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DESTROYING SANCTUARY This page intentionally left blank Destroying Sanctuary The Crisis in Human Service Delivery Systems Sandra L. Bloom, MD Brian Farragher, LCSW, MBA 1 2011 1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offi ces in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright 2011 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Bloom, Sandra L., 1948– Destroying sanctuary : the crisis in human service delivery systems / by Sandra L. Bloom, Brain Farragher. p. cm. Includes bibliographical references and index. ISBN 978-0-19-537480-3 1. Mental health services—United States. 2. Social services— United States. I. Farragher, Brain J. II. Title. RA790.6.B65 2011 362.1—dc22 2010012021 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper This book is dedicated to the administrators, managers, direct and indirect care staff in our healthcare, mental health, and social services who, every day, are willing to take on the emotional labor of doing whatever they can do to relieve the suffering of those in their care. The world is a daycare center and we are each given some toys to play with. Roy Stern, M.D. Contents Preface xv Prologue: October 1996 xxi Sanctuary Retreat, October 25, 1996 xxii Introduction: January 2010 3 Sanctuary 4 “Aha” Experiences for Health and Human Services 5 Systems in Crisis: The Impact of Biological Reductionism 6 System Degradation: Systems in Crisis 8 New Mental Models 9 Organization as Machine 10 Organization as Living Being 10 Thinking About Operating Systems: A Useful Metaphor 11 Hardware, Software, and Operating Systems 11 The Human Operating System and the Virus That Disrupts It 12 Organizational Culture: The Organizational Operating System 13 Organizational Stress, Parallel Process, and Trauma-Organized Systems 14 A Word About Vocabulary 15 Chapter Summaries 18 A Cautionary Note 21 1. Human Service Organizations: Dead or Alive? 23 The Case of the Separated Garbage 23 Mental Models Shape Our World 25 Organizations as Machines 26 Health Care as Commodity: The Failed Balancing Act of U.S. Health Care 27 Mental Models of the Healing Professions 28 Aesculapian Authority 29 Community Responsibility 30 Health Care and the Threat of Communist Enslavement 30 Privatization Rules 31 viii Contents Managed Care and Ethical Confl icts 33 Mental Models for U.S. Capitalism 36 Lessons Learned? 38 Mental Health: An Example of a System Under Siege 40 System as Machine 40 Social Engineering Cannot Address Adaptive Problems 42 Interlocking Crises 43 What Happened to the Social Psychiatry? 45 The Personal Is Political 46 A Biopsychosocial Model and General Systems Theory 48 The System Bites Back 49 Reductionistic Behaviorism 49 Deinstitutionalization and Deregulation 50 And That Brings Us to Today 51 The Economic and Human Burden on the System 52 Managed Care and Inadequate Payment 54 Transinstitutionalization and Inappropriate Care 54 Just Don’t Ask About Trauma 57 Systems in Crisis 58 Conclusion 60 2. “I Gotta Get Out of This Place”: Workplace Stress as a Threat to Public Health 61 It’s All about Stress 61 Kinds of Stress 61 Allostatic Load 63 Adverse Childhood Experiences: A Public Health Nightmare 63 Adverse Childhood Experiences and the Workforce Crisis 65 Trauma Touches Everyone 67 Workplace Stress: Defi nitions, Scope, and Costs 68 “Normal” Sources of Workplace Stress 69 Downsizing and Turnover 70 Workload and Job Complexity 72 Role Defi nitions 75 Relationships, Diversity, and Health Disparities 78 Inadequate Training and Career Development 79 Regulation, Paperwork, and Corporate Compliance 83 Professional Values, Ethical Confl icts, and Burnout 83 Disruption in the Organizational Operating System 87 Lack of Mission Clarity 88 Lack of Innovation and Stagnation 89 Conclusion 90 3. When Terror Becomes a Way of Life 91 Attachment: The Human Operating System 91 Mirror Neurons: Wired at Birth for Social Relationship 92 Contents ix Attachment in Adults 95 Social Support 95 Attachment to the Group 96 Group Cohesiveness 98 Trauma Disrupts Attachment 98 The Young Brain Organizes Around Trauma 99 Attachment Trauma and Betrayal Trauma 100 Disrupted Group Attachment Threatens Survival 100 Deindividualization and Ostracism as Disrupted Attachment 101 Disrupted Attachment, Stress, and Trauma 102 The Human Stress Response: What Does Everyone Need to Know? 102 When Terror Becomes a Way of Life 106 Individualism, the Common Good, and Modern Day Stress 106 Loss of Basic Safety and Chronic Hyperarousal 107 Loss of Emotional Management 108 Diffi culties With Learning, Memory, and Decision Making 109 Miscommunication, Confl ict, and Alexithymia 112 Authoritarianism and the Danger to Democracy 114 Learned Helplessness 115 Punishment, Revenge, and Injustice 115 Addiction to Trauma, Trauma-Bonding, and Traumatic Reenactment 118 Grief, Reenactment, and Decline 121 The Germ Theory of Trauma and Public Health 122 Time-Binding Animals 125 Existential Terror and Terror Management Theory 125 Social Problems are Preventable 126 Who Deserves Empathy? 127 Science: Enemy or Ally? 128 Conclusion 129 4. Parallel Processes and Trauma-Organized Systems 131 Organizations as Complex, Adaptive, Emergent Systems 131 The Concept of Groupmind 132 General Systems Theory 132 Living Systems Are Characterized by Emergence 134 Not Sick or Bad, But Injured 135 Living Systems With Visible and Invisible Groups 136 Group Stress Responses 137 Group Emergency Responses to Threat 137 When Threat Becomes a Way of Life: Parallel Processes Emerge 139 Sanctuary Trauma 142 Sanctuary Harm and Collective Trauma 142 Social Defense Systems 143 Bion and Basic Assumption Groups 144 Jung and Shadow Groups 145 x Contents Menzies and Social Defense 145 Institutional Uncertainty 146 Institutional Trauma and Breakthrough Anxiety 146 The Social Defense System Operating Today 148 Parallel Process: A Trauma-Informed Understanding of Social Defensive Structures 150 What Is Denied Comes Back to Haunt Us 152 When Tragedy Strikes: The Impact of Chronic Stress and Collective Trauma 152 Conclusion 154 5. Lack of Safety: Recurrent Stress and Organizational Hyperarousal 155 Crisis in Human Service Delivery 155 Six Stages of Crisis Management 156 Violence in the Human Service Workplace 158 Dangerous Professions 159 Workplace Aggression and Bullying 161 Adult Psychiatric Inpatient Suicide 163 Working With Traumatized Children: Child Protection Workers 165 Chronic Crisis Equals Chronic Hyperarousal 166 Loss of Social Immunity 169 Thwarting Basic Needs 170 Triggering Mistrust 170 The Betrayal of Trust 172 The Blame Culture 174 The Silencing Response 175 Moral Distress 177 Unrelenting Systemic Stress 178 Conclusion 180 6. Loss of Emotional Management 181 Emotional Intelligence and Trauma 181 Emotional Resonance and Contagion 182 Emotional Labor 183 Economic Invisibility and the Legacy of Gender Discrimination 186 Emotional Labor and Job Requirements 188 Training for Emotional Numbing 188 Dehumanizing Caregiving 189 All You Do Is Talk to People 190 Managers and Emotional Labor 191 Organizational Emotions 192 Emotions and Organizational Crisis 193 Groupthink 195 Contents xi Conformity 197 The Abilene Paradox 197 Chronically Fear-Based Organizations 198 Confl ict in the Workplace 201 The Nature of Confl ict 202 Confl ict and Emotional Intelligence 204 Different Kinds of Confl ict 205 Confl ict Management Strategies 206 Confl ict Management Under Stress 207 Chronic Confl ict and Organizational Learning 209 Conclusion 210 7. Organizational Learning Disabilities and Organizational Amnesia 211 Organizational Learning Disabilities 211 Chronic Stress Interferes With Learning and Adaptation 212 What Is the Increase in Value We Are Aiming for? 213 No Time for Process—Failure of Integration 214 Wisdom Walks out the Door and Is Not Replaced 215 Labeling That Prevents the Expansion of Knowledge 217 Self-Fulfi lling Prophecies: Setting the Trap for Reenactment 220 Filtering out Trauma 223 Organizational Memory and Organizational Amnesia 224 Failures in Memory Storage 226 Downsizing Memory 227 Organizational Amnesia and the Mental Health System 228 Those Who Cannot Remember the Past… 229 Factors Contributing to Loss of Knowledge 230 Trauma and Organizational Memory 235 Compromised Decision Making 236 Absence of Participation in Decision Making 237 Decision Making Under Stress 238 Stress and Group Performance 239 The Destructive Aspects of Silencing Dissent 240 Group Polarization: Why It Must Be Safe to Dissent 241 Dissent Is Rarely Welcomed 242 Conclusion 243 8. Miscommunication, Confl ict, and Organizational Alexithymia 245 Patterns of Organizational Miscommunication 245 Different Lenses, Different Points of View 246 Different Theories, Different Mental Models 246

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