What Is Trauma-Informed Care & How to Deliver It

What Is Trauma-Informed Care?

According to the Trauma-Informed Care Implementation Resources Center, which is a part of the Center for Health Care Strategies (CHCS), trauma-informed care is the consideration that a patient’s life experiences shape their health and how they engage in healthcare.

“A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient’s life situation — past and present — in order to provide effective health care services with a healing orientation,” CHCS says on its website.

For example, knowing and understanding that a patient is a foreign refugee who has fled war will help healthcare providers determine how they can most effectively and respectfully deliver healthcare. Patients who have experienced adverse life events may be reticent to trust, especially in a medical setting, and healthcare organizations need to develop strategies to build that trust and serve these patients well.

Trauma-informed care is important because experiences of trauma can be inherently linked to health and wellness. Numerous studies have tied adverse life events, particularly adverse childhood events (ACEs) to risky health behavior. In a seminal 1998 study, researchers showed a connection between ACEs and risky health behavior that can cause death in adulthood.

And according to the Substance Abuse and Mental Health Services Administration (SAMHSA), those findings further prove the need for trauma-informed care.

“Because of the ACE study, and other subsequent research, health care policymakers and providers increasingly recognize that exposure to traumatic events, especially as children, heighten patients’ health risks long afterward,” SAMHSA advocated in an issue brief written by CHCS and the Robert Wood Johnson Foundation. “As health care providers grow aware of trauma’s impact, they are realizing the value of trauma-informed approaches to care.”

Ultimately, trauma-informed care is a wraparound approach to care that aims to make the healthcare experience better for all patients, regardless of previous adverse experiences. According to CHCHS, trauma-informed care seeks to:

• Realize the widespread impact of trauma and understand paths for recovery;
• Recognize the signs and symptoms of trauma in patients, families, and staff;
• Integrate knowledge about trauma into policies, procedures, and practices; and
• Actively avoid re-traumatization.

It should be emphasized that there is no one singular definition of trauma, most experts agree. According to SAMHSA, some examples of trauma may include, but are not limited to:

• Experiencing or observing physical, sexual, and emotional abuse
• Childhood neglect
• Having a family member with a mental health or substance use disorder
• Experiencing or witnessing violence in the community or while serving in the military; and
• Poverty and systemic discrimination.

It should also be emphasized that healthcare organizations should not reserve trauma-informed care for patients who have reported a trauma. Such a system relies on self-reports, and trauma victims are often reticent to report or relive their adverse experiences; in other words, some trauma victims may fall through the cracks. Approaching all patients with a trauma-informed mindset will be essential, experts indicate.

Benefits of Trauma-Informed Care

As noted above, trauma-informed care is important for making the patient feel more comfortable and trusting in a medical environment. In turn, patients may become more engaged and activated in their own health and personal wellness.

“Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness,” CHCS says on its website. “It can also help reduce avoidable care and excess costs for both the health care and social service sectors.”

There hasn’t been much concrete study of the impacts trauma-informed care can have. In 2018, researchers looked at the feasibility of implementing an operationalized trauma-informed care approach in an addiction and rehabilitation center, and found it both improved organization culture and boosted patient satisfaction and planned discharges.

Areas for future study may include the impacts trauma-informed care has on patient engagement, patient experience, and treatment adherence or access.

Implementing trauma-informed care

Like many patient engagement and experience principles, trauma-informed care will look different in every organization and with every patient. Because every patient’s trauma is different, trauma-informed care cannot be scripted or prescribed.

In fact, trauma-informed care does not need to be reserved only for patients who report experiencing an adverse event, nor should it be reserved only for patient-provider communication. Rather, it should be baked into everything a healthcare organization does for every patient.

“A comprehensive approach to trauma-informed care must be adopted at both the clinical and organizational levels,” CHCS said, adding its own emphasis. “Too frequently, providers and health systems attempt to implement trauma-informed care at the clinical level without the proper supports necessary for broad organizational culture change.”

When organizations reserve trauma-informed care for patient-provider communication only, it creates an “unsustainable” shift in clinic operations, CHCS added. It also fails to acknowledge how non-clinical staff can both be healers or cause re-traumatization.

Clinical level trauma-informed care

Trauma-informed care delivered on the clinical level, or as a part of patient-provider interactions, relies heavily on empathy and understanding. According to SAMHSA, clinicians practicing trauma-informed care should consider:

• Involving patients in the treatment process
• Screening for trauma
• Training staff in trauma-specific treatment approaches
• Engaging referral sources and partnering organizations

Clinical care that is trauma-informed will emphasize patient empowerment, patient choice and shared decision-making, and patient safety.

Clinicians will need to consider trauma with many choices they make during the clinical encounter. For example, Anita Ravi, MD, the CEO of the PurplEHealth Foundation in New York City, said she’s very careful about how she begins exams with the mostly low-income people who visit her clinic. Ravi serves a traditionally marginalized population, many of whom have experienced some sort of trauma in their lives.

When she starts an exam, Ravi, a family medicine physician, said she’s judicious about how she asks patients to take off their underwear as to not re-traumatize them. These patients may be rape victims, or maybe they only have one pair that needed to be cleaned. Ravi said it’s not her job to judge or make patients feel further discomfort.

“Now I change the language in how I talk about it with people,” Ravi said in a previous interview. “I say, ‘Okay, and if you just want to undress from the waist down, and you can put everything on the side.’ I don't want to imply societal pressures anymore. I'm trying to be as respectful or sensitive as possible, and you just have to learn and do better each time.”

Again, trauma-informed care is not a script; rather, it’s a philosophy that healthcare providers should integrate into their existing patient-provider communication skills. In doing so, they can assure that the clinical experience does not re-traumatize patients.

Organization level trauma-informed care

Re-traumatization can also occur at a systems level, meaning healthcare organizations should look at how their non-clinical processes can harm patients.

“Changing organizational practices to fit trauma-informed principles will transform the culture of a health care setting,” according to SAMHSA. “Experts recommend that organizational reform precede the adoption of trauma-informed clinical practices.”

Trauma-informed care at the organization level can include anything from how the clinic is designed to certain policies it upholds. It may also include the accessibility of clinical and social services.

Physical considerations for organization-level trauma-informed care may include the lighting in parking areas, monitoring who comes in and out of the building, judicious positioning of security personnel, and welcoming language of signage.

Organizations should also acknowledge the role that their non-clinical staff members, like front officer workers or administrators, play in trauma-informed care. In addition to training clinical staff in patient communication, organizations should assure non-clinical staff receive the same education.

For non-clinical staff, trauma-informed care means more than just being a welcoming, smiling face in the clinic—although that’s helpful. Non-clinical staff should also be trained in conflict resolution, compassionate communication, and maintaining privacy and confidentiality.

Non-clinical staff members should also understand how important maintaining a schedule is. That not only includes patient scheduling but also providing patients with the information they need before a visit. Non-clinical staff can help communicate what a patient might expect during the encounter and should notify patients if there are upcoming changes to the visit.

Healthcare organizations working to embed trauma-informed care into their operations may consider a patient advisory council. PACs help provide the patient perspective about systems-level changes. When organizations have a PAC, especially a diverse one, they can incorporate patient needs and preferences into their organizational culture and improve the accessibility and usability of certain services.

Trauma-informed care cannot follow a singular roadmap, experts agree. There are many ways healthcare organizations can practice trauma-informed care, and that will likely depend upon the unique needs of the patient population and the patient-provider relationship.

Regardless of specific needs and skillsets, however, CHCS said healthcare organizations can begin practicing trauma-informed care by building awareness and buy-in among staff while also protecting the burnout levels of staff members themselves.

From there, organizations should consider workforce and hiring decisions with its specific trauma-informed care principles and continue to foster a safe environment in which staff members may practice trauma-informed care.