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Current Symptoms Self-Report Form Week of:

Appendix Trauma Interview

Instructions: Please check the response next to each item that best describes your behavior during the past week.
(for Therapist’s Use in Session )
Never or
Rarely Sometimes Often Very Often

Fail to give close attention to details or make careless

1
mistakes in my work

2 Fidget with hands or feet or squirm in seat

Have diffiTRAUMA INTERVIEW

culty sustaining my attention in tasks or
3
fun activities

Leave myClient: ______________________________________

seat in situations in which seating is Date: _______________________
4
expected
Therapist: ______________________________________
5 Don’t listen when spoken to directly
Note: This interview is structured on the assumption that a thorough assessment or intake has
6 Feel restless
already been conducted, that this evaluation confirmed the experience of at least one DSM-IV
Criterion A trauma and the diagnosis of PTSD or significant symptoms of PTSD, and that
Don’t follow through on
the therapist hasinstructions andinformation.
reviewed this fail to
7
finish work

culty___________
Have diffiAge: Educational
engaging in leisure doing______________
activities orlevel: Date of birth: _______________
8
fun things quietly
Race:: __________  - African American  - Asian/Pacific Islander
9 Have difficulty organizing tasks and
- Biracial
activities  - Spanish Origin
 - Caucasian  - Other
10 Feel “on the go” or “driven by a motor”
- Native American  - Unknown
Avoid, dislike, or am reluctant to engage in work that
11 Marital Status: ______________ Living with: _____________ Work Status: ___________
requires sustained mental effort

12 Current employment or job: ____________________________________________________

Talk excessively

13 Psychiatric
Lose things necessarydiagnoses oractivities
for tasks or conditions (obtain before session from initial evaluation;
review as needed):
Blurt out answers before questions have been
14 completed__________________________________________________________________________
15 Am easily distracted
__________________________________________________________________________
16 Have difficulty awaiting turn
__________________________________________________________________________
17 Am forgetful in daily activities
__________________________________________________________________________
18 Interrupt or intrude on others

From R. A. Barkley & K. R. Murphy (1998), Attention-Deficit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.

Reprinted with permission.Mastery

TM

Treatments That Work Reclaiming Your Life From a Traumatic Experience

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Any other current treatments (may obtain from initial evaluation or ask as needed):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

SAY TO THE CLIENT: I’m going to ask you some questions about the trauma and how you
have been feeling and doing lately or since the time of the trauma. Some of what we will discuss
may be difficult for you to talk about. If there is anything I can do to make our conversation less
difficult for you, please let me know. Do you have any questions before we begin?

I have information from your initial assessment (or intake) with ______________ [name intake
assessor if not self ], so I know what you told him/her about your trauma. I understand from
his/her notes that . . . [Briefly summarize the trauma information obtained in the intake.]

Is that about right? Is there anything you would like to add?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Sometimes people have experienced other traumatic events at other times in their lives. Has this
happened in your life? Have you ever experienced, or witnessed, or been confronted with other
traumatic events?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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Note to clinician: If client is unsure, you may want to list all or some of the following to give
him/her an idea of what comprises a Criterion A trauma:
Natural disaster (e.g., tornado, hurricane, fire, or flood)
Serious accident or serious injury
Combat or being in a combat zone
Sudden life-threatening illness
Accidental death or murder of a close friend or family member
Suicide of a close friend or family member
Being attacked with a gun, knife, or other weapon
Attacked without a weapon but with the intent to kill or seriously injure
Severely beaten (i.e., beatings that left marks or bruises), or witnessing severe physical
violence
Sexual abuse as a child or adolescent
Physical force or the threat of physical force leading to unwanted sexual contact
Rape or attempted rape
Aggravated assault

IDENTIFICATION OF TARGET TRAUMA (i.e., the one that will be of primary focus in PE
treatment)

SAY TO THE CLIENT: Of all these things that happened to you [interviewer summarize trau-
matic events endorsed by client], which one is currently bothering you the most? Which causes
you the most distress? [Use additional probe questions as needed if the client has difficulty identify-
ing an event; e.g., “Which one most often comes into your thoughts when you don’t want to think
about it? Which one upsets you the most? Which one is the worst? In which event were you most
afraid?”]

Specify target trauma: _________________________________________________________

SAY TO THE CLIENT: Do you remember what you were thinking and feeling at the time?
When it was happening, did you think you would be killed or seriously hurt?
No □ Yes □

During the ___________________________ [insert identified trauma], did you feel helpless,
horrified, or terrified?
No □ Yes □

If there was an assailant or perpetrator(s), who was it/who were they?

1 - Stranger 9 - Boyfriend/girlfriend
2 - Acquaintance 10 - Husband/wife/partner
3 - Enemy 11 - Organization
4 - Terrorist 12 - Authority figure (specify) _____________________________
5 - Friend 13 - Relative
6 - Parent 14 - Neighbor
7 - Sibling 15 - Other ____________________________________________
8 - Clergy member 16- Unknown _________________________________________

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Where did the trauma occur?

1 - Own residence 6 - School 11 - Car, bus, train, plane
2 - Assailant’s residence 7 - Institution 12 - Workplace
3 - Friend/relative’s residence 8 - Battlefield 13 - Other (describe) ___________
4 - Park, street, alley 9 - Public place ________________________
5 - Parking lot/garage 10 - Abandoned property ________________________

What, if any, physical injuries did you have? Have these injuries continued to cause or to be a
problem for you?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Were you given medical attention? Was it helpful? Are you still under medical care for these in-
juries or problems?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Has any criminal or legal action resulted from this trauma? What is the status of that now? (If
appropriate:) How is that affecting you?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

SAY TO THE CLIENT: I’m going to ask you some questions now about who, if anyone, you
blame for the occurrence of this trauma. I want you to know that there are no right or wrong
answers to these questions, and we don’t think that it is necessary that you place blame. We ask
them because it is often helpful to me in our work together to understand how YOU view this
event and how you have responded to it. OK?

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Who, if anyone, do you blame for the occurrence of the trauma?

1 - Myself 5 - Friend or acquaintance
2 - Assailant(s) or perpetrators 6 - The environment
3 - An organization 7 - Chance
4 - The government 8 - Other (describe) ____________________________

How so? (i.e., how is the person or organization responsible?)

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Have you been feeling guilty about the trauma or your response to it? Shamed? Angry? How
much have these feelings been present for you?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Physical and Mental Health Since Trauma

How has your physical health been since the trauma? (Or, if trauma was long ago: how has your
health been lately?)

□ Good □ Fair □ Poor

What health problems, if any, are you having? Are these related to the trauma?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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How is your support system? Who do you like to spend time with or talk to? Have you been
connecting with your friends and family lately?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

How has your mood been since the trauma? (Or, if trauma was long ago: how has your mood
been lately?) Have you been feeling down or depressed? Are you as interested in things as you
usually are?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Note: Even if client does not endorse depressed mood, ask the following questions about suicidal
ideation and behavior:

Since the trauma, have you ever thought that life is not worth living, or thought about suicide?
If yes, how often?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Have you gone so far as to make a careful plan as to how you would kill yourself ? Have you
taken any action on this (e.g., selected a location or date, bought a gun, obtained pills)?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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Do you intend to act on this plan or intend to hurt yourself ?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Have you made a suicide attempt since the trauma or at any time? When? (Assess as needed.)

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Have you ever deliberately hurt yourself in any way? (If necessary: For example, people some-
times scratch or cut or burn themselves on purpose, or otherwise act in potentially self-harming
ways.) Ask as needed: What do you do to harm yourself ? When did you last hurt yourself ?
How do you manage the urges now if you don’t act on them?

If yes, describe:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Have you sought psychiatric or psychological help as a result of the trauma? Crisis intervention?
(not including this treatment)
No □ Yes □

If yes, describe:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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Have you been to the hospital since the trauma for an emotional or nervous condition? Suicide
attempt? Alcohol or drug treatment?
No □ Yes □

Tell me why you were hospitalized:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Summarize current risk assessment and plan if indicated:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Alcohol and Drug Use

I’d like to ask you about your use of drugs or medications. Since the trauma, have you used:
(Go through each of the categories below)

Prescription medications (Note specific meds and frequency of use) ______________________

______________________________________________________________________

______________________________________________________________________

Street drugs (Note types and frequency of use) _____________________________________

______________________________________________________________________

______________________________________________________________________

Over-the-counter medications (Note type and frequency of use) ________________________

______________________________________________________________________

______________________________________________________________________

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On average, about how many drinks containing alcohol do you have per day? (Consider one
drink to be a -ounce can of beer, one cocktail, or a -ounce glass of wine.) Has your pattern of
use changed since the trauma? If yes, how so?

______________________________________________________________________

______________________________________________________________________

Have you ever had legal, social, or employment problems because of your alcohol or drug use?
No □ Yes □

Do you consider yourself to have a drinking or a drug problem?

No □ Yes □

Is there anything else about your life now or about how the PTSD is affecting you that you
think I should know now?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Copyright © 2007 Oxford University Press