Screening for Trauma in Court Settings

Fellow PRA staff member Lisa Callahan and I recently had the opportunity to work with the NYS Office of Court Administration (OCA) and the Queens Treatment Court (QTC) on a project to identify trauma screening best practices and to pilot the use of the recommended screening instruments across all five parts of the Court:  Treatment Court, DWI Court, Mental Health Court, Veterans Treatment Court and Drug Diversion Court. Working with OCA and QTC staff through a series of conference calls and on-site meetings, we were able to examine the screening needs across all parts, and the specific needs of each part.

Based on the structure of the court process, population characteristics of defendants in each of the court parts (and diversity therein), and expressed needs of the Court and clinical staff, we were able to pinpoint a series of measures that were well-validated, frequently-used in other court settings, and feasible for administration during the time defendants were in contact with the Court.  Based on the feedback received from our initial recommendations, the Court determined that a PTSD symptom screening measure, partnered with a trauma history measure, would provide the most clinical benefit, both to assist the Court in making referrals to appropriate community-based treatment providers, and in assisting the treatment providers in making treatment decisions and working with the defendants once enrolled in their respective programs.

After careful review of the literature, current court practices, and taking into account the needs of the Queens Court and characteristics of its defendants, we recommended the following measures for pilot testing:

Screening for PTSD Symptoms:

The PTSD Checklist – Civilian (PCL-C)

The PCL-C is a 17-item, self- or clinician-administered checklist that corresponds to key symptoms of PTSD and results in a severity score. The PCL-C is applied generally to any traumatic event and can be easily modified to focus on specific time periods or to, for example, pre or post-deployment, before or after arrest, etc. The PCL-C is widely-used, very valid, available at no cost, and takes approximately 10 minutes to administer.

The Impact of Events Scale (IES-R) – This second screening measure is being administered during the validation pilot period to all individuals who are eligible for the treatment courts to confirm the PCL-C results, and to examine how this measure compares clinically and practically to the PCL-C.  Among the reasons this second screening measure was chosen for pilot testing is that unlike the PCL-C, which is only available in English and Spanish, the IES-R is available in numerous languages including English, Spanish, Korean, Chinese, French, Japanese, and German.  The IES-R is a 22-item measure, also available at no cost,  where the scoring of the responses results in PTSD subscale scores for Intrusion, Avoidance, and Hyperarousal, reflecting the DSM criteria for PTSD, although it is not diagnostic. The IES-R can be quickly administered on line (web-based) or with pen/paper and may be repeated at regular intervals to assess treatment progress.

Trauma History/Impact of Traumatic Events:

The Trauma History Screen (THS)1

The THS was developed to quickly assess exposure to a broad range of stressful life events and experiences.  The THS is a 13-item measure that asks about 11 events and one general event (includes military trauma). For each event endorsed, individuals are asked how many times it happened. They then provide details such as the age it happened, what happened, whether it was an actual threat of death or injury, and feelings of helplessness and dislocation. Defendants are asked to rate the distress level associated with each event endorsed. The THS has a low reading level and is free. For purposes of the Queens Court project, we modified the THS per the Court’s suggestion to include two additional probes per event to examine current trauma—“Are you still bothered by what happened to you?” and “Has this type of event happened to you in the past month?”

Although the THS has scoring guidelines, for purposes of this project, the THS is not formally “scored.” It is simply used to gather more information about specific trauma events to help inform referral decisions to community-based treatment providers by the Court, and to assist treatment providers by providing a preliminary assessment of trauma exposure.

The Combat Exposure Scale (CES)

If the defendant screened positive for military service during the initial interview or was known to the Court as having a history of service in the US Armed Forces, a modified version of the CES was administered to eligible defendants. The CES is a free, 7-item measure that assesses wartime stressors experienced by combatants. Persons with military experience may have trauma or PTSD that is not combat-related. Research shows that persons with military experience, especially women, have higher pre and post-deployment trauma exposure than the civilian population. The CES was modified per suggestions from the Court staff and consultants from the Queens Courts, adding two items and modifying a third (existing) item to better assess experiences of OEF/OIF veterans.

The measures we discuss are among the most appropriate and well-validated measures for use in court settings, although some of the aforementioned recommendations may be specific to the needs of the Queens Court project. Many other excellent screening and assessment measures exist. Some may be too cumbersome or time consuming to feasibly administer in the frequently brief time many courts have with each defendant for this purpose. Others may be prohibitively complex to administer and/or score in a court setting or by untrained staff. Other measures may be too costly for the limited resources available.

Among the key factors to consider in deciding which screening and assessment measures might work in your court are:

Examine the needs of the court

For what purpose are defendants screened? What staff is available to administer the screening instrument? How much time does staff have with defendants? In what setting are instruments administered? What resources are available?

Examine the needs of the defendant population

What language(s) are primary among defendants? Are there likely to be defendants with a history of military service?

Examine which instruments meet these needs

Take care to utilize only well-validated measures. Make sure the court and staff understand how to use and interpret results. Make sure each measure administered has a clear purpose and use in the court process.

One of the best resources on screening and assessment for Post Traumatic Stress Disorder (PTSD) and trauma symptoms and experiences is the National Center for PTSD, operated by the US Department of Veterans Affairs.

Stay tuned for a joint publication from SAMHSA’s GAINS Center and the National Association of Drug Court Professionals (NADCP) on Creating Trauma-Informed Courts to be released in 2013!  In the meantime, visit the GAINS Center’s website for more information on this topic.

1 Carlson, EB, et al. (2011).  Development and validation of a brief self-report measure of trauma exposure:  The Trauma History Screen.  Psychological Assessment, 23(2), 463-477.

Invisible wounds of war, Recovery supports, SMVF