Minding the Gap: Complex Relational Trauma Survivors’ Experiences Navigating Healthcare

Abstract

Introduction

Complex relational trauma (CRT) occurs in close relationships where adversity is prolonged, repeated and inescapable. Despite the known connections between CRT and adverse health outcomes, anecdotal reports from survivors indicate that education on CRT is not translating into more effective clinical practice, resulting in substandard and even harmful experiences of healthcare.

Methods

Using a patient-oriented research methodology, we recruited N = 13 participants with CRT from Canada and the United States. The sample was primarily female (N = 9), with a range of ages (20-69 years) and races/ethnicities. Participants completed a demographic questionnaire and participated in an individual qualitative healthcare interview. Data were analyzed using a hybrid inductive/deductive thematic analysis using NVivo 15.

Results

In terms of both mental and medical healthcare, similar themes emerged, including structural and financial barriers to care, experiences of invisibility, invalidation, and re-traumatization, identification of factors that supported safety, trust, and disclosure, as well as a need for specialized understanding of CRT as distinct from PTSD. Meta-themes that emerged included a need for practitioners to better understand the intersection of physical and mental health concerns in persons with CRT, as well as more integrative and holistic care.

Conclusions

People with CRT report that they are not currently being well served in the healthcare system. Future research should ascertain providers/trainees’ knowledge and skill base regarding CRT, which can inform on opportunities for further education. Findings also suggest that survivors would benefit from efforts to address siloed care, which undermines effective pathways to health and well-being in survivors.

Keywords

complex PTSD adverse childhood experiences healthcare patient-oriented research trauma-informed care

Introduction

Complex trauma typically refers to trauma that is prolonged, repeated, inescapable, and typically within an interpersonal context.¹ The classic example of complex trauma exposure occurs in close, one-on-one relationships, known as complex relational trauma (CRT); examples include adverse childhood experiences (ACEs), intimate partner violence, or bullying/coercion and abuse (emotional, physical, sexual).^2,3 Other sources of complex trauma include those that are impersonal (e.g., chronic illness), institutional (e.g., police misconduct, justice system failures, religious organizational abuse), or based on being a member of certain identity groups (e.g., systemic racism, forced migration, and religious persecution).

CRT is not just a mental health issue. In fact, studies in both childhood and adulthood indicate that CRT is broadly associated with mental and physical health issues across the lifespan.^4-6 Much of the original work in this area came from studies of ACEs, including Felitti et al.’s⁷ landmark ACE study, which has been replicated in numerous studies since^8,9 Specifically, following childhood adversity, in the mental health realm, some survivors can develop complex post-traumatic stress disorder (CPTSD)^10,11; whereas for others, it can result in other mental health conditions such as treatment-resistant depression, generalized anxiety, eating disorders, psychosis, or substance use.¹² In the physical health realm, people exposed to childhood adversity have been shown to be at increased risk for a variety of medical conditions in adulthood, including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.⁷ Research has indicated a dose-response relationship, with particular risk being associated with four or more ACEs.¹³ That said, mitigating factors can protect against adverse outcomes. For example, in the case of children, a sense of mastery, strong self-regulation or executive functioning skills, a supportive cultural or faith background, and a stable relationship with at least one caring and supportive adult have all been identified as protective factors.¹⁴

The health burden of CRT survivors is further underscored by the prevalence of CRT in the general population. For example, a recent U.S. epidemiological report indicating that among U.S. adults surveyed between 2011–2020, approximately two thirds reported at least one ACE and one in six reported four or more ACEs.¹⁵ A recent systematic review and meta-analysis by Bellis and colleagues⁴ noted that total annual costs attributable to ACEs were estimated to be US$581 billion in Europe and $748 billion in North America, and a 10% reduction in ACE prevalence could equate to annual savings of as much as 3 million DALYs, or $105 billion. Likewise, intimate partner violence is also highly prevalent. U.S. statistics indicate that that more than 1 in 3 women and more than 1 in 6 men have experienced intimate partner violence in their lifetime,¹⁶ and in Canada, rates of intimate partner violence (IPV) rates have been increasing over time, with 117,093 victims reported by police in 2022, a 19% increase since 2014.¹⁷ Given the mental and physical health comorbidities associated with CRT, it is increasingly recognized as a major public health issue.¹⁸

Research Objective

The current study was, in fact, initiated by a community member (the fourth author) with lived experience of CRT. Since 2014, she has run an online forum and psychoeducational website for survivors of CRT known as Out of the Storm, with over 14,000 registered survivors from more than 87 countries. The fourth author had observed over the course of many years that, despite the prevalence of CRT and its documented impact on health outcomes, many survivors reported great difficulty in accessing trauma-informed care (TIC). It was her contention that despite growing awareness of the necessity and utility of TIC, survivors’ perspectives were rarely centered in this work, which might account for their difficulty in accessing the care they need. That is, there was a significant gap between what is known in the literature, and what is being provided in routine clinical care. As such, the objective of this project was to conduct a qualitative study with two central research questions: (1) what are survivors’ lived experiences of navigating mental and physical healthcare, and (2) what their perspectives are on what TIC might look like.

The fact that a survivor initiated the project means we adopted a patient-oriented research (POR) methodology in this study, an approach where people with lived experience (PLE) either guide or initiate a research project that is meant to enhance clinical relevance and impact.^19,20 More specifically, this was a patient-led study, given the fact that a PLE initiated and co-led the study. The study team consisted of researchers, clinicians, students, and PLE (including the fourth author) who worked together to develop an interview schedule that would effectively tap our questions of interest and draw out experiences relevant to the gap in healthcare for CRT survivors.

Methods

Participants

The study protocol and procedures were reviewed and approved by the University of Victoria’s Human Research Ethics Board. Participants were eligible for inclusion if they were age 19 years and older who currently resided in the United States or Canada. CPTSD remains uncodified in the DSM-5,²¹ the main diagnostic manual for psychiatric disorders in North America. Because of this, and the fact that CRT leads to outcomes beyond CPTSD, we did not require a formal diagnosis for inclusion but were willing to accept participants with self-report of CRT. Prospective participants were excluded if they were less than 19 years old, had difficulties communicating in English, and were likely to have difficulty tolerating an individual qualitative interview.

Measures

Participants completed a self-report survey before the qualitative interview. Instead of giving diagnostic questionnaires, we administered a comprehensive demographic questionnaire, including questions about the type of CRT exposures participants had had, current mental health diagnoses, when they came to understand that they had been exposed to CRT, and the impact of CRT on various domains of their lives.

Qualitative Interview

Each participant underwent an individual qualitative interview asking about experiences navigating both mental healthcare as well as medical healthcare. Within medical healthcare, we asked particular questions about dental care, as this is known to be a particular source of distress for certain survivors, presumably due to its invasive and aversive nature combined with the vulnerability of being in the prone position to receive care. We inquired about experiences that were both trauma-inducing as well as trauma-reducing, as well as perspectives on TIC specific to CRT, and how care could be improved. The research team co-developed the interview guide, led by the insights and lived experiences of the fourth author both as a CRT survivor as well as the leader of an international forum for other survivors. Before beginning the study, we piloted the interview by having the second author administer it to the fourth author, who provided feedback and suggestions for minor adjustments.

Procedures

In spring 2025, we used convenience sampling to recruit potential participants from an established international online forum for complex trauma survivors, a local platform for recruiting participants for health research, and social media. Given the nuances and complexities in healthcare across different geographic regions, we limited the scope of our recruitment to individuals residing within the United States and Canada. Interested participants saw the recruitment flyer, which directed them to an email address to contact the research team, after which they were directed to complete an eligibility screener. If passed, they were provided with a Letter of Informed Consent, directed to the demographic questionnaire, and scheduled for their interview. Participants then completed a 60-90 minute individual interview on Zoom. The interviews were conducted by the second author, a (male) Bachelor’s student in Psychology who had several years’ professional experience working with complex trauma survivors and who was under the supervision of the first author, a clinical psychologist with extensive clinical and research expertise in complex trauma. Participants had no prior relationship to the interviewer, who introduced themselves and explained the purpose of the study. Regular check-ins and opportunities for breaks were provided during the interview, with additional opportunities to ground at the beginning and also the conclusion of the interview. We did not do formal member checking, but rather relied on the clinical expertise and lived experience of our team members. Participants were recruited and interviews conducted until we achieved saturation of themes.

This report was prepared in consideration of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.²²

Planned Analyses

Self-report/demographic data were summarized using Microsoft Excel. Qualitative interviews were transcribed and subsequently analyzed by the second and third authors using thematic content analysis via NVIVO 14, with secondary review by the first and fourth author. We used a hybrid approach to establish our coding scheme, meaning that the initial coding scheme was drawn inductively from the interview questions, then supplemented with a deductive approach, wherein themes that emerged from the interviews (supplemented by observations and field notes) were integrated throughout the process.²³ Participants did not provide feedback on the final findings.

Reflexivity Statement

As noted above, the current study was not simply a POR study, but a patient-led study. This meant that the fourth author was a co-lead for the study team, drawing on their own lived experience, as well as that of the thousands of members on their CRT support forum. The patient partner led the development of the interview protocol, participated in piloting of the interview, and then reviewed the results as a form of member-check before completion of the final results.

Other members of the research team also had lived experience of complex trauma, adding further to the role of lived experience in interpreting the data.

Results

Demographics of the Sample

Thirteen individuals agreed to participate in the study, with no study dropouts. The sample was majority female of white North American background (10/13, 77%), with an average age of 46.2 years (SD = 18.8, range 20-75). Detailed demographic information for the sample is found in Table 1.

Table 1.

Demographics for the Sample

		N (%)
Sex	Female	9 (69%)
Sex	Male	4 (31%)
Gender	Woman	9 (69%)
	Man	3 (23%)
	Transgender	1 (8%)
National Origin	USA	8 (61%)
	Canada	4 (31%)
	Other	1 (8%)
Ethnicity	White/North American	10 (76%)
	Indigenous	1 (8%)
	Middle Eastern	1 (8%)
	South Asian	1 (8%)
Education	High school	1 (8%)
	College or Undergraduate	7 (54%)
	Graduate	3 (23%)
Employment Status	Full-Time	4 (31%)
	Part-Time	1 (8%)
	Retired	4 (31%)
	Student	1 (8%)
	Unemployed	2 (16%)
	No Response	1 (8%)
Annual Income	<5,000	3 (23%)
	20-50,000	3 (23%)
	50-70,000	4 (31%)
	>75,000	2 (15%)
	No Response	1 (8%)

Self-Reported Description of Trauma Exposure/History

All participants endorsed a history of CRT. With regards to diagnoses given by a trained provider, 11/13 (85%) of participants received a traumatic stress diagnosis, most commonly PTSD (7/11) with fewer being diagnosed with CPTSD (5/11). Participants endorsed a variety of other formally given diagnoses, including mood disorder such as depression and bipolar disorder (7/13, or 54%), anxiety disorders (7/13, or 54%), and fewer numbers reporting neurodivergence and dissociative disorders (both 2/13). Participants were asked about the impact of CRT on various domains of everyday function, using a 5-point Likert scale ranging from a “very small negative impact” to a “huge negative impact” (or not applicable), with “medium impact” as the median response. A majority of people reported medium impact or higher on work (10/13, or 77%), on intimate partnership (12/13, or 92%), friendship (8/13, or 62%), and family (11/13, or 85%). Participants were also asked how long they were in an abusive relationship before they realized that this was not “normal”; most participants (9/13, or 69%) reported 16 years or longer, which makes sense given the fact that most participants reported childhood abuse and neglect amongst their CRT exposure history. Most participants were given an understanding of having survived CRT through healthcare treatment such as that provided by a therapist or medical provider.

Qualitative Research Findings

The interview itself was separated into two parts – one focused on medical/dental care, and one focused on mental health care – with similar questions in each section. Using our hybrid approach, we organized the data first into primary themes (or sub-themes), and then meta-themes that aggregated those primary/sub-themes. The overall data analysis structure is presented in Table 2, with narrative explanation of the themes below.

Table 2.

Meta-Themes and Sub-Themes from Thematic Analysis

Healthcare Type	Meta-Theme	Sub-Themes
Medical and Dental Care	Invalidation and silencing in clinical encounters	• Complex trauma history • Non-disclosure of substance use and other coping behaviors • Aspects of identity relevant to healthcare • Dismissal in healthcare
	Healthcare as a source of re-traumatization	• Trauma-inducing experiences in medical care • Trauma-inducing experiences in dental care
	Pathways to safety and connection	• Trauma-reducing experiences in healthcare • Trauma-reducing experiences in dental care • Factors that increase disclosure of trauma histories and coping mechanisms
	Reimagining what trauma-informed care could look like	• Survivors’ personal definition of TIC • Being a partner in care • Education required for providers
	Structural barriers to trauma-informed care	• Systemic barriers to TIC • Education required for providers • Factors that increase disclosure of trauma histories and coping mechanisms
Mental Health Care	Structural and financial exclusion from appropriate care	• Financial barriers • Barriers to finding trauma-informed providers • Systemic and educational barriers to TIC
	Invisibility and invalidating responses within the system	• Experiences of dismissal and invalidating responses • Mixed experiences with professional support • Systemic and educational barriers to trauma-informed care
	Safety, trust, and the slow unfolding of disclosure	• Building trust takes time • Selective or withheld disclosure • Collaborative relationships foster empowerment
	The duality of mental health care: harm and healing	• Experiences in mental health care: challenges and growth • Need for specialized understanding of complex trauma • Collaborative relationships foster empowerment

Note. TIC = trauma-informed care.

Section 1: Medical and Dental Care

Meta-Theme 1: Invalidation and Silencing in Clinical Encounters

Participants described how healthcare settings often failed to acknowledge trauma histories or contributed to emotional withdrawal, fragmented care, and reinforced the need to remain guarded. Even when disclosure occurred, it was often met with skepticism or minimization, leading to long-term mistrust in the professional relationship.

“No, they have not ever asked me that. Some specialists have included PTSD on a general intake form, but when I check the box for PTSD it is not ever followed up on.” – P00.

“The last medical professional I told was a surgeon … I had a surgery scheduled, but I was having a bad trigger, and my mind and body were not ready for surgery. So, I said, “I need to reschedule this.” Him and his staff were pretty upset, and I felt forced to say why … He didn’t seem to care.” – P05

“I'm not even gonna bother, because I’m just being told that, like, I'm making this a bigger deal than it actually is. So, why would I trust you with anything if you don't trust me?” – P07

“With trauma disorders, coming from a childhood where I was taught that I was less than everybody else, [not being listened to] reinforces the, ‘I’m the dummy here, and you’re the smart one, and I need to shut up and let you tell me what to do.’ That’s where it re-traumatizes.” – P01

Meta-Theme 2: Healthcare as a Source of Re-Traumatization

Rather than offering relief, many healthcare interactions were themselves experienced as traumatic. Participants recounted scenarios involving lack of consent, physical invasiveness, and emotional disempowerment. These encounters triggered past trauma, exacerbated distress, and deterred future help-seeking. Even well-intentioned providers could unwittingly induce harm when they failed to slow down, communicate, or respect personal boundaries.

“I felt terribly alone. I felt disconnected. I felt like I was a piece of meat. For months after, every time I had a little bit of heart pain, I was flashing back to [my childhood trauma].” – P14

“I know that they were doing what they thought would be helpful, but that was triggering me even more!” – P05

“I've definitely been, like, scared to go to a dentist … I pretty much haven't been back to a dentist since, like pre-COVID.”- P06

Meta-Theme 3: Pathways to Safety and Connection

In contrast to harmful experiences, participants described moments when care felt affirming, safe, and even healing. These positive encounters centered around empathy, clear communication, and emotional attunement. Participants emphasized that trauma-informed care was not necessarily complex or time-consuming, but grounded in respect, presence, and the honoring of patient autonomy.

“It wasn’t just the absence of triggering that flowed from having trauma-informed care; the way that they treated me and responded was actually healing in and of itself!” – P00

“The hygienist was just explaining things before she was doing them … to me that bodily autonomy is helpful.” – P07

“A poster on the walls that just says, ‘I'm a safe place to talk trauma,’ would help me open up very quickly.” – P01

Meta-Theme 4: Re-Imagining What Trauma-Informed Care Could Look Like

Participants offered a vision of trauma-informed care grounded in understanding, adaptability, and mutual respect. Rather than passive recipients, they wanted to be treated as knowledgeable partners in their own care. TIC was defined by flexibility, holistic attention, and communication that emphasized consent and collaboration. Many described what was missing from current systems, framing TIC not as a set of checkboxes but as a relational, human-centered approach.

“You don’t have trauma sitting in front of you, you have a patient. It sounds cliché, but bringing more humanity and empathy into the space and open communication makes me feel safer.” – P04

“Actually, trauma-informed care is super simple … it just means that you’re not making things worse while you're interacting with that client.” – P00

“I have a responsibility to partner with this professional, and together we’re gonna make me better.” – P01

Meta-Theme 5: Structural Barriers to Trauma-Informed Care

Participants pointed to systemic limitations from rushed appointment times to medical education that obstructed the delivery of trauma-informed care. They expressed empathy for individual providers but emphasized that the broader structure of healthcare is not designed with trauma survivors in mind. Some questioned whether dominant cultural values in medicine reward emotional detachment and control over kindness or relational skill.

“You can’t really speak when you're there, either. So, that's a practice where it would be very beneficial to have a form that says: Hey, you know, it’s very common for people with a history of trauma to find dental work difficult. These are some of the things I can do to make the experience more pleasant. Do you have other ideas for me?”- P00

“When they’re trying to pump patients through the office 10 minutes at a time, that doesn’t leave a lot of time for anything else other than the one thing they want you to talk to them about.” – P08

“It doesn’t seem like the kind of thing that [doctors] are taught about in school. And on top of that, a lot of these people have already been out of school for - I don't know, decades?” – P02

“I feel sorry for doctors, you know? I think the majority of them are all - of course - caring people, and that's why they get into the profession. But it’s so dictated by insurance companies …” – P11.

Section 2: Mental Health Care

Meta-Theme 1: Structural and Financial Exclusion From Appropriate Care

Participants consistently described how systemic and financial structures exclude them from accessing timely, specialized, and trauma-informed care. This exclusion is driven by cost barriers, insurance limitations, and the scarcity of complex trauma-literate providers.

“If I was not financially comfortable, then it would be impossible… many thousands of dollars.” — P00

“Finding a trauma therapist is like pulling teeth.” — P03

“The system is against real trauma care; doctors don’t have time due to insurance.” — P11

Meta-Theme 2: Invisibility and Invalidating Responses Within the System

Participants repeatedly experienced invalidation and misinterpretation of their trauma-related symptoms, often due to provider ignorance of complex trauma. This led to structural dismissal of CPTSD, emotional harm, and breakdowns in care.

“My dissociation was interpreted as loneliness, very minimizing.” — P09

“My therapist did not know what complex PTSD is. We were both working from a knowledge deficit.” — P00

“She said, ‘No, you do not dissociate.’ So I believed her.” — P05

Meta-Theme 3: Safety, Trust, and the Slow Unfolding of Disclosure

Healing relationships require time, safety, and trust. Participants described a gradual process of disclosure, often shaped by prior invalidating experiences. Trust was enhanced through trauma-informed approaches and collaboration, while shame and fear led to silence or concealment.

“There are things that have to stay hidden.” — P03

“You should be a partner instead of a patient.” — P06

“It has taken 22 years for me to dole out very carefully… one more thing. I didn’t even tell him I drank too much until I had gone into rehab.” — P01

Meta-Theme 4: The Duality of Mental Health Care – Harm and Healing

Mental health care experiences spanned a continuum from re-traumatization to empowerment. Those who accessed trauma-informed, transparent, and collaborative care described growth. Others encountered rigid, dehumanizing systems that hindered recovery.

“Hospital stays were prison-like, not healing.” — P03

“My current therapist is open to learning together and adjusts treatment.” — P00

“Transparency reduces anxiety and allows me to be present.” — P07

Discussion

Interpretation of Findings

The purpose of the current study was to answer two key research questions: (1) what are survivors’ lived experiences of navigating mental and physical healthcare, and (2) what their perspectives are on what TIC might look like. Our synthesis and interpretation of the findings are found below.

The ‘Elephant in the Room’

Prior research indicates that patients often welcome the opportunity to disclose their trauma history with providers who are confident, competent, and compassionate.²⁴ However, our study participants painted a picture where complex trauma is often the ‘elephant in the room’ that goes unacknowledged, despite its documented connection to multiple health outcomes. Many complex trauma survivors are known to experience great shame, and initiating disclosures about their trauma experiences can be an arduous and risky proposition.^25-27 Indeed, participants in our study reported episodes of being invalidated or dismissed – sometimes referred to as ‘medical gaslighting’.²⁸ Such experiences can reinforce survivors’ views of the world as being unsafe and unsupportive, leading them to shut down or withdraw from care altogether. Another reason for perceived invalidation may be that a certain number of providers lack appropriate knowledge and training related to complex trauma and health and do not know how to incorporate survivors’ disclosures, when offered. A third reason for perceived invalidation could be a byproduct of a healthcare system that fails to acknowledge that complex trauma is a valid condition distinct from classical PTSD.²¹ This is particularly pertinent in the North American context, where insurance and billing for healthcare services often depends upon recognized diagnostic codes.

It should also be acknowledged, however, a lack of inquiry from providers might reflect debate in the literature about screening for CRT. For example, there has been discussion of the utility and safety of universal screening for ACEs – specifically, the possibility for false positives, as well as the harms that could be created when there is a lack of support available if screening is positive.²⁹ Conversely, a recent review of intimate partner violence literature noted that many screening programs have only been tested in research contexts that have significant external supports, which questions their application in the routine practice of healthcare.³⁰ Furthermore, desire to disclose trauma history is not universal, and if questions are not posed correctly, they can raise concerns about confidentiality and feel intrusive and stigmatizing.³¹ This suggests a possible impasse in initiating dialogue around trauma in some cases.

What Should Heal, Can Hurt

Participants reported dismissive and invalidating experiences in healthcare – either pertaining to the relationship between trauma and health, or just describing their health difficulties more generally. Part of this could be due to interpersonal styles of healthcare professionals. In their recent systematic review, Patel and colleagues³² note that empathy and compassion are not simply inherent traits of healthcare providers, and it may be worthwhile to intentionally train and cultivate them during medical education. They report on previous literature indicating that empathy and compassion tend to decline over the course of medical training and residency, although more recent literature has questioned this decline, which may be due to a purposeful implementation of training around patient-centered care. As such, some of the experiences of participants in our study (and other CRT survivors) may be related to the age/cohort in which providers were trained.

Other issues could be (a) either training that is not up-to-date, or (b) a lack of access to trauma-relevant training altogether. This could be argued to be the case not only for CRT, but even single-incident or classical PTSD. Particularly if practitioners have not received education in this area for some time, their understanding of trauma and its relationship to health may be outdated, and inaccurate information could be as harmful as a lack of information.^33,34 For example, the American Psychological Association in 2017 published clinical practice guidelines on the care of people with traumatic stress and PTSD, guidelines that were criticized for being too medicalized and symptom-focused, with not enough focus on the relationship between trauma and the body, and a lack of consideration of the interpersonal and cultural dimensions of complex trauma.³⁵ This is further compounded by the fact that the DSM-5²¹ does not acknowledge CPTSD as a diagnosis separate from PTSD, so survivors’ experiences could be dismissed or misdiagnosed. CRT survivors – and clinicians who specialize in working with survivors – find it much more useful and de-stigmatizing to consider survivors’ responses as adaptations to prolonged traumatic exposures, rather than symptoms to be managed, adaptations that kept the survivor alive during the period of active trauma. In the words of Viktor Frankl³⁶ in Man’s Search for Meaning, “an abnormal reaction to an abnormal situation is normal behavior”. Viewing survivors’ experiences this way helps to diffuse shame, acknowledge their strength and resilience, and foster hope that life can be lived differently, with the support of caring and compassionate providers.

Trauma-Informed Care: Barriers and Opportunities

Participants in our study identified that TIC was something that was desirable for them as a central marker of good quality healthcare. Yet at the same time, they were well aware that, despite the best intentions of healthcare practitioners, healthcare systems in many countries worldwide are over-taxed and under-resourced. This problem may only have worsened in the post-COVID pandemic era, with increased proportions of providers reporting severe burnout or other mental health challenges related to overwork and unmanageable job demands.³⁷ As such, many healthcare providers and even administrators may themselves feel that they are operating in crisis mode with little room to innovate. Contemplating special services for trauma survivors may feel like a luxury that they cannot afford either based in time or in cost.^38-42

That said, there are several benefits to a healthcare system adopting TIC. First and foremost, TIC is a systems-level approach to healthcare.⁴³ Rather than singling out trauma survivors for individual treatment, TIC endeavors to provide a welcoming environment for all patients, regardless of their trauma histories, with the goal of enhancing both patient and provider satisfaction as well as response to the care that is provided.^44,45 This is particularly beneficial when providers may feel that treating – or even speaking about – trauma directly is beyond their scope of practice. Second, survivors may experience difficulty in speaking up about their experiences and their needs because of the secrecy, silence, and shame associated with their trauma experiences or, conversely, based on past experiences of dismissal and invalidation.^46-48 TIC does not require survivors to disclose their trauma but assumes that a significant amount of people moving through healthcare have trauma histories, and the goal is to be welcoming to all.

In systems that are over-taxed and under-resourced, finding approaches to care that are effective and efficient is paramount. This is underscored by the fact that our participants reported structural and financial barriers to accessing good quality healthcare. An approach that may facilitate the implementation of TIC is through the adoption of more integrative care models. While they may require more upfront time and resource investment, they can lead to greater efficiency, once implemented.⁴⁹ Greater collaborative care facilitates consistency across providers as well as interprofessional communication, which means that survivors do not have to disclose their trauma story repeatedly, which can in turn minimize re-traumatization.⁵⁰

Finally, cultural safety and humility should be central considerations of collaborative care models generally or TIC specifically. CRT survivors are not a monolith, and different aspects of identity such as race/ethnicity, gender, socioeconomic status, sexual orientation, and national heritage are associated with structural harms and can interact with and compound the experiences of trauma survivors.^51,52 In designing care programs, providers and administrators could benefit from considering system impacts using frameworks such as the ADDRESSING model in order to center the intersectionality of trauma survivors.⁵³

Limitations and Future Directions

The first limitation is that our study only recruited participants from the United States and Canada. Given that healthcare systems differ significantly from country to country, some of the issues identified in our study (e.g., structural barriers due to economic resources) may be more or less relevant in different geographic locales. The current research would benefit from replication in other countries with different forms of healthcare supports, to compare survivors’ experiences in other parts of the world. Related, a second limitation is the limited diversity of our sample; future studies would benefit from recruiting more racially/ethnically diverse participants, including those who are newcomers.

A third limitation of our study is that participants were comprised of persons who are aware of living with CRT, and how this has impacted their engagement with the healthcare system. In fact, many individuals may not actually know that they have survived CRT. Because complex trauma, by definition, occurs in situations that are prolonged, repeated, and inescapable, traumatic exposures may become so normalized in such environments that survivors may not immediately recognize their experience as having been ‘traumatic’. It may be interesting in future studies to solicit healthcare experiences from people who do not have explicit recognition of surviving CRT and compare/contrast their responses to the current participants. For example, given the negative self-concept that is often part and parcel of complex trauma,¹⁰ survivors who do not have awareness of what they have survived may be more prone to internalize difficult healthcare experiences as their “fault”, rather than a failure of the system.

Conclusion

In sum, the current study demonstrates that CRT survivors experience difficulty accessing TIC within both medical and mental health settings, and that a lack of access to appropriate care may have significant negative effects both on overall health as well as creating experiences of re-traumatization. While there is growing awareness of TIC, greater efforts need to be pursued to increase the safety and inclusivity of healthcare for trauma survivors – something that could prove to be more cost-efficient for the healthcare system once broadly implemented.

Supplemental Material

Supplemental Material - Minding the Gap: Complex Relational Trauma Survivors’ Experiences Navigating Healthcare

Supplemental Material for Minding the Gap: Complex Relational Trauma Survivors’ Experiences Navigating Healthcare by Colette M. Smart, PhD, Mitchell L. Gaudry, BSc, Nika Marefat, Lori Herod, EdD, Jessica Lazar, PsyD, Malachi Gillihan, MA in The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

Supplemental Material - Minding the Gap: Complex Relational Trauma Survivors’ Experiences Navigating Healthcare

Footnotes

Author Note

Artificial intelligence was not used in the development of this manuscript.

Acknowledgements

We wish to acknowledge anonymously the team of six patient partners who worked with us to create the knowledge translation resource derived from this article. Likewise, we also want to thank Hiro Ito, Madeline Nealis, and Heather Strosher of the BC SUPPORT Unit for support in recruiting and onboarding our patient partner team.

ORCID iD

Colette M. Smart

Ethical Considerations

The Human Research Ethics Board of the University of Victoria approved this study (File/Approval # 24-0280-02).

Consent to Participate

All participants provided written informed consent prior to enrollment in the study.

CrediT Role Descriptors

C. M. Smart: Conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, supervision, writing (original draft).

M. Gaudry: Data curation, formal analysis, investigation, methodology, visualization, writing (review and editing).

N. Marefat: Data curation, formal analysis, investigation, methodology, visualization, writing (review and editing).

L. Herod: Conceptualization, methodology, writing (review and editing).

J. Lazar: Methodology, writing (review and editing).

M.Gillihan: Methodology, writing (review and editing).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funding from Island Health (Mental Health & Substance Use (MHSU), Island Health, Vancouver Island, BC, Canada Scholar in Residence Award – C. M. Smart). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. (Note: There is no specific grant number for this award.)

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

De-identified data from this study are not available in a public archive. Due to the sensitive nature of qualitative data and risk for identification of participants, data will not be made available.*

Study Registration

This study was not formally registered.

Analytic Plan Pre-Registration

The analysis plan was not formally pre-registered.

Analytic Code Availability

There is no analytic code associated with this study.

Materials Availability

Materials used to conduct the study are not publicly available.

Supplemental Material

Supplemental material for this article is available online.

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