Trauma-informed health care
Trauma-informed care (TIC) is a framework that requires change to organizational practices, policies, and culture1 that reflect an understanding of the widespread impact of trauma and potential paths for recovery, and actively seek to prevent re-traumatization2. In health care, TIC usually includes universal trauma precautions and practice changes for patients with a known trauma history. Universal trauma precautions emphasize patient-centered communication and care, often with careful screening for trauma3, safe clinical environments (e.g., quiet waiting areas), and shared decision making for all patients4. Under a trauma-informed clinical approach, providers collaborate across disciplines, use streamlined referral pathways, and remain aware of their own trauma histories and stress levels when they know patients have experienced trauma3, 4. TIC can also be implemented in oral health settings5.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved quality of care
Improved health outcomes
Improved mental health
Reduced post-traumatic stress
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced substance abuse
What does the research say about effectiveness?
Trauma-informed health care is a suggested strategy to improve quality of care and health outcomes for patients who have suffered trauma2, 3, 4, 6. Available evidence suggests that trauma-informed care (TIC) may reduce use of seclusion and restraints in inpatient mental health settings7, 8, 9, and improve mental health and reduce substance abuse when implemented as part of an integrated social services and health care model10, 11, 12, 13. Additional evidence is needed to confirm effects.
Results from the Women, Co-occurring Disorders and Violence Study (WCDVS) suggest TIC can improve post-traumatic symptoms and mental health, reduce drug use problem severity11, 13, and may also improve physical health14, particularly with intensive counseling that addresses substance abuse, mental health, and trauma-related issues together11, 13, at a cost similar to usual care12. Initial results from Project Kealahou, a Hawaii-based TIC model for at-risk female youth, also suggest improvements in both clinical and functional domains with minimal cost increases10. A Massachusetts pilot project that adapts the Attachment, Regulation and Competency (ARC) framework in two youth residential treatment settings indicates decreases in trauma-related symptoms, particularly PTSD symptoms, and use of restraints15.
Experts suggest that organizations that adopt trauma-informed practices communicate about the transformation process, engage patients in organizational planning, train clinical and non-clinical staff, work to create safe environments for patients and staff, and engage with referral sources and partnering organizations16. Screening approaches that help patients understand the link between traumatic experiences, unhealthy behavior, and health outcomes are also recommended4, and organizations that screen for trauma should have resources available to address it, on site or by referral3.
Implementation Examples
Trauma-informed care (TIC) is being introduced in health care organizations and clinics across the country. In December 2015, the Center for Health Care Strategies launched the Advancing Trauma-Informed Care initiative at 6 health care organizations to understand how trauma-informed approaches can be implemented across the health care sector. Pilot sites reflect a range of health care settings, including the Montefiore Medical Group in Bronx, NY, and the San Francisco Department of Public Health in CA16.
TIC models such as Sanctuary and Risking Connection can support the transition to trauma-informed practices in health care organizations17. Risking Connection has been adapted into a continuing medical education course called Trauma-Informed Medical Care18.
Implementation Resources
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.
CPTS-Health care toolbox - Center for Pediatric Traumatic Stress (CPTS). Health care toolbox.
Footnotes
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1 AIR-TIC - American Institutes for Research (AIR). Trauma-informed care (TIC).
2 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.
3 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.
4 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.
5 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.
6 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.
7 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.
8 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.
9 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.
10 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.
11 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.
12 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.
13 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.
14 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.
15 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.
16 CHCS-Menschner 2016 - Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation. Hamilton, NJ: Center for Health Care Strategies (CHCS); 2016.
17 CEBC - California Evidence-Based Clearinghouse for Child Welfare (CEBC). Information and resources for child welfare professionals: List of programs.
18 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.
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