Toward Integration of Trauma, Resilience, and Equity Theory and Practice: A Narrative Review and Call for Consilience

Abstract

Investigating the roots of health and illness has inspired unprecedented growth in research on trauma and adversity across academic and scientific disciplines. Can this science achieve its potential? How? Much of this research remains siloed and fragmented, limiting integrative approaches to translating science into a unified paradigm. From age-old traditions to the health, social, and basic sciences, this established and rapidly growing body of work has overwhelmingly found that experiences, both positive and negative, profoundly influence life course health. Such convergence across disciplines highlights the complex, intersectional nature and impact of experiences and reveals consilience: agreement of findings across diverse fields. This narrative review explored 400 sources to curate a representative sample of 98 tracing the evolution of trauma theory and practice from the 19th century to the present. It emphasizes research from 1970 to 2022, with a specific focus on adverse childhood experiences, everyday discrimination, sexual and gender minority stress, acculturative stress, and positive childhood experiences. This research reveals how experiences are a cause, catalyst, and key ingredient of health or of illness, disability, and disparities. The review also proposes steps toward a unified paradigm and showcases innovative integrated models and applications. These examples provide a more comprehensive and nuanced understanding and lead to more effective solutions. Recognition of consilience can connect multidimensional insights on trauma, resilience, and equity to spark further cross-sector innovations toward health, prevention, and justice. Realizing the promise of consilience will require a new era of radical intentionality, ongoing dialogue, and interdisciplinary collaboration to achieve necessary system transformation.

Introduction

Over the past 50 years, science has revealed many of the roots of health and illness. Major contributions to the growing understanding of the complexity of health have come from studies of trauma and resilience. The explosion of neuroscience, public health, clinical, and social science research is catching up to the empirical observations of ancient global wisdom traditions.¹ All experiences, especially when they occur in childhood, shape our health.

Experiences are biologically embedded through perception, interpretation, and response by the brain and the brain’s continuous bidirectional communication with the body.² All experiences dynamically influence brain–body connectivity and processes, with impact on both short- and long-term physiology and psychology. Research demonstrates that, on the one hand, positive experiences, such as having basic needs met, receiving consistent early nurturing, and living in safe and caring communities, support health. For example, policy solutions providing family economic support, like the Child Tax Credit, are associated with school success, as well as reducing infant mortality and intimate partner violence³; evidence-based parenting education and support improves parent well-being and prevents child maltreatment⁴; and school district-level, inclusive anti-bullying policies prevent suicide, particularly for lesbian, gay, bisexual, transgender, queer, and others (LGBTQ+) youth.⁵

Enhancing protective factors to boost well-being and prevent trauma is possible and is already happening.

On the other hand, myriad adverse experiences can dysregulate the brain–body system, leading to a wide range of physical and emotional disorders. The persistent observation by thousands of studies that adverse experiences are frequently associated with subsequent illness is one of the most important scientific discoveries of the past century.⁶ Further, the recognition that the injury from traumatic experiences is cumulative helps to explain one of our most pressing problems—health disparities.⁷

Current scientific and social norms favor understanding complex problems by reducing them into smaller parts, which are then considered as separate problems. Such a part-by-part analysis appears to make complex problems more manageable, yet it can obscure the big picture. Focusing only on components also discourages recognition of deeper systemic elements, such as structural factors.

Stepping back, we can appreciate that each of us has had a unique combination of positive and adverse experiences. Moreover, every individual functions in an intersectional space.⁸ Distinctions based on categories such as race, gender, sexual orientation, class, and ability are overlapping and interdependent reinforcements of social advantage or disadvantage. Such cultural distinctions are powerful psychologically, may lead to discrimination, and through the embodiment of experience, have genuine biological impact via the regulatory pathways of the stress response system.⁹

Despite the enormous repository of peer-reviewed research on trauma and resilience, several formidable challenges remain. Many healthcare providers struggle to put the science into practice or to consistently integrate diverse research insights. Notwithstanding evidence that positive experiences are equally or more powerful than negative experiences, the field continues to prioritize investigation of trauma.¹⁰ Amid the rapid proliferation of research in the past three decades, the study of any particular type of trauma has often been siloed without linking to other fields of trauma study with similar or potentially interconnected findings. Without a comprehensive theoretical framework, the sheer scope of and connections between different traumatic experiences is hard for anyone to conceptualize, likely resulting in missed opportunities for application or innovation in clinical or educational settings.

In addition to understanding the origins and trajectory of disease, the science of trauma and resilience can make major contributions toward cultivating health, flourishing, and equity. But can this science achieve its potential? How do we get there?

Several other emerging fields have addressed these questions through a deliberate effort toward scientific consilience, a unity of knowledge, as a critical step toward progress.^11,12 Building consilience identifies common themes, parallels, and converging patterns of thought and data, without disregarding how distinct lines of inquiry can vary and make unique contributions. Thus, we can begin to see how a broader theoretical framework based on an integrated understanding of this science can lead to new, more effective prevention and treatment efforts.

The aims of this narrative review are to 1) trace the evolution of our thinking about trauma, resilience, and equity, with a specific focus on comparing and contrasting important work from the past 50 years; 2) highlight consilient research findings that support integration and begin to identify gaps preventing integration of theory and practice; 3) propose elements of a unified paradigm; and 4) showcase promising extant frameworks and applications that can be guides toward further integration and innovations improving health and well-being for all. See Figure 1 for a brief case illustrating the complex intersectional life experiences of a typical adult patient and offering some guiding questions for reflection. This case will be expanded upon in the “Discussion” section.

Figure 1:

Sample case and guiding questions.

Methods

For this narrative review,¹³ the authors searched PubMed, PsycINFO, and Google Scholar. The authors reviewed 400 sources to curate a representative sample of 98 addressing the evolution of trauma theory and practice from the 19th century to the present, with particular emphasis on work from 1970, the year of the first description of “acculturative stress,”¹⁴ through 2022. The present review and sample also include current theoretical, research, practice, or policy advancements emerging from this research. For the focused review from 1987 to 2022, the literature searched used the keywords “adverse childhood experiences,” “everyday discrimination,” “sexual and gender minority stress,” “acculturative stress,” and “positive childhood experiences.” The authors chose these five bodies of work because of their robust scientific contributions, study of prevalent experiences, use of a specific measurement questionnaire, and investigation of broad multisystem health consequences. Everyday discrimination (ED), sexual and gender minority stress (SGMS), and acculturative stress (AS) were chosen specifically because of the authors’ commitment to integrating equity into every conversation about trauma and resilience.

Inclusion criteria were 1) English language, 2) peer-reviewed, 3) full text, 4) content focused on either the origins of the five bodies of work, and further, the relationship between these constructs and physical health, mental health, health behaviors, and/or social well-being, as well as the integration of these constructs into theory or practice. Non-English language articles were excluded. The authors of the present review iteratively discussed the final selection of included articles until they achieved consensus.

Results

Historical foundations

This section begins with a brief review of major milestones in the scientific evolution of trauma and resilience theory, highlighting the historical and political context of each period that influenced prevailing perceptions and attitudes toward the health consequences of lived experiences. Table 1 presents a glossary of relevant terms.¹⁵ Glossary terms are italicized the first time they appear in the text below.

Table 1:

Glossary¹⁵

Term	Definition
Acculturative stress/trauma	Psychological adjustment required when individuals from one culture come into contact with another culture.
Allostatic load	The cost of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or chronic environmental challenges perceived as stressful.
Angels in the nursery	Positive memories of childhood, including intense affect shared between parent and child in which the child feels understood, accepted, and loved, can provide children with a core sense of security and self-worth they can draw on when they are parents.
Community/collective trauma	An aggregate of trauma experienced by community members or an event that impacts a few people but has structural and social roots and consequences. The definition for community can vary.
Complex trauma	Chronic, interpersonal traumas that begin early in life and have multiple physical, emotional, and social effects over time.
Consilience	Agreement or harmony among two or more disparate scholarly disciplines regarding concepts or underlying principles that lead to a comprehensive theory.
Critical consciousness	“...Social group identification, discontent with distribution of social power, rejection of social system legitimacy, and a collective action orientation…”16
Culture shock	A state of confusion and/or distress experienced as a result of exposure to a new, strange, or foreign social and/or cultural environment.
Cumulative trauma	Threatening or harmful experiences that increase successively by adding more and more in terms of frequency, chronicity, or intensity or with multiple types.
Developmental trauma disorder	A proposed complex posttraumatic stress disorder diagnosis for children characterized by traumatic exposure, pattern of repeated dysregulation in response to trauma cues, persistently altered attributions and expectations, and functional impairment.
Dose–response	A measure or relationship that compares the strength of exposure (dose) to the occurrence, range, and intensity of clinical impact (response). The exposure and the impact may be positive or negative.
Embodiment	The way we literally incorporate, biologically, in the societal and ecological context, the material and social world in which we live.
Equity	Fairness and justice in receiving necessary resources, access, and treatment, specifically with freedom from bias or favoritism.
Everyday discrimination	Discriminatory interpersonal events that may appear trivial or even normal. First studied in Black Americans and later in many races, ethnicities, and other marginalized populations.
Historical trauma	A complex and collective wounding experienced over time and across generations by a group of people who share an identity, affiliation, or circumstance.
Identity	“...a set of meanings defining who one is in a role (eg, father, plumber, student), in a group or social category (eg, member of a church, an American, a female), or a unique individual (eg, a highly moral person, an assertive person, an outgoing person).”17
Intergenerational trauma	A phenomenon in which the descendants of a person who has experienced a terrifying event show adverse emotional and behavioral reactions to the event that are similar to those of the person himself or herself. The exact mechanisms of the phenomenon remain unknown but may involve effects on relationship skills, personal behavior, and attitudes and beliefs that affect subsequent generations. The role of parental communication about the event and the nature of family functioning appear to be particularly important in trauma transmission.
Intersectionality	The complex and cumulative way that the effects of different forms of discrimination (eg, racism, sexism, and classism) combine and overlap—especially in the experiences of marginalized people or groups.
Life course model	An approach that takes a temporal and societal perspective on the health and well-being of individuals and generations, recognizing that all experiences and stages of a person’s life are intricately intertwined with each other, with the lives of others born in the same period, and with the lives of past and future generations.
Positive childhood experiences	Factors that increase the likelihood of successful development, such as safe, stable, nurturing relationships and environments.
Regulation	Biological and emotional processes that support adaptation to stimuli and maintaining a stable internal environment.
Resilience	Ability to recover from, or adjust to, change or adversity.
Single event trauma	An event that is experienced as threatening or harmful and that has a clear beginning and end. Once the event is over, survivors can reach a place of safety and may be able to seek help and recover.
Sexual and gender minorities	Individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex. Also may include individuals with same-sex or -gender attractions, those with a difference in sex development, and those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by nonbinary constructs of sexual orientation, gender, and/or sex.
Sexual and gender minority stress	A theory proposing that LGBTQ+ people experience chronic stress related to their stigmatization by heterosexist societies. Minority stressors may include internalized homophobia, stigma, and actual experiences of discrimination and violence.
Trauma	Any event experienced as threatening or harmful to an individual or group and which may have lasting effects if unbuffered or untreated.
Weathering	Early deterioration of health and physiologic wear and tear, as a consequence of the cumulative impact of repeated experience with adversity and marginalization. Originally described in Black Americans, this phenomenon is experienced in other marginalized and oppressed groups.

LGBTQ+, lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more.

The trauma behind hysteria

Although widespread study of psychosocial adversity did not appear in Western scientific literature until the late 20th century, the seeds of this work were planted almost a century before. In the late 19th century, an early-career Freud reported after interviewing 18 patients with neuroses or “hysteria,” that all were survivors of childhood incest. Freud’s case study, The Aetiology of Hysteria, had table-turning sociopolitical implications but was immediately dismissed by the prevailing medical establishment.¹⁸

Hysteria was so common among women that if his patient’s stories were true, and if his theory were correct, he would be forced to conclude that what he called “perverted acts against children” were endemic, not only among the proletariat of Paris, where he had first studied hysteria, but also among the respectable bourgeois families of Vienna, where he had established his practice. This idea was simply unacceptable. It was beyond credibility.^18,p14

Such radical findings had no viability in the patriarchal social order or medical theory of the day. Succumbing to explicit and implicit pressure, Freud quickly abandoned his original theories, which eventually inspired his now-discredited developmental theory of psychosexual stages.

Trauma from war: Shell shock

Progress in the field of traumatic stress research was stymied until decades later when the anguish of veterans returning from World War I manifested in a syndrome of neurosis peculiarly similar to the “hysteria” of decades before. Colloquially described as “shell shock,” medical professionals such as Myers were among the first to document their findings formally.¹⁹ Although some perceived shell shock to represent “cowardice or malingering,” Myers found a link between exposure to explosions and a constellation of physical and psychological symptoms.²⁰ Still, even more time would go by before the symptoms of shell shock would be formally acknowledged in 1980 as the consensus diagnosis of posttraumatic stress disorder (PTSD).²¹

Early insights into childhood trauma

Almost 100 years after Freud’s hysteria case study, Terr, a prominent early psychiatrist and childhood trauma researcher, wrote about acute traumatic events and the effects of ongoing exposure to real (not imagined) interpersonal trauma.²² Beyond the trauma caused by a single event, understanding the effects of repeated, compounded, and unmitigated trauma shed light on how expansive, severe, and urgent this problem is in our society. Attention to the cumulative impact of trauma also highlighted its effects on child development.

Cloitre and others built upon this work by exploring the effects of complex trauma and developmental trauma disorder.²³ They noted that “complex trauma exposure results in a loss of core capacities for self-regulation and interpersonal relatedness,” and an increased risk for additional trauma exposure and cumulative impairment, such as mental illness, addiction, and chronic physical disease, as well as legal, vocational, and family problems. Cook²⁴ proposed 7 domains as a framework for understanding the effects of long-standing childhood adversity (Figure 2, with additional details):

Figure 2:

Complex trauma in children and adolescents (2003). Used with permission from the National Center for Child Traumatic Stress.²⁴

1. Attachment

2. Biology

3. Affect regulation

4. Dissociation

5. Behavioral regulation

6. Cognition

7. Self-concept

Although this work greatly advanced understanding of the developmental consequences of repeated interpersonal trauma, most studies did not include a formal focus on the effects of historical or intergenerational trauma nor account for the ongoing broader-level adversities and collective trauma experienced within communities (eg, poverty, discrimination, structural racism). In many neighborhoods, exposure to community violence is unconscionably high and often still goes unrecognized. Even trauma experts Bell and Jenkins were stunned to find such a high prevalence of witnessing violence in their school-based study; 75% of youth 10–19 years old living in moderate-to-high violence communities had witnessed a robbery, stabbing, shooting, or killing.²⁵ Throughout history, many authors from marginalized and oppressed communities (Tecumseh, Wilde, DuBois, Baldwin, Lourde, and others) clearly describe the deleterious mind–body impact of their lived experience.

Despite rich evidence from research and personal accounts, early investigators had to defend their findings against the general belief that various forms of trauma either did not actually occur or did not have the purported impact. Importantly, in each successive era, regardless of the type of trauma they were studying, researchers found surprisingly similar symptomatology and consequences.

Dose–response, allostatic load, and weathering

A foundational concept in studying links between experience and subsequent clinical impact is the dose–response relationship. In the 19th century, pharmacologists developed dose–response methodology, which was then adapted to clinical epidemiology in the mid-20th century.²⁶ Although not always a linear relationship, in general, the magnitude of the biological response is proportional to the dose of any exposure, including experiences.

In the early 1990s, the emergence of the concepts of allostatic load (from stress of any type)²⁷ and weathering (from stress of being a member of a marginalized group)²⁸ linked the amount of trauma exposure to its multifaceted detrimental effects on human physiology. When an individual encounters persistent dysregulation from chronic stress, the ability to maintain physiologic homeostasis becomes increasingly impaired (greater allostatic load), eventually resulting in disease, morbidity, and premature mortality.

Chronic stress and cumulative trauma are universal, yet simultaneously disproportionately prevalent, in oppressed and marginalized communities as a result of differential environmental and historical exposures. For example, Spinazzola noted that Black youth were more likely to be exposed to community violence but White youth were more likely to be exposed to interpersonal violence.²⁹ Although specifics may differ across demographics, these unequal exposures at community and societal levels perpetuate, if not widen, known health disparities by race and class.

Early thoughts about resilience: Protective factors

Considering the protracted and daunting legacy of adversity among children and families who have been marginalized and oppressed, the prognosis for health and well-being appears bleak. However, risks must be understood in the context of protective factors.³⁰ In the 1970s, Masten, Garmezy, and other psychologists began studying what resources and influences protect children³¹ and help them develop resilience, a manifestation of brain network capacity that supports recovery and the ability to respond to challenges.³² For children, foundational attachment relationships with primary caregivers and other nurturing adults buffer the adverse impact of routine developmental challenges, oppressive structures, and discriminatory encounters and assist children and youth in developing positive coping skills across the life course.^33–36 Meeting basic needs, bolstering self-esteem, fostering supportive relationships, and focusing on physical health and other strategies that prevent and mitigate trauma also effectively build resilience.³⁷

Bell emphasizes the importance of cultivating resilience as a response to the cumulative trauma experienced by youth.³⁸ Benedek describes work by Anna Freud and Dorothy Bellingham who highlighted the positive role of protective factors on trauma symptomatology in children, such as the role of parents who sought to calm their children during threatened violence during World War II. She also notes positive trauma processing following discrete traumatic events; for example, survivors’ posttraumatic play was identified after a 1956 tornado in Vicksburg, Mississippi, struck a theater during a children’s matinee.³⁹ Finally, Lieberman et al point to positive memories from childhood (angels in the nursery), which support optimal development and can be a critical component of healing and recovery.⁴⁰

Recent advances in understanding the impact of experiences on health

Nineteenth and 20th-century psychiatry, psychology, and social work scholarship paved the way for the explosion of public health and social science research taking place today. Exploration of the cumulative effects of psychosocial experiences, augmented by the advent of new concepts in neuroscience with sophisticated brain imaging technology and deeper understanding of child development, gained traction in the 1990s. This work revealed that experiences, from individual to structural, are embodied with their impact on the physical body as well as on emotions and cognition.

Five bodies of work from the many areas within the current science of trauma, resilience, and equity are highlighted: Adverse childhood experiences (ACEs), Everyday Discrimination (ED), Sexual and Gender Minority Stress (SGMS), and Acculturative Stress/Trauma (AS), which emerged from trauma science, and positive childhood experiences (PCEs), which is based on resilience literature.

Adverse Childhood Experiences

The landmark adverse childhood experiences (ACE) study, first published in 1998,⁶ grew out of a stunning clinical observation—that childhood sexual abuse was common among obese patients in a supervised weight loss program and was strongly associated with attrition from the program despite successful weight loss.⁴¹ ACEs is perhaps the most well-known body of research within trauma science (so much so that the term ACEs has become shared language and synonymous with all types of childhood trauma).

The ACE Study developed and administered a 10-item questionnaire to investigate the prevalence of different types of childhood adversity in the home (abuse, neglect, and household distress) among a middle-class, insured, and highly educated sample, and it explored the relationship between these experiences with adult health and social outcomes. ACEs were common: nearly two-thirds of participants reported at least one ACE. Cumulative ACEs were associated, in a dose-dependent manner, with a multitude of deleterious physical, mental, and social outcomes throughout the life course, including six of the ten leading causes of death in the United States. Further, ACEs cluster together: for individuals reporting at least one ACE, there was an ~90% chance of a second ACE and an~60% chance of havingthree or more ACEs.⁴² Altogether, the epidemiological rigor of the ACE study and consistent findings among subsequent studies of more diverse populations in the United States and globally have provided a large, still-growing, and compelling evidence base for the cumulative effect of psychosocial experiences on health.

Everyday Discrimination

One noticeable omission in many trauma studies is the adverse experience of discrimination, particularly racial discrimination. The health impacts of racism must be understood within the context of structural discrimination. According to Williams, a social scientist, “Racism is an organized system that categorizes and ranks individuals, devalues and disempowers populations regarded as being inferior to others, and differentially allocates opportunities and resources.”⁷

Because he found scant empirical evidence in the literature about the impact of racism and discrimination on health, Williams sought to develop a more robust evidence base.⁴³ In 1997, one year prior to the first ACE publication, Williams published the nine-item ED Scale, assessing the occurrence and frequency of unfair treatment in the daily life of Black Americans. Such experiences include being insulted, threatened, or harassed; having others act afraid of you; or having people act as if you were dishonest, not smart, or not as good as others. Although this scale was designed to assess the experiences of Black Americans, subsequent research has demonstrated its validity across multiple populations, including other racial and ethnic groups, sexual and gender minorities, and elders.

Studies of ED have demonstrated the close relationship between the level (dose) of chronic exposure to unfair treatment and the occurrence and severity of many chronic illnesses (eg, sleep disorders, cardiovascular disease, diabetes, cancer, mental distress).⁴⁴

Sexual and Gender Minority Stress

In 2003, Meyer developed a new conceptual framework, the SGMS model, to explain health disparities experienced by sexual and gender minorities resulting from exposure to a hostile, discriminatory, and dysregulating social environment. Meyer’s research, as well as > 100 subsequent studies, found that minority stress is associated with increased emotional suffering, including anxiety, depression, suicidality, substance use, eating disorders, and PTSD.⁴⁵ Testa and colleagues expanded this work in 2015 and developed a gender minority stress and resilience measure, with additional attention to transgender and gender nonconforming persons. This measure has research and clinical applications, including increased understanding of gender minority experiences, as well as stress and resilience factors and the assessment of whether specific therapies or interventions are helpful in reducing risk and supporting resilience.⁴⁶

Substantial evidence suggests a dose–response relationship between specific SGMS processes, including prejudice, expectations of prejudice, concealment of sexual orientation, and internalized stigma, and a host of physical health outcomes (eg, impaired immune and endocrine function, obesity, poor sleep, a higher incidence of cancer and infectious and respiratory diseases).⁴⁷ Additional research is underway to evaluate which stresses are shared with other marginalized groups and which are unique to the SGM community. Gender minority individuals (transgender and gender diverse) and persons with a bisexual sexual orientation suffer the most discrimination and the most psychological and physical dysregulation.⁴⁸

Acculturative Stress/Trauma

In the mid-20th century, the concept of culture shock⁴⁹ emerged to describe the disorientation and distress of individuals undergoing a major cultural transition. In the 1970s, this experience was relabeled “acculturative trauma.”¹⁴ Eventually, additional researchers developed a relevant questionnaire.⁵⁰ Although rarely mentioned in lists of adverse experiences, acculturative trauma is among the most common. Its impact can be short term or lifelong.

Although early studies focused on populations experiencing a major transition from immigration or colonization, later investigations demonstrated similar adverse experiences among any community adapting to a new culture or social norm. Studied populations include immigrants, colonized indigenous peoples, foster children, military personnel, incarcerated people, those starting a new school or job, and more.

Common characteristics of acculturative trauma include a deep sense of loss, disorientation, feelings of exclusion, discrimination, marginalization and isolation, and loss of identity and sense of belonging. Persons experiencing AS often lose key social support networks and face cultural clashes with the dominant culture. Documented mental health impacts include anxiety, depression, PTSD, and substance use. Physical health issues include sleep disorders, digestive problems, metabolic dysregulation—especially obesity and diabetes—cardiovascular disease, and chronic pain.⁵¹

Exploration of Resilience: Positive Childhood Experiences

Positive experiences are emerging as critical elements of research and practice agendas directed toward equitably promoting flourishing and also preventing and mitigating adversity. Over time, researchers developed a short list of positive influences on long-term development.⁵² This short list helped inform the Benevolent Childhood Experiences (BCEs)⁵² and the PCEs questionnaires⁵³: two instruments designed to explore how positive experiences with family and friends, within school, and in the community can mitigate adversity and support healthy development.

When researchers administered the BCEs scale to racially and ethnically diverse pregnant women who had faced childhood adversity, they observed a dose-dependent relationship between more positive experiences and less psychopathology and stress.⁵² The inclusion of PCEs questions in the 2015 Wisconsin Behavioral Risk Factor Surveillance Survey revealed a dose–response relationship between PCEs and lower levels of adult depression and poor mental health.⁵³ Furthermore, a 2018 study of > 3000 children at 6–13 years of age examined the impact of the type and timing of positive experiences on developmental outcomes. Relational health across childhood development, and particularly in the perinatal period, appeared to be the most important predictor of current functioning.¹⁰ Finally, new research from 2023 is beginning to demonstrate that PCEs are also protective of physical health.^54,55 Enhancing PCEs and focusing on building individual and relational strengths in childhood may therefore be an effective strategy for promoting adult health.

Discussion

Celebrating the contributions and identifying the gaps

The ACEs, ED, SGMS, AS, and PCEs work made monumental contributions toward understanding the origins of health or illness. Although these models each focus on different types of adverse and positive experiences, the side-by-side comparison among all 5 bodies of work in Table 2 clearly demonstrates that the associated adverse and positive health outcomes are remarkably similar from one study to the next.⁵⁶ Suffering from adversity and trauma of any type increases risk for disease while positive experiences support well-being by buffering adversity and building resilience.

Table 2:

A comparison: Adverse Childhood Experiences, Everyday Discrimination, Sexual and Gender Minority Stress, Acculturative Stress, and Positive Childhood Experiences⁵⁴

Study characteristics	Study construct
	ACE	ED	SGMS	AS	PCE
First publication date	1998	1997	1995	1988	2015
Experience types	10 types of abuse, neglect and household distress—occur before age 18	Discriminatory interpersonal events, which may appear trivial or even normal—occur at any age	Interpersonal prejudice and discrimination experienced by stigmatized sexual and gender minority groups—occur at any age	Novel experiences: immigrant, foster care, college, military—occur at any age	Individual, family and community experiences promoting safe, stable, nurturing relationships and environments—occur before age 18
Considers developmental timing of experiences	Yes	No	No	No	Yes
Includes community or structural level considerations	No	Yes	Yes	Yes	Yes
Specific assessment questionnaire	Yes	Yes	Yes	Yes	Yes
Dose–response demonstrated	Yes	Yes	Yes	Yes	Yes
Likelihood of associated health conditions/behaviors
Chronic diseasea	↑	↑	↑	↑	↓
Chronic pain	↑	↑	↑	↑	↓
Health risk behaviorsb	↑	↑	↑	↑	Unk
Inflammatory biomarkersc	↑	↑	↑	↑	↓
Maternal–child health problemsd	↑	↑	↑	Emerging	Unk
Mental health problemse	↑	↑	↑	↑	↓
Premature mortality	↑	↑	↑	↑	Unk

^aChronic disease, such as cardiovascular disease, chronic lung disease, diabetes, obesity, sleep disorder and/or more.

^bHealth risk behaviors, such as substance use (tobacco, alcohol, drugs), high risk sexual behavior and/or more.

^cInflammatory biomarkers, such as cortisol, C-reactive protein, Interleukin 6 and/or more.

^dMaternal–child health problems, such as teen and unintended pregnancy, prematurity, low birth weight, fetal death and/or more.

^eMental health problems, such as depression, anxiety, suicidality, hallucinations and/or more.

↑, increased likelihood; ↓, decreased likelihood; ACEs, adverse childhood experiences; AS, acculturation stress; CRP, C-reactive protein; ED, everyday discrimination; IL-6, interleukin-6; No, absent; PCEs, positive childhood experiences; SGMS, sexual and gender minority stress; Unk, unknown; Yes, present.

Landmark contributions to our understanding include the ACE Study’s finding that adverse experiences are highly likely to occur in clusters and that single event trauma is rare.⁶ Congruent with groundbreaking work in trauma therapy, the ACE Study also highlighted the important framing that behaviors conventionally viewed as self-defeating or counterproductive often represent adaptations stemming from adversity.^41,57,58 The dose–response relationship observed across studies between ACEs and other traumatic experiences with adverse health outcomes, as well as the power of positive experiences to mitigate adversity and build resilience, emphasizes that the accumulation of all experiences matters profoundly. The identification of specific positive experiences and their cumulative impact on favorable outcomes guides us toward optimal prevention and treatment.

Nevertheless, as revolutionary as these bodies of work and those that preceded them may be, gaps remain. First, these studies tend to focus on single levels of the socioecological spectrum and rarely account for the multiple identities of each individual. In 1989, Crenshaw underscored the conceptual limitations of single-issue analysis with her theory of intersectionality.⁸ Although the ACEs and ED work occurred around the same time and revealed very similar findings, there has been little synthesis of these two approaches with each other, or with SGMS or AS. Krieger reminds us that

…we are not one day White or a person of color, another day working class or professional, still another day a woman or a man or transgendered, on yet another day straight or lesbian, gay, bisexual or transgender, and yet another immigrant versus native born. We are all these at once—and our research [education and clinical practice] needs to integrate these conjoint social facts the same way our bodies do, each and every day.^59,p942

Next, these studies are primarily epidemiological and document the associations between personal characteristics of the research participants, their exposure to trauma, and subsequent physical or psychological disease. Understandably, epidemiologic researchers have been reluctant to hypothesize about causal biologic pathways. Given parallel advances made in neuroscience about the dynamic nature of neural networks, our individual interpretation of experiences, and the physiologic manifestations of both, there is an urgent need to explicitly integrate epidemiology, neuroscience, and other relevant disciplines.

In addition, ACEs, ED, SGMS, and AS have remained primarily problem- and disease-focused, without much consideration of the impact of positive experiences and the human capacity for resilience. Even PCEs and BCEs are first and foremost about mitigating adversity rather than primary creation of health and well-being. This problem-focused emphasis continues to pathologize human experience and has the potential to cultivate a belief in inherent brokenness that may exacerbate discrimination. Simultaneously, it may reinforce siloed and inequitable medical care.

ACEs and PCEs explicitly connect childhood experiences with life course health, but much of the other work does not. Most of the work described above omits systematic examination of how developmental timing, frequency, and intensity of experiences affect outcomes. Finally, little of this science has penetrated clinical practice, health care education, or research in general. Figure 3 summarizes the field’s current gaps and limitations.

Figure 3:

Gaps, challenges, and obstacles to consilience.

Toward A new unified framework and applications

In this review, the authors acknowledge the foundation of empiric knowledge passed on generationally by indigenous peoples and connect it to now-decades-old research in sociology, biomedicine, neuroscience, child development, public health, psychology, and more. This review draws attention to the paradox that although most research in traumatic stress and resilience has been siloed, these bodies of work converge upon many of the same findings and conclusions. This convergence strengthens not only the credibility of the field but also each individual body of research.

Collectively, this work has made progress that can positively influence all pillars of the health care system (ie, clinical care, education, research, community partnerships, and systems redesign). Yet, for this science to achieve its desired impact, there is a need to move beyond siloed approaches and make deliberate efforts toward an integrated model of trauma–resilience–equity that is rigorous and comprehensive and can be applied practically and universally. The recognition of the hidden truth of consilience among diverse elements of the expansive body of work related to trauma, adversity, and neurobiology reveals embodiment of experiences via physiologic regulation/dysregulation as the common root and thus a focus for prevention and intervention. Harnessing this synergy has the potential to promote unprecedented breakthroughs in health care.

Consilience highlights the value and challenges of integrating diverse perspectives to arrive at a more complete understanding of complex phenomena. The term, which describes both a concept and a dynamic process, was coined by the influential 19th-century thinker Whewell although the idea has been acknowledged by scientists throughout history.⁶⁰ Whewell’s famous example of consilience was Newton’s law of universal gravitational attraction integrating Newton’s own experimental observations with Kepler’s laws of planetary motion, which until then had not been seen as interrelated. Acknowledging the connectedness between the two theories strengthened the claims of each, establishing the foundation for groundbreaking discoveries in astronomy and physics. Similarly, awareness of consilience can foster development of a unified theory of what causes, treats, and prevents illness and human suffering, offering a pathway toward health innovations, interdisciplinary models of care, health education reform, and a paradigm shift within health care focused on well-being, resilience, and equity. This theory will reconnect mind and body, past and present, individual and collective, positive and negative, science and lived experience, the specific and the general, multiple disciplines, and more. It will be translatable and scalable in education, practice, and research.

This review takes a concrete step toward consilient theory and practice through a systematic approach of identifying connections, patterns, and underlying principles that transcend different disciplines. As we come to appreciate the convergence of findings from seemingly disparate fields, new comprehensive models can emerge that encompass multiple, previously unexplained dimensions of complex findings. Figure 4 presents actions the scientific community could take to build consilience, as well as a summary of foundational concepts.

Figure 4:

Next steps in trauma, resilience, and equity consilience.

Current Innovations–Progress toward Integration

Emerging conceptual frameworks, measurement tools, research, clinical, educational, and policy innovations are integrating historically separate ideas and applications of the science of trauma, resilience, and equity. Below, as well as in Supplementary Table 1, the authors offer a few of the many brilliant innovations that are part of deliberate efforts toward a unified model of trauma–resilience–equity with relevant applications. To advance health and equity, these efforts are interweaving lessons learned from science with indigenous wisdom, contemplative practice, cutting-edge technology, social justice principles, and collaboration with those with lived experience. Although not comprehensive nor fully cohesive, these examples can inspire and guide us in developing and scaling additional effective prevention and treatment strategies.

Conceptual frameworks

The minority stress mosaic framework,⁶¹ a paradigm based on findings from both a systematic literature review and neuroimaging, is designed to capture the complex, multidimensional nature of identity, particularly for the LGBTQ+ community. This model calls for an expansion of the PTSD construct to include minority stress and an intersectional approach to future neuroimaging research. Accounting for both minority identity experiences alongside unique individual experiences and processes and pathways in response to stress, it acknowledges that the neurobiological impact of all experiences taken together results in regulation and resilience or dysregulation and injury.

Other notable integrated frameworks include the Indigenous Wellness Pyramid⁶² and ecosocial theory.⁵⁹ The National Native Trauma Center and partners created the Indigenous Wellness Pyramid as a response to the deficit-based ACE model. This framework includes culturally tailored strategies, such as intergenerational and traditional healing, tribal sovereignty, and cultural revitalization. It combines them with acknowledgment of historical pain and suffering to support positive experiences, wellness and balance, longevity, and thriving and safe communities. Ecosocial Theory embeds biology in its social and ecological contexts for a more complete and nuanced understanding. The theory proposes that 1) patterns of population health and disease are created by the embodiment of lived experience in their social and ecological context; 2) determinants of disease distribution—including inequities—are outside people’s bodies, most dependent on macro-level phenomena, and shaped by gene expression rather than frequency; 3) in societies with social divisions based on power and property, the greater absolute burden of disease is on those with less power and fewer resources; and 4) disease distribution cannot be explained solely by disease mechanisms because these pathways do not account for changing rates and patterns or the complexity of these changes across time and place.

Research

Promising research demonstrates the impact of interventions that combine diverse principles from neurobiology, attachment, identity, anti-racism, and trauma-informed care. A national randomized controlled trial connecting social justice with developmental neuroscience and sophisticated technology demonstrated that poverty reduction initiatives can catalyze meaningful and measurable physiologic improvement in infants of mothers experiencing poverty.⁶³ In this study, an extra $300/month in the first year of life—accounting for~20% of the annual parental income—positively changed infant brain activity on electroencephalogram, reflecting the multifaceted impact of supporting parents. The Strong African American Families (SAAF) program combines several approaches (strengthening parent–child attachment; confronting and buffering children’s exposure to racial discrimination; a life course approach with long-range follow-up of 14 years) and demonstrates improved mental health and metabolic outcomes. The SAAF randomized controlled trial of culturally respectful positive parenting prevented the development of prediabetes at age 25 when delivered to families of 11-year-old Black boys.⁶⁴ A natural history study linked a person’s critical consciousness of structural racism motivating collective action to enhanced immune status in Black women with HIV.¹⁶ A pilot of trauma-informed organizational change reduced patient violence in an emergency department and improved patient satisfaction and staff morale.⁶⁵ Finally, a municipal home repair program reduced crime in Black urban communities in a dose-responsive fashion.⁶⁶

Clinical practice

Person- and community-centered, culturally tailored, developmentally appropriate, relationally safe strategies are key ingredients for producing desired outcomes. The Illinois Birth-to-Three (IB3) project adapted evidence-based, trauma-informed parenting psychoeducation and therapeutic programs to assist birth parents and substitute caregivers in addressing the effects of maltreatment on child well-being, promoting secure attachment, and permanency outcomes. From 2013 to 2020, the program included > 2500 children aged 0–3 years entering out-of-home care and their caregivers. Children in the intervention group achieved levels of family unification 53% higher than those assigned to services as usual.^67,68

Effective and integrated assessment of trauma, equity, and resilience would explore and synthesize each person’s unique blend of experiences, particularly in the formative years, and apply nuanced interpretation toward co-creation of tailored prevention and treatment strategies. Trailblazing work toward this goal is the Neurosequential Model of Therapeutics (NMT), developed by neuroscientist and child psychiatrist Bruce Perry.⁶⁹ Recognizing that key brain functions develop in a predictable (sequential) order, NMT is “developmentally sensitive.” Using open-ended questions, this model can identify trauma or neglect of all kinds occurring during specific developmental periods and balance this with information about the quantity and quality of relational experiences (“relational density”). NMT’s intergenerational lens includes positive and adverse maternal, familial, and community experiences, particularly during “critical developmental periods.” It also incorporates family, community, and traditional culture as key regulatory supports in a multimodal collaborative healing regimen. Thus, NMT’s individualized, comprehensive, and balanced methodology approaches a unified theory and practice.

Individual patient care: A case example

Figure 5 applies a unified framework to the introductory clinical case. The goals of this approach are to 1) identify and connect “the what” (the clinical presentation) and “the why” (the underlying experiences influencing the presentation) and 2) help restore balance to brain–body physiology to foster health and well-being. Armed with scientific knowledge of the potential impact (positive or negative) of experiences, it is possible to build a richer understanding of the trajectory of patient concerns and anticipate steps to cocreate an effective treatment plan.

Figure 5:

Applying the unified framework integrating trauma, resilience, and equity to a sample case.

Limitations

This narrative review is neither systematic nor exhaustive and may have missed key material from the bodies of work included, in both English and other languages. It may also have excluded important related concepts and findings from other scholars, journalists, and people with lived experience.

Conclusion

This review traces the evolution of rigorous biological and social science, social justice ideologies, and indigenous wisdom. Taken together, the history and research evidence compel us to recognize the profound impact of lived experiences on health, to acknowledge the burden of those of us who have been systematically oppressed, and to expand self- and collective compassion and care to advance a consilient health care paradigm and practice. The authors advocate for a unified model integrating key elements: enhancing positive/protective experiences, fostering healing, and removing sources of distress, whether they are the result of child maltreatment, discrimination, poverty, structural barriers, all of these, or other experiences.⁷⁰

The review also showcases existing and effective integrated individual- and population-level prevention and healing ways of thinking and acting that warrant recognition and further development. These innovations are beginning to fulfill the potential of consilient science and can serve as early implementation examples of a unified model producing the health care and health professional education that all of us need and deserve.

There is not one right way but, rather, many paths to cultivate healing and thriving, as well as many yet to be discovered. Successful integration will require leadership from science, partnership with communities that centers lived experience in all aspects of the work, and concrete support from government, philanthropy, and business. This is a call for all of us to engage in radical intentionality, ongoing dialogue, and cross-sector collaboration toward consilience.

Supplementary Material

Table S1