OTORRINOLARINGOLOGÍA Y OFTALMOLOGÍA PRUEBAS Prueba

At times, residential treatment may be a necessary and desirable choice of treatment due to circumstances in which physical separation from the family and

community setting is inevitable (mainly due to safety reasons). Despite being a necessity, the trauma and loss that is experienced from being removed from the family is one that may have a further detrimental impact on the youth. Other problems experienced by traumatized youth who are admitted to RTFs include: (1) stigmatizing labels associated with being “institutionalized;” (2) inability to transfer learned skills within a protective shelter environment to independent living and/or in the community; (3) the negative influence of adolescent peers whose problems have caused their own removal from the normal community life; (4) institutional structure and rules that prevent the development of individualized programs and oppose adolescents’ normal needs for privacy and sexual expression; and (5) the risk of maltreatment, abuse and neglect (Ingram, Katz & Katz, 1991).

Issues of maltreatment, abuse and neglect that take place in residential facilities will be specifically highlighted as some critics, such as Sandra Bloom (1997), have argued that psychiatric facilities need to be “transformed” before services are effectively rendered to individuals and families. Bloom (1997) began her work as a psychiatrist treating adults in an inpatient psychiatric hospital in Philadelphia, Pennsylvania. She

recognized early on in her career that the adult clients that were being treated in her inpatient hospital-based program had experienced tremendous childhood adversity, leading to increased pathological symptoms. These symptoms were then exacerbated within the system that was providing treatment as the clients were being re-traumatized. The facilities that were “supposed” to create a sanctuary place for these clients to heal and recover from their traumas were ill-equipped to manage the demands of the

psychological, social, and physical problems of the clients. These clients who came into the psychiatric facilities expecting help, understanding, and comfort, instead found rigid rules, humiliating procedures, conflicting and often disempowering methods, and

inconsistent, confusing and judgmental explanatory systems. These clients were exposed to further “sanctuary-trauma” and “sanctuary-harm,” terms that address the trauma the takes place within the SOC (Bloom & Farragher, 2013).

Specifically, sanctuary-trauma “occurs when an individual who suffered a severe stressor next encounters what was expected to be a supportive and protective

environment but discovers only more traumas” (Bloom & Farragher, 2013, p. 142). Similarly, the concept of “sanctuary-harm” is applied to events in psychiatric settings that do not meet the formal criteria for trauma but involve insensitive, inappropriate,

neglectful or abusive actions by staff or associated authority figures and invoke in clients a response of fear, helplessness, distress, humiliation or of lost trust in staff (Bloom & Farragher, 2013, p. 142). Instead of “creating sanctuary,” the rehabilitative systems ultimately cause more damage in the treatment process. “Creating sanctuary” refers to the shared experiences of creating and maintaining physical, psychological, social, and moral safety within a social environment- any social environment- and thus reducing systemic

violence and counteracting the destructive parallel processes (Bloom & Farragher, 2013, p. 47). “Parallel processes” emerge when organizational problems began to mirror the problems in the clients and continue to unfold as organizations begin to buckle under the influence of toxic stress (Bloom & Farragher, 2011). More concretely, parallel processes are described as the following:

When two or more systems- whether these consist of individuals, groups, or organizations- have significant relationships with one another, develop similar affects, cognitions and behaviors. They can be set in motion in many ways, and once initiated leave no one immune from their influence. Parallel processes move from one level of a system to another, changing form along the way. (Bloom & Farragher, 2011, p. 151)

Parallel processes can either be destructive or constructive in nature. They are not inherently negative or dysfunctional; it depends entirely on what is being “paralleled.” Parallel processes evolve unconsciously, outside of awareness, are at work in all human systems and can stand in as metaphors, if not actual representations, for each other (Bloom & Farragher, 2011, p. 150). Unfortunately, in the delivery of services in human services, parallel processes often occur destructively. Destructive parallel processes:

Occur when another person, series of people, or an entire organization is drawn into re-creating destructive scenarios with people they are supposed to be helping. The results of the parallel process is that organizations and society, as a whole, frequently recapitulate for individuals the very experiences that have proven so toxic for them in the first place, while individual reenactments tend to shape the

structure and function of those institutions. (Bloom & Farragher, 2011, p.150- 151).

The outcome of these parallel processes is the development and maintenance of a traumatized system that is unable to provide effective treatment. The complex

interactions between the traumatized clients, stressed staff, and pressured organizations create a social and economic environment that is frequently hostile to the aims of recovery (Bloom & Farragher, 2011, 2013). The bottom line is that there is no clear dividing line between “us” and “them”- between the people who need help and those that offer that help. Frequently, the helpers themselves are “wounded warriors” subjected to their own personal life experiences (Bloom & Farragher, 2011).

In sum, service providers have experiences in their background that may be quite similar to the life histories of their clients, hence hindering recovery. Bloom’s (1997) work on sanctuary-trauma and destructive parallel processes within rehabilitation organizations clearly shed light on many systemic problems that exist in the service delivery in human services. Overall, her work with traumatized individuals and families led to the development of the “Sanctuary Model,” which has been adapted nationally by human service organizations, including the RTF where data was collected for this study. As defined by Bloom & Farragher (2013):

The Sanctuary Model addresses the theoretical and practical complexity necessary for organizational change. It is not a trauma-specific intervention as it functions underneath all the other things that go in a treatment program, all the approaches, kinds of therapy, techniques and practices. It is designed to change the operating system of the organization, that is, the organizational culture. It integrates long-

establishing but often forgotten good organizational practice with the newer sciences of attachment, trauma, and interpersonal neuroscience. The Sanctuary Model is specifically designed to create the context within which groups of people in an organization are encouraged and supported to make what are sometimes radical shifts in the very foundations of the way they think, what they feel, how they communicate, and how they practice. (p. 29-30)

The primary goal of the Sanctuary Model is to facilitate the development of an organizational culture that can contain, manage, and help transform challenging life experiences that have molded and often deformed for the clients that are in the care of these organizations (Bloom & Farragher, 2013).

To achieve these goals, the Sanctuary Model is built upon the “four pillars” of sanctuary: (1) trauma theory, (2) the sanctuary commitments, (3) SELF, and (4) the sanctuary toolkit. Trauma theory provides the scientific underpinning for the Sanctuary Model. The sanctuary commitments provide the anchoring values and are tied directly to developmentally grounded, trauma-informed treatment goals as well as the overall health of the organizational culture (Bloom & Farragher, 2013). The SELF acronym stands for safety, emotional management, loss, and future. It is a simple and easy-to-use conceptual framework that provides a “compass” for everyone to navigate the challenges of complex interventions (Bloom & Farragher, 2013). SELF provides a non-linear, cognitive

behavioral, therapeutic approach for facilitating movement that targets individual clients, families, staff problems and/or whole organizational dilemmas. The sanctuary toolkit offers practical, grounded tasks that support implementation (Bloom & Farragher, 2013). The Sanctuary Model sets the framework for re-working the SOC so that trauma-

informed care can be provided to the vulnerable populations involved in these rehabilitative systems.