Using the “Sanctuary SELF Model” in Individual Therapy — Working With Adolescents — A Therapist’s Primer
The purpose of this article is to share an approach to individual therapy consonant with a client-centered approach, CBT (cognitive behavioral therapy), and TF-CBT (trauma-focused — cognitive behavioral therapy). The Sanctuary Model, created by Dr. Sandra Bloom is a trauma-based model and treatment modality. Understanding the concepts herein allows for incorporating aspects of the approach to fit your clients’ therapy needs be they victims of past abuse, trauma, or loss. This understanding allows for use of conceptual-theoretical derivatives that can be generally applied. For those who have been trying to maintain fidelity to the TF-CBT model, it becomes apparent that “one size” does not fit all. One of the greatest values of the SELF model is its allowance for processing loss through the use of psychoeducation. Based upon an assessment of treatment needs, even resistant clients can be more amenable to personal growth and greater emotional and behavioral regulation.
In order to begin it’s important that folks have some familiarity with the SELF Model.. If you aren’t familiar with the model or Dr. Sandra Bloom’s work, please review the embedded link below. Briefly, come to know SELF. The acronym stands for S-safety, E-emotions AND emotional management, L-loss, and F-future. It seems that these are readily understood concepts and of great importance.
“…the Sanctuary Model provides a structure and common language for people in human services fields to communicate and collaborate with each other. Said Dr. Sandra Bloom, developer of the model: “Social workers, psychiatrists and nurses don’t share a common way of working with clients. The Sanctuary Model gets everybody on the same trauma-informed page.”
Her model is flexible and parsimonious. It is neither as prescriptive as TF-CBT, nor is it limited to trauma. It’s highly generalizable. This becomes very useful for those clients who are resistant or unwilling/unmotivated to work and, for those who don’t have trauma as a primary treatment concern. It can be more fitting and applicable to a wider array of past-rooted, angst-driven, emotional dysregulation. The model’s presupposition suggests that much anxiety and emotional turmoil is related to “loss”. Often we find ourselves working with clients who may not meet the criteria for a PTSD diagnosis. However, many have been exposed to and struggle with forms of loss such as divorce, abandonment (physical and/or emotional), and unresolved bereavement.
I incorporate many of my own beliefs into my work — my own thoughts, feelings, and experiences. Since becoming acquainted with the Sanctuary Model, I’ve come to understand its value as a trauma-based theory that serves as both a CBT model and as one that dovetails smoothly with TF-CBT. Some believe true mental health comes from allowing oneself to experience all 5 of their primary emotions and be able to manage them.
I’ve also most recently become aware of Brene Brown and her outstanding approach; ideas that validate both the Sanctuary Model and my approach. Perhaps you’re aware of her work? Dr. Brown’s specialty includes a focus on vulnerability, courage, authenticity and shame. Note the vulnerability-shame theme can be tied directly to the Sanctuary Model’s concept of loss and resonates with the emotions of scared and ashamed.
“Vulnerability isn’t good or bad. … To feel is to be vulnerable. To believe vulnerability is weakness is to believe that feeling is weakness. To foreclose on our emotional life out of a fear that the costs will be too high is to walk away from the very thing that gives purpose and meaning to living.” Aug 22, 2018
Every session, every interview needs to begin with an initial triage. We must determine the ‘mindspace’ of a particular client at the beginning of every session. When the notion of triage is addressed the concept is to ascertain how much? How mad? How sad? (Rarely are we faced with situations requiring triage of “glad”.) How scared? How ashamed? The greatest concern can be had for those latter two emotions. Humans who experience high levels of fear or embarrassment — shame, have great degrees of stress and anxiety. As well, those states if consistently presented in either highly acute means and/for extended periods of time certainly result in mental illness. Likewise, those experiencing high degrees of either dearly need advocacy to minimize them. As well, across the full range of emotions, being able to experience them at lower levels is indicative of mental health and resiliency. Low levels of fear (scared) allow for increased levels of safety. An example of this would be when your intuitions ‘tells’ you that you’re in the midst of some dangerous circumstance or environment. These feelings are pre-consciously suggesting fight or flight. “Freeze” is not necessarily a functional response despite being a symptom and part of the sequelae of trauma. Ashamed may be most debilitating at high levels and tends to strip away ego strength. However, at low levels embarrassment can be a strong indicator of conscience and inculcated pro-social family values
The SELF model is both a cognitive/behavioral model and is based upon trauma treatment. Dependent upon a client’s course of treatment over time, a greater amount of the SELF model may be introduced and used in sessions. As a construct it allows both therapist and client the comfort of its innocent structure. It can be readily integrated into that working phase of treatment that calls for more affective processing. As well, if accustomed to fits and starts in clients close to that working phase, it can also be of benefit to get a “stuck” client back on track.
Also, as sessions proceed over time and greater rapport has been developed, the “check-in” portion of each and every session can be evaluated. The therapist can compare and contrast with the client’s self-report of both their “doing” status and their “emotional status”. One will know the client’s making progress when the daily behavioral, “doing” report is becoming more consistently positive. Then the therapist can bring attention to the correlation of more positive behaviors coinciding with reports of more positive emotional status. By this point in time almost every client has been provided with psychoeducation of “the cognitive triangle”. Once the client’s been able to see and feel the connection between choices of different behaviors — perhaps lessening over-thinking — ruminating cognitive distortions, it’s time to bring the “triangle” to a more holistic whole. When the therapist has helped the client develop interventions — coping strategies that do have benefit, bring their attention to the action. Changing behavior is crucial as it’s the best way for an individual to experience the validation of accomplishment and validation that supports their “personal reality’. (We tend toward seeking evidence to support our beliefs.) Changing behavior can be the ‘easiest’ in-road to changing thinking patterns.
So, you want to be a therapist? Then please keep this in mind; thoughts are what we hear. Sometimes those thoughts include feelings. Understand that feelings always include thoughts. Regardless, do attend to the unspoken feelings.
In my experience I’ve come to observe a real commonality with clients. One of the therapist’s primary roles is advocacy via Carl Rogers’ necessary conditions.. We need to provide congruence (genuineness or realness), unconditional positive regard (acceptance and caring), and accurate empathy (an ability to deeply grasp the subjective world of another person). It’s been said that while these are the necessary prerequisites in the helping relationship, they alone are not sufficient. Quite often I feel the need to view clients within their environments; home community, family and our culture. In that last regard, we can, at times, share that similar culture. We live in a culture that’s comfortable with anger “Mad”. Sad appears to be an emotion our culture struggles to accept, express or manage….Likewise SADNESS SCARES people. It’s weird. This, again, is where Brene Brown is spot-on! We must learn to embrace our weaknesses, vulnerability, and fear. We must allow ourselves to accept, even welcome all of our emotions in order to manage them! Our client’s manifestations of our culture tend to typically mix-up mad and sad — as if they ‘cross-pollinate’. Many are uncomfortable with feeling sad and/or expressing sad and consequently they tend to behave “anger” when they’re struggling to express sadness. And, often they’re unaware of an unintended outcome; one similar to a defense mechanism, it keeps others at a distance. The behavior gets reinforced and they’re not aware of the dynamics or process. But, in their pushing others away, via that angering, they also pre-consciously add to and reinforce their sadness through the absence of healthy relationships.
If working with the family, use of the SELF psychoeducation “model” can be a very useful “hook” for forming an alliance. Doing so rarely if ever betrays your alliance and advocacy for the client. Quite often parents view their kids as beyond repair. In providing psychoeducation with parents one can readily combine Sanctuary components with TF-CBT. I use Sanctuary SELF in a manner equivalent to what I’m presenting here; those thoughts/philosophies consonant with the aforementioned models. The Sanctuary Model is very user friendly — not confusing — as it has little psychological jargon. I use the same “check-in” format with primary caregivers and over time teach them its relevance and usefulness. In particular, after covering “mad”, “sad”, and “glad” when arriving at “scared” and “ashamed” an opportunity presents to assuage parent feelings toward-about their child. When presenting “scared” or fear, it is always noted and stressed that low levels of fear are in fact good. It’s a safety default. This can also be a good point to address sensory or physiological response to fear. Furthermore, when explaining meanings of “ashamed” parents may be encouraged to hear that their children do have an underlying core of family values. Again, lower levels of “ashamed” are indicative of a conscience and superego. Conscience, or character, is acting as if your mother is watching you all the time; that one recognizes the difference between right and wrong.
Individual Therapy Sessions
For all individual therapy sessions proceed as follows:
Begin each session with your greeting: “Hello, how are you doing?” and follow that with a Sanctuary greeting: “How are you feeling?” All the while the clinician simultaneously needs to conduct an initial “triage” assessment.
First, understand this as a flexible and open-ended construct, a general underpinning and foundation. It’s not formulaic. The “method” also provides structure…I don’t know about you, but in my therapy endeavors I have good days when I can be really attuned — “clicking”. And, I have days when I’m just not quite on my game. This doesn’t even account for however many of our clients work toward genuine goals and are motivated. Also understand that distinctions need to be made between motivation, resistance, and preconscious avoidance. All three can appear similar yet they convey different dynamics and circumstances. As well, they’re not necessarily mutually exclusive. A client could present with features of all three.
Be cautious in how you interpret my use of the term “structure”. This construct is a guide for reference, but each individual and each individual session is an organic process; at the time, in the moment. It’s not to be adhered to in a strict sense or some sort of rigid fidelity. It is not proscriptive.
So, the individual session starts with the “check-in”. I start every session the same way: “How are you doing?” and “How are you feeling?” This “check-in” early-on in placement is a form of psychoeducation. Initially, clients think my inquiry as “how are you doing?” is simply a greeting. In time they come to realize its place within “the cognitive triangle”. Hence, the “doing”. After we’ve covered “stop, think, do” or “stop, think, act” in CBT psychoeducation it becomes akin to the use of “gradual exposure” in all TF-CBT sessions. I look for a behavioral report in every session. Likewise, the second question is typically prompted and I explain “please choose from the 5 primary emotions” (those of the SELF model: mad, sad, glad, scared, and ashamed). I ask that the client choose from one of those five primary emotions. Often I’ll receive responses of “mixed” and when so, I’ll further ask that they identify their two “mixed” emotions. Ambivalence is not atypical. Depending on the level of their ambivalence, and possible cognitive dissonance, it can be quite uncomfortable.
This part of the structure could also be considered psychoeducation on emotional regulation or within the framework of the Sanctuary SELF mode. It is an ongoing education related to learning one’s emotions. I will often suggest to clients ‘you can’t manage what you don’t know’; which is why one needs to learn more about emotions. I’m also highly attentive to reports of “scared” and “ashamed” as they might need to be triaged and then perhaps become the focus of the session. I also typically will ask clients to “scale” negative emotions.
How I “work it”. First, there’s no need to get caught-up in correcting the typical error of mistaking feelings for thoughts. Because almost all responses to Activating Events go through cognition first (the exceptions being acute “fight, flight, or freeze” responses). Remember the distinction between emotions and feelings? They’re not synonymous. Next help teach “emotions”; that one can’t manage what they don’t know. So, teach them how to more accurately identify emotions. Most therapists themselves, when in training often struggle in reporting thinking states as feelings.
If we’ve not yet worked specifically on CBT interventions, these ventures can be a prelude; used to further explore emotions, thoughts, and feelings. It is imperative that you understand the difference between emotions and feelings. Emotions are the basic core of our affective functioning. Feelings are emotions verbalized through thoughts. All “feelings” have already been run through the filter of cognition — those based upon past experience and one’s own cognitions. Clearly, this latter term, cognitions, carries with it levels of distortion or irrationality; those contained in our cognitive filters. This is not part of the Sanctuary Model nor TF-CBT. Being specific in our language is often critical. Making this distinction has been the result of my own training as a therapist and is my synthesis of the treatment modalities mentioned.
The Sanctuary Model works for me. It’s at first a psychoeducation model that allows for cognitive processing without the natural “trauma avoidance” or resistance that we often face. At its surface, the model’s generalizability can be perceived as innocuous. It’s less “threatening” than engaging in affective processing. I also believe that psychoeducation in and of itself is therapy. , If done conscientiously with those clients who are more receptive it is “therapy”. Again, as part of my training and part of my style, the therapist is required to teach clients what they are doing and why. I’m very open and transparent about this. I’ve made it a part of my style/approach and it helps in developing improved rapport.
ENDING? Remember that question, “how are you doing”? Well, after multiple sessions, as the therapy process moves along, our adolescents start making the connection that coping skills are all actually “doings” — distractions from negative emotions, feelings, and negative errors in thinking. The “intervention” exists in the doing and the change in behavior; knowing the cognitive triangle can help extinguish negative feedback loops and lend momentum toward more positive thoughts and feelings. This “doing” is a huge accomplishment. I don’t know of any other outcome that so greatly influences one’s self-esteem as does accomplishment or mastery of one’s SELF.
