I am wondering if the Suggested Guidelines for Implementation of a Trauma-Informed Approach include peer support. I work in a community mental health agency where there are employed peers and this is very helpful for the people receiving services. In my state, peer counselors are accepted in our organizations and our co-workers value our lived experience. How will other organizations that want to become trauma-informed integrate this?

In regards to #6, I think training on trauma-informed priciples be mandatory for all staff. This is important for every person in the organization. In my professional and personal life, the first person in an organization who greets a client has a profound impact on the culture of the agency. Those people, front desk staff, office administrators, need to be trained in trauma-informed principles even if they don't provide services because their interactions affect clients.

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 Three: Suggested Guidelines for Implementation of a Trauma-informed Approach

With regard to Paragraph 2, “Policy,” we note that it is important to not only have a policy stating the agency’s commitment to trauma-informed principles, but also to integrate a trauma-informed approach into all of the agency policies.

With regard to Paragraph 5, “Services and interventions,” we recommend deleting the word “empirical” in the phrase “best available empirical evidence” to reflect a more accurate and complete understanding of evidence as including experiential and contextual evidence, as well as empirical evidence.

With regard to Paragraph 6, we suggest revising the phrase “from vicarious exposure to highly stressful material.” We are concerned that this phrase unintentionally refers to individuals and their life experiences as “highly stressful material.” We therefore recommend editing this phrase to say, “from bearing witness to the traumatic experiences of others.”

With regard to Paragraph 8 and Paragraph 9, we suggest that when referring to “evidence-based trauma-specific interventions” and “evidence-based trauma-specific services,” the phrase “as appropriate” be included, as trauma treatment is not appropriate in all settings (i.e., some agencies, while they may use a trauma-informed approach, may not be a trauma treatment organization).

I live in a state that is STRONGLY advocating trauma-informed protocols across all human services systems. We have poured hundreds of thousands of dollars into professional training for a couple years and the state government is proposing over a million dollars more for just the upcoming year. I can tell you that the facilities that have been the primary focus of this vast support and funding effort have not embraced TIC. If there are national-level trainers, performance evaluators, contract assessment reviewers or anyone else present that is "watching" the staff complies- demonstrating they know what to do and what it is- but the minute, literally, the door closes, it is back to business as usual- restraints, seclusion, violent forced drugging, arrogant, power-over staff attitudes, the whole nine yards. If our state can't do it after all this effort, who can? And what is to be done about shifting the cultural paradigm? Maybe looking at higher education curricula is indicated- my son is in college studying therapeutic interventions and there is not a WORD about trauma to be seen.

Any government website talking about trauma should not hide from the elephant in the room, VIOLENT atrocities in the form of forced psychiatry laws allow countless to be traumatized by government "mental health services".

How can a government that is guilty of traumatizing innocent people and torturing them really claim to be having a serious conversion about trauma?

More government lies, more government workers with their head in the sand.If SAMHSA cared about people who have had traumatic lives it would move to outlaw all forced psychiatry so as to ensure people no longer had to live in fear of having their brain raped by the state.

Psychiatry is a fraud and "behavioral health" is a pathetic weasel phrase covering up the quack notion that human life is a "health problem". Quack bureaucrats with DSM labels and drugs, wouldn't know the first thing about healing trauma.

•The “Policy” domain can be expanded to include the practice of using knowledge of trauma and recovery to inform the creation and review of all policies and procedures.
• “Services and interventions” domain should include language around providing services and interventions in a flexible manner to ensure that trauma survivors receive supports that are tailored to individual needs.
•The “Training and workforce development” domain should include training on development and the needs of children and youth, in addition to adults. Traumatic experiences and impact should be placed in the context of development. Staff self-care should not only be a topic of training but self-care practices should be supported by organizational policy and practice.
•The “Organizational and community multiagency protocols” domain is unclear. Perhaps the associated practices could be included under the “cross-sector collaboration” domain.
•Quality assurance and financing domains should assess and support a variety of practices that include but are not limited to “evidence-based practices”. This allows organizations to implement practices that show promise and require more evidence to become recommended practice with trauma survivors.
•The “Physical environment of the organization” domain should include language around establishing an environment that ensures physical and emotional safety.

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The guidelines provide an excellent framework for beginning the assessment process for the development of an organizational change strategy to support a trauma informed approach. The key domains to be considered are very comprehensive and relevant. However, the focus is solely on assisting organizations to identify strengths and weakneses in order to provide milestones for measuring implementation progress. One key variable omitted is assessment of resources needed by an organization to do this. Domain # 9 references designing financing structures to support a trauma-informed approach which is absolutely critical. However, nowhere in the guidelines is there an acknowledgement that government funding streams are a major source of financing for many organizations and are not within their authority to redesign.

In addition, domain #7 assumes that cross-agency collaboration can be accomplished solely through cross-agency protocols without acknowledging funding requirements as well as legal and regulatory constraints that can sometimes inhibit cross-agency collaboration.

Clearly, SAMSHA is making an excellent contribution in assisting organizations to design a trauma-informed approach. Reference is made in the conclusion to the guidelines that they will serve to advance a common understanding of trauma across service sectors and provide a foundation for SAMSHA's efforts around training and technical assistance and development of a measurement strategy for trauma. To provide further assistance, it would be helpful if SAMSHA could assume a leadership role in collaboration with other federal agencies to promote cross-systems development of a trauma informed approach vis a vis federal policy and planning requirements and financing incentives to support state and, local efforts .

It is important to understand that the conceptualization of “Trauma” and any treatments or principles are founded on cultural beliefs and general premises that may not relate across all cultural groups. A Trauma-Informed Care organization must acknowledge and be prepared to acknowledge the impact of trauma depending on the cultural context in which it happens and the responds to individuals or community impacted by threatening or traumatic events may differ based on their cultural beliefs. An organization who will effectively engage their consumers and their workforce must have an understanding of the cultural differences related to trauma. For example the conceptualization of even the definition of trauma may differ among cultural groups such as religious groups. The coping mechanisms and the conceptualization of the impact of life threatening events may differ among religious groups or different cultural or ethnics groups. Some groups seek healing within their community while other seek healing through traditional forms of medical treatment. Some will conceptualize a life-threatening event as a tragedy that must be overcome, while a different cultural group may conceptualize it as karma, or as another event that happens that must be embraced and just needs to be accepted as is.