Tackling poor health outcomes: the role of trauma-informed care

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Part of Health and care services for people sleeping rough

Over the past few months I’ve been interviewing, reading and writing about the provision of health and care services to people who sleep rough. One concept has particularly stood out to me from what I’ve heard: trauma. It’s something I’ve been hearing more about recently, both in this research and in other health and care contexts.

Our understanding of the breadth of the definition of trauma is growing. One well-used definition comes from the US Substance Abuse and Mental Health Service Administration:

The concept of adverse childhood experiences (ACEs), is one that researchers and policy makers are using to think about the impacts of trauma. ACEs are potentially traumatic events experienced before reaching the age of 18, including but not limited to abuse or neglect in childhood and distressing family events such as witnessing domestic violence or a parent going to prison. It’s estimated that almost half of the adult population of England have experienced at least one ACE, while 9 per cent have experienced four or more. ACEs are therefore far from rare.

'We heard about how people who were sleeping rough with substance misuse problems were also often dealing with longstanding trauma, but that health services were often not set up to recognise or meet this need.'

People who are homeless are more likely to have experienced trauma than the general population, and homeless people with the highest support needs are also the most likely to have experienced multiple ACEs. In our research, some interviewees described the impact of trauma on people (not) accessing services, while others highlighted the importance of an approach in services for homeless people that recognises the impact of trauma. For example, we heard about how people who were sleeping rough with substance misuse problems were also often dealing with longstanding trauma, but that health services were often not set up to recognise or meet this need. If services don’t take trauma into account, given that people who have experienced trauma may be reluctant to engage with health care in the first place, there is a risk that some will not receive the support they need.

This is not just an issue for services supporting people who are homeless. Multiple ACEs are also associated with higher risks of a range of poor health outcomes. Additionally, they are not evenly distributed: higher ACE counts are associated with living in a deprived area or being female. For all these reasons, it’s important to consider how services across the health system respond to people who have experienced trauma.

A trauma-informed approach to healthcare aims to provide an environment where a person who has experienced trauma feels safe and can develop trust. This might look like a health care provider explaining why they are asking sensitive questions, responding with compassion when a person refuses a medical exam or test, or enabling the person to take control, for example, asking them to share what they’ve found helpful or harmful in similar situations in the past. Lots of research in this area focuses on mental health services because of established links between trauma and mental distress. The NHS long-term plan commits to developing trauma-informed care in relation to a community offer for people with severe mental health problems, but also a service for vulnerable young people in contact with the youth justice system. Additionally, an expectation of trauma-informed approaches in mental health services accessed by people sleeping rough is included in the NHS mental health implementation plan.

'This work requires a cultural shift, not simply a behavioural one – a change in the way front-line staff understand the impact of trauma, which in turn influences their practice.'

Given that people who have experienced trauma will interact with a range of services throughout their lives, it makes sense that front-line staff across sectors have at least a working knowledge of the impacts of trauma. The Scottish Government are aiming to develop understanding of trauma across the workforce – including not only mental health but also the physical health, social care, education, and justice sectors. They commissioned NHS Education for Scotland to produce a knowledge and skills framework that sets out different levels of expected expertise depending on an individual’s particular role. As of this year, 3,000 front-line workers had been given some form of training. There is also work being undertaken in Wales. Public Health Wales have published a number of reports examining ACEs and their impacts on the Welsh population to inform a focus on ACEs and addressing them across public services.

This work requires a cultural shift, not simply a behavioural one – a change in the way front-line staff understand the impact of trauma, which in turn influences their practice. Training is a good place to start, but there are many competing asks on NHS staff time. Initiatives to promote trauma-informed approaches need to ensure a focus on the system-level change needed to deliver them, not simply relying on changing individual practice.

Finally, it’s important to remember that while anyone can use a service that is trauma-informed, services that are not trauma-informed risk excluding people who have experienced trauma. As well as enabling a more person-centred approach for anyone who uses a service, this is a change with potential to improve healthcare for people who currently face poor outcomes.

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James Wardle

Comment date
06 May 2020


I’m not a professional but I’ve accessed private and NHS services and I think you may want to look into a practice in San Francisco. A US study showed a direct correlation of the number of childhood traumas like divorce, abuse, substance abuse etc. The more trauma the worse the health outcomes become such as diabetes, heart disease, obesity, mental illness and so on. 70,000 surveyed and I think it was across the income brackets. For 35 years, I saw psychiatrists and nurses and therapists and one day, I discovered narcissistic abuse. Then I read a book called c-ptsd: from surviving to thriving. At Chapter 2, as tears ran down my face, I realised I was not edging to bipolar disorder having suffered bouts of mania, I was not severely depressed, I was not borderline personality disorder as a nurse suggested. I stopped takung high doses of venlafaxine and other antipsychotics immediately and without consulting psychiatry. I’m feeling physicalky better since Drc 18 however my trauma was a father with narcissistic personality traits and essentially I was the dreamy one, the one they kick. They literally have a shattered inner self and my pain gives them narcissistic supply. At 48 I have bo boundaries at all. That could affect me in terms of being used financially or in a relationship. It’s hard to say but I tried dating after leaving a narcissistic ex partner, and luckily a friend of mine, a former straight cage fighter who had a background of boarding school issues, was literally ny big brother. If a predator starts down the sexual route, my need for love means ill ignore red flags like that. He was my boundary.
I have 4 significant childhood traumas and I have to manage the condition. Normal motivation won’t work fir me as I was taught by my family im not worthy of a reward for anything. You have goals and rewards and you are motivated by that. My brain is wired to abandon my needs / keep my head down. Normal techniques i iust fail. I am suffering manic symptoms now but have chosen therapy specialising in empath - narcissistic personality dynamic. I use mindfulness, therapy and write. You know what Id say is its ok to talk about mental illness unless you have got one. Noone virtue signals for us. We need connection and stigma makes us disconnected. I was told an unproven assertion that i gad a brain chemical imbalance. THERE IS NO MEDICAL EVIDENCE that supports that assertion. If you want some ideas of how to think blue sky, Im an ISTJ, I see the world as it could he. Noone has ever asked for any feedback about care. Ever. I had my choices taken away. And a 27 year old policeman is the only intervention when i was treated like an equal. He hit a hime run. Incidentally US didn’t want to screen as it’s not comfortable for them. And she said this, if you have children drinking from a well getting sick, you can write prescription after prescription and theyll still get sick... or tou can ask “what the hell is in this well?” Someone will hear me one day. Noone wver replies. Ever.

angela moulson

Clinical Specialist Lead Mental Health,
NHS Bradford & Craven CCG
Comment date
30 April 2020

we are interested in improving our trauma informed pathway in a systematic way as we are conscious people labelled with borderline or unstable personality disorder are usually victims of trauma and need help not stigmatising and rejection
I wonder if there is any work going on in the country at present we could learn from?

ann hemingway

Professor of Public Health,
Bournemouth University
Comment date
20 February 2020

I was touched by your comment and wanted to highlight some emerging routes to well being for those suffering with complex PTSD I have been involved in evaluating an equine assisted intervention which is now offered in five sites in the south of england, for individuals where talking is not working. Its called the horse course and is having some incredible outcomes it teaches basic level horse whispering and there is no diagnosis or labelling included. Have a look at the website any professional can make a referral including nurse, social worker, teacher, doctor etc. Here is a link to their website http://www.thehorsecourse.org/ may I wish you luck with finding some support please be aware that you are not alone in being in this position and there are emerging opportunities which do not require individuals to be re-traumatised by endlessly recounting what has happened but enable them to be accepted as a fellow human being who wants to move forward. x


Comment date
14 January 2020

I am currently banging my head against a brick wall, and have found the last 18 months very distressing trying to receive help for Complex PTSD. So far I have received the maximum 20 hours of therapy (as I was referred to short term services), and told I must wait 6 months to re-access the services. I have been affected all my life by my childhood traumas, resigned myself that I was just different to everyone else and found coping mechanisms to help me exist, rather than live. After finding an article on CPTSD it was a revelation, my life made sense for the first time, and gave me some hope. Due to trust issues it took me a further 12 months to convince myself to access GMMH. Contacting GMMH has left me more traumatised and added to abandonment/rejection traumas I already had. I have raised an official complaint as the current system does not have any grasp on how CPTSD affects the programming of your mind, I will not let this inadequate system continue to push me over the edge. I have had to be a fighter all my life and will not give up fighting the system.

Simon James

Chief Executive,
Interlink RCT
Comment date
04 December 2019

We are looking at how we take a community development approach to tackling trauma / ACES. But it seems many public services are designed to protect the system by stigmatising the most vulnerable and putting barriers in the way of care and support. Not sure how you tackle systemic problems without leadership that can acknowedge and address the problem is the system not the person rewuiring support.

Deborah Fenney

The King's Fund
Comment date
21 November 2019

Thanks for your comment, Jacqui - it's really interesting to hear from your experience in independent advocacy . And I agree, the work on Minority Stress is really interesting too - sadly there were so many things I couldn't squeeze into this blog!

Jacqui Jobson

Director of Advocacy,
Connected Voice
Comment date
18 November 2019

I found this a really interesting read and very important to raise the issue of trauma informed practice across health and social care. As an Independent Advocacy service, far too often we see the result of service users being excluded from systems that are not able to meet their needs. looking through a trauma informed lens is not only of great benefit to service users but would also save on much wasted time and resources, when people do not engage. Also I think it is worth looking at the impact of "Minority Stress"; a lot of work has been done in the US and Canada evidencing the impact this has in terms of PTSD and trauma and the resulting health inequalities.

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