When conducting assessments for trauma as a psychologist, it is important to have a plan in place on the provision of mental health services and resources for the client or participant. Those participants who screen as having posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), acute stress disorder (ASD), or who may not qualify for a disorder but still have significant symptoms in amount or severity should be referred for more in-depth assessments or treatment. The International Society for Traumatic Stress Studies (ISTSS) (Forbes et al., 2020) suggests treatments of varying evidence bases for recommendations. This also aligns, and in some cases conflicts, with ethical standards as proposed by the American Psychological Association (APA) (2017) and the International Union of Psychological Science (IUPS) (2008). However, a crucial consideration is the barriers to such treatments, such as cultural factors, socioeconomics, and available resources, which may be difficult to access in some areas of the world.
Trauma assessments could occur in at least two different scenarios, either within the context of a research assessment, or in a clinical environment. In a research context, the APA’s Ethical Principles of Psychologists and Code of Conduct (2017) states in section 8.08 that in order to reduce the risk of harm to participants, debriefing should occur quickly following the conclusion of the research. However, this is conflictual with debriefing as an early intervention in a clinical setting following assessment. The ISTSS (Forbes et al., 2020) reviewed evidence and found that debriefing interventions were largely ineffectual, including psychoeducation, in both individual and group interventions. It must be noted, though, that this was specific to those who had been exposed to trauma within the prior three months, and there appeared to be little research included for its use with survivors and refugees of civil war and genocide. This is relevant because the author of this paper, Emily Lutringer, is working to adapt the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) into cultural idioms of distress for Syrians, who have significant rates of multiple trauma exposures occurring for potentially over a decade (Hassan et al., 2015). In doing an assessment for research purposes, individuals may have been exposed to trauma longer than three months ago. ISTSS (Forbes et al., 2020) guidelines found strong evidence to recommend the following psychological treatments for adults with PTSD: cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT, and prolonged exposure.
In conducting clinical assessments, there may be clients who are recently exposed to trauma, and therefore could partake in prevention and early interventions if they show symptoms of trauma on the assessment. ISTSS (Forbes et al., 2020) found that single sessions of EMDR and Group 512 PM had emerging evidence to prevent or treat symptoms of PTSD. Brief dyadic therapy and self-guided internet-based interventions also showed emerging evidence for multiple-session prevention. Stronger evidence was found in early treatment multi-session interventions of trauma-focused CBT, cognitive therapy, and EMDR. Of pharmacological interventions, only hydrocortisone showed emerging evidence.
In any situation in which an individual screens positively for trauma symptoms or PTSD, there may be barriers to accessing the most effective treatments – or even any interventions at all. Firstly, the interventions proposed by ISTSS (Forbes et al., 2020) are primarily Western models, and may not be culturally appropriate in other contexts (Narvaez, 2019). While ISTSS (Forbes et al., 2020) offers a few treatments which may have limited efficacy which could be culturally accessible, such as acupuncture, it is notably lacking in covering the evidence for interventions from indigenous psychologies which would be highly culturally relevant.
Another serious concern is the lack of access, such as low rates of mental health providers, remote areas, high demand with limited availability, and socioeconomic factors (Patel, 2007). Rojas et al. (2019) found that mental health care could be utilized in such situations through the use of internet-based interventions in a variety of formats, such as virtual counseling, phone apps, and specialized video games. As more people worldwide have access to the use of internet and cellphones, these interventions could reach larger populations and at lower costs. There are two caveats to this, though. Firstly, there are still many areas of the world without such internet or cell phone access. Secondly, internet and phone-based interventions appear to have mixed results in their effectiveness, although ISTSS was able to give a standard recommendation for the use of guided internet-based trauma-focused CBT in adults diagnosed with PTSD (Forbes et al., 2020).
Other barriers include stigma and poor mental health literacy (Wong et al., 2019). For example, Syrians typically hold strong stigmas around mental health and may be afraid to seek help for how others may judge them or their families (Hassan et al., 2015). Wong et al. (2019) had positive results in their pilot study evaluating the reduction of stigma through a mental health course in Hong Kong. Similar strategies for psychoeducation and normalization may be valuable when working with people in high-stigma cultures, as they may otherwise resist any PTSD intervention.
Any mental health resources should include facilities or providers who have experience working with the specific population, to meet the ethical standard of competency (APA, 2017; IUPS, 2008). A researcher would ideally, finding an option that participants could engage in immediately after the study if they chose would allow them to process any trauma that came up without a waitlist. As the assessments are specifically measuring for trauma, a participant may suddenly become aware for the first time that they are suffering from a mental illness and may need immediate support. Furthermore, providing exceptional mental health and other resources is critical to preventing the re-enactment of trauma or intergenerational trauma which could lead to a continued cycle of violence (van der Kolk & McFarlane, 1996). It constitutes the ethical responsibilities of beneficence and nonmaleficence, fidelity and responsibility, justice, and respect for people’s rights and dignity (APA, 2017) not only to individual participants, but in taking a responsibility in the reduction of harm in communities as well.
References
American Psychological Association [APA]. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code
Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956
Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.
International Union of Psychological Science [IUPS]. (2008). Universal Declaration of Ethical Principles for Psychologists. https://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html
Narvaez, D.F. (October 20, 2019). Indigenous Psychologies Contrast With Western Psychology. Psychology Today. https://www.psychologytoday.com/us/blog/moral-landscapes/201910/indigenous-psychologies-contrast-western-psychology
Patel, V. (2007). Mental health in low-and middle-income countries. British medical bulletin, 81(1), 81-96.
Rojas, G., Martínez, V., Martínez, P., Franco, P., & Jiménez-Molina, Á. (2019). Improving Mental Health Care in Developing Countries Through Digital Technologies: A Mini Narrative Review of the Chilean Case. Frontiers in public health, 7, 391. https://doi.org/10.3389/fpubh.2019.00391
Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press.
Wong, P. W. C., Arat, G., Ambrose, M. R., Qiuyuan, K. X., & Borschel, M. (2019). Evaluation of a mental health course for stigma reduction: A pilot study. Cogent Psychology, 6(1), Article 1595877. https://doi.org/10.1080/23311908.2019.1595877