Designing Safe & Supportive Spaces for Victims of Sexual Exploitation

Designing Safe & Supportive Spaces for Victims of Sexual Exploitation One of a series of white papers by Page professionals Lisa Ulibarri and Natale Stephens

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Introduction

Recent media attention on high-profile instances of child exploitation and sex trafficking have led the American public to take notice at a critical time.

COVID-19 has driven an unprecedented rise in screen time, bringing with it elevated exposure and vulnerability to online sexual exploitation and grooming, increased isolation, heightened risk-taking, along with reduced access to education, prevention, and treatment resources.

The stakes are high, and the individuals and families caught in cycles of abuse and trauma are often re-traumatized by the very systems put in place to serve them. It will require the collaboration of many professionals who interact with youth in our communities to identify, prevent and respond to reduce the prevalence of trauma, reduce stigma, and work towards long term health and societal re-integration.

As design professionals our part in the continuum of care for individuals who have been victimized is by its nature limited, but the environments we design have the capacity to remove barriers and better support caregivers and survivors as they do the hard work of healing. Design strategies for facilities that house and care for underage victims of exploitation and trafficking must be informed by the larger circumstances of the issue, therapy models and treatment plans. As such, there is no one-sizefits all solution, however as we seek to better understand individual experiences, we can begin to develop environmental standards that resist re-traumatization while promoting physical, mental and social health.

It is our intent with this paper to share what we are learning and further the conversation around how to design reliably safe, adaptive, personcentered environments of care that increase a sense of well-being, improve psychological safety, and promote resilience. Though our focus here will be on supportive residential environments, many of the design principles identified will apply to broader healthcare and justice environments in which victimized individuals will receive services.

Trauma

With estimates ranging from 1,400 to 2.4 million minors affected, there is no true estimate of the scope of exploitation and sex trafficking of minors in the U.S, due often to under-reporting. With instances reported in all regions of the country, Americans can no longer view the exploitation of children as a problem that occurs somewhere else. It is not an overseas problem, and it effects individuals across all socio-economic groups.

Though laws have been enacted intended to fight human trafficking, they have typically focused on convicting perpetrators. Provisions specific to the protection of children are relatively recent, the earliest of which was the 1978 Mann Act amendment in response to the introduction of child pornography around the same time. A problem that always existed finally began receiving some attention. Since then, additional revisions to the Mann Act as well as new laws to fight human trafficking and combat child exploitation have been enacted, but the problem of child sexual exploitation continues to grow. Often, the law lags behind technology, and as a society we are continually trying to keep up with our ever more connected digital world.

In the landmark Adverse Childhood Experiences (ACE) study published in 1998 by the Centers for Disease Control (CDC) and Kaiser Permanente, researchers identified a link between traumatic events that occur during childhood and a higher likelihood of negative health and behavioral outcomes later in life. In this population there is a prevalence of Complex Trauma, defined by the National Child Traumatic Stress Network (NCTSN) as simultaneous or sequential occurrences of child maltreatment including emotional abuse and neglect, sexual abuse, physical abuse, and witnessing domestic violence - that are chronic and begin in early childhood.

As trauma becomes recurring, behavioral issues start to arise that result in negative coping mechanisms when presented with triggering environmental, physical, and/ or emotional stimuli. The most common diagnosis for Complex Trauma patients is Post Traumatic Stress Disorder (PTSD), however other complications such as affect disorder, addiction, eating disorders, dissociative disorders, biological illness, and sexual disorders are all possible consequences and coping mechanisms, and may present themselves as patients get older.

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Designing Safe & Supportive Spaces for Victims of Sexual Exploitation

Stages of Recovery

The NCTSN notes a relative consensus among care professionals that a phase-based approach to treatment is the most effective in treating Complex Trauma. Each phase is a building block for the next, and though most treatment programs incorporate three main phases, it is important to note the progress from one phase to the next will not always be linear, nor are all treatment programs the same. As design professionals we must work with our clients to understand the specific needs of each facility.

Among the different treatment models, Herman’s Stages of Recovery stands out in its approach to patient care. The program was created by Judith Herman MD, a member of the Department of Psychiatry at The Cambridge Hospital. In this therapy model, Herman focuses on how each stage works to “restore power and control to the survivor.” The outcome seeks for survivors to gain “basic capacities for trust, autonomy, initiative competence, identity, and intimacy.”

The stages focus on the individual, rather than process-oriented, or trauma-focused.

Before treatment can begin, Herman recommends a full and complex assessment in order to establish a clinical diagnosis. This allows for additional diagnoses and co-morbidities to be identified to develop a successful, individualized treatment plan.

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Stage 1: Safety and Stabilization addresses a survivor’s basic needs within a safe physical environment: sleep regulation, nutrition, exercise, symptom management, and immediate substance abuse treatment if applicable. This first stage sets up the progression of treatment, restoring dignity while providing a place of refuge where a survivor can re-establish control over their body and begin to expand that control outward into their environment. As the initial focus on the physical body is so crucial, caregivers need to be watchful of destructive behavior such as self-harm, eating disorders, and impulsive actions.

In Stage 2: Remembrance and Mourning, a survivor is mentally ready to tell their story and face the trauma, supported by a calming environment that fosters a sense of acceptance and comfort. The therapist acts as a supporter in listening and empathizing with the survivor. Together, both parties begin to reassemble the history of the trauma and reframe the experience as a past memory. The therapist helps to examine the moral questions of guilt, shame, and responsibility linked to past actions and consequences. Additionally, a survivor mourns their lost childhood and opportunities of what could have been. It is imperative in this stage to still be watchful of destructive behavior such as suicidal ideation, as delving deep into the trauma may be triggering.

As a survivor begins to be ready for Stage 3: Reconnection and Integration, they reorient their perspective by accepting their past as a part of their life story that does not determine their future. Stage 3 starts the task of rebuilding life and pursuing future aspirations. As they work to reconnect themselves to the community, the initial needs, such as a safe living environment and financial stability, remain important.

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At this point, a survivor is more knowledgeable and better equipped with healthy coping mechanisms. They may begin to delve deeper and seek resolution or closure in the form of activism, judicial justice, or community involvement. An individual who has endured Complex Trauma understands that there are irreversible long-lasting effects, but Herman emphasizes that they see their part in a society striving to be better.

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Designing Safe & Supportive Spaces for Victims of Sexual Exploitation

Design Elements for Residential Treatment Facilities With a better understanding of the needs for residential treatment facilities for adolescent victims of exploitation and sex trafficking - designers can begin to identify environmental design features to best support a survivor’s recovery. There are design elements that will be universally applied, tied to trauma-informed environmental design, and those that will be tailored to each stage of recovery. Driven by research and specific care models, design features will vary from project to project.

We begin by outlining the design elements that may evolve in support of Herman’s Stages of Recovery including: design elements supporting the role of House Guardian, Breakout Space, Garden, and environmental opportunities for Self-Expression.

Design Elements Supporting The Role of House Guardian

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The House Guardian may be the primary caregiver or therapist assigned to the housing unit. They may act as a guiding figure, leading group sessions and/or building morale among the residents. Their proximity within the unit as a supervisor is dependent on the therapy stage.

In Stage 1, the house guardian is most likely a nurse or a medical staff member providing constant supervision. A nurse station should be integrated into the open environment, providing around the clock supervision. The station should be placed in a location that maximizes observation of the unit. The house guardian attends primarily to residents’ physical needs, such as nutrition, administering medication, and monitoring physical safety.

In Stage 2, the house guardian role expands beyond basic supervision and physical needs to providing support for the emotional needs of the residents. In this stage, the guardian may have an office with visibility to the unit but can be enclosed for private conversations. The observation role is still present but may now rely more on electronic security and/or monitoring in lieu of around the clock physical observation.

In Stage 3, the growing autonomy and independence of the residents means the house guardian role can transition away from observation and supervision toward mentorship and support of the activities of daily living.

At this point, the house guardian may no longer be physically on the unit but will still run daily check-ins and provide resources and opportunities for continued growth and community re-integration of residents.

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Designing Safe & Supportive Spaces for Victims of Sexual Exploitation

Break-Out Space

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Break-out spaces should be provided to support each stage of recovery and may be used adaptively if designed to support multiple functions at the outset. In some cases, this will be an intimate one-on-one space, in others it may be a larger multi-purpose group setting and depending on the stage of recovery it may be on or off the unit.

To support residents in Stage 1, a breakout space is separate from the unit as it may function as a temporary refuge for residents in the case of an incident. There, they can work through the problem with their caregiver in a safe environment, away from the triggering event/person. The room should not be too large to preserve the feeling of safety and should be designed as a safe room with abuse and ligature resistant materials and fixtures. The room can be located near the House Guardian as it may be used flexibly within the larger therapy treatment program.

To support residents in Stage 2, a breakout space is located within the residential unit to promote communal healing. Glazed partitions should be used to separate the space from the open living area while maintaining visibility from the House Guardian’s office. This space functions as a breakout area, a quiet reflective space, and/or a therapeutic safe zone, where residents are encouraged to discuss difficult topics in a safe environment.

To support residents in Stage 3, a breakout space is again separate from the unit but serves as a large multi-purpose room. The size accommodates larger events and gatherings to help integrate residents into the surrounding community. Its location within the complex acts as a neutral zone where different ideas and expressions can come together, fostering better understanding and empathy among the residents.

Self-expression & Personalization

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As part of a person-centered, rather than trauma-focused, approach is it important to provide an individual choice and control. One of the most basic ways to achieve this is to provide opportunities for personalization and self-expression in the environment. This will also facilitate communication and further bonding among residents and caregivers.

Opportunities for self-expression should mirror the individual’s journey through the treatment program.

In Stage 1, self-expression may take the form of a marker board on the outside of each resident’s door. These boards can be used by both caregivers and residents to write notes, convey important information, track progress, set reminders, etc. This type of passive communication may be less intimidating for new residents.

In Stage 2, self-expression can expand into a small nook in the wall outside each resident’s room. This nook can be used however the resident sees fit, like showcasing and starting conversations about creative work. The contents inside the nook can also be changed out to reflect the growth that each resident experiences through the program.

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In Stage 3, self-expression looks similar to what might be typically seen in an apartment or home. Artwork and pictures are placed around the unit and/or complex, working in harmony together to display each resident’s contribution equally. This promotes individuality and supports the newly realized sense of self and vulnerability that may have been previously hard to express.

Garden

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The Garden in the context of Herman’s Stages of Recovery can be seen as an extension of self-expression but deserves its own attention because access to the outdoors, whether physical, visual or both, is perhaps one of the most important supportive environmental design elements.

The garden, at any stage, is meant to be a self-directed creative space where residents have an opportunity to connect to nature and freely express themselves.

In Stage 1, the garden may be a flower box that sits outside a window.

In this stage, residents may not be able to go outside freely without intense supervision, so a flower box offers access to nature in a controlled environment.

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In Stage 2, the garden is outdoors with sectioned space designated for each resident. It is a larger space to work with more freedom to express themselves. Residents can also see what others are doing and spark inspiration, connection, and conversation.

In Stage 3, the garden is a communal garden that is shared among all residents of the complex. There are no assigned areas and people are encouraged to work together towards a common goal. It reflects larger societal expectations with greater individual independence and responsibility.

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The first priority is to create supportive environments that resist re-traumatization.

People experiencing trauma can be hyper aware and/ or hyper sensitive to their surroundings.

Trauma-Informed Common Design Elements A trauma-informed care approach acknowledges the need to understand an individual’s life experiences in order to deliver effective care and has the potential to improve engagement, treatment adherence, health outcomes, and provider and staff wellness. A set of guidelines is emerging to inform effective treatment (source: CDC): ▪ ▪ ▪ ▪ ▪ ▪

Safety Trustworthiness & Transparency Peer Support Collaboration & Mutuality Empowerment & Choice Cultural, Historical & Gender Issues

Trauma-informed design is an emerging focus for healthcare designers, in support of these care guidelines, and focused on the built environment.

Page has been developing a series of best practices based on available research and project experience. It important to note that best practices are not a substitute for empathy. There isn’t a single “magic bullet” solution that will work all - designing for the average is designing for no one. We are looking at a broad range of built environments and developing considerations with the ultimate goal of providing supportive physical environments in which all individuals can thrive.

The first priority is to provide an environment that resists re-traumatization. This means removing or reducing known adverse stimuli and environmental stressors while providing soothing designs with limited visual complexity. It is also important to understand that individuals experiencing trauma can be hyper aware of and/or hypersensitive to their surroundings.

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Designing Safe & Supportive Spaces for Victims of Sexual Exploitation

SAFETY

RESIST RETRAUMATIZATION

Protect individuals and staff. Provide visible security, and well-lit public and exterior spaces.

TRUST Involve end users in the decision-making process.

Consistent, open, respectful and compassionate communication. Prioritize privacy and confidentiality.

CONNECTION Plan for varying levels of social density. Give individuals the choice to engage or disengage.

Respect boundaries.

CHOICE Empower individuals to make their own choices & have as much control of their environment as is safely possible.

EQUITY & INCLUSION Being aware of how an individual’s culture affects how they perceive trauma, safety, and privacy. Provide adequate and equal access for those with physical or developmental disabilllities

WHOLISTIC

RESILIENCE & RECOVERY

Consider the whole health of individuals. Provide a welcoming environment with access and views to nature.

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Places Along the Edge These are areas of semi-private seating along the edges of communal living space. They could be benching in a corner of the living room or a breakfast nook in the kitchen. The seating provides an opportunity for residents to be exposed to social activities without joining if they are not ready. Conversely, they also serve as a temporary escape if the environment becomes too overwhelming.

Provide choice around engagement and dis-engagement. Create spaces that support multiple levels of interaction and allow balance between connecting with others and being able to retreat, to allow patients to feel more situational control (citation: Dix & Williams, 1990; Gulak, 1991; Schweitzer, Gilpin & Frampton, 2004)

Seating for Two This seating arrangement provides a space for intimate one-on-one conversation and an opportunity to pair residents together in a buddy system. This may be a nook located between two bedrooms and can be a source for displaying art or self-expression.

An individual’s sense of safety, perceived crowdedness, relationship to staff, etc. are affected by furniture arrangement. Face to face may be perceived as confrontational, sitting corner to corner invites conversation and interaction. In common areas seating should be oriented so users are facing out from sheltering walls. Ample distinction between seating areas reduces the pressure to socialize. (citation: Broker, Rohricht, & Priebe, 1995; G. Evans, 2003; Tirlington, 2004)

Circadian Daylighting Re-establishing circadian rhythm is an essential part of physical and mental healing of the residents. Safety concerns, or project location, may limit opportunities for outdoor connection. Upper clerestory windows and light shelves are a good way to distribute daylight and restart circadian rhythms when direct outdoor access is not possible.

Maximizing glazing, daylight, and access to the outdoors supports healing and fosters a greater independence and should be applied as appropriate to the specific security needs of the project.

Visible Security Mechanisms Visible locking mechanisms provide visual safety to residents and deter attempts to escape. Layering different types of mechanisms and systems allows for the greatest security coverage. Additionally, mechanisms and alarm systems that make noise can alert caregivers and others if there is an emergency.

Obvious security measures can support an individual’s feeling of safety, but it is important to balance this with trust, individual control and the ability to self-manage the activities of daily life. Be considerate of how the environment may communicate a power differential between staff and resident and strive to provide an experience that fosters a sense of trust, acceptance and comfort.

Defensible Beds The idea of defensible beds is part of the ongoing effort to establish and enforce physical and mental safety. Beds should be placed out of direct line of sight of the door and window if there is one. However, the bed should still be in a position where staff can maintain observation. From the bed’s location, the window and door should both be clearly visible. This arrangement within the room relates to the feng shui concept of a “commanding position” that improves a resident’s perception of security.

Rendering

Construction Mock-up

Color Theory Color theory has a large impact on how space is perceived, so hue, saturation, and lightness all need to be considered when designing a space. In pediatric healthcare settings, there have been numerous studies showing the physical and psychological effects of color in different room contexts. Each color has a generic association between it and the prospective health results, but bear in mind, there is no one definitive correlation between one another.

Equity & Inclusion There is no specific design recommendation around equity and inclusion because no two people’s experiences are the same. In order to better understand the experiences of those who will be treated in this environment it is important to work closely with caregivers and advocates to develop model experiences and relevant touchpoints. It is within this context that you can begin to identify opportunities to design a more equitable and inclusive environment. This may include the use of language and graphics, providing adequate and equitable access for those with physical or developmental disabilities, and fostering an experience of acceptance by using the design to embrace a culture of respect that connects individuals to their community.

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The design recommendations discussed here are just scratching the surface of potential considerations for this patient population. Great care is needed to understand the lived experiences and ramifications of individuals who have experienced sexual exploitation and trafficking.

Complex mental and physical health conditions may overlap, requiring us to plan for a broad spectrum of needs. It is important to understand how the environment can avoid being a barrier to health, and support or even enhance a treatment program. Such an architectural feat requires an evidence-based design approach and illustrates the importance of striving to understand the human behind the condition we aim to help treat.

Citations HERMAN, JUDITH L. “Recovery from Psychological Trauma.”

Psychiatry and Clinical Neurosciences, vol. 52, no. S1, 1998, https:// doi.org/10.1046/j.1440-1819.1998.0520s5s145.x. Accessed 19 Oct. 2021.

National Child Traumatic Stress Network Complex Trauma Task Force.

“Complex Trauma in Children and Adolescents.” The National Child Traumatic Stress Network, 2003. https://www.nctsn.org/sites/default/ files/resources//complex_trauma_in_children_and_adolescents.pdf Development Services Group, Inc. “Commercial Sexual Exploitation of Children and Sex Trafficking.” Literature Review, Washington, D.C.: Office of Juvenile Justice and Delinquency Prevention. Aug. 2014. https://ojjdp.ojp.gov/mpg/literature-review/csec-sex-trafficking.pdf Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. DOI: 10.1016/s0749-3797(98)00017-8. PMID: 9635069.

IOM (Institute of Medicine) and NRC (National Research Council).

2013. Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Washington, DC: The National Academies Press.

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