Responses of a Sample of Practicing Psychologists to Questions About Clinical Work With Trauma and Interest in Specialized Training

Abstract

This study reports on selected findings from a survey conducted by the American Psychological Association Practice Organization, which assessed the number of hours per month that practicing psychologists estimated they spent treating trauma survivors and their interest in additional clinical training on trauma-related issues and topics. Respondents reported 14.3 mean number of hours spent working with trauma survivors over the past month. Of the 76% of the sample who treated any trauma patients, the mean was 16.9 hours. Although trauma psychology is not currently an integral component of the standard curricula in graduate-level education, generalist psychology practitioners are treating trauma-related concerns in their clinical practices. It is imperative therefore to ascertain if they are adequately trained in specialized trauma recognition, assessment, and treatment. The fact that almost 64% of survey respondents expressed interest in participating in educational endeavors to learn more about trauma-related clinical topics suggests that such a need exists and that more training opportunities, including ongoing continuing education offerings, should be organized.

Full text

Responses of a Sample of Practicing Psychologists to
Questions About Clinical Work With Trauma and Interest in
Specialized Training
Joan M. Cook,
Department of Psychiatry, Yale University School of Medicine and National Center for PTSD,
West Haven, Connecticut
Omar Rehman,
American Psychological Association, Washington, DC
Lynn Bufka,
American Psychological Association, Washington, DC
Stephanie Dinnen, and
Department of Psychiatry, Yale University
Christine Courtois
Independent Practice, Washington, DC
Abstract
This study reports on selected findings from a survey conducted by the American Psychological
Association Practice Organization, which assessed the number of hours per month that practicing
psychologists estimated they spent treating trauma survivors and their interest in additional
clinical training on trauma-related issues and topics. Respondents reported 14.3 mean number of
hours spent working with trauma survivors over the past month. Of the 76% of the sample who
treated any trauma patients, the mean was 16.9 hours. Although trauma psychology is not
currently an integral component of the standard curricula in graduate-level education, generalist
psychology practitioners are treating trauma-related concerns in their clinical practices. It is
imperative therefore to ascertain if they are adequately trained in specialized trauma recognition,
assessment, and treatment. The fact that almost 64% of survey respondents expressed interest in
participating in educational endeavors to learn more about trauma-related clinical topics suggests
that such a need exists and that more training opportunities, including ongoing continuing
education offerings, should be organized.
Keywords
psychotherapy; evidence-based practice; professional practice; stress disorders; posttraumatic;
education
Many individuals in the United States are exposed to traumatic events at some point in their
lives (Breslau et al., 1998; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), a statistic
that extends to individuals in other countries around the world (e.g., De Vries & Olff, 2009).
Conservative estimates indicate that almost 60% of Americans have experienced at least one
© 2011 American Psychological Association
Correspondence concerning this article should be addressed to Joan M. Cook, Yale School of Medicine, Department of Psychiatry,
National Center for PTSD/NEPEC/182, 950 Campbell Avenue, West Haven, CT 06516. Joan.Cook@yale.edu.
NIH Public Access
Author Manuscript
Psychol Trauma
. Author manuscript; available in PMC 2013 June 03.
Published in final edited form as:
Psychol Trauma
. 2011 September 1; 3(3): 253–257. doi:10.1037/a0025048.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

event in their lifetime that would be considered traumatic, such as child maltreatment,
interpersonal violence, natural disaster, war, or serious accident, (Breslau et al., 1998).
Although the majority of individuals who experience a single potentially traumatic event do
not have long-term negative consequences, a substantial minority (especially those who are
multiply traumatized, particularly during childhood) develop significant mental and
behavioral health difficulties (Courtois & Ford, 2009; Kilpatrick et al., 2003). Indeed,
traumatic exposure has been implicated as a risk factor for numerous major mental
disorders, including depression, substance abuse/dependence, Posttraumatic Stress Disorder
(PTSD), other anxiety disorders (Green et al., 2010; McLaughlin et al., 2010), dissociative
disorders, and personality and developmental disturbances and disorders. In addition, trauma
is associated with physical health problems, negative health behaviors such as smoking and
excessive alcohol consumption, poor social and occupational functioning, and overall
decreased quality of life (Kessler, 2000). Naturally, a history of traumatic exposure and
related disorders and problems in functioning are much more prevalent in clinical samples
than in the general population. Thus, the relevance of trauma to general clinical practice is
very high (Gold, 2004).
Exposure to trauma and its potential and resultant negative consequences have been
recognized as a public health problem of major proportion (U.S. Department of Health &
Human Services, 2003; U.S. Surgeon General, 1999). Although the scientific literature on
traumatic stress is large and growing exponentially, most psychologists and other medical
and mental health providers have only a cursory knowledge of the impact of trauma and
related treatment. Events of national and international scope throughout the past decade,
such as the terror attacks of September 11th, the wars in Iraq and Afghanistan, and
devastating natural disasters such as the Asian tsunami of 2004, Hurricane Katrina, and the
Haitian earthquake have deepened public awareness of the of different types of trauma and
their potential posttraumatic consequences. In addition, there is an increased societal
acknowledgment over the past several decades of the scope of interpersonal violence, both
inside and outside of the home and family. This improved awareness has likely had the
effect of encouraging a greater number of trauma survivors to seek mental health services
for their posttraumatic reactions. This, in turn, will lead to an associated need for mental
health professionals to be knowledgeable and trained in delivering such specialized services.
There are likely additional reasons for the increase in those seeking trauma-specific
treatments. For example, there are now empirically sound assessments for traumatic
exposure and PTSD (Wilson & Keane, 2004) and well-established efficacious treatments for
PTSD in both children and adults (for review, see Foa, Keane, Friedman, & Cohen, 2009).
Certainly the existence of psychometrically reliable and valid diagnostic assessment tools
suggests increasing accuracy in diagnosis and potentially referrals for trauma-specific
treatments.
Relatedly, there are also now governmental agencies dedicated to the understanding and
addressing the needs of trauma survivors (e.g., the National Center for PTSD and the
National Child Traumatic Stress Network). More specifically in 1989, in response to a U.S.
Congressional mandate, the Department of Veterans Affairs created the National Center for
PTSD to serve as a research and education center of excellence on PTSD, with primary
purpose of improving the well-being of American veterans (National Center for PTSD,
2011). In addition, through grants awarded through numerous federal agencies, the National
Child Traumatic Stress Network was established in 2000 to improve access to care,
treatment, and services for children and adolescents exposed to traumatic events through
academic and community-based collaborations (Pynoos et al., 2008). Both the National
Center for PTSD and the National Child Traumatic Stress Network have trained large
numbers of clinicians to deliver evidence-based treatments for PTSD. For example, over the
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past several years, two evidence-based psychotherapies, Prolonged Exposure and Cognitive
Processing Therapy, have been nationally rolled out within the U.S. Department of Veterans
Affairs (Karlin et al., 2010). Numerous efforts to disseminate and implement evidence-based
trauma treatments took place following the 9/11 terrorist attacks in New York City (e.g.,
Amsel, Neria, Marshall, & Suh, 2005; CATS, 2007; Norris & Rosen, 2009). In addition,
several state governments have engaged in training their mental health workforce in trauma-
specific treatment (e.g., Northwestern University Mental Health Services and Policy
Program, 2008). It may be that some governmental agencies recognize that engaging in
trauma-specific treatments is an important avenue for efficient and effective delivery of
services as well as cost containment.
Unfortunately, trauma-related material is not routinely included in the professional training
of most psychologists, nor is it included in the training of allied professionals (Courtois &
Gold, 2009). At present, the best available data on the inclusion of trauma psychology in
undergraduate and graduate training in psychology comes from a systematic series of web-
based searches by the Division 56 Education and Training Committee (American
Psychological Association, 2009). In addition, the Association of Psychology Post-doctoral
and Internship Centers (APPIC) reports there are currently 171 postdoctoral or graduate
internships offering a major in trauma, PTSD, or sexual abuse with an additional 614
offering intensive study in these fields as a minor (APPIC, 2011). The findings indicate that
there are still relatively few clinical or counseling programs and internship sites that
routinely offer such topics as part of their training. The result is a major gap in service needs
and the ability to deliver specialized trauma-relevant and responsive services (Courtois,
2001). This is especially problematic since the treatment of trauma survivors has been found
to have relational, topical, and risk management challenges that are different than those
found in other treatment populations and that can confound the therapist and interrupt the
therapy. Moreover, if not managed knowledgeably, these challenges can overwhelm and
harm both the therapist (through vicarious traumatization) and client (through
retraumatization).
In order to best prepare to meet the need of the expanding population of trauma survivors
seeking mental health services, more information is desirable regarding psychologists’
current practice patterns, background training to provide services, and interest in additional
training. An initial step in gathering this important information was undertaken by the joint
efforts of the American Psychological Association’s Practice Organization (APAPO) and
APA’s Division of Trauma Psychology (Division 56). Items on the amount of clinical time
spent working with trauma survivors and interest in additional training in trauma were added
to a survey of practicing psychologists conducted by the APAPO. The purpose of this article
is to report on preliminary findings in response to these trauma-specific questions.
Method
The APAPO added two items to a web-based survey which was conducted in September
2010. One item was an estimation of the amount of time practicing psychologists spent in
the treatment of traumatized clients (i.e., “In your last typical month of professional practice,
how many hours did you spend in clinical work with traumatized patients?”). The second
item was psychologists’ perceived need to develop greater expertise in providing services to
traumatized clients via additional training (i.e., “If specialized training opportunities were
offered to advance your expertise in working with trauma patients, how likely would you be
to participate?”). The potential responses were:
not at all, a little, somewhat, very much
, and
completely
.
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In addition, participants were asked a number of other questions including whether they
provided direct psychological services and the number of years they had provided such
services. In the survey, direct psychological services were defined as any psychological
services delivered through face-to-face interaction with a patient/client, such as clinical
interviewing, psychotherapy, psychological/personality assessment or testing, and other
related services.
E-mail invitations were sent by the APAPO to a random selection of 1,973 (out of 37,343)
practicing psychologist members. The APAPO is a companion organization to APA, whose
members are psychologists who provide mental and behavioral health services and who are
licensed to practice in their respective jurisdictions. The APAPO promotes the professional
interests of practicing psychologists in all settings.
It is estimated that approximately 20% of the invitations did not reach their intended
recipient, either due to invalid e-mail addresses or spam filtering. Each potential participant
was sent three reminders to complete the survey. The first reminder was sent two months
after the survey launched, while the second and third were sent a month after the previous
reminder. Two hundred nineteen individuals looked at the survey but did not answer any
questions and 276 individuals participated. Of these, 263 provided complete data and 13
provided partial information. Eysenbach (2004) suggested that in the reporting of web-based
surveys, various response metrics, such as view, participation, and completion rates, should
be reported. Lack of information about the number of unique visitors to the website
prevented calculation of exact view and participation rates. An estimate of participation rate
is the number of website survey registrations (219 + 276 = 495) divided by the number of
subscribers who were sent e-mails (1,973) is almost 40%, which is likely very conservative
because it is unlikely that every subscriber who was sent an e-mail visited the website. The
completion rate among individuals who consented to participate was 95% (263 out of 276).
Regarding the representativeness of the sample, there do appear to be differences between
participants and the APAPO membership in regards to several demographics, namely age,
gender, and ethnicity. The APAPO membership appears to be younger (X = 53.3 vs. 57.7
years), have more women (57% vs. 48%), and contain more ethnic minorities (5.5% vs.
4.8%) than survey respondents.
Results
The mean age of participants was 57.7 years (
SD
= 8.8) with a range from 31 to 81. Fifty-
three percent were men. Ninety percent were White/Caucasian, 1.5% Hispanic, 1.1% Black/
African American, 1.2% other, and 4.2% declined to answer the question on race/ethnicity.
Two hundred sixty one participants reported that they provided direct psychological services
(95.6%) and 12 did not (4.4%). Thus, responses below are based only on those who provide
direct services. The mean number of years in practice was 26.7 years (
SD
= 9.6), with a
range of 4 to 55 years.
Of the 245 who provided a response to the two trauma questions, the mean number of hours
spent working with trauma survivors was 14.3 (
SD
= 18.5) with a minimum of 0 and a
maximum of 92. Of those, 16% did not spend any time working with trauma survivors over
the past month; 25% spent a little time (1–5 hours); 50% spent some time (6–15 hours); and
9% spent a good deal of time working with trauma survivors (16–92 hours). Of those who
reported any clinical work with trauma survivors (
N
= 206; 84%), the mean number of hours
was 16.9 (
SD
= 19.0).
Regarding interest in specialized training opportunities in trauma psychology, 23 (10.5%)
responded that they had
no interest
, 45 (19.9%) endorsed
a little
, 72 (31.9%) indicated
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somewhat
, 63 (27.9%) said
very much
, and 16 (7.1%) said
completely
. The relationship
between time spent working with survivors and interest in specialized training was
examined. Spearman’s rho (.372) was significant at p. <001, indicating that 37.2% of the
variance in interest in training is explained by time spent working with survivors. More
specifically, the majority (61.5%; 24 out of 39) of those who did not do any clinical work
with trauma survivors expressed little to no interest in specialized training. The majority
(61.3%; 48 out of 62) of those who reported conducting a little clinical work with survivors
expressed at least some interest in specialized training. The majority (81%; 117 out of 144)
of those who worked some or often with trauma survivors expressed interest in additional
training.
Discussion
This first step in gathering data on practicing psychologists’ current clinical work with
trauma survivors and interest in specialized training is informative despite the fact that the
sample size was small, the percentage of respondents fairly low, and the representativeness
of the sample is unknown. For example, the mean number of hours spent working with
trauma survivors in a typical month was reported by this cohort to be 14.3 hours. Given that
trauma is widespread in the general population and that rates are known to be higher in
clinical populations, it might be assumed that trauma may be a more pervasive issue in
clinical practice than reported by this sample. It remains an open question as to whether
individuals experiencing trauma-related problems are being adequately identified by
therapists and are receiving appropriate or sufficient treatment.
Given that trauma-related topics are not currently integral components of the standard
professional training curricula in psychology and allied professions (Courtois, 2001;
Courtois & Gold, 2009), it is likely that psychologists (and other medical/mental health
professionals) have had inadequate training in the recognition, assessment, and treatment of
trauma. While trauma is not always the primary, direct, or sole cause for all psychological
problems, it may be a hidden variable that increases client’s risk or compounds difficulties
or prevents recovery from other mental health disorders. Moreover, as the complexity of
trauma increases, developmental and comorbid conditions also increase (e.g., dissociation,
complex PTSD), creating an even greater need for specialized knowledge and skills
pertinent to these issues (e.g., Courtois & Ford, 2009). Therapists who work with trauma and
who have little to no specialized training run the risk of practicing outside of their area of
competence.
The extreme circumstances in which some traumas occur and the attendant psychological
consequences can create conditions that increase the risk for practitioners, including their
ability to set and maintain appropriate therapeutic boundaries and limits. Specialized
training helps therapists to know of the various “treatment traps” and risks that are common
in this population and to develop skills and strategies in their management (Chu, 1988). In
addition, the conditions that promote the occurrence of certain types of trauma and
exacerbate the effects of trauma require the practitioner to be sensitive and responsive to
social, political, and cross-cultural issues. Age, ethnicity, disability status, gender, and
sexual orientation become critical components to integrate into culturally competent trauma
practice (Brown, 2008). In a related vein, the conditions of traumatic exposure create
personal and relational difficulties in many survivors that enter the treatment process,
including mistrust, problems of emotion regulation, and ambivalence about the possibility of
recovery (e.g., Cloitre et al., 2010). Mental health professionals working with traumatized
clients should be trained to expect such relational process and client characteristics, and
receive training and supervision in ways to most productively approach and work with these
issues.
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There are additional reasons to insure adequate training in the trauma-specific treatment. It
is suspected that without adequate training, well-intentioned clinicians may collude with
their client’s avoidance symptoms, and thus potentially reinforce beliefs that treatment is not
effective or is too painful to consider. Additionally, without adequate training, clinicians
may retraumatize the client.
Increasing promotion of evidence-based treatment of PTSD has thus far had limited impact
on patterns of community practice (Becker, Zayfert & Anderson, 2004; Gray, Elhai, &
Schmidt, 2007; Pignotti & Thyer, 2009; Rosen et al., 2004; Sprang, Craig, & Clark, 2008).
For example, Becker and colleagues (2004) assessed the use of imaginal exposure for PTSD
in a random sample of licensed psychologists from three states. Even though roughly half
reported at least some familiarity with exposure therapy for PTSD, only a minority used it in
clinical practice. Additionally, attitudes toward and utilization of evidence-based practice
were examined in a sample of ISTSS members, the majority of whom were psychologists
(Gray et al., 2007). While most reported being favorably inclined toward using empirical
research to inform their clinical work, less than half reported that they primarily used
evidence-based treatments for PTSD.
Although information from the present study came from only two survey items, the
magnitude of interest reflected in the data is striking, particularly because the survey was
aimed at practicing psychologists in general, not trauma practitioners in particular. Indeed,
the use of the phrase “traumatized patients” might have influenced the responses that were
received and indicate underreporting of services. For example, it is possible that clinicians
might have only included hours where they focused on PTSD instead including other
trauma-related deleterious mental and behavioral health outcomes such as depression,
economic problems, occupation problems, and chronic pain/health problems. Thus, different
phrasings might have led to even larger reports of the number of hours in practice with
trauma-exposed clients working on a range of issues. More research is needed in regard to
which practitioners provide psychological services to trauma survivors, what they are
currently doing, and what kinds of training prepared them (e.g., graduate coursework,
practicum placement, internship rotation, specialized internship, postdoctoral training, on-
the-job training, and informal experience). Further information is also needed on what
additional training practitioners need in order to provide high quality services and on what
topics (e.g., particular types of trauma, information on assessing trauma-related pathology
treatment) and formats (e.g., weekend workshops, web-based instruction, video courses)
they would be interested in accessing training.
Perhaps one of the most important findings was that clinicians who are not seeing
“traumatized patients” do not report an interest in educational opportunities. Given the scope
of trauma exposure and its consequences, it seems quite surprising that these clinicians do
not have trauma-exposed clients in their practices who are actually dealing with trauma-
related emotional, social, or economic consequences. One fundamental question from these
data then is how the traumatic stress field reaches out to those clinicians who don’t believe
they have a stake in trauma education.
Fundamental to successful matriculation in work with traumatized populations is adequate
supervision and consultation, both for practicing clinicians and those still in training.
Movement toward a competency-based model of training and assessment has taken hold in
the broader field of psychology and numerous other health care disciplines (APA, 2006;
Epstein & Hundert, 2002). Although not yet proposed in trauma training, a competency-
based framework can assist in identifying the training and assessment needs of students and
practitioners working with traumatized populations. The cube model for competency
development (Rodolfa et al., 2005) provides a means for assessing learning and outlines
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competency attainment at each stage of a psychologist’s career (from doctoral training
through continuing education). Essential to mastery of competencies at each stage is the
provision of support and feedback through supervision, consultation, and mentoring.
Recognition of the current lack of standardization and accessibility to trauma-specialized
training has led to a call for the integration of trauma into the standard curriculum for
psychology students and highlights the unique opportunity practicum, internships and
externships, and clinical training courses provide in their unparalleled access to supervised
clinical experience (Courtois, 2001; Courtois & Gold, 2009; Hatcher & Lassiter, 2007). The
current lack of a formal curriculum, formal supervision, and means of assessment for trauma
training extends into the professional workforce, placing the burden of accessing trauma
training resources on individual clinicians motivated by their exposure to traumatized
individuals in their practice (Courtois & Gold, 2009). The fact that almost 64% of the
sample expressed interest in participating in educational endeavors to learn more about
trauma and its treatment suggests both the need and the imperative for additional training,
both in the professional training curriculum and in continuing education endeavors.
Acknowledgments
This project described was supported by Award K01 MH070859 from the National Institute of Mental Health. The
content is solely the responsibility of the authors and does not necessarily represent the official views of the
National Institute of Mental Health or the National Institutes of Health.
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