Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Universal Trauma-informed Care

United States Poet Laureate Joy Harjo. Public domain.


Understanding perpetrators of violence as potential trauma survivors can inspire empathy in clinicians and contribute to a universal, trauma-informed approach to patient care.

When I learned about intimate partner violence (IPV) in medical school, I felt confident that I could one day provide quality, empathic care to patients suffering from abuse. What concerned me was imagining interactions with perpetrators of violence—the patients who actually abused their partners. Would I make it through a visit without passing judgment or behaving differently towards them? Might I be at risk of them using violence against me? Couldn’t I just get out of it and have someone else see the patient?



I joined the VA healthcare system after residency, and my practice evolved towards patients facing trauma and its aftereffects. I took care of hundreds of Veterans with a history of adverse childhood experiences (ACEs), combat exposure, military sexual trauma (MST), and homelessness. I learned things that changed my perspective on people facing stigmatized illness—for example, almost one third of Veterans seeking treatment for substance use disorder have PTSD. I also learned that many people who use violence against others have their own disturbing stories of abuse and loss.



A feeling of dread

One day in clinic a medical assistant informed me that my next patient had just gotten out of jail for domestic violence. I took a deep breath, noticing a lingering, deep-seated feeling of dread. I opened the exam room door to find a middle-aged man with deep wrinkles lining his face and a voice that confirmed decades of tobacco use. He had been incarcerated five times in his life, mostly for drugs, now for domestic assault.



My patient’s history of trauma

During the social history, I asked my standard screen for trauma, “Many of us have experienced something difficult in childhood, in the military, or later as an adult that has had lasting impacts on our physical or mental well-being. Do you think that’s relevant for you?”


“My father was a piece of shit,” he said.


He told me about a time when he was seven years old, working with his father in the garage. His father asked him to get a Phillips screwdriver, but he returned with a flat-head. His father retaliated with a forceful blow to his son’s head.


Watching my patient as he spoke, I imagined a seven-year-old boy, scared and faultless. I thanked him for sharing his story, and considered how perhaps the hard road he had traveled as a child had shaped who he became as an adult. While personal trauma did not excuse his wrongdoings, it certainly informed them. I adjusted his blood pressure medication, counseled him on tobacco cessation, and walked him down the hall to meet our behavioral health psychologist, a partnership we are fortunate to have in the VA. I shook his hand and wished him well, hoping to see him again in follow-up.



A universal trauma-informed approach to patient care

I recently heard an interview with Joy Harjo, the first Native American Poet Laureate of the United States. She described growing up with a father who abused her, her mother, and her siblings. In her book, Crazy Brave: A Memoir, she writes, “My father would get angry. He would get angry because his mother died of tuberculosis when he was a baby, because his father beat him, because he was treated like an Indian man in lands that were stolen away along with everything else.” Her poignant narration highlights how trauma is often woven into the fabric of an individual’s life through social and historical factors beyond their control.



Stories like these illustrate a sobering theme—that trauma is pervasive, and that witnessing and/or directly experiencing violence in childhood has lasting effects on the adult brain, body, and behavior. Encountering a “difficult” or “abusive” patient should prompt inquiry about the patient’s own trauma history.



What I know is this: recovering from trauma can be as complex as the origin of trauma itself. Thinking of perpetrators of violence as potential trauma survivors can inspire empathy in clinicians and contribute to a universal, trauma-informed approach to patient care.