Once the clinician gains an overall sense of the veteran’s level of psychosocial functioning, a broader assessment of psychological symptoms, and responses to those symptoms that may be impairing, can be useful. However, this process can also be difficult and confusing since a wide range of emotional and cognitive responses to deployment and post-deployment stressors including increased fear and anxiety, sadness and grief, anger or rage, guilt, shame and disgust, ruminations and intrusive thoughts about past experiences, and worries and fears about future functioning may be expected. Often a good clinical interview can elicit some information about the most salient symptoms for a particular veteran, which can be supplemented with more structured assessment using diagnostic interviews and questionnaires.
Again, clinicians must use their judgment in responding to transient normal responses to potentially traumatizing events versus symptoms that may reflect the development or exacerbation of a psychological disorder. Sometimes assessing both psychological responses and even responses to those responses can help determine whether some form of treatment is indicated.
For instance, veterans may appropriately respond to the presence of painful thoughts and feelings by crying, talking with others about their experiences, and engaging in other potentially valued activities such as spending time with friends and family. However, others may attempt to suppress, diminish or avoid their internal experiences of pain by using alcohol or drugs, disordered eating, self-injurious behaviors (such as cutting), dissociation and behavioral avoidance of external reminders or triggers of trauma-related stimuli.
Given that a full range of psychological responses may be seen, and given that multiple symptoms (and co-morbid disorders) may be present, one challenge to the clinician during the assessment process is to prioritize targets of potential treatment.
A few general rules of thumb can be helpful:
First, one must immediately attend to symptoms that may require emergency intervention such as significant suicidal or homicidal ideation, hopelessness, self-injurious behavior or acute psychotic symptoms.
Second, it is useful to address symptoms that are most disruptive to the veteran (which should be evidenced by a careful assessment of psychosocial functioning).
Finally, the best way to develop a treatment plan for a veteran with diverse complaints is to develop a case formulation to functionally explain the potential relationship between the symptoms in order to develop a comprehensive treatment plan.
Substance abuse, disordered eating, and avoidance of trauma-related cues may all represent attempts to avoid thoughts, feelings and images of trauma-related experiences. Thus, developing an intervention that focuses on avoidance behavior per se, rather than on specific and diverse symptoms
Past distress and coping
In determining the extent of treatment needed for a particular presenting problem, an assessment of the history of the problem and the veteran’s previous responses to similar stressful experiences is useful. A general sense of pre-deployment work and interpersonal functioning, along with any significant psychological history can place current distress in context.
A diathesis-stress model suggests that veterans with a history of mental health difficulties can be at increased risk for psychological problems following a stressful event such as deployment to a war zone, although this relationship is not absolute.
Another area worth assessing that can provide a wealth of pertinent information is the veteran’s general orientation toward coping with difficult life events and its potential relationship to current painful thoughts, emotions and bodily sensations. Many veterans will enter into their military experience with a flexible and adaptive array of coping skills that they can easily bring to bear on their current symptoms. In other cases, veterans may have successfully used coping strategies in the past that are no longer useful in the face of the current magnitude of their symptoms.
Coping styles can be assessed with one of a number of self-report measures. However, through a sensitive clinical interview, one can also get a general sense of how often the veteran generally uses common coping styles such as stoicism, social support, suppression and avoidance, and active problem solving.
Previous traumatic events
While there is evidence in the literature for a relationship between repeated lifetime exposure to traumatic events and compromised post-event functioning, this relationship may be less evident among veterans who are seen in the months following their return from war. However, there may still be important clinical information to be gained from assessing a veteran’s lifetime experience with such traumatic events such as childhood and adult sexual and physical abuse, domestic violence, involvement in motor vehicle or industrial accidents, and experience with natural disasters, as well as their immediate and long-term adjustment following those experiences.
Obviously, the assessment of potentially traumatizing events that occurred during deployment will be an important precursor to treatment for many veterans of modern war, particularly for those who struggle with symptoms of re-experiencing, avoidance/numbing, dissociation, or increased arousal. VA and other mental health clinicians can be highly skilled in many of the clinical subtleties involved in this assessment such as:
1. The importance of providing a safe and nonjudgmental environment.
2. Allowing the veteran to set the pace and tone of the assessment.
3. Understanding the myriad of issues that involve the disclosure of traumatic experiences such as shame, guilt, confusion, and the need by some soldiers to appear resilient and unaffected by their experiences.
However, unique deployment stressors accompany involvement in each contemporary military action that may be important to assess. Thus, clinicians need to balance their use of current exposure assessment methods with openness to hearing and learning from each new veteran’s personal experience.
Section 1 of the Deployment Risk and Resiliency Inventory, developed by Daniel and Lynda King and colleagues at the National Center for PTSD, can provide an excellent starting point for the assessment of deployment-related stressors and buffers. Items on this measure were derived from focus groups with Persian Gulf veterans, and they provide useful information about some of the newer stressors associated with contemporary deployments.
The inventory describes nine domains of war zone stressors that modern war veterans may have experienced. A careful assessment of each of these domains can be useful both as a starting point for assessing any potential ASD and/or PTSD and more generally to establish a sense of the potential risk and resiliency factors that may bear on the veteran’s current and future functioning.