their wounds at the source, Frewen added.

“If trauma isn’t there, great; move on,” he said. “But I think psychologists will be surprised to discover how often a trauma history is looming there. If we just treat traumatic reactions as a behavioral issue, and we don’t get to where this all came from in the beginning,” he added, “I think our treatment will be less effective.”