Introduction to the Special Section on Innovations in Trauma-Informed Health Care

Why Trauma-Informed Health Care and Why Now?

The year 2023 marked the 25th anniversary of the first publication of the landmark Kaiser Permanente–CDC Adverse Childhood Experiences (ACE) Study,¹ while the year 2024 is the 20th anniversary of the release of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Concept of Trauma and Guidance for a Trauma-Informed Approach.² The ACE study highlighted the high prevalence and cumulative impact of childhood adversity on lifelong health and SAMHSA gave us a roadmap for conceptualizing and implementing trauma-informed care (TIC). Honoring these important contributions is one purpose of this special section.

Another purpose for this special section is to acknowledge the robust body of multidisciplinary health and social science research, which demonstrates that traumatic experiences, as well as positive ones, can profoundly shape an individual’s health and well-being across the life course.^3–5 This science is the foundation of TIC, a strengths-based approach that aims to encourage awareness of and responsiveness to the impact of trauma; emphasizes physical, psychological, and emotional safety; creates opportunities for healing, recovery, and thriving; and resists retraumatization.⁶ The TIC framework and the evidence supporting it are so compelling that clinicians, patients, educators, and policymakers are collaborating to transform health care into a high-value, cost-conscious, equitable system of care that is supportive of both patients and practitioners and has measurable positive outcomes.^7–10

One example of a group working to transform health care is the Collaborative on Trauma-Informed Health Care Education and Research (TIHCER, pronounced “tīs-er”),¹¹ a multidisciplinary group of health professionals with extensive practice and research experience in TIC. Since 2018, its members have been working together to advance TIC through groundbreaking interprofessional education, research, and clinical care. TIHCER envisions all health care professionals and systems being resilient, trauma-informed, and equitable. TIHCER served as a catalyst for this special section and several of the contributions included herein are authored by its members.

Articles in the Special Section

The 12 complementary articles in this special section highlight the gaps in the current health care landscape while illustrating promising approaches and models that can be adapted and implemented throughout diverse settings. These articles provide an invaluable compendium of conceptual and practical guidance for health care professionals to encourage further development, implementation, and evaluation of TIC.

Original Research

The 4 original research articles include topics on using clinical vignettes to increase clinician identification of ACEs; organizational readiness for ACE screening implementation; a perinatal mental health intervention; and mitigating clinician burnout utilizing TIC. First, Piszczor et al demonstrate medical students’ knowledge and attitudes toward ACEs and TIC in clinical scenarios using a patient vignette to assess students’ ability to identify ACEs as contributing factors to patient health. Their findings indicate that medical students would benefit from training and curricular efforts focused on ACEs and TIC. In the study that follows, Machtinger et al use a 16-item organizational tool to assess clinic readiness to provide TIC and implement ACE screening in a statewide community clinic learning collaborative. The authors emphasize that supporting a clinic’s trauma-informed system change is foundational for successful implementation of ACE screening. Next, Goldstein et al examine whether women, both with and without ACEs, show a differential response to a personalized mobile health–enhanced cognitive-behavioral intervention with mindfulness enhancement on maternal distress and emotional regulation outcomes from pregnancy to 3 months postpartum. Preliminary exploration suggests the possibility that individuals with a history of ACEs may benefit from enhanced trauma-informed content to optimize the effects of a perinatal intervention. Finally, Lewis-O’Connor et al describe nurses’ experiences and assess their professional quality of life after the first phase of the COVID-19 pandemic and redeployment efforts. The authors found that clinical nurses and nurse leaders endorsed enhancing a culture of wellness by leveraging trauma-informed approaches to build resilience and promote compassion satisfaction.

Review Articles

The 2 reviews include topics on TIC implementation in health care and the integration of trauma, resilience, and equity theory and practice. A systematic review of reviews and realist synthesis conducted by Goldstein and Chokshi et al aimed to understand the interventions and strategies effective in implementing TIC across diverse health care systems. Using the SAMHSA 10 TIC implementation domains as the organizing framework, they identified individual and organizational outcomes (eg, practitioner training, cross-sector collaboration, and patient engagement) that contribute to bringing about culture change and facilitating sustainable TIC implementation. Their discussion highlights future directions for the successful spread of TIC across health care and addresses the most salient gaps in TIC policy, education, and research. To frame how the field can advance through a holistic, consilient approach, the narrative review by Sonu et al traces the evolution of trauma theory and practice in the health and social sciences, acknowledging the intersectional, complex nature of trauma that is universal yet disproportionately prevalent in marginalized communities. The authors share innovative frameworks and applications that prioritize health, resilience, and equity while integrating social justice ideologies and indigenous wisdom to guide us in new directions toward a unified paradigm and practice.

Brief Reports

The 2 brief reports focus on TIC competencies for undergraduate medical curricula and barriers to ACEs screening in pediatrics and perinatal care. Gerber et al demonstrate applications of the TIC Competency Set to infuse the science of trauma and healing into core curricular content and context of undergraduate medical education to improve competence and experience of trainees and patients. The authors’ set of concrete curricular examples can aid efforts to integrate TIC into undergraduate, graduate, and continuing medical education. A second brief report by Watson et al describes the combined lessons learned from a collective 8 years of ACEs screening implementation in pediatric and obstetric populations in 2 large integrated health care systems. The authors’ work validates previous research, confirming the feasibility of ACE screening in pediatric and prenatal care and the authors recommend incorporating ACE screening combined with brief, empathic conversations as a standard of care, thus acknowledging the impact of childhood adversity on a patient’s overall health.

Commentaries

The 4 commentaries feature resilience and TIC, primary care as a protective factor, trauma-informed leadership and workforce wellness, and TIC principles applied to the clinical care of weight management. Leitch and McCaw highlight the limitations of the traditional pathology-based model and advocate for expanding the TIC framework in clinical care to include resilience and positive experiences. The authors highlight the academic science of resilience, advances in neuroscience, and attention management skills that can be incorporated into clinical care. Next, Machtinger et al describe a vision for adult primary care as a protective factor to transform health care delivery and overcome disparities by promoting safe, stable, nurturing relationships. This commentary provides real-world examples of clinics and health care systems that have improved health outcomes as a result of operating with safe, stable, nurturing relationships as a central component of clinical care. In their commentary, Elisseou and Garroway et al outline a roadmap for trauma-informed leadership and workforce wellness in health care systems, which all too commonly are distressing environments for staff and patients, in part because of the nature of the work but also due to lack of a trauma-informed culture. The authors propose that these practices and policies can transform the work environment into a resilient and flourishing one sustained by leadership that prioritizes and creates a TIC organizational culture. The fourth, by Mossier-Mills et al, addresses weight bias and stigma by adopting a TIC model of inquiry to skillfully and sensitively navigate clinical discussions about weight with patients. The authors provide examples of reflective questions and practical clinical guidance framed within each of the 6 TIC principles of care to help guide the clinical encounter.

Conclusion

This special section honors the work of past and present innovators committed to a paradigm shift in health care. These works are based on the science of trauma, resilience, and equity and prioritizes understanding and supporting human well-being and recovery. The commentaries offer a vision for what is possible. The reviews share historical context, existing innovations, and essential elements and current gaps in the TIC landscape. The original research and brief reports illustrate concrete steps that researchers, clinicians, and educators are taking toward trauma-informed transformation. As impressive as the work showcased in this special section is, it is only a small fraction of the TIC work happening around the country and around the world. Nevertheless, there is still more for all of us to do to realize the full potential of TIC. Our intent for this special section is to inspire you to advance your trauma, equity, and resilience education, practice, and research in your own health care settings and beyond.