Fiorenzo Ranieri
In clinical work with adults and adolescents, one of the main challenges is understanding how a traumatic or excessively distressing event has changed a person’s life. We are not concerned only with symptoms, but with the disruption of existential continuity: relationships, energy, everyday functioning, self-perception, and the capacity to imagine the future.
This change is often silent. It may not emerge during initial clinical interviews and can remain hidden for months, sometimes even years.
Within a psychotherapeutic approach, the clinical interview remains the primary tool for understanding the subjective dimension of trauma, the way in which the person speaks about it (or does not speak about it), the quality of relationships, the bodily and emotional experiences associated with the event, and the capacity to represent it mentally.
The clinical encounter — particularly during adolescence — provides a space in which the therapist can directly observe aspects that no questionnaire can fully capture: emotional fluctuations, defensive patterns, brief episodes of withdrawal, and sudden lapses of attention when a painful memory is approached.
Alongside the clinical interview, however, certain instruments can provide a complementary perspective. They do not replace the therapeutic relationship, but they make it possible to explore areas that often remain obscure because the person does not know how to describe them, does not consider them important, minimises or normalises them, or because they emerge only when investigated through specific questions.
Brief instruments, which can also be administered as semi-structured interviews, allow us to explore — sensitively and using an internationally shared language — the dimensions most affected by trauma: everyday functioning, perceived quality of life, social participation, and the feeling of still being “oneself”.
From this perspective, two instruments developed by the World Health Organization (WHO) are particularly useful. They can be used either separately or together with adults and adolescents aged 15 and over: the WHOQOL-BREF, which assesses perceived quality of life, and the WHODAS 2.0 (36-item version), which assesses functioning and disability according to the ICF model.
These are brief, straightforward questionnaires that can be used in clinical and psychotherapeutic settings and — when necessary — also in more structured assessments, such as evaluations in forensic psychology.
To facilitate their use in clinical and psychotherapeutic settings, I provide links to the WHOQOL-BREF (also available from this link) and the WHODAS 2.0 – 36-item version (also available from this link).
The AltreAdolescenze website also provides an Excel file for automatic scoring of the individual questionnaires, allowing individual item scores to be entered, domain means to be calculated, scores to be transformed onto a 0–100 scale, and graphs and interpretative summaries to be generated. These can also be useful for monitoring changes over the course of therapy.
In my clinical experience, it is useful to administer both instruments to the same person. A brief description of the two questionnaires follows.
WHOQOL-BREF
Perceived quality of life in physical, psychological, relational and environmental domains
The WHOQOL-BREF measures how a person evaluates their life and well-being following a stressful or traumatic event. It consists of 26 items rated on a 1–5 scale, organised into four domains:
- Physical health (energy, fatigue, pain, activities of daily living)
- Psychological health (self-esteem, positive/negative feelings, body image)
- Social relationships (support, emotional relationships or intimacy)
- Environment (safety, resources, opportunities for leisure, quality of the surrounding environment)
There are also two global items:
“How would you rate your quality of life?”
“How satisfied are you with your health?”
When is it useful in clinical work?
When there is a general decline in well-being that is difficult to define. When the person says “I feel bad” but is unable to identify where the change lies. When trauma has had a widespread impact on different areas of life (school, work, relationships, body). When the aim is to monitor the effectiveness of a therapeutic process over time.
How is it administered?
Self-administered or as a semi-structured interview; 5–10 minutes; suitable for adolescents aged 15 and over (between 12 and 14, a youth version is preferable).
Interpretation
Scores for the four domains are transformed onto a 0–100 scale:
0 = very poor quality of life
100 = very high quality of life
This transformation makes it possible to compare the different areas of a person’s life immediately.
WHODAS 2.0 – 36 items
Everyday functioning according to the ICF model
WHODAS is the WHO measure of actual functioning over the previous four weeks. It assesses six core domains:
- Cognition (concentration, communication)
- Mobility (moving around, walking)
- Self-care (washing, dressing, eating)
- Getting along with others
- Life activities (household and everyday activities)
- Participation (social roles, involvement, community life)
Each item is rated from 1 (no difficulty) to 5 (extreme difficulty).
When is it useful in clinical work?
When the person maintains good emotional insight but has difficulty “functioning”. In cases of social withdrawal or reduced activity. When trauma has affected participation in school or working life. When it is necessary to identify areas of difficulty that have not emerged explicitly during the clinical interview. It can also be useful for describing a person’s level of autonomy and participation in a way that can be readily communicated to others.
Administration
Time: 10–15 minutes; self-administered, clinical interview or proxy interview; suitable for adults and adolescents aged 15 and over (ages 13–14 only when fully comprehensible).
Interpretation
Raw mean score from 1–5, WHO transformation to a 0–100 scale, and profile across the six domains.
WHODAS makes it possible to see quickly which areas of life are most impaired, providing an extremely useful overview both in clinical practice and in integrated assessment and treatment pathways.
Why WHOQOL and WHODAS Are Particularly Useful After Trauma
Two people who have experienced the same traumatic event may show very different patterns.
For example, one person may maintain adequate functioning while reporting a profound decline in well-being; another may continue to perceive themselves as “doing well” despite serious difficulties in social participation; yet another may alternate periods of clear functioning with phases of marked withdrawal.
WHOQOL and WHODAS make it possible to distinguish between:
- subjective experience (WHOQOL);
- impact on actual functioning (WHODAS);
- consistency or discrepancy between these two dimensions.
These instruments complement clinical assessment; they do not replace it. They may be particularly useful when trauma is difficult to verbalise or when the person tends to minimise, confuse or amplify certain aspects of their experience.
Essential References
World Health Organization. (1998). WHOQOL User Manual. Geneva: WHO. (Original manual for WHOQOL-100 and WHOQOL-BREF)
World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva: WHO. (Theoretical model underlying WHODAS 2.0)
World Health Organization. (2010). Measuring Health and Disability: Manual for WHO Disability Assessment Schedule WHODAS 2.0. Geneva: WHO. (Official WHODAS 2.0 manual)
The WHOQOL Group. (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine, 28(3), 551–558.
De Girolamo, G., Rucci, P., Scocco, P., Becchi, A., Coppa, F., & D’Addario, A. (2000). Quality of life assessment: Validation of the Italian version of the WHOQOL-Bref. Epidemiologia e Psichiatria Sociale, 9(1), 45–55. (Italian validation of the WHOQOL-BREF)
Üstün, T. B., Kostanjsek, N., Chatterji, S., & Rehm, J. (Eds.). (2010). Measuring Health and Disability: Manual for WHO Disability Assessment Schedule WHODAS 2.0. Geneva: WHO.
Federici, S., Meloni, F., & Vicentini, C. (2023). Psychometric properties of the Italian proxy version of the WHODAS-Child for autism spectrum disorder. Journal of Intellectual Disability Research. (Preliminary Italian adaptation of the WHODAS-Child)
Group WHOQOL. (1995). The World Health Organization Quality of Life assessment (WHOQOL): Position paper from the World Health Organization. Social Science & Medicine, 41(10), 1403–1409.