One of the strongest forces keeping people from seeking or accepting help for post-trauma effects is the myth that these effects are signs of being weak, cowardly, or "crazy." With a basic understanding of the very logical processes that the body and brain go through to keep us alive and functioning under stress -- and the effects of those processes once danger subsides -- people often begin to drop that sense of shame and self-blame, connect with others, and consider getting help. As they gain a better understanding of human resilience, they begin to connect with their own resilience, and to understand that the body's reactions to stress and threat are signs of strength, rather than weakness. In all of your provisions for public education and services to people with post-trauma effects, please address the urgent need to provide user-friendly, de-stigmatizing education on the nature of human resilience, the body's and brain's reactions to stress and threat, and ways of using that knowledge to build resilience, accept help, and recover from the effects of trauma.

Trauma in older adults is an important issue to address and act on in a comprehensive prevention strategy. According to the best available estimates, between 1 and 2 million of Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection. Elder abuse adversely impacts mental and physical well-being in several ways and may lead to increased use of medical and social services. As the population ages, the frequency of occurrence of elder mistreatment will undoubtedly rise (National Academy of Sciences, 2003). Specific strategies for preventing and treating elder trauma should be included.

Building on the success of “gender-specific care” to treating particular groups and communities, it is our opinion that these groups play a leading role in “defining” the nature of their experience. Obviously, the pool of trained professionals able to properly identify and administer care tailored to a specific demographic (in this case, gender) is rather large, but shrinks considerably when applied to AI/ANs. Keeping this in mind, our hope is for SAMHSA to involve considerable first-hand consultation and education from Tribal leaders in determining the unique circumstances involved in ongoing intergenerational trauma.
In doing so, SAMHSA can properly approach what is an inherently culture-specific phenomenon with a culturally appropriate method of care. Echoing a previously stated theme of continuous involvement and consultation, it is crucial that community-based care involve members of said community in a role beyond mere recipient.

Evangelyn "Angel" Dotomain, MBA
President/CEO
Alaska Native Health Board

Objective 2.4.2 talks about the ability of first responders to respond appropriately to people with mental health and substance use problems and histories of trauma. Action step 1 talks about “partnering with criminal justice and law enforcement groups to expand the use of crisis intervention training and pre-booking diversion” and action step 2 aims to provide training and TA for first responders. Though it is very important that our criminal justice system and first responders better meet the needs of individuals who have experienced trauma, it is important to note that the types of strategies and interventions suggested would be a huge cultural shift for many criminal justice groups and first responders. The plan should include an action step to develop a plan to get criminal justice partners to buy into a philosophy that will best meet the needs of individuals with mental and substance use disorders and histories of trauma. Similarly, a step should be included to ensure buy-in from first responders around the training and technical assistance that they will be provided.

Though, assessment is often implied after one screens positive for trauma, it is still not always used. Behavioral health providers do not always know the most appropriate/evidence based assessment techniques and or tools to use when assessing trauma. Assessment is a key component to providing the right treatment for someone who has experienced trauma and in need of care.
The plan should include assessment under Objective 2.2.1 and include corresponding action steps to ensure appropriate assessment methods are used before treatment.
or the plan should develop an additional, separate, objective for assessment that includes the development of a compendium of assessment tools and techniques for trauma.
It is interesting to note that under Objective 2.1.3: “Build a trauma informed behavioral health system,” Action Step 3 states “create core competencies for direct service professionals for screening, assessing and treating trauma among diverse populations.” However, no where in the plan do we see any steps for ensuring the right assessment tools and skills are available to service providers or that assessments even take place. This is curious because as the plan currently reads, it almost appears to only recommend trauma assessment for “diverse population.”

Individuals with psychiatric disabilities are more likely to be unemployed or underemployed, and experience discrimination in the workplace. A study conducted by Stuart (2006) found that people with psychiatric disabilities were unemployed at a rate three to five times higher than the rate for people without disabilities (NCD, 2008). Further, the study reports an unemployment rate for people with a diagnosis of schizophrenia estimated as high as 90 percent. Services and supports for persons with psychiatric disabilities to become and remain employed are crucial, and SAMHSA should take a leading role in partnership with the US Department of Labor to meet the needs of this population.