Psychosocial and Trauma Assessment
Comprehensive Diagnostic Evaluations at J. Flowers Health Institute
The information presented on this page is an overview of the average evaluation of this nature and is offered here as a resource. At J. Flowers Health Institute, our evaluations are customized and tailored to the individual’s needs. We specialize in providing truly comprehensive health and wellness evaluations and a workable plan for future health to those who want to improve their quality of life.
If you would like to learn more about J. Flowers Health Institute, please do not hesitate to reach out.
What is a Psychosocial and Trauma Assessment?
Table of Contents
According to an article from the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 50% of those receiving behavioral health help (such as in therapy) have a history of trauma.1
Therapists estimate this number is higher for those who have a history of mental health disorders and struggle with substance abuse.
As little as 10 years ago, doctors thought it was best to treat substance abuse and mental health disorders separately. Today, research shows that to treat one condition (such as substance abuse), the other condition must also be addressed (such as how the underlying trauma affected a person).1
This is why doctors may assess for trauma. If a doctor can recognize that a person has a history of trauma, they can better plan an approach for treatment.1
Determining State of Mind with a Psychosocial Assessment
Determining Readiness for Treatment
A person’s readiness for treatment can affect them from the beginning as they may be less inclined to answer questions about their lives if they went into treatment unwillingly or aren’t ready to change. Lacking motivation or showing unwillingness for treatment is common. A medical professional may have to change their approach to help a person develop their motivation before pursuing further treatment courses.
Key Components of Psychosocial Assessments
Identifying the Chief Complaint
Get a Patient's History During a Psychosocial Assessment
History of the Presenting Illness
A medical professional will ask questions about the client's history. If substance abuse seems to be an underlying condition, a doctor may ask about when the person started using a particular substance or substances, how much they use, and how often they use it. The doctor may also ask the patient to describe a time when they felt they had hit rock bottom, and they may ask if the patient has sought treatment before or if they've made any personal attempts to recover from their addiction.
A medical professional will ask the patient if a doctor has ever diagnosed them with a mental illness. They may ask them in their own words what medical condition they've been diagnosed with or if they have any medical conditions a doctor has prescribed medications for.
During this portion of the assessment, it's vital for the medical professional to consider if a person has suicidal thoughts or behaviors, such as cutting or making a plan for self-harm.1
A person's past medical history is important in deciding what kinds of treatments they may need. If a person has multiple complicated medical issues (like heart or lung problems or diabetes), they may require a different level of care while they treat the conditions they are at the facility for. Also, the National Institute of Mental Health has identified that people who have chronic medical conditions are more likely to experience mental illness.
A medical professional should review a person's list of medications to determine if any medicines could be causing or contributing to their symptoms. It's also important to ask if a person is taking more of the medication than prescribed or is taking the medicines differently than prescribed. Finally, it's important to ask the patient what they believe they are taking a specific medication for.
Questions for this section may focus on where a person was born and raised, as this can give clues into a person's cultural beliefs or how they were raised. Other questions may be about the person's family of origin, as well as about their current relationships, number of children, and available social support network. This information could help identify the support a person may have for treatment in the future.
Where a person works currently or has worked in the past can provide cues as to the types of stress or work-related concerns a person may have. Example questions include:
- Do you like your current job?
- Do you get along well with your co-workers?
- Have you ever lost your job?
- How many jobs have you had in the last five years?
Educational history questions may include asking about the highest grade a person has completed, as well as the schools a person may have attended in the past. A key question could be about whether or not a person has ever had discipline problems at school, such as always being in trouble or having to perform remedial education.
Knowing a person's previous problems with the law can convey the extent to which they've had problems with their substance abuse or behavioral health in general.
A medical professional will ask about a person's childhood history. Examples include how a person would describe their childhood, what they were like as a child, and whether or not they had any traumatic experiences in their childhood that may still affect them now.
Assess Factors That May Affect Recovery
A medical professional can ask if a person identifies with any religious background and if they regularly attend religious services. A doctor may ask what role spirituality plays in a person's life.
Some of the earlier questions may help to inform the cultural portion of the assessment (such as where a person was born and raised). However, a medical professional may ask how a person's cultural background affects them, including how their culture may view substance abuse.
A medical professional can ask if a person feels secure in their finances or if they are struggling financially. Other questions could include, "Do you frequently worry about your finances?" and "Have you ever stolen or engaged in other illegal acts to help your finances?"
A medical professional will ask questions that may include the following:
- in the past month/year, have you been physically hit, kicked, or punched by another person?
- Do you have anyone in your life who threatens you with physical harm?
- Have you ever been forced to have sexual contact with a person (even if it is your spouse or significant other) when it was unwanted?
- Have you ever been abused emotionally or physically by another person?
Make Determinations During a Psychosocial Assessment
Determining Alcohol and Drug Use
In this part of a psychosocial assessment, a medical professional emphasizes to the patient the importance of being as honest as possible when it comes to their history of drug and alcohol abuse. The medical professional may ask questions about how much a person is drinking or using drugs each day and how the person feels about their substance abuse. Other questions may be about how often a person uses the drug or alcohol and how much a person may have used in the past.
Determining Coping Skills
A lack of positive coping skills can be a trigger for substance abuse and other health problems. A medical professional could ask the patient a question like "How do you cope with stress in your life?"
Determining Interests and Abilities
When a person struggles with addiction, they often stop doing things they used to enjoy in favor of using drugs or alcohol. However, it's important to explore the hobbies a person used to have or things they would enjoy doing. This can help guide later treatment decisions. Examples of questions include:2
- What hobbies do you have?
- What would you say you are good at?
- What makes you happy?
Mental Status Examination
The mental status examination during a psychosocial assessment has several different aspects to consider. Usually, this will appear on the medical professional's chart as check-boxes for quick assessment purposes. Examples of factors to observe during the mental status examination include:
- Presence of hallucinations, delusions, or strange thoughts
How Psychosocial Assessments Benefit Treatment
Types of Trauma Assessments
Childhood Attachment and Relational Trauma Screen (CARTS)
Global Psychotrauma Screen (GPS)
Clinician-Administered PTSD Scale (CAPS)
How Trauma Assessments Benefit Treatment