The summary working definition is a good starting point but I think the lengthier working statement does more justice to the complexity of trauma. There may be a trauma taxonomy/ language that I'm unaware of but I do think there may be fundamental differences in the dynamics of an individual's trauma experience depending on whether the causation was based in interpersonal or family relationships vs in community - based event or large scale disaster. The "who or what" that created the trauma is important in framing the responses to it. Similarly there are dynamics distinctions between privately- based( eg child ****** abuse) and publicly - based ( eg hurricane disaster)traumas . Some traumas impair an individuals ability to successfully negotiate basic developmental stages and the "stuckness" is played out in addictive compulsive/ avoidance patterns that can affect multiple generations . Implications for unacknowledged( denied) , unaddressed( avoided) and unresolved ( unchanged) stages of trauma response? Existential/ spiritual implications? Traumatic events have in common ( I think) an extraordinary/ non-ordinary, overwhelmingly shattering, boundary- invading quality that insults the integrity and sanctity of an individuals sense of self, safety and security in the world, with impact ranging from spiritual/ existential issues to deeply carried cellular memories . I've rambled too long here. Many thanks to the team that prepared the working statement.

I appreciate the current working definition for "trauma". I also know that there is much work to do to enhance the definition so that it is more broadly accepted and more well-defined.

As a trauma survivor, no one has to tell me what the definition should be. I feel the effects quite often, both individually and within my community. This was the case on 2 July 1984.

At age 10, I witnessed my mother, Jacqueline and my 12 year-old brother, Anthony, get shot and killed by my mother's estranged boyfriend, Marshall. Marshall took his own life that day, but not before he made me beg for my life at gunpoint. With a huge network and support system, I survived. Without it, I wouldn't be alive today.

It is within the context of past trauma that I make my comments today. I also recognise the voice of those who have not a voice today. I honour the silent victims and survivors who struggle each day, putting one foot in front of the other, to strive and do the best they can with the tools or lack of tools they have. There is hope, help, recovery and healing.

Thinking positively leads me to my view of the working definition for trauma.

Let's start with the positive so that we focus on what is strong about the definition for trauma.

POSITIVE

i. I appreciate that the individual can experience an event or "series of events" or "set of circumstances". This provides the context for the requirement of a stimulus in order for the individual to have a response. It is key to understand that some individuals do not respond to an event in the same way. What may be traumatic for one person may not be traumatic for the other person. There may be some other factors that also hinder a response to a stimulus such as a disability, etc.

ii. it is important to include "physically" and "emotionally". Often missing is the emotional impact that a harmful or threatening event has on a person. The media, in 1984, mentioned in a news report that I was "physically safe, but was unhurt". The idea that I was "unhurt" when witnessing such violence is untrue. The media and other entities, systems, institutions, organisations and individuals need to see both representations in the definition.

ii. trauma has "lasting adverse effects on the individual's physical, social, emotional, or spiritual well-being" is also a requirement for this definition to be true, in my opinion. trauma may precipitate a "moral crisis" and have a lasting effect. Often, many do not acknowledge trauma's effect on the "spiritual well-being". It's important to include.

CONSTRUCTIVE

Currently, I do not recommend any word changes. I will note that organisations such as the NCTSN make valid points regarding the passiveness of the definition. In addition to other feedback, it is imperative to continue the dialogue, even in increments as planned.

We have a major opportunity to help define trauma, however, the opportunity lies in the ability for the definition to educate others around the issue of trauma.

The following comments are submitted by the National Center on Domestic Violence, Trauma & Mental Health. We are encouraged by SAMHSA’s ongoing work and interest in trauma and trauma-informed approaches, and we appreciate this opportunity to provide comment.

Part One: Defining Trauma

We suggest adding a statement regarding resiliency in the section titled, “What do we mean by Trauma? The Three R’s,” acknowledging that resiliency factors can also affect how a person is impacted by trauma and can mitigate some of the potentially adverse effects of trauma.

We suggest a change to the phrase “individual’s cultural beliefs (e.g., the subjugation of women and the experience of domestic violence.” While a person’s experiences are affected by their beliefs, we find the wording of the parenthetical to be confusing and we are concerned about the unintended implications. We also note that a person’s experiences may be affected by a range of beliefs, including religious beliefs. We therefore suggest simply using the phrase “individual’s beliefs” and deleting the parenthetical.

In the interest of reflecting in our language an understanding that everyone’s experience of trauma and its effects is different, we suggest changing “eventually wears a person down” to “can eventually wear a person down.”

We suggest changing “spiritual beliefs and the search for meaning” to “an individual’s spiritual beliefs and search for meaning.”
We suggest replacing “a sexually abused individual” with “an individual who has been sexually abused.”
We suggest changing “a victim of domestic violence harshly interrogated in a shelter” to “a victim of domestic violence harshly interrogated by law enforcement.”
We agree that communities may avoid, overlook, or misunderstand the impact of trauma and that this may often be re-traumatizing and interfere with the healing process. In addition, it is important to note that communities may sometimes also contribute to the perpetuation and legitimization of gender oppression and gender-based violence, as well as other forms of discrimination and violence.

We think that the examples included here of "events or circumstances inflicted by one group on another" are highly relevant to many people’s lives and we are glad to see them included here. For many groups, these examples may represent ongoing traumatic events or circumstances as well as past events or circumstances that have contributed to historical trauma. We suggest including a definition of historical trauma in this section. Historical trauma refers to cumulative emotional and psychological wounding across generations, emanating from massive group trauma experiences. We also suggest including more examples of historical trauma that may be highly relevant for communities in the United States. For example, many American Indian/Alaskan Native (AI/AN) communities have experienced forced removal, forced sterilization, and abuses related to boarding schools. It is important to note that AI/AN communities and many other communities are also experiencing ongoing traumatic circumstances. Therefore, we also suggest adding a sentence to this section acknowledging that, for many groups, traumatic events and circumstances, such as mass incarceration and events and circumstances resulting from the lack of tribal jurisdiction to respond to violence against women living on tribal lands, may be ongoing.

The National Center for Child Traumatic Stress appreciates the opportunity to comment on the working definition of trauma; the ideas related to a trauma-informed approach; and the suggested guidelines for implementing a trauma-informed approach. NCCTS staff and members of the National Child Traumatic Stress Network (NCTSN) contributed to this effort, but are concerned that many potentially serious problems remain with the current drafts; these problems may hamper the implementation of a comprehensive trauma-informed approach. More details are below, but the NCCTS/NCTSN members are also available to assist with a revision.

The concerns regarding the definition fall into 3 main areas:

1. Lack of integration with scientific evidence. There has been enormous progress in the trauma field over the past 2 decades, as represented by advancements in the definition of trauma and elucidation of a developmental framework for PTSD as in the proposed ICD-11 and DSM-5 (for children and adults) and by the breadth of trauma research in many areas. SAMHSA definition runs contrary to the current scientific understanding of traumatic stress and represents a step backwards. The definition also ignores the long history of veteran and military trauma research, and provides few references to any scientific research.

2. Definition minimizes the meaning of trauma.
a. The definition is not clear about what constitutes a traumatic event. Essentially, according to the definition, anything is traumatic as long as an individual’s subjective experience deems it as traumatic. This is most apparent in the 3 examples provided (removal from an abusive home environment; refugee displacement; and military deployment). These are situations that increase risk for exposure to traumatic events, rather than traumatic events per se. The examples and the definition itself overemphasize the "subjective" nature of trauma and describe events that are related to (and in some cases consequences of) the trauma and neglect the real experiences of trauma exposure. Life threat is not mentioned. For example, deployment may be a serious stressor and a strain that deserves focused family assistance, but it should not be confused with a traumatic combat event. It is exposure to life-threatening war experiences while deployed (e.g., witnessing others being killed; narrowly escaping death from the blast of a detonated roadside bomb) that may be traumatic. As a result, these examples should be deleted because they misdirect attention from the serious traumatic exposures of abusive homes, civil war conditions and combat. There are some experiences that almost everyone would recognize as traumatic, but the definition is either silent on those experiences or equating them with stressful life events that some people merely "take in stride." In the NCTSN definition of child traumatic stress (see below) it is stated that the traumatic event “overwhelms their ability to cope,” which is more specifically linked to functional impairment indicators in the DSM.
b. The definition may result in major confusion on the part of patients, family members, and providers by its failure to distinguish exposure to the stressor from the reaction to the stressor, or to define any kind of reaction that is not a general response to stress. The definition does not acknowledge the powerful impact of trauma on individuals. This devaluation of the concept may actually hinder the cause of trauma survivors; it allows anyone who experiences any symptoms to any adverse experience to define themselves as traumatized. It also allows the importance of trauma treatment to be dismissed by those who would question the breadth of its definition.

3. “Evidence-based” treatments/practices are not included.
a. Information regarding evidence-based practices is mostly absent; this represents a serious gap in this proposal. This absence of information regarding the most effective practices does a disservice to the trauma field and to trauma survivors who should be offered the highest quality, most effective, and most up-to-date and scientifically proven treatments available. While problems with access to services and the need for a broader evidence base are acknowledged, it is recommended that SAMHSA uphold its responsibility as the prominent federal agency charged with overseeing mental health services for Americans, to make a stronger statement about the need for high quality, evidence-based, and trauma-specific services as part of any trauma-informed approach. The NCTSN has information about evidence-based practices on its website, as do other organizations, such as the National Center for PTSD.

4. Trauma-informed approach is too narrow. The NCTSN has developed a comprehensive definition of what constitutes a trauma-informed child and family services system (see below); this definition correlates best with the SAMHSA proposed “trauma-informed approach” proposal. This definition was developed collaboratively with representatives of provider groups, families and consumers, and researchers. This definition was provided to SAMHSA as part of the process, but much of the NCTSN definition is not reflected in the SAMHSA proposal; for example:
a. While the SAMHSA definition includes the idea of “responding,” i.e., putting knowledge into practice, too much of the supporting documentation focuses on the more passive idea of “recognizing” trauma. It is insufficient to merely “realize” and “recognize”; there is little information regarding the tools needed to respond, e.g., training, supervision, staff support, screening, collaboration, and more.
b. When “responding” is further detailed in the SAMHSA proposal, the emphasis is on staff needs vs. patient/client needs. Patients/clients and their families should be a priority. In the NCTSN definition, details regarding responding are emphasized, and three points (of the 7 provided) are particularly relevant for this discussion and are missing from the SAMHSA proposal. The NCTSN definition emphasizes the following steps as important:
i. To routinely screen for trauma exposure and related symptoms. Using trauma screening and assessment procedures is mentioned briefly, but nothing about the need for them to be evidence-based, or other information about what a proper screening procedure would entail.
ii. To use culturally appropriate evidence-based assessment and treatment for traumatic stress and associated mental health symptoms;
iii. To emphasize continuity of care and collaboration across child-service systems. There is little to no mention of the importance of collaborating across child-serving systems in this section, except in passing as part of a long list of items.

More information about the NCTSN definition of child and family trauma-informed service systems is available at this link: (http://nctsn.org/resources/topics/creating-trauma-informed-systems)

The section on community trauma should also note that a community’s response to an individual experiencing trauma can play an important role in the individual’s ability to recover. If a community neglects or responds negatively to an individual who has experienced a traumatic event, the individual may be further traumatized or have difficulty recovering. On the other hand, if a community understands and strongly supports an individual experiencing trauma, his/her recovery process will likely be easier. Furthermore, it should also be recognized that some immigrant groups that move to the United States bring trauma from certain cultural practices they have experienced in their countries and/or continue to practice them while living here. Female ******* mutilation in certain African communities is an example of a practice that could be traumatic for the individual but his/her community sees as normal and may not understand (or choose to ignore) the feelings experienced by the traumatized individual.

•The definition should qualify that traumatic events or circumstances are outside of what is usual to avoid understanding any stressful experience as traumatic.
•The definition should include reference to the neurophysiological aspects of a traumatic experience and the effects of that experience.
•The definition should frame the effects of trauma within the context of development to ensure inclusion of child and adult experiences.
•The current definition refers to trauma as having “lasting adverse effects” which implies that all experiences of trauma result in long-term challenges. The definition should allow for a range of possible impact that includes short-term and/or long term effects.

Suggested Definition Revision:
Individual trauma results from an event, series of events, or set of circumstances outside of what is usual, that is experienced by an individual as physically or emotionally harmful or threatening, and that has short-term and/or long-term adverse effects on the individual’s physiological, psychological, and/or developmental functioning, potentially impacting physical, social, emotional, and/or spiritual well-being.