OBJECTIVE: A growing awareness of the sequelae of trauma has prompted
clinical and administrative mandates that psychiatric assessments must
include inquiry about whether patients have experienced trauma or abuse.
This study was designed to assess how a trauma history obtained through
mandated inquiry is recorded and how it is used in diagnostic formulation
and treatment planning. METHODS: Histories of physical and sexual abuse and
other trauma were reviewed in the charts of 180 outpatients receiving
psychotherapy at an urban teaching hospital clinic. The extent and variety
of traumatic experiences and the quality of clinicians' assessment of
trauma histories were measured by a rating instrument developed for the
study. RESULTS: Mandated inquiry led to the detection of histories of
traumatic experiences for 72 patients (40 percent). The recognition of
trauma did not trigger appropriate evaluation. Only 11 percent of
clinicians mentioned posttraumatic stress disorder symptoms. Only one in
ten charts of patients with histories of trauma contained diagnostic
assessments or treatment plans that adequately incorporated the trauma
history as a factor in the patient's presentation for treatment.
CONCLUSIONS: Although mandated inquiry led to the detection of substantial
abuse and trauma, this information was rarely used in assessment and
treatment planning. Implementation of mandated inquiry should be
accompanied by relevant education and supervision to ensure that clinicians
understand the diagnostic and treatment implications of past trauma.