Dr. Sandra Bloom is a psychiatrist largely responsible for the creation of the Sanctuary Model, which is both a framework for treating trauma, as well as an organizational change model that integrates evidence-based trauma interventions with the benefits of therapuetic communities. The brillance of this model is that it optimizes the safety and healing of all parties involved in social systems of care: patients and clinicians, prisoners and judges, victims and advocates, addicts and counselors. It is a model, in my opinion, that is applicable across all organizations no matter what their purpose, because it provides a roadmap for how humans should treat one another, no matter what position they may find themselves in.

Why do we need it? Because most social/healthcare service organizations are in crisis. U.S. healthcare problems were detailed in a number of publications by the Institute of Medicine, with outcomes indicating that the U.S. has the most expensive healthcare system in the world, yet ranks far down the list in terms of overall quality. But it is not just our healthcare system that is in dire need of overhauling. Our education, criminal justice, mental health, child welfare, and…yes, our addiction treatment system are all struggling to meet the needs of the populations they serve. The Santuary Model suggests that the problems are rooted in unhealthy systems, not individual people. If we understand the system, we then stand a chance of making changes within the system that ultimately translate into better outcomes for all involved.

Across the different social systems, the problems are similar: reduced funding, decreased training and education, more paperwork, more surveillance and  micromanagement, greater staff turnover, and lots of stress across all levels of organizations. These factors then translate into organizations that are chronically stressed, attempting to do more with less, always operating in a reactive/crisis mode, ultimately leading to folks being chronically hyperaroused. In this state, it is like Brian Farraher, CEO of Andrus Children’s Center has said, “Managing like your hair is on fire.”  Stress leads to a loss of basic safety and trust, a breakdown of emotional intelligence, behaviors that result in more conflict, and staff who feel disempowered. As relationships become strained, more autocratic approaches to leadership (counseling/healthcare/justice) emerge, and then folks just stop talking. In essence, organizations stop learning. The outcomes are costly for all involved.

The Santuary Model is the antidote. It acknowledges that stress, trauma…life problems, exist not only in the clients who show up for help (or are mandated for help), but also in the helpers. The served and the servers are mirrors of each other, and both require focus and attention on seven commitments:

Implementing the Sanctuary Model in organizations, and incorporating the commitments into all of our lives, means embracing our responsibility to the common good of all people, to our future, to our planet. The details of the commitments, and how best to implement them are documented on the Sanctuary Website and in Creating Sanctuary: Toward the Evolution of Sane Species.

If we ignore the warning signs so clearly right in front of us, “Human history becomes more and more a race between education and catastrophe.” HG Wells, Outline of History, 1920

There are many things I struggle to manage in my life, including time, food (or more correctly my weight), exercise and making sure my dog gets her heart medicine every eight hours. I have other vices as well, but what links all of these things together is that they are ongoing issues that come and go in my life. At times I eat healthy, exercise regularly, and use my time well. Yet at other times I find myself scarfing down junk food, skipping workouts all together, and feeling like a mouse on a never-ending treadmill.

Addictive behavior is similar in that it also comes and goes to varying degrees over time, it is not a constant. Although some can find permanent solutions to end particular behaviors (“I just stopped smoking and never went back to it”), for most people, even if one behavior goes away, another usually takes its place perpetuating the problem of addiction just in a different form. Because objects of addiction can also come and go, it is easy to see why dealing with addiction can become so hard – different addictions, different times, different problems, but most often sharing many underlying traits. As a result, I believe that the most humane way of dealing with addiction is by utilizing a management approach that aims to decrease harm for all behaviors over time, and improve ones quality of life. Too often I see people going in and out of treatment, attempting desperately to put a lid over the behavior and banish it forever, only to get depressed and frustrated when it returns in its original form, or surfaces in another addiction. So how do we manage behavior? Whether it’s addiction or giving my dog her pills, I have found four key things that make a difference:

Awareness: You cannot manage anything if you are not aware of it and how it plays out in your life. Awareness is not so easy these days because we are bombarded from every side with people vying for our attention. But you must increase your awareness of the behavior you wish to change if you have any chance of success. How do we do this? (1) utilize reminder messages on your computer, phone, on sticky notes, put them on electronic calendars that email you reminders, set alarms to go off at critical times, (2) talk with someone about the behavior on a regular basis and process your progress – could be a therapist, friend, pastor, mentor, coach, spouse – who does not really matter so much as just having an ongoing connection and doing it, (3) utilize a form of meditative practice to help clear away psychic junk and make more room to help you stay aware of what is truly important to you, and (4) set-up your environment in such a way as to increase awareness: find new routes to work that avoid high-triggery places, get rid of the extra refrigerator in the garage where you store beer, add things that you want to focus on instead of the addiction like an easel for painting, a musical instrument, or perhaps a pet if you don’t have one.

KISS: Yes, the tried and true Keep It Simple Stupid (OK, maybe the stupid needs to go) applies to managing behavior change. The more complicated you make it, the less likely you will succeed. Simple means we don’t try to change too many things at once, and we do our best to find the simplest and easiest way to accomplish our goal. Earlier this year I significantly changed my diet and felt great. More energy, better sleep, all the things promised from this new way of eating materialized. Yet a few weeks later I was back to my normal, disappointed that I could not maintain what I started. But I shouldn’t have been. I changed too much too fast. We humans live so much by habit, and the many routines our brains lock into very often determine our behavior even when we desperately want to behave differently. In a recent post I mentioned how the environment also sets us up, particularly for making it difficult to eat healthy. We have to be begin by making small incremental changes that support new brain connections, new habits. Change is a process with many different drivers, the key is finding the one that works best, and just staying on the road.

Statistics. For many statistics is a foreign language, existing in a country you never want to visit. But in truth, we live statistics every day of our life. We read sports statistics, check weather reports, listen to stock updates, and hear percentages thrown around in the news. Statistics is the science of making effective use of data, and in the case of managing behavior, there are many things that can be helpful to track over time: days abstinent, relapses, weight, money lost, time spent on particular activities, etc. We track things because of our limited ability to keep a lot of this in our head, to remember the specifics. Keeping a record of progress provides a clear indication of how well we are staying on the road. It provides us feedback that is critical to successful change. Our tracking methods can be as simple as keeping a tally on a notepad, or creating more elaborate outcomes on spreadsheets. I have seen a number of those struggling with addiction get very caught up in statistics, particular days abstinent, where relapses become devastating events instead of opportunities for growth and learning. Statistics should always be used to help us grow, learn, and better manage our behavior over time.

Social Support: You’re aware of what you want to manage, you put a program in place that is simple, easy to stick with, and does not change too much too fast, and you begin to track your progress. The final key and perhaps the most important is understanding that managing any behavior change we make is embedded within the social systems in which we exist: family, school, work, clubs, self-help groups, church, sports, neighborhoods. We are social creatures by nature and influenced greatly be those around us. Successful change requires taking stock of our social connections, both those that support our change and are positive, and those that clearly contribute to perpetuating problems we wish to stop. I have said many times that addictions are ultimately about relationships, and the goal is to replace unhealthy relationships with objects with healthy relationships with people. This is an ongoing process of learning how our past relationships influence our present ones, and how we can heal past wounds and emotionally mature in a way that allows to both receive and give love.

As we begin a new year (and a new decade), many of us will set goals to better manage behaviors in our life. Whether the desire is to reduce drinking, drug use, or have a more fulfilling relationship with food or sex, we stand a much better chance of succeeding when we utilize the above four keys. Happy New Year!

Change is tough. Really tough. Whether dealing with an addiction or making a change in an organization to improve treatment, we are wired to keep doing the things we have always done and resist the new. My last post provided an academic framework for how we should get evidence-based practices commonplace in real-world treatment and educational settings, but doing so often means going against the grain – big time! It means being a change agent in an organization that often does not want to change. It means knowing you have science on your side, and continuing to work at breaking down the walls of ignorance – even when all your peers seem to be against you. Why? Because those who struggle with addiction deserve the absolute best when it comes to treatment and getting help. And when they seek out help from those who are not aligned with science, the outcomes simply are not as good. 

A collegue of mine a few years into her work as an addiction’s counselor emailed me recently about her efforts to enact change within her organization:

“With regard to my attempts to enlighten others on topics such as housing first initiatives and pharmacological treatment for alcohol dependence, I am finding that scientific findings are no match for anecdotal evidence based upon meaningful personal experience.  My colleagues/superiors are either entirely skeptical or they simply minimize the validity of addiction interventions that are non-traditional or abstinence based.  The resistance seems to derive from defensive beliefs that the research methods are somehow flawed, the purpose and designs are somehow biased, and the results are somehow over-inflated, over-reported, or just misinterpreted. It is so disheartening. Beyond that, there is the very real challenge in finding funding for medications and housing. I was also told I have to terminate a client who continues to relapse though I adamantly oppose.  My attempts to advocate for this client with, I believe, sound rationale are ignored and viewed as my unwillingness to accept supervision, etc.  All of this leaves me quite shaken.  Yet I love working with the folks I work with.  For now anyways.”

It’s no wonder that the turnover rate for addiction counselor’s is higher than in the fast food industry! Not only is it challenging helping patients, but the job is made even more difficult when working in organizations that resist change, resist embracing findings from research, and fail to acknowledge the limitations of personal experience.

So what to do? We need to be smart about how we go about making changes, in our life, and in organizations. We need to be aware that change is a process, often with many underlying factors that can influence outcomes. And we need to recognize what science tells us about change. This includes understanding the limitations of the widely adopted Stages of Change Model (see #11).

If you are contemplating a personal change, you might benefit from reading The First 30 Days by Ariane De Bonvoison. A very readible approach that focus on optimism and eliminating fear. If your challenge is implementing change within treatment organizations, a great place to start is The Change Book – A Blueprint for Technology Transfer and the Change Book Workbook.  There are other great resources specific to personal and organizational change, but the key message is that it is a lot harder than people think. It takes perseverance, commitment, and discipline. I applaud my colleague for continuing to push what is right her treatment organization.