Staff Perspective: Updated VA/DoD Clincal Practice Guideline for the Mangement of PTSD (Part One)

Staff Perspective: Updated VA/DoD Clincal Practice Guideline for the Mangement of PTSD (Part One)

In late 2017, the Department of Veterans Affairs in conjunction with the Department of Defense published an update to their practice guidelines for the management of Posttraumatic Stress Disorder (PTSD). This two-part blog will highlight the major recommendations of the new practice guideline: part one will focus on recommendations for screening and assessment and part two will focus on treatment considerations. Although we hope that these blogs help to clarify the major elements of the new guideline, we strongly suggest that all clinicians review the guideline for themselves. The full guideline as well as the Clinician Summary and Pocket Guide can all be viewed and downloaded in PDF format here.

Part 1: Screening and Assessment of PTSD: New Recommendations from the Department of Veterans Affairs and Department of Defense

Take a few moments to think about the way you generally approach your first session with a new military client whom you suspect may have been exposed to trauma. What critical pieces of information do you hope to obtain? What information tends to be more difficult to gather? What are your goals? What are your biggest concerns or challenges when it comes to speaking with clients about their potentially traumatic experience? How do you even begin a conversation about trauma in a way that does not feel abrupt or invalidating?

Undoubtedly, meeting with a military client who may be struggling to cope with the effects of experiencing a psychological trauma can be challenging. Many clinicians (including myself) worry that they won’t be able to gather all the information necessary to adequately diagnosis PTSD and/or any other relevant mental health diagnoses. On top of that, it is incumbent upon us to gather the information that our templated intake assessments require and to build rapport with out new client. An additional layer of challenge is the time-limited nature of the screening and assessment phase that often characterizes mental health care delivery in large systems that serve military clients. Despite these challenges, we work diligently within the parameters of our organizations to provide the best care possible.

The good news is that the new screening and assessment guideline is fairly clinician-friendly, in my opinion. The goal of the guideline is to provide clinicians with the most up-to-date information on best practices while focusing on strategies that will likely comport well with standard clinical care. Overall, the guideline emphasizes balancing the use of specific evidence-based strategies with client preferences and goals for treatment. Client-centered care and shared decision making is highlighted throughout the guideline. Let’s take a closer look at the new recommendations for screening and assessment.

It is recommended that all new military clients be screened for PTSD initially and also on an annual basis, when appropriate. The use of well-validated, self-report screening tools such as the Primary Care PTSD Screen of DSM-5 (PC-PTSD-5) and PTSD Checklist for DSM-5 (PCL-5) is strongly recommended. These measures can be quickly administered, scored, and interpreted prior to an assessment session, providing the clinician with an efficient way to gather information about potential trauma exposure and symptoms of PTSD that can be used to guide the clinical interview. It is recommended that these screening measures be repeated as necessary and at least on an annual basis. PTSD symptoms may fluctuate over time and military clients may experience traumatic events after the initial screen. It should be noted that screening measures, regardless of their quality, are not intended to be substitutes for thorough assessments. However, measures like the PCL-5 are a great way to generate hypotheses about the presence, or absence, of a potential trauma history and a diagnosis of PTSD.

If a military client screens positive for PTSD during the screening phase, it is recommended that clinicians complete a comprehensive biopsychosocial assessment. In addition to the elements that are commonly included in this process (e.g., safety assessment, mental health history, medical history, military history), the guideline strongly suggests including assessment of trauma history and duration as well as a thorough assessment of PTSD symptoms. PTSD should be assessed during the course of the clinical interview in conjunction with information gleaned from PTSD self-report measures or structured clinical interviews such as the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Assessment of symptoms related to potential co-morbid conditions is also recommended, especially symptoms of presenting issues that commonly co-occur with PTSD such as Major Depressive Disorder, Substance Abuse Disorder, history of TBI, and pain. 

Lastly, once the assessment is completed, it is recommended that the clinician provide the client and his/her family with feedback. It can be tempting to skip this step of the assessment process in order to begin treatment as quickly as possible. However, explanation of the results of an assessment is an ethical responsibility for psychologists (American Psychological Association, 2016). While the National Association of Social Workers Code of Ethics does not specifically mention assessment feedback, provision of adequate informed consent, which includes explanation of the potential risks and benefits associated with services, is an ethical standard (2017).  Not only is providing feedback an ethical obligation, it is good clinical care. Informed clients who have had the opportunity to ask questions, to express preferences for treatment, and to share their unique goals are likely to be more engaged in their treatment. According to the guideline, feedback should include a summary of the assessment findings, information about any diagnoses that have been given, and information about available treatments and their relative efficacy. Ideally, this should be an interactive discussion that includes an effort to elicit the client’s unique preferences and goals for treatment, culminating in an initial plan for treatment. The National Center for PTSD offers many free resources for clients and their families that can be useful to include in the feedback process.

I hope that this brief review has given you a sense of the new VA/DoD guideline for screening and assessment of PTSD. Stay tuned for part 2 of this blog in which I will review the recommendations for the management of PTSD symptoms. In the meantime, I encourage you to review the full guideline (or at least the pocket guide).

Interested in learning more about PTSD screening and assessment? Do you enjoy attending CDP webinars? Fan of corny jokes? If you answered “yes” to at least two of those questions, then you should check out “Assessing Military Clients for Trauma and Posttraumatic Stress Disorder.” I’ll be co-hosting this webinar (and providing the corny jokes) with my esteemed colleague Kelly Chrestman, Ph.D.  For more information about this 4-hour webinar, please click here .

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Andrew Santanello, Psy.D., is a licensed, clinical psychologist and Cognitive Behavioral Therapy trainer at the Center for Deployment Psychology.

References

American Psychological Association. (2002). Revision of ethical standard 3.04 of the

Ethical Principles of Psychologists and Code of Conduct” (2002, as amended 2010). American Psychologist, 71, 900. Retrieved from:  http://www.apa.org/ethics/code/ethics-code-2017.pdf

National Association of Social Workers. (2017). Code of Ethics of the National

Association of Social Workers. Washington, DC: Authors. Retrieved from:  https://www.socialworkers.org/LinkClick.aspx?fileticket=ms_ArtLqzeI%3d&portalid=0

U.S. Department of Veterans Affairs, & U.S. Department of Defense. (2017). VA/DoD

clinical practice guideline for management of post-traumatic stress. Washington, DC: Authors. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal.pdf