Title: Trauma-informed Care for Nurses and Allied Healthcare Professionals
Subject: This practical book equips nurses and healthcare practitioners with essential knowledge and skills for understanding and supporting people who are experiencing mental and emotional distress as a result of the unresolved effects of past trauma. The book explores why people experiencing stress or dist
Author: Sarah Housden
Keywords: Skills for mental health professionals; PTSD; Adverse childhood experiences; social work; Causes of mental health problems; post traumatic stress disorder; nursing; Occupational health; ACEs; Experiencing mental distress; Service user involvement

What Is Trauma?

Trauma-informed Care for Nurses and Allied Healthcare Professionals

What is trauma?
Claire Moran
Case study
Ashley’s story
Looking back, it is difficult to pinpoint a precise occasion when I first experienced what I would now call abuse at the hands of another person. I guess in some ways, it started with emotional neglect, which meant that I never really learnt to respect and value myself or to put appropriate boundaries in place. The boundaries, now, look like a big part of it. I wanted so much to be loved by my family, and to have a sense of belonging, that when my older brother, Jack, invited me to jump into bed with him to keep warm, I hardly thought twice about whether I wanted to do it. He wanted me to snuggle up with him, and that was the closest I’d come in a very long time, to anyone wanting to be with me or spend time with me.
Actually, it was probably the closest thing to receiving a show of affection I’d ever had. It was okay that first time. He touched bits of me that I knew were meant to be kept private, but he didn’t hurt me. I really did feel loved and wanted. Things changed gradually, over the coming weeks, becoming more intimate. Then one day, Dad walked in on us and there was one almighty row. My brother moved out that evening to sofa-surf with friends, and we gradually lost touch with him altogether. I was left feeling emotionally bewildered, with neither Mum or Dad being willing to talk to me about Jack, and me not daring to mention anything about what had happened with him to friends at school. I felt abhorrent to my family and didn’t want anyone else knowing about what I had done, for fear of losing their friendships.
By the time I reached late teens, I was getting what I’d call properly interested in boys and had a few boyfriends in fairly quick succession. I was pretty much happy for them to treat me as they liked, without objecting to parts of my body being handled by relative strangers, after them not seeing the light of day since my experiences with Jack. It was easy enough getting on the contraceptive pill and for a time I settled for a life of short relationships with little emotional engagement. I hardly got chance to say much more than ‘hello’ before most of the men I was acquainted with would lead me to the bedroom. Somewhere deep inside I knew that I was worth more than this, but it did seem in line with what I knew of the relationships some of my friends were having at the time, so I put these sexual encounters down to something I would have to learn to put up with. It seemed to me to be part of what it meant to be a woman. Even so, I felt like I was being handled like a bag of potatoes, or as I secretly thought of myself, a lump of meat whose feelings were unrecognised.
I was in my early twenties when I first said ‘no’ to one of the men who wanted to have sex with me. This led very quickly, within moments it seemed, to a beating and being raped. Only I didn’t see it as rape, as much as the natural conclusion to a miserable life story. I certainly never reported what had happened as rape and could hear my internalised judge, if the case was brought to court, saying: ‘what did you expect?’.
I stopped going out after that, and steered clear of friends who enjoyed pubbing and clubbing as I felt like there was something about me which attracted abuse. Instead, I spent the evenings watching telly and only went out when work required me to – a necessity to pay the rent on my flat. I felt so worthless and was fearful of ever having a relationship with a man again.
I can’t exactly say what led to the decision to end my life a few months later. What I can say is that my somewhat rough handling by some staff at the local emergency department, alongside the quickly fired questions from their mental health liaison team, left me in no frame of mind to talk about my experiences. So, I was sent home to try taking my life again, and again, until five years later when someone gave me the time and space to begin to share and understand my life story, and to start the long process of healing through learning to love and care for myself.
Introduction
The word ‘trauma’ has become ubiquitous in the English language over the last decade or so, thanks in part perhaps to the prevalence of its colloquial use across social media platforms. Originating from the Greek meaning ‘a wound, a hurt, a defeat’, the contemporary use of the word trauma has been increasingly associated with psychological harm. The language and labels we choose have powerful effects, and the recognition of psychological trauma perhaps reflects a sociocultural shift, in which psychological ‘wounds’ are being recognised in our cultural lexicon.
Chapter aims
This chapter focusses on providing a detailed and comprehensive overview of trauma and includes information and ideas which seek to explore:
•		What causes trauma and the aspects of trauma contributing to long-term psychological harm.
•		Different types of trauma and the damaging effect of neglect.
•		Wider societal patterns of inequality and disadvantage which can contribute to the lasting effects of traumatic experiences.
•		Recognising our role in supporting people to share their story and to move towards recovery.
What is trauma?
Let’s start by imagining that trauma is a normal reaction to a significant event – something which is emotionally distressing and causing pain. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5-TR) (APA, 2022) defines traumatic events as exposure to actual or threatened death, serious injury or sexual violence through direct experience, witnessing or learning about violent or accidental traumas that have occurred for close family members or friends. Childhood trauma may include physical, sexual or psychological neglect and abuse, disasters or terrorism, family or community violence, bereavement and serious accidents or life-threatening illness (National Child Traumatic Stress Network, 2020). The World Health Organization (WHO) estimated that in 2014, approximately 36%, 22% and 16% of children worldwide have experienced emotional abuse, physical abuse and neglect, respectively. Some researchers define two different types of trauma, namely: ‘event trauma’ which is a sudden, unexpected traumatic event such as an accident; and ‘process trauma’ which is a continued exposure to a long-lasting stressor, such as war or physical abuse (Shaw, 2000).
The contemporary western mental health system is characterised as being diagnostic led. There are several diagnoses associated with trauma, such as post-traumatic stress disorder (PTSD), complex PTSD, developmental trauma disorder (DTD), attachment disorder and emotionally unstable personality disorder (EUPD). All these diagnoses share a collection of symptoms including emotional dysregulation, somatic symptoms and interpersonal difficulties, alongside cognitive and behavioural difficulties. As nurses and allied health professionals (AHPs) practising in a holistic and person centred way, our interest should be in the individual and the symptoms we see in front of us, and their current presentation, focussing on how we might be able to help to alleviate those symptoms, regardless of diagnosis.
The Centre for Disease Control Adverse Childhood Experiences (ACEs) (Felitti et al., 1998) study was a seminal project, exploring the myriad impacts of psychological trauma across the lifespan by surveying historical health outcomes of 17,000 individuals in California. They found a direct link between childhood trauma and the onset of chronic disease, imprisonment and even unemployment in adults. The original questionnaire indicated ACEs in three areas: abuse (emotional, sexual, physical), neglect (physical, emotional) and household dysfunction (mental illness, imprisoned family 
member, witnessing violence towards mother, substance abuse, divorce). The study found that the presence of four or more ACEs was linked to early mortality. In the context of the United Kingdom, the Office for National Statistics (ONS, 2020) indicates that one in five adults aged 18–74 years (8.5 million people) experienced at least one form of child abuse before the age of 16, whether this was emotional, physical or sexual in nature, or involved witnessing domestic violence.
To qualify as adverse events, McLaughlin et al. (2019) noted that experiences of threat or deprivation must either be chronic or involve single events that are severe enough to require significant emotional, cognitive or neu- robiological adaptation by an average child (for example, sexual abuse). There is extensive empirical literature on the relationship between the cumulative number of ACEs and mental health difficulties (Hogg et al., 2023). Furthermore, the idea of cumulative risk modelling acknowledges the impact of multiple adverse experiences on a person, impacting their ability to process future adverse events (Oral et al., 2016).
Researchers have found a relationship between adverse experiences and behavioural problems amongst children and adolescents, anxiety disorders, depression and suicide attempts. Four or more ACEs increased the risk of depression (4.5 times) and suicide attempts (12.2–15.3 times) (Felitti et al., 1998; Hogg et al., 2023). However, Kelly-Irving and Delpierre (2019) offer a critique on ACEs, acknowledging that although the literature surrounding ACEs was a helpful move towards recognition of psychological trauma, ACEs cannot be removed from the wider socioeconomic landscape. The original ACE study did not account for wider social experiences such as racism and sexism, instead focussing on trauma within the household. For context, subsequent research details that people from black and ethnic minority groups are likely to die younger due to social circumstances (ONS, 2020) and also receive poorer treatment in the healthcare system (Hamed et al., 2022). These are significant systemic traumas that were not included in the original ACEs questionnaire.
There is a need for a wider definition of ACEs as many research participants report stressful experiences that are not included on the original scale, but which are likely to belong in the same category (Finkelhor et al., 2015). Examples include social isolation and victimisation, as well as perceived discrimination. Further forms of adversity described in the literature include bereavement, sudden and frequent relocations, serious accidents, life-threatening childhood illness, pornography (exposure to or participation 
in), prostitution, natural disasters, kidnapping, torture, war, refugee camps and terrorism (Oral et al., 2016).
Adverse experiences are also related to poverty. The United Kingdom has one of the highest rates of child poverty in Europe (Bradshaw, 2023). A recent WHO and UN report detailed that mental health difficulties are mostly determined by social factors, rather than biochemistry (WHO and United Nations, 2023). Marmot et al. (2020) indicate that health inequalities have increased in the United Kingdom and that life expectancy has stalled. Climate change is another emerging global context that can result in frequent traumatic experiences due to disaster exposure and unplanned migration (Olff et al., 2025).
Defining trauma explicitly is complex as the subjective interpretation of an experience can be more relevant that the objective facts of the event, meaning that it is not necessarily the trauma itself, but the sense that we make of it, which can be psychologically and emotionally damaging in the long term. This involves recognising the role played by the emotions and thoughts associated with the event, along with the cumulative effect on a person, which itself can depend on a multitude of factors, both personal and systemic. In a narrative review of 15 years of psychotraumatology, Olff et al. (2025) noted that there is no universal experience or response to trauma. They found that symptoms experienced following trauma differ depending on the age and developmental phase, sex and gender, sociocultural and environmental contexts of the individual, as well as on systemic socio-political forces. Furthermore, the effects of trauma may be mitigated by, and depend on, levels of resilience and access to social support, as well as the educational attainment of individuals and the social groups to which they belong.
This becomes pertinent in practice for nurses and AHPs, because it signifies that we would do well not to assume the meaning or impact of trauma for an individual. Instead, we must remain open and curious to the person in front of us in every healthcare encounter.
Traumatic experiences
Attachment, relational and developmental trauma
Research has consistently demonstrated that complex interpersonal trauma has a severe impact on the developing child when it happens in the context of attachment (George, 2025; Lucre et al., 2024). Attachment is a clinical term 
used to describe the lasting psychological connectedness between human beings (Bowlby, 1969). To survive and thrive, attachment and connection with caregivers is essential. A growing brain needs a supportive environment and language acquisition, emotionally attentive caregivers, adequate nutrition and some stress, termed ‘eustress’ – stress which is believed to have positive effects on health and performance (Shonkoff et al., 2012).
Human beings are distinct from other animals in that infants remain immature and dependent on their mothers for much longer than other primates and are slower to attain developmental milestones such as walking (Rosenberg, 2021). The result is that infant brains grow rapidly while experiencing a richer sensory and social environment than they would have, if following the typical developmental course of a primate (Bjorklund, 2022). The malleable brain plasticity of an infant allows for dynamic responses to the socio-emotional environment they are born into, with repeated interactions and communications supporting memory-making and laying the foundation for relationships. Vygotsky’s (1978) social learning theory understands human development as being a socially mediated process, by which children acquire cultural beliefs, values and strategies from their surrounding environment, including their caregivers. The early years of an infant’s life are seen as a ‘window of opportunity’ as well as a ‘point of vulnerability’ (Andersen, 2003), while other research has demonstrated that the first two years of a child’s life are the most critical for forming attachments (Prior and Glaser, 2006).
Humans are relational beings – we exist in relation to ourselves, to others and to the wider sociocultural environment of family, friends, workplaces, the government and the natural world in which we live. The complexity of the human experience means that while we are compelled towards connection and cooperation, we are also vulnerable to interpersonal harm. A child or adolescent is dependent upon their caregivers for safety and security, nurture and care. The process of healthy attachment involves micro-traumas whereby a child might hurt themselves and become distressed and the caregiver soothes the child. The attachment bond is thereby strengthened. Sometimes, the caregiver perhaps cannot attend to the child in time, but this is survivable in a consistent, loving environment – it is good enough (Winnicott, 2000).
However, in environments where caregivers are not present, or are a frightening presence, the child has no choice but to attach, for purposes of survival, to a caregiver who is causing them harm. Living in fear and relying 
on this caregiver for such things as food and shelter result in prolonged exposure to chronic stress, which impacts the brain and behaviour as well as subsequent attachments. The necessity of this dependence on an unreliable caregiver can result internally in mixing up concepts of care and love with those of abuse and neglect, the effects of which can last a lifetime.
Often, the adults we see in mental health services have been victims of childhood trauma. As opposed to PTSD, often associated with an event trauma, such as an experience of war (see Chapter 4), complex PTSD (C-PTSD) is a diagnosis associated with trauma in the context of relational attachment, in a trusted relationship (see Chapter 5 for further information).
The experience of relational or attachment trauma can have a deeply profound effect and impact on future relational experiences. Bowlby (1969) referred to this as the ‘internal working model of the self’ and proposed that the attachment styles learned in early childhood form a model for future attachments into adulthood. Childhood trauma may serve as a template for future relational patterns with caregiver-like figures encountered during adulthood (Selwyn et al., 2021). This can manifest in repeated abusive relationships, as a compulsion towards a known model of relationships that feels familiar. An example of this is seen in the case study of Ashley, who experiences repeated abusive and emotionally neglectful relationships through adolescence, following a relatively early childhood trauma of sexual abuse which becomes associated with self-blame and a poor sense of bodily autonomy. It is not only the amount of trauma, but also the nature of the trauma exposure that has a relationship with one’s self-concept. This is supported by findings in the research literature concerning adults, which suggests that child sexual abuse is linked to worse outcomes later in life, relative to other trauma exposure types (Maniglio, 2009).
Trauma begets trauma, meaning the experiencing of relational traumatic events are implicated in further traumatic events across the lifespan. Notably, the nature and intensity of the effects of trauma on a person greatly depend on the type and timing of these events during sensitive developmental periods (Tomoda et al., 2024). Adolescence, between 10 and 19 years, is a sensitive period for brain development. It is therefore helpful to know when trauma took place. Childhood maltreatment that occurs earlier in life and continues for a longer duration is associated with the worst outcomes (Dunn et al., 2018).
Emotional abuse is pervasive and can include many things, such as controlling behaviours, manipulation, invalidation and constant criticism.
Hoeboer et al. (2021) found that emotional abuse, as opposed to any other form of maltreatment, was associated with more severe PTSD symptoms. The association between exposure to childhood trauma and mental health outcomes is found to be larger in those with greater exposure, with a particularly increased risk for those exposed to emotional abuse and neglect (Humphreys et al., 2020). Childhood emotional abuse is implicated in insecure attachment styles, alongside difficulties in identity formation, intimacy and empathy, as well as symptoms of hopelessness, substance abuse, psychosis and borderline personality disorder (Spinazzola et al., 2021). Emotional abuse can be challenging to identify and evidence, due to its insidious nature and the invisibility of the wounds.
The trauma of neglect
Whereas emotional, physical and sexual abuse could be conceived of as being done to a person, neglect can perhaps be characterised as a chronic absence of doing the things which are needed for healthy development. It is empty space where love should be. Neglect in the very early stage of development can have catastrophic effects on attachment and child development. To survive and thrive, a child needs connection, nourishment and language. Without these, brain and social development is impacted (Lyons- Ruth et al., 2023).
Neglect can take on various forms in modern society, including physical neglect, such as not having enough food to eat and warm clothes, or neglect of the home environment, including lack of hygiene or hoarding. Emotional neglect can involve not feeling listened to, heard or believed by caregivers.
It is now known that neglect is associated with neurocognitive alterations, impairing psychosocial functioning and increased risk of developing psychiatric disorders (2023). Carvalho Silva et al. (2024) emphasise the need for paying increased attention to the effects of neglect on children, due to its impact on health outcomes across the lifespan. Neglect has been found to be the strongest risk factor for developing major depressive disorder or depressive symptoms, particularly in females, in comparison to other types of maltreatment (Carvalho Silva et al., 2024). In England, the number of looked after children has increased every year since 2008, and most children in care are there due to abuse or neglect (NSPCC, 2024a). Looked after children are also more likely to have a mental health issue, and lower levels of wellbeing (Miller et al., 2023).
Neglect also features as a symptom of alcohol and substance misuse, impacting dependants. Estimated figures for children of alcoholics (COAs) in the United Kingdom are in excess of 70,000 (NSPCC, 2024b) and link to there being in excess of 600,000 dependent drinkers in England (Alcohol Change, 2018). The nature of alcohol and drug use leads to an unreliable caregiver who may oscillate from extreme high moods to absence and sleeping all day.
To extend our understanding of neglect, we might also consider the experience of individuals within a neglectful system. With 4.3 million children, or 30% of all children in the UK, living in poverty (House of Lords, UK Parliament, 2024). With cuts in state benefits in recent years, including for some of the most vulnerable in society, alongside issues associated with social determinants of health linked to class and racism, it is essential to consider the wider systemic trauma experienced by a person existing in a world that appears to discriminate against them consistently.
Systemic/structural trauma
Systemic trauma refers to experiences of oppression, discrimination and prejudice based on the systems surrounding us, which are associated with the politics of power. This could refer to disability, gender or ethnicity, for example, and is a vital consideration when working with patients and service users.
Structural racism can include not only interpersonal acts of discrimination, but also wider socioeconomic structures, maintained through prejudice, discrimination, policies, practices, social norms and the structures of wider society. Health inequalities more clearly impact ethnic minoritised individuals, such as higher mortality rates in the healthcare system, notably exacerbated by COVID-19 (Essex et al., 2022). Racial trauma is also likely to be under-reported due to lack of awareness or bias amongst clinicians and discomfort in discussing these issues (Kirkinis et al., 2018). In addition to this, children are more likely to be taken into care if they are male and of black or mixed ethnicity (NSPCC, 2024a).
In terms of gender discrimination, the National Policing Statement (2024), recorded over one million crimes related to Violence Against Women and Girls (VAWG) during 2022–2023, accounting for 20% of all police-recorded crime. There was also an increase of 37% in recorded VAWG-related crime between 2018 and 2023. Males are more likely to experience non-sexual assault and 
combat-related trauma, while females are more likely to be exposed to sexual assault and childhood sexual abuse (Dalvie and Daskalakis, 2021).
It is also helpful to consider the differences in gendered responses by diagnosing clinicians to people who have experienced traumatic events. In our current medically focussed diagnostic system, women are more likely to receive a diagnosis of emotionally unstable personality disorder or borderline personality disorder than men, with these diagnoses often being associated with experiences of childhood trauma. By contrast, men are more likely to receive a diagnosis of anti-social behaviour disorder and are more likely to be imprisoned – with prisoners often reporting high levels of childhood trauma (Wolff and Shi, 2012).
Effects of trauma
Physiological responses
Research has demonstrated that trauma or stress experienced during childhood and adulthood increases the risk of developing psychopathology such as post-traumatic stress disorder and depression (Dalvie and Daskalakis, 2021). Understandings of the body’s stress response suggest that it is a complex and integrative process that involves, neuronal–neuroendocrine–immune interactions and that these interactions are also influenced by an individual’s genetic background. Adverse patterns of social experiences – such as neglect and abuse – are associated with atypical structural and functional brain features (McLaughlin et al., 2019), while exposure to chronic stress can induce neuronal remodelling and is associated with increased anxiety and PTSD symptomology (McEwen, 2019).
Exposure to the threat of trauma stimulates the autonomic nervous system (ANS), resulting in hyperarousal states accompanying survival responses such as fight, flight, submission and freeze (see, for example, Siegel, 2006). Responses can include those which go beyond the traditionally identified ‘fight or flight’:
•		Freeze – feeling paralysed or unable to move
•		Flop – doing what you’re told without being able to protest
•		Fight – fighting, struggling or protesting
•		Flight – hiding or moving away
•		Fawn – trying to please someone who harms you
•		Faint – succumbing to a horizontal position whereby blood supply increases to the brain
These bodily responses to threats and stressors have biologically evolved to enable survival. However, a household where the threat is unremitting and in the context of dependence on attachment figures, this will lead to chronic stress on bodily systems and presentations of mental distress with symptoms such as hypervigilance and heightened responses on exposure to triggers, even at times where the threat is not acute. The combination of the over-appraisal of the threat, alongside the self-assessment of inability to cope, results in potentially extreme emotional reactions to any perceived threat.
It is also important to note that for many trauma survivors, the body can become a source of pain, intrusion and shame. Survivors may therefore feel disconnected from their bodies and from their reactions to stressors.
Emotional dysregulation and mental health outcomes
Childhood is characterised by elevated neural plasticity and developing neurobiological systems, and therefore, chronic stress in childhood appears to effect emotions and the mediation of stress responses later in life, increasing the risk for psychological distress presenting as psychiatric disorders (Olff et al., 2025). Extensive research has demonstrated a link between childhood trauma and mood disorders (for example, Galatzer- Levy et al., 2018; Melamed et al., 2024; Winston and Chicot, 2016). One meta-analysis revealed that 46% of individuals with depression report childhood maltreatment (Nelson et al., 2017).
One of the notable effects of interpersonal trauma appears to be emotional instability, which may materialise in various ways, such as suicide attempts, self-harm, relationship difficulties and even physical health issues. Traumatic events may have a wide range of transdiagnostic mental and physical health consequences, not limited to post-traumatic stress disorder (Olff et al., 2025). Altered patterns of emotional, cognitive and social development have been observed consistently amongst children who have experienced adversity (McLaughlin et al., 2019).
Understanding the impact of trauma on the brain and relational behaviour calls into question the diagnostic approach taken by modern-day mental healthcare systems. A psychiatry-led system results in a reliance on the 
medical model of health – when so often what we are seeing is, realistically, a normal response to abnormal and damaging circumstances.
Nurses and AHPs working in emergency departments will experience attendance by those who have tried to take their lives more often than is the case for health practitioners working in other settings. Past trauma may show itself in patients with substance misuse issues, relationship difficulties, inability to stay in employment or interactions with service providers which come across as challenging.
It is also helpful to consider somatic symptomology. Given that many health practitioners work across physical and mental health settings, it is essential to be aware that we may come across patients with somatic symptoms. These are physical problems that do not have an identifiable physiological origin, causing significant stress and functional impairment to the individual (Greenman et al., 2024). Patients presenting with medically unexplained symptoms are prevalent in healthcare, accounting for around 45% of all GP consultations (Jadhakhan et al., 2022). Kratzer et al. (2022) linked symptoms of hyperarousal seen in patients with somatic symptoms, with a biopsychosocial understanding of childhood trauma, noting that early bodily experiences of chronic stress may lead to later over-appraisal of physical symptoms. It can be helpful to consider trauma as a transdiagnostic vulnerability factor when working with patients experiencing fatigue, pain and other physical issues. Research continues to explore this area.
However, it is both helpful and hopeful to note that the most common response to trauma is resilience. In a narrative review of research focussing on trauma, Olff et al. (2025) identified moderating factors that may be able to differentiate between trajectories of risk and resilience, and found that aspects of emotional functioning, such as coping flexibility, coping strategies and style, perceived self-efficacy, optimism, neuroticism and resilience beliefs, play potentially significant roles.
Why is understanding trauma important for health professionals?
Working in modern healthcare means that we will come across various forms of trauma – not only as a clinician treating our patients, but also, perhaps, as a victim ourselves. A health practitioner working in the emergency department might see repeated attendance of some people, due to suicidal 
ideation and actions. In these moments, there is a danger that the stigma in the system might result in not treating these patients with the care they need.
An important consideration in terms of the service user’s emotional response to trauma is shame. Shame can be conceived as a global devaluation of the self (Budiarto and Helmi, 2021). Unfortunately, shame has sometimes been used in clinical practice, to reprimand people who have harmed themselves or experienced suicidal thoughts and actions. Given the likelihood of service users having an existing trauma-derived sense of shame, this approach from a health professional can be devastatingly detrimental to the long-term recovery of the individual. Hence, in the case study of Ashley, we see a five-year journey of repeated self-harming before someone takes a non-judgemental approach to understanding and listening.
Patients remember those who are kind to them, who listen and who do not make them feel ashamed. Some patients experience systemic healthcare trauma from services. This can take the form of not being believed or not being listened to, resulting in a complex relationship with healthcare providers which can lead to feelings of suspicion, and a reluctance to engage, combined with a fear of authority. (Chapter 8 provides further information on the risks associated with re-traumatisation.)
Most healthcare professionals experience increasing complexity in their caseloads within contemporary healthcare practice. Given the extent of traumatic experiences across the population, amidst the backdrop of systemic inequalities, it is likely we will frequently meet traumatised patients. However, equipped with the knowledge and understanding of cause and effect, we are better able to validate patients and support them to get the help they need.
Tools for now: small changes that can make a big difference
All health practitioners need to be aware of the need to sensitively signpost service users and patients to services which are likely to be of most help to them, doing this in a way which emphasises your understanding of what they have experienced.
1.		Be aware that you and your colleagues may also have experienced trauma of some kind (see Chapter 9 for further information). Pay attention to your own history and experiences, seeking to learn ways in which 
to protect yourself. Developing self-awareness and resilience through reflection along with discussions with a trusted colleague, friend or family member, are useful facets of this.
2.		Listen to and remain curious about the stories of patients and service users, listening to their narratives with open and empathic responses. Working with people who have experienced trauma is not so much about identifying what is wrong with a person, as listening to their stories of survival and recovery.
3.		It may be possible to introduce sensitive approaches to screening for trauma histories in settings such as the emergency department, through validated questionnaires, clinical interviews and discussion with the service user, or by reviewing past patient records. This can give us a better understanding of the wider issues that might bring people back to our services and in some cases, avoid the risks associated with re-traumatising people.
4.		Listen to service users and patients, supporting them as they find words to express what has happened or is happening for them.
5.		Offer validation to service users and patients, recognising that past experiences of health and care systems may have damaged them and that winning the trust of traumatised individuals takes time. Be especially aware that past experiences of shaming within healthcare settings, and fear of this being repeated, may be contributing to how the person is presenting in the moment.
6.		Recognise that you can make a significant difference just by demonstrating compassion, kindness and empathy. You don’t need to know all the details of an individual’s story to be able to care. Listen to what they are willing to share without asking intrusive questions.
7.		Be mindful that traumas which occurred in childhood and adolescence have an impact across the lifespan. A person’s age does not exclude them from the ongoing effects of early life traumas, and it is worth noting that incidence of suicide amongst older adults (over 65s) is correlated with adverse childhood events (Sachs-Ericsson et al., 2016)
Reducing and managing trauma: systemic and longer-term approaches
Research helps explain how some people are able to overcome childhood adversity and others are not. The most common factor for children who do well despite experiencing adverse events is having a stable, supportive relationship, 
which helps them respond to adversity in ways which promote recovery. ‘Additionally, when caregivers actively help children develop skills to interact with others and to cope with stress, this capacity to manage stress lessens the effect of toxic stress – essentially transforming it to tolerable stress’ (Herndon and Waggoner, 2021: 30). Such secure, stable and nurturing relationships help children thrive, reach their potential and overcome the likelihood of long-term harm linked to ACEs (CDC, 2024). When we prevent or reduce the impact of ACEs, we also prevent potential later involvement in crime, alcohol and substance misuse, depression, self-harm and suicide, alongside reducing risks of long-term ill-health through conditions like cancer, diabetes and heart disease (CDC, 2024). Resilience can best be established by providing safe environments, giving attention where it is needed, building trust in relationships, listening to feelings when these are expressed and providing opportunities for success (Pizzolongo and Hunter, 2011).
Actions health practitioners can take
•		Talk with children about their mental health and hold supportive conversations around any challenges they are experiencing.
•		Help children and young people learn how to recognise and manage emotions by positively supporting the expression of feelings.
•		Keep an eye out for any unusual or exaggerated signs of stress and distress such as social withdrawal, changes in school performance, anger and altered patterns of eating and sleeping.
•		Guide parents in positively reinforcing their children through praise, as this plays a key role in emotional development and building self-esteem.
•		Support parents and families with understanding and actioning the above.
Actions for more widespread change
•		Campaign for government policies and adopt organisational policies that provide families with support with childcare costs and healthy nutrition.
•		Advocate for workplaces to adopt policies that help parents balance work and family responsibilities like paid time off for caregiving and flexible work schedules.
•		Increase opportunities for all families to access quality childcare and education.
•		Advocate for government funding to provide free or low-cost, evidence-based training, aimed at enabling schools, community groups and parents to play a substantial part in reducing the impact of ACEs by supporting children’s resilience.
Summary of learning points
This chapter has explored a range of theoretical and practical approaches to understanding trauma and supporting people who have experienced trauma. These include:
•		The causes of trauma as embedded in attachment and unreliable support systems in the early years of life, affecting brain and psychological development including the ability to form trusting relationships.
•		A recognition of the long-term damaging effects of sustained complex trauma caused by physical, psychological, emotional or sexual abuse, as well as through physical and emotional neglect of young people, alongside single-event traumas which may occur at any stage of life.
•		The compounding and exacerbating effect of wider societal patterns of inequality and disadvantage, including racism and poverty, which contribute to the lasting effects of traumatic experiences across the lifespan.
•		Recognition of the importance of not shaming any individual, and of the key part that health practitioners can play in supporting people to share their stories and take steps towards recovery.
Questions for reflection and discussion
1.		What insights have you gained by reading this chapter? How can these insights change the way you work with people who may have experienced trauma?
2.		How might you, within your current or any future health and care roles, introduce ways of identifying whether past trauma is impacting on the present actions of patients and service users?
3.		Identify ways in which the organisation for which you work can take action to build resilience amongst children and adults who may have experienced either single-event or sustained trauma.
4.		In what ways might understanding the impact of trauma on longterm physical and psychological health, support your care planning with all individuals, whether or not you have ascertained that they have experienced trauma?
5.		How might identifying past traumas help you in supporting the physical wellbeing of your patients and service users?
Recommended follow-up reading
Bowlby, J. (2005). A secure base: Clinical applications of attachment theory (Routledge Classics). Abingdon: Routledge.
Clark, C. and Aboueissa, A. (2021). Nursing students’ adverse childhood experience scores: A national survey. International Journal of Nursing Education Scholarship, 18(1): 20210013.
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DOI: 10.4324/9781003635604-2