Skip to main content
integrationModule 11 of 12

Trauma-Informed Care

SAMHSA's six principles as default posture. ACE awareness.

Essential Understanding
Roughly two-thirds of adults have at least one Adverse Childhood Experience, and healthcare encounters are themselves frequent sites of retraumatization. Compassion that is not trauma-informed can do harm. Trauma-informed care is not a specialty; it is a default posture that should be taught to every clinician.

Why this module matters

The original ACE Study (Felitti et al., 1998) established the prevalence and clinical relevance of trauma exposure. SAMHSA's Trauma-Informed Approach (2014) operationalized trauma-informed care through six principles.

Current evidence demonstrates that providers themselves often carry trauma histories that shape their clinical responses. Without explicit trauma-informed training, the skills of the Application Phase can inadvertently retraumatize patients with trauma histories. This module is not about treating trauma. It is about not making it worse.

Learning objectives

By the end of this module, students will be able to:

  • Cite the prevalence of ACEs and the clinical implications for adult care
  • Apply SAMHSA's six principles (safety, trustworthiness, peer support, collaboration, empowerment, cultural responsiveness) to a clinical scenario
  • Recognize retraumatization risks in routine clinical encounters
  • Adapt standard clinical practices (the physical exam, the medical history, the treatment discussion) to reduce retraumatization risk

SAMHSA's six principles

1

Safety

Ensuring physical and emotional safety in clinical settings.

2

Trustworthiness and transparency

Building and maintaining trust through clear communication.

3

Peer support

Drawing on those with lived experience as part of the care team.

4

Collaboration and mutuality

Partnering with patients, leveling power.

5

Empowerment, voice, and choice

Recognizing patient strengths and decision authority.

6

Cultural, historical, and gender issues

Recognizing structural sources of trauma.

Core concepts

The ACE Study and prevalence

Felitti et al. (1998) demonstrated that adverse childhood experiences (ACEs) were strongly associated with adult health risks. Approximately two-thirds of adults report at least one ACE and one in six report four or more. The clinical implication is that trauma history is the norm, not the exception, in adult healthcare.

Retraumatization in routine care

Clinical encounters can retraumatize without anyone intending harm. Common triggers include physical exams without explicit consent and explanation, restraints during procedures, sudden touch, removal of clothing, isolation, and the experience of being talked about rather than to.

What clinicians can change

Trauma-informed practice is mostly small changes: explaining what is about to happen and asking permission, offering control where possible (which arm, where to sit, when to start), narrating physical exam findings as you go, watching for somatic markers of activation in the patient. These adaptations cost almost no time and substantially reduce retraumatization risk.

A trauma-informed approach asks not "what is wrong with you?" but "what happened to you?"
Adapted from SAMHSA (2014)

Required readings

  • Substance Abuse and Mental Health Services Administration. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach (HHS Publication No. SMA 14-4884). SAMHSA.

  • Felitti, V. J., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

  • Rushforth, A., et al. (2023). Self-compassion interventions to target secondary traumatic stress in healthcare workers: A systematic review. International Journal of Environmental Research and Public Health, 20(12), 6109.

Suggested learning activities

The retraumatization audit

60 minutes

Students review three routine clinical practices (the physical exam, intake history, treatment discussion) and identify retraumatization risks. They then propose adaptations that reduce risk without changing clinical content.

The SAMHSA principles application

90 minutes

In groups, students apply each of the six principles to a specific clinical setting (an emergency department, an outpatient clinic, an inpatient unit) and describe what each principle would look like in practice.

The somatic markers practice

45 minutes

Students learn to recognize somatic markers of patient activation (rapid breathing, withdrawal, dissociation, hyperarousal) and practice de-escalation moves.

Personal trauma awareness

Asynchronous, optional

Students reflect on their own trauma history and how it might shape their clinical responses. This is offered as optional and confidential. Faculty should not require disclosure.

Time and sequence

Total time

2 sessions of 90 minutes plus clinical integration

Prerequisites

Modules 1 through 10 (Cultural Humility particularly)

Pairs well with

Module 12 (Moral Resilience)

Recommended placement

Late curriculum, with revisits

Common pitfalls

  • Treating trauma-informed care as a specialty. SAMHSA's framing is that trauma-informed care is a posture for all care, not a specialty for some patients.
  • Conflating trauma-informed with trauma treatment. This module is about not making trauma worse. It is not about treating trauma.
  • Ignoring the clinician's trauma. Many clinicians have trauma histories. Their clinical responses are shaped by it. The module should acknowledge this honestly.

Faculty teaching notes

Faculty teaching this module should have personal trauma-informed training. SAMHSA offers resources, and many trauma-informed care training programs are available. Faculty should also be prepared for student disclosures of personal trauma history, which sometimes occur in this module. Have referral resources ready before teaching.