Using Theory in Human Services Organizations Prepare: Prior to beginning this discussion, read Chapter 6 of Making Strategy Count in the Health and Human Services Sector. Chapter 5 is a recomm

109 CHAPTER 6 Strategy, Sanctuary, and Turnaround Editors’ note: This chapter features two perspectives on the Sanctuary Model ®.

The chapter begins with a case study on a Strategy Counts initiative pilot site based in Rochester, New York, in which the Sanctuary Model is applied as one component of the organization’s turnaround effort. Following this practical example of the Sanctuary Model in one organization is a reprinted article highlighting the theoretical framework of the Sanctuary Model from the peer-reviewed Families in Society: The Journal of Contemporary Social Services. F INDING H OPE: A C ASE S TUDY ON S TRATEGY R EDESIGN AND T URNAROUND Michael Mortell, Christina Gullo, and Patricia Winsten Christina Gullo estimates that when she joined St. Joseph’s Villa as CEO in late 2010, the 68-year-old agency was just months from closing its doors. It was entering its third year of operating with a deficit and projected a loss of $1.2 million in 2011, the largest thus far.

Gullo undertook—and achieved—a dramatic 1-year fiscal turnaround.

The change in executive leadership also presented the opportune time for the Villa to take a critical look at its strengths, weaknesses, and future. Agency leaders understood that to survive and thrive, the Villa would have to trans - form its strategic focus and organizational structure to become change-agile, competitive, and continuously innovative. Today, Villa of Hope continues to work toward transformation in four key areas: strategy, leadership, culture, and performance evaluation. Now, midway through its journey of transformation, Villa of Hope is elevating its strategic capacity, identifying areas of growth, strengthening its infrastructure, and reshaping its identity with a new name, mission, vision, and culture. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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110 Making s trategy Count in the h ealth and huM an s erviCes s eC tor On the Journey to Reinvention When St. Joseph’s Villa unveiled a new name, logo, and tagline in April 2013, it was the most visible manifestation of the transformational journey under - way. Now called Villa of Hope, the agency that was on the brink of closure is looking ahead to a hopeful future. Even though the agency had downsized from 72 residential beds to 48 just before Gullo arrived, a consistent drop in residential occupancy and a high rate of unplanned discharges added to the fiscal crisis. Gullo gath- ered an entirely new executive leadership team and immediately tackled the agency’s finances. Programs that were not financially or operationally feasible and did not fit the core service area were cut or eliminated, space was consolidated to buildings owned in order to reduce fixed expenses, and a number of staff members were laid off. At the same time, the agency achieved a rate increase that resulted in $500,000 annually, and it submit- ted proposals for new programming. It reduced its $3.5 million line of credit to $1.5 million and secured it with property assets, freeing founda- tion dollars for major initiatives. New metrics were designed to track cash flow, assess fluctuations, and project discharges. Every program now has a monthly profit-and-loss statement, instilling a new accountability among leadership and management. A major gift campaign is raising unrestricted funds. The result? Since mid–fiscal year 2012, the Villa has been operating with a surplus and has invested resource dollars to start new programs and build upon existing infrastructure.

Transformation. The board and senior leadership realized that they could not merely plug holes in the budget. Nothing less than transformation would enable the agency to remain viable and impactful into the future. A strat - egy team was formed to drive the transformational project, comprising the board chair, the CEO, and 10 cross-functional staff members. In August 2011, the strategy team began preparing a proposal to become a Strategy Counts pilot site that identified four areas for transformation: strategy, leadership, talent/culture, and performance evaluation. With a great deal of the foundation in place, had the Villa not been selected as a pilot site, the transformation work most certainly would h\�ave continued. When the selection process ended in December, Gullo and the strategy team learned that the Villa would be one of the pilot sites conduct- ing a transformational project. Becoming a pilot site provided $100,000 for an 18-month period beginning in January 2011, engagement with peers in the cohort learning group, and, to some degree, an external vote of confidence to carry on with the transformation effort. The Villa used the expertise of a local consulting firm with a reputation for assisting in strategy creation that empowers leaders and improves client Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 111 results. The consultants coached the strategy team and provided a neutral voice to objectively assess the agency’s weaknesses, navigate conflict, and clarify thinking in the strategic process. Why Invest in Strategy? Previously, the agency had a strategic plan that it considered “evergreen” limited metrics to map progress. For a turnaround to begin, leaders needed to know how the agency was doing relative to similar organizations. The strategy team identified several factors that underscored the need for transforming the Villa. These included the rapid pace of change within the human services sector at the state and community levels, the ability to implement and share knowledge at all levels of the organization, and the need to track and measure progress on objectives on a timely basis. An extensive assessment of agency needs led by the strategy team revealed elements that needed addressing if the Villa was to realize its potential and expand its impact on youth. The assessment included a SWOT analysis, competitive analysis for each program area, and 26 interviews with internal and external stakeholders, including the senior leadership team, cross-functional staff, board members, donors, family members, clients, and municipal and communit y collaborators. The following were identified as areas of weakness in the Villa’s capacity:

• Slowness to change in response to changing economic and social conditions • Programs not aligned with changing community needs (e.g., residential vs. community-based services) • Focus on short-term program funding rather than building long-term capacity and fiscal viability • Strategic plans poorly aligned with day-to-day operations • Lack of outcome data to use in reporting and responding to successes and challenges • Outdated organizational structure; role confusion The organizational structure, Gullo observed, was inefficient, outdated, and incapable of reacting quickly. Throughout the organization communica- tion was poor, there was a lack of accountability, and staff were only minimally included in decision making. “It was a deficit-focused, crisis-driven culture,” Gullo says. “The staff members were operating in firefighting mode.” Anticipated Outcomes. Transformation of the organization was expected to provide widescale, far-reaching, and sustained results to the Villa’s stake - holders and, critically, to youth and families in crisis. The strategy team articulated the following seven outcomes in their strategy counts proposal: Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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112 Making s trategy Count in the h ealth and huM an s erviCes s eC tor • Expansion of successful core services As a result of strategically designing our vision, goals, and objectives, we anticipate expansion in areas identified by growth potential and finan - cial viability such as after-care, juvenile justice programs, skill building, and specialized residential and outpatient clinics.

• Elimination of nonaligned programs and services Utilizing the results of our needs assessment, revised mission, and information from the strategy-mapping process, we will “right-size” our organizational structure according to our core services and eliminate or adjust programs that are not responsive to the current economic and social environment. Database performance tracking will guide our ongoing evaluation and alignment of programs and services.

• Reconfiguration of existing services and capturing greater program efficiencies The strategic mapping process will reconfigure our services to be more efficient because of the development of performance targets and tracking client outcomes. Human resources, finance, and development functions will be aligned to support agency objectives, and database tracking will\� ensure that goals and objectives are met.

• Development of new value-added services through innovation Greater organizational efficiency will allow us to collaborate with other organizations. Agencywide culture change will take place through implementation of the Sanctuary Model, ensuring that services are client- informed and achieve lasting results.

• Greater resilience in the face of economic downturns, enhanced sustainability of \� effective programs, and enhancement of revenues for service delivery Strategic expansion of successful programs, key collaborations with municipal and community partners, clarification of our vision and mission, and tracking of performance data will build capacity for revenue and position us to benefit from federal, state, and local fund - ing opportunities—increasing our fiscal capacity to endure economic downturns.

• Successful reorientation of board energies to issues central to the responsibilities of governance Board involvement at all levels of our strategic process will ensure engagement and reap benefits from board expertise/knowledge.

Aligning board members with our clarified vision, mission, and goals allows them to better represent the Villa in the community and focus attention on governance and the cultivation of donors.

• Greater social impact on the communities served All transformation efforts are directed toward this all-important goal.

Organizational development will change agency culture to be driven by client need. Clear strategic goals and ongoing measurement of objectives will allow us not only to serve more youth and families in crisis but to serve them better. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 113 Early Steps Gullo soon realized that as the agency was forging ahead in transforming, it had to stabilize a few aspects that affected day-to-day operations. Over the next 6 to 8 months, the agency planned for and developed new policies and procedures. New safety measures were put in place, and each operational area was assessed to begin to reduce inefficiencies and redundancies.

Getting the right talent in the right seats was also important. A clini - cal director position was created. The management team was restructured, making sure people were in the jobs best suited to their skill sets. Roles and responsibilities across the organization were revised and clarified. Although the Villa was financially fragile, it invested $270,000 to align compensation and benefits with competitive market data. The agency also committed to extensive training and development. Throughout these changes, Gullo communicated with staff transpar - ently and frequently. She knew that with knowledge comes buy-in, and that buy-in leads to higher performance and, ultimately, to improved outcomes. With a more solid foundation underpinning it, the Villa worked with a consultant to define its strategic intent and objectives. The goal was to be competitive, change-agile, and continually innovative.

Culture and Talent. Gullo observed that the client population had changed and that the staff were not trained to respond to their high levels of trauma.

After extensive research, the Villa implemented Sanctuary, a trauma-informed model of care that not only guides treatment but also shapes the culture and values of the entire organization. “The selling point was that Sanctuary is a whole-system approach,” Gullo says. “It focuses on the people who seek treat - ment, and equally on the community of people and systems that provide it.” The Sanctuary Model brings a perspective that asks: “What’s happened to you?” rather than “What’s wrong with you?” when organizing goals and assess - ing strengths and challenges. Sanctuary’s seven commitments have become Villa of Hope’s guiding principles, the overarching philosophy for how the agency provides services and works within the community (Esaki et al., 2013):

• Nonviolence • Emotional Intelligence • Social Learning • Open Communication • Social Responsibility • Democracy • Growth and Change The Sanctuary Model’s recognition of the inherent resilience in people and the belief that they can heal makes it the very core of the agency’s cultural transformation. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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114 Making s trategy Count in the h ealth and huM an s erviCes s eC tor A pilot group of 50 cross-functional staff members was trained first; after that a handful of them trained the remainder of Villa employees. From March to June 2012, 350 employees participated in a 3-day “Sanctuary 101\�” course. The Sanctuary Model brings families directly into the treatment plan - ning process, which previously had not been followed throughout all Villa programs. Combined with Villa of Hope’s growing capacity to effectively measure outcomes and impact, this new approach is transforming agency programs into ones that are client-driven and that are informed by current research and best practices. Recently, the Villa began using an evidence-based screening tool to assess 40 developmental assets on intake, midway through treatment, and on discharge (Scales et al., 1999). These data are incorporated into treatment plans to help customers strengthen their life skills. Gullo recognizes that culture change takes time, but she is encouraged by the new sense of cohesiveness, accountability, and willingness to work together toward a shared vision. Transformational Leadership. Innovation is a critical component of Villa of Hope’s transformation strategy. Each member of the strategy team receives training and skill building to become an innovative leader. These newly empowered leaders in turn infuse their work teams with the skills they need to understand and execute the mission, vision, and strategic objectives. Ongoing, focused work sessions throughout the organization are designed to stimulate staff to gather performance data, contribute innovative ideas, and report challenges and successes. The Villa is now working on an internal curriculum for ongoing supervisory and manage - ment training. This was piloted in June 2013 to all existing managers and supervisors. Financial Turnaround. In the 3 previous years, including 2011, the Villa had experienced a steady decline in revenue and significant structural defi- cits in the budget. While the services were moving from being residential- based to being community-based, costs were not reduced in proportion. The Villa relied heavily on cash reserves and asset sales. In addition, over $1 mil- lion of a $3 million line of credit was being used to cover operations. Though the agency has a foundation, a restrictive debt structure made accessing the Villa’s foundation funds difficult, even for strategic investments.

Several steps were taken to address the fiscal issues facing the Villa, including hiring a Rochester-based financial management firm as a consult - ant. In 2012, a total of $1.2 million in cost reductions were made, primarily by reducing head count of staff members. The agency secured a rate increase from the New York State Office of Children and Family Services that was made retroactive to July 1, 2012, shortened delays in Medicaid reimburse - ment by two weeks, and improved the organization’s capital structure. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 115 The Villa’s organizational structure was revised to create clearer roles and responsibilities while focusing on improving residential program per - formance. While this was already common practice in many agencies, the Villa now budgets at the program and department levels with a monthly profit-and-loss statement. Further, each program undergoes an assessment of its fit with the mission and its overall profit or loss, which helps ensure that the agency breaks even and helps staff anticipate shortfalls before they occur. Since mid–fiscal year 2012, the Villa has been operating with a surplus and has invested resource dollars to start new programs and build upon existing infrastructure. Forging a New Identity A critical component of the agency’s new strategic direction was revision of the mission, vision, and value statements—that is, of its very identity. In preparation for rebranding, the agency spent more than a year in extensive research and conversation with crucial stakeholders. The challenge was to honor the agency’s rich legacy while positioning the organization not as a place for troubled youth but as a partner helping youth and families achieve a hopeful future .

In spring 2013, St. Joseph’s Villa emerged as Villa of Hope. “Hope is what we are all about,” Gullo says. “Our name, our vision, our values, and our treatment philosophy offer the hope that youth and families can rebuild, recover, and renew.” Performance Evaluation. Lack of resources and infrastructure has ham- pered the Villa’s ability to measure outcomes and community impact.

Currently, most data are extracted manually. The balanced scorecard demands an investment in information technology. Consultants recently analyzed Villa of Hope’s IT needs based on each program area’s newly defined targets and metrics. The Villa issued a request for proposal for a data system to track outcomes related to client profiles and activities, perfor - mance measures, and fiscal controls and expenditures. “New technology to track outcomes will allow us to consistently evalu - ate our progress and determine outcome success,” Gullo says. “It also will foster innovation and accountability, giving staff the data to make program - matic decisions that are client-informed, embedded in best practices, and responsive to change.” The Villa is moving to a pay-for-performance system, with the new vision and guiding values translated into operational goals. They are being written into job descriptions and linked to new performance appraisal and supervisory tools. Managers are currently being trained in the tools for the upcoming fiscal year, and the tools will be used for a full year before staff begin being rated in real time in the summer of 2014. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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116 Making s trategy Count in the h ealth and huM an s erviCes s eC tor Villa of Hope’s Priorities for 2013 The strategy team recently implemented the balanced scorecard tool. A one- page strategy map translates the vision into clearly defined quarterly goals and objectives, performance targets, and metrics (see Figure 6.1). The map also informs the organizational structure needed for success. The senior leadership team reviews the scorecard at least monthly, if not weekly.

In fiscal year 2013, the agency focused on continuing to be a more com - petitive, and therefore more sustainable, agency. The Villa recognizes that a key to driving sustainability is matching qualified, enabled, and motivated direct-care staff with youth and families in need. In 2013, the Villa has strong program performance, and occupancy is at its highest level in years. The agency added new programs were added, generating significant revenue and resulting in operating surpluses for the second half of fiscal year 2012 and for fiscal year 2013. A strategic program analysis highlighted opportunities to increase effi - ciencies, expand programs with high growth potential, and identify emerging opportunities. Programs continue to be assessed using a mission-and-margin basis. Villa of Hope added an eight-bed critical care residential program for girls in June 2012. The agency’s new day respite program for children living at home is the only one of its kind in the area. Recently the Villa received a state grant to provide home- and community-based services for juvenile offenders. Revenue is now up 8%. This was achieved through the investment of funds in direct-care staff, safety, compensation, strategy development, training, the Sanctuary model, and rebranding. The Villa has also invested in leadership development, com - munication, transparency, empowerment, accountability, improving morale, and attracting very strong talent for key positions.

Next Steps. The transformation work is still in process. After the agency has completed its infrastructure-building phase, each department will cre- ate its own strategy map, aligned with the overall agency map. “This \�is very different from how the organization used to do strategy,” says Gullo. “We are embedding it at every level of the organization. Strategy now drives our decision making.” Looking ahead, Villa of Hope will continue to focus on specialized residential care and will leverage its expertise in care management, addic - tion services, and community-based programs. It sees a niche in trauma- informed treatment that increases the functionality of the youth served, with a focus on building life skills in young adults ages 18 to 25. Lessons Learned. Gullo learned that eagerness to move forward quickly actually set them back. “I think we got ahead of ourselves because the infra - structure wasn’t there yet. We had to pull back and do things in the right Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Talent and culture Value Impact Internal Process Customer Mission: Villa of Hope is a community of caring professionals. We offer a range \ of specialized services for youth and families to develop skills for lasting success.

Vision: Villa of Hope will be the proven provider of innovative, high-quality hu\ man services. We will collaborate agencywide and form compassionate partnerships with youth, families, and\ the community.

Values: Relationships based on caring, hope and respect are the foundation of ou\ r efforts.

I4. Corporate compliance • Percent programs/departments that successfully pass the internal audit TC2. Performance excellence •New PA Tool I1. Client staff and community safety • Decrease in program de ned “critical incidents” TC1. The RIGHT… people in seats with tools •Role descriptions •Supervision framework/document I3. Quality improvement and operational ef ciency • Data collection—Impact/outcomes C1. Preferred provider • Partnership •Referral agency/family satisfaction V1. Successful client outcomes •Percent achieves discharge criteria having completed integrated care plans C2. Develop life skills • 40 developmental assets V2. Financial viability •100% Breakeven operations (revenue vs. expenses) •Unrestricted funds to grow ($800K) 2012–2013 year TC3. Physical/Emotional wellness •Self-care plan •Health wellness initiatives I2. Technology Ef ciency •Technology identi ed, required and being utilized as scheduled TC4. Competitive salary and bene ts •Alignment of salaries with competitive market data FIGURE 6.1 Villa of Hope Strategy Priorities 2013 /Measures. Source: Villa of Hope (2013). 117 Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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118 Making s trategy Count in the h ealth and huM an s erviCes s eC tor order,” she says. “If we had pushed through, we would have been trying to grow an organization on a very unstable foundation.” The experience also reinforced the importance of having the right peo - ple, in the right seats, with the right skill set. Gullo recognizes that culture change has to start at the top: “The CEO and senior leadership team have to all be on the same playing field, saying, doing, and modeling the same behaviors.” With the strategy to drive them and the Sanctuary model to guide them, Villa of Hope’s progress toward transformation has been nothing short of astonishing: a fiscal turnaround, high occupancy, new sources of revenue, dramatic performance improvement, accountable leadership and staff, greater resilience and agility, new collaborations, a renewed sense of hope, and a culture driven by client need and empowered by innovation. It all adds up to another word vital to the Villa’s future: reinvention. References Esaki, N., Benamati, J., Yanosy, S., Middleton, J., Hopson, L., Hummer, V., & Bloom, S. (2013). The Sanctuary Model: Theoretical framework. Families in Society: The Journal of Contemporary Social Services, 2(92).

Scales, P. C., & Leffert, T. (1999). Developmental assets: A synthesis of scientific research on ado- lescent development. Minneapolis, MN: Search Institute, p. 5.

Villa of Hope. (2013). Strategy map of priorities and measures. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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119 THE SANCTUARY MODEL : THEORETICAL F RAMEWORK Nina Esaki, Joseph Benamati, Sarah Yanosy, Jennifer S. Middleton, Laura M. Hopson, Victoria L. Hummer, and Sandra L. Bloom This article provides a theoretical framework for the Sanctuary Model. The Sanctuary Model is a trauma-informed organizational change intervention developed by Sandra Bloom and colleagues in the early 1980s. Based on the concept of therapeutic communities, the model is designed to facilitate the development of organizational cultures that counteract the wounds suffered by the victims of traumatic experience and extended exposure to adversity.

Details of the Sanctuary Model logic model are presented. Implications for Practice • Emerging research suggests the importance of organizational culture in the delivery of evidence-based mental health services and, thus, the need for organizational interventions such as the Sanctuary Model.

• By creating a restorative culture through the Sanctuary Model, ser - vice providers can be emotionally available to each other and their cli- ents, resulting in positive relationships that create the conditions for resilience.

The Sanctuary Model represents a theory-based, trauma-informed, evidence- supported (National Child Traumatic Stress Network, 2008; Rivard, Bloom, McCorkle, & Abramovitz, 2005), whole-culture approach that has a clear and structured methodology for creating or changing an organizational culture.

The objective of such a change is to more effectively provide a cohesive con - text within which healing from physical, psychological, and social traumatic experience can be addressed. As an organizational culture intervention, the Sanctuary Model is designed to facilitate the development of structures, pro - cesses, and behaviors on the part of staff, clients, and the community as a whole that can counteract the biological, affective, cognitive, social, and exis - tential wounds suffered by the victims of traumatic experience and extended exposure to adversity (Bloom, 2011).

Reprinted with permission from Families in Society: The Journal of Contemporary Social Services (www .alliance1.org/fis), published by the Alliance for Children and Families. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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120 Making s trategy Count in the h ealth and huM an s erviCes s eC tor History Beginning in 1980, Sandra Bloom, Joseph Foderaro, and Ruth Ann Ryan worked in both hospital and outpatient settings with people who survived overwhelmingly stressful and often traumatic life experiences. Building on the concept of therapeutic communities, in which staff and clients col - lectively participate in creating a system of healing (Jones, 1953, 1968; Lees, Manning, Menzies, & Morant, 2004; Main, 1946), and using the work of Silver (1985, 1986), who described “sanctuary trauma” as expecting a wel - coming and healing environment and finding instead more trauma, Bloom and her colleagues formed the Sanctuary, a trauma-specific program for adult survivors. The Sanctuary Model, an outgrowth of the Sanctuary, is a blueprint for clinical and organizational change that promotes safety and recovery from adversity through the active creation of a trauma-informed community. Today, the Sanctuary Model has been expanded to include both adult- and child-serving agencies across the United States and in seven countries around the world (Sanctuary Institute, 2012).

Theoretical Framework The Sanctuary Model is an organizational intervention that is grounded in constructivist self-development theory (CSDT; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995), burnout theory (Maslach & Jackson, 1981; Maslach, Schaufeli, & Leiter, 2001), and systems theory (Bertalanffy, 1974), utilizing the valuation theory of organizational change (Hermans, 1991; Weatherbee, Dye, Bissonnette, & Mills, 2009) to improve organizational culture. Its goal is to improve organizational culture by educating staff on the effects of trauma and stress on behavior, changing the mindset of staff regarding behavior of clients from being pejorative (i.e., sick) to being the result of injury, and providing tools to change individual and group behav - ior. The theoretical framework addresses dynamics at both levels, and by so doing, the model aims to improve the quality of service delivery and, ulti - mately, improve client outcomes.

Constructivist Self-Development Theory CSDT (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995) is an integrative personality theory that provides a framework for under - standing the impact of childhood maltreatment on the developing self (Saakvitne, Tennen, & Affleck, 1998). With origins in psychoanalytic theory, self-psychology, social learning, and cognitive development, this theory describes the unique impact of traumatic events that arises from inter - actions among aspects of the person, the event, and the context (Brock, Pearlman, & Varra, 2006); thus it is a constructivist theory of personality development. Because it highlights those aspects of development most likely to be affected by traumatic events, it is also a clinical trauma theory (Saakvitne et al., 1998). Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 121 CSDT describes three self-capacities: the ability to maintain a sense of connection with benign others (inner connection); the ability to experience, tolerate, and integrate strong affect (affect tolerance); and the ability to main- tain a sense of self as viable, benign, and positive (self-worth). Dra\�wing from theory and research on attachment (Bowlby, 1988), CSDT suggests that self- capacities develop through early relationships with caregivers and allow one to learn to regulate one’s inner state. The capacity to maintain a sense of connection with others is posited to form the basis from which the other self- capacities (affect regulation and a sense of self-worth) develop (Brock et al., 2006). CSDT establishes the foundation for understanding the disruptions in social and behavioral functioning that accompany exposure to trauma and the strong relationship between attachment and emotion regulation.

Sanctuary draws from this knowledge and focuses on creating a community environment within the treatment system that allows clients to restore con- nections with others. A primary goal of establishing this organizational com- munity environment is to allow the development of multiple relationships that will ultimately help clients regulate their internal states. Burnout Theory The term burnout was coined by Herbert Freudenberger (1974), a clinical psy- chologist familiar with the stress responses exhibited by staff members in “alternative” institutions such as free clinics and halfway houses (Jackson, Schwab, & Schuler, 1986). Burnout is typically referred to as a condition in which workers become worn out or exhausted because excessive demands have been placed on their energy, strength, and resources (Freudenberger, 1974). Maslach and Jackson (1981) developed a multidimensional construct of burnout that encompasses three components: emotional exhaustion, increasing depersonalization of clients, and decreased feelings of per - sonal accomplishment. Emotional exhaustion is the depletion of emotional resources and the feeling that one has nothing left to give psychologically.

Depersonalization occurs when a worker develops negative and callous attitudes toward their clients and begins to treat clients as objects rather than persons. Decreased feelings of personal accomplishment result when a worker begins to develop a negative view of their achievements on the \�job or begins to believe that personal expectations are not being met (Poulin & Walter, 1993). Of the three components of burnout, it is most commonly associated with emotional exhaustion (Poulin & Walter, 1993). It is the most widely accepted and recognized aspect of burnout and is also the one that most resembles traditional measures used to study job performance (Jackson et al., 1986). Various types of job-related stressors, such as work overload, role ambiguity, role conflict, limited job autonomy, and client demands, have been shown to contribute to burnout (Kowalski et al., 2010; Peiro, Gonzalez- Roma, Tordera, & Manas, 2001; White, Edwards, & Townsend-White, 2006). Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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122 Making s trategy Count in the h ealth and huM an s erviCes s eC tor The individual experiences stress and, without adequate resources for cop - ing, may face strain, exhaustion, and attitudinal and behavioral changes indicative of burnout (Maslach, 1982). Workplace support has been identified as an important organizational factor for worker outcomes such as burnout or job satisfaction (Himle, \� Jayaratne, & Thyness, 1991; Yoo, 2002). For example, social support from supervisors serves as preventive of burnout and also provides emotional relief to workers (Swanson & Power, 2001; Yoo, 2002). The Sanctuary Model suggests that 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 positive relationships in order to begin to self-regulate. The Sanctuary Model is informed by burn- out theory through attention to the well-being of staff and their need for adequate support within the environment.

Systems Theory Bertalanffy (1974), one of the architects of systems theory, asserted that a sys - tem is defined as a constellation of components in mutual interaction (Iglehart, 2009). In an open system, energy is imported from the environment (inputs), transformed to create a technology, and then exported back into the environ - ment (outputs). Significant features of an open system are interrelatedness of subsystems, boundary maintenance, system equilibrium, system functions (socialization, social control, communication, and feedback), system adapta - tion and maintenance for survival, and the relationship between the system and its environment (Katz & Kahn, 1978; Netting, Kettner, & McCurtry, 2008). One of the guiding assumptions of most organizational theory is that organizations are systems. Organizations are a confluence of interlocking parts. Programs, work units, frontline staff, clientele, boards of directors, administrators, and organizational constituents are components of organiza- tional systems. A common understanding among participants differentiates the organization and its members from those people and structures that are not part of the organization (Norlin & Chess, 1997). A change in one part of the system produces change in the entire system. In addition, organizations are subsets of larger systems, often referred to as the organization’s suprasystem (Hasenfeld, 1992; Norlin & Chess, 1997). For example, organizations are affected by what happens in the surrounding community, or by events in social, economic, or political systems. The Sanctuary Model incorporates\� this understanding of organizations as systems, in that the organization itself is seen as the primary target for the intervention, with staff, clients, and other stakeholders composing that system as recipients of the intervention.

Valuation Theory of Organizational Change As explored by Weatherbee et al. (2009), Hermans’ valuation theory (Hermans, 1991) with its related self-confrontation method (SCM; Hermans, 1976; Hermans, Fiddelaers, de Groot, & Nauta, 1990) is a therapeutic approach Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 123 that can facilitate access and insight into deeper structures of organizational change through a focus on the valuations or personal meanings that organi - zational actors bring into the workplace (Hermans & Hermans-Jansen, 1995; Weatherbee et al., 2009). Valuation theory, which draws on the work of Mead (1934), is rooted in the metaphor of the person as a storyteller giving special significance to particular events or groups of events that function as units of meaning for them (Hermans & Hermans-Jansen, 1995). As individuals and organizational groups perceive organizational change in different ways, with a variety of attributed meanings and interpretations, this may lead to significant differences between the valuations held by individuals, work groups, or the organization as a whole. Thus there exists significant poten - tial value in the use of the SCM to elicit organizational valuations and bring them to the surface so that they may be discarded, reinforced, or molded to facilitate change processes in organizational environments (Weatherbee et al., 2009). The valuation theory allows for clinical research methodologies to be integrated into the study of organizational change, because psychothera- peutic methods access interpretations and understandings of organizational culture and change (Kets de Vries, 1991; Schein, 1993). Similarly, the context in which the change occurs, including historical elements, must be consid- ered (Pettigrew, Woodman, & Cameron, 2001). Valuation theory is a proven method for accessing and understanding the underlying or deeper inter - pretations, cognitions, beliefs, and values held by individuals (Weatherbee et al., 2009). SCM, which assesses attitudes toward the past, present, and envisioned future of individuals’ experiences, can shed light on those con- textual, temporal, and historical elements that influence attitudes to\�ward organizational change (Weatherbee et al., 2009). The Sanctuary Model intro- duces training, skill building, and tools into an organization to generate self- confrontation among individual staff members as well as among groups within the organization, culminating in change in the system as a whole. A Socioecological Logic Model for the Sanctuary Model Organizations are the primary vehicles for delivering positive changes on multiple levels to consumers and are also an integral part of any social service system; therefore, organizations have a significant role in effecting change in the system. The Sanctuary Model uses a logic model to connect activities and outcomes at each socioecological level: individual, interper - sonal, organizational, and community (see Figure 6.2). From left to right, the model identifies common input and activity logic model components leading to outcomes. From top to bottom, the model depicts the levels of the socio - ecological model, beginning with individual-level activities and outcomes at the top and progressing down and ending with community-level activities and outcomes. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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FIGURE 6.2 Sanctuary Model Logic Model. Relationship Building Time COMMUNITY ORGANIZATIONAL INTERPERSONAL INDIVIDUAL Inputs Activities Outcomes Short-TermMid-TermLong-Term • Tr aining participation • Acceptance of role on Steering Committee and Core Team • Use of safety plans and self-care plans and rescripting Tr aining:

• 5-day leadership • Core team • General staff • Clients/families • Stak eholders • Orientation • Boosters • Self-reﬂection regarding power and conﬂict • Adoption of new lens through which to view organizational dynamics • Perception of clients as injured • Increased knowledge of milieu dynamics • Increased awareness of vicarious trauma • Changes in self-perception for clients • Improved conﬂict management skills • Personal commitment to organizational change • Willingness to serve as a role model and representative for others • Improved treatment outcomes for clients • Improved emotional regulation demonstrated by a majority of staff • I mproved stress management demonstrated by a majority of staff • Core team practice of year 1 implementation tasks • Community meetings, S.E.L.F. treatment plans/problem solving, psychoeducation and supervision Skill Building:

• On-site TA • Phone TA • Implementation manuals • Practice-based learning materials • Staff share a common language • Increased focus on future • Increased hope and morale • Improved recognition of feelings by both staff and clients • Demonstrated social responsibility among members • Improved regulations and enhanced funding streams that give priority to evidence- supported trauma interventions • Exploration of organizational change • Reduction in untow ard events • Increased team collaboration • Stronger sense of community • Awareness of coworker strengths and vulnerabilities •I ncreased ability of staff and clients to avoid and reduce reenactment • High-functioning multidisciplinary teams • Seven Commitment monthly themes • Implementation tasks related to certiﬁcation • Policy and practice work group activities T ools:

• Fi delity checklists • Toolkit lessons • Psychoeducation manuals • Increase in Seven Commitment behavior by leaders and staff alike • Changes in policy and procedures to align agency practice with the Seven Commitments of Sanctuary • Increased Core Team involvement in organization decisions • Improved staff recruitment and retention • Staff and client satisfaction • Appropriate distribution and use of power • Sanctuary Network Conference and events • Social media participation • Policy and advocacy work by regional groups • Increased knowledge by staff of the Sanctuary Network of organizations, their missions, and potential collaborations • Demonstrated social responsibility among community members • Increased knowledge by outside stakeholders of the Sanctuary implementation process • Sanctuary organizations share best practices (i.e., presentations at Sanctuary Network Days) • Increased altruism—sharing information, practices, and products with others, such as federal and state policymakers outside the Sanctuary Network • Increased sense of staff inclusion in decision making • Leaders feel more hopeful and efﬁcacious • Decreased turnover in staff 124 Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 125 Inputs Inputs refer to the resources needed to initiate and sustain a program. In implementing and sustaining organizational change through the Sanctuary Model, inputs fall into three categories: training, skill building, and tools.

Training. This consists of 5-day leadership training; Core Team training; general staff training; psychoeducation for clients, families, and internal and external stakeholders; new staff orientation training; and ongoing staff booster trainings. The Core Team is a multidisciplinary team with represent - atives from each level of the organization who are agents of change within the organization. These various training courses are facilitated by Sanctuary Institute faculty using a specially designed curriculum for each of the train - ing courses this above, in conjunction with written materials and film clips.

The content of all of this training consists of some combination of didactic and experiential learning activities in four areas known as the four pillars (described in Table 6.1). Skill Building. This consists of technical assistance through on-site consul - tations, phone calls, written materials for staff training, and a series of activi - ties for the Core Team that are executed by Sanctuary Institute faculty in the following areas: embedding the Seven Commitments in policy and practice, using the S.E.L.F. (safety, emotion management, loss, and future) framework for problem solving, applying trauma theory to systems, interpreting many client behaviors as trauma responses, managing conflict, and using the con - cepts of the Sanctuary Model in supervision. T ABLE 6 .1 The Four Pillars of the Sanctuary Model Trauma Theory Overview of information about how traumatic experiences affect the brain and therefore influ- ence thoughts, feelings, and behaviors.

Seven Sanctuary Commitments Philosophical underpinnings of the Sanctuary Model that describe how community members agree to behave with each other and the values to which the organization subscribes.

S.E.L.F.

Acronym for the organizing categories of safety, emotion management, loss, and future, used to formulate plans for client services or treatment as well as for interpersonal and organiza- tional problem solving.

Sanctuary Toolkit Set of 10 practical applications of trauma theory, the Seven Commitments, and S.E.L.F., which are used by all members of the community at all levels of the hierarchy and reinforce the concepts of the model. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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126 Making s trategy Count in the h ealth and huM an s erviCes s eC tor Tools. The inputs category of tools consists not only of training in the Sanctuary Toolkit but also of support from Sanctuary Institute faculty through ongoing phone and on-site consultation for troubleshooting when there are problems implementing any of the tools. In addition, a set of fidel - ity checklists are provided that can be used to measure adherence to the practices and the Sanctuary Certification Standards, which detail the man - ner and frequency of practice of the tools for different types of settings.

Finally, staff members can use four Sanctuary psychoeducation manuals to deliver lessons to clients about the four pillars of the Sanctuary Model in either group or individual settings. Each manual is designed to apply to clients who are operating at a specific developmental level. The 10 tools in the Toolkit are detailed in Table 6.2. Individual-Level Activities and Outcomes The individual-level activities that contribute to implementation of the Sanctuary Model are participation in training and acceptance of a role in the Sanctuary Steering Committee and Core Team. In addition to engagement in these forums for individual activity, the practice of safety plans, self-care plans, and rescripting traumatic reenactment also contribute to outcomes on the individual level. Generally, organizational leaders participate in the initial 5-day train - ing with the outcome of individual engagement in a self-reflection and a new lens for looking at their own organization’s functioning. The 5-day training also results in the experience of leaders in understanding their own behaviors, their use of and experience of power within the organiza - tion, and an appreciation for their own as well as the staff’s and clients’ experience of personal and organizational adversity. These leaders who attend the initial training are expected to accept a role in the organization’s Sanctuary Steering Committee, a small group of five to seven leaders who are charged with organizing the process of Sanctuary implementation and maintaining contact with the Sanctuary Institute faculty. The outcomes of participating in the Steering Committee are (a) recognition of oneself as a role model to all staff practicing the model and (b) greater insight into one’s use of power and one’s own role in conflict and organizational reenactments. Accepting a role in the Core Team is another individual-level activity in creating organizational change through Sanctuary. Participation in the Core Team means that an individual agrees to represent his or her peers as part of an implementation team that participates in structured activities to rein - force the practices of the model and explore opportunities for change in the organization. Participation results in a change in practice with clients that includes a perspective that moves from judgmental to one that assumes that clients are using ineffective skills for managing distress, and that one must use relational opportunities to teach new and more effective skills. Similarly, Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 127 team participation also results in the capacity for individual participants to apply this understanding and practice to peers and administrators, thereby improving knowledge of milieu dynamics. Participation in regular staff training is an individual-level activity for all staff that results in a clearer understanding of the organization’s expecta - tions for relational interactions among and between clients and staff. The use T ABLE 6.2 Tools in the Sanctuary Model Toolkit Core Team Primary vehicle for implementation of the Sanctuary Model, which consists of a cross section of staff from all levels of the organization’s hierarchy charged with executing the implementation steps.

Supervision Individual or group meetings to review performance that include opportunities to discuss issues of vicarious trauma, self-care, and updating safety plans.

Training Ongoing support to staff in use of the Sanctuary Model concepts through educational materials and interactive learning opportunities.

Community Meetings All community members begin meetings by answering three questions designed to promote feelings identification, a focus on future, and a connection to community.

Team Meetings Way to structure meetings among staff members that allows for them to reflect on the work, discuss team functioning, and service delivery issues.

Self-Care Planning Practice of identifying and committing to practice a set of activities that one can do to manage stress both inside and outside the workplace.

Red Flag Reviews Response to critical incidents that follows a protocol to focus on solutions over problems.

Safety Plans Visual reminders of emotion management practices represented as a list of activities, tech- niques, or skills to be used in situations that may trigger inappropriate behaviors.

S.E.L.F. Service Planning Framework for organizing service planning meetings and documents that explores functioning, challenges, goals, and progress in the areas of safety, emotion management, loss, and future.

Sanctuary Psychoeducation Educational materials about the effects of trauma; the Sanctuary Tools and Concepts delivered to clients and families. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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128 Making s trategy Count in the h ealth and huM an s erviCes s eC tor of safety plans and self-care plans, part of the Sanctuary Toolkit, are individ - ual activities in which practitioners create immediate and long-term ways of managing stressful situations. The resulting outcomes of practicing both of these tools are increased awareness of vicarious trauma and improved emo - tion management skills and personal stress management skills. The appli - cation of rescripting, which is the recognition of one’s prescribed role in a conflict and the conscious and decisive action to do something outside of that role as a way to disrupt traumatic reenactment, results in an increased sense of agency in the individual in resolving interpersonal conflicts. Overall, the practice of applying knowledge obtained in training results in a stronger commitment to positive organizational change and increased knowledge of trauma symptoms and strategies for effective intervention, which eventu - ally lead to changes in client perceptions of themselves as well as improved outcomes for clients.

Interpersonal-Level Activities and Outcomes Interpersonal activities consist of the practice of several tools as wel\�l as exe- cution of specific Core Team actions detailed in the first-year tasks of the Sanctuary Implementation Guide. These include creating a communication plan; having a kickoff event; engaging in self-assessment; learning the organ- izational trauma history; holding a conflict retreat; and exploring the power, values, beliefs, and assumptions across the agency. These activities result in deeper exploration of organizational change, development of a shared lan- guage for understanding and solving problems, increased team collabora- tion, and increased hope and morale among workers. The community meeting tool among staff and clients brings groups of people together for a very short meeting in which each member reports a feeling, a goal, and a person to ask for help. The outcomes of this practice are increased awareness of the feelings of others, improved ability to focus on the future rather than dwell on the past, and a stronger sense of community among members of the organization. Team meetings offer similar outcomes for staff, in that team members who meet together in this forum have an increased understanding of each other’s triggers, can use this knowledge to intervene more appropriately with each other in the milieu, and have a clearer sense of each individual’s vulnerability to reenactment within the team. This increased knowledge allows for faster resolution of interpersonal conflict as evidenced by disrupted reenactment, fewer untoward events, and improved teamwork. Red Flag Reviews, which allow anyone in the commu - nity to bring a concern to be addressed and to use the trauma-informed, problem-solving framework of S.E.L.F., result in more collaborative and crea - tive solutions to client and organizational issues, and encourage higher lev - els of functioning in multidisciplinary teams. Service planning using a multidisciplinary approach and the S.E.L.F.

framework as a way to organize client problems, goals, and interventions results in an increased focus on resolving issues of emotion management, Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 129 loss related to trauma or exposure to adversity, and sense of hope for the future rather than overemphasizing client behavioral control in the service of safety as the exclusive priority. Psychoeducation for clients and supervision for staff are tools that reinforce the common language of trauma and adversity and that help clients and staff avoid traumatic reenactments. Organization-Level Activities and Outcomes The organization-level activities are represented by operationalizing the Seven Commitments, since these are the values to which organizations using Sanctuary aspire. The purpose of each of the Seven Commitments is to combat the negative effects of exposure to trauma and adversity through construction of an environment that systematically exposes a traumatized individual to repetitive restorative experiences within the treatment setting.

Each commitment is described in Table 6.3. Operationalizing these commitments, aligning policies and prac - tices with these commitments across all areas of the organization (leader - ship, human resources, admissions, milieu, and treatment/clinical), and evaluating progress against the Sanctuary Certification Standards are the organizational activities. The results of these activities are alignment of prac - tices and policies as well as behavior of leaders and staff with the Seven Commitments. Leaders report feeling more hopeful and effective, and they demonstrate appropriate use of and distribution of power. The active role of the Core Team in operationalizing the Seven Commitments results in mem - bers’ increased participation in decisions, often also reflected in the general experience of all staff. Increased participation correlates with increased cli - ent and staff satisfaction, reduced turnover, and improved recruitment and retention.

Community and Societal Activities and Outcomes Community activities fall into two categories: (a) the community of Sanctuary agencies, also known as the Network, and (b) the society at large, which includes funders, regulators, referents, stakeholders, and colleagues.

Both types of “community” have an evolutionary quality to the way in which Sanctuary concepts and tools get applied within their respective settings. Within the Network, agencies learn early on about other Network agen - cies and their client base, as well as a little about what products and practices they use. The purpose is to help Network agencies begin not only to see each other as potential resources and partners in the implementation process but also to function as a community that can ultimately speak with a stronger voice regarding issues of trauma and the healing process—and a commu - nity that is data-driven. The result of this effort is that Network agencies become increasingly confident about sharing their effective practices with others (demonstrating social learning). Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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130 Making s trategy Count in the h ealth and huM an s erviCes s eC tor The second category of community involves the society at large. In this context, the goal is to reach out to colleagues, consumers, and governmental bodies in order for them to recognize the effects of trauma on children and their families and those who serve them. The results of these activities are improved regulations and enhanced funding streams that give priority to evidence-supported trauma interventions. Discussion Application of a socioecological logic model to the Sanctuary Model inter - vention process is beneficial is several ways. First, the logic model high - lights positive systems change as a primary goal of Sanctuary Model T ABLE 6.3 The Sanctuary Model’s Seven Sanctuary Commitments Nonviolence The community works toward ensuring that all members are safe and refrain from hurting each other.

Emotional Intelligence Recognizing and anticipating the influence that emotions have on behavior and using that information to guide practice.

Democracy Encourages community members to share decision making in whatever ways are most appropriate for their group. This is based on the premise that diversity of opinion yields a better result and that people are more likely to support something they have helped create.

Open Communication Members agree to be aware of how they communicate with each other. Community members agree to talk about issues that affect the whole community, no matter how difficult they may be, and to do so in a direct and open way. Leaders practice transparency in regard to deci- sions or issues that affect everyone. All community members have the information they need to be successful.

Social Responsibility Agreement that the community will take care of itself and its members. Members share respon- sibility for doing good work, adhering to the rules of the community, and being accountable for their behaviors and decisions.

Commitment to Social Learning Creating an environment that allows people to learn from each other, their experiences, and their mistakes.

Growth and Change The belief that individuals, groups, and systems can grow and heal. We create situations that promote growth out of our comfort zones and create a sense of disequilibrium that forces movement. Growth and change are achieved through inquiry, self-reflection or assessment, and acquiring knowledge. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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Chapter 6 strategy, sanCtuary, and turnaround 131 implementation by clearly articulating potential change at higher socio - ecological levels. Second, the model differentiates between activities and outcomes at each level of the social ecology, providing a framework for corresponding trauma-informed activities and outcomes. This framework promotes outcome measurement at all levels, potentially informing indi - vidual organizational intervention projects, as well as the overall devel - opment and evaluation of the Sanctuary Model across various settings.

Third, because the Sanctuary Model itself is informed by systems theory, the socioecological logic model is theoretically complementary and allows for a trauma-informed, systems-inclusive approach that is useful in plan - ning, implementing, and evaluating Sanctuary Model organizational interventions. Although useful, there are some limitations related to the application of the socioecological logic model to the Sanctuary Model for trauma-informed organizational change. First, though the proposed logic model provides a solid framework distinguishing activities and outcomes for each discrete level, changes in organizational culture and at the community level are complex and may require efforts from multiple agents. As such, it is often difficult to attribute change to a single program or intervention when meas- uring change across organizations and systems. Second, an organization’s or community’s capacity to and readiness for change will influence its abil- ity to successfully implement and achieve systems-level changes. For exa\�m- ple, child welfare organizations often suffer from change fatigue associated with repetitive organizational restructuring, which may detrimentally affect their workers’ readiness for change and capacity to take on new initiatives.

Third, the theoretical frameworks that inform the Sanctuary Model do not distinguish between the constructs of organizational culture and climate and do not specifically account for climate factors, which may be an impor\�tant consideration when examining the social context within which large-scale change occurs. Enhanced testing is critical seeing that the Sanctuary Model is the only trauma-informed organizational intervention of its kind, cur - rently being implemented in over 250 agencies in a variety of settings an\�d communities across the nation (for implementation details, see Sanctuary Institute, 2012, n.d.). Conclusion Individuals who have experienced trauma continue to suffer from sub - optimal physical and mental health. Yet, research demonstrates that survivors of trauma can be resilient if they are connected to positive, caring service providers (Harney, 2007; Larkin, Beckos, & Shields, 2012).

Unfortunately, high turnover and emotional exhaustion among staff who work with traumatized individuals threaten to create an environment in which it is difficult for these clients to build meaningful connections with providers. Making Strategy Count in the Health and Human Services Sector : Lessons Learned from 20 Organizations and Chief Strategy Officers, edited by Tine, MGA, JD, FCPP, FAAN Hansen-Turton, and Michael Mortell, Springer Publishing Company, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1572950.

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132 Making s trategy Count in the h ealth and huM an s erviCes s eC tor The Sanctuary Model aims to reverse these trends through a set of tools that create an emotionally and physically safe environment for traumatized clients and everyone connected with them. Although more rigorous evalua - tion of the Sanctuary Model is needed, the emerging research demonstrates that it is a promising approach for creating a healthy environment that pro - motes emotional health and well-being for agency personnel and the clients they serve (Rivard et al., 2005; Stein, Sorbero, Kogan, & Greenberg, 2011). By protecting the emotional health of agency personnel, the Sanctuary Model creates a context in which service providers can be emotionally available to each other and their clients, resulting in positive relationships that create the conditions for resilience. References Bertalanffy, L. (1974). General systems theory and psychiatry. In S. Ariete (Ed.), American handbook of psychiatry (2nd ed., Vol. 1; pp. 1095–1117). New York: Basic Books.

Bloom, S. L. (2011). The Sanctuary Model. Retrieved October 18, 2011, from http://www .sanctuaryweb.com/trauma-informedsystems.php Bowlby, J. (1988). A secure base. New York: Basic Books.

Brock, K. J., Pearlman, L. A., & Varra, E. M. (2006). Child maltreatment, self capacities, and trauma symptoms: Psychometric properties of the Inner Experience Questionnaire.

Journal of Emotional Abuse, 6(1), 103–125. doi:10.1300/J135v06n0106 Freudenberger, H. J. (1974). Staff burnout. Journal of Social Issues, 30(1), 159–165.

Harney, P. A. (2007). Resilience processes in context: Contributions and implications of Bronfenbrenner ’s person-process-context model. Journal of Aggression, Maltreatment & Trauma, 14(3), 73–87.

Hasenfeld, Y. (1992). Human services as complex organizations. Newbury Park, CA: SAGE.

Hermans, H. J. M. (1976). Value areas and their development: Theory and method of self- confrontation. Amsterdam, The Netherlands: Swets & Zeitlinger.

Hermans, H. J. M. (1991). The person as co-investigator in self-research: Valuation theory. European Journal of Personality, 5(3), 217–234.

Hermans, H. J. M., Fiddelaers, R., de Groot, R., & Nauta, J. F. (1990). Self-confrontation as a method for assessment and intervention in counseling. Journal of Counseling & Development, 69(2), 156.

Hermans, H. J. M., & Hermans-Jansen, E. (1995). Self-narratives: The construction of meaning in psychotherapy. New York: Guilford.

Himle, D. P., Jayaratne, S., & Thyness, P. (1991). Buffering effects of four social support types on burnout among social workers. Social Work Research & Abstracts, 27(1), 22–27.

Iglehart, A. P. (2009). Managing for diversity and empowerment in human services age\�n- cies. In R. J. Patti (Ed.), The handbook of human services management (2nd ed.; pp. 295–318).

Thousand Oaks, CA: SAGE.

Jackson, S. E., Schwab, R. L., & Schuler, R. S. (1986). Toward an understanding of the burn- out phenomenon. Journal of Applied Psychology, 71(4), 630–640.

Jones, M. (1953). The therapeutic community: A new treatment method in psychiatry. New York: Basic Books.

Jones, M. (1968). Beyond the therapeutic community: Social learning and social psychiatry. New Haven, CT: Yale University Press.

Katz, D., & Kahn, R. (1978). The social psychology of organizations (2nd ed.). New York: Wiley.

Kets de Vries, M. F. R. (1991). Organizations of the couch. San Francisco, CA: Jossey-Bass.

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