Sanctuary Model

1. Introduction

Version followed: the Sanctuary Model as currently disseminated by the Sanctuary Institute (ANDRUS, Yonkers NY): four pillars (trauma theory, Seven Commitments, S.E.L.F., the ten-tool Sanctuary Toolkit), as described by Esaki, Bloom et al. (2013) and the NCTSN fact sheet and training guidelines. Earlier versions are noted where they differ: the original adult inpatient programme "The Sanctuary" (1980–2001) and the 2001–2003 youth residential adaptation, which used the SAGE framework (Rivard et al., 2003).

What it is. The Sanctuary Model is not a session-based psychotherapy. It is a whole-organisation, trauma-informed model of culture change for human-service settings. Sandra L. Bloom (psychiatrist), Joseph Foderaro and Ruth Ann Ryan developed it from 1980, starting on an adult acute inpatient unit, and later adapted it with ANDRUS for children's residential care. It is now used in residential care, schools, group homes, foster care, juvenile justice, outpatient and community settings. The NCTSN lists it for ages 4 and up with no upper limit, and says session count does not apply. [source: Esaki et al. 2013; NCTSN fact sheet; Bloom interview, inSocialWork ep. 10; Crossnore handbook 2017]. Bloom and Brian Farragher wrote the later books.

How change happens. The model holds that the therapeutic environment is a critical determinant of recovery [source: Rivard et al. 2003]. Organisations are living systems. Chronic stress and work with traumatised people can make them "trauma-organised", and in a parallel process clients, staff and leadership come to mirror each other's lack of safety, reactivity, helplessness and loss of purpose. Change therefore targets the whole system. Leaders change first and the change spreads down. Everyone, from clients to the CEO, shares one language (S.E.L.F.), one set of values (the Seven Commitments) and a small set of daily practices (the Toolkit). Through these, clients learn safety, emotion management, grieving and future orientation inside relationships, while staff stop re-enacting trauma through coercion. [source: Esaki et al. 2013; Orchard Place overview 2019; Bloom interview]. The theoretical bases named by the developers are therapeutic-community and democratic-community practice, Silver's concept of "sanctuary trauma", constructivist self-development theory, burnout theory, systems theory and Hermans' valuation theory [source: Esaki et al. 2013].

For a psychotherapist. A clinician meets the model in two ways: inside a Sanctuary-implementing agency, delivering psychoeducation, S.E.L.F. planning and red-flag work and supporting staff; or by borrowing its tools for individual, family or group practice. The second use is outside the published model and is marked [synthesis] where described.

2. Framework

Sanctuary works on two levels: the organisation's implementation pathway, and the client- and team-level use of S.E.L.F. and the Toolkit.

2a. Organisational implementation (Sanctuary Institute version)

Typical duration is 30–36 months of consultation; the NCTSN fact sheet says full implementation may take 2–5 years [source: NCTSN training guidelines; NCTSN fact sheet; Esaki et al. 2013]. Licensing: ANDRUS is the only licensed US provider, and MacKillop Family Services is the licensed subcontractor in Australia [source: NCTSN training guidelines]. Costs and contacts in that document are dated [uncertain: current figures not verified].

Version note: the 2001–2003 trial used eight hours of initial staff training plus ongoing consultation and later booster training, unit mission statements, twice-daily community meetings, and a 12-session weekly psychoeducation group. It tracked progress with a "Sanctuary Milestones" checklist [source: Rivard et al. 2003].

2b. Client, team and organisation level: S.E.L.F.

• S.E.L.F. stands for Safety, Emotion management, Loss, Future. It replaced the earlier SAGE sequence (Safety, Affect modulation, Grieving, Empowerment), which was renamed for youth [source: Rivard et al. 2003].
• S.E.L.F. is explicitly non-linear. ANDRUS trainers describe its domains as "phases you move in and out of, not stages you climb" [source: SELF in Schools, ANDRUS 2017]. It applies equally to a child, a family, a staff team or the whole organisation [source: SELF in Schools; Carlson slides].
• Safety is "where work starts and ends": it is checked first, and loss or future work is pursued only on a safe footing [source: Crossnore handbook 2017].
• No formal criteria for moving between S.E.L.F. domains are documented [uncertain]. Practical guide [synthesis]: work on loss only when the client has a working safety plan, can name feelings and use one or two regulation skills, and has no acute risk; return to safety whenever an incident, placement change or anniversary destabilises them.
• Format at client level: daily community meetings (start and end of day, often also at shift changeovers); personal safety plans; a weekly psychoeducation group (the 2003 version had 12 sessions; a 2017 agency handbook describes six topics, two sessions each: trauma theory, S.E.L.F. overview, safety, emotion management, loss, future); S.E.L.F.-structured treatment-planning conferences; red-flag reviews as needed [source: Rivard et al. 2003; Crossnore handbook; Orchard Place overview]. Length of stay is set by the service, not the model.

3. Guiding principles

The Seven Commitments. Names vary by source and year: "Democracy" also appears as "Shared Governance", and "Social Learning" as "Inquiry and Social Learning" [source: NCTSN fact sheet; Esaki et al. 2013; Crossnore handbook; Carlson slides].

• Nonviolence: physical, psychological, social and moral safety for everyone, including freedom from microaggressions, bullying and retaliation. In practice: no one, staff included, is allowed to harm anyone; coercion and restraint are treated as failures to learn from, not as treatment.
• Emotional intelligence: recognise, contain and manage emotion; move from flooding and reactivity to considered responses. In practice: staff name and manage their own feelings before acting on a client's behaviour, and teach the same skills.
• Social learning (inquiry): a "living-learning" environment where everyone learns from experience and mistakes, and questions established authority, including their own. In practice: treat incidents as information; notice and unlearn routines before adding new ones.
• Democracy / shared governance: participation is everyone's responsibility, with the hierarchy flattened as far as the setting allows. In practice: involve the people a decision affects, including clients, and teach the listening, compromise and conflict skills this requires.
• Open communication: say what you mean, kindly; leaders are transparent; dissent is invited; organisational "undiscussables" are named. In practice: raise problems directly and early, not in corridors.
• Social responsibility: balance individual rights with community responsibility, including distributive, procedural and interactional justice. In practice: each member shares responsibility for the rules, the work and their own behaviour, and listens to the group for parallel processes.
• Growth and change: individuals and organisations can heal; the model deliberately creates some disequilibrium to prompt movement. In practice: hold hope for clients and staff, and frame every review towards what will be different.

Further principles from the sources:

• Ask what happened, not what is wrong. Behaviour is a survival response and symptoms have meaning [source: Crossnore handbook; Carlson slides; SELF in Schools]. In practice: formulate aggression, running away or shutdown as learned protection before choosing a response.
• Trauma affects the whole person: biological, psychological, social and moral [source: Bloom interview]. In practice: safety plans and S.E.L.F. reviews cover all four kinds of safety, not just the physical.
• The environment is the treatment; the whole team provides it [source: Rivard et al. 2003; Crossnore handbook]. In practice: cooks, teachers and night staff are trained and included.
• Parallel process: the stress and safety at the top of an organisation reflect what happens on the units [source: Crossnore handbook; Orchard Place overview]. In practice: when a client group is escalating, also look at what is happening among staff and leaders.
• Leadership-led change. Bloom compares bottom-up change to "rolling boulders uphill" [source: Bloom interview]. In practice: clinicians should secure leadership sponsorship before introducing the tools agency-wide.
• Shared language. Everyone uses S.E.L.F. and the same tools [source: Esaki et al. 2013; Bloom interview]. In practice: write notes, plans and incident reviews in S.E.L.F. terms so meaning carries across roles.
• Solutions over problem description. Red-flag reviews and community practices spend more time on solutions than on problems. One agency operationalises this as about 30% problem and 70% solution [source: Esaki et al. 2013; Carlson slides; Anglicare SELF framework (secondary)]. In practice: cut the incident narrative short once it is understood.
• Reenactment awareness. Traumatised people, and the staff and systems around them, tend to recreate familiar dangerous patterns through the victim, perpetrator and rescuer roles [source: Crossnore handbook; Orchard Place overview]. In practice: in a crisis, ask which role each person, including you, has slipped into.
• Staff wellbeing is clinical: vicarious trauma, burnout and compassion fatigue degrade care, so self-care planning and supervision are part of the model [source: Esaki et al. 2013; Orchard Place overview]. In practice: treat a team's exhaustion as a risk factor for client harm.
• Fidelity with grassroots ownership. The developers aimed to give structure without losing the model's democratic, grassroots character [source: Rivard et al. 2003]. In practice: adapt tool wording locally, but keep each tool's function and frequency.
• Cultural safety: safety includes cultural safety, and there are adaptations for work with Aboriginal and First Nations people [source: NCTSN training guidelines; Anglicare SELF framework]. In practice: add cultural-safety questions to S.E.L.F. reviews.
• The phrase "universal precautions" for trauma is not used here [uncertain].

4. Intervention inventory

The toolkit has ten named tools: Community Meetings, Core Team, Training, Safety Plans, Psychoeducation, Team Meetings, Red Flag Reviews, Self-Care Plans, Supervision, and either Mentoring & Coaching or S.E.L.F. Service Planning, depending on the source [source: Anglicare guide 2018; Esaki et al. 2013]. The published sources describe the steps below only partly. Where steps were not found, they are labelled [synthesis]. Exact certification frequencies for each tool are in the Sanctuary Certification Standards (not drawn on here) [uncertain].

4.1 Community Meeting

• Purpose: a short, ritual check-in that brackets the day, a meeting or a shift with a commitment to safety. It builds emotion identification (words instead of actions), goal-setting and future orientation, and trust in others. It also enacts democracy, since everyone's feelings and goals count. Use it at the start and end of each day, at the start of every meeting, at staff and programme changeovers, and whenever an individual or the community needs support, for example after a young person returns from absconding [source: Crossnore handbook; Clarke & Royes 2014; Rivard et al. 2003].
• Steps:
  1. Gather everyone present (clients, staff, any others in the setting), ideally in a circle, all as equal participants [source: Clarke & Royes 2014].
  2. Each person answers three questions in turn. Morning or start: "How are you feeling?", "What is your goal for today?", "Who will you ask for help?" End of day (one agency's version): feeling, highlight of the day, and what you will do for self-care. The 2003 protocol also had members share successes at day's end and discuss community problems [source: Crossnore handbook; Anglicare guide 2018; Rivard et al. 2003].
  3. Feelings are named in one sentence ("I feel ___"). This is for identification only, with no processing or justifying [source: Orchard Place overview].
  4. The goal should be concrete and for today. For help, name a person, ideally someone in the room. Reframe the question if a client cannot answer [source: Orchard Place overview].
  5. Whoever is named as a helper acknowledges it, because the response builds connection [source: Clarke & Royes 2014].
  6. Keep it "sharp and succinct" [source: Clarke & Royes 2014]. Staff answer honestly too, which models the skill.
  7. Work towards staff and residents leading the meeting jointly; this is a 2003 implementation milestone [source: Rivard et al. 2003].
• Example language (illustrative): "Let's check in. I'll start: I feel a bit tired. My goal is to finish the case review by lunch. I'll ask Sam for help with the rota." To a client who is stuck: "Pick the closest word, mad, sad, scared, glad. Just the word is fine." After someone names a helper: "Jordan, you've been asked. Are you OK to be that person today?"
• Watch for:
  • Answers that become storytelling or processing. Gently cap them and offer a private follow-up [synthesis].
  • Non-committal or flippant answers. Accept them, as Clarke & Royes describe [source: Clarke & Royes 2014], and model your own answer.
  • A disclosure of risk (wanting to hurt self or others). Stop the round for that person, keep them company, and follow your risk procedure [synthesis].
  • Signs it is working: clients name a wider range of feeling words, set more specific goals, and name helpers who are actually present. Escalations at transitions should fall [synthesis].

4.2 Personal Safety Plan

• Purpose: a short, visual list of the person's own coping actions for when they feel unsafe, overwhelmed or triggered, giving safe alternatives to harmful behaviour. Clients, staff and families all make one [source: Crossnore handbook; Esaki et al. 2013; Rivard et al. 2003].
• Version note: some services use a fuller, staff-held plan. Based on the child's trauma and behavioural history, it lists triggers, likely escalation and suggested staff responses, and is updated from observation and input from the child and significant others [source: WA Sanctuary Framework 2020]. Use both: the pocket card for the person, the fuller plan for the team [synthesis].
• Steps:
  1. Introduce the tool and complete your own plan alongside the client to show it is for everyone [source: Crossnore handbook; synthesis on doing it together].
  2. Explore what has calmed them before. Use a small card with 4–5 blank lines [source: Crossnore handbook; Orchard Place overview].
  3. Write 4–5 concrete, doable actions in the client's own words. Examples from the sources: deep breathing, a walk, talking to a friend, leaving the room, positive self-talk, imagining a safe place, music, writing or drawing.
  4. Agree who may see it. Plans may be private, but sharing with helpers is encouraged [source: Crossnore handbook].
  5. The client carries it all day and uses it when needed. Staff prompt its use early in escalation.
  6. Before home visits or discharge, build a home version with the family; staying safe is a prerequisite to leaving care [source: Crossnore handbook].
  7. Review and update it in supervision, team meetings and S.E.L.F. planning [source: Crossnore handbook; Esaki et al. 2013].
• Example language (illustrative): "When things get too big, what's one thing you can do with your body? One thing you can do with your mind? Who's one person you could go to?" During escalation: "Looks like things are getting big. Want to grab your safety plan? Which one feels doable right now?"
• Watch for:
  • Items that are unrealistic in the setting, for example "go home". Replace them with workable ones.
  • Plans that exist on paper but are never used. Rehearse them when calm [synthesis].
  • If self-harm or suicide risk is present, this coping card does not replace a formal suicide safety plan and risk assessment under current standards, including lethal-means counselling about secure storage and removal [synthesis].
  • Signs it is working: the client reaches for the plan unprompted, and holds and restraints decrease. Reduced restraint is a reported benefit at programme level [source: NCTSN fact sheet].

4.3 Self-Care Plan

• Purpose: a formal, proactive plan of regular habits, not in-the-moment coping, to protect against stress, vicarious trauma and burnout. All staff complete one, and in some services children do too [source: Crossnore handbook; Orchard Place overview; WA Framework].
• Steps:
  1. Start from self-compassion [source: Carlson slides].
  2. Cover four arenas [source: Orchard Place overview]:
     • personal: physical, psychological, social and moral or spiritual care;
     • professional: learning about trauma, supervision or study groups, taking breaks;
     • societal: public education, community or social action;
     • organisational: teamwork, supervisory support, blame-free problem-solving.
  3. Commit to specific activities, at work and outside it [source: Esaki et al. 2013].
  4. Review the plan in supervision. Some agencies screen with the Professional Quality of Life Scale (ProQOL), a licensed instrument that measures compassion satisfaction, burnout and secondary trauma [source: Orchard Place overview; Esaki et al. 2013].
• Example language (illustrative, supervisor to clinician): "What's on your plan this month, and which part has slipped? What would make it easier to keep, here at work?"
• Watch for:
  • Self-care used to shift blame onto individuals for structural overload. The model's organisational arena means leaders must also change workload and supports [synthesis based on Esaki et al. 2013].
  • Signs it is working: lower burnout and secondary-trauma scores, and less sick leave and turnover [synthesis; turnover reduction is a stated aim in Esaki et al. 2013].

4.4 S.E.L.F. Psychoeducation (groups, individual, family)

• Purpose: to teach clients and families how adversity and trauma affect them, using the four pillars, in a way that is educational yet therapeutic. Clients learn to link past experience to present behaviour and gain a shared language with staff [source: Esaki et al. 2013; Crossnore handbook; Orchard Place overview].
• Materials and versions: four developmentally pitched psychoeducation manuals; Teaching Families about Sanctuary; the Sanctuary Multi-Family Group Curriculum; the Learning Through Film Curriculum (English and Spanish); "BEST SELF" activities in WA residential care. The 2003 version was a 12-session weekly group covering developmental needs, self-perception, self-esteem, social skills, information processing, emotion and behaviour management, empathy and attachment, and problem-solving [source: Esaki et al. 2013; NCTSN training guidelines; WA Framework; Rivard et al. 2003]. The licensed curricula are not drawn on here: session-by-session content beyond topic names is [uncertain].
• Steps (structure from sources; facilitation detail [synthesis]):
  1. Facilitators are social workers or clinicians plus Core Team members [source: Crossnore handbook].
  2. Run about 12 sessions across six topics: trauma theory, S.E.L.F. overview, safety, emotion management, loss, future. Mix didactic and experiential activities [source: Crossnore handbook].
  3. Typical content per topic [synthesis drawing on the sources' definitions]:
     • Trauma theory: survival responses (fight, flight, freeze), the "primitive" versus "thinking" brain, learned helplessness, reenactment.
     • Safety: the four kinds of safety; making a safety plan.
     • Emotion: simple feeling words (mad, sad, scared, glad, shamed); managing feelings rather than suppressing or exploding; putting feelings into words instead of actions.
     • Loss: naming losses (abuse, neglect, separation, "getting stuck"); grieving and saying goodbye; refraining from reenactment.
     • Future: hope, choices, new roles and patterns, goals. [source for content: Crossnore handbook; Carlson slides; Orchard Place overview; SELF in Schools]
  4. Practise the skills in daily unit life and before home or community passes [source: Rivard et al. 2003].
• Example language (illustrative): "When your body thinks you're in danger, the thinking part of your brain goes offline for a bit. That's not you being bad; it's your alarm system. Today we'll look at what sets yours off."
• Watch for:
  • Loss content can trigger trauma memories. This is psychoeducation, not memory processing. Do not invite detailed trauma narratives in the group. Note distress and follow up individually.
  • If someone dissociates or floods, ground them: orient to the room and date, slow breathing, feet on floor, their safety plan. Then close with a future-focused step [synthesis].
  • Refer clients who need trauma-memory work to an evidence-based individual trauma treatment, delivered once safety is established [synthesis].
  • Signs it is working: clients start using S.E.L.F. words spontaneously and can describe a trigger and a response [synthesis].

4.5 S.E.L.F. Service (Treatment) Planning Conference

• Purpose: to structure care-planning meetings and documentation around the four S.E.L.F. domains. The plan then addresses emotion management, trauma-related loss and hope for the future, not only behavioural control for safety. The child and family give and receive feedback from the whole team [source: Esaki et al. 2013; Crossnore handbook; Orchard Place overview].
• Steps: (the meeting order is [synthesis]; the domains and participants come from the sources)
  1. Invite the client, the family and the whole team. Open with a community-meeting check-in [source: Orchard Place overview, for team meetings].
  2. Safety: physical, psychological, social and moral safety now. Is the safety plan current and used? What are the incidents and risks? Include cultural safety and the needs of the most vulnerable family members [source: Anglicare SELF framework; Carlson slides].
  3. Emotion: what feelings drive the current behaviour ("if all behaviour is communication, what is it saying?"). Which regulation skills are emerging?
  4. Loss: early and current losses; how these affect trust; what could be repaired; overlooked or disenfranchised grief; transitions coming up.
  5. Future: strengths, hopes and goals, and the one change that would make a difference. Celebrate progress.
  6. Agree actions under each heading, with the client's own goals in their words. Record them in the S.E.L.F. format so every discipline reads the same plan [source: Esaki et al. 2013; Anglicare SELF framework (secondary) for question content].
• Example language (illustrative): "Let's go round S.E.L.F. Safety first: how safe have you felt this month, in your body, in your head, with people here? … Now Future: if next month went well, what would be different?"
• Watch for: meetings that stall in Safety and turn into a list of incidents. Keep problem talk short and solution talk long; one agency uses a roughly 30/70 split [source: Anglicare SELF framework]. Signs it is working: the plan includes loss and future goals, and the client speaks for themselves.

4.6 S.E.L.F. Problem-Solving Analysis ("the problem behind the problem")

• Purpose: to analyse any individual, team or organisational problem through the same four lenses, find the underlying issue, and plan a response. Uses include assessing a child, planning behavioural interventions, responding to classroom conflict, evaluating a classroom or unit, and managing expected and unexpected changes [source: SELF in Schools; Esaki et al. 2013; Orchard Place overview].
• Steps: (sequence [synthesis]; the elements come from the sources)
  1. State the problem in one or two sentences.
  2. Ask each S.E.L.F. question of each level involved: the client, the staff and team, and the organisation, looking for parallel process [source: Orchard Place overview].
  3. Ask what loss or unexpressed feeling sits underneath. In a collective disturbance, look for emotion detached from its real source, often unspoken feeling towards those in power [source: Crossnore handbook; Orchard Place overview].
  4. Generate Future actions at each level, and assign owners.
• Example (from the sources): ANDRUS trainers describe a student for whom safety meant staying calm, emotion management involved physical activity, and the loss work addressed grief over her mother [source: SELF in Schools].
• Example language (illustrative): "Before we decide on consequences, let's S.E.L.F. this. What's making him feel unsafe? What feeling is he showing us? Has anything been lost recently, like a visit, a staff member leaving, or an anniversary?"
• Watch for: S.E.L.F. used as a label-filling exercise. Signs it is working: the plan changes because of what the analysis found.

4.7 Red Flag Review (Red Flag Meeting)

• Purpose: a rapid, multidisciplinary, solution-focused meeting called in response to a crisis or concern. Triggers include absconding (AWOL), a physical hold, rising aggression, injury, a complaint from a client, staff member or family, or any issue the community must address together. The underlying idea: the more people help solve a problem, the more likely it is handled well [source: Crossnore handbook; Orchard Place overview; WA Framework; Esaki et al. 2013].
• Steps:
  1. Anyone, at any level, may call a review [source: Esaki et al. 2013; Crossnore handbook].
  2. The caller sets a time and notifies attendees. These can include the client and family where appropriate, administrators, social workers, nursing, psychiatry, teachers and ancillary staff. Invite non-team members for a fresh perspective [source: Crossnore handbook; Orchard Place overview].
  3. Keep it short [source: Orchard Place overview]. Open with a check-in [synthesis].
  4. Briefly describe what happened, without blame. Then move quickly to analysis and solutions using S.E.L.F. [source: Esaki et al. 2013; Orchard Place overview].
  5. Agree actions, owners and a follow-up date. Update the client's safety plan and the team plan [synthesis].
  • The Institute's formal red-flag protocol is not drawn on here [uncertain]. Its exact steps and timeframes are [uncertain].
• Example language (illustrative): "I'm calling a red flag on Jay's two holds this week. Fifteen minutes, 2 pm, nurse's office; can school join? Let's spend two minutes on what happened, then S.E.L.F. it and leave with a plan."
• Watch for:
  • Reviews that drift into blame or disciplinary process. Redirect to solutions.
  • Reviews never called by front-line staff, a sign that open communication is not yet safe [synthesis].
  • Signs it is working: fewer repeat incidents of the same type, and staff calling reviews early [synthesis].

4.8 Team Meetings (including shift changeovers)

• Purpose: a regular, safe place where as many caregivers as possible reflect on their work, team functioning and service delivery, ask for help, and give constructive feedback. This helps prevent collective disturbances [source: Esaki et al. 2013; Crossnore handbook].
• Steps: (agenda items from the Crossnore handbook and Orchard Place overview; order [synthesis])
  1. Open with a community-meeting check-in.
  2. Check on staff wellbeing.
  3. Review a basic Sanctuary concept.
  4. Review client histories in S.E.L.F. language.
  5. Discuss vicarious trauma.
  6. Plan individual interventions.
  7. Review client and staff safety plans.
  8. Cover new initiatives and staff concerns, then housekeeping.
• Example language (illustrative): "Before the cases: how is the team doing after last night? On a scale of 1–10, how safe does this team feel right now?"
• Watch for: meetings that become pure logistics. Signs it is working: staff raise disagreements in the meeting rather than outside it [synthesis].

4.9 Recognising and interrupting reenactment

• Purpose: to notice when clients, staff or the organisation are recreating familiar trauma patterns through the victim, perpetrator and rescuer roles, which can shift quickly. Naming the roles in the moment reduces reenactment [source: Crossnore handbook; Orchard Place overview; Carlson slides].
• Steps: (the sources name the concept, not a procedure; steps [synthesis])
  1. Teach the three roles in staff training and client psychoeducation.
  2. Staff identify their own triggers in supervision.
  3. During or after a crisis, ask: who is in which role, and is this a familiar story for this client?
  4. Choose a response that steps out of the role, for example declining to punish or to rescue, and offering a safety-plan choice instead.
  5. Debrief the episode in team meeting or supervision.
• Example language (illustrative, supervision): "When he called you useless, what did you feel pulled to do? Punish, rescue, or give up? Which of those has he met before?"
• Watch for: staff splitting into "rescuers" and "enforcers" around one client. This is a common sign of reenactment at team level [synthesis].

4.10 Supervision

• Purpose: individual or group review of performance that addresses vicarious trauma, self-care plans, safety plans and therapeutic practice. Staff are assessed against the Seven Commitments and on trauma-specific interventions [source: Esaki et al. 2013; NCTSN fact sheet; WA Framework].
• Steps: (structure [synthesis])
  1. Check in using the three questions.
  2. Review the supervisee's self-care and safety plan.
  3. Discuss cases using S.E.L.F.
  4. Explore reenactment and parallel process.
  5. Reflect on the commitments: where were they lived or breached this month?
  6. Agree learning goals.
  • A Supervision and Leadership Retreat is part of implementation [source: NCTSN training guidelines]. Its content is [uncertain].
• Example language (illustrative): "Which commitment was hardest to live this week?"
• Watch for: supervision used only for compliance checks.

4.11 Classroom or community constitution (school application)

• Purpose: a jointly written agreement that works as a safety contract and enacts democracy. One ANDRUS classroom's constitution committed members to honesty, caring for one another, and letting go of problems and moving on [source: SELF in Schools].
• Steps: (steps [synthesis])
  1. The group brainstorms what makes the room physically, emotionally, socially and morally safe.
  2. Draft the agreement in the group's own words.
  3. Everyone, including staff, agrees to it or signs.
  4. Display it.
  5. Revisit it at community meetings when it is breached.
  • A related item from the 2003 version: units drafted their own mission statement during training [source: Rivard et al. 2003].
• Example language (illustrative): "What would this room need to be like for you to feel safe here, all four kinds of safe?"
• Watch for: rules imposed by staff and labelled "democratic".

4.12 Organisational tools (for clinicians on a Core Team or leading change)

• Steering Committee: 5–7 senior leaders who organise implementation, liaise with Institute faculty, and act as role models [source: Esaki et al. 2013].
• Core Team: a multidisciplinary group drawn from every level and representing peers. It is largely front-line staff, meets regularly (monthly in one service), carries out milestones, delivers module training, facilitates psychoeducation, and gathers feedback so that every voice is heard [source: Esaki et al. 2013; Anglicare guide 2018; WA Framework; NCTSN training guidelines]. Some services add Local Implementation Teams and "Sanctuary Champions" [source: Anglicare guide 2018].
• Training cascade: leadership five-day immersion; Core Team train-the-trainer; 18-hour direct- and indirect-care modules; new-staff orientation; boosters [source: NCTSN training guidelines].
• Year-one structured activities [source: Esaki et al. 2013]:
  • communication plan and kickoff event;
  • organisational self-assessment;
  • learning the organisation's own trauma history, i.e. past crises, losses and leadership changes [elaboration synthesis];
  • conflict retreat;
  • examining power, values and assumptions.
  • Detailed formats are [uncertain].
• Fidelity checklists and certification: checklists measure tool use; the Certification Standards specify how and how often each tool is practised in each setting; peer certification is described in 2a [source: Esaki et al. 2013; NCTSN training guidelines].
• Mentoring & coaching: listed as a tool in one service's ten-tool list; no procedure was found [source: Anglicare guide 2018] [uncertain].
• Example language (illustrative, Core Team facilitator): "Our self-assessment says staff don't feel safe admitting mistakes. That's a Safety problem at our level. What would make it safe to say 'I got that wrong' in this building?"
• Watch for: a Core Team made up only of managers; tools that exist in policy but not on the floor.

4.13 Adapting the tools in individual or outpatient therapy [synthesis]

This section is the author's own synthesis; the sources only state that the model has been adapted to outpatient and community settings [source: Crossnore handbook].

• Purpose: to bring the S.E.L.F. language and tools into individual or family sessions, especially for clients who also attend a Sanctuary agency, so the language stays consistent.
• Steps:
  1. Open sessions with the three questions.
  2. Co-create a pocket safety plan in session one.
  3. Use S.E.L.F. as the treatment-plan structure and review it every 4–6 sessions.
  4. Teach the reenactment triangle as psychoeducation.
  5. Close sessions with a Future step.
  6. Liaise with the client's residential, school or agency team using S.E.L.F. headings.
• Watch for: S.E.L.F. is a framework, not a trauma-processing method. If memory processing is indicated, use an evidence-based trauma therapy with its own readiness criteria, and keep Sanctuary tools as the safety scaffold.

5. Handling problems

Leadership not on board / bottom-up attempts. Bloom says change must start with leadership; without it, front-line staff struggle against senior people who do not understand the model [source: Bloom interview]. Response: do not roll out tools agency-wide from the clinical team alone. Seek a leadership sponsor and a Steering Committee. Meanwhile, use the tools within your own team or caseload, and frame them to leaders in terms of incidents, restraint and turnover [synthesis].

Change fatigue and low readiness. Readiness for change, including fatigue from repeated initiatives in child welfare, affects success [source: Esaki et al. 2013]. Response: run the readiness assessment honestly. Start with one or two high-yield tools (community meeting, safety plans) and build on early visible wins [synthesis].

Fidelity drift or loss of the democratic spirit. Early focus groups showed a need for more training, structure and modelling, and the developers added booster trainings. They also tried to keep a grassroots character [source: Rivard et al. 2003]. Response: schedule boosters, use fidelity checklists in supervision, and rotate who leads community meetings, residents included [source: NCTSN training guidelines; Rivard et al. 2003; rotation is synthesis].

Collective disturbance (team-wide upset, scapegoating, rumours). Strong emotion detaches from its source and attaches to unrelated events. It persists until it is linked back to its source, and often arises when negative feelings towards those in power cannot be voiced [source: Crossnore handbook; Orchard Place overview]. Response: call a red-flag review or a team meeting and run a S.E.L.F. analysis across all levels to find the "problem behind the problem". Leaders invite the unspoken feelings directly, for example about restructuring, a staff death or funding cuts [source: same; leader invitation is synthesis].

Parallel process (clients escalating while staff are depleted). Response: treat rising client incidents as a signal to check staff safety, workload and leadership communication too. Review self-care plans and offer extra supervision [source: Crossnore handbook; Orchard Place overview; Esaki et al. 2013].

Staff resorting to control, restraint or punishment. Response: treat any hold or seclusion as a red-flag trigger [source: Orchard Place overview]. Review it through reenactment and S.E.L.F., not blame. Update the client's safety plan and the staff response plan. In supervision, use Nonviolence and Emotional Intelligence as the reference points. Follow local legal and policy rules on restrictive practices [synthesis for the last two].

Client refuses or mocks the community meeting. Non-committal answers are accepted [source: Clarke & Royes 2014]. Response: model your own answer and allow "pass" or a single feeling word. Never punish non-participation, which would breach the commitments. Follow up one-to-one, and offer a role, such as timekeeper or co-leader [synthesis].

Disclosure or distress during a community meeting or group. Response: acknowledge it briefly and do not process it in the group, since the format is identification only [source: Orchard Place overview]. Arrange immediate private follow-up. If the disclosure involves abuse or a risk to self or others, follow safeguarding and mandatory-reporting duties and current suicide risk-assessment practice [synthesis].

Overwhelm or dissociation during loss work. No published guidance was found [uncertain]. Response [synthesis]:

• Stop the content. Ground the person: orient to time, place and the people present; slow breathing; sensory anchors; their safety plan.
• Return to Safety in S.E.L.F. terms and close on a small Future step.
• Review readiness before resuming.
• Sanctuary does not prescribe trauma-memory processing. Refer for an evidence-based trauma therapy, with its own readiness criteria and dosing, where indicated.
• Never use groups or loss work to search for or "recover" memories.

Safety plans not used (non-adherence). Response [synthesis]: check that the items are doable in the setting and in the client's own words. Rehearse them when calm, and have staff prompt their use early in escalation. Celebrate each use at the end-of-day meeting. Update the plan in S.E.L.F. planning when items stop working [source for review points: Crossnore handbook].

Rupture between client and staff or therapist. Response [synthesis]:

• Name the rupture openly, in line with Open Communication.
• Look at it together through the reenactment triangle ("did I end up feeling like another adult who let you down?").
• Repair in words, and record the repair as a Loss and Future item in the plan.
• Where the rupture involved harm or a complaint, a red-flag review is appropriate [source: Crossnore handbook lists complaints as a trigger].

"Democracy" misread as no limits. Response [synthesis]: the sources describe shared decision-making suited to each group and distinct staff and client roles [source: Esaki et al. 2013; Rivard et al. 2003]. Explain which decisions are shared, which belong to staff for safety or legal reasons, and why.

Secondary trauma and burnout in the clinician. Response: keep and review your own self-care plan, use supervision for vicarious trauma, and consider ProQOL screening [source: Orchard Place overview; Esaki et al. 2013].

Cultural mismatch. Response: add cultural-safety questions to S.E.L.F. reviews and use the published Aboriginal and First Nations adaptations where relevant [source: NCTSN training guidelines; Anglicare SELF framework].

Using the tools outside a Sanctuary organisation. Use the name "Sanctuary Model" only for licensed implementation. The tools can inform individual practice, but the model's mechanism is organisational and needs the whole system [source: NCTSN training guidelines on licensing; framing is synthesis].

Sources

Sources:

• Sanctuary fact sheet (NCTSN)
• Sanctuary training guidelines (NCTSN)
• The Sanctuary Model: Theoretical Framework — Esaki, Benamati, Yanosy, Middleton, Hopson, Hummer & Bloom (2013), Families in Society 94(2)
• Rivard, Bloom, Abramovitz et al. (2003), Assessing the implementation and effects of a trauma-focused intervention for youths in residential treatment, Psychiatric Quarterly 74(2)
• Clarke & Royes (2014), The Sanctuary Model and Community Meeting, Therapeutic Communities 35(4)
• inSocialWork podcast episode 10 transcript: interview with Sandra L. Bloom
• SELF in Schools: Problem Solving through the Sanctuary Model (Spinner & Lapin Zou, ANDRUS, 2017)
• Sanctuary Handbook (Crossnore, June 2017)
• Sanctuary Overview (Orchard Place, 2019)
• Sanctuary guide 2018 (Anglicare)
• Sanctuary SELF framework (Anglicare)
• Residential Care and Secure Care Sanctuary Framework (WA Department of Communities, 2020)
• The Sanctuary Model slides (Carlson, Minnesota Center for Chemical and Mental Health)
• Restoring Sanctuary, OUP Academic book page (abstract only)
• Bloom (1994) chapter record, Drexel Research Discovery (metadata only)

Further reading (not drawn on):

• Bloom, S. L. (1994). The Sanctuary Model: developing generic inpatient programs for the treatment of psychological trauma. In M. B. Williams & J. F. Sommer (Eds.), Handbook of Post-Traumatic Therapy, pp. 474–491.
• Bloom, S. L. (1997). Creating Sanctuary: Toward the Evolution of Sane Societies. Routledge.
• Bloom, S. L., & Farragher, B. (2011). Destroying Sanctuary: The Crisis in Human Service Delivery Systems. Oxford University Press.
• Bloom, S. L., & Farragher, B. (2013). Restoring Sanctuary: A New Operating System for Trauma-Informed Systems of Care. Oxford University Press.

The licensed Sanctuary Institute materials (Implementation Guide, staff training manuals, psychoeducation curricula, Certification Standards) are not drawn on here. Details that depend on them are marked [uncertain].