In recent years, trauma-informed care¹ has become a valuable tool to assist health care providers in delivering more person-centered care. Trauma-informed care seeks to both acknowledge the role trauma plays in people’s lives and the impact it has on their health and well-being, and to engage in practices that prevent retraumatizing individuals. As the health care sector, like many industries, faces its own racial reckoning^2,3,4 trauma-informed approaches to care should not overlook the critical impact of racism and racialized trauma⁵ on patient health and staff well-being. The work of trauma-informed care requires a nuanced understanding of not only how trauma impacts the lives and care of patients, but the root causes behind that trauma. Health care organizations that adopt a trauma-informed approach to care should acknowledge and be held accountable for the historical and present-day trauma experienced by patients and staff from communities of color.

This brief outlines six considerations for health systems and provider practices looking to integrate a focus on racial equity to enhance trauma-informed care approaches and promote racial justice. It draws from the experiences of two organizations — the Stephen and Sandra Sheller 11th Street Family Health Services (henceforth 11th Street Health Center)⁶ and Bread for the City⁷ — participating in the Advancing Integrated Models initiative, funded by the Robert Wood Johnson Foundation. 11th Street Health Center, operated in partnership with Family Practice and Counseling Network,⁸ is a federally qualified health center (FQHC) located in Philadelphia, Pennsylvania, where it provides clinical, health promotion, and mind-body wellness services to a predominantly Black patient population. Bread for the City in Washington, D.C., also an FQHC, provides wrap-around services, including food, to primarily Black individuals and families, many of whom experience food insecurity.

Incorporating racial equity into any existing framework, such as trauma-informed care, requires a significant shift in organizational culture. To catalyze and sustain such a shift, it is important to involve leadership in any planned culture change from the start. For example:

Identify leadership’s starting point. Does leadership already have an understanding or accepted definition of trauma-informed care that can be built upon? Knowing the starting point can provide some initial direction for the organization to lean into, though it is important to recognize that this starting point, and the journey, will be different for everyone.  

Highlight the importance of incorporating racial equity in trauma-informed care for leadership by drawing explicit connections between existing definitions of trauma and the parallels seen in communities of color impacted by racism.

Building organizational knowledge of race, racial trauma, and the impact of racism on health care delivery for patients is an essential first step for organizations interested in incorporating a racial equity focus into their trauma-informed approach to care. This could include:

Recognizing past and present harm from the top down, with leadership at the forefront of acknowledgments. Many health system and provider practices, whether intentionally or not, have contributed directly to racialized harm within their own communities,⁹ which has led to generations of mistrust and harmful relationships between health systems, communities, providers, and patients. Without explicitly acknowledging histories of racism and bias and how they continue in the present day, efforts to incorporate racial equity into trauma-informed care will lack the genuine self-reflectiveness and authenticity that is needed to address these harms. Organizations like Bread for the City work with staff to ensure their understanding of the historical trauma experienced by Black communities at the hands of the health care system and what it means to be antiracist.¹⁰ Bread for the City requires all staff, including medical providers and board members, to attend an Undoing Racism Community Organizing Workshop hosted by the People’s Institute for Survival and Beyond.¹¹ Bread for the City patients who are interested in attending the training can do so free of charge. Similarly, new staff at 11th Street Health Center are trained in antiracism, with a focus on language, messaging, and how to incorporate antiracism into their individual efforts.

Establish a library of definitions and/or an organizational framework for what incorporating racial equity into trauma-informed care looks like. 11th Street Health Center worked with staff to identify where their former trauma- informed care model did not incorporate racial equity. This process began almost 10 years ago, revealing that in many settings, racism was the “elephant in the room” – always there, but never explicitly acknowledged. This realization ultimately evolved into 11th Street Health Center’s first formal training on race and racism, with staff trainings as just one small piece of broader efforts to develop an antiracist culture throughout their organization. While the Sanctuary Model¹² was applied, 11th Street Health Center also developed a staff committee on race and racism. The committee was developed with the assistance of Resources for Human Development, a national non-profit that creates innovative, person-centered services that support people of all abilities.¹³ 11th Street Health Center customized these sessions and trainings to reflect topics relevant to staff, with the approach for these trainings evolving over time. Sample topics include:

• Healing, advocacy, and social justice;
• White fragility, white solidarity, and white silence;
• Body-centered healing practices for racialized stress; and
• Intersections of mental health and race.

Lean into the knowledge of subject matter experts and prioritize engaging with outside consultants. Many organizations already have individuals with subject matter expertise in this area, and it is important to lift up this experience if it is readily available. If it is not, don’t be afraid to actively seek it out. Many organizations benefit from setting aside dedicated funding for a role, or even multiple roles, that work specifically on issues of racial equity. Bread for the City has hired racial equity consultants to support the reimagining of their program work and to facilitate staff meetings focused on racial equity review and planning processes. To maximize success with this strategy, it is incredibly important that this role is not siloed but has cross-departmental and leadership support. Racial equity should be embedded across all organizational initiatives and must be embraced and modeled by leadership.

Many health systems and provider practices may want to advance racial equity within their organizations, but without an explicit vision for what this looks like, even the best laid plans can fail. Building on an existing trauma-informed care framework can be helpful for this purpose, such as the Substance Abuse and Mental Health Services Administration’s “Principles to a Trauma-Informed Approach.”¹⁴

Health systems and providers interact with people when they are at their most vulnerable — when they need help and when they might feel unsafe or disempowered. It is important to recognize the power dynamics at play when pursuing more equitable, trauma-informed practices. The below questions may help health systems and providers reflect on how to embed racial equity within their trauma-informed care efforts as it pertains to their community and organization:

• What does trauma look like in the community you serve?
• Where are the community-identified pain points in the delivery of health care?
• How have you as an organization been complicit in compounding this trauma?
• What would racial equity look like at your organization? How does this relate to trauma-informed care?

Problems and systems created over generations will take time to fix. There are, however, opportunities for accountability in health care right now. Consider establishing avenues to identify the current status quo in the form of an antiracism and/or organizational equity assessment. 11th Street Health Center is adapting a self-assessment tool for antiracism¹⁵ to learn about staff views around antiracism related to personal and professional development, advocacy, and hiring practices. Additional ideas for measures could include incorporating equity components into programs and reducing health disparities. ¹⁶

Racism is primarily an issue of power. To address this, health systems and provider practices committed to racial equity should prioritize centering patient and community voice across their work, ¹⁷ particularly in strategies developed to directly address existing and historical power dynamics. People of color and their communities are the best informed on how racialized trauma and structural racism impact their lives, and it is vital to incorporate their lived experiences into all racial equity efforts.

Bread for the City includes patients on their Board of Directors, allowing them to provide input on how the clinic functions. 11th Street Health Center conducted a survey of patients and community members as a part of their patient recruitment and engagement efforts to better understand how to deliver culturally relevant care that aligns with community needs by learning how patients experience care at their health center and identifying barriers to quality care. 11th Street Health Center also created an Antiracism Advisory Council as part of their community outreach initiatives. The Antiracism Advisory Council supports the development of shared antiracist language and collectively creates goals and strategies to sustain antiracism efforts in practice at the health center, ensuring that patient and community voice are centered in this work.

Incorporating a focus on racial equity into trauma-informed care is one of many ways to support a more equitable health care system, and it is not just for patients. Staff provide better care when they themselves feel supported and seen.¹⁸ Considerations for supporting staff of color include:

Understanding the working experience for staff, particularly staff of color. Staff of color often have lived experience with health inequities and trauma, making it particularly difficult and even morally conflicting to engage in practices they may feel are harmful to their community. This may include bearing witness to acts of racial health injustice and not being in a position of power to stop it or having to follow organizational policies and procedures that have a disparate impact on their communities. Consider formalizing ways to acknowledge this and encourage the elevation of the lived experiences these staff have, especially when working with patients from similar backgrounds. This may include giving staff of color a safe space or affinity group to share their thoughts on how they have experienced and participated in care delivery and incorporating that feedback into organizational best practices. Surveying staff (e.g., a staff satisfaction survey) on their experiences can help uncover more information on how they are feeling about the intersection of their work and their identities.

Establishing clear processes for reporting harmful interactions committed against both patients and staff. Staff of color, particularly individuals working in predominantly white workplaces, often have limited avenues to address microaggressions they may experience themselves or witness. Consider creating transparent processes for reporting incidents of racism, bias, and other harmful interactions, while also allowing for feedback on these processes from affected staff and patients for quality improvement purposes.

Creating intentional opportunities for healing. Burnout and exhaustion, particularly among individuals experiencing the duality of being racialized in the health system and having to provide care to their own communities, are common. 11th Street Health Center has prioritized opportunities for healing by incorporating mindfulness and mind-body modalities into their workplace culture. ¹⁹

Racism is trauma and should be treated as such in any comprehensive trauma-informed care framework. Bread for the City and 11th Street Health Center are two examples of organizations that are embracing the opportunity to embed a focus on racial equity into their trauma-informed practices, but the field is ripe with organizations working at the intersections of antiracism and trauma. Many of these efforts are led by people of color working to make change in their communities²⁰ that give both patients and staff the resources and support they need to confront and eradicate racism and trauma within the health care system.

1. For more information on trauma-informed care, see CHCS’ Trauma-Informed Care Implementation Resource Center. Available at: https://www.traumainformedcare.chcs.org/
2. D. Kroman. “Revered doctor steps down, accusing Seattle Children’s Hospital of racism.” Crosscut. December 31, 2020. Available at: https://crosscut.com/equity/2020/12/revered-doctor-steps-down-accusing-seattle-childrens-hospital-racism
3. “Take Racism Out of Medical Algorithms.” Scientific American, December 1, 2020. Available at: https://www.scientificamerican.com/article/take-racism-out-of-medical-algorithms/
4. U. Blackstock. “Why Black doctors like me are leaving faculty positions in academic medical centers.” January 16, 2020. Available at: https://www.statnews.com/2020/01/16/black-doctors-leaving-faculty-positions-academic-medical-centers/
5. For more information race-based traumatic stress, see https://www.mhanational.org/racial-trauma.
6. Drexel University College of Nursing and Health Professions. “Stephen and Sandra Sheller 11th Street Family Health Services.” Available at: https://drexel.edu/cnhp/practices/11th-street/
7. Bread for the City Home Page. Available at: https://breadforthecity.org/
8. The Family Practice and Counseling Network Home Page. Available at: https://www.fpcn.com/
9. A. Frakt. “Bad Medicine: The Harm That Comes from Racism.” New York Times, January 13, 2020. Available at: https://www.nytimes.com/2020/01/13/upshot/bad-medicine-the-harm-that-comes-from-racism.html
10. Ibram X. Kendi  Home Page. Available at: https://www.ibramxkendi.com/
11. The People’s Insititute for Survival and Beyond. “Undoing Racism® Community Organizing Workshop.” Available at: https://pisab.org/undoing-racism-community-organizing-workshop/
12. About the Sanctuary Model. Available at: https://www.thesanctuaryinstitute.org/about-us/the-sanctuary-model/
13. Resources for Human Development. Available at: https://www.rhd.org/
14. Centers for Disease Control and Prevention. “Infographic: 6 Guiding Principles to a Trauma-Informed Approach.” Available at: https://www.cdc.gov/cpr/infographics/6_principles_trauma_info.htm
15. R. Wells. “Self-Assessment Tool: Anti-Racism.” Available at:  https://unitedwayaddisoncounty.org/client_media/files/ReneeWellsAntiRacismSelfAssessmentTool.pdf
16. American Hospital Association. “Health Equity Resource Series: Data-Driven Care Delivery: Data Collection, Stratification and Use.” March 2021. Available at: https://www.ifdhe.aha.org/system/files/media/file/2021/04/ifdhe_real_data_toolkit_1.pdf
17. A. Spencer and A. Nuamah. Building Effective Health System-Community Partnerships: Lessons from the Field. Center for Health Care Strategies, March 2021. Available at: https://www.chcs.org/resource/building-community-partnerships-lessons-from-the-field/
18. L.H. Hall, J. Johnson, I. Watt, A. Tsipa and D.B. O’Connor (2016). “Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review.” PloS one, 11, e0159015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938539/
19. Center for Health Care Strategies. “Building a Culture of Mindfulness: 11th Street Family Health Services.”May 2018. Available at: https://www.chcs.org/resource/building-a-culture-of-mindfulness-11th-street-family-health-services/
20. Project LETS. “Race and Mental Health.” Available at: https://projectlets.org/race-and-mental-health