Providing Therapy to Providing Therapy to Trauma Survivors Trauma Survivors

who have a who have a Developmental Developmental

Disability Disability

Sheila Mansell, Ph.D., Sheila Mansell, Ph.D.,

Chartered Psychologist in Private Chartered Psychologist in Private Practice Practice

Edmonton, ABEdmonton, AB

Presentation OutlinePresentation Outline The process involved in The process involved in evaluating client’s evaluating client’s

cognitive, communication, social, behavioural, and cognitive, communication, social, behavioural, and emotional status is outlined in detail.emotional status is outlined in detail.

An important aspect of this evaluation involves An important aspect of this evaluation involves understanding how trauma and other mental health understanding how trauma and other mental health concerns may manifest in a person with a concerns may manifest in a person with a developmental disability developmental disability (i.e., the dual diagnosis and (i.e., the dual diagnosis and developmental effects literature will be covered developmental effects literature will be covered here).here).

This evaluation process provides an essential This evaluation process provides an essential foundation for identifying treatment, mental health, foundation for identifying treatment, mental health, and behavioral concerns and using different and behavioral concerns and using different therapeutic accommodations. It also sets the stage therapeutic accommodations. It also sets the stage for necessary decision making about involvement for necessary decision making about involvement with client social and personal supports.with client social and personal supports.

Presentation OutlinePresentation Outline The necessity of significant contact and communication The necessity of significant contact and communication

with client social and personal supports will be with client social and personal supports will be presented. These relationships are essential and presented. These relationships are essential and provide information about client functioning both prior provide information about client functioning both prior to entering treatment and throughout it. to entering treatment and throughout it.

This communication provides a gauge about both client This communication provides a gauge about both client functioning and behavioural concerns occurring functioning and behavioural concerns occurring throughout treatment and treatment efficacy that can throughout treatment and treatment efficacy that can allow the clinician to modify interventions and supports allow the clinician to modify interventions and supports as needed. as needed.

Treatment invariably involves teaching and supporting Treatment invariably involves teaching and supporting client supports in their efforts to understand the client supports in their efforts to understand the client’s abuse experience, the differing behaviours and client’s abuse experience, the differing behaviours and reactions that can occur, and to help them enhance reactions that can occur, and to help them enhance client coping skills.client coping skills.

Presentation OutlinePresentation Outline

Literature outlining the different accommodations Literature outlining the different accommodations that therapists use in this work will be presented. that therapists use in this work will be presented.

Accommodations refer to specific changes that a Accommodations refer to specific changes that a therapist uses to ensure that therapy is therapist uses to ensure that therapy is appropriately adapted to meet the cognitive and appropriately adapted to meet the cognitive and communicative and emotional needs of a survivor communicative and emotional needs of a survivor with developmental disabilities. with developmental disabilities.

Different therapeutic accommodations Different therapeutic accommodations and and intervention models intervention models are presented. A composite are presented. A composite illustration is provided from this psychologist’s illustration is provided from this psychologist’s private practice.private practice.

Emphasis will be placed on student participation.Emphasis will be placed on student participation.

Initial Contact Initial Contact and and InformationInformation GatheringGathering

At initial contact the therapist will begin an At initial contact the therapist will begin an ongoing evaluation of different aspects of the ongoing evaluation of different aspects of the client’s functioning.client’s functioning.

The evaluation process occurs in different ways The evaluation process occurs in different ways throughout therapy. throughout therapy.

Learning about various aspects of the client’s Learning about various aspects of the client’s functioning and manifestations of trauma from functioning and manifestations of trauma from different sources is crucial to helping you make different sources is crucial to helping you make decisions about the treatment options that may decisions about the treatment options that may or may not be available. or may not be available.

Evaluation and Gathering Evaluation and Gathering Information Information

Treatment entails careful evaluation of Treatment entails careful evaluation of the client’s abilities and emotional and the client’s abilities and emotional and diagnostic status. Gathering information diagnostic status. Gathering information from many sources is crucial to identify from many sources is crucial to identify treatment issues and clarify treatment treatment issues and clarify treatment choices and progress.choices and progress.

Developing working relationships with Developing working relationships with the client’s support systems is an the client’s support systems is an essential component for starting essential component for starting treatment. treatment.

A client may not be able to report and A client may not be able to report and communicate about their subjective communicate about their subjective emotional experience or history and emotional experience or history and there can be heavy reliance on others' there can be heavy reliance on others' perceptions. perceptions.

Care must be taken when evaluating Care must be taken when evaluating the integrity of these information the integrity of these information sources and to be aware of possible sources and to be aware of possible hidden agendas from caregivers.hidden agendas from caregivers.

Communication with Communication with Caregivers Caregivers

Interviewing and Interviewing and Consulting Consulting

Family members, case manager, or staff Family members, case manager, or staff provide vital information. Documentation is provide vital information. Documentation is similarly valuable.similarly valuable.

It is helpful to educate the staff or family It is helpful to educate the staff or family about the manifestations of trauma and the about the manifestations of trauma and the differing functions of client’s behaviours. differing functions of client’s behaviours.

It is critical that support persons (where It is critical that support persons (where appropriate) are enlisted to support appropriate) are enlisted to support treatment goals and are taught different treatment goals and are taught different strategies to reinforce treatment goals and strategies to reinforce treatment goals and generalizability of client coping skills. generalizability of client coping skills.

The research findings overall indicate this The research findings overall indicate this population is more likely to suffer from population is more likely to suffer from emotional disturbances and are likely to emotional disturbances and are likely to experience the same range of experience the same range of psychopathology found in the general psychopathology found in the general population (Eaton & population (Eaton & Menolascino, 1982).Menolascino, 1982).

The combined vulnerability to mental The combined vulnerability to mental disorders and trauma experiences are disorders and trauma experiences are important considerations in treatment.important considerations in treatment.

There is also a well established heightened There is also a well established heightened vulnerability to abuse of all varieties.vulnerability to abuse of all varieties.

Heightened Vulnerability Heightened Vulnerability to Mental Disorder to Mental Disorder

Developmental or Age Developmental or Age EffectsEffects

Charlot (1998) indicates that a person's Charlot (1998) indicates that a person's developmental level impacts the presentation developmental level impacts the presentation of clinical surface features. Symptoms may of clinical surface features. Symptoms may take on different meanings depending on a take on different meanings depending on a person's stage of development. person's stage of development.

People at similar stages of cognitive People at similar stages of cognitive development to a young child will display the development to a young child will display the same variation in phenomenology. same variation in phenomenology.

Misdiagnosis may occur when developmental Misdiagnosis may occur when developmental effects are not taken into consideration. effects are not taken into consideration.

Anxiety and Mood Anxiety and Mood DisordersDisorders

Charlot (1998) notes that adults display Charlot (1998) notes that adults display some features that are similar to children some features that are similar to children without developmental disabilities when without developmental disabilities when depressed that include higher rates of depressed that include higher rates of irritable mood and associated conduct irritable mood and associated conduct problems. problems.

When evaluating for mood disorders When evaluating for mood disorders Lowry (1998) outlines the importance of Lowry (1998) outlines the importance of operationally defining key symptoms and operationally defining key symptoms and to consider what a person with a to consider what a person with a developmental disability is likely to do if developmental disability is likely to do if he or she is experiencing such symptoms. he or she is experiencing such symptoms.

Behaviour Changes and Behaviour Changes and TriggersTriggers

Focusing on behaviour changes can help Focusing on behaviour changes can help clinicians decide whether a behaviour is clinicians decide whether a behaviour is a manifestation of a longstanding a manifestation of a longstanding cognitive, psychopathological, or a cognitive, psychopathological, or a recent traumatic experience. recent traumatic experience.

It is important to learn It is important to learn as much as as much as possible possible about the trauma to identify about the trauma to identify potential triggers that may be present.potential triggers that may be present.

Note that triggers may internal and/or Note that triggers may internal and/or externalexternal

Functions of Different Functions of Different BehavioursBehaviours

It is helpful to view a number of behaviours in terms of It is helpful to view a number of behaviours in terms of what psychological functions these serve (e.g., what psychological functions these serve (e.g., reassurance, closeness, intimacy, avoidance, escape, reassurance, closeness, intimacy, avoidance, escape, self-protection, etc.) when the person is unable to self-protection, etc.) when the person is unable to adequately verbally communicate either their emotional adequately verbally communicate either their emotional states or their needsstates or their needs. .

This perspective is especially important to convey to This perspective is especially important to convey to caregivers to reduce the likelihood of personalizing caregivers to reduce the likelihood of personalizing negative behaviours.negative behaviours.

Teaching caregivers about this and other interventions Teaching caregivers about this and other interventions to support appropriate client coping and emotional to support appropriate client coping and emotional problem solving problem solving is especially is especially criticalcritical in trauma in trauma treatment.treatment.

Changes and LossesChanges and Losses Fruitful areas to explore include learning Fruitful areas to explore include learning

about recent changes in the client's about recent changes in the client's physical or social environment, such as a physical or social environment, such as a move from school to day programming or a move from school to day programming or a workshop, a change of residence, loss of a workshop, a change of residence, loss of a favorite staff member, or anniversary dates favorite staff member, or anniversary dates of losses. of losses.

Losses frequently awaken other losses and Losses frequently awaken other losses and compound the experience of trauma.compound the experience of trauma.

Loneliness and unresolved grief should not Loneliness and unresolved grief should not be overlooked and are often devastating.be overlooked and are often devastating.

Proceed with CautionProceed with Caution

When relying on others' reports of the When relying on others' reports of the person's behaviour and symptoms there is a person's behaviour and symptoms there is a strong emphasis on the observables, strong emphasis on the observables, however, this can result in an overemphasis however, this can result in an overemphasis on externalizing type behaviours and a on externalizing type behaviours and a failure to recognize internalizing symptoms failure to recognize internalizing symptoms that may be present in trauma related that may be present in trauma related effects or mood disorders. effects or mood disorders.

Professional liaison is a necessity in this Professional liaison is a necessity in this work.work.

TraumaTrauma Typically refers to experiencing events that Typically refers to experiencing events that

are perceived as life threatening.are perceived as life threatening. Produces a range of short and long term Produces a range of short and long term

effects that may include PTSD, other anxiety effects that may include PTSD, other anxiety related difficulties related to the trauma, and related difficulties related to the trauma, and depression. depression.

Mental Disorder, poor coping skills, and Mental Disorder, poor coping skills, and other losses may compound these effects and other losses may compound these effects and present additional issues for consideration. present additional issues for consideration.

Trauma effects do not differ significantly in Trauma effects do not differ significantly in people with developmental disabilities.people with developmental disabilities.

Preparation for therapyPreparation for therapy The client needs to know why they are seeing you.The client needs to know why they are seeing you.

Ensure the client understands what they are Ensure the client understands what they are expected to do and why. Informed consent is expected to do and why. Informed consent is essential. essential.

There can be a belief that they are “in trouble” and There can be a belief that they are “in trouble” and this needs to be dealt with by providing this needs to be dealt with by providing appropriate reassurance sooner rather than later. appropriate reassurance sooner rather than later.

Termination issues also need to be dealt with early.Termination issues also need to be dealt with early.

Client’s Appraisal Client’s Appraisal

The client’s appraisal and understanding of the trauma The client’s appraisal and understanding of the trauma is crucial. The person may not always experience is crucial. The person may not always experience exploitive relations as traumatic. The responses of exploitive relations as traumatic. The responses of others are very important in shaping adjustment others are very important in shaping adjustment following trauma.following trauma.

Some education about different things people can feel Some education about different things people can feel is important as not all clients will make the connection is important as not all clients will make the connection between their emotions and behaviours and the between their emotions and behaviours and the trauma they experienced.trauma they experienced.

Goals should be concrete and restricted to resolving Goals should be concrete and restricted to resolving specific, concrete, real life problems and helping specific, concrete, real life problems and helping clients develop direct emotional problem solving skills. clients develop direct emotional problem solving skills.

Implications for Therapy Implications for Therapy

Problems with self-report and Problems with self-report and understanding internal states like understanding internal states like emotions, figures of speech, time and emotions, figures of speech, time and other abstract concepts often mean other abstract concepts often mean traditional talk therapy may be fraught traditional talk therapy may be fraught with misunderstandings.with misunderstandings.

Remember verbal information is not Remember verbal information is not always interpreted or received as always interpreted or received as intended.intended.

Communication IssuesCommunication Issues The lower the person's level of functioning The lower the person's level of functioning

the more likely it is that the person's ability the more likely it is that the person's ability to communicate and process language will be to communicate and process language will be impaired.impaired.

It is important to learn about the client's It is important to learn about the client's receptive and expressive language and to receptive and expressive language and to understand the implications for understand the implications for discrepancies. discrepancies.

Many assumptions are made about client Many assumptions are made about client comprehension due to acquiescence and/or comprehension due to acquiescence and/or ffeigning understanding.eigning understanding.

Communication IssuesCommunication Issues Opportunity for misunderstanding is Opportunity for misunderstanding is

constant. Clinicians need to be vigilant constant. Clinicians need to be vigilant about simplifying communication, about simplifying communication, avoiding jargon and using plain English.avoiding jargon and using plain English.

Simple questioning techniques can help Simple questioning techniques can help assess whether or not the client assess whether or not the client understands you or the words that they understands you or the words that they use. use.

Monitor verbal responses carefully. Use Monitor verbal responses carefully. Use physical gestures and observe the client's physical gestures and observe the client's nonverbal interactions, especially with nonverbal interactions, especially with caregivers. caregivers.

Therapists must seek clarification, offer hypotheses Therapists must seek clarification, offer hypotheses and construct interpretations and construct interpretations in simplified form in simplified form . .

This is time consuming and requires patience.This is time consuming and requires patience.

Education and repetition is often essential and Education and repetition is often essential and client attention span is sometimes very short.client attention span is sometimes very short.

Restrict content and be flexible. Consider Restrict content and be flexible. Consider nonverbal and body oriented alternatives. nonverbal and body oriented alternatives.

Being directive is often helpful and must be Being directive is often helpful and must be balanced with providing appropriately mbalanced with providing appropriately meaningful eaningful choices. choices.

Therapy AccommodationsTherapy Accommodations

Identifying Treatment Identifying Treatment IssuesIssues Expectations and treatment goals need to be Expectations and treatment goals need to be

reasonable. Determine the different parties’ reasonable. Determine the different parties’ goals for treatment. Remember that these goals for treatment. Remember that these can be in direct conflict.can be in direct conflict.

What are the presenting problems What are the presenting problems (nightmares, irritability, social withdrawal, (nightmares, irritability, social withdrawal, panic attacks, etc.) and what strategies will panic attacks, etc.) and what strategies will you need to help the client and to help their you need to help the client and to help their support system help them cope better. support system help them cope better.

Focus on the here and now is vital. Focus on the here and now is vital. Remember time concept is poorly developed.Remember time concept is poorly developed.

  

It is vital to have a long-term perspective It is vital to have a long-term perspective about behaviours and factors effecting about behaviours and factors effecting client coping and resiliency.client coping and resiliency.

Consider …Consider … What are the client’s areas of strength?What are the client’s areas of strength? What has allowed them to cope and how?What has allowed them to cope and how? What social networks or friendships can What social networks or friendships can

help support the person in their healing? help support the person in their healing?

Resiliency Resiliency

Strength BuildingStrength Building

It is important to emphasize the ability to It is important to emphasize the ability to cope with emotions and to not have the cope with emotions and to not have the client placed in situations in which they client placed in situations in which they cannot cope (i.e., in the presence of trauma cannot cope (i.e., in the presence of trauma related stressors).related stressors).

Repeatedly learning about one’s coping Repeatedly learning about one’s coping ability is crucial to believing that one can ability is crucial to believing that one can cope and reduces the sense of powerlessness cope and reduces the sense of powerlessness that defines the trauma experience. that defines the trauma experience.

CopingCoping Problems with coping and problem solving are Problems with coping and problem solving are

inherent in cognitive delay. inherent in cognitive delay.

Securing system support and cooperation, Securing system support and cooperation, gathering more information and helping the gathering more information and helping the client develop an emotion vocabulary is client develop an emotion vocabulary is essential. essential.

Providing this foundation allows the involved Providing this foundation allows the involved parties to cope with emotions that are parties to cope with emotions that are brought up as a consequence of addressing brought up as a consequence of addressing the trauma. the trauma.

Treatment frequently starts with helping Treatment frequently starts with helping the client and their system develop good the client and their system develop good coping and emotional problem solving coping and emotional problem solving strategies.strategies.

As you gather more information you will As you gather more information you will be better able to determine whether or be better able to determine whether or not the client will be a good candidate for not the client will be a good candidate for direct one to one type therapy direct one to one type therapy interventions.interventions.

Take the time to determine this and Take the time to determine this and remember there are other options remember there are other options available that may include a consultation available that may include a consultation model or a consultation – therapy model. model or a consultation – therapy model.

Decisions about Decisions about TreatmentTreatment

Decision-making about Decision-making about treatment treatment

Where a client may be too low Where a client may be too low functioning (either cognitively or functioning (either cognitively or communicatively ) to benefit directly communicatively ) to benefit directly from direct one to one therapy (as a from direct one to one therapy (as a given therapist may be able to given therapist may be able to provide it) it is essential that a more provide it) it is essential that a more emotionally based coping skills, emotionally based coping skills, problem solving approach consulting problem solving approach consulting with direct care staff is employed.with direct care staff is employed.

Consultation – Consultation – intervention intervention

Support systems need assistance to Support systems need assistance to understand the manifestations of the client’s understand the manifestations of the client’s trauma , as well as strategies in order to trauma , as well as strategies in order to support the client, and to help them develop support the client, and to help them develop greater resiliency. greater resiliency.

In some cases it may not be possible to In some cases it may not be possible to meaningfully address the trauma directly meaningfully address the trauma directly with the client. with the client.

The goals for intervention must have a The goals for intervention must have a greater emphasis on coping, resiliency, and greater emphasis on coping, resiliency, and self-protection. self-protection.

Consultation Consultation

Many approaches are helpful and Many approaches are helpful and successful. successful.

Those approaches that teach client Those approaches that teach client support systems about the behavioural support systems about the behavioural manifestations of trauma, different manifestations of trauma, different supportive intervention techniques, and supportive intervention techniques, and promote understanding and respect of promote understanding and respect of the client’s emotional states and needs the client’s emotional states and needs are often extremely well suited to this are often extremely well suited to this population. population.

Composite Case Composite Case IllustrationIllustration Ariel is an 22-year-old female who reported Ariel is an 22-year-old female who reported

that she experienced substantial emotional that she experienced substantial emotional and sexual abuse in her family of origin. and sexual abuse in her family of origin.

At the time of the initial referral Ariel was At the time of the initial referral Ariel was living in a supported living arrangement living in a supported living arrangement away from her family and was having away from her family and was having substantial coping difficulties, anxiety, substantial coping difficulties, anxiety, irritability, and anger and aggressive irritability, and anger and aggressive outbursts. outbursts.

Ariel exhibited a substantial history of Ariel exhibited a substantial history of sleep problems, nightmares, irritability, sleep problems, nightmares, irritability, and anxiety. and anxiety.

Ariel already had service providers Ariel already had service providers involved with her and appropriate involved with her and appropriate releases of information were obtained to releases of information were obtained to talk with those working with her at home. talk with those working with her at home.

   Working with Ariel’s service providers Working with Ariel’s service providers

was necessary, as their cooperation was was necessary, as their cooperation was vital for a good history as well as vital for a good history as well as providing for support outside the initial providing for support outside the initial evaluation and subsequent treatment.evaluation and subsequent treatment.

Evaluation process Evaluation process included:included:

semi-structured and structured semi-structured and structured interviews with those working closest interviews with those working closest with Ariel to obtain information with Ariel to obtain information concerning her personal/family and concerning her personal/family and other relevant history information (she other relevant history information (she had difficulty providing a coherent had difficulty providing a coherent history).history).

document review to determine medical document review to determine medical and medication history and level of and medication history and level of functioning in a variety of domains.functioning in a variety of domains.

Formal dual diagnosis, adaptive Formal dual diagnosis, adaptive functioning, and behavioral measures functioning, and behavioral measures were used to obtain indicators of Ariel’s were used to obtain indicators of Ariel’s current emotional functioning and current emotional functioning and behaviors. behaviors.

The results of the interviews file reviews, The results of the interviews file reviews, and mental health assessment revealed and mental health assessment revealed that Ariel’s level of cognitive and adaptive that Ariel’s level of cognitive and adaptive functioning were mildly delayed. functioning were mildly delayed.

Previous speech language Previous speech language assessment revealed she showed mild assessment revealed she showed mild expressive language delay and a expressive language delay and a moderate to severe receptive moderate to severe receptive language delay. Ariel appeared to language delay. Ariel appeared to understand more than she did due to understand more than she did due to her expressive ability and vocabulary.her expressive ability and vocabulary.

Evaluation revealed that Ariel met Evaluation revealed that Ariel met the DSM-IV diagnostic criteria for the DSM-IV diagnostic criteria for Post-Traumatic Stress Disorder Post-Traumatic Stress Disorder (PTSD) and Dysthymic Disorder.(PTSD) and Dysthymic Disorder.

Consultation with service Consultation with service providersproviders

Ariel's anger and irritability were important Ariel's anger and irritability were important reasons for her referral but service providers reasons for her referral but service providers needed to understand how this behavior was needed to understand how this behavior was symptomatic of her depression and trauma symptomatic of her depression and trauma history. Helping them understand how to history. Helping them understand how to approach her when she was emotionally approach her when she was emotionally distressed was essential.distressed was essential.

   Service providers were taught both the Service providers were taught both the

communicative and self-protective functions of communicative and self-protective functions of her behaviors and how to help her practice her behaviors and how to help her practice coping strategies.coping strategies.

InterventionsInterventions Early interventions were devoted to Early interventions were devoted to

teaching Ariel about the purpose of our teaching Ariel about the purpose of our visits, clarifying roles/responsibilities, visits, clarifying roles/responsibilities, establishing goals, and teaching about establishing goals, and teaching about feelings. feelings.

Ariel ’s treatment goals included sleeping Ariel ’s treatment goals included sleeping better, "feeling less tired", and being less better, "feeling less tired", and being less anxious and angry. She was frequently anxious and angry. She was frequently irritable, noncompliant, and verbally irritable, noncompliant, and verbally aggressive and was consistently facing aggressive and was consistently facing consequences for her aggressive behaviour. consequences for her aggressive behaviour.

Ariel used a lot of behaviors to express Ariel used a lot of behaviors to express her feelings and had few words to her feelings and had few words to describe her needs.describe her needs.

Emphasis was placed on helping her Emphasis was placed on helping her develop the vocabulary to develop the vocabulary to communicate assertively and communicate assertively and appropriately.appropriately.

Several pictorial interventions were Several pictorial interventions were used to teach her a vocabulary for used to teach her a vocabulary for feelings. A scaling technique (using 0 feelings. A scaling technique (using 0 to 3) was used to describe level of to 3) was used to describe level of emotional intensity.emotional intensity.

Scaling helped Ariel have more Scaling helped Ariel have more control and be less overwhelmed control and be less overwhelmed when she felt emotions intensely. when she felt emotions intensely.

She initially needed prompting but She initially needed prompting but eventually used it more eventually used it more independently. independently.

Throughout treatment Ariel’s Throughout treatment Ariel’s comprehension of language was comprehension of language was assessed through questioning assessed through questioning techniques. techniques.

Ariel used terms that she had been Ariel used terms that she had been exposed to but did not understand (e.g., exposed to but did not understand (e.g., saying “stressed” when she meant sad).saying “stressed” when she meant sad).

At each session a review was given of At each session a review was given of the previous session’s content and some the previous session’s content and some of the feelings that were talked about.of the feelings that were talked about.

Ariel tended to agree to Ariel tended to agree to recommendations, but would not always recommendations, but would not always follow through due to language, follow through due to language, memory, and comprehension problems memory, and comprehension problems (e.g., taking medications).(e.g., taking medications).

With meds her reduced depressive and With meds her reduced depressive and anxiety symptoms improved her ability to anxiety symptoms improved her ability to engage in treatment and increased engage in treatment and increased communication with her service providers communication with her service providers improved my ability to gauge where Ariel improved my ability to gauge where Ariel was and was not making progress and why. was and was not making progress and why.

   Cognitive behavioral strategies (anger Cognitive behavioral strategies (anger

management and modified relaxation management and modified relaxation techniques) were used in and out of session techniques) were used in and out of session to promote generalizability. to promote generalizability.

Since treatment Ariel exhibited fewer Since treatment Ariel exhibited fewer behavioral, sleep, depressive, and anxiety-behavioral, sleep, depressive, and anxiety-related symptoms.related symptoms.

Ariel has made progress in understanding Ariel has made progress in understanding to some degree the emotional effects of her to some degree the emotional effects of her sexual abuse. sexual abuse.

Although Ariel was showing fewer Although Ariel was showing fewer symptoms and greater coping she still symptoms and greater coping she still required ongoing required ongoing service provider support service provider support to use strategies and to maintain treatment to use strategies and to maintain treatment gains.gains.

Guidelines for DiagnosisGuidelines for Diagnosis

Diagnosis becomes complicated Diagnosis becomes complicated due to the traditional reliance on due to the traditional reliance on the client's ability to give a verbal the client's ability to give a verbal report of symptoms.report of symptoms.