Trauma Screening, Brief Intervention, and Referral to Treatment: Translating ACE Research into Trauma-Informed Practice

Background and Purpose: The majority of adults in our society have endured psychological trauma over the life course that, if left unaddressed, can undermine health, human capital, and well-being.  Moreover, trauma-affected adults often transmit trauma “material” to their children in the form adverse childhood experiences (ACEs).  While people of all socioeconomic statuses (SES) experience trauma, it is not equally distributed.  Individuals from low-SES backgrounds report higher levels of ACE- and trauma-exposure compared to more affluent adults.  Therefore, policies and practices are needed to address not only the widespread distribution of ACEs and trauma but also their concentration among low-income adults.

Methods: We have developed a trauma screening, brief intervention, and referral to treatment (T-SBIRT) protocol designed to: a) detect trauma exposure and symptoms among adults receiving healthcare services, and b) successfully refer patients to trauma-focused mental health treatment when indicated.  The T-SBIRT structure mimics that of the well-validated alcohol SBIRT protocol and follows motivational interviewing principles.  Allied health professionals such as social workers or nurse practitioners ask prospective T-SBIRT participants if they are willing to discuss stress and trauma.  After securing consent, service providers help participants understand and identify life stressors, lifetime exposure to potential traumatic events, and post-traumatic stress symptoms with the aid of validated screeners.  Using open-ended questions and reflection, providers then explore ways in which participants have cultivated resilience and demonstrated vulnerability to trauma.  Finally, providers invoke motivational strategies to complete mental health service referrals as needed.

Results: We have implemented the T-SBIRT protocol within community-based primary care clinics serving low-income, urban-dwelling patients at risk for trauma exposure.  We collected indicators of feasibility including suitability, acceptability, compliance, integrity, and outcomes.  Results indicated that T-SBIRT was suitable for patients.  Of the full sample (N=112), over 90% reported exposure to at least one lifetime traumatic event, and the majority produced a positive result on a post-traumatic stress disorder screener.  Participants also rated the protocol, on average, as very acceptable using the Treatment Acceptability and Preferences measure.  Patient compliance was 100%, meaning all patients who were offered T-SBIRT services accepted and completed them.  Regarding treatment integrity, T-SBIRT providers completed 97.2% of the protocol steps, a high rate of provider adherence.  Finally, 62.5% of participants accepted a mental health referral.

Conclusions and Implications: T-SBIRT represents an approach to translating ACE and trauma knowledge into practice.  It is a promising means by which trauma can be addressed within healthcare programs serving low-income adults.  Aiming to enhance adult health and well-being and to disrupt intergenerational trauma cycles, T-SBIRT can be feasibly implemented within health clinics according to study results.  Implications and future directions will be discussed, including a forthcoming randomized field trial whereby T-SBIRT will be implemented and tested in health clinics serving chronically unemployed adults enrolled in workforce development programming.