The Power of Trauma-Informed Work to Transform Personal Relationships

Prevalence of Trauma in the U.S. Population

The groundbreaking Adverse Childhood Experiences (ACEs) Study conducted by Dr. Vincent Felitti in collaboration with the Centers for Disease Control and Prevention (CDC; Felitti et al., 1998) highlighted both the astonishing prevalence of adverse childhood experiences in the United States, along with its significant impact on longer-term health outcomes. Three overarching categories of adverse childhood experiences were studied: abuse, neglect, and household challenges, with each category further subdivided into multiple subcategories. The number of categories of these adverse childhood experiences was then compared with measures of adult risk behavior, health status, and disease.

More than half of respondents reported at least one, and one fourth reported >2 categories of childhood exposures. A graded relationship was found between the number of categories of childhood exposure, and each of the adult health risk behaviors and diseases studied. Persons who had experienced a higher number of ACEs were found to have increased health risks for alcoholism, drug abuse, depression, suicide attempt, smoking, poor self-rated health, >50 sexual intercourse partners, sexually transmitted disease, increased physical inactivity, and severe obesity. In addition, the number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases, including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease (Felitti et al., 1998).

Given the implications of the study for public health, the CDC has been tracking the prevalence of ACEs across the United States for a number of years through the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is the nation’s premier health-related telephone survey system that collects state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. Established in 1984 with 15 states, the BRFSS now collects data in all 50 states, the District of Columbia, and three U.S. territories and completes more than 400,000 adult interviews each year, making it the world’s largest continuously conducted health survey system (Centers for Disease Control and Prevention, 2023a).

The prevalence of ACEs from the BRFSS data has been similar to that of the original ACEs study (Centers for Disease Control and Prevention, 2023b). Almost two thirds of surveyed adults reported at least one ACE, and more than one in four reported three or more ACEs. ACEs are common across all populations.

How Trauma Affects Relationships

Child maltreatment negatively contributes to behavioral, emotional, and relational challenges across the lifespan (Banford Witting & Busby, 2019; Fitzgerald & Gallus, 2020; Fitzgerald & Morgan, 2023) and is detrimental to both couple and familial relationships (Kong et al., 2019; Riggs & Kaminski, 2010). The relationship between child maltreatment and challenges with adult interpersonal relationships may be explained by mental health challenges such as depression and social anxiety (Fitzgerald & Morgan, 2023).

One of the core aspects of human development and well-being is the ability to form healthy relationships with others (Godbout et al., 2019). Bowlby (1984) proposed the attachment theory to explain the human drive to form relationships with others and to maintain a desired level of proximity to significant attachment figures. He suggested that an attachment behavioral system regulates the child’s responses when experiencing emotional distress and that attachment figures who offer contact, reassurance, and comfort facilitate the child’s development of emotional regulation and well-being, as well as expectations that close relationships will provide a safe haven and a secure base. These conditions, in turn, are thought to stimulate the development of positive models of self and others in relationships (Bowlby, 1984).

In an extension of Bowlby’s theory to adults (Hazan & Shaver, 1987), insecure attachment is typically conceptualized as comprising two dimensions: abandonment anxiety and intimacy avoidance. The abandonment anxiety dimension represents the individual’s fear of relational rejection and abandonment, in combination with a lack of self-worth. It is thought to involve a hyperactivation of the attachment system that keeps the focus on signals of relational threats and on the search for love and security. The avoidance of the close relationship dimension, on the contrary, reflects an individual’s emotional suppression, self-reliance, and discomfort with closeness and interdependence, based on expectations that others will be unavailable and unsupportive. It involves deactivating the attachment system to reduce negative emotional states and vulnerability to rejection (Mikulincer & Shaver, 2017).

In the case of abuse or neglect, attachment schemas are typically negative. For example, young children who are being maltreated often infer negative self- and other characteristics from such acts. They may conclude that they must be intrinsically unacceptable and deserving of such treatment and may come to see themselves as helpless, unlovable, or weak and view others as inherently dangerous, rejecting, or unavailable (Godbout et al., 2014). As a result, survivors of childhood maltreatment may internalize negative schemas about themselves, others, and their relationships with other people, leading to insecure attachment. Empirical data have generally supported these propositions, with the link between childhood maltreatment and insecure attachment being widely documented in abused or neglected children (Muller et al., 2012) and in adults with maltreatment histories (Erozkan, 2016; Godbout et al., 2009, 2014; MacIntosh et al., 2015).

Social Support and Healthy Relationships

Research has shown that the survivors of childhood adversity benefit from strengthening social support and perceived social support (Cheong et al., 2017). Perceived social support is best understood as an individual’s sense that others will provide them with aid when needed. Different types of social support include emotional support, demonstrated by providing trust, empathy, love, and care; instrumental support, which reflects offering tangible services or practical help; appraisal support, which includes providing affirmation or information relevant for self-evaluation; and informational support, which is the provision of knowledge (House, 1981; Tjin et al., 2022). Studies on perceived social support have consistently shown it to be associated with reduced stress and improved physical and mental health (Haber et al., 2007), and that perception of available social support is a better buffer of psychological distress than actual availability of social support in some studies (Cohen & Wills, 1985; Evans et al., 2013).

Positive relationships can help the healing process from past trauma and/or adversity. Trust, honesty, and compassion are the three elements of a healing relationship. Being loved, respected, understood, and connected to others has been shown to have a profound effect on health (Jonas, 2018). Trust allows one to feel emotionally and physically safe. Honesty provides space for one to reveal one’s true feelings without harm from another. Compassion allows one to be understood and to receive kindness. Honest and open communication is essential to healing relationships. Good communication skills build strong relationships; they ensure that the interpersonal environment optimizes one’s ability to heal (Jonas, 2018).

The Sanctuary Model

The Sanctuary Model^®, an evidence-supported, trauma-informed organizational change intervention, facilitates the creation of therapeutic, supportive organizational cultures in which individuals can heal (California Evidence-based Clearinghouse for Child Welfare, 2021; Esaki et al., 2013). The model is built upon initial efforts undertaken by Dr. Sandra Bloom, Joseph Foderaro, and Ruth Ann Ryan, who 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 collectively participate in creating a system of healing (Jones, 1953, 1968; Lees et al., 2004; Main, 1946), the model has now been implemented in more than 275 organizations worldwide (Sanctuary Institute, n.d.-a).

Though the Sanctuary Model is an organizational intervention, the clinical underpinnings are grounded in constructivist self-development theory (CSDT; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). CSDT is an integrative personality theory that provides a framework for understanding the impact of childhood maltreatment on the developing self (Saakvitne et al., 1998; see Esaki et al., 2013, for further theoretical details). The model is structured around four primary principles—trauma theory, the Seven Sanctuary Commitments, S.E.L.F., and the Sanctuary Tool Kit. Trauma theory reflects what we know about how traumatic experiences affect the brain and, therefore, influence thoughts, feelings, and behaviors. The Seven Sanctuary Commitments are the 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. The Commitments are as follows: Nonviolence, Emotional Intelligence, Democracy, Open Communication, Social Responsibility, Social Learning, and Growth and Change. S.E.L.F. is the acronym for the organizing categories of safety, emotion management, loss, and future, which is used to formulate plans for client services or treatment, as well as for interpersonal and organizational problem-solving. The Sanctuary Tool Kit is a 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 (see Esaki et al., 2013, for more details).

The implementation of the Sanctuary Model is accomplished through a combination of trainings and consultations provided by the Sanctuary Institute Faculty members, who are based at the Sanctuary Institute, a division within ANDRUS, a nonprofit agency in Yonkers, New York. The Faculty members move an organization through a series of steps to align the practices, attitudes, and philosophies of an organization toward a trauma-informed perspective. The process is operationalized, and four manuals are shared with agency staff to assist in the implementation (Sanctuary Institute, n.d.-b).

Role of Sanctuary Model Faculty

The Sanctuary Institute Faculty member is responsible for planning, developing, monitoring, and delivering site training and consultation services. Specific job tasks include providing phone and on-site consultation to support the implementation process, delivering training to a Core Team of representative employees, supporting Core Team representatives to provide ongoing training to other agency staff, and delivering Five-Day Trainings, the initial training for leaders and other key members of an organization, as needed. Much travel is required of Sanctuary Institute Faculty, with Faculty typically traveling 60% of the time. Given the complexity of the model, Sanctuary Faculty are often recruited from agencies that have successfully implemented the model (Salary.com, 2023).

Recruitment and Sample

Sample selection consisted of purposive sampling. Upon study approval by the university Institutional Review Board (approval #1162223) on October 19, 2022, the senior director of the Sanctuary Institute sent an electronic letter of invitation to each Sanctuary Institute Faculty member, which included an explanation of the study, an indication of her support, a statement indicating that she will be blind to who participates or not, and a note about further details to be emailed shortly by the course instructor. Shortly afterward, the course instructor sent a follow-up email to all Faculty providing further details of the study, including the process by which study participants would be interviewed by student researchers via Zoom for between 45 min and an hour, and eligibility to enter a raffle for a US$25 Amazon gift card. In addition, it was noted that an informed consent form providing further details of the study would be sent and reviewed with interested participants before the interview. Those interested in participating in the study were asked to email the course instructor. The course instructor assigned interested study participants to one of three groups of MSW students (two teams with three students and one team with four students) in sequential order. Students followed up with interested participants via email to schedule interviews.

Participation in the study was completely voluntary and confidential, and there was no risk of retaliation against those who declined to participate. The senior director of the Sanctuary Institute did not know which Faculty chose to participate in the study. Out of the 11 Faculty, eight (73%) agreed to be interviewed.

Seven of the eight participants (87.5%) were female; three identified as white (37.5%), three were African American/Black (37.5%), one was Hispanic (12.5%), and one was Bi-racial (12.5%). They ranged in age from 34 to 76, and one completed high school (12.5%), one completed college (12.5%), and six obtained Master’s degrees (75%).

Data Collection

Individual interviews were selected as the method of data collection. Students were trained on and practiced how to conduct high-quality qualitative study interviews. A semistructured interview guide, informed by the research question, was developed by the 10 students in the course. The 18-question guide, including demographic questions, was designed to gather background about the Faculty’s experiences training and consulting on the model, as well as eliciting perspectives on how consulting on the Sanctuary Model impacted their personal relationships, if at all. The guide included questions about whether they use the Sanctuary Model in their personal life, if so, in what ways, and if the use of the model in this area may have impacted their personal relationships in any way. The following are examples of the questions:

Interested readers can request a copy of the questions from the corresponding author.

All interviews were conducted via Zoom, lasted between 20 and 60 min, and most (5; 63%) were conducted by two students. The informed consent form was reviewed in advance of the interview, informing participants that the interview would be digitally recorded (upon their agreement), transcribed, and analyzed. Upon completion of each interview, the audio recording was transcribed using Otter.ai and reviewed and revised for accuracy by one of the student group team members.

Data Analysis

Two of the authors/researchers of this article reviewed each of the transcripts and wrote memos summarizing initial impressions. They then coded the transcripts individually, looking for common themes throughout each interview and across all eight interviews.

In line with the hermeneutic circle of analysis described by Wilding and Whiteford (2005), researchers iteratively reviewed whole transcripts, analyzed sections of data to relate them back to the participants’ full reported experience, and synthesized sections into themes. This approach highlights the value of a phenomenological study’s power to learn from specific, often small populations’ lived experiences as “an interpretive process situated in an individual’s lifeworld,” valuing participants as observers who understand their experiences by interpretive means that include context-relevant bias (Neubauer et al., 2019, p. 92). Concurrently, this approach generates data that, by its nature, is limited in scope and, therefore, limited in application without further exploration. The unique target population sample is not large enough to test saturation, but results suggest a strong trend toward saturation with repeated themes and consistency across participant data.

Findings were developed through a process to reduce researcher bias. Initially, researchers read the complete transcripts for gestalt understanding and then re-read for initial identification of themes. The analysis team, comprised of two researchers, practiced observer triangulation by meeting to review, identify key sections of data, and practice reflectivity, or bracketing (Lietz & Zayas, 2010), before returning to the transcripts to re-read with particular focus on key sections, statements emblematic of proposed themes, and connections within and across participant data. A second discussion to confirm themes and identify clear, concise data points for reporting took place before drafting and collaboratively refining the findings.

Learning About Trauma

As a trauma-informed system, the Sanctuary Model requires Faculty to have a deep and layered understanding of trauma, its impact on individuals and groups, and trauma-informed approaches to people, systems, and situations. Every participant shared how, in their reported view, understanding trauma shifted their thinking and approach to the people in their personal lives. Quotes supporting this finding are below, with the assigned participant number noted in parentheses after each statement.

Several participants described the value of understanding the biological responses to trauma, such as stress, hormones, and brain function, identifying this understanding as coming from, or being enhanced by, their intimate work with the Sanctuary Model:

The model has educated me about the impact of trauma on, you know, an individual and on their brain and on their relationships. Right? And so, that has me operating from that question of “what has happened to people?” rather than “what’s wrong?” I’m less judgmental, you know. (7)

Others talked about valuing this shift from “what’s wrong with you” to “what happened to you” and how this relates to increased empathy:

And I think at the core of it, having a greater understanding of trauma, the impact of trauma, but also the tools of how to work through trauma, those different aspects of Sanctuary, you know, that can only help relationships. Because it builds empathy. It builds understanding, it builds self-awareness, and it builds curiosity, right, you know? . . . And if you rewound, and went back to the start of that argument, and at the beginning of it before laying into that other person for whatever the argument was about, you just pause and ask, what happened? What happened to this person across [from me]? It completely changes the dynamic awareness of trauma and the, you know, tools associated with it. Those are invaluable just for life and relationships, I’d say. (5)

Understanding trauma appears to be foundational both for Sanctuary Model facilitation and the changes the Faculty observed in their personal lives.

Alignment With Personal Values

Every participant referenced how the Sanctuary Model components align with their personal values. The resonance of personal values and model values appears in the data during questions explicitly related to values and also in the discussion of how participants came to work for the Sanctuary Institute, indicating that pre-existing values and awareness of and choice to align with the Sanctuary Model values both occur in our study sample:

You know, in a lot of ways, those [Seven Commitments] are aligned with my core values, which is why I’ve been a big fan of Sanctuary for a long time. So I think I use it [in my personal life], but I don’t explicitly name it in the same way that I might when I would train it or when I’m conversing with coworkers at work. (5)

I resonate with and align with all of the tenets of the model . . . . There’s nothing I push back on, because it’s all so much alignment, in alignment with who I am. (4)

It’s who I am, and there’s these titles that are in alignment with who I am, you know? (7)

The word “alignment” emerged organically in the data multiple times and was not used in any questions in the interview protocol.

Growth as an Individual

With an awareness of trauma and alignment of values, participants’ description of using the model personally follows. The data suggest that the most common ways participants utilized the tools were for internal processing, interpersonal life, and navigating daily activities. Each participant describes using the model to support different aspects of personal growth, such as self-awareness:

I’ve used it like, I need help finding how I really feel when— I’ve got better at it, and I do it more often. So that’s been huge for me just personally” (1); and emotional intelligence,

I certainly have an, a significantly increased ability to manage my emotions in my personal relationships since I started and kind of understanding how traumatic reenactment works and how you recreate situations. (8)

Others reported finding the Model valuable in navigating personal interactions as well as parenting their children:

“I use the Tools every day. Every day. The S.E.L.F. model. And the reenactment triangle . . . . It gave me a foundation and a language which I have used both in my personal life, in my supervisory relationships, and with clients. And with organizations, obviously . . . . Yeah. I always, always, always think when I have an interaction that feels a little off, ‘What’s happened to them?’ It’s just second nature. So there’s no judgment. There’s no preconception. It’s such a healthy way to begin to understand what people present you with . . . . So parenting is not typically made easier by your academic training, but the model is so applicable to so many situations that— [sighs] yeah, God did it help! [laughs]. (6)

Faculty’s use of components of the Sanctuary Model in daily life presents a counterpoint to the intense, complex dynamics the model is designed to support in organizations:

You know, before I go into the grocery store, I sit down and I use, you know, do a quick S.E.L.F. check with myself to see where I am emotionally so that I’m actually buying the things that I intend to buy in the grocery store, instead of buying comfort food and junk food and, you know, Ben & Jerry’s. [chuckles] Or when I am buying Ben & Jerry’s, that I’m doing that intentionally . . . . I lean on it when I don’t— it’s not even when I don’t know what else do, I just lean on it. It’s just, it’s how I function in the world. (2)

When asked if they use the Sanctuary Model in their life, another participant’s enthusiastic answer sums up many responses. “Girl yes, of course! I said life changing! I know, you got to ask that question. But yes!” (7).

Sharing Tools and Theory

Sharing the Sanctuary Model Tools and values with family and friends appears in the majority of interviews with participants (7; 88%). This theme encompasses sharing language, tools, perspectives, and practices that can then be used to improve relationships on a daily basis, over time, and at times of extreme stress. For some, the sharing reportedly leads to shifted, increasingly trauma-informed perspectives in people close to them:

So [my spouse] will say, well, maybe there’s more there than meets the eye. Or maybe that’s the coping mechanism, instead of that’s bad behavior, you know? So it’s, so he’s becoming more sensitive. But that’s from being around me. (4)

Other facilitators explicitly use Sanctuary Tools as normal family functioning:

I’ve certainly introduced the S.E.L.F. protocol and Community Meeting in our family . . . . So we do that sometimes as a family, so we’ll “S.E.L.F. it,” ya know. And use Community Meeting as a way to connect, as one of the tools. (1)

Another participant notes the value of Sanctuary Tools during the overwhelming life event of their father’s death and the problematic family dynamics that followed:

Really incorporating the philosophies, the beliefs, the values, the understanding of the Model—it is transformative. And when people get it, they don’t let it go . . . . So much so that when my father died two years ago, . . . I taught my nephews how to do Community Meeting—they’re grown, they’re adults—but I taught my nephews how to do Community Meeting because I needed to do Community Meeting before all of the running around that we needed to do. [Then the situation after the funeral] was really ugly. And it had the possibility of really disrupting our relationship. And then we had a conversation that was about grace and about supporting one another and about, about grieving, and they had the opportunity to say to me what they were seeing, right? And it, it transformed our relationship. Right? . . . Now, they don’t know Sanctuary, but it was, it was—we basically had a Red Flag Meeting for our family, right? (2)

Improved Relationships

Improved relationships can occur in many ways, and participants specifically cited increased perspective, better boundary setting, increased number of close relationships, and shared understanding and communication as occurring in their lives due to their work with the Sanctuary Model. The data describe improved relationships with friends, partners, and spouses, extended family members, and across generations, both older and younger:

It just helps me have more compassion in my relationships. It helps me operate from that perspective, “what has happened?” so that I’m not out there trying to fix my friendships, right, and fix people in those friendships rather. Yeah, so it’s allowed me to have healthier relationships. (7)

It has made my relationships happier. It’s included more people than I might have otherwise. (4)

Healthy, happy relationships also require making and maintaining healthy boundaries:

I will also say that it has helped me to, to be able to let go of people and things that are not the best or . . . that can be toxic for me, without feeling guilty about it . . . . I think mostly it has helped me not to fall into reenactments. (3)

Many participants spoke about people not wanting to give up the model—themselves, their trainees, and people in their personal lives—once they experience it:

It just has opened up a whole new world for him and a way for him to think about his own life and how we talk about things. So it’s a, it’s a commonality that we now share and an understanding of what triggers each of us of where that came from. (6)

Limitations

Limitations of this exploratory study include those common in phenomenological studies that use a hermeneutic, or interpretive approach, of newly studied phenomenon. These include a small target sample, findings that cannot be generalized, and call for further quantitative empirical research to strengthen the findings. Although the study sample reflects a respectable number of Sanctuary Institute Faculty (73%), it is confined to a sample from one agency and limited to practitioners who choose to facilitate trauma-informed organizational change. Furthermore, the improvement in the quality of relationships was only assessed by the Sanctuary Institute Faculty, and not by family members or friends, or over time, with a longitudinal study. These limitations could be addressed in further studies of organizational models and in studying the Sanctuary Model with additional experimental designs.

Implications for Practice