Version July 2025
INTRODUCTION —
Many patients have experienced traumatic events that affect their daily functioning, physical and mental health, and sense of well-being. Some traumatic events are experienced by individuals, while others affect communities, generations, or cultures. Awareness of the effects of trauma, and implementation of a trauma-informed approach in the medical setting, has the potential to improve patient care and ultimately improve health outcomes. The creation of physical and emotional safety requires incorporation of trauma-informed principles and practices [1].
This topic will provide an overview of trauma-informed care for adults. Considerations for particular patient populations including children are discussed separately:
(See "Intimate partner violence: Diagnosis and screening".)
(See "Intimate partner violence: Intervention and patient management".)
(See "Intimate partner violence: Epidemiology and health consequences".)
(See "Intimate partner violence: Childhood exposure".)
DEFINITION OF TRAUMA —
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as resulting from "an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being." Trauma can occur as a result of physical or sexual violence, abuse, neglect, loss, disaster, war, and other emotionally and/or physically harmful experiences [2].
This broad and experiential definition highlights that trauma exposure is ubiquitous, and related to health [3]. However, there is individual variation in the impact that particular traumas have on a person's health. Understanding and implementing clinical care techniques that can mitigate the effects of trauma has the potential to improve health for us all.
People can experience traumas at the individual, interpersonal, and community levels in myriad ways, at any moment, and over the course of their lifetimes with a variety of symptom complexes (figure 1). Fortunately, we can also build resilience from these experiences over the lifetime as well.
HOW DOES TRAUMA AFFECT HEALTH? —
Trauma exposure can manifest with symptom complexes as well as long-term increases in rates and severity of common diseases and exposures (table 1).
Our understanding of the health effects of trauma has grown over the past decades, as various populations have been observed to suffer the effects of traumatic situations.
Sources of information — Some of the key situations in which an understanding of the effects of trauma has been observed are listed below:
●Recognition of posttraumatic stress disorder (PTSD) in veterans of the Vietnam War was a key first step in a broader appreciation of the effects of trauma. However, this early conception focused on the psychiatric effects alone and may have delayed consideration of the broader health effects of traumatic exposure [4].
●Around this same time, intimate partner violence (IPV) came to be understood as a serious challenge to survivors' mental and physical health, with potentially life-threatening ramifications stemming from the assertion of power and control of one person over another. Epidemiologic studies noted that people experiencing IPV had a higher prevalence of physical and mental health conditions, but at the time the mechanism by which this occurred was not clear [5].
●In the late 20th century, the 'weathering hypothesis' noted that African American women as a group often had poorer health outcomes than their White counterparts, and it was postulated that the stresses of socioeconomic disadvantage and racism were responsible [6].
●At the turn of the 21st century, the Adverse Childhood Experiences (ACE) Study, a retrospective study of memories of childhood adversity including physical and mental abuse, neglect, and witnessing chaos/stress in the home, found that ACEs were very common and that there was a direct linear relationship with poor adult physical and mental health, including shortened lifespan. At the time, researchers postulated that 'maladaptive coping' was responsible for poor health later in life, as survivors of these challenges survived and self-soothed, trying to reregulate their nervous systems with behaviors that also carried risks such as tobacco, alcohol and drug use, less safe sex, and disordered eating that could lead to poor health and even early death that had been observed [7]. The ACE study was later replicated in all states across the United States [8,9].
●Studies done on Holocaust and 9/11 survivors have pointed us toward an additional layer, whereby exposure to severe stress can be passed to future generations through epigenetic inheritance via forces at play pre, peri, and postnatally [10].
●Medical professionals who witness and vicariously experience patients' suffering have been noted to have higher rates of suicide and premature exit from the profession. The same mechanisms discussed below are postulated as an explanatory model for the burnout of health care providers [11].
Proposed biologic mechanisms — A variety of traumatic exposures (war, IPV, childhood adversity, community adversity) are risk factors for poor health. Basic science research has offered us the insight that all these exposures have a common denominator in disrupting neurobiology at the cellular level. This work draws on a theory of attachment first conceived by John Bowlby, who posited that a sense of safety with an early caregiver offers a foundation for healthy nervous system development and regulation [12]. When safety is threatened, the stress triggered in the body manifests in disruptions of the normal cascades of hormones responsible for healthy emotional, social, and cognitive development and maintenance of well-being. These effects in the hypothalamic-pituitary axis as well as the sympathetic nervous system upregulate stress hormones and affect learning, memory, mood, inflammation, and aging systems, which, in turn, affect every aspect of health. Interventions directed at restoring balance and regulation by activating the parasympathetic nervous system have the potential to mitigate these significant health effects and can be practiced in the patient-clinician relationship [13,14].
In normal development, individuals move through life experiencing sensory inputs, responding to them, and returning to homeostatic balance. In a trauma-exposed individual, the sympathetic arousals do not settle back to baseline relaxation on the parasympathetic side. Rather, signals are sent to the prefrontal cortex (seat of focus, attention, thinking) and the amygdala (seat of fear and memory), signaling the hypothalamus to activate the biochemical cascade where cortisol is released from the adrenal glands. Overactivation of this system can affect the development of other brain systems key for learning, memory, and mood. Over time, an individual can develop a narrower 'window of tolerance' when exposed to stressors of multiple kinds. Affected persons experiencing subsequent stressors may be triggered at the physiologic level to either respond more vigilantly in 'fight or flight' mode, or the dorsal vagal nerve may trigger the opposite type of reaction where a person freezes and may appear to dissociate (to avoid re-experiencing a traumatic event) [15].
These cascading courses of sympathetic hormones can, over time, reset a person's homeostatic 'set point' to higher levels of cortisol and proinflammatory cytokines. Bathing the brain in these hormones can contribute to higher incidence of common medical problems driven by inflammation such as heart disease, cancer, and autoimmune disease, as well as greater emotional reactivity in everyday life.
Much has been written about how the stress experienced by marginalized populations has led to higher rates of common diseases. Further, chronic stress may also exert epigenetic effects on deoxyribonucleic acid (DNA) methylation that can lead to early cell death via telomere shortening, a biologic explanation for the 'weathering hypothesis'. These changes are passed on outside of typical inheritance patterns from one generation to another as elucidated by studies in Holocaust survivors, those who have experienced effects of colonization and slavery, and other offspring of historical trauma [10].
The ACE study has uncovered how ACEs are strongly related to the development of risk factors for disease, and even progression to early death throughout the life course [7]. Of note, this linear model suggests that these inheritances, exposures, experiences, and effects on the body build upon one another and progress inexorably, and for some individuals, this may be the case. While this can occur, it is more likely that a weblike model with intersecting experiences and exit points would be a more accurate depiction, given that individuals experience, process, and are affected by trauma differently [16]. Our potential to intervene as clinicians sensitive to these exposures and mechanisms in relationship with our patients offers the possibility of helping individuals exit this progression and move towards a healthier life course.
TRAUMA-INFORMED CARE —
Trauma-informed care is an approach that acknowledges the impact of traumatic events and aims to provide the patient with a sense of safety, agency, and control over their environment and decisions.
Goals — Healthcare settings can be intimidating and potentially retraumatizing for many patients, especially those from marginalized backgrounds [17-21].
The goals of trauma-informed care are to:
●Invite and welcome all patients to come for care
●Invite patients to engage actively in their care and disclose all their concerns
●Enable medical providers to be well enough to offer care, even regarding sensitive/challenging concerns/diagnosis
Trauma-informed care as a universal precaution — Because trauma is so ubiquitous, the general approach and specifics below are recommended as standard of care to be employed when caring for and interacting with all, as a 'universal precaution', rather than in a case-finding manner [22].
Organizational approach — As a general approach, the Substance Abuse and Mental Health Services Administration (SAMHSA) notes the four Rs (realizes, recognizes, responds, resists retraumatization) [23]. A program, organization, or system that is trauma-informed:
●Realizes the widespread impact of trauma and understands potential paths for recovery
●Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system
●Responds by fully integrating knowledge about trauma into policies, procedures, and practices
●Seeks to actively resist retraumatization
(figure 2)
Key principles — SAMHSA has offered a definition of trauma-informed care, as well as principles that can be employed to improve patient care. These principles represent best practices for all patient care, given the ubiquity of traumatic exposures [4]. The SAMHSA approach stresses six principles that can be implemented in clinical care, as well as at the organizational and community levels. These include:
●Safety
●Trustworthiness and transparency
●Peer support
●Collaboration and mutuality
●Empowerment
●Attention to cultural, historical, and gender issues affecting health
While all of these principles are important, establishing safety is key, given the challenges with trust stemming from violations of healthy relational attachment that are at the forefront for many trauma survivors. Safety opens up the possibility of understanding individuals' unique experiences and identities and facilitates collaboration toward well-being. The table below provides some additional definitions of each tenet and practical examples of ways to integrate these principles into everyday care: (table 2)
THE CLINICAL ENCOUNTER
General approach — In order to ensure a safe and welcoming environment, best practices include introducing yourself with your name, offering and asking about self-identified pronouns, and possibly with eye and/or physical contact, such as a handshake, gauging the patient's willingness to engage and backing off if you sense discomfort.
Asking an open-ended question about any identities or preferences that are relevant can be a helpful way of eliciting cultural, racial, ethnic, religious, and/or gender-related needs for care. For example, if the patient's religious practice causes them to prefer a gender-concordant caregiver, do your best to accommodate this request.
Keeping at eye level and keeping physical barriers such as computers from blocking your sight line, while keeping exits clear can facilitate the interview.
Discussing trauma — We ask new patients about trauma history as part of the social history, and pursue intimate partner violence (IPV) inquiry if the patient is at high risk or there is clinical concern, always normalizing such inquiry. (See "Intimate partner violence: Diagnosis and screening", section on 'Screening recommendations'.)
Discussions of trauma may be best conducted in private, without family or others in the room. If a patient volunteers another type of trauma exposure, we listen generously, offering nonverbals such as nodding and eye contact, and ask clarifying questions if the patient seems open, but avoid obtaining information on every aspect of events unless the patient volunteers them. The clinician should ask the patient what to include in, or leave out of, the visit documentation.
This technique relates to empowering patients to offer just as much of their story as they feel you need to know which will also enable them to contain the stress of disclosure and leave your office with dignity. As you would with IPV disclosure, empower patients by acknowledging the significance of what they have been through and their strength, along with your appreciation that they are trusting you with the information, and your willingness to support them, including through referrals to peers and other organizations.
Example:
●"Thank you so much for telling me about that experience."
●"I am sorry you had to go through that."
●"You are so strong to have made it here today and to have chosen to share this important story with me."
●"I want to support you in any way I can."
●If a patient appears distressed or anxious, you could offer a mindful breathing technique for coregulation such as square breathing, where, together, you can inhale for a count of four seconds, hold for four seconds, exhale for four seconds, and hold for four seconds, repeating the cycle for a couple of minutes. This coregulating activity can activate the parasympathetic nervous system and slow down pulse, relieving anxiety for patients and practitioners [24].
Telemedicine interviews and care — Telemedicine visits present special considerations for safety and privacy. Positive aspects include the potential to reach vulnerable populations with limited transportation. However, there are challenges, especially if the patient has limited Wi-Fi or internet resulting in phone rather than video visits. Telemedicine is discussed in detail separately. (See "Telemedicine for adults".)
●Best practices – First and foremost, ask if patient is in a private space, if they can use headphones for the visit, and if there is a word they would like to use should they feel unsafe or need to leave the call. Wait until the patient moves to privacy and/or places headphones before proceeding with any inquiry. Avoid inquiry about safety if another person is visible on the call.
•For clinicians, if working from nonclinical environment, blur your background or project professional screen.
•Avoid commenting on items in patients' backgrounds unless they initiate.
•Allow patients to terminate the call when they need to.
•Avoid having telehealth calls with patients if they are in a vehicle and it is not stationary. Patients may be choosing to take a call from their vehicle for privacy, but for their safety, they should not be driving.
•If there are significant concerns requiring a thorough physical examination, arrange for in-person visit with transportation if possible.
Best practices for telemedicine visits are also discussed separately. (See "Telemedicine for adults", section on 'During the visit'.)
The trauma-informed care physical examination — Trauma-informed care examination techniques include (but are not limited to) language used before, during, and after the examination, and techniques for positioning both the patient and provider to maximize privacy and empowerment.
The following is a comprehensive approach to the trauma-informed care examination [25]:
Before — Before the examination, ask if the patient has had any prior challenges with medical care or considerations that could make the examination easier, especially if it is an invasive examination (eg, oral, rectal, pelvic).
●Check for patient readiness by observing them before beginning.
●Assess if the patient appears nervous or fidgety, and inquire and offer support.
●Let the patient know what examinations you hope to perform and why.
●Perform the examination the same way for all patients.
●Remind the patient that you offer these examinations for all people with their symptoms/concerns/screening needs.
●Ask if they have any concerns.
●Ask if there are ways to make them more comfortable; sometimes patients could prefer a support person in the room, to wear headphones, or to do the examination on a different day when they feel more mentally prepared.
●Offer a chaperone (which is standard of care for some examinations, and a rule in many clinics).
●Ask questions (eg, "How have pelvic exams been for you in the past? Is there any way I can make the procedure more comfortable for you?").
During — During the examination:
●Attend to draping and modesty.
•Offer a gown and drape that covers the individual's body fully.
•Leave the room if you are asking a patient to undress.
•Knock and ask if it is okay to re-enter the room and wait if not until okay.
●Introduce examination components.
●Use clinical, nonpersonalizing language (eg, "I'm going to examine the thyroid now. In order to examine the thyroid completely, I will stand next to you and palpate the front of the neck, where the thyroid gland is, as you take a sip of water.").
●Explain why (eg, "I will be more able to be sure I am palpating that gland when it moves with sipping the water.").
●Ask permission (eg, "Is it ok to do the thyroid exam now?").
●Stay within eyesight.
•In general, don't stand behind the patient if you can accomplish the same examination standing to the side. Patients will be less surprised by examination movements if they can see you.
•Respect personal space.
•Stand as close but no closer than needed to examine ears and recheck blood pressure. If you must hold the patient's arm next to your body hold near your waist, rather than next to your breast tissue.
●Use simple, clinical language.
•Choose words like examine, palpate.
•Avoid 'touch' or 'feel.'
•Choose words like "the" to precede body parts (the thyroid), even if it may feel awkward.
•Avoid using 'your' or 'for me.'
•Choose 'normal', healthy.
•Avoid 'looks good.'
●Check in.
•As you proceed from one examination procedure to the next, ask the patient how they are doing.
●Use professional touch.
•Sometimes a touch on the shoulder while examining the lungs can be grounding and balancing.
•Notice the patient's body language. If they relax it is ok to continue with light balancing touch; if they wince/withdraw/appear uncomfortable or ask you to avoid touch, do as they request.
●Be efficient.
•Don't be superficial in your examination, but don't linger on areas longer than necessary.
After — After the examination:
●Express thanks.
•For being willing to attend to their health, for giving you permission to participate in their care, for their trust.
●Discuss results and possible next steps as applicable (eg, "I hear some fluid in the lungs. A follow-up x-ray can help us be more certain if you have a pneumonia infection and help me decide if you need antibiotics.").
Patients with dissociation — Trauma-exposed persons can cope in several ways both during the initial event and if subsequently triggered. Some individuals may become anxious and unable to complete the examination due to sympathetic nervous system activation. Others may have coped by dissociating, an overmodulation in the nervous system that causes individuals to appear to have lost touch with reality. If during a sensitive examination, a patient becomes distressed, disoriented, or tries to move from the examination table in the midst, immediately stop the examination, and invite the patient to get dressed. To assist with recovery, you may want to change examination rooms and offer water to transition away from the trigger of distress. Assure the patient is accompanied until they become reoriented and reassure them that they are safe. Consider doing mindful breathing with them to help with grounding.
Reschedule the rest of the examination for another day. Consider whether to discuss the incident with the patient when they return to clinic to strategize what you can do to support them in success if it is a procedure that must be done. As a last resort, consider performing the examination under anesthesia with patient's assent.
Dissociation related to posttraumatic stress disorder (PTSD) is discussed separately. (See "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis".)
Documentation — Documenting traumatic exposures and patient preferences for care can be important for communication with other providers, the legal system, and with patients themselves.
With the move towards open notes, some patients may feel empowered by noting that the clinician has listened to them and accurately heard the situation and they may find it helpful to have a plan they agreed upon together reiterated in the chart that they can access later. They may be relieved not to need to repeat that history to other providers who will hopefully read their chart. On the other hand, patients may feel that the information told in the clinical visit was private and did not need to be recorded, which could impede trust with that provider, so if a patient requests that you do not include information do your best to adhere to that request (see "The clinician-patient relationship in the era of information transparency"). In general, we should always use respectful language that would not in any way upset patients. Best practice is to remind trauma-exposed patients that the medical record is a legal record and that recording specifics may be helpful for them in the legal realm as well as communicating to other clinicians.
In the most extreme situation, a perpetrator of violence or someone who might react violently to a secret identity or other patient information may have access to patients' chart passwords due to coercion. Institutions have tried to offer workarounds for these situations to improve safety, such as selectively closing certain note types (such as psychiatric documentation) or being able to open or close sensitive notes at patient request or provider discretion, but these latter systems rely on potentially fatigued providers to attend to and remember to perform extra clicks for safety. These strategies are less effective and more prone to fatigue and error than system approaches. This remains a challenging and controversial area [26]. (See "The clinician-patient relationship in the era of information transparency", section on 'Privacy concerns'.)
BEST PRACTICES FOR ONGOING CARE —
Trauma-informed care environmental protections, especially related to privacy in waiting and examination rooms, can be helpful to all patients.
●Privacy – Institutions are increasingly sensitive to putting policies in place to safeguard privacy and safety. Offering patients paper or kiosk questionnaires about sensitive topics such as intimate partner violence (IPV), other trauma, and personal identity are great practices but can be problematic for low-literacy, non-English-speaking patients or those requiring assistance to enter into the care setting. Working to have interpreters and extra staff members who can escort people with disabilities are steps to assuring the privacy and comfort of all [27].
●Lateness policies – Lateness policies, while respectful of staff time and breaks, can disproportionately affect patients with social contextual challenges such as homelessness, limited transportation, reliance on family members, or mobility challenges that may impede their timely arrival. Turning patients away when they have arrived for care without ascertaining the circumstances can feel unwelcoming, especially to those patients who may already be intimidated about presenting to institutions for help [28]. Patient navigators may have an important role to play in assisting patients to arrive to the clinic in a timely manner [29].
●Education – Best practices include ensuring that medical trainees have basic competency in trauma-informed care [4,30]. Trauma-informed care educational competencies for undergraduate medical education have been endorsed by the Association of American Medical Colleges and offer a standard for training medical students, residents and faculty [31].
●Organizational efforts – Institutions can utilize trauma-informed care principles to improve patient care, as well as staff well-being and retention [32].
SUMMARY AND RECOMMENDATIONS
●Trauma – Trauma results from an event or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, and have lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. It can occur as a result of violence, abuse, neglect, loss, disaster, war, and other emotionally and/or physically harmful experiences. (See 'Definition of trauma' above.)
●Health effects of trauma – Trauma results in the chronic upregulation of stress hormones, resulting in a higher incidence of common medical problems driven by inflammation such as heart disease, cancer, and autoimmune disease, as well as mental illnesses such as posttraumatic stress disorder (PTSD). (See 'How does trauma affect health?' above.)
●Trauma-informed care – Key principles of trauma-informed care include:
•Safety
•Trustworthiness and transparency
•Peer support
•Collaboration and mutuality
•Empowerment
•Attention to cultural, historical, and gender issues affecting health
(See 'Key principles' above.)
●The clinical encounter – Elements of the clinical encounter that are informed by trauma-informed care practices include providing a safe and welcoming environment; respecting cultural, racial, ethnic, religious, and/or gender-related needs for care; asking about trauma history; and respecting privacy during telemedicine visits. (See 'The clinical encounter' above.)
●Physical examinations – Trauma-informed care examination techniques include (but are not limited to) language used before, during, and after the examination, and techniques for positioning both the patient and provider to maximize privacy and empowerment. Providers should be alert to the possibility of dissociation. (See 'The trauma-informed care physical examination' above.)
●Documentation – Documenting traumatic exposures and patient preferences for care can be important for communication with other providers, the legal system, and with patients themselves. Open notes may pose challenges to patient privacy. (See 'Documentation' above and "The clinician-patient relationship in the era of information transparency", section on 'Privacy concerns'.)
