Written by Annie Lewis-O’Connor
TRAUMA-INFORMED CARE has become a popular term that is
commonly referenced today in a myriad of systems, such as schools, substance
use treatment, health care and behavioral health. Yet its application into
practice has much variability. This article will address:
Understanding what defines trauma varies from person
to person and is dependent on an individual’s life experiences, as well as their
personal and professional attributes. Over the last few decades, we have become
keenly aware that not everyone who is impacted by trauma is negatively impacted—but
for those who are, we must seek to understand what that impact is and what
would help that person to heal.
For example, look at the more than 440,000 lives lost to
COVID-19 in the United States and the impact each death had on the family of
each victim. Consider the impact the pandemic has had on people infected with
the virus, the economic challenges, and the racial injustices, including
Whether you work with people through legal, health, or
community services, understanding how this trauma has impacted an individual
helps to inform the way in which you deliver those services. Prevalence of
trauma is well documented. Benjet et al conducted general
population surveys in 24 countries (n=68,894 adults) across six continents.
Researchers assessed for exposures to some 29 traumatic event types. Findings
indicated that more than 70% of respondents reported a traumatic event and
30.5% were exposed to four or more traumatic events. Over half of the traumatic
events reported in the study included witnessing death or serious injury, the
unexpected death of a loved one, being mugged, being in a life-threatening
automobile accident, or experiencing a life-threatening illness or injury. Exposures
to trauma varied by country and socio-demographic; history of prior traumatic
events and further analysis into race and ethnicity would further help to
inform root causes. Exposure to interpersonal violence had the strongest
association with subsequent traumatic events (Benjet 2016).
Similar large survey studies in the U.S. reveal a high
prevalence of traumatic life experiences, with 90% reporting a serious adverse
lifetime event. First launched in 2010 by CDC’s National Center for Injury
Prevention and Control, the National Intimate Partner and Sexual Violence
Survey (NISVS) is an ongoing, nationally representative survey that assesses
intimate and sexual violence, stalking, and victimization among adult women and
men in the United States (Kilpatrick et al 2013; Breeding et al 2014; Black et
A review of the literature finds a wide range of definitions
for trauma. According to the Substance Abuse and Mental Health Services
Administration (SAMHSA), trauma includes “an event, series of events, or set of
circumstances that is experienced by an individual as physically or emotionally
harmful or life threatening and has lasting adverse effects on the individual’s
health and well-being.” (SAMHSA 2014) For the purpose of this article, trauma
will be defined as individual, interpersonal, and collective traumas
(Lewis-O’Connor et al 2019).
Individual trauma includes personal experiences, either direct
or witnessed. For example, individual trauma may include a poor diagnosis, the loss
of a loved one, a fall, a motor vehicle crash, witnessing a traumatic event, or a traumatic
Interpersonal trauma includes those experiences
that occur in the context of a relationship, such as child maltreatment,
domestic and sexual violence, human trafficking (labor and sex), or elder abuse.
Collective trauma refers to the cultural, historical, and
socio-political trauma that impacts individuals and communities across generations.
Collective trauma includes institutional barriers, and social determinant of
health (“isms”, poverty, food and housing insecurity, economic, and education inequities).
These forms of trauma are not mutually exclusive; rather,
there is often an intersection between the various forms (Lewis-O’Conner et al
2019), as shown in Figure 1.
In 1994, SAMHSA convened the Dare to Vision conference, an event
that was intentionally designed to bring trauma to the foreground. It was the
first national conference in which women who had survived trauma talked about
their experiences and ways in which standard practices in hospitals
re-traumatized and, often, triggered memories of previous abuse (SAMHSA 2014).
Today, trauma-informed care is represented with six guiding
principles. These principles are grounded in evidence and that evidence offers
us an opportunity that should inform our policies and procedures.
As we consider the challenges and opportunities to embed trauma-informed
approaches systemically, we must consider developing a pedagogy that advances health
equity and social justice with mindful attention and intention to traumas that
are rooted in structural racism, oppression, explicit bias, and stigma. We
provide services to diverse individuals; thus, we must be proactive in employing
policies and procedures that use a social-justice lens. One tool that may
advance these efforts is applying the six principles of trauma-informed care. Ideally
these principles are applied with a triple aim: organizationally (policies and
procedures); staff to patient/client; and staff to staff.
GUIDING PRINCIPLES OF TRAUMA-INFORMED CARE• Safety—Physical & Psychological• Transparency & Trustworthiness• Cultural, Historical, & Gender Acknowledgment• Peer Support• Empowerment, Voice, and Choice• Collaboration & Mutuality
As you look at these guiding principles, let’s consider
translating these through the eyes of a victim or survivor. This person might
What are they going to ask me? Do I have
to tell them everything?
Will I react to the questions, and will
they think I am crazy because I still get triggered and have body memories? Are
they going to do something that hurts? I really have terrible pain tolerance.
I wonder if they will give me choices,
will they hear me? Will they repeat things when I don’t understand, or will
that annoy them? Will they help me to connect with other professionals that
they want me to see, or will I need to figure this out on my own?
Will they understand what I bring with
me from my culture, my historical background—my race, my culture, my ethnicity?
Gosh I hope they don’t ask: Why did you… Or Why didn’t you…
I wonder, what are they typing into
the computer? Who is going to see this and are they capturing what I am saying?
I hope I will feel safe, that I can
share, that I can get help and support, that I can find and use my voice and
that I can be acknowledged for who I am—not what happened to me.
Principle 1: Safety—Physical & Psychological
When considering the principle of safety, you
want to consider physical and psychological safety. What are the
individual’s strengths? How do they best cope with stress? What triggers them,
and what is helpful? For example, a patient who suffered a non-fatal
strangulation might share that she plays a musical instrument, that she does
not like her neck or mouth examined, and that she copes best when receiving
small amounts of information at a time.
Principle 2: Transparency & Trustworthiness
Transparency and trustworthiness are key
principles for people who have experienced trauma, violence, or abuse. Many
victims and survivors trusted someone who hurt them, and sometimes the systems
that were intended to help actually re-traumatized individuals. State with
clarity what you can and can’t do.
Principle 3: Cultural, Historical, & Gender
Acknowledge how structural barriers and bias have
marginalized people of color. Cultural, historical, and gender acknowledgment
requires everyone to receive training on unconscious bias and stigma, self-reflection,
and a commitment to system changes.
Principle 4: Peer Support
Peer support is not only the support we put in place
for patients and clients, but also the support we build into our structures to
support each other. Do you hold optional debriefs? Do you have trained peer
supporters? Do you assess staff for compassion fatigue or burnout? Do you
promote opportunities for team building? For patients and clients, do you always
assess their available resources? Do you assess for social determinants of
health and connect the patient to additional services needed?
Principle 5: Empowerment, Voice, and Choice
While this principle is likely one to which we might all personally
relate, it is often the principle that we might fall short on. Do you do things
for or to a patient or client, or do you do things with them?
Do you lift their strengths, or do you focus only on deficits and pathology? Do
you accept an individual’s decision even when you don’t agree?
Principle 6: Collaboration & Mutuality
Finally, collaboration and mutuality begs a few
questions: 1) How is information shared among team members, and are there ways
to improve? and 2) What are the barriers to collaboration, and how are they
being addressed? Addressing this principle will require due diligence and
commitment to address barriers, access, and engagement to allow for optimal
collaboration and mutuality.
How can you apply the principles of trauma-informed care
into broad-range practices?
For the past decade, I have been reflecting and pondering
how the principles of trauma-informed care can be integrated into all service
areas that provide care to victims and survivors. While my area of practice has
been primarily health care, I work with an interdisciplinary team including law
enforcement, community, and social-service agencies. When these principles are
applied across integrated systems, the process and outcomes often have a
I recommend that you start with forming a task force across
your organization and service lines, including senior sponsorship. I suggest co-chairs
(or tri-chairs) of diverse colleagues. Invite anyone with interest in trauma-informed
care, or those wanting to learn. Eventually, a group forms and you get some
traction! Set meeting dates for the year, include agenda items, and after the
meeting, send out a short summary with actionable items. Let the principles of trauma-informed
care guide your work: be inclusive, listen, learn, and share together. Consider
holding an annual symposium where you share your accomplishments and set goals
for the upcoming year.
Trauma-informed care is a theoretical framework that offers organizations
and practices, staff, and patients approaches that promote healing and
About the Author
Dr. Annie Lewis-O’Connor is a dually board-certified
Pediatric and Women’s Health Nurse Practitioner. She is the founder and director
of the C.A.R.E Clinic (Coordinated Approach to Resiliency & Empowerment) at
Brigham and Women’s Hospital in Boston, Massachusetts. Lewis-O’Connor addresses
violence from four pillars: research, policy, education, and clinical practice.
Currently, she is a clinical scholar with the Robert Wood Johnson Foundation
(2018-2021). Since 2012, Lewis-O’Connor has served as co-chair of the MGB
Trauma-Informed Care Initiative. She received her Master’s in Nursing from
Simmons College in Boston, a Master’s in Public Health from Boston University,
and her PhD from Boston College.
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