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



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.
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
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.
psychotherapy; evidence-based practice; professional practice; stress disorders; posttraumatic;
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.
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.
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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
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
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.
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
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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.
The mean age of participants was 57.7 years (
= 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 (
= 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 (
= 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 (
= 206; 84%), the mean number of hours
was 16.9 (
= 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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, 63 (27.9%) said
very much
, and 16 (7.1%) said
. 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
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
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
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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.
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
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... Sexual assault has been identified as the most prevalent form of trauma experienced by women. Interestingly, over 60% of counselors already in practice reported they would benefit from training and education on trauma counseling (Cook, Dinnen, Rehman, Bufka, & Courtois, 2011;Jones & Cureton, 2014). It is both critical and timely to include thorough training on trauma, sexual assault, and technology facilitated sexual-assault (e.g., cyber-sexual assault) in this digital age. ...
... Despite the copious numbers of individuals impacted by trauma, Parker and Henfield (2012) noted that counselors revealed feeling unequipped to treat trauma survivors. Despite the fact sexual assault has been identified as the most prevalent form of trauma experienced by women, over 60% of counselors already in practice reported that they would benefit from training and education on trauma counseling (Cook et al., 2011;Jones & Cureton, 2014). It is both critical and timely to include thorough training on trauma, sexual assault, and technology facilitated sexual-assault (e.g., cyber-sexual assault) in this digital age. ...
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Over the past decade, cyber-sexual assault (also known as "nonconsensual pornography" or "revenge porn") has gained the attention of legal experts, the media, and most recently, the counseling profession. Whereas this nonconsensual sharing of sexually explicit images online, through social medial, or other forms of technology has been demonstrated to have significant impacts on victims, researchers have focused heavily upon the legality of these actions (i.e. should there be consequences for posting nude/semi-nude photos of non-consenting adults to the internet), but there has been a lack of attention to the mental health consequences of cyber-sexual assault on victims. The purpose of this study was to provide empirical support to how the psychological aftermath of cyber-sexual assault mirrors that of sexual assault and thus should be taken as seriously as sexual assault (clinically and legally). This study was conducted to investigate the direction and strength of relationships among latent variables associated with trauma symptomology (i.e., emotional dysregulation, trauma guilt, post-traumatic stress disorder, and depression) in a sample of survivors of cyber-sexual assault. This investigation specifically tested whether modeling latent variables emotional dysregulation as measured by the Brief Version of the Difficulties in Emotion Regulation Scale [DERS-16] (Bjureberg et al., 2015) or trauma guilt as measured by the Trauma-Related Guilt Inventory [TRGI] (Kubany et al., 1996) as the independent variable, where the remaining latent variables of post-traumatic stress disorder as measured by the Impact of Events Scale Revised [IES-R] (Weiss & Marmar, 1996) and depression as measured by the Center for Epidemiologic Studies Depression Scale Revised [CESD-R] (Eaton et al., 2004) were modeled as dependent variables, was a good fit for data collected from cyber-sexual assault survivors. Furthermore, the secondary analysis investigated whether modeling the latent variables of emotional dysregulation and trauma guilt as mediating variables on the direction and strength of relationship on the dependent variables of post-traumatic stress disorder and depression was a good fit for data collected from cyber-sexual assault survivors. To test the hypotheses that cyber-sexual assault survivors would show increased trauma symptomology similar to physical sexual assault survivors a structural equation model was developed. The results of the structural equation model (SEM) analyses identified trauma guilt contributed to 14% of the variance of emotional dysregulation; which then served to mediate the outcome variables most significantly. In fact, Emotional Dysregulation contributed to 67% of the variance in the levels of PTSD symptomology, and 44% of the variance in the levels of Depression.
... Yet, despite the high rates of exposure and the negative outcomes in traumatized individuals and their resultant high need for medical and mental health services, the majority of professionals in these fields receive minimal or no formal training in trauma-related assessment or interventions (Courtois & Gold, 2009;Kumar et al., 2019). Traumatized individuals have a high rate of service utilization, making the shortage of providers who have received training in trauma consequences and treatment approaches cause for great concern (Cook et al., 2011. Courtois and Gold (2009) observed that "the vast majority of those professionals interested in developing expertise in psychological trauma must find a way to accomplish it on their own, often after their graduate studies are completed" (p. ...
... For example, in study, programs that offered a trauma-related course tended to have more full-time faculty members, potentially increasing the pool of individuals with the necessary expertise. Given that the majority of practicing psychologists report having received no formal training in traumatic stress studies (Cook et al., 2011), a program with fewer full-time faculty members may have no one on staff who can competently teach such a course. Because these courses are often developed and taught by faculty who have a specific interest in or passion for the topic, if they leave their position, none of the remaining faculty may be able or willing to continue to offer the course. ...
... However, experiencing multiple types and/or repeated exposure (e.g., sexual or physical abuse) to traumatic events, or inescapability of the trauma exposure, particularly during early childhood development, can increase the likelihood and complexity of functional impairments appearing throughout the lifespan at varying points along the way (Briere et al. 2008(Briere et al. , 2016aCourtois and Ford 2013;Herman, 1997;Terr 1991). Unfortunately, many clinicians do not receive training in their graduate programs or internship sites on how to effectively assess trauma or posttraumatic reactions (Brand 2016;Cook et al. 2011;Courtois and Gold 2009;Simiola et al. 2018). Further, research has demonstrated that lack of training or bias caused by the dissemination of misinformation, which also occurs during training, can interfere with the recognition of dissociation and related phenomena in clinical samples (Dorahy et al. 2005;Ginzburg et al. 2010;Leonard et al. 2005;Leonard and Tiller 2016;Perniciaro 2015). ...
... Dissociative symptoms and DDs are particularly important for forensic evaluators to understand because many mental health professionals receive either no or insufficient training in the identification or assessment of any form of dissociative presentation, which can lead to misdiagnosis (Cook et al. 2011;Dorahy et al. 2005;Leonard et al. 2005). For example, hearing voices is often assumed to be indicative of psychosis. ...
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Forensic evaluators frequently utilize diagnoses as a way to document the nature and severity of impairment and/or injury in civil and criminal cases despite diagnostic manuals being primarily created for use in clinical and research setting (Frances and Halon, Psychological Injury and Law, 6, 336-344, 2013). Psychological trauma holds a unique place in diagnostic nosology, as it is both an experience and various sets of persistent symptoms that are required to meet criteria for the diagnoses that are most commonly associated with exposure to adverse/traumatic event(s) (Dalenberg et al. 2017; Smith, Temple Law Review, 84(1), 1-70, 2011). A problem exists with being able to directly diagnose complex posttraumatic reactions, including complex PTSD (CPTSD) and dissociative disorders, which are the result of repeated, prolonged, and inescapable abuse most often perpetrated during childhood (Courtois and Ford 2013; Herman, Journal of Traumatic Stress, 5, 377-391, 1992, 1993, 1997; Terr, American Journal of Psychiatry, 148, 10-20, 1991), although also seen in persons tortured or held as prisoners of war as adults. Although a large research and clinical literature has developed to describe this phenomenon CPTSD has only recently been introduced into the International Classification of Diseases-11th Edition (World Health Organization [WHO], 2018), and remains absent from the DSM. The author will discuss the importance of assessing a person’s lifetime exposure to traumatic events in forensic evaluations, emphasizing exposure to multiple and/or inescapable trauma early in development. This article will also explore the very broad range of posttraumatic conditions—particularly those on the more complex end of the spectrum that are frequently either invisible or baffling to forensic evaluators whose training has not included this emerging area of study.
... Furthermore, many clinicians and forensic experts have not been adequately trained about assessing complex trauma and dissociation, so they may not be aware with the spectrum of symptoms associated with complex trauma Henning et al., 2022;Kumar et al., 2022;Nester, Hawkins, & Brand, 2022). Most practicing psychologists have not received formal training in traumatic stress studies (Cook et al., 2011). Yet, a lack of training about trauma and dissociation and disbelief about the genuine symptoms expressed by someone living with DID could cause harm to individuals living with DID. ...
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Background: Individuals with dissociative identity disorder (DID) experience severe and broad-ranging symptoms which can be associated with elevations on measures designed to detect feigning and/or malingering. Research is needed to determine how to distinguish genuine DID from simulated DID on assessment measures and validity scales. Objective: This study examined whether the Miller Forensic Assessment of Symptoms Test (M-FAST), a screening measure of malingering, could differentiate between individuals with DID and DID simulators. Method: Thirty-five individuals with clinical, validated DID were compared to 88 individuals attempting to simulate DID on the M-FAST. A MANCOVA compared the two groups on total M-FAST score and subscales. Univariate ANCOVA's examined differences between the groups. A series of logistic regressions were conducted to determine whether group status predicted the classification of malingering. Utility statistics evaluated how well the M-FAST discerned clinical and simulated DID. Results: The M-FAST correctly classified 82.9% of individuals with DID as not malingering when using the suggested cut-off score of six. However, utilizing a cut-off score of seven correctly classified 93.6% of all participants and maintained adequate sensitivity (.96) but demonstrated increased specificity (.89). Conclusions: The M-FAST shows promise in distinguishing genuine DID when the cut-off score is increased to seven. This study adds to the growing body of literature identifying tests that can adequately distinguish clinical from simulated DID. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
... Dissociative experiences are common in our daily lives in the general population, ranging from mild to severe detachment, affects approximately 2-18% of individuals in the general population. Few mental health professionals receive systematic training in the assessment and treatment of trauma related psychological problems, and even fewer about traumatized individuals who have dissociative reactions (Cook et al., 2021). In light of this, increasing knowledge of the relationship between dissociative symptoms and psychological stress among adolescents is imperative. ...
... Frye is, for all intents and purposes, a popularity contest, has the theory been "generally accepted" by the relevant professional community. Given how unlikely it is for a psychologist or psychiatrist to encounter any training in any trauma-related topic during their career (Cook, Rehman, Bufka, Dinnen, & Courtois, 2011;Simiola, Smothers, Thompson, & Cook, 2018), it is not difficult for an opposing attorney to find a psychologist who knows nothing about trauma psychology, nor has read even one of its many peerreviewed journals, to opine that complex trauma, BTT, and IBT are not generally accepted because the psychologist in question has never heard of them, and for testimony to be disallowed by the judge. ...
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This paper discusses considerations for treating or evaluating sexual harassment claims in individuals with a history of complex trauma. The author reviews how a history of repeated trauma in early childhood increases risk for later victimization, including sexual harassment (Courtois & Ford, 2013; Herman, 1992). Further, she provides a brief overview of how attachment disruptions and other adverse childhood experiences (ACE) create difficulties with emotion and interpersonal regulation. She discusses how the complexity of the symptom profile provides a unique context for therapeutic intervention and evaluation, as well as the importance of staying firmly grounded in one’s role when the courts are involved (Greenberg & Shuman Professional Psychology: Research and Practice, 28(1), 50–57, 1997). Utilizing her more than 30 years of experience as a forensic evaluator, the author provides case material throughout the manuscript to highlight potential pitfalls and strategies for maintaining the therapeutic alliance or role as a forensic evaluator.
... Though mental health professionals reported significantly higher competencies in overall topics prior to the training, the reflective post-training scores showed marginal differences across professions, and non-mental health professionals attained a good level of understanding in mental health topics and foundational skills that are crucial to trauma-informed services. It is also notable that mental health providers often do not receive professional training on trauma-related topics [35,36], let alone specifically on refugee mental health. T In fact, mental health professionals reported the low baseline scores on refugee CMDs, cultural influences on trauma and mental health outcomes, multi-tiered interventions, and trauma-informed care in this study. ...
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Refugee mental health needs are heightened during resettlement but are often neglected due to challenges in service provision , including lack of opportunities for building capacity and partnership among providers. We developed and implemented culturally-responsive refugee mental health training, called Cross-Cultural Trauma-Informed Care (CC-TIC) training. We evaluated CC-TIC, using a free listing and semi-structured retrospective pre-and post-training evaluation with five localities in two states in the U.S. The results showed significant improvement in providers' knowledge of trauma impacts, cultural expressions of trauma/stress-related symptoms, and culturally-responsive trauma-informed care. Trauma-informed care specific to refugee resettlement was regarded as the most helpful topic and community partnership building as the most requested area for future training. This study emphasizes that culturally-responsive trauma-informed approaches can help bridge gaps between mental health care and resettlement services and promote exchanges of knowledge and expertise to build collaborative care and community partnership.
Objective Psychologists are primary care professionals responsible for providing treatment to people exposed to trauma. However, there has been limited research exploring psychologists’ perceptions of their practice and trauma-informed care when treating people exposed to trauma. The current study aimed to investigate: 1) psychologists’ perceptions of assessing and treating trauma-exposed clients; and 2) psychologists’ perceptions of trauma-informed practice and their need for further training in this area. Method Surveys were completed by 99 psychologists, and the data were analysed using thematic analysis. Results Psychologists reported the importance of further trauma-related training and showed an inconsistent understanding of trauma-informed practice. Conclusions Changes in tertiary education for psychologists were recommended to assist future psychologists to develop competency and confidence in assessing and treating trauma-exposed clients. It was also recommended that psychologists with insufficient knowledge in this field to undertake further training in this area.
The COVID-19 pandemic and heightened awareness of racial injustice and discrimination in the United States are likely to have a negative impact on mental health. This is concerning, given the already alarming prevalence rates of trauma exposure and adverse childhood experiences in the U.S. general population prior to the current pandemic, their immediate and long-lasting effects on human development across the life span, and their documented effects on adult chronic health conditions. For clinical mental health counselors (CMHCs) to respond effectively to the needs of the U.S. general population, entry-level counseling programs must provide comprehensive trauma training and education. The purpose of this article is to provide information about clinical competencies and relevant training requirements for CMHCs in trauma prevention and treatment to highlight the need to require comprehensive trauma training in entry-level academic training programs for CMHCs through relevant research and policy.
Objective: Psychologists are at the forefront of assessing and treating clients who been affected by trauma. This study determined the proportion of Australian postgraduate psychology courses that provide training on trauma in coursework units. Method: Descriptive statistics and content analysis were used to analyse the trauma-related contents of online unit handbooks from Masters of Psychology courses that were offered in 2019. Results: Forty-two unit handbooks from 25 courses delivered by 16 institutions explicitly mentioned trauma-related content, equating to 31.65% of courses included in the present study. Of those unit handbooks, 30 were unique (i.e., not duplicates across courses at the same institution). Content analysis of the unit handbooks revealed (a) trauma was most commonly discussed as a disorder (e.g., post-traumatic stress disorder, stressor-related disorders) and (b) postgraduate psychology students were often taught about trauma-related assessment, intervention and theory. Conclusions: Trauma training appears limited within postgraduate psychology coursework in Australia. Further research is warranted into how well-prepared psychology graduates are to work with clients who have been exposed to trauma. Such preparedness is vital in the current Australian climate whereby many individuals are impacted by potentially traumatic loss or adversity, for example, due to bushfires and COVID-19. KEY POINTS What is already known about this topic: • The effects of traumatisation are highly variable across individuals and thus psychologists must be well-informed about the different presentations of trauma. • Trauma- and stressor-related disorders are often challenging to treat and psychologists must be well-trained in appropriate interventions for doing so. • Mental health practitioners often lack the appropriate support and training in addressing the needs of clients who have been affected by traumatising events. What this topic adds: • Only a minority of postgraduate psychology courses in Australia appeared to contain information about trauma. • Further research is warranted to continue to explore psychologists’ training and competency development in trauma-informed practice. • Systemic changes to postgraduate psychology courses are required to ensure all provisional psychologists receive foundational knowledge and skills in supporting clients who have been impacted by trauma.
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Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment. We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents. We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations. Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs. We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes. In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.
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In recent years, evidence-based practice (EBP) has been a major focus in the social work profession. Concern has been expressed regarding licensed clinical social workers (LCSWs) using novel unsupported interventions, especially those that made claims of efficacy in the absence of empirical evidence. The present exploratory study surveyed 191 LCSWs from 34 different states with diverse clinical specialties who advertised their services on the Internet. Participants were asked about specific supported and unsupported interventions used in their practices and the reasons for their choices and attitudes toward EBP. It was found that the majority reported using interventions that had empirical support. However, three-fourths of the sample also reported using at least one novel unsupported intervention in their practice. The use of novel unsupported interventions was found to be statistically more likely among women. The entire sample scored above the midpoint on the Evidence-Based Practice Attitude Scale (EBPAS), indicating an overall positive attitude toward EBP. Moreover, the present study found a weak but significant positive correlation between number of novel unsupported interventions used and EBPAS score. It appears that a positive attitude toward EBP and the use of novel unsupported interventions are not mutually exclusive.
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The field of traumatic stress studies has developed rapidly over the course of the past two decades. A large body of data is now available regarding the prevalence of various forms of trauma and the personal and societal toll of traumatization. Numerous studies of the psychological impact of trauma have been undertaken, resulting in a preliminary understanding of a range of immediate and long-term posttraumatic reactions and conditions. These findings, in turn, have led to the development of a variety of interventions both initially and in the longer-term aftermath that are designed to prevent and ameliorate posttraumatic distress. At the present time, much of this information has not been incorporated into either the general undergraduate or graduate curricula and is particularly lacking in professional education. This is extremely unfortunate because professionals from many disciplines have an integral role in providing services to victims that, in turn, are essential to their ability to recover. Professionals require specific, focused knowledge about trauma. They also require training on the needs of victims and effective means of intervening with them in order to provide these necessary services. This paper is a call for the inclusion of traumatic stress studies across the relevant undergraduate and graduate curricula in general and into professional education, especially the medical and mental health professions.
In recent years there has been a growing interest regarding the integration of evidence-based practice into social work curricula and practice (Howard, McMillen, & Pollio, 2003; Thyer, 2004). However, there has also been a growing concern about the proliferation of novel interventions that lack empirical support and yet make claims of efficacy in the absence of evidence (Thyer, 2007) as well as conventional social work interventions that lack empirical support and yet remain unquestioned (Gambrill, 2006). Although studies have been conducted that have examined the theoretical orientations and other practice patterns of clinical social workers, to date, with the exception of the pilot study (Pignotti & Thyer, 2009) that preceded this dissertation, no study has systematically examined the intervention choices of licensed clinical social workers (LCSWs) including the use of novel unsupported therapies. The present dissertation examined the reported usage of novel and conventional unsupported and empirically supported therapies by 400 LCSWs from 39 different states who responded to an Internet survey. The purpose of the study was to determine what interventions were reported currently being used by LCSWs, reasons for choosing interventions, and their attitudes towards evidence-based practice. Prior to data analysis, the list of the therapies reported being used by LCSWs was presented to a panel of expert reviewers and therapies were classified as empirically supported therapies (ESTs), novel unsupported therapies (NUTs) or conventional unsupported therapies (CUTs). The study hypotheses were that: 1) females would be more likely than males to use CUTs and NUTs; 2) respondents who report an affiliation with eastern/new age or nondenominational/spiritual religions would be more likely to use NUTs; 3) clinical experience would be more highly rated than empirical evidence as a reason for selecting a therapy; 4) LCSWs with a theoretical orientation of cognitive-behavioral would value evidence from research more highly than LCSWs of other orientations and 5) LCSWs who use NUTs and/or CUTs will score higher on the Divergence subscale of the Evidence-Based Practice Attitudes Scale (EBPAS; Aarons, 2004) than those who did not use such therapies. The results showed that although an overwhelming majority of the sample reported using ESTs (98%), three-quarters of participants also reported using at least one NUT and 86% used at least one CUT. The hypothesis that females were more likely to use NUTs and CUTs was supported and females also used a higher number of NUTs. The hypothesis that participants reporting eastern/new age and nondenominational/spiritual religious beliefs use a higher number of NUTs was also supported, although they were not more likely to use any NUT. It was found that participants, as hypothesized, valued clinical experience over research evidence and LCSWs with a theoretical orientation of cognitive-behavioral were found to value research evidence more highly than those of other theoretical orientations. The hypothesis that LCSWs who use NUTs and/or CUTs will score higher on the Divergence subscale of the EBPAS was not supported. This study offers preliminary evidence that the use of NUTs is widespread among LCSWs, although the limitation is noted that the present sample may not necessarily be representative of all LCSWs. It also appears that given the fact that actuarial judgment has been shown to be more accurate than clinical judgment (Dawes, Faust & Meehl, 1989) LCSWs may be under-valuing research evidence. It is also evident that the use of ESTs and NUTs are not necessarily mutually exclusive and although the EBPAS indicates that overall our sample had a positive attitude towards EBP, future research needs to examine a fuller definition of the term that includes their understanding of the term and specific practices.
The Child and Adolescent Trauma Treatments and Services Consortium (CATS) was the largest youth trauma project associated with the September 11 World Trade Center disaster. CATS was created as a collaborative project involving New York State policymakers; academic scientists; clinical treatment developers; and routine practicing clinicians, supervisors, and administrators. The CATS project was established to deliver evidence-based cognitive-behavioral trauma treatments for children and adolescents affected by the September 11 terrorist attack in New York City and to examine implementation processes and outcomes associated with delivery of these treatments. Referrals were obtained on 1,764 children and adolescents; of these, 1,387 were subsequently assessed with a standardized clinical battery and 704 found to be eligible for services. Ultimately 700 youth participated in the project. Treatments were delivered in either school or clinic settings by clinicians employed in 9 provider organizations in New York City. All participating clinicians were trained on the cognitive behavioral therapy models by the treatment developers and received case consultation for 18 months by expert clinician consultants and the treatment developers. The challenges of mounting a large trauma treatment project within routine clinical practices in the aftermath of a disaster and simultaneously evaluating the project have been significant. We outline the major challenges, describe strategies we employed to address them, and make recommendations based on critical lessons learned.
Mental health practitioners are often called upon to provide services to children, adolescents, and families in the aftermath of traumatic experiences such as child neglect, sexual or physical abuse, family/domestic violence, sexual assault, interpersonal violence, school and community violence, serious accidental injury, catastrophic medical illness, traumatic bereavement, or mass casualty events, including natural and man-made disasters. The National Child Traumatic Stress Network (NCTSN) was established in 2001 to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. This article describes the development of the NCTSN, its structure, programs, and many of the products and resources--including online lectures, training programs and videos, and searchable databases of child trauma resources--available through the NCTSN Web site ( to assist professionals in providing state-of-the-art assessment, treatment, and services to these children and their families. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This article provides a conceptual framework for training in professional psychology focused on the construct of competency. The authors present a 3-dimensional competency model delineating the domains of knowledge, skills, attitudes, and values that serve as the foundation required of all psychologists, the domains of functional competencies that broadly define what psychologists do, and the stages of professional development from doctoral education to lifelong learning through continuing education. The goal in presenting this model is to provide a conceptual frame of reference for those responsible for psychology education, credentialing, and regulation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)