Trauma-informed and trauma-responsive approaches are increasingly discussed across healthcare. In pain medicine, they are particularly relevant — but they also require some nuance.

People attending pain services may have experienced previous trauma, difficult healthcare encounters, repeated invasive investigations or procedures, or years of living with symptoms that have sometimes been poorly understood. We will often know very little about those experiences.

At the same time, persistent pain is complex. Biological, structural, neuropathic, nociplastic, psychological and social factors may coexist, and our responsibility remains to assess these carefully rather than allowing any single explanatory model to dominate.

For me, trauma-responsive pain medicine is therefore less about identifying trauma and more about how we practise in the presence of uncertainty about somebody's previous experiences.

We do not need a trauma history to practise differently

There can be a temptation to think of trauma-informed care as something relevant primarily to patients with a disclosed history of significant trauma.

In practice, disclosure is neither necessary nor always desirable.

A patient may not wish to discuss previous experiences. They may not consider them relevant to the consultation. They may have experienced healthcare itself as frightening or disempowering. Or there may simply be aspects of their history that we do not know.

Universal principles such as explaining before examining, seeking permission, offering meaningful choices and preserving control therefore have advantages over trying to identify which patients require a different approach.

They are also simply good clinical practice.

Trauma should not become an explanation for unexplained pain

This is perhaps the area in which pain medicine needs to be particularly careful.

There is good reason to understand pain within a biopsychosocial framework and to recognise the influence of context, threat, previous experience and nervous-system processing.

But explanatory models can sometimes move too quickly from association to attribution.

A history of trauma does not establish the mechanism of somebody's pain.

Nor should the presence of psychological distress, adverse childhood experiences or previous trauma prematurely end investigation of new or changing physical symptoms.

Structural pathology and altered pain processing are not mutually exclusive. Neither are neuropathic pain and psychological distress. A patient may have significant musculoskeletal disease alongside sensitisation, or a focal pain generator within a much broader persistent pain presentation.

Trauma-responsive care should therefore broaden our understanding of the patient without narrowing our differential diagnosis.

Language matters

Many people reaching pain services have already encountered phrases such as:

“Your scans are normal.”

“There is nothing structurally wrong.”

“Your nervous system is overreacting.”

“Stress is making your pain worse.”

The clinical intention behind these statements may be entirely reasonable. Their interpretation by the patient can be very different.

For someone who has spent years trying to establish why they hurt, an explanation based on sensitisation or nervous-system processing can easily sound like another version of the pain isn't real.

This does not mean avoiding discussions about nociplastic mechanisms, central sensitisation, stress, sleep or psychological contributors.

It means placing them alongside — rather than instead of — the rest of the clinical formulation.

“There are several things that may be contributing to your pain” is often a more useful starting point than trying to identify a single explanation.

Examination is an intervention too

We understandably think carefully about consent for procedures. The same principles are useful during physical examination.

Pain consultations can involve examination of the spine, pelvis, abdomen, chest wall or other areas where patients may feel particularly vulnerable.

Small changes can alter that experience considerably: explaining what we are looking for; asking before exposing or touching an area; allowing the patient to reposition themselves where possible; limiting examination to what is clinically useful; and making it clear that the patient can ask us to stop.

None of this needs to make examination cumbersome.

It often makes it better.

Interventional pain medicine presents particular challenges

Many pain procedures are performed with the patient awake.

The patient may be positioned prone, unable to see what is happening, partially exposed and aware that needles are being introduced into their body. Monitoring, sterile drapes and the physical environment can further reduce their sense of control.

For most people this is manageable. For some it is profoundly difficult.

Where clinically feasible, it can help to establish beforehand how the patient would like the procedure to be conducted: whether they prefer explanation throughout or minimal commentary; whether they would like warning immediately before needle insertion; and how they can signal if they need a pause.

A patient becoming unusually quiet, distressed, dissociated or unable to engage during a procedure may need us to stop and reassess rather than simply complete it as efficiently as possible.

Technical success and a good procedural experience are not necessarily the same thing.

Control is not the same as avoidance

There is an important balance here.

Trauma-responsive care does not mean avoiding necessary examination, investigation or treatment whenever these generate anxiety or discomfort.

Nor does patient-centred care require clinicians to offer choices that are clinically inappropriate.

The useful distinction is between unavoidable discomfort and avoidable loss of control.

We may not be able to make an injection painless. We can usually explain what is happening.

We may need to examine a painful area. We can explain why.

There may be only one clinically appropriate treatment. We can still involve the patient in decisions about whether and when to proceed.

This preserves professional judgement while reducing unnecessary powerlessness.

Pain itself can make healthcare feel unsafe

Trauma-responsive practice is also relevant in the absence of previous psychological trauma.

Persistent pain can create its own history of threat.

Repeated painful procedures, frightening acute episodes, unsuccessful treatments, unexpected postoperative pain, difficult hospital admissions or previous experiences of not being believed can all influence subsequent healthcare encounters.

A patient who appears apprehensive, hypervigilant or reluctant to engage is not necessarily being difficult or resistant to treatment. Their behaviour may make considerably more sense when viewed in the context of what has happened previously.

That does not require us to diagnose trauma.

It requires curiosity.

Trauma-informed or trauma-responsive?

The terms overlap, and both are useful.

Trauma-informed care describes an understanding of the prevalence and potential consequences of trauma and the incorporation of that knowledge into healthcare systems and practice.

I increasingly use trauma-responsive to describe clinical encounters because it emphasises what we actually do with that understanding.

It asks a practical question:

Is there anything about the way I am consulting, examining or treating this person that I could reasonably adapt to preserve safety, choice and control?

Sometimes the answer is no.

Sometimes a very small adjustment makes an enormous difference.

Good pain medicine leaves room for what we don't know

Pain medicine frequently requires us to tolerate uncertainty.

Imaging may not explain symptom severity. Several pain mechanisms may coexist. Treatment response may help refine a diagnosis without providing absolute certainty.

The same humility is useful when considering somebody's wider experience.

We rarely know everything that has happened to the person sitting in front of us, and we do not need to.

Trauma-responsive practice does not require clinicians to become therapists, elicit trauma histories or reinterpret persistent pain through a psychological lens.

It asks something considerably simpler:

Can we deliver the clinical care this person needs while preserving as much safety, dignity, choice and control as possible?

That is not separate from good pain medicine.

It is part of it.

For clinicians

My approach to trauma-responsive practice has been informed in part by my work with The Flying Child CIC, founded by Sophie Olson, which works to improve understanding of childhood sexual abuse and trauma-responsive practice.

Wye Sanctuary welcomes referrals and self-referrals for people living with persistent or complex pain, including those for whom previous healthcare experiences, examination or procedures may make accessing treatment particularly difficult.

Disclaimer:
This article is intended for general professional education and does not replace individual clinical assessment or applicable clinical guidance.