Many patients, particularly those seeking care for behavioral health and substance use needs, may have a history of trauma. Trauma may impact how a patient engages with health care, including how they engage with their care team and in treatment.
This section is intended to support practices in the development and implementation of a patient and staff-centered trauma-informed approach at all levels of the primary care practice.
Drivers of Success
- Evidence-based curriculum/staff/leadership training (annual & continuous) – for everyone
- Integrated & strengths-based approach to screening patients
- Updated policies and procedures
- Physical environment & reception area/desk (safe space)
Definition
SAMHSA defines trauma as “experiences that cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of experiences that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being” (SAMHSA TIP 57).
Examples of trauma include childhood neglect, physical, sexual, and emotional abuse, having a family member with a mental health or substance use disorder, violence in the community, poverty and systemic discrimination, including racism.
What is a trauma-informed approach?
SAMHSA identifies four key elements of a trauma-informed approach:
- Realizing the prevalence of trauma
- Recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce
- Responding by putting this knowledge into practice
- Resisting re-traumatization of individuals and staff
A trauma-informed approach shifts the narrative from “what is wrong with you?” to “what happened to you?” Adopting a trauma-informed approach goes beyond clinical care; it requires an organization culture shift. Buy-in from an engaged leadership team and clear communication about organization’s journey to become trauma-informed are essential for success.
Engaged Leadership in Action: Trauma Informed Care
- Leadership team is visibly supportive and committed to creating a trauma-informed culture, including freeing up staff & provider time to attend trainings
- Staff wellness is prioritized & self-care tools and tactics are used and promoted
- Patients and families are engaged and their voices are valued
Key resources:
We consider the resources below to be key foundational resources. You will find excerpts from these key resources throughout this section.
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Fostering Resilience and Recovery: A Change Package
Source: National Council for Mental Wellbeing
This comprehensive change package outlines a framework for implementing a trauma-informed initiative within your primary care organization.
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Laying the Groundwork for Trauma-Informed Care
Source: Center for Health Care Strategies
This brief includes practical recommendations for health care organizations interested in becoming trauma-informed. It draws from the experiences of pilot sites in Advancing TraumaInformed Care (ATC).
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Trauma-Informed Care Implementation Resource Center
Source: Center for Health Care Strategies
This website provides resources from trauma-informed care leaders across the country to help improve patient outcomes, increase patient and staff resilience, and reduce avoidable health care service use and costs.
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SAMHSA: Concept of Trauma and Guidance for Trauma Informed Care Approach
This manual introduces a concept of trauma and offers a framework for becoming a trauma-informed organization, system, or service sector.
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TIP 57: Trauma-Informed Care in Behavioral Health Services
Source: SAMHSA
This manual helps behavioral health professionals understand the impact of trauma on those who experience it. The manual discusses patient assessment and treatment planning strategies. These strategies support recovery and the development of a trauma-informed care workforce.
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Six Principles of a Trauma-Informed Approach
Source: National Council for Mental Wellbeing
This table, an excerpt from the Fostering Resilience Change Package, lists six principles of a trauma-informed approach, the definition of each principle, and examples of the principles in practice.
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Evidence-based Curriculum & Training
To be a trauma-informed organization, regular and ongoing evidence-based training for all staff at all levels is essential; this includes clinical staff, non-clinical staff, and leadership.
Trainings should seek to meet a variety of objectives:
- Build awareness of trauma & an understanding effects of trauma on health and behavior
- Support staff wellness
- Share strategies to create a safety and build trust with patients
- Apply strategies to identify and address trauma
- Highlight opportunities to sustain learnings from trainings
And can take a variety of formats:
- Training for new staff
- Annual all-staff training
- Incorporate “bite size” concepts into existing meetings
- Sustain and extend the learnings through train the trainer models to reach more staff
- Practice and apply principles – use team meetings, care team huddles, etc.
Many organizations offer trauma-informed care training. Here are few that we recommend:
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Trauma-Informed Approach Staff Training Schedule
Source: National Council for Mental Wellbeing
Outlines a training plan for organizations, and includes PPT training resources
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Trauma-Informed Care Training Center
Offers training and certification in TIC to individuals and organizations, without regard to area of practice or professional credentials.
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Boston Children’s Hospital
Offers training and consultation to develop capacity of students/trainees, providers, programs, and policymakers to better understand, disrupt, and act upon oppressive processes.
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Riverside Community Care
Source: Riverside Trauma Center
Offers support services including on-site response, grief counseling, and referrals to help people after critical incidents.
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Veto Violent: Preventing Aces
Source: CDC
Trainings to help you understand, recognize, and prevent Adverse Childhood Experiences.
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Strengths-based Approach to Screening
Trauma Inquiry & Response
Inquiring about, identifying, and responding to trauma can help providers, care teams, and patients better understand how trauma plays a role in health-related behavior and outcomes.
The National Council for Mental Wellbeing has identified key steps for healthcare organization to prepare to conduct trauma inquiry and response:
- Establish policies and clinical pathways for identifying and responding to trauma.
- Develop an adequate referral network.
- Provide education to patients about the connection between trauma and health.
- Build staff capacity to conduct trauma inquiry and response.
- Prevent retraumatization among patients.
There are many different types of trauma, and each will warrant different responses. Some experiences of trauma will require immediate response and intervention, while other disclosures of trauma may benefit most from a display of empathy and an offer to connect the patient with additional resources and follow-up support. See more in the Behavioral Health Integration section.
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Resource
Identify and Respond to Trauma Among Patients
Source: National Council for Mental Wellbeing
Change Concept 4 of the Fostering Resilience and Recovery Change Package outlines various approaches to trauma inquiry and identifies response examples for different types of trauma that a patient may disclose.
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Screening Script Template for Trauma Inquiry
Source: National Council for Mental Wellbeing
This tool is a suggested script to use with patients before you introduce your trauma screening at their initial and subsequent appointments.
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The UMASS Child Trauma Training Center’s Centralized Referral System (LINK-KID)
A free resource for families, providers, and professionals looking to refer children to trauma-focused evidence-based treatment throughout Massachusetts.
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Education, Inquiry and Response Workflow
Figure 1. illustrates an example education, inquiry, and response pathway
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Using a Trauma Informed Approach in All Screening
A trauma-informed approach should be used in all screening, including when asking patients about their health-related social needs.
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Partner Resource
Motivational Interviewing, Trauma Informed Care, HRSN Screening Webinar
Source: This is a placeholder – upload C3 webinar!
This webinar displays the most efficient ways to navigate conscientious Trauma-Informed Care and how to effectively screen patients for trauma
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Updated Policies & Procedures
It is important to develop policies, procedures, and workflows for responding to trauma. In addition, policies and procedures can help ensure that you have a trauma-informed workforce and that you maintain a safe physical and emotional space for patients. Policies that support a trauma-informed workforce must extend into all facets of an organization.
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Human Resources Policy Toolkit
Source: National Council for Mental Wellbeing
This resource includes numerous trauma-informed care human resource policy templates
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Trauma-Informed Care Interview Questions
Source: Center for Health Care Strategies
When interviewing candidates for employment at your organization, you may want to consider their knowledge of and experience with trauma-informed care.
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Tools for Transformation: Becoming Accessible, Culturally Responsive, and Trauma-Informed Organizations
Source: National Center on Domestic Violence, Trauma & Mental Health
The purpose of this tool is to support organizations in their efforts to become more accessible, culturally responsive, and trauma-informed in their approach and services.
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Checklist for Trauma-Informed Human Resources Practices
Source: National Council for Mental Wellbeing
This series of checklists aims to facilitate the implementation of trauma-informed human resources practices through the lifecycle of an employee
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A Safe Physical & Emotional Space
A safe physical and emotional space should take into account to following aspects:
- Reception area
- Physical exams
- Language and word choice
Peer Support roles are key members of the care team. Recovery Coaches, Family Partners, and Community Health Workers who have lived experiences can play an important role in creating safe physical and emotional spaces for patients. However, in a trauma-informed environment, all staff have undergone training and understand their role in creating a safe physical and emotional space.
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Creating Safe Healthcare Environments for Patients and Staff
Source: Center for Health Care Strategies
This fact sheet lists simple, clear recommendations for how to create safe physical and social & emotional spaces
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The Importance of Trauma Informed Design
Source: Forbes
This article includes tips for incorporating trauma-informed design principles into new and existing spaces
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Trauma Informed Environment Assessment Tool
A simple tool to assess an organization’s physical space
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Trauma-Informed Physical Assessment
Source: National Council for Mental Wellbeing
This presentation provides guidance on conducting a trauma-informed physical exam, including tips and strategies for before, during, and after an exam
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