Trauma-informed health care

Trauma-informed health care is a suggested strategy to improve quality of care and health outcomes for patients who have suffered trauma (Brown 2022a, Purtle 2020, CWF-TIC 2016, Raja 2015, SAMHSA-Trauma 2014, Ko 2008). Additional evidence is needed to confirm effects.

Patient health and process outcomes. Available evidence suggests that trauma-informed care (TIC) may reduce use of seclusion and restraints on patients in inpatient or residential treatment settings (Brown 2022a, Purtle 2020, Muskett 2014, Hodgdon 2013, Azeem 2011, Borckardt 2011). TIC may improve patients’ mental health (Hales 2019, Suarez 2014, Cocozza 2005, Morrissey 2005), including post-traumatic symptoms (Oral 2020, Cocozza 2005), reduce substance misuse (Cocozza 2005), and may improve physical health (Weissbecker 2007) when implemented in substance use and mental health treatment settings at a cost similar to standard care (Domino 2005). TIC increases screening for trauma, appropriate referrals, and improves outpatient referral follow-up rates (Brown 2022a, Oral 2020). TIC training interventions may modestly improve quality of care (Brown 2022a) and patient satisfaction (Gundacker 2021, Oral 2020). In emergency department settings, TIC may improve physical and emotional safety for patients identified as victims of violence, suspected human trafficking victims, and youth at risk for suicide (Brown 2022a).

Health care staff outcomes. TIC training interventions improve health care staff knowledge, attitudes, and behaviors (Brown 2022a, Gundacker 2021, Oral 2020, Purtle 2020), including increasing health care provider comfort working with trauma-exposed patients (Powers 2023, Gundacker 2021, Oral 2020). Health care staff, who may have their own personal histories of trauma (Oral 2020), are at higher risk of experiencing workplace-related trauma either directly from patients or indirectly from secondary exposure to traumatic events (Brown 2022a); TIC contributes to safer working environments by reducing assaults on staff (Purtle 2020), decreasing trauma-related triggers, and improving staff resiliency (Brown 2022a, Oral 2020).

Challenges in the health care system. Experts in trauma-informed care suggest that the U.S. medical system is not well set up to provide care that can mitigate traumatic experiences and improve health outcomes for those suffering from trauma (Oral 2020). Barriers to TIC include lack of national guidelines for TIC training, and a demonstrated need for broader systematic support for its implementation (DeAndrade 2024, Chokshi 2020, Dichter 2018). Validated and detailed TIC training protocols need to be adopted broadly (Morra 2024) to effectively guard against re-traumatization (Raja 2021). Elements of the patient experience may directly impact patients’ trust and willingness to disclose traumatic experiences, including short appointment times that leave patients feeling rushed, and decreased continuity of care in academic hospital settings where trainees rotate in and out of a clinic (Matthew 2022). Development of specific and appropriate screening approaches, and tools that help patients understand the link between traumatic experiences, unhealthy behavior, and health outcomes are also recommended (Raja 2021, CWF-TIC 2016). Organizations that screen for trauma should have resources available to address it, on site or by referral (Raja 2015).

Experts suggest that organizations that adopt trauma-informed practices communicate about the process, engage patients and community leaders in organizational planning, train clinical and non-clinical staff, and collaborate with referral sources and partnering organizations (Brown 2022a, CHCS-Menschner 2016). Experts recommend using a multi-system TIC approach that includes health care systems, school systems and other relevant government service institutions to improve health, social, and educational outcomes in communities (Oral 2020).

It is unclear what impact trauma-informed care (TIC) interventions have on health disparities.

Trauma is widespread, both in the U.S. and worldwide (Lewis-O'Connor 2019), and traumatic experiences have significant impacts on well-being and increase risk of many adverse outcomes, including physical and mental health problems, arrest and incarceration, academic difficulties, and homelessness (AAP-Duffee 2021, Oral 2020). People of color, with lower incomes, with less education (AAP-Duffee 2021, Stolbach 2017), or with disabilities (AAP-Duffee 2021), as well as people living with HIV (Kalokhe 2023), sexual or gender minorities, immigrants and refugees, and those involved with the justice-system are more likely to experience trauma (AAP-Duffee 2021). The increased risks of experiencing trauma contributes to the health inequities that are already the most pronounced for people from these groups (AAP-Duffee 2021), such as the higher lifetime prevalence of post-traumatic stress disorder among Blacks compared to other groups (Morra 2024).

Discrimination against marginalized groups increases exposure to traumatic experiences (e.g., hate crimes and police profiling), and residents in communities that are racially and/or economically segregated may be at higher risk of exposure to neighborhood violence and resulting traumatic loss, which can contribute to negative physical and mental health outcomes (Stolbach 2017). Marginalized groups may also experience historical trauma, the collective, transgenerational emotional and psychological injury of specific ethnic, racial, or cultural groups, and their descendants, who have experienced major events of oppression such as forced displacement or slavery (AAP-Duffee 2021).

The concept of trauma-informed care (TIC) emerged in the 1990s with the creation of a TIC framework by the Substance Abuse and Mental Health Administration (SAMHSA) based on research to improve the care provided to survivors of sexual violence and people with substance use disorders (Brown 2022a). This was reinforced by the landmark Adverse Childhood Experiences (ACEs) study, which demonstrated how common and pervasive trauma experiences are across the U.S. (Morra 2024). Initially, trauma-informed practice was implemented in the mental health, substance misuse, and child welfare sectors (Purtle 2020). It has since attracted broader interest and support for implementation in the U.S.; congressional bills related to trauma-informed approaches increased from zero in 2010 to 28 in 2015 (Purtle 2020).

• What resources and partnerships are needed to systematically incorporate trauma-informed care into your local health care settings? Are there opportunities for community members or patients to support change?
• What traumatic events have patients experienced? Who is more at risk of exposure to collective trauma in your community?
• Is there trauma-informed training available for health care providers and staff in your community? Does the training help recognize stereotypes and biases in addition to teaching trauma’s impact on youth and their families?
• Are there appropriate resources to adequately implement trauma-informed care as standard of practice? Do they encourage collaboration across sectors to improve care for children and families?

Trauma-informed care (TIC) is being introduced in health care organizations and clinics across the U.S.. The Centers for Disease Control and Prevention (CDC) launched the Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action in 2023, which has funded 12 programs across the country focused on preventing adverse childhood experiences through data to action (CDC-Preventing ACEs). In January 2020, California implemented the ACEs Learning and Quality Improvement Collaborative to improve readiness to provide TIC and increase trauma screenings (Machtinger 2024). In 2019, the Center for Health Care Strategies (CHCS) began an initiative to implement trauma-informed and family-centered pediatric care and is currently supporting a multi-state learning community to identify and adopt best practices across health care institutions (CHCS-Child health transformation).

TIC models such as Sanctuary (a theory-based approach) and the Risking Connection Training Model can support health care organizations adopt trauma-informed practices (CEBC). Risking Connection has been adapted into a continuing medical education course called Trauma-Informed Medical Care (Green 2015).

CPTS-Health care toolbox - Center for Pediatric Traumatic Stress (CPTS). Health care toolbox.

Machtinger 2019 - Machtinger, E. L., Davis, K. B., Kimberg, L. S., Khanna, N., Cuca, Y. P., Dawson-Rose, C., Shumway, M., Campbell, J., Lewis-O’Connor, A., Blake, M., Blanch, A., & McCaw, B. (2019). From treatment to healing: Inquiry and response to recent and past trauma in adult health care. Women’s Health Issues, 29(2), 97–102.

PACEs-TIC toolkits - PACEs Connection. Positive & adverse childhood experiences (PACEs): Trauma-informed care (TIC) toolkits.

SAMHSA-NCTIC - Substance Abuse and Mental Health Services Administration (SAMHSA). National Center for Trauma-Informed Care (NCTIC).

SAMHSA-NCTIC TIP57 - Substance Abuse and Mental Health Services Administration (SAMHSA). National Center for Trauma-Informed Care (NCTIC). (2014). Trauma-informed care in behavioral health services. Treatment Improvement Protocol (TIP) Series 57. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); 2014 HHS Publication No. (SMA) 13-4801.

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AAP-Duffee 2021 - Duffee, J., Szilagyi, M., Forkey, H., & Kelly, E. T. (2021). Trauma-informed care in child health systems. Pediatrics, 148(2), e2021052579.

AIR-TIC - American Institutes for Research (AIR). Trauma-informed care (TIC).

Azeem 2011* - Azeem MW, Aujla A, Rammerth M, Binsfeld G, Jones RB. Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing. 2011;24(1):11–15.

Borckardt 2011* - Borckardt JJ, Madan A, Grubaugh AL, et al. Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services. 2011;62(5):477–483.

Brown 2022a - Brown, T., Ashworth, H., Bass, M., Rittenberg, E., Levy-Carrick, N., Grossman, S., Lewis-O’Connor, A., & Stoklosa, H. (2022). Trauma-informed care interventions in emergency medicine: A systematic review. Western Journal of Emergency Medicine, 23(3), 334–344.

CDC-Preventing ACEs - Centers for Disease Control and Prevention (CDC). (2024, May 16). Program: Essentials for childhood: Preventing adverse childhood experiences through data to action. Retrieved October 22, 2024.

CEBC - California Evidence-Based Clearinghouse for Child Welfare (CEBC). Information and resources for child welfare professionals: List of programs.

CHCS-Child health transformation - Center for Health Care Strategies (CHCS). (n.d.). Child Health Transformation Resource Center. Retrieved October 22, 2024.

CHCS-Menschner 2016 - Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation. Hamilton, NJ: Center for Health Care Strategies (CHCS); 2016.

Chokshi 2020 - Chokshi, B., Walsh, K., Dooley, D., Falusi, O., Deyton, L., & Beers, L. (2020). Teaching trauma-informed care: A symposium for medical students. MedEdPORTAL, 11061.

Cocozza 2005* - Cocozza JJ, Jackson EW, Hennigan K, et al. Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment. 2005;28(2):109–119.

CWF-TIC 2016 - Hostetter M, Klein S. In focus: Recognizing trauma as a means of engaging patients. Transforming Care: Reporting on Health System Improvement. New York: The Commonwealth Fund (CWF); 2016.

DeAndrade 2024* - DeAndrade, S., Pelletier, A., Grossman, S., Lewis-O’Connor, A., Dutton, C., Royce, C. S., & Bartz, D. (2024). Trauma-informed care training in U.S. and Canadian Ob/Gyn residencies. Violence Against Women, 10778012241230328.

Dichter 2018 - Dichter, M. E., Teitelman, A., Klusaritz, H., Maurer, D. M., Cronholm, P. F., & Doubeni, C. A. (2018). Trauma-informed care training in family medicine residency programs: Results from a CERA Survey. Family Medicine, 50(8), 617–622.

Domino 2005* - Domino ME, Morrissey JP, Chung S, et al. Service use and costs for women with co-occurring mental and substance use disorders and a history of violence. Psychiatric Services. 2005;56(10):1223–1232.

Green 2015 - Green BL, Saunders PA, Power E, et al. Trauma-informed medical care: A CME communication training for primary care providers. Family Medicine. 2015;47(1):7–14.

Gundacker 2021 - Gundacker, C., Barreto, T. W., & Phillips, J. P. (2021). A scoping review of trauma-informed curricula for primary care providers. Family Medicine, 53(10), 843–856.

Hales 2019* - Hales, T. W., Green, S. A., Bissonette, S., Warden, A., Diebold, J., Koury, S. P., & Nochajski, T. H. (2019). Trauma-informed care outcome study. Research on Social Work Practice, 29(5), 529–539.

Hodgdon 2013* - Hodgdon HB, Kinniburgh K, Gabowitz D, Blaustein ME, Spinazzola J. Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework. Journal of Family Violence. 2013;28(7):679-692.

Kalokhe 2023* - Kalokhe, A. S., Adam, E., Colasanti, J., Livingston, M., Root, C., & Sales, J. M. (2023). Differences in trauma-informed care implementation by clinic-level factors across Ryan White HIV Clinics in the Southeastern United States. AIDS Care, 35(2), 222–229.

Ko 2008* - Ko SJ, Ford JD, Kassam-Adams N, et al. Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice. 2008;39(4):396–404.

Lewis-O'Connor 2019 - Lewis-O’Connor, A., Warren, A., Lee, J. V., Levy-Carrick, N., Grossman, S., Chadwick, M., Stoklosa, H., & Rittenberg, E. (2019). The state of the science on trauma inquiry. Women’s Health, 15, 1745506519861234.

Long 2022* - Long, T., Aggar, C., Grace, S., & Thomas, T. (2022). Trauma informed care education for midwives: An integrative review. Midwifery, 104, 103197.

Long 2024* - Long, T., Aggar, C., & Grace, S. (2024). Trauma-informed care education for midwives: Does education improve attitudes towards trauma-informed care? Midwifery, 131, 103950.

Machtinger 2024 - Machtinger, E. L., Eberhart, N. K., Ashwood, J. S., Jones, M., Sanchez, M., Lightfoot, M., Kuo, A., Malika, N., Leba, N. V., Williamson, S., & McCaw, B. (2024). Clinic readiness for trauma-informed health care is associated with uptake of screening for adverse childhood experiences. The Permanente Journal, 28(1), 100–110.

Matthew 2022 - Matthew, A., Moffitt, C., Huth-Bocks, A., Ronis, S., Gabriel, M., & Burkhart, K. (2022). Establishing trauma-informed primary care: Qualitative guidance from patients and staff in an urban healthcare clinic. Children, 9(5), 616.

Morra 2024 - Morra, C., Nguyen, K., Sieracki, R., Pavlic, A., & Barry, C. (2024). Trauma-informed care training in trauma and emergency medicine: A review of the existing curricula. Western Journal of Emergency Medicine, 25(3).

Morrissey 2005* - Morrissey JP, Jackson EW, Ellis AR, et al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services. 2005;56(10):1213–1222.

Mosley 2020* - Mosley, E. A., & Lanning, R. K. (2020). Evidence and guidelines for trauma-informed doula care. Midwifery, 83, 102643.

Muskett 2014* - Muskett C. Trauma-informed care in inpatient mental health settings: A review of the literature. International Journal of Mental Health Nursing. 2014;23(1):51-59.

Oral 2020 - Oral, R., Jennissen, C., Wojciak, A. S., Segal, R., Wibbenmeyer, L., Nielsen, A., Conrad, A., Zarei, K., Coohey, C., & Peek-Asa, C. (2020). Nationwide efforts for trauma-informed care implementation and workforce development in healthcare and related fields: A systematic review. The Turkish Journal of Pediatrics, 62(6), 906–920.

Powers 2023* - Powers, A., Langhinrichsen-Rohling, R. A., Sonu, S. C., Haynes, T., & Lathan, E. C. (2023). Brief trauma-informed care training to enhance health care providers’ knowledge, comfort, and implementation of trauma-informed care in primary care clinics: A pilot effectiveness study. Psychological Services.

Purtle 2020* - Purtle, J. (2020). Systematic review of evaluations of trauma-informed organizational interventions that include staff trainings. Trauma, Violence, & Abuse, 21(4), 725–740.

Raja 2014* - Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: Providing trauma-informed care. The Journal of the American Dental Association. 2014;145(3):238–245.

Raja 2015* - Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine: Current knowledge and future research directions. Family & Community Health. 2015;38(3):216-226.

Raja 2021* - Raja, S., Rabinowitz, E. P., & Gray, M. J. (2021). Universal screening and trauma informed care: Current concerns and future directions. Families, Systems, & Health, 39(3), 526–534.

SAMHSA-Trauma 2014 - Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); 2014.

Stolbach 2017* - Stolbach, B. C., & Anam, S. (2017). Racial and ethnic health disparities and trauma-informed care for children exposed to community violence. Pediatric Annals, 46(10).

Strait 2020 - Strait, J., & Meagher, S. (2020). Trauma-informed care in pediatrics: A developmental perspective in twelve cases with narratives. The Permanente Journal, 24(2), 19.045.

Suarez 2014 - Suarez E, Jackson DS, Slavin LA, Michels MS, McGeehan KM. Project Kealahou: Improving Hawai’i’s system of care for at-risk girls and young women through gender-responsive, trauma-informed care. Hawai’i Journal of Medicine & Public Health. 2014;73(12):387–392.

Varghese 2022* - Varghese, L., & Emerson, A. (2022). Trauma-informed care in the primary care setting: An evolutionary analysis. Journal of the American Association of Nurse Practitioners, 34(3), 465–473.

Weissbecker 2007* - Weissbecker I, Clark C. The impact of violence and abuse on women’s physical health: Can trauma-informed treatment make a difference? Journal of Community Psychology. 2007;35(7):909–923.

WI DHS-Resilient Wisconsin - Wisconsin Department of Health Services (WI DHS). (2024). Resilient Wisconsin. Retrieved October 22, 2024.