Sanctuary as a Safety Culture

The Sanctuary ModelThe concept of “sanctuary” refers to the important emphasis we place on the active and conscious development of a sense of safety within the context of a therapeutic milieu [1]. In other organizational settings it has been referred to as the creation of a “safety culture” defined as “the product of individual and group values, attitudes, perceptions, competencies, and the patters of behaviors that determine the commitments to and the style and proficiency of, an organization’s health and safety management…. characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by the confidence in the efficacy or preventative measures”(p.1124) [2].

Safety, however, is not a particularly easy subject to define. Haigh has described this fundamental necessary attribute of any therapeutic environment as “containment”, and in doing so focuses on the bimodal aspect of true safety: the “maternal” sense of support, tolerance of distress, and connection along with the “paternal” sense of limits, discipline and rules [3]. We found that to adequately talk about safety in the community context, we had to understand four levels of safety simultaneously and dynamically: physical safety, psychological safety, social safety, and moral safety. For any of us thrive and grow we must feel safe.  For people who have been the victims of violence and abuse this is all the more important.  We know that people who have been injured by violence are keenly attuned to any and all threats in the environment.  Although it is always possible they will react to perceived threats, we want to ensure real threats do not exist.

By making a commitment to nonviolence we commit to eliminating all threats to safety including physical, aggression, demeaning language, threatening glares, apathy, avoidance and any other behavior that permits people to impose their will on each other and abase power. If staff do not feel safe they cannot help clients feel safe and if clients do not feel safe they cannot do the difficult work necessary to change.



Physical Safety

The Sanctuary ModelPhysical safety is the easiest aspect of a safety culture to describe, largely because it relies on tangible and concrete factors that can be easily evaluated and measured. Physical safety is usually what people think of when describing the sense of being safe, since without it, other forms of safety are difficult to achieve. Psychiatry has always recognized the importance of physical safety. Locked doors, bars on the windows, straitjackets, seclusion and restraints have all been used – and misused – in the service of physical safety. Unfortunately, however, an exclusive focus on the maintenance of physical safety tends to result in the creation of environments more like prisons than therapeutic spaces.

Feeling physically safe requires an environment that is free of threats to our physical wellbeing. Such an environment is free from:  suicidality and self-destructive behavior: physical or sexual attacks on others; dangerous risk-taking behavior; substance abuse; physical hazards such as toxins, weapons; predatory aggression or coercion; threats; helplessness and lack of control; learned helplessness. Physically safe environments encourage: supportive and caring relationships; non-coercive forms of persuasion; healthy, safe, relational sexual behavior; good health practices; commitment to nonviolence to self and others; healthy expression of anger and assertiveness; opportunities for mastery experiences; avoidance of further experiences with helplessness; patience; repetition; structure that ensures success.

People who have been physically violated often present to human service delivery systems with defensive aggression. They are likely to need help managing their aggression and may be easily provoked to aggression because of chronic hyperarousal. They are likely to expect other people to be violent toward them so they need positive, nonviolent experiences with caregivers and may have to be “deconditioned” to violence in an environment that repeatedly responds to provocation with nonviolent behaviors.
As we have discovered, our refusal to tolerate violence of any sort constitutes our best defense against any breach in physical safety [1]. Physical safety alone does not constitute a safe environment for growth. Likewise, breaches in physical safety generally do not occur until the other forms of safety have already been violated.

Psychological Safety

The Sanctuary ModelWhat are common threats to psychological safety? Unfortunately, they happen all too frequently in the workplace: sarcasm, lecturing, put-downs, outbursts, public humiliation, negative tone of voice or body language, inconsistency, unfairness, rigidity, favoritism, endless rules and regulations; infantilizing treatment, blaming and shaming. We are all vulnerable to these kinds of behaviors from others but people who have been psychologically unsafe while growing up are particularly vulnerable to being profoundly reinjured by psychological torments and to adopting behaviors that have been inflicted upon them in the past.

People who have been repeatedly psychologically violated will have adapted to the emotional abuse but are likely to have done so using maladaptive coping skills that are then repeated in the present. They need to be respected for their ability to manage tormenting situations in the past but they also need to recognize the need for change and in all likelihood, a need for an expanded version of emotional intelligence skills. They are likely to suffer from a great deal of cognitive confusion about goals and about methods for achieving those goals – many of them will have been successfully brainwashed in abusive homes. As a result, they will benefit from an environment that teaches and models a different way of thinking about and being in the world.

The Sanctuary ModelMany of them will have suffered disrupted attachment experiences and anything that triggers attachment disruption again  -  such as the loss of people who are currently important in their lives, as when staff members suddenly depart – is likely to trigger similar feelings of profound distress like that which existed in the past. Depending on the nature and quality of childhood relationships, they may require relational experiences in the present that are essentially corrective. Their lives may have been corrupted by experiences of betrayed trust so they are likely to have difficulty trusting trustworthy people in the present. If you recall what we discussed about the high incidence of exposure to childhood adversity in the staff and in the general population, then it should be clear here that we are not just referring to the clients who present to social service and mental health settings, but to everyone. This is why creating a psychologically safe environment is so important – it is important for everyone in the community.

Psychological safety refers to the ability to be safe with oneself, to rely on one’s own ability to self-protect against any destructive impulses coming from within oneself or deriving from other people and to keep oneself out of harm’s way. This ability to self-protect is one of the most shattering losses that occurs as a result of traumatic experience and it manifests as an inability to protect one’s boundaries from the trespass of other people. Another loss is a sense of self-efficacy, the basic sense of experiencing oneself as having the ability to relate to the world on one’s own terms without abusing power and without being abused by it. A sense of personal safety is achieved as the injured individual learns how to be effective in protecting themselves from violations of their personal and psychological space. An environment that is psychologically safe encourages self-protection, attention and focus, self-knowledge, self-efficacy, self-esteem, self-empowerment, self-control, self-discipline, consistency, initiative, curiosity, achievement, humor, creativity, and spirituality.

Social Safety

Workplaces are, by their very nature, social environments and social safety describes the sense of feeling safe with other people. How many of us have ever felt truly safe in a social setting, a setting in which we felt secure, cared for, trusted, free to express our deepest thoughts and feelings without censure, unafraid of being abandoned or misjudged, unfettered by the constant pressure of interpersonal competition and yet stimulated to be thoughtful, solve problems, be creative, and be spontaneous? Yet this is the kind of setting that human beings need to maximize their emotional and intellectual functioning in an integrated way. Our social system is created to produce human beings who will fit into a highly industrialized, competitive, often cutthroat capitalist environment that still prepares many of us for mortal combat. Our social system is not designed to maximize the human potential for growth, self-exploration, mutual co-operation, nurturing of the young, artistic endeavor, or creative expression and exploration.

The Sanctuary ModelInterpersonal relationships continue to pose enormous challenges for victims of childhood adversity whether they are clients, staff, or managers. Victims of trauma- particularly interpersonal trauma - have serious difficulties in their ability and  willingness to trust other people. Experience has taught them that people are dangerous, betraying, and duplicitous. If they have been injured as children, then they have come to expect bad treatment and are often suspicious of kindness. They expect that other people will violate their boundaries and may have learned that the way to get along in the world is to violate the boundaries of others. They are likely to need help with learning social skills, particularly those required for good organizational communication and participatory environments. They may exert pressure on others to conform to their normative expectations of domination and if they are put in situations where they are supervising other people may using a bullying style.

Creating a safe social environment requires a shift in perspective away from viewing only the individual, towards viewing the individual-in-context. In so doing, the entire community serves as a model of “organization as therapist” [4] so that all of the chaotic, impulsive, and painful feelings of the members can be safely contained and defused. A strict emphasis on the individual is exchanged for the work of creating and sustaining a well-bounded structure within which all the therapeutic interactions can safely take place [5].

The Sanctuary ModelIt is also the social milieu that provides our clients and ourselves with the very necessary “reality confrontation”.  As we inevitably recreate the relational patterns we have learned as children within a social context, we are afforded the opportunity to change those patterns in order to achieve a higher degree of psychological and social safety. It’s easy to see then, how placing someone who is already injured into a highly dysfunctional organization could be a major barrier to healing. And why an individual approach simply is insufficient. When we send a traumatized child or adult back into a violent home or a violent community, we cannot expect that any gains made in treatment will be powerful enough to immunize them against violence.

As you think about social safety in the context of your workplace, ask yourself some questions. Can people hold productive conversations or do they just advocate for their own views? Do they blame others for problems or look at problems from the perspective of the overall context? Do they assume that their view is the only view or do they inquire about different perspectives? Are they open to talking about differences and similarities between each other? Are they genuinely interested in creating something new for the future? Is there general recognition that the goal is integration not competition?

A socially safe environment is one that is free from abusive relationships of all kinds. People are not isolated but instead are connected to each other in a network of support. Emotion is successfully managed and the level of emotional intelligence is high. The past can be looked at dealt with, and finally left behind. There is tolerance for diverse opinions, beliefs and values but what ties everyone together is a shared belief in the importance of being safe. There is tolerance for individual eccentricities as long as these peculiarities do not harm others. Boundaries are clear, firm, but flexible. There is a high level of awareness in a socially safe environment, about group dynamics and the likelihood of getting caught in reenactments with other people as well as a willingness to learn how to get out of these tough situations without harm. People can work productively and creatively toward a shared goal.

Moral Safety

Creating a morally safe helping environment is probably more challenging today than it has ever been.  The term “moral distress” describes situations where you know what the right thing to do is, but doing it is thwarted by constraints. Social service and mental health providers experience moral distress when they must act in a way that contradicts their personal beliefs and values. There is a sense of being morally responsible but unable to change what is happening [6]. It has been shown that moral distress is a result of reactions originating in acting, or not acting, in ways that go against one’s conscience and moral beliefs. 

Conversely, a morally safe environment is one where you are able to do your work with a sense of integrity because your sense of what is right is supported by the institution within which you work and the people who directly supervise you. Of course, what is right is likely to be perceived differently depending on who you are, your experience, and where you are in the hierarchy of the organization. So like the rest of what we describe as Sanctuary, discovering moral safety is a process that is constantly unfolding. It is an attempt to reduce the hypocrisy that is present, both explicitly and implicitly, in our social systems.

This is a fundamentally important quest for patients who are victims of abusive power because their internal systems of meaning are likely to have become confused and contradictory [7]. Exposure to corruption can be contagious; exposure to abusive authority can create abusive behavior on the part of those who were once abused. Repetitive experience of injustice can make a person unable to act justly and more likely to seek revenge. So people who have been exposed to adversity, particularly at the hands of others, can only find a different kind of meaning and life purpose if they are exposed to environments that are different – not replicating – their earlier abuse. And people who have been exposed to adversity, injustice and trauma are likely to have a great deal of confusion about what is right and what is wrong, how people should be treated and should not be treated. As a result, their level of moral intelligence may be compromised and they require an environment within which other people are modeling a different way of relating to each other and the world around them.

The Sanctuary ModelA morally safe environment engages in an on-going struggle with the issues of honesty and integrity.  Creating a morally safe environment means we must take a self-evaluative look at our therapeutic presumptions, our training, our rationalizations, and our fixed beliefs, as well as our practice. We must look at our own issues with authority and become willing to participate in, not just manage, the relational web that forms the structure of our workplaces. We are forced to ask ourselves, “What do we really believe in?” “What is it that we are actually doing, and what are we trying to achieve?” “Will the means get us to the desired ends?” “Do the means justify the ends?” “Do the activities we are prescribing lead to autonomy, connectedness, and empowerment or dependence, alienation and helplessness?”

These can be tough and embarrassing questions with answers that are, at times, noxious and difficult to swallow, particularly for managers who feel morally responsible for what happens in their organization. In an era of managed – some would say, mangled – care a morally safe environment demands that we be honest with our clients about our limitations, about our increasing inability to provide them with what we know they need, while continuing to offer them hope for the future and encouragement to keep on with the struggle towards recovery, even when they cannot get the support they deserve.

Similarly, our clients must confront the breaches in moral integrity that characterize the specific systems within which their normative behavior developed, be it their family, a religious organization, a cult, or an institution. This breach in moral integrity also relates to the fundamental reasons that people seek services in the first place, quite often because they are a clear and present danger to themselves or others. To be morally safe, we must honestly look at the ways in which our bureaucratic structures created for greater efficiency in handling large numbers of people, can inadvertently dehumanize the very people the organization is supposed to serve, because the greater the distance between actually living human contact, the easier it is to create policies and enforce procedures that cause people to suffer more not less. Additionally, we are all forced to look at the ways in which our culture reinforces the messages conveyed by the institutions within which we are socialized. This entails looking at the way our society – not just our organizations - is organized around unresolved traumatic experience and decide what we are going to do within this moral universe [1, 8-12].

References

  1. Bloom, S.L., Creating Sanctuary: Toward the Evolution of Sane Societies. 1997, New York: Routledge.
  2. Cox, S., B. Jones, and D. Collinson, Trust relations in high-reliability organizations. Risk Analysis, 2006. 26(5): p. 1123-1138.
  3.  
  4. Haigh, R., The quintessence of a therapeutic environment: Five universal qualities, in Therapeutic Communities: Past, Present and Future, P. Campling and R. Haigh, Editors. 1999, Jessica Kingsley Publishers: London:. p. 246-257.
  5. Whitwell, J., Management issues in milieu therapy: Boundaries and parameters. herapeutic Communities: The International Journal for Therapeutic and Supportive Organizations, 1998. 19(2): p. 89-105.
  6. Campling, P. and R. Haigh, eds. Therapeutic Communities: Past, Present and Future. 1999, Jessica Kingsley: London.
  7. Austin, W., V. Bergum, and L. Goldberg, Unable to answer the call of our patients: mental health nurses' experience of moral distress. Nursing Inquiry (NURS INQUIRY), 2003 Sep; 10 (3): 177-83 (23 ref).
  8. Janoff-Bulman, R., Shattered assumptions: Towards a new psychology of trauma. 1992, New York: Free Press.
  9. Bloom, S.L., Neither liberty nor safety: The impact of trauma on individuals, institutions, and societies. Part III. Psychotherapy and Politics International, 2005. 3(2): p. 96-111.
  10. Bloom, S. and M. Reichert, Bearing Witness : Violence and Collective Responsibility. 1998, Binghamton NY: Haworth Press.
  11. Bloom, S.L., Neither liberty nor safety: The impact of trauma on individuals, institutions, and societies. Part IV. Psychotherapy and Politics International, in press.
  12. Bloom, S.L., Neither Liberty Nor Safety: The Impact Of Fear On Individuals, Institutions, And Societies, Part I. Psychotherapy and Politics International, 2004. 2(2): p. 78-98.
  13. Bloom, S.L., Neither Liberty Nor Safety: The Impact Of Fear On Individuals, Institutions, And Societies, Part I I. Psychotherapy and Politics International, 2004. 2(3): p. 212-228.