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| S.E.L.F. A Nonlinear, Cognitive Behavioral Approach to the Treatment of Complex Personality Disorders. Sandra L. Bloom, M.D.
A large and growing body of research has demonstrated that there is a high degree of comorbidity between substance abuse, exposure to child maltreatment and a variety of other traumatic experiences, depression, self-harming behavior, suicidality, and a variety of personality disorders. Although recognizing these connections is a critical component to devising an adequate plan for recovery, the result is an exponentially more complex clinical picture. S.E.L.F. is a simple conceptual framework for managing great complexity. As part of the Sanctuary Model, S.E.L.F. provides a nonlinear, cognitive behavioral therapeutic approach for facilitating client movement through the four critical stages of recovery: Safety (attaining safety in self, relationships, environment, and beliefs); Emotional management (identifying levels of affect and modulating affect in response to memories, persons, events); Loss (feeling grief, dealing with personal losses, and confronting resistance to change), and Future (trying out new roles, ways of relating and behaving as a “survivor” to ensure personal safety and help others).Using S.E.L.F., the clients and staff are able to embrace a shared, non-technical and non-pejorative language that allows them all to see the larger recovery process in perspective. The accessible language demystifies what sometimes is seen as confusing and even insulting clinical or psychological terminology that often confounds clients and line-staff, while still focusing on the aspects of pathological adjustment that pose the greatest problems for any treatment environment. Much of the initial focus in any treatment setting must be on Safety and Emotional Management. In S.E.L.F. the definition of Safety encompasses four domains: physical, psychological, social, and moral. As such the development of a safety plan embraces problems as diverse as self-mutilation, drug addiction, and chronic suicidality to interpersonal abusive behavior, racial slurs, rumor-mongering, and inadequate self care. Most of the problem behaviors and overwhelming emotions that present difficulties for clients, clinicians and behavioral health settings reflect problems with appropriate Emotions. Loss can be clinically recognized as a failure to make progress, continued acting-out, reenactment behavior, chronic depressive symptoms, sudden regression, and unresolved bereavement. Future represents the objective – the hopeful vision of what the future can look like as a result of recovery and includes the willingness to engage in transformation that would lead beyond the “sick” role and requires the assumption of personal and social responsibility, appropriate risk-taking, education, and progressive change in self image, behavior and interpersonal relationships.The further utility of S.E.L.F. is that it can simultaneously be employed in a parallel process manner to deal with problems that arise within the treatment setting between staff and clients, among members of staff, and between staff and administration. Applied to such issues of staff splitting, poor morale, rule infraction, administrative withdrawal and helplessness, and misguided leadership, S.E.L.F. can also assist a stressed organization conceptualize its own present dilemma and move into a better future through a course of complex decision making and conflict resolution. S.E.L.F. has now been demonstrated to be of great value within many different treatment settings: inpatient; outpatient; parenting programs, children’s residential programs; domestic violence shelters; and substance abuse facilities. Research funded by the National Institutes of Mental Health has been conducted to study the implementation of The Sanctuary Model and the S.E.L.F. framework within a residential setting.Articles Related to S.E.L.F.*
Every outpatient and inpatient mental health setting, child protection service, parenting program, domestic violence shelter, school, and homeless shelter today must contend with the issue of a past history of exposure to trauma in their clients. Grant applications and federal funding sources insist that programs become “trauma-informed”. But how can professionals – some with extensive professional training, and some with very little formal training – address the issues that arise surrounding past abuses and exposure to violence without “opening up a can of worms”? The S.E.L.F. Psychoeducational Group Curriculum is a good way to start, addressing the fundamental problems surrounding exposure to violence without needing to focus on specific individual events within a group setting. The most elementary aspect of becoming trauma-informed is education. Trauma recovery begins with psychoeducation. Educating people about the impact of overwhelming life experience helps to get everyone “on the same page” with a shared and coherent organizing framework that does not stigmatize the injured person but instead allows a much closer and empathic understanding between client and caregiver. Unlike most of the theoretical jargon that informs so much of mental health treatment, educating people about the psychobiological effects of serious, recurrent, and chronic stress “rings bells” for them. Even people with little education can easily grasp very complex concepts because the concepts are consistent with their own experience. Much of educating people about trauma is simply giving them words for what they already know and helping them see patterns where no patterns existed for them before. S.E.L.F. is not a staged treatment model, but rather a nonlinear method for addressing in simple words, very complex challenges. Victims of overwhelming life experiences have difficulty staying safe, find emotions difficult to manage, have suffered many losses and have difficulty envisioning a future. As a result, they are frequently in danger, lose emotional control or are so numb that they cannot access their emotions, have many signs of unresolved loss, and are stuck in time, haunted by the past and unable to move into a better future. The four concepts: Safety, Emotions, Loss, and Future represent the four fundamental domains of disruption that occur in a traumatized person’s life and within these four domains, any problem can be categorized. Naming and categorization are the first steps in making a problem manageable. The S.E.L.F Psychoeducational Group Curriculum is designed to provide clients – and staff – with an easy-to-use and coherent cognitive framework that can create a change momentum. Because it is a model that is “round” not square, circular, not stepped, it provides a logical framework for movement. We think of S.E.L.F. as a compass through the land of recovery that can help guide individual treatment, staff decision, team treatment planning, and an entire institution. It is not constrained by gender, age, race, religion, or ethnicity because the domains of healing that S.E.L.F. represents are human universals, unbound to any time, place, or person. In our residential programs, children as young as four are comfortably using the S.E.L.F. language – and using it appropriately. The S.E.L.F. Psychoeducational Group Curriculum has been almost twenty years in the making. The authors of this curriculum founded The Sanctuary® programs, originally in-patient adult programs to treat complex problems related to a past history of child abuse and neglect and now extended to children’s residential programs, adult substance abuse programs, and a variety of outpatient programs for children and adults. We now have a Sanctuary Institute to formally train programs in the Sanctuary Model. Our S.E.L.F. groups evolved organically from our need to teach our adult clients how to:
This curriculum has grown out of that experience and has been adapted to the unique environments that today characterize the mental health and social service world. Introductory information, an essay on the Sanctuary philosophy, and a Table of Contents that lists all the available lessons can be downloaded for free at any point. Each individual lesson in the curriculum can then be purchased on-line after signing a licensing agreement that allows a program the right to copy the material but only for that program’s use. Each lesson includes:
For the most part, each lesson is independent of every other lesson and there is no fixed order within which the lessons must be taught. We arranged the curriculum this way for some very specific reasons:
It is not necessary to read the Resource material in order to have the groups be beneficial. However, we believe that as staff members watch the outpouring of new information that will inevitably arise from the group process, their curiosity is likely to be stimulated and we wanted some material to be readily available to them. In some of the lessons we have also suggested some relevant movie titles pertaining to the topics. Although this is a trauma-informed curriculum, we do not frequently address head-on the issue of trauma, maltreatment or abuse. Again, this was intentional - words like "trauma" and "abuse" are highly charged for many people and are frequently misunderstood. We focus instead on the results of exposure to trauma - experiences that everyone can relate to, whether they have been traumatized or abused in the past or not :
Likewise, many of the lessons can be used for family groups without the need to create an atmosphere of recrimination, guilt or accusation. Finally, we recognize that the staff members in most mental health and social service environments are stressed, frequently demoralized, frustrated, and overburdened. Many of the direct line staff - and in many cases the professionally trained staff - have little if any experience in running groups and may be intimidated by the prospect of using a group format. Unfortunately, failure to create a safe group atmosphere wastes an enormous human resource for positive change. Recognizing this dilemma, we have tried to create scripts for group leaders that will create an interactive but contained process, even while opening up painful subjects. Using an educational format - that includes handouts, flipcharts, a question-and-answer format - promotes a containing environment quite different from a typical process group that can be far more difficult to manage. In this way, staff members can discover the power of the group process in helping people to learn, grow and change, while simultaneously building community within their setting. *S.E.L.F. was formerly called "S.A.G.E." standing for "Safety", "Affect management", "Grieving", and "Emancipation" - concepts equivalent to S.E.L.F. but we have found the latter concepts - Safety, Emotions, Loss, and Future simpler and easier for anyone to understand
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