Sanctuary in Adult Inpatient
Sanctuary in a General Hospital
The following is an excerpt from the Introduction to "This book is the story of how a group of friends and clinicians came to a better understanding of some of the mysteries of life. People who consider themselves patients or victims of trauma may certainly find the information contained within these pages of benefit. But I am not as much interested in writing about how we taught our patients as I am in sharing what they taught us. These lessons have been personally and professionally transformative and if properly understood could contribute to transformative changes in the concentric series of social systems of which we all are a part. In Chapter 1 and 2, I will focus on what traumatic experience does to the body, the mind, the relational network, and the ontology of the victim and those close to the victim. Learning about the effects of trauma is not as simple as learning a new body of information. Traumatic experience forces us to develop new categories, new ways of thinking about our past, our present, and our future. Trauma theory challenges, reinterprets, expands, and even demolishes many of our existing paradigmatic structures - the underlying rules and practices that give form and meaning to our lives. These rules are partly or wholly unconscious, undefined, simply accepted as the way things are. They define the way we perceive reality. In the practice of psychiatry, nature and nurture have run as parallel and often warring etiologic positions. Just as today, other times in our past have witnessed efforts by biological reductionism and genetic determinism to drown out the voices of nurture, environment, and development (Kirshner and Johnston 1982). In Chapter 3 we hear again a few of those insistent voices arguing for the essentially social construction of human existence. One of the most important lessons we have learned is that honoring and learning from the past is the only way of guaranteeing safety in the present and ensuring that we have a future. It is profoundly true, as Santayana reminds us, “Those who cannot remember the past are condemned to repeat it.” We cannot hope to integrate the biological, the psychological, the social, and the philosophical without learning from the wisdom of the past. In Chapter 4 I pick up the threads of my story and recount how we were changed by - and changed - our small experimental society as a result of what we learned about trauma. We called the physical and psychological result of this change The Sanctuary, and in this section I will describe our experience of creating and maintaining a therapeutic milieu that is designed to address the needs of adults who were traumatized as children. For years the inpatient setting has been considered a laboratory for social change. But before we had an understanding of trauma it was difficult to generalize from the small microcosm of a psychiatric inpatient unit to the larger social sphere in any significantly relevant way. No commonly shared language could adequately express our insights. Psychiatric disorder was constituted of basic “otherness” that bore little if any causal relationship to the outside world. Trauma theory has taught us that this perception is nonsense, that most psychiatric disorder is the culmination of “normal reactions to abnormal situations,” situations largely created by the failure of our social systems to provide traumatized children with the protection and care to which they have a right. As this recognition grew, the implications became enormous. Our tiny inpatient community was a small system embedded in a series of concentric systems that failed us in the same way that we were failing our patients, and that they had been failed as children. In fact, the degree of health in those “parent” systems was a limiting ceiling on how healthy we could make our own, not at all unlike the situation in which children find themselves when confronted with impaired parents. We realized clearly that without reverberating change in the hierarchy of systems, we would continually find ourselves fighting to maintain the safety and security of the unit, forced to mount psychic and corporate battles to protect the state of health we had achieved. This drain of energy, consequently, took its toll on the development of further progress. This has been an extremely useful lesson in graphically detailing the necessity of total system change and the difficulties involved in attempting to fix a part without fixing the whole. It was humbling to discover that our system and the systems around us are as resistant to change, manipulative, and stubborn as any of the psychiatric patients we were treating. This was another example of the dawning recognition that the wall we establish between them and us is an arbitrary one, born out of our need to distance ourselves from our own shortcomings rather than out of any sense of absolute reality. I have come to believe that we have had a number of experiences with victims of trauma that may have a great deal of relevance for the social systems within which we all must function. In Chapter 5 I speculate about the potential for social reconnection. Everyone seems to recognize that we presently are in need of change. Argument abounds, however, about what form that change should take. Powerful forces in our society are pushing for a movement backward in an attempt to undo the perceived damage that has been wrought by the profound changes of the last half century. Other forces are pushing us forward into a “new age,” which is described either in dark forecasts of apocalyptic doom or idyllic utopianism. Community life has broken down dramatically, and we are only beginning to recognize how important to our daily survival is the web of connection that a community provides. But there are relatively few voices talking about how we get from “here” to “there.” Part of the problem may be that we do not yet have any kind of a clear vision about where “there” is. We do not spend a great deal of time envisioning a better future for ourselves and our children and even less time figuring out how to make that future a reality. Nor have we had available to us an understanding of how “complex adaptive systems” function. Only now is a model for systems change being developed (Holland 1995). We have, however, learned a great deal about the human elements within any system that create the most chaos and disorder. That is why I think I have something to share with you. I have been a part of a better system for the last fifteen years. It is not idyllic or utopian. It does not work flawlessly. But it is more responsive to human well-being than any other system I have ever encountered. As a result, we have learned a great deal about what is important to human beings - all human beings - and some important lessons about how human systems succeed and how they fail. My world view has changed almost entirely as a result of what I have learned about what happens to human beings who are exposed to overwhelming stress. These changes have been alternately terrifying and exciting, frustrating and gratifying, infuriating and pleasurable. At times I seek out new knowledge, a new way of looking at the world. At other times, I regress, harking back to old and timeworn explanations for puzzling feelings and behaviors. This new way of viewing the world is far more personally demanding and draining than the old. In the last ten years, my life has totally and unexpectedly changed both personally and professionally. I now have bigger areas of clarity about things that were in a muddle before and this understanding has brought with it more compassion for myself, for other people, and for our sad, struggling world. But there is no longer any place to hide. I see what is meant by the saying “ignorance is bliss”. Now that I know more about the ways of the world and how the pieces fit together, I cannot bear the silence that gives consent. Suffering demands a voice, a witness, and that means giving up the freedom to be a bystander. This book is a call for more company out here, on the edge, on the firing line, speaking out against tyranny in all its forms, including the tyranny of a dying and deadly vision. We are on the threshold of a new millennium. Signs of social strain are manifest all around us. Our existing paradigmatic structures no longer adequately hold us. We appear to lack adequate methods to solve problems that are global, interconnected, ecological, and biopsychosocial. We lack an alternative vision for the future, and as the Bible says, without a vision a people perish. When Thomas Kuhn (1970) talked about a “paradigm shift” he noted that it is impossible for an old paradigm to be overturned until a new paradigm is born. I believe that our work with some of the most injured and socially alienated of human beings provides us all with important information about what we need to do to reconnect to each other and to the natural world that sustains us. These patients have provided us with some vital pieces of a new paradigm, the still hazy outlines of a new way of thinking, relating, and behaving, and a new way of defining reality. I have used the phrase “creating sanctuary” as a way of illustrating the verb-noun, process-object, every-changing organic nature of what The Sanctuary means. A sense of safety, wholeness, life, caring, and home is something each of us actively creates - or destroys - every moment of our lives. It is the ultimate choice of every human being, of every human community. It is my hope that the insights we have gained from our work with some of the most injured warriors in the battle of life can contribute to an interdisciplinary, interracial, transgendered, global conversation leading to a new, more humane and attainable vision for the centuries to come."
Creating Sanctuary: Toward the Evolution of Sane Societies, by Dr. Sandra Bloom about the experience of Dr. Bloom and her colleagues in creating an inpatient program that specialized in the treatment of adults who had been maltreated as children. The program was started in 1980 and was closed in 2001. Several programs for adults are presently adopting the Sanctuary Model by training at the Sanctuary Institute and participating in the Sanctuary Network.
Related Articles
Bloom, S. L. Editor (2000), Special Edition, The Sanctuary Model, Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations. Summer.
Sanctuary in a State Hospital
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Video clips from original Sanctuary program treatment team at Friends Hospital in Philadelphia, PA (1996-1999)
