by Nina Esaki, Sarah Yanosy, Zachary D. Randolph & Joseph Benamati
The following article is an original manuscript / preprint of an article published by Taylor & Francis in the Journal of Social Work Practice on 17 September, 2019, available online: https://www.tandfonline.com/doi/full/10.1080/02650533.2019.1665001
One of the authors, Zach Randolph, is St. Joseph’s Clinical Services Director, and is pleased to share the article with the community.
While most recovery programs serving veterans include evidence-based treatment practices for PTSD and substance use, they overlook two essential elements of healing that are specific to the needs of veterans: restoring purpose and the capacity for trust. Simplistic definitions of recovery from trauma and substance use for veterans often describe the absence of PTSD symptoms and abstinence from substance use. A fuller and more accurate definition of recovery requires not just the absence of symptoms, but honors how a veteran has been changed by his or her experience, and includes reintegration back into his or her home community. This article will explore how the Sanctuary Model®, an evidence-supported, clinically grounded organizational intervention implemented in a residential substance use treatment program, provides a vehicle for reshaping a trauma-organized worldview to a trauma-integrated worldview for veterans.
According to data on health care utilization from the Department of Veterans Affairs (VA; 2015), approximately 2.7 million troops have served or are serving since the inception of the two military conflicts in Afghanistan and Iraq. Since 2002, over 1.9 million Operation Enduring Freedom (Afghanistan), Operation Iraqi Freedom/Operation New Dawn (Iraq) veterans have left active duty and become eligible for VA health care, and close to 1.2 million (61%) have obtained VA health care since then. The most common mental health problems among veterans returning from Afghanistan and Iraq are post-traumatic stress disorder (PTSD), affective disorders such as depression, and substance use disorders (Tenhula et al., 2014). The rate of comorbid PTSD/substance use disorders (SUD) was found to be 17.4% in one study of OEF/OIF VA patients (Baker et al., 2009). Comorbid PTSD/SUD is associated with emotional, physical, and functional problems and it is recommended to treat PTSD and SUD concurrently (Norman, Tate, Anderson, & Brown, 2007; Ouimette, Brown, & Najavits Lisa, 1998).
Studies have shown that in addition to these mental health problems, sub-diagnostic symptoms and challenges in a variety of domains of functioning and community involvement are quite common (Gaudet, Sowers, Nugent, & Boriskin, 2016; Pietrzak, Goldstein, Malley, Johnson, & Southwick, 2009; Sayer et al., 2010; Tenhula et al., 2014). Sayer et al., (2010) found that 40% of Afghanistan and Iraq combat veterans in their study sample reported at least some difficulty in readjusting to civilian life within the past 30 days. Gaudet et al., (2016) found that moral injury, often manifested in feelings of personal shame, was strongly correlated with interpersonal problems, social anxiety, and isolation. Difficulties in social and family relationships and in job and daily functioning were the most common types of problems cited. Notably, the vast majority of those experiencing readjustment challenges also reported an interest in assistance for community reintegration challenges. A recent Institute of Medicine report (2013) concluded that the readjustment needs of veterans, service members and families who have experienced deployment “encompass a complex set of health, economic, and social issues” (Institute of Medicine, 2013, p. 2), while there is little evidence regarding the effectiveness of these programs (Tenhula et al., 2014). Although the VA offers a full continuum of mental health services and has focused heavily over the past several years on providing evidence-based psychotherapies for a variety of mental and behavioral health conditions (Karlin et al., 2012; Karlin, Taylor, Gimeno, & Manber, 2013), few efforts have focused on improving resilience and functioning among veterans dealing with the full range of readjustment experiences and challenges (Tenhula et al., 2014).
Residential Treatment Programs for Veterans
For over 30 years, residential treatment has been a cornerstone of U.S. efforts to assist veterans with PTSD (Rosenheck, Fontana, & Errera, 1997). Until recently, these programs have predominantly provided treatment to veterans who served in the Vietnam War (Johnson, Fontana, Lubin, Corn, & Rosenheck, 2004; Johnson, Rosenheck, & Fontana, 1997; Johnson et al., 1996). However, as a result of the recent wars in Afghanistan and Iraq, there is now a new generation of veterans who are presenting to residential treatment with war-related problems (Cook et al., 2013). A substantial proportion of returning veterans have significant psychological symptoms, impairment and disability, with almost one-third suffering from PTSD, major depression, traumatic brain injury, or a combination (Schell & Marshall, 2008). Afghanistan and Iraq veterans have higher levels of acute PTSD symptoms and anger-related problems than veterans from other generations at time of admission to residential programs (Fontana & Rosenheck, 2008). In addition, they have shorter lengths of stay and lower treatment satisfaction as well as lower levels of treatment engagement and adherence in treatment generally (Erbes, Curry, & Leskela, 2009). These problems may be partly attributed to some of the distinct characteristics of these most recent military conflicts such as extended tours, multiple deployments, and increased likelihood of redeployment (Hoge et al., 2004). Thus, the need for modifications to existing PTSD residential programs (Cook et al., 2013).
In a recent study conducted in 38 VA residential treatment programs for PTSD (Cook et al., 2014), providers reported that increased intensity and cohesion of the milieu were of greatest benefit to veterans. Support and connection with other veterans was viewed as essential to treatment effectiveness, particularly in terms of veterans support for one another in their treatment and serving to normalize the patients’ reactions to trauma. The milieu is credited with challenging veterans when they attempt to isolate, do not fully participate in treatment, or display behaviors that are historically part of their presenting problems. Providers also suggested that living in a group setting with other veterans promotes interpersonal interactions thus normalizing, validating and supporting veterans’ attempts to achieve behavioral, emotional, and cognitive change (Cook et al., 2014).
Staff cohesion was also noted to be one of the essential and effective components of VA PTSD residential treatment. Many likened their team to a “family” that is supportive and increases effective coping in dealing with work-related stress. In addition, providers explain that the staff created a milieu of respectful conflict resolution, open communication, and mutual goals that served as a model for interpersonal functioning for veterans. In their investigation, the most effective teams were those who consistently engaged in formal team meetings, additional informal mechanisms of communication, group problem-solving, and treatment planning. These types of teams are also thought to model positive social interactions for veterans (Cook et al., 2014). More research is needed to understand how staff cohesion impacts patient outcomes and how this information can be used to improve the quality of care for veterans (Cook et al., 2014).
Challenges with Reintegration
In the first systematic study of community reintegration problems and associated treatment interests among Afghanistan-Iraq combat veterans who use VA medical care, more than one-half of this select population struggled with anger control problems and nearly one-third had engaged in behaviors that put themselves or others at risk since homecoming, such as dangerous driving and greater alcohol or drug use (Sayer et al., 2010). Not surprisingly, veterans with probable PTSD reported more reintegration problems and expressed interest in more kinds of services for reintegration problems than did veterans without PTSD. Regardless of PTSD status, however, Afghanistan-Iraqi combat veterans faced challenges in multiple domains of functioning and community involvement after deployment. Left untreated, these problems could have deleterious effects not only on the individual but also on his or her family, community, and society as a whole. Many of the problems that veterans endorsed, including social functioning, employment issues, anger control, and spiritual struggles, fall outside the traditional scope of medical practice (Sayer et al., 2010). VA mental health providers, who usually have the requisite skills to address these issues, may struggle to keep up with demand. Furthermore, it remains unknown whether evidence-based treatments for PTSD would lead to satisfactory improvements in functioning and readjustment outcomes.
Findings from a qualitative study examining the challenges that Afghanistan and Iraq war veterans experienced when reintegrating into civilian life, highlighted the importance of personal identity as created by interactions with one’s community (Demers, 2011). According to Ricoeur (1992) and others (Baerger & McAdams, 1999; Pasupathi, Mansour, & Brubaker, 2007; Whitty, 2002), we can only know ourselves and find meaning in our lives through narrative. It is through the continual retelling of our stories that we know who we are today. These narratives create our personal myths that change over time (McAdams, 1993). We choose to remember events in a particular way, we set goals and expectations, we regulate emotions, and we can imagine possible future selves based on our current lives (Pasupathi, Weeks, & Rice, 2006). Traumatic experiences create an additional challenge to maintaining a continued sense of personal identity because of their highly disruptive and emotionally charged nature (Janoff-Bulman, 1992). Burnell, Hunt, and Coleman (2009) assert that reconciliation comes about when negative narratives are integrated as one coherent chapter of a life story. In their work with veterans, Burnell et al. (2009) and Pillemer (1998) found that veterans identified telling their stories to others as an effective way to cope with war memories. Some achieved coherence through professional aid, and others achieved it through positive interactions with informal social support networks, including comrades, family and friends, and the general public (Burnell et al., 2009).
Description of Intervention
The Sanctuary Model is an evidence-supported (Elwyn, Esaki, & Smith, 2015; National Child Traumatic Stress Network, 2008; Rivard, Bloom, McCorkle, & Abramovitz, 2005), clinically grounded organizational intervention that was developed by Dr. Sandra Bloom and her colleagues at an inpatient psychiatric hospital in Philadelphia in the 1980s (Esaki et al., 2013). Training and consulting on the model is provided by the ANDRUS Sanctuary Institute based in Yonkers, NY. Sanctuary was based on emerging studies of PTSD in veterans, specifically work by Dr. Stephen Silver. He posited that soldiers returning from Vietnam experienced hostility, anger and rejection from their communities, in addition to the trauma they had experienced at war, finding that home – a place where they expected to find sanctuary – was instead toxic and unaccepting. His analysis resulted in an understanding of “sanctuary trauma,” which described the exacerbation of existing PTSD through replication of adversity and trauma in the community (Silver, 1986).
Sanctuary uses an engagement strategy and continuous reinforcement of positive self-regard by assuming a position of curiosity rather than blame when addressing behaviors. This takes the form of changing the central question asked about the people being served from “What’s wrong with you?” to “What’s happened to you?” as the first step in recognizing the influence of the past on current behaviors and functioning.
The Sanctuary Model developers recognized that Dr. Silver’s ideas also applied to treatment environments. They saw that mental health systems, including their own, were punitive and focused more on extinguishing problematic behavior rather than on real healing and recovery. They found that many of the patients they were treating for chronic mental illness had been misdiagnosed and improved greatly when provided trauma specific treatment. They also discovered that their team dynamics had a significant impact on the quality of client care and outcomes. Dr. Bloom and her colleagues chose to name their hospital unit “The Sanctuary” as a tribute to Dr. Silver’s work and to demonstrate a commitment to avoiding re-traumatizing patients through exposure to a dysfunctional treatment setting.
As an organizational intervention with clinical components based on constructivist self-development theory (CSDT; Brock, Pearlman, & Varra, 2006), Sanctuary has a macro focus on shaping the treatment environment as well as a micro focus on integrating trauma-responsiveness into the individual treatment experience of each veteran resident. Sanctuary embraces holistic definitions of trauma and of recovery, using a broad and multifaceted approach to decreasing symptoms and improving mental health and community functioning for veterans. In this model, trauma is understood as the experience of one’s coping being overwhelmed by an adverse event or the accumulation of stressful experiences (Van der Kolk, 1987). In this definition, “trauma” is not defined by an event itself, but by the inability to cope with the disruptive physical, psychological, social and/or spiritual impact of the exposure. Recovery from trauma is defined in Sanctuary with a holistic lens as well; it is the integration of adverse experiences into the larger narrative of one’s life and identity as well as the restoration of coping in the areas of maintaining safety, regulating emotion, managing loss and creating future. In this way, it is adaptive functioning as well as world view that are the targets for intervention.
The Sanctuary Model is comprised of four pillars which define its practice and drive implementation. The first pillar, Psychobiology of Trauma, suggests that many behavioral symptoms are a direct result of coping with adverse experiences. What are identified as maladaptive behaviors may in fact be misapplied survival skills. Since organizations are comprised of staff affected by the nature of the work they perform to assist traumatized clients, as well as external organizational stressors (e.g., decreased funding, increased pressure to demonstrate outcomes), policies and procedures can also become skewed by this highly powerful interchange (Hingley-Jones & Ruch, 2016; Rogers, 2001). A focus on traumatic re-enactment and parallel process highlights that just as human beings are susceptible to the manifestations of trauma through symptoms, organizations themselves are equally vulnerable.
The second pillar is a set of values, the Seven Sanctuary Commitments, which encourages trauma-responsive behaviors throughout the community. These Commitments are adapted from Therapeutic Communities in the UK and shape the treatment environment to create reparative experiences for trauma survivors. The Commitments target direct behavioral, psychological and cognitive symptoms of trauma with a mitigating culture. The Commitments are described below:
Third, the Sanctuary Model includes use of the acronym, S.E.L.F., which stands for Safety, Emotion Management, Loss and Future and represents the organizing framework for treatment planning, community conversations and collaborative decision-making. This framework is also used for describing organizational problems and constructing solutions without becoming paralyzed by repetitious analysis of the problem and assignment of blame.
Fourth, the Sanctuary Tool Kit is a set of practical and simple interventions that reinforce the language and philosophical underpinnings of Sanctuary for both staff and clients and support an organization’s creation of a trauma-informed culture. The Tools are defined in the chart below:
Sanctuary implementation is a three year process that engages all staff, including direct care service providers, leadership, administration, and support staff and follows a prescriptive set of steps to integrate the concepts and Tools into practice across all domains. The first year centers on engagement and consultation that strengthens trauma-informed skills in leadership, supervision, communication and conflict management. The second year centers on adapting policies and practices to align with Sanctuary, and consultation deepens and adds to existing skills. The third year centers on evaluating progress against the Sanctuary Certification Standards.
Case Example: Creating Sanctuary
The Colonel C. David Merkel M.D. Veterans Residence in St. Joseph’s Addiction Treatment & Recovery Centers opened on July 7, 2014 as a result of a grant from the New York State Office of Alcohol and Substance Abuse Services in response to the increasing number of service members returning from the recent war efforts in Afghanistan and Iraq who are in need of long-term, quality treatment services.
The Merkel facility provides living space and support for up to 25 male veterans. Because the facility is not affiliated with the Federal VA, it defines “veteran” as anyone who has served in any branch of the military, for any length of time, regardless of discharge status. This is a unique definition since it provides opportunities to many service members who are challenged with a substance use disorder and end up being less than honorably discharged. These heroes are granted very limited VA benefits following their service, yet are quite often those who are in most need of substance use and other co-occurring treatment services.
In addition to providing residential care spanning six to twelve months with a typical stay of eight months, the Merkel Residence staff acknowledges the prevalence of trauma-induced disorders such as PTSD, anxiety and depression, along with substance use. The treatment philosophy used in the facility is one of experiential recovery. Experiential recovery, informed by the Sanctuary Model, allows for a series of experiences that, based on trust, allow veterans to create their own individual sense of direction and purpose. The Sanctuary Model is the foundation upon which a series of experiences, based on model principles, allows for the internalization of a new worldview that is full of hope. Veterans are supported in finding their voices, identifying their problems, and coming up with a narrative of how their trauma experience is part of their life story to develop a vision and purpose for the future.
The staff, comprised mostly of veterans, spouses and children of veterans, and those with experience working with veterans, was introduced to the Sanctuary Model prior to the opening of the facility. Thus, they were able to “internalize” the model prior to the veterans being introduced to the program. Through the use of the Seven Commitments, Tools and shared language, the staff learned to form deeper relationships and take care of each other. They were able to create and share their own trauma recovery stories; resulting in the creation of a common purpose: providing high quality trauma-responsive services through trusting work relationships.
Using the framework of the Sanctuary Model, staff and clients changed. A “team” is a “family,” a “system” is a “relationship,” “contracts” become “interventions,” “Corrective Action Plans” become “Professional Enhancement Plans,” “I” is “we” and those who are served are much more than “residents, consumers, or clients;” they are “heroes” and considered part of the “family” for their “season” or “treatment episode.” Language is a powerful tool that can be used to do harm, or heal. Old school, punitive ways of attempting to “snap” people out of their unhealthy behaviors has shifted to a strength and resiliency-based experience in restoration.
The program is framed in a few ways to help the families understand the collective purpose, goals and practice. First, there are three phases, the Red, White and Blue, throughout a veteran’s treatment episode to identify what privileges they can enjoy and where they stand in their treatment. The Red Phase is an acclimation time for the hero to complete his orientation, sign paperwork, begin a comprehensive evaluation and begin to learn the tenets of the Sanctuary Model to create a safe environment for themselves and those around them. This phase typically lasts around 30 days, until a treatment plan can be created identifying individual problem statements and goals directly correlating to declared areas of growth. Heroes are asked to stay on the facility grounds during this phase in order to begin building trust between themselves and the team surrounding them. They may enjoy personal family visits during this time, but this phase is focused on them grounding themselves, supported by their introduction to the Sanctuary Commitments, and preparing them for their treatment episode.
The second phase of treatment is the White Phase and this is where the real work begins in terms of treatment and therapy. A structured daily schedule is created for each hero and they are expected to engage in individual sessions focusing on challenges such as their substance use history, relationship histories, military experiences, mental health, legal histories, and anything else identified in their treatment plans. Sessions such as an open processing group, a resiliency group, and a Sanctuary psycho-education group are offered. Throughout this phase, the heroes are encouraged to increase the amount of home family interactions to foster reconciliation and relationships. This happens in the form of phone calls, tele-conference calls, family visits, conjoint sessions, couples retreats and a very unique three-day family session. The formal three-day family session consists of intensive group therapy focusing on substance use and co-occurring challenges, identifying purpose in the roles within relationships and specific trust-building reconciliation between family members. Typically two or three family members, at the expense of the Veterans Program, will join their hero for three days of intensive experiential therapy addressing self-care, communication, and coaching to safely share specific experiences including how family members were affected by the hero’s substance use or PTSD. The group sessions are usually comprised of between four to six residents and their family members, totally between 12 and 18 participants. During this experience, the heroes are encouraged to spend as much time as possible interacting and practicing the skills and principles of Sanctuary-living with their family members in order to renew faith and hope for the future. The heroes and their families are encouraged to process and remain open to explorative feedback about their experiences in order to share in social learning and responsibility collectively; helping to normalize past experiences, reducing the debilitating “I’m the worst” thoughts or feelings, and learning healthier ways to interrelate.
The Blue Phase is the final phase of one’s treatment episode and this time is largely focused on practicing the skills gained and engaging in social experiences that promote healthy reintegration back into their families and communities. Off-site visits may be approved, and families begin to work with the counselors to prepare for welcoming, or perhaps not inviting, their dad, husband, brother and son back. A hero can prepare for and engage in a part-time job during this time or, more commonly, begin a college career either online or at one of two local colleges. Individual and group sessions now focus on gauging the practical application of skills learned, engagement of newfound recovery habits and purpose-seeking. These men are the role models, the potential leaders of the program, and are expected to engage in an agreed upon number of volunteer hours within the community. One of the primary volunteer activities is leading Peer Led Groups that includes a weekly House Meeting that brings staff and heroes together to discuss collective concerns, needs, and the practice of the Commitments to problem-solve.
The Sanctuary Model has also been infused into the Multidisciplinary Treatment Team meetings. Members briefly identify perceived challenges of individual residents, and the majority of time is spent inviting them in and collectively helping them identify resiliency traits based on their actions.
One example of a Sanctuary-informed communication from staff to client is: “Kyle, we recognize that you were less than honest earlier this week when you told us that you weren’t feeling well and needed bed rest. We wanted to let you know that we applaud you for having the insight to recognize your feelings and a desire to advocate for your well-being. With that being said, we want to encourage you to stretch yourself by engaging in groups that may make you feel uncomfortable in order to receive positive support from your peers and staff. Are there ways that we can assist you in clarifying when you are feeling physically ill which appropriately requires rest and when you are feeling emotionally uncomfortable so that we might remind you of your insight and desire to make personal changes?” Using the Sanctuary Model framework, Kyle is treated respectfully, sensitively challenged to identify the source of his pain and redirected towards fulfilling his self-identified goals and purpose.
By using the Sanctuary Model, the staff at the Merkel Residence feel more fulfilled in their respective roles and have developed a sense of collective purpose that allows all to deliver services based on empathy, compassion, truth and grace. Clients are able to trust the environment which then leads to a sense of safety, allowing for vulnerability which is the foundation for healing. The vulnerability allows for processing and reframing negative past experiences and worldviews that cannot happen in treatment settings lacking trust and safety. When the past can be reframed and staff and clients can begin to realize that they are not trying to “cure” themselves of their trauma, but to find peace with it, gratitude is present and joy in the anticipation of the future. The clients are more willing to engage in social reintegration, attend college, or find a vocation that gives them purpose. They are willing to take the risk of relating to family members, children and friends whom they deeply value, but with whom they have had difficulty connecting due to their psychological and emotional pain. The clients are able to make it back home.
From the perspective of the Program Manager of the Colonel C. David Merkel M.D. Veterans Residence, implementation of the Sanctuary Model has increased the capacity for trust and restored a sense of purpose, leading to an integration of trauma experiences and improved functioning for their veteran clients. These outcomes resulted from a macro and micro approach to recovery. At the macro level, Sanctuary influences the environment for treatment by creating staff relationships that promote attachment and healing by fostering trust and purpose. Worker burnout, particularly emotional exhaustion of direct service providers, can be a barrier to their emotional availability to serve as adequate attachment objects for clients who need relationships in order to begin to self-regulate. Sanctuary practices promote well-being of staff and their having adequate support within the environment.
This is manifested in the following ways:
Promoting a trauma-integrated world view with staff: The education of staff about re-enactment as a manifestation of trauma offers direct service providers a lens for understanding the challenges of their work. The practice of “re-scripting” traumatic re-enactment provides an avenue for diminishing the personal toll that client behavior may take. Rather than seeing clients, themselves, or their programs as sick or bad, providers are better able to recognize the behaviors as symptoms of psychological injury, increasing their own capacity to cope.
Promoting purpose with staff: The adoption of the Seven Sanctuary Commitments in an organization establishes relational norms among co-workers that minimize role ambiguity, role conflict and limited job autonomy – some of the job stressors associated with worker burnout. In addition, an understanding of client behavior as expressions of traumatic experiences can lead to more effective interventions, resulting in improved job satisfaction.
Promoting trust with staff: The S.E.L.F. framework, with a focus on physical, psychological, social and moral safety for all members of the community, maintains an expectation for attention to these matters for staff as well as for clients. This acronym, a shared language among staff, also encourages responsiveness to emotions, loss and future for staff. Attention to these experiences among peers and supervisors is intended to encourage greater social support.
Reinforcing purpose, trust and world view with staff: The Sanctuary Tools, specifically staff Community Meetings, Safety Plans, Self-Care Plans, Supervision and Sanctuary Training create cognitive and emotional buffers as well as psychological first aid for staff exposed to work stress. These Tools are practiced within community with prescriptive and reinforcing repetition of practices that require tolerating vulnerability, developing insight about their roles as teammates and as contributors to the emotional, social and psychological tone of the milieu.
On a micro level, constructivist self-development theory (CSDT; Brock et al., 2006), helps explain how Sanctuary shapes world views and promotes the restoration of trust and purpose for clients. Sanctuary creates a community environment within the treatment system that promotes connections with others. A primary goal of establishing this organizational community is to allow the development of multiple relationships that will ultimately help clients regulate their internal states.
Promoting a trauma-integrated world view with clients: The Seven Sanctuary Commitments create a set of expectations for how all members of the community will interact with each other. These relational norms result in interpersonal experiences that reshape frame of reference, self-capacities, ego reserves, central psychological needs and perceptual and memory systems.
Promoting purpose with clients: The S.E.L.F. framework for organizing treatment creates a language that helps to bolster the ability to maintain a sense of self as viable, benign, and positive by replacing pejorative diagnostic language with language that appreciates past experience, strengths and the impact of trauma on functioning. In addition, the language used throughout the milieu to refer to clients (i.e., heroes, warrior citizens) reinforces the expectations of having a continued role within the community and society.
Promoting trust with clients: The education of staff in the psychological effects of trauma encourages engagement and attachment rather than punitive reactions to disruptive client behaviors. This same education for clients helps promote understanding and compassion for hurtful choices or behaviors in themselves or others.
Reinforcing purpose, trust and world view with clients: The Tools, specifically Community Meetings, Safety Plans, and Sanctuary Psychoeducation, are practical daily client activities that reinforce respectively the importance of attachment relationships, emotion regulation and an appreciation for the unique impact of traumatic events that arises from interactions among aspects of the person, the event and the context in which treatment takes place.
The journey home for veterans can be eased when those around them understand the impact that wartime experiences can have on those who serve. Taking lessons from veteran reintegration after the Vietnam War and combining current trauma science, this article provides an example on how one residential program, outside the traditional VA system, used a novel clinical approach to create a Sanctuary with a new generation of veterans to facilitate reintegration back into their home communities.
The problems of war are very old, but providing services based on a holistic perspective that focuses on the individual and the system within which he/she is being treated, is very new. We can no longer “treat the symptoms” and pretend that environment, relationships, organizational expectations, and treatment biases don’t matter. They do matter.
This article offers support for practitioners who are willing to become part of the healing process. It represents a powerful use of the entire milieu to include the curative aspects of the parallel process, re-engineering trauma re-enactments, and a set of philosophical commitments which are the foundation of the Sanctuary Model. It also provides hope to veterans who question their worth and place in society by offering a safe environment in which they can explore what happened to them, and in which they can reclaim their lives.
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