Directions: Respond to the prompts following each of the scenarios below based on the topical readings and any other resources you find helpful. Each response should be 75-100 words.
Scenario 1: Jeannine and Robert have been together for five years and have been married for the past three years. They live in an apartment together. There have been a few instances of physical violence from Robert toward Jeannine throughout the relationship, mostly shoving her around and, a couple of times, slapping her, always followed by effusive apology, explaining his actions as stress from his job. Imagine you are Jeannine’s counselor and she reveals that Robert has been showing signs of more violence, escalating in verbal threats. A couple of weeks ago, he grabbed her by the shoulders and shook her so violently, she ended up with a sore neck and migraine headache. Last week, he punched her in the ribs a couple of times, resulting in bruising, which she revealed to you. She fears for her safety, though she is not yet ready to move out or leave him.
1. Describe Jeannine’s level of lethality:
2. Devise a harm reduction plan for Jeannine.
3. Explain why you devised the harm reduction plan the way you did:
Scenario 2: Maria states she met Justin at a party a couple months ago. They have gone out a few times. Justin has never been to Maria’s house but she has been to his apartment; client states she usually meets him at a restaurant or club. Maria tells you that the other night, while out with Justin, he became “physically aggressive.” She reports that she woke the next morning at her home with a lack of memory from the night prior. She tells you that she was too ashamed to report it to the police and she wasn’t sure what happened. Imagine you are Maria’s counselor and she reveals to you that yesterday Justin became abusive and threatening toward her after she refused his sexual advances. Justin threatened that he would break off their relationship and find someone “more mature” in her attitude toward sex. She is afraid that he will follow through on his threats to break off their relationship. You know from past visits that she has self-esteem problems.
1. Describe Maria’s level of lethality.
2. Devise a safety plan for Maria:
3. Explain why you devised the safety plan the way you did:
Scenario 3: Arthur and Melissa have been married for seven years but have been separated for the past year. The couple has two small children. They share custody. Imagine Arthur is your client, and, during a session, Arthur reveals that Melissa has recently become physically violent with him, slapping and punching him, but he has been too embarrassed to disclose the abuse. Client states that his wife has never acted this way before and he is afraid that the children may not be safe when left alone with her. Client states he is unsure about how to protect himself and, more so, his children.
1. Describe Arthur’s level of lethality:
2. Devise a safety plan for Arthur:
3. Explain why you devised the safety plan the way you did:
CNL-545 Trauma Case Study
Reason for Referral
Maryam is a 17-year-old Caucasian female university student who was referred to your agency by her physician, Dr. Jaffee. Maryam presented in her doctor’s office complaining of lack of sleep. Dr. Jaffee did not give her medication, as Maryam has reported drinking three to four glasses of vodka and orange juice per night to sleep. Dr. Jaffee’s report indicates the patient is sleeping 2-4 hours per night and often awakens with nightmares. Blood tests were normal with the exception of slightly elevated liver enzymes. Blood pressure was 130/94. Patient was scheduled for a follow-up appointment in 2 weeks.
Behavioral Observations
Maryam arrived on time for her appointment. She was driven to the appointment by her university roommate. The client appeared anxious, had circles under her eyes, and was tearful during the intake. Maryam was oriented to time, place, and person. Client vocabulary was above average. Client appeared tired and despondent evidenced by low voice, soft speech, and flat affect.
Presenting Problem
Maryam states “I can’t drive a car. I’m too afraid that someone will hit me or I’ll hit someone else. I can’t sleep so I don’t get up to go to class in the morning.” Client states, “I’m afraid to drive.” She goes on to state, “I made such a horrible mistake; I don’t deserve to live. I’m so stupid.”
Client states that she was involved in a three-car accident 2 months ago. Client reports one person was critically injured and the other was treated and released at the hospital. Client reports she received a citation, as she turned in front of two oncoming cars at a red light.
Support System
Client reports that she lives in student housing on the campus of a local university. She has one roommate who brought her to today’s appointment.
Legal: Client is facing legal problems due to the accident.
Family Support: Maryam’s family lives out of state. She has no relatives who live locally.
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Review the Trauma Case Study for Maryam. Write a 750-1,000-word essay answering the following questions. Your number one goal is to make sure she is safe.
Provide appropriate support for your answers by citing the current version of the DSM.
· What are the key assessment issues to consider?
· Do you think this is a crisis situation? Why or why not? Explain.
· What is the client’s immediate need? Be specific.
· What specific interventions do you feel are necessary with this client?
· What is the possible diagnosis for this client? Provide supportive reasoning for your diagnosis. Why?
· Is this client suffering a stress disorder? Define which one and the symptoms associated.
· How does the biology of trauma present in this case?
· Should Maryam’s family be notified? Explain.
· Would you feel competent enough to work with this client? Why or why not?
· Should you seek additional resources to help with this case? Explain.
· Do you have coordination or treatment issues to consider? Explain.
Include a minimum of three scholarly references in addition to the textbook.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.
This assignment is informed by the following CACREP Standard: 5.C.2.f. Impact of crisis and trauma on individuals with mental health diagnoses.
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ASSESSMENT OF TRAUMA, POSTTRAUMATIC STRESS DISORDER, AND RELATED MENTAL HEALTH OUTCOMES
DAWNE S. VOGT, LISSA DUTRA, ANNEMARIE REARDON, REBECCA ZISSERSON, AND MARK W. MILLER
There are many complexities inherent in the assessment of veterans who have served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Not only do many OEF and OIF veterans have histories of exposure to a range of potentially traumatic or highly stressful events, but the consequences of these exposures may manifest themselves in varied mental health problems following deployment. Therefore, the development of a comprehensive clinical case conceptualization requires an in-depth under- standing of the deployment-related experiences that increase veterans’ risk of mental health problems, as well as the postdeployment mental health sequelae that are most relevant for this population.
Consistent with this goal, we begin this chapter with a discussion of predeployment, deployment, and postdeployment factors that may be asso- ciated with postdeployment sequelae to provide a conceptual framework
for the assessment process. We then review state-of-the-art methods for the assessment of trauma exposure, posttraumatic stress disorder (PTSD), and functional impairment in OEF and OIF veterans. We conclude with a discussion of the importance of assessing motivation to change, particularly as it applies to the veteran’s willingness to initiate and engage in treatment, and the importance of comprehensive assessments. To help facilitate an understanding of the clinical applicability of the information covered in this chapter, we reference the following clinical vignettes throughout our discussion.
CLINICAL VIGNETTES
“Bob” is an unemployed 25-year-old OIF Army veteran who was a medic during his recent 12-month deployment in Iraq. He returned from deployment 8 months ago and is now living with his father, a Vietnam veteran, with whom Bob has always had a tumultuous relationship. During his deployment, Bob witnessed two close friends suffer severe injury as a result of improvised explosive devices (IEDs) planted in abandoned cars, as well as the acciden- tal shooting of a civilian adolescent Iraqi boy. Although he was not injured himself, Bob was constantly on guard when passing cars or other objects in the road, and since returning home, he has avoided driving whenever possible. He also avoids the dark, as many of his missions occurred at night, and he sleeps fitfully most nights because of nightmares related to explosives. He has maintained contact with many of the soldiers who were deployed with him. They became close buddies while deployed and now meet up weekly at a local pub to drink and rehash stories about their experiences in Iraq. Because of his tardiness due to hangovers, Bob has lost two jobs since returning from deployment. Bob’s father, who struggled with alcoholism throughout Bob’s childhood, is concerned about Bob’s recent drinking. Bob, however, has brushed off his father’s concerns. Drinking helps him to relax and makes it easier for him to participate in conversations about his deployment experiences. Otherwise, he would avoid such conversations altogether because even thinking about Iraq makes him anxious.
“Jane,” a 33-year-old Army reservist and stay-at-home mother of twin toddlers, just returned from her deployment to Iraq 6 month ago. Her hus- band of 5 years cared for their daughters during the 10-month deployment. Although Jane was comforted knowing that she and her husband had ade- quately prepared their family for her temporary absence, she still found it difficult to be away from them for so long and was particularly upset about missing her daughters’ first steps. She had a lonely experience while in Iraq, because she was not close to her fellow soldiers and constantly felt
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that she had to “prove” herself as a female soldier. The men she worked with seemed to think she was not capable of successfully carrying out her duties as an explosive ordinance disposal specialist because she was a woman. In several instances, men who had been assigned to work on her team com- plained about the assignment, and she overheard one man tell his peers, “She’ll spend too much time doing her hair and nails to get the job done!” She also overheard a few of the men making lewd jokes about her, which made her feel particularly uncomfortable given that she was raped in her early 20s. She did not report these experiences to her superiors because the soldiers never directly harassed her, and she was concerned that her superiors would not take her seriously if she complained. Although Jane was not injured while deployed, nor did she directly witness soldiers being injured, part of her job was to take detailed reports of American troops’ injuries and deaths related to explosives. Yesterday, her husband told her that she has been “different” since returning home. She is constantly irritable, easily loses her temper with the children, and seems distant from her family. When he asked if she would consider seeking professional help, Jane responded, “Only weak soldiers see shrinks—I’m fine!”
“Mike” is a married, 53-year-old National Guard veteran who, after 17 years of service and 3 years before his planned retirement from the mili- tary, was activated to serve in Iraq. Although the deployment was a surprise to both his immediate family and his family of origin, with whom he main- tains strong positive relationships, they were all supportive of his service. Despite this support, as well as his own pride in serving his country, Mike worried about his ability to keep up with the younger soldiers as an older “weekend warrior.” He had a difficult time while deployed. The climate was unbearably hot and dusty, and living conditions were crowded. Day-to-day living was a struggle for him, whereas his fellow troops, many half his age with previous deployment experience, appeared to acclimate much faster to the environment. Mike was sleep deprived and physically exhausted, and he felt he could not keep up with his younger peers. Despite having a good relationship with other unit members, he was preoccupied with what was occurring back home, given that his family had been experiencing financial strain before his deployment. Although he had some difficulty with moderate insomnia and mild irritability upon returning from deployment, within a couple of months, he felt back to “normal.” He received a job pro- motion, providing his family with more financial security, and he felt that his deployment experiences helped him realize how important his family was to him. He made an effort to spend more quality time with them and began to enjoy life more than he had before his deployment. Currently, however, he fears being deployed again and worries about the toll another deployment would take on him and his family.
UNDERSTANDING THE DEPLOYMENT EXPERIENCES OF OEF AND OIF VETERANS
A number of psychosocial factors from the predeployment, deployment, and postdeployment period may contribute to OEF and OIF veterans’ post- deployment mental health. The following sections review those factors that have been found to be most salient in prior research.
Predeployment Factors
Service members do not experience traumatic stressors in a vacuum, even though they may perceive and describe traumatic experiences as such. Each service member’s unique history of prior life experiences is likely to influence how he or she responds and adapts to deployment stressors. It is important to note that veterans struggling with the deleterious effects of deployment-related traumatic stressors may not be aware of the ways in which their predeployment experiences, such as prior trauma exposure, may affect their reaction to sub- sequent stressful experiences. Therefore, they may not volunteer information about such experiences during a clinical assessment.
Gathering information about a veteran’s history of exposure to stressful or traumatic life events can provide a basis for ascertaining what that veteran’s baseline propensity for developing posttraumatic sequelae may have been before deployment. We know, for example, that individuals who experience multiple traumas over their lifetimes are significantly more likely than those without such experiences to develop posttraumatic stress symptoms in response to sub- sequent trauma exposure (Vogt, King, & King, 2007). A careful assessment of the veteran’s history of highly stressful or traumatic life events, including exposure to community or domestic violence, physical assault, sexual abuse, emotional abuse, previous combat duty, loss of loved ones, and other highly stressful life events, is important when assessing the impact of deployment- related trauma on OEF and OIF veterans.
In considering Jane’s experience, for example, it appears that her expo- sure to male soldiers’ lewd jokes may have been bothersome, in part, due to her predeployment experience of rape in early adulthood. This is not to say that the jokes would not have bothered her if she did not have a rape history, but it is possible that this type of predeployment stressor may have primed her to perceive lewd jokes in a particularly threatening way. If we were to learn that Jane was not taken seriously by the police when she disclosed the rape, a further parallel could be drawn between her predeployment experience and her decision not to disclose her discomfort to her superiors while deployed, for fear of not being taken seriously. Further, such an experience could also be associated with Jane’s avoidance of acknowledging or seeking assistance
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for her postdeployment symptoms. Jane’s vignette demonstrates how an assess- ment of a veteran’s predeployment life stressors, including the manner in which the veteran perceived, interpreted, and reacted to such stressors, may aid a clinician in gaining insight into that veteran’s experience of and reaction to deployment stressors.
A second predeployment factor that clinicians should consider assessing is the veteran’s childhood family environment, particularly with respect to early experiences of cohesion, accord, and closeness in the family of origin. Research has consistently demonstrated that adverse childhood experiences, including childhood abuse, lack of social support, unstable living conditions, and parental interpersonal violence, are implicated in maladaptive stress responses and the development of PTSD in veteran populations (D. A. King, King, Foy, & Gudanowski, 1996; Schnurr, Lunney, & Sengupta, 2004). Moreover, childhood adversity, defined as the presence of mentally ill or alcoholic family members, exposure to domestic violence, childhood abuse, or a combination of these, has been shown to predict the development of PTSD above and beyond combat exposure alone (Cabrera, Hoge, Bliese, Castro, & Messer, 2007). This suggests that childhood adversity and, in particular, adverse childhood family functioning, may place service members at risk for the development of mal- adaptive reactions in response to deployment-related trauma. Conversely, the experience of a positive, supportive, and cohesive childhood family environ- ment has been demonstrated to act as a protective factor in the face of such stressors (McNally, Bryant, & Ehlers, 2003). This environment may provide children with the opportunity to internalize adaptive social, communication, and problem-solving skills, as well as to develop a perception of the world as generally safe and predictable. These skills and worldviews may, in turn, set the stage for adaptive functioning in response to stressful life events throughout adulthood.
Mike’s vignette provides a good example of the protective role that positive relationships within one’s family of origin may play. As noted in this vignette, Mike comes from a close family, and it is likely that positive family experiences during childhood contributed to his successful readjustment after returning from deployment through their impact on his ability to cope with the stress of deployment. Bob’s vignette describes his historically tumultuous relationship with a father, who struggled with alcoholism throughout Bob’s childhood. This history is representative of the type of childhood environment with the potential to increase one’s risk of reacting in maladaptive ways to stress, as evidenced by Bob’s tendency to drink when triggered by his friends’ conversations about Iraq. His adverse childhood experiences may have also increased his risk of developing PTSD symptoms later in life, particularly in response to deployment stressors. Bob does appear to be struggling with such symptoms, including reexperiencing (i.e., distress at traumatic reminders),
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avoidance (i.e. avoiding driving), and hyperarousal (i.e., difficulty sleeping), and further clinical assessment could potentially reveal that he meets full criteria for PTSD.
As this discussion illustrates, predeployment factors can make service members vulnerable to maladaptive stress reactions in response to deployment stressors in a variety of ways. Inclusion of these factors in clinical assessments of OEF and OIF veterans may help clinicians understand both how and why individual veterans respond in such unique ways to the various types of stressors they encounter while deployed, as well as assess the varying levels of stress or vulnerability to stress that the veterans “carry” with them into their deployment experiences.
War-Zone Deployment Factors
The type of stressors on which most clinicians are likely to focus when assessing OEF and OIF veterans are those most directly related to deployment, namely, direct combat experiences. Although combat experiences may, indeed, represent some of the most stressful experiences endorsed by veterans, many additional deployment-related stressors warrant clinical attention when assess- ing OEF and OIF veterans. In an attempt to provide a structure for a thorough assessment of such stressors, we propose that these stressors may be conceptu- alized as belonging to two distinct categories: mission-related and interpersonal stressors. Mission-related stressors reflect stressful or traumatic experiences associated with the specific tasks and activities of deployment, as in the case of combat missions and associated warfare-related stressors. Interpersonal stressors, in contrast, refer to stressful or traumatic experiences that are associated with being separated from friends and family, as well as having to work and live in close quarters with other service members. Notably, both of these stressor cate- gories have been demonstrated to be significantly associated with posttraumatic symptoms after deployment (L. A. King, King, Vogt, Knight, & Samper, 2006; Vogt, Samper, King, King, & Martin, 2008).
Mission-related stressors include combat experiences traditionally asso- ciated with warfare, as well as exposure to the aftermath of battle. Examples of combat experiences that OEF and OIF veterans are likely to endorse include being attacked or ambushed, shooting or directing fire at the enemy, witnessing injury or death, and participating in special missions, patrols, or invasions that involved these experiences. Exposure to the aftermath, or consequences, of battle may involve events such as observing or handling human remains, as well as observing other consequences of combat, such as devastated com- munities and homeless refugees.
Both Bob’s and Jane’s vignettes describe their exposure to combat expe- riences and the aftermath of battle, with Bob having witnessed his friends’
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IED-related injuries and the shooting of a civilian boy and Jane having taken detailed reports of service members’ injuries or deaths. Bob’s experiences of combat and related aftermath consequences were more direct than Jane’s because he personally witnessed the events when they occurred and had a personal relationship with the victims of the IED explosives, whereas Jane was informed about injuries or deaths of services members she did not personally know. Because research has demonstrated that both proximity to traumatic events (American Psychiatric Association, 2000) and having a close relation- ship with the victim(s) of such events (Ziaaddini, Nakhaee, & Behzadi, 2009) increase an individual’s risk of developing PTSD, it is possible that Bob’s experience may have placed him at particularly high risk for PTSD. Clinicians should be cautioned, however, not to underestimate the potential deleteri- ous effects of more indirect trauma exposure, as in Jane’s vignette. Because of the nature of her job, Jane may have actually experienced a longer duration of such exposure, and research has shown that prolonged exposure to trauma is also asso- ciated with posttraumatic sequelae (American Psychiatric Association, 2000).
Combat experiences and exposure to the aftermath of battle represent objective events and circumstances and do not include personal interpretations or subjective judgments of these experiences. However, factors that rely heavily on veterans’ emotional or cognitive appraisal of such experiences, regardless of whether these appraisals accurately represent reality, should also be captured in the assessment. In defining the type of traumatic event that qualifies for a diagnosis of PTSD, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition—text revision (DSM–IV–TR; American Psychiatric Association, 2000) describes such an event as having “threatened death or serious injury, or a threat to the physical integrity of oneself or others” (p. 467), a description that appears to capture the concept of an objective stressor. The DSM–IV–TR also describes the individual’s response to that objective stressor as having “involved intense fear, helplessness, or horror” (p. 467), which seems to reflect the more subjective aspects of an individual’s experience. Notably, a person’s appraisal of potentially traumatic events is associated with that person’s risk of developing PTSD in response to that event (L. A. King, King, Bolton, Knight, & Vogt, 2008), which points to the importance of addressing subjective factors in clinical assessments of OEF and OIF veterans.
Consistent with this perspective, clinicians are encouraged to attend to a veteran’s level of perceived threat during deployment, reflected in the extent to which a veteran feared for his or her safety and well-being while deployed, particularly in response to the types of mission-related stressors previously discussed. Some examples of perceived threat include the fear of being unsafe, attacked, or exposed to either enemy or friendly fire, as well as concerns about encountering IEDs or becoming sick in response to vaccina- tions, pesticides, or pollution. Bob’s fear of encountering IEDs in the road
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illustrates a perceived threat that is common among deployed OIF veterans. Because he personally witnessed his friends being injured by explosives, his fear of being harmed by an IED was likely rooted in a threat that was realistic while he was in Iraq. He continues to perceive this threat after returning to the United States, however, where he is significantly less likely to encounter explosives, and that perception in turn results in his avoidance of driving. Jane’s story provides another example of perceived threat in that she may have perceived the soldiers’ lewd jokes as threatening, particularly given her history of sexual assault. Although we do not have evidence that these soldiers intended to assault Jane or that she was otherwise physically unsafe, her mental state of feeling unsafe may have negatively affected her experience of and reaction to the variety other stressors she encountered while deployed.
Clinicians should also be cognizant of veterans’ exposure to lower level stressors that may not qualify as traumatic events per se but that may render veterans more vulnerable to maladaptive stress reactions. Veterans’ experience of difficult living or working environments may cause significant stress in and of themselves, as well as contribute to difficulty coping with other stressful or traumatic events experiences during deployment (L. A. King et al., 2006). Examples of difficult living and working environments that OEF and OIF veterans may report include uncomfortable climates, loud noises, crowded workspaces, long workdays, exhaustion, and lack of daily living resources (e.g., clean clothes, quality food, showers). The day-to-day stress that some OEF and OIF veterans face as the result of such difficult environments may have deleterious effects, rendering them less likely to respond adaptively to the other deployment-related stressors with which they must contend. It is notable that this particular stressor may be objective or subjective in nature (or both), in that some veterans may be exposed to objectively difficult living or working environments, whereas others may subjectively perceive their environments to be more difficult than their peers would. Mike’s story illustrates this type of daily stress in that he regularly struggled with an uncomfortable climate and poor living conditions, in addition to feeling constantly exhausted during his deployment. Although his peers are described as adapting more easily than Mike to their environment, Mike’s subjective perception of the environment as difficult may have impeded his ability to do his job successfully while deployed, as well as potentially strained his ability to deal adaptively with other deployment stressors.
Mike’s vignette also exemplifies his perception of feeling unprepared for deployment, which is another mission-related stressor worthy of clinical attention. In addition to perceptions of the adequacy of training for the deployment experience, the concept of deployment preparedness refers to the perceived availability of necessary supplies, equipment, and protective gear during deployment. The extent to which service members feel prepared for
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deployment may also depend on the congruence between what they expected to occur during deployment and their actual experiences while deployed.
In addition to the aforementioned mission-related stressors, veterans may also experience a range of interpersonal stressors during deployment. Such interpersonal stressors include concerns about life and family disruptions related to deployment, general or sexual harassment, and lack of social support from military peers and leaders while deployed. As with mission-related stressors, service members may directly experience some of these interpersonal stressors as traumatic in nature, or the stressors may play a more indirect role in increasing service members’ risk of maladaptive reactions to other deployment stressors.
Both Mike’s and Jane’s vignettes describe their experience of family- related concerns during deployment. Whereas Mike worries about his family’s financial stability, Jane is distressed about missing her children’s development and other important family events. These are examples of interpersonal stres- sors that often receive little attention in clinical assessment of OEF and OIF veterans but that may serve to distract service members from their deployment duties and generally disrupt their day-to-day functioning during deployment. Service members may worry about the deleterious effects of deployment on their relationships with significant others, as well as about their inability to be avail- able to loved ones to offer them assistance, support, or care. These concerns may be exacerbated by deployment circumstances that render service members unable to communicate easily with loved ones back home. In addition, some National Guard and Reservist service members may worry about losing out on job advancement opportunities and experience deployment as negatively affecting their career advancement.
Another key interpersonal stressor that may have an impact on OEF and OIF veterans’ adjustment during and after deployment is harassment, a term encompassing both general and sexual harassment. General harassment refers to harassment that is nonsexual in nature but that may occur on the basis of sex, gender role, race, ethnicity, or other personal characteristics. Examples of such harassment include indirect resistance to one’s authority, deliberate sabotage, indirect threats, and constant scrutiny. Sexual harassment includes unwanted sexual contact or verbal conduct of a sexual nature by other service members, commanding officers, or civilians in the war zone. Such harassment can range on a continuum from gossiping about the service member’s sex life to sexual assault or rape. Both general and sexual harassment can contribute to a hostile working environment and generally make day-to-day life unpleasant. In the extreme, serious forms of harassment, such as sexual assault, are often experienced as traumatic by the service member and, in turn, may lead to post- traumatic sequelae. Although both men and women are at risk of experiencing sexual harassment while deployed, research has consistently demonstrated that
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women are more likely to report military sexual harassment (e.g., Kimerling, Gima, Smith, Street, & Frayne, 2007). Studies investigating the prevalence of military sexual trauma have reported that approximately one quarter (Hankin, Spiro, Miller, & Kazis, 1999) to one half (Katz, Bloor, Cojucar, & Draper, 2007) of all female veterans endorse having had such experiences.
Jane’s vignette depicts a deployment experience encompassing both general harassment, with respect to her male colleagues’ complaints about having to work with her because she is a woman, as well as sexual harassment, given the lewd jokes they make about her. As previously discussed, these harass- ing experiences may cause her to feel threatened by her own unit members (i.e., perceived threat), in the context of her rape history (i.e. a predeployment stressor). Jane’s experience provides an example of how the interplay of various predeployment and deployment stressors may increase an individual’s vulnera- bility to poor mental health outcomes in response to deployment stress exposure.
Jane’s deployment experiences further illustrate the importance of social support from military peers and leaders, which is another interpersonal factor that clinicians should consider when assessing OEF and OIF veterans. Social support has been demonstrated to act as a protective factor in many studies that have examined the impact of stressors on mental health outcomes, and thus it is no surprise that social support experienced during deployment can buffer the impact of stressful experiences on service members (L. A. King, King, Fairbank, Keane, & Adams, 1998). Conversely, a lack of social support can lead to poor mental health outcomes after deployment and, interestingly, this association has been found to be particularly strong for female veterans (Vogt, Pless, King, & King, 2005). In deployment contexts, social support refers to assistance and encouragement in the war zone by the military in general (e.g., feeling valued by the military), unit leaders (e.g., perceiving leaders as trustworthy and dependable), and other unit members (e.g., feel- ing a sense of camaraderie with peers). If we consider Jane’s experience, which entailed her feeling lonely, being harassed by peers, and not perceiving her superiors as sufficiently trustworthy to disclose her concerns about these issues, we can logically conclude that her deployment experience was unsupportive. We can further infer that exposure to such an unsupportive deployment envi- ronment may have made it particularly difficult for Jane to deal adaptively with the additional stressors she may have experienced while deployed. In contrast, Mike’s vignette illustrates the role of positive experiences of social support. Though Mike experienced his deployment as extremely stressful in many ways, the fact that he had good relationships with his peers may have contributed to an easier adjustment after returning from deployment.
In this section, we have presented a conceptualization of deployment stressors that includes both mission-related and interpersonal stressors, the latter of which may sometimes be overlooked in standard clinical assessments
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of OEF and OIF veteran populations. We now turn our attention to two postdeployment factors that may also play a role in veterans’ adjustment following deployment.
Postdeployment Factors
The transition back home from deployment can be a difficult one for many veterans, and the nature of this transition may have important clinical implications for veterans’ postdeployment adjustment. Here, we focus on two key postdeployment factors, namely, postdeployment stressors and social support, both of which have been demonstrated to be associated with post- deployment mental health outcomes (Vogt et al., 2007).
Exposure to additional life stressors in the postdeployment period may interfere with the normative recovery process of a veteran who has experienced deployment stress. When assessing postdeployment stressors, clinicians should consider gathering information about general stressful life events that are unrelated to deployment, such as physical or sexual assaults, serious illness or death of loved ones, and vehicular accidents, in addition to events that may be more directly related to reintegration, such as unemployment, legal or financial problems, divorce, and family conflict. Bob’s vignette describes the difficulty he experiences maintaining a job after returning from deployment because of his drinking, which represents one example of the type of post- deployment stressor some OEF and OIF veterans may experience. Mike, in contrast, appears to experience an easier transition. He gets a promotion at work, looks forward to spending more time with his family, and does not face any major stressors when he returns, which bodes well for his postdeployment prognosis.
A second important postdeployment factor likely to be associated with postdeployment adjustment is the extent to which family, friends, coworkers, and employers, as well as the community more generally, provide emotional sustenance and instrumental assistance, or social support, to service members when they return from deployment. Emotional sustenance reflects the extent to which these individuals provide compassion, companionship, a sense of belonging and general positive regard, whereas instrumental assistance refers to the provision of more tangible assistance in the form of resources, materials needs, and help with accomplishing tasks. The importance of social support with respect to the deployment period was discussed earlier, and its importance applies to the postdeployment adjustment period as well. Mike’s story stands out as representing a veteran’s experience of returning to a supportive family environment, and therefore it is not surprising that he not only quickly reintegrates into his life back home but even appears to enjoy life more than he had before deployment. Bob’s postdeployment experience seems to represent a
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more mixed experience, in that he moves back home with his father, with whom he has not had a good relationship, suggesting that he may not be a good source of support for Bob. Additionally, whereas Bob may perceive his veteran friends as supportive, the fact that he has to drink to tolerate conver- sations with them is problematic and suggests that they may not provide Bob with sufficient emotional support.
Both of the stressors presented here overlap with factors presented earlier in this section. Specifically, postdeployment stressors are analogous to predeployment stressors, and postdeployment social support parallels the concept of deployment social support. Such overlap points to the importance of assessing the cumulative effect of stressors on service members over time, beginning with the predeployment timeframe (as early as childhood) and moving throughout the deployment time period into the postdeployment time frame. Assessment of deployment stressors in isolation may not provide clinicians with the depth of understanding they are likely to attain by conduct- ing a more longitudinal assessment.
In the next section, we turn to the assessment of PTSD and associated sequelae of deployment stress and trauma exposure, using the previously presented vignettes to illustrate postdeployment health problems that may be especially salient for OEF and OIF veterans.
TRAUMA AND PTSD ASSESSMENT
Many factors must be considered to ensure an adequate assessment of PTSD and associated comorbidity. These factors are discussed in the following subsections and summarized in Table 3.1.
Initiating the Assessment and Setting the Context
Given the sensitive nature of the experiences that will be disclosed, along with the fact that service members may be wary of mental health professionals, it is critical that clinicians begin a PTSD assessment with a focus on establish- ing rapport and building trust with the veteran. An important first step in this process is to emphasize the collaborative nature of the assessment. Developing this sense of shared purpose might begin by soliciting information from the veteran about what he or she hopes to accomplish by participating in the assessment and including this perspective when talking about what the assess- ment is intended to achieve. The clinician should describe what will happen during the assessment and how the assessment fits with the veteran’s desire for practical help with problems. An explanation about the role of assessment in determining treatment priorities and setting treatment goals can facilitate
the veteran’s commitment to the assessment process. After establishing this shared vision, the session should shift to a more intense, data-gathering mode, with the focus on the recent history of the presenting problem(s), including any current stressors and crises. A thorough risk assessment should be conducted to evaluate the possible presence of suicidal and homicidal ideation, violent and aggressive behaviors, and substance-related problems. This information can then be used to inform the development of a treatment plan.
Importance of Comprehensive Assessment
Just as service members do not experience traumatic stressors in a vacuum, they also do not undergo assessment and treatment planning in one. Their efforts at reintegration are likely to consume significant psychological, physical, and emotional resources that can interfere with their willingness to engage in an extensive assessment process. From a clinician’s perspective, a comprehen- sive assessment of psychological functioning takes time, and clinicians may have legitimate concerns about delaying the start of treatment or worry that veterans may terminate treatment prematurely if the assessment process is too onerous. One way to address these concerns is to use an abbreviated assessment
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battery. However, there are important advantages to a more comprehensive assessment.
First and foremost, an abbreviated assessment may not provide clinicians with the depth of understanding they are likely to gain through a more com- prehensive assessment. By its very nature, the abbreviated assessment requires clinicians to selectively limit the number and type (structured interview vs. self-report) of instruments used, the breadth of the diagnostic evaluation, and the assessment of other domains of functioning that may materially affect case conceptualization and treatment planning. The resultant treatment plan may not accurately reflect the veteran’s individual experience.
Second, a comprehensive assessment that incorporates basic psycho- education about issues of concern to the veteran can enhance veterans’ com- mitment to treatment. Continued engagement provides veterans an opportunity to build rapport with and trust in the assessment clinician and to garner much- needed empathy and compassion. Emotional support plays an important role in postdeployment adjustment, and, to the extent that veterans are unable to access sufficient social support in their daily lives, the therapeutic relationship can provide much-needed support.
Finally, a comprehensive assessment can serve to demystify the psycho- therapy process as well as reduce the anxiety that often accompanies early work in psychotherapy. These experiences can be the building blocks of a strong working alliance and may serve the veteran well throughout both the assessment and treatment process.
Risk and Resilience Factors
As previously discussed, clinicians should be encouraged to conduct assessments of OEF and OIF veterans’ history in a manner that will capture the complexity of the various risk and resilience factors veterans may have experienced before, during, and after deployment. In turn, thorough assessments of these factors can provide a more integrated clinical picture of veterans’ deployment experiences and related sequelae. The Deployment Risk and Resilience Inventory (DRRI; L. A. King et al., 2006; the DRRI is available at http://www.ncptsd.va.gov/ncmain/assessment/drri_intro.jsp) is one tool that may be especially useful in this regard, given that these scales were constructed to explicitly assess each of the factors presented in the model described earlier in this chapter. The scales are designed so that they may be administered as a set or individually, giving clinicians the option to select the scales that are most relevant for their particular assessment goals. The full inventory takes approximately 40 min to complete, and individual scales can be completed in 2 to 3 min. Although there are currently no clinical cutoff scores for the DRRI, these scales may be administered as part of the intake process and can
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provide a useful starting point for a more in-depth discussion of factors that contribute to current symptomatology.
Identifying the Criterion—A Event
The first step in assessing PTSD is to establish that the traumatic event described by the veteran qualifies as a Criterion A event, as defined by the DSM–IV–TR (American Psychiatric Association, p. 467). A qualifying event must meet the following two criteria: “(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (p. 467); and “(2) the person’s response involved intense fear, helplessness, or horror” (p. 467). The Traumatic Events Questionnaire (TEQ; Vrana & Lauterbach, 1994), which has demonstrated good test–retest reliability (Vrana & Lauterbach, 1994), is one measure that can assist clinicians in deter- mining whether the event described by the veteran qualifies as a Criterion A event. For each of 11 specific traumatic events, the TEQ inquires about fre- quency and age at occurrence, as well as to what extent the respondent expe- rienced the event as traumatic. Individuals often endorse more than one qualifying event, thereby creating uncertainty as to which traumatic event should be the focus of the PTSD assessment. Bob, for example, witnessed his friends being injured by IEDs and the shooting of an Iraqi civilian boy. Either or both of these experiences may be related to his PTSD symptoms. For situations in which multiple qualifying events are endorsed, clinicians should ask the veteran to identify the event that continues to cause her or him the most distress, and that event should be used as the index trauma for assessment purposes. This will facilitate the transition to subsequent treatment in which contemporary cognitive–behavioral therapies for PTSD, such as cognitive processing therapy and prolonged exposure, focus on one event at a time. In cases of patients with histories of multiple traumas, it is important for the psychotherapist to remain cognizant of the legacy of these other events and address them in treatment as the focus shifts over time.
Structured Clinical Interviews
After the clinician has identified the index trauma, a structured clinical interview can be administered. Structured interviews are preferred because they yield more accurate diagnoses than unstructured psychiatric interviews (Miller, Dasher, Collins, Griffiths, & Brown, 2001), can be helpful in track- ing client progress during treatment, and may lead to improvements in treat- ment outcome (Lambert et al., 2003). Two well-validated clinical interviews for the assessment of PTSD include the Clinician Administered PTSD Scale
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(CAPS; Blake et al., 1995) and the Structured Clinical Interview for DSM–IV (SCID; First, Spitzer, Gibbon, & Williams, 1996). These interviews are especially well suited to the assessment needs of veterans because both measures have demonstrated adequate to excellent reliability and validity for veteran populations (Keane et al., 1998; McFall, Smith, Roszell, Tarver, & Malas, 1990; Weathers, Keane, & Davidson, 2001). The CAPS is a partic- ularly useful tool for conducting an in-depth assessment of the three primary PTSD symptom clusters (i.e., reexperiencing, avoidance and numbing, and hyperarousal symptoms) described in the DSM–IV–TR. Using a Likert-type response format to rate both the frequency and intensity of each of 17 PTSD symptoms, the CAPS allows for the assessment of both current and lifetime PTSD status, which may be helpful in assessing chronic PTSD. It is impor- tant to note that the CAPS also addresses other symptoms often associated with PTSD, including trauma-related guilt and dissociation. In addition, it allows for ratings of subjective distress, as well as social and occupational impairment, which contribute to an understanding about the functional impact of the traumatic sequelae.
Although the CAPS allows for an in-depth assessment of PTSD, the SCID-PTSD module may be a more practical assessment tool for clinicians with time constraints. The PTSD module can be administered in 15 to 45 min depending on the complexity of the veteran’s clinical presentation, whereas the CAPS usually requires an hour to administer. The SCID (First et al., 1996) is a widely used structured clinical interview organized into separate modules for each DSM–IV Axis I disorder. The PTSD module is a 21-item structured interview corresponding to DSM–IV criteria for PTSD, in which symptoms are rated to reflect their absence or presence at a subclinical or clinical level. Given high rates of comorbidity between PTSD and other Axis I disorders (Breslau, Davis, Andreski, & Peterson, 1991; Breslau, Davis, Peterson, & Schultz, 2000; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kulka et al., 1990), another advantage of the SCID is the availability of modules that assess for mood, anxiety, and alcohol use disorders. Unlike the CAPS, however, the SCID does assess symptom frequency or severity.
The specific assessment goals and the unique clinical presentation of each veteran help determine which clinical interview to employ. Given Bob’s symptoms of hypervigilance, nightmares, and avoidance, for example, the CAPS might be preferable because it can provide a thorough assessment of the frequency and intensity of his symptoms, as well as of the impact of these symptoms on his daily functioning. Because Jane has a history of rape in her early 20s and was then exposed to deployment-related stressors a decade later, the CAPS could be a useful tool with which to assess PTSD symptoms over different periods in her life. In Mike’s case, the SCID might be a more efficient use of time and resources because it is not immediately apparent
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whether Mike experienced a Criterion A event or whether he is currently experiencing PTSD symptoms.
Self-Report Measures
Many reliable and valid self-report measures are available for the assess- ment of PTSD symptomatology. Self-report measures, as adjuncts to struc- tured clinical interviews, can provide useful information about domains of interest. The PTSD Checklist (PCL; Weathers, Litz, Huska, & Keane, 1991) is a 17-item self-report measure with items that correspond directly to DSM–IV diagnostic criteria for PTSD. The PCL, which takes approximately 5 to 10 min to administer, can be used as both a screening tool for PTSD and as a measure of symptom severity. The veteran rates how bothered he or she has been by each symptom over the past month using a Likert-type response format. A cutoff score is then employed to identify the probable presence of PTSD. Because it takes a fairly short period of time to administer, the PCL lends itself to tracking treatment progress over time and can be administered at the outset of each treatment session to monitor changes in symptom severity. The PCL has been validated with populations of veterans, car accident survivors, and sexual assault survivors (Smith, Redd, DuHamel, Vickberg, & Ricketts, 1999; Weathers, Litz, Herman, Huska, & Keane, 1993). It has demonstrated adequate test–rest reliability (Ruggiero, Del Ben, Scotti, & Rabalais, 2003) and has been shown to have good sensitivity and specificity in identifying PTSD in soldiers returning from combat (Bliese et al., 2008).
The Mississippi Scale for Combat-Related PTSD (Keane, Caddell, & Taylor, 1988) is a 35-item self-report measure for combat veterans that assesses most of the DSM–IV PTSD criteria, as well as other symptoms frequently associated with PTSD, including substance abuse, suicidality, and depression. The measure, which has demonstrated excellent test–retest reliability, sensi- tivity, and specificity (Keane et al., 1988), takes approximately 10 to 15 min to administer. Respondents are asked to report on the severity of symptoms “since the event,” and, as with the PCL, a cutoff score can be used to indicate the probable presence of PTSD. A noncombat version of the measure, the Civilian Mississippi Scale for PTSD (Norris & Perilla, 1996), which has been validated in community samples, may be useful for assessing noncombat-related PTSD symptoms.
When possible, collateral information from family or friends can provide valuable information about veterans’ symptoms. Their observations and per- ceptions can shed additional light on the functional impact of these symptoms. Of course, acquisition of collateral information requires the consent of the veteran, which may be facilitated through a discussion of the perceived benefits of such information. Ideally, this information would be obtained through
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in-person interviews, but collateral self-report measures can also be used. The Collateral Mississippi Scale for PTSD (Kulka et al., 1990), which is the spouse–partner–family member version of the Mississippi Scale, is one of the few collateral measures that have demonstrated adequate reliability, specificity, and sensitivity.
If time and resources permit, the Minnesota Multiphasic Personality Inventory (MMPI–2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) may be indicated for veterans with more complicated clinical presen- tations. The MMPI–2 includes a 46-item, empirically derived PTSD scale (Keane, Malloy, & Fairbank, 1984; Lyons & Keane, 1992), which has demon- strated good test–retest reliability (Herman, Weathers, Litz, & Keane, 1996). This scale is unique in that it is less face-valid than other measures of PTSD, such that veteran’s responses are less likely to be influenced by social desirabil- ity or other response biases. The PTSD scale, which is highly correlated with other self-report measures of PTSD (Herman et al., 1996), can be admin- istered in conjunction with other scales from the MMPI or as a stand-alone instrument. In addition, the MMPI–2’s validity scales can provide useful information about potential over- or underreporting of symptoms. Clinicians should interpret the MMPI–2’s validity scales with caution, however, given that combat veterans with severe symptoms may respond in a manner that is consistent with a “fake-bad” response, raising questions about whether these scores reflect elevated psychopathology or overreporting (Frueh, Hammer, Cahill, Gold, & Hamlin, 2000). These extreme symptom elevations may genuinely reflect the sequelae of being exposed to traumatic events. As with the use of other self-report measures, it is important that these data are inter- preted within the context of other sources of information.
Assessment of Comorbidity
In populations of veterans who have been diagnosed with PTSD, studies report rates of comorbidity with other Axis I disorders ranging from 50% to 92% (Brown, Campbell, Lehman, Grisham, & Mancill, 2001; Kulka et al., 1990; Orsillo et al., 1996). PTSD also frequently co-occurs with Axis II disorders, as demonstrated by studies that have assessed the full range of range of comor- bid personality disorders in samples of individuals with PTSD. For example, among a group of veteran inpatients with PTSD, Bollinger and colleagues (2000) found that 79% of their sample met criteria for an Axis II disorder, including avoidant (47%), paranoid (46%), obsessive–compulsive (28%), and antisocial (15%) personality disorders. PTSD comorbidity can complicate assessment and treatment because individuals with comorbid Axis I or Axis II disorders (or both) tend to have more severe PTSD symptoms (Back, Sonne, Killeen, Dansky, & Brady, 2003; Brady & Clary, 2003; Zayfert, Becker, Unger,
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& Shearer, 2002) and may be less likely to respond well to treatment (Cloitre & Koenen, 2001; Zlotnick et al., 1999). Thus, an assessment of comorbid psychiatric disorders is an important component of any comprehensive assessment.
As a practical and time-effective way to assess for potential comorbid disorders, use of a screening measure is recommended. The SCID (First et al., 1996) offers a semistructured screening and history section that can provide information about possible comorbid conditions and the context in which the veteran’s presenting complaint occurs. This screen includes probe ques- tions that explore etiological factors, as well as previous coping and treatment efforts. If there is reason to suspect the presence of personality pathology, clinicians may also consider administering the self-report screening question- naire (SCID–Q) included in the Structured Clinical Interview for DSM–IV Axis II Personality Disorders (SCID–II; Spitzer, Williams, Gibbon, & First, 1990). As a follow-up to the SCID–Q, clinicians may selectively administer relevant modules of the SCID–II to assess for specific personality disorders. The Symptom Checklist—90—Revised (SCL–90–R; Derogatis, 1983) is a time-saving measure that allows for the assessment of a broad range of psychi- atric symptoms. This self-report inventory, which takes approximately 12 to 15 min to administer, requires respondents to rate how much they are both- ered by 90 psychiatric symptoms using a 5-point Likert-type response format, ranging from not at all to extremely.
Beyond diagnostic symptoms and syndromes, individuals with PTSD often present with other problems that cause functional impairment and require clinical attention. Three factors that warrant special consideration when assessing veterans are an avoidant coping style, anger management problems, and substance abuse. Information about these factors can be obtained through both formal and informal means, including the use of structured and unstructured interviews and self-report measures. If the assessment takes place over multiple sessions, patients can be assigned self-monitoring tasks, similar to cognitive–behavioral homework assignments, which can provide more salient information than retrospective reporting about these factors.
Knowledge about a veteran’s coping style can provide relevant infor- mation about how the individual manages stress. Veterans may employ a wide variety of coping strategies, including suppression, avoidance, active problem solving, or accessing social support. Because research shows that nonavoidant coping styles are associated with better psychological functioning for Vietnam veterans with PTSD (Wolfe, Keane, Kaloupek, Mora, & Wine, 1993), an avoidant coping style may serve as early target for clinical intervention.
Veterans with PTSD are likely to present with significant anger regulation difficulties (Taft & Niles, 2004). Anger dysregulation may have deleterious effects on many domains of a veteran’s life, including his or her social and
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occupational functioning, and at extreme levels may be associated with violent behavior and related legal consequences. Therefore, a detailed understanding of the manner in which a veteran experiences, expresses, and copes with anger may be critical for effective treatment planning. One widely used self-report measure, the State–Trait Anger Expression Inventory (STAXI; Spielberger, 1988), contains subscales that distinguish between state and trait anger, as well as between the experience and expression of anger. This measure can be used to identify whether individuals are likely to express anger overtly versus contain it, as well as assess their ability to manage feelings of anger effectively.
Alcohol or drug abuse may be a preexisting problem for some veterans or may arise as a result of the significant stressors experienced during the deployment or postdeployment period. Veterans may begin drinking as a means to cope with uncomfortable emotions. In fact, the Millennium Cohort Study (Jacobson et al., 2008) found that Reserve and National Guard service members who endorsed combat exposure were at higher risk for new-onset heavy drinking, binge drinking, and alcohol-related problems compared with non- deployed service members. Notably, the youngest members of this cohort were at highest risk for all alcohol-related problems. The assessment of substance use problems can generally begin with informal questions about the veteran’s use of drugs and alcohol. If the veteran’s responses suggest significant sub- stance use, a more formal screening measure can be employed. The CAGE questionnaire (Ewing, 1984), which was designed to screen for alcohol use but can be adapted for drug use, can elicit information regarding the quantity and frequency of a veteran’s alcohol or drug use, as well as assess the functional impact of such use. For the purposes of diagnosing substance abuse and dependence disorder, the Substance Use Disorder Module of the SCID (First, Spitzer, Gibbon, & Williams, 1996) can be employed.
Other Factors to Consider
Two factors that might have a significant impact on treatment outcome are resistance to change and motivation to change. Among military veterans, there may be unique factors that promote resistance to mental health treat- ment. Their military training and experiences may promote self-reliance and facilitate the belief that seeking help is a sign of weakness. This issue was raised in Jane’s vignette when she expressed concern that going to a “shrink” would mean that she was weak and unable to deal with her own problems. Consistent with this perspective, in a study by Hoge et al. (2004), OEF and OIF veterans reported concern that they would be stigmatized by peers and leaders if they sought help for mental health problems. Particularly emblematic is the finding that OEF and OIF soldiers who screened positive for psychiatric disorders were twice as likely to report concerns about being seen as weak or
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harming their career compared with those without psychiatric disorders. Furthermore, among those who screened positive for a psychiatric disorder, 38% reported that they did not trust mental health professionals. Being aware of these concerns, clinicians can offer reinforcement for veterans’ efforts to seek support. From a practical standpoint, OEF and OIF veterans often have to juggle full-time jobs and family responsibilities that interfere with their ability to attend sessions regularly or to attend sessions that are only available during a 9-to-5 workweek. Scheduling flexibility may facilitate the assessment process and increase the likelihood that the veteran will follow through with treatment recommendations. In addition, motivation to change may be enhanced by building on the existing strengths of patients. For example, to the extent that a patient has supportive family members, enlisting their involve- ment in treatment may be particularly beneficial. Cognitive–behavioral conjoint therapy for PTSD (Monson, Fredman, & Adair, 2008; Monson, Schnurr, Stevens, & Guthrie, 2004) is an example of a treatment that involves family members in the treatment of PTSD.
The transtheoretical model (Prochaska, DiClemente, & Norcross, 1992) provides a mechanism for assessing motivation to change, particularly as it applies to one’s willingness to initiate and engage in treatment. The model explicates five stages of change: precontemplation (i.e., being unaware of or denying the problem), contemplation (i.e., considering change), preparation (i.e., taking initial steps), action (i.e., changing behavior), and maintenance (i.e., sustaining changes over time). An assessment of the veteran’s stage of change may be carried out in an unstructured manner by asking her or him which of the symptoms or problems identified during the assessment she or he considers to be problematic. Veterans might also be asked which symptoms or problems their friends, loved ones, or supervisors have told them they need to work on. Once the veteran identifies the key problem(s), follow-up questions can be asked to determine what steps, if any, have been taken to address these problems. Alternatively, a questionnaire may be employed to assess the veteran’s motivation to change. The University of Rhode Island Change Assessment (McConnaughy, Prochaska, & Velicer, 1983), for example, is an instrument that assesses general motivation for psychotherapy, as well as an individual’s motivation to change specific problems, such as problematic substance use behaviors. Notably, evidence suggests that veterans’ motivation to work on symptoms in treatment may be problem-specific (Rosen et al., 2001). Using our clinical vignettes as an illustration of this phenomenon, Bob might be in the precontemplative stage of change with respect to his drinking behavior but in the preparation stage with respect to his PTSD symptoms. Clinicians should consider the level of motivation for change on treatment planning. For example, Bob may be willing to engage in combat-related exposure-based therapy to address his PTSD symptoms, but he may not be willing to talk about
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the negative consequences of his alcohol use or acknowledge the link between his alcohol use and PTSD symptoms. An assessment of the veteran’s motivation for change can provide a clinician with useful information regarding the appro- priateness of employing specific motivational enhancement techniques, such as motivation interviewing, as a component of the veteran’s treatment plan.
In conclusion, a comprehensive assessment of PTSD facilitates the development of a clinical case conceptualization and salient treatment plan. Conducting such an assessment requires an in-depth understanding of not only the deployment-related experiences that increase a veteran’s risk for mental health problems but also the predeployment factors that affect veterans’ reactions to trauma experiences. A thorough assessment of related factors, including veterans’ coping skills and motivational factors, allows for a treatment plan that is tailored to the unique characteristics and life experiences of the individual veteran. Further, it provides essential information about veteran’s motivation to change, particularly as it applies to her or his willingness to initiate and engage in treatment. Assessment and treatment planning should be considered an ongoing process rather than a one-time event. Treatment priorities are likely to change over time, given that factors such as symptom severity, functional impairment, and stage of change rarely remain static. Ongoing assessment of these factors across time is an essential part of providing