The physiology and neurology of trauma and post-trauma responses are easily understood if they're explained in everyday language. Gaining a basic understanding of these things can be liberating, empowering, de-stigmatizing, and a source of immense relief. This kind of information answers the question on everyone's mind -- "am I crazy?" -- with a resounding "no." This kind of understanding also helps people integrate their emotional and physical experiences, and provides a context for the very important work of modulating their stress responses and emotional reactions. This, in turn can bring about much higher levels of psychological safety, whether people are simply trying to live their lives or entering modes of therapy (e.g., exposure-based interventions) that will require strong skills in self-modulation if they are to remain safe and effective.

1. It makes sense to me that SAMHSA is using the two terms trauma-informed care and trauma-informed approach synonymously. The example of the criminal and juvenile justice sectors using trauma-informed approach may suit their organizations better. While it may be ideal for there to be more "care" involved in corrections work, I think that issue is more complex than the scope of this paper.

2. Many people who experience trauma do feel shame. And because our culture tends to shame trauma survivors, many people don't self-identify as trauma survivors. Also, I think there is a misconception in our culture that only certain things traumatize a person. So, I feel there are people who do not understand this new trauma definition and wouldn't categorize themselves as trauma survivors. I think this needs to be reflected in the three R's.

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 Two: A Trauma-Informed Approach

A trauma-informed approach includes avoiding retraumatizing those who seek assistance as well as ensuring that additional harm is not being done. Furthermore, facilitating participation and meaningful involvement of people receiving services and their families is also an important element of providing trauma-informed services. A trauma-informed approach also means actively supporting healing and well-being. We therefore suggest adding this to the description of a trauma-informed approach.

We suggest reconsidering the use of the term consumers. While this term was originally coined in the context of empowering people who access mental health services, it may not be the term that many people who are accessing mental health services identify with today. In addition, if SAMHSA intends for this definition to be relevant outside of the behavioral health setting, the term consumers may be too narrow.

We suggest reconsidering the use of the term realize in the context of the first of the three R’s, “realizing the prevalence of trauma.”

Trauma screening and assessment procedures can be helpful in the context of trauma treatment, although it is important that these screening and assessment procedures are themselves done in a way that is trauma informed. However, while being able to recognize possible signs of trauma during interactions is an important part of being trauma informed, trauma screening and assessment may not be helpful or appropriate outside of a trauma treatment setting. We suggest revising this paragraph to reflect that understanding.

With regard to what it takes to maintain a trauma-informed approach, we suggest adding that support for supervising staff and leadership is also important.

We suggest revising the sentence, “The organization has practitioners trained in evidence-based trauma practices” to include “as appropriate to the services they are providing.” This addition will reflect a recognition of the difference between a trauma-informed approach and trauma-specific interventions, some of which may be evidence based.

The intervention Seeking Safety is not specific to domestic violence. We therefore suggest removing the word “domestic” from the phrase “interpersonal or domestic violence.

We recommend deleting the word “persuasion” from the phrase “characterized by belief in persuasion and trust” as that word has a coercive connotation that is not in line with the intended meaning of this sentence.

With regard to Paragraph 9, “Cultural, historical, and gender issues,” we recommend changing the title to “Gender responsive, culturally relevant, and attentive to historical trauma.” We also recommend revising this paragraph to reflect that organizations should not only seek to move past biases on an agency level but should actively work toward the broader elimination of racism, sexism, and other biases.

•The first “r”, “realizing the widespread impact of trauma” requires some clarification. It seems that this is about understanding the broader context of trauma and its’ impact in general.
•Including a general understanding of how to foster resilience and recovery as opposed to the more vague “potential paths for healing”, grounds the definition in trauma-related terms.
•Moving from realizing trauma in a broad sense, it seems that recognizing signs and symptoms should be further grounded to the particular system one is involved with vs. “the system” not clearly defined.
•The term “client” is not used in all settings. The term “survivor” is more universal and strengths-based. Survivors should be identified first in a list of “staff, clients, and others.”
•In the third part of the definition, a trauma-informed approach should fully integrate knowledge of trauma and recovery into all aspects of programming.

Suggested Definition Revision:
A program, organization, or system that is trauma-informed realizes the broader prevalence and impact of trauma on individuals, groups, organizations, and communities and how to foster resilience and recovery; recognizes the signs and symptoms of trauma in survivors, staff, and others involved in a particular program, organization, or system; and responds by fully integrating knowledge of trauma and recovery into policies, procedures, practices, and settings.
www.familyhomelessness.org

It seems more appropriate to use the language ‘Trauma Informed Care’ instead of ‘Trauma Informed Approach.” Are these terms to be used interchangeably? Per the information that exists on the following link http://www.samhsa.gov/nctic/, the National Center for Trauma Informed Care (NCTIC) “seeks to change the paradigm from one that asks, "What's wrong with you?" to one that asks, "What has happened to you?" Is this the same paradigmatic shift that is being sought through the implementation of ‘Trauma Informed Approach?’ I am assuming so, but think it needs to be made clear whether or not Trauma Informed Approach and Trauma Informed Care are the same thing. Based on the framing in the explanation it appears that the delineation is based on the setting (i.e. healthcare versus employment). Saying that the two are similar implies that the difference is more than just setting. Is this the case? Or are there other factors that demonstrate a difference between the 2 terms?

In the section entitled “What is the difference between trauma-specific interventions and services, trauma-informed care, and trauma-informed approach?,” the 3rd paragraph states “Trauma-specific services recognize that recovery occurs within the context of relationships characterized by belief in persuasion and trust rather than coercion…” This language does not convey a message of cooperation and collaboration amongst the involved parties. Perhaps changing “belief in persuasion” to “collaboration” would send the message that the decisions to be made evolve from agreement.

Also, cultural competance should be a separate core principle in order for organizations to respond effectively.

For SAMHSA, the NCTSI evaluation team in FY 2006 and FY 2007 conducted key informant interviews and focus groups with 84 Network TIS-affiliated experts in the field of child trauma to evaluate SAMHSA’s definition of the Trauma Informed Services (TIS).
We recognize that the definition for trauma-informed services has been modified but we still think some of the comments made by the NCTSN experts are still relevant.
SAMHSA’s definition of Trauma-Informed Services in 2005:
Trauma-informed services are designed to 1) reduce the impact of trauma on children/adolescents through screenings, assessments, referrals, supportive services, outreach, crisis response; 2) train service providers around specific services or interventions; and/or 3) implement service system changes to improve delivery of trauma treatment and services. Trauma-informed services also include interventions that target service providers such as informing them of the impact of trauma in their service populations and/or improving their response to traumatized children/adolescents.
Results from the formative inquiry indicate that most expert respondents agreed with all, or almost all, of the SAMHSA definition of TIS. Experts consistently reported that the definition of TIS should be refined and/or expanded to list potential target audiences for TIS, incorporate elements of cultural sensitivity, include a description of the impacts of trauma, and emphasize the need for education/training. In addition, expert respondents in the key informant interviews and focus groups agreed that the most essential element for a trauma-informed mental health system was “trauma screening and assessment upon entering a system,” closely followed by “specialized trauma programs integrated with mental health and substance abuse services.” In the key informant interviews, the most commonly cited least essential element for a trauma-informed mental health system was “the existence of a State trauma policy or position,” although the focus groups considered this to be a critical element.
Specific suggestions were:
I. List potential target audiences for TIS
1. Address services to teachers and parents to recognize the important role that they can play
2. Explain that TIS should target the whole family system and community
II. Expand/refine the definition
1. Tweak the opening sentence to make it a little more universal, but a bit more specific for a community
2. The Emergency Services language may make someone assume that the trauma is a result of an acute event, rather than refer to the range of traumas.
3. Emphasize the partnership in the definition
4. Acknowledge that a TIS system has a specialized body of knowledge and skills
5. Include clinical treatment or therapy
6. Include case management, secondary prevention, and targeting at-risk populations in various settings.
7. Include a discussion of assessment and replace the word “treatment” with “assessment and treatment”
8. Also, instead of the word assessment, include the work “comprehensive assessment”
9. Include prevention-focused services (specifically what can be done in terms of outreach and education to help prevent trauma)
10. Include at the end “ improving their response to traumatized children/adolescents as well as knowing how not to retraumatize the children/adolescents”
III. Further define/clarify terms
1. Define the broad term “traumatic event” (e.g., physical trauma, traumatic events related to hospitalization for other diseases)
2. Service system should be clarified, possibly ‘child’ service system to include child welfare and juvenile justice. But overall a more detailed definition of the service system
3. Add a second tier/level of definition to further elaborate on what is already included
4. Identify preschoolers specifically rather than using the broad classification of children
5. State that TIS are evidence based
6. Clearly define supportive services
IV. Incorporate element of cultural sensitivity
1. State that the services are provided in a culturally informed/sensitive environment
2. Add a cultural piece
V. Include a description of the impacts of trauma
1. Address the impacts of doing trauma work on the service providers (e.g., vicarious traumatization)
2. Add the impact of trauma and its effects (e.g., anger, violence) on the entire family
VI. Emphasize the need for education/training
1. Add a piece on educating community members on TIS
2. Incorporate TIS training into graduate programs, social work, and other mental health programs
VII. Native American participants emphasized that the definition of provider needed to be broader for Native populations.
1. Providers can be natural healers, peacemakers or tribal leaders or others determined by the each community
2. In some communities there are paraprofessionals and community health members who ‘have healing ways’
3. Due to the lack of resources on the reservations, the telephone and telemedicine are other ways of providing services to children and their families
Key Principles of Trauma-Informed Services:
Focus group and key informant interview participants were asked to review a list of 15 essential elements for a trauma-informed mental health system, outlined by National Technical Assistance Center for State Mental Health Planning in 2006 and to identify which elements they considered to be the most and least critical for a trauma-informed children’s mental health service system.
15 principles of trauma-informed service systems were outlined:
1. The existence of a State trauma policy or position
2. Trauma screening and assessment upon entering a system
3. Clinical practice guideline and approaches for trauma treatment
4. Specialized trauma programs integrated with mental health and substance abuse services
5. Procedures to avoid retraumatization
6. Staff trauma awareness, training, competencies, and job standards
7. Linkages with higher education
8. Regulations that address trauma
9. Research, needs assessment, and quality improvement data regarding trauma
10. Funding strategies for trauma-specific services
11. Consumer involvement
12. Cultural sensitivity and appropriateness
13. Coordination across service systems
14. Trauma-informed disaster and terrorism response
15. An identified point of responsibility for trauma in the State mental health department
Overall focus group participants seemed to rate the following three essential elements as most critical: trauma assessment and screening upon entering system, consumer involvement, and cultural sensitivity and appropriateness. The primary points of disagreement between focus group and key informant respondents centered on the existence of a state policy related to trauma and the involvement of higher education.
The following list of elements were generated by the key informants and endorsed by focus group participants as elements that should be considered /incorporated into an Essential Elements list.
a. An increased number of providers in facilities to provide these services
b. State-level planning
c. Public education system (K-12)
d. Prevention initiatives
e. Community awareness education
f. More focus on the importance of underserved populations
g. An interface between local, Federal, and State guidelines

Although a trauma-informed approach is discussed in the context of what a program, agency, organization or community thinks abouts and responds to those who have experienced trauma, the focus of change seems to be limited to change in organizational culture and the people within an organization. While comprehensive organizational culture change that goes beyond those directly delivering services is essential, it is not sufficient to address a cross service systems response to trauma. Reference needs to be made to including public and private funders and public sector policymakers as key stakeholders who need an understanding of trauma and its effects. The decisons made by these stakeholders have a significant influence on an organization's capacity to undertake the organizational cultural change necessary for a trauma informed approach. Their scope of influence includes budgetary resources and laws and regulations that may inhibit the development of a trauma informed approach.