Juliet Koprowska, senior lecturer in social work, the University of York
Organisations react to stress and distress in the same way as people. This is the premise of the Sanctuary model created by Sandra Bloom, a psychiatrist, and Brian Farragher, a social worker. They integrate theory, research and practice into a penetrating analysis of the shortcomings of modern ‘human service delivery systems’, and to provide an alternative model.
The model has roots in psychodynamic and systems thinking, and draws inspiration from historical examples of humane care. Recent research into ‘macro’ factors such as the consequences of inequalities in developed countries, as well as at the individual level – the long term effects of childhood abuse and trauma in childhood – feed into it.
A humane approach
It emphasises that the difficulty and distress experienced by service users, and that felt by frontline workers, middle managers, senior managers and organisations are connected.
The model calls for organisations to create a humane approach to workers and service users alike. Managers can use the model to ‘take the temperature’ of their own teams and services.
‘Not sick or bad, but injured’
One of its key concepts is to think of people not as sick or bad, but as injured. Bloom and Farragher substitute the question “What’s wrong with you?” with the question “What happened to you?”
They see interpersonal trauma and violence as a prime cause of people’s distress, alongside material disadvantage and discrimination, citing powerful data from US research about the long-term effects of adverse childhood experiences on physical, mental and social health.
Coping well with the effects of trauma depends on consistent and reliable understanding and support from other people, yet people seeking help may be misunderstood or dismissed.
‘Only rarely was their reality acknowledged’
A recent UK example is the belated recognition of child sexual exploitation, by celebrities, politicians, priests, people in positions of authority and power in the caring professions, and by gangs.
Many of the victimised children and young people told someone. Only rarely was their reality acknowledged, and their traumatic experiences continued, leaving deeper scars.
Traumatic early lives can make it harder to seek help directly. Unconscious mechanisms such as dissociation and repression mean that people may “blank out” and fail to remember what has happened to them, yet display emotions and behaviour that do not seem to make sense.
They may use alcohol, drugs, food, or self-harm, to try and soothe unbearable emotional pain. They may become hostile, angry, dismissive, sometimes handing out the very treatment they have experienced, so their behaviour repels other people and turns them away.
‘Human concern and support’
People who have been hurt by people need to be helped by people; only through the solace of human concern and support can recovery begin. Yet this is not easy to provide – the horrific nature of people’s experiences is hard to bear.
Social workers and other professionals cannot do it alone; we too need the solace of human companionship and support to make it possible.
And that includes an acceptance of the “unacceptable” feelings we sometimes have, of disgust and shock and rage, or of wanting to run away, and not ask the right questions because we do not want to hear the answers.
Fear of blame
Social workers, like service users, are not immune to self-destructive coping mechanisms, and may resort to alcohol and food for comfort. No doubt some also turn to drugs and self-harm; these are still taboo subjects, that carry a powerful fear of being blamed and disciplined rather than understood, which of course keeps them out of sight.
Some social workers have traumatic backgrounds themselves, which can be reawakened by exposure to clients’ trauma.
Bloom and Farragher argue that organisations “are living complex systems and as such are vulnerable to the impact of trauma and chronic stress”; like individuals, organisations can be injured rather than sick or bad.
The impact goes underground
They can (unconsciously) try to protect themselves by avoiding work with the underlying issues service users bring. This avoidance is institutionalised through tick box forms, procedures that prevent people from telling their story, strict time periods for contact, for example.
The impact of unspoken, unexplored issues goes underground, where anxiety is felt but not said. Managers may be aware that social workers talk informally about practice that feels unsafe, in order to find a proper, non-critical forum for this discussion.
‘Blame is pushed down the hierarchy’
External pressures such as funding cuts and reorganisations that fragment people’s relationships also stress organisations. “Human groups under stress tend to become less democratic and more hierarchical and authoritarian,” say Bloom and Farragher, and chronic stress can lead to autocratic, bullying and scapegoating behaviour, where dissent is not tolerated.
This in turn may lead to frontline workers behaving in similar ways with their service users, out of fear and anxiety. Blame is pushed down the hierarchy.
A whole system approach
Organisational culture is not something that can be changed by one individual, though certainly the individual’s actions can make a difference. But for this reason, Bloom and Farragher take a whole system approach to change.
They propose seven “Sanctuary commitments” to guide the organisation in all its operations:
- emotional intelligence
- social learning
- open communication
- social responsibility
- growth and change.
In order to create a humane working environment, organisations need to operate at every level according to cultural and ethical norms that recognise the demands of working with traumatised people.
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