This unique case study presents the evidence-based design of a recovery home for child victims of commercial sex trafficking and analyzes the impact the built environment had on the success of this trauma recovery program. Courage Worldwide provides a pioneering model of care in innovative therapeutic homes. Presenters will explain the “H.E.A.R.T” model and analyze how the design of the Courage House is integral to this care model. Hear the specifics for how research findings on the built environment and mental health were incorporated to facilitate the provision and acceptance of care and residents’ positive perceptions and engagement.

1. UsingHealingDesignto
RescueChildrenfromCommercialSexTrafficking(CSE)
HCDExpo 2016 | Houston,TX
Marc Schweitzer, M.Arch., AIA
Planetree Pioneer,Planetree LifetimeAchievement Award,2007
Speakers :
Dr.Benjamin Keyes, PhD, EdD
Divine Mercy University
Caren Cupp, M.Arch.
Director of Design Stafford KingWiese Architects
JennyWilliamson
Founder and CEO, CourageWorldwide, Inc.
Patient Experience Specialist, Stafford KingWiese Architects

2. I. Obtaina comprehensiveoverviewof credibledesignresearch on
behavioralhealth facilities
II. Understandthe importance of the built environment to therapy
treatmentoutcomes.
III. Evaluateapplicationof research to a design for a mental health
facility(using exampleof residential CSE trauma recoveryprogram).
IV. Contributeto the designof a POE study to measure the success of
designdecisions.
LEARNINGOBJECTIVES

3. Person
Centered
Healing
Environment
Survivors
Therapy
Model
Design Theory
Research
Evidence

4. PRESENTER
CourageWorldwide,Founder& CEO
JennyWilliamson

5. Teen victims of sex trafficking.
SURVIVORS

6. The truthis
Slavery Still Exists
And it is happening in our own
Backyard.

7. Courage House Northern California Campus

8. PRESENTER
DirectorofInternship&Training-EasternStates
DivineMercy University
Dr. BenjaminKeyes, PhD, EdD

9. Healing Emotional/Affective Responses to Trauma:
HEART Model by Design
Presented by:
Benjamin B. Keyes, PhD, EdD
Divine Mercy University
Houston Tx., 2016

10. TRAUMA RESOLUTION
Narrative Memory
Trauma
Implicit Memory
(horror/fear)
Narrative + Implicit Memory (no gaps)

11. PTSDBRAIN

12. THETRAUMATIZEDCHILD
“Repeated trauma in the adult life erodes the structure of
the personality already formed, but repeated trauma in
childhood forms and deforms the personality. The child
trapped in an abusive environment is faced with the
formidable task of adaptation. She must find a way to
preserve a sense of trust in people who are untrustworthy,
safety in a situation that is unsafe, control in a situation that
is terrifyingly unpredictable, power in a situation of
helplessness. Unable to care for or protect herself, she must
compensate for the failures of adult care and protection
with the only means at her disposal, an immature system of
psychological defenses.”
- J. Herman, p. 96

13. THE H.E.A.R.T. MODEL
The H.E.A.R.T. Model is a
Psychological/Spiritual Model originally
designed to be used in resolution and
healing from the effects of long-term
complex trauma brought on by early
childhood sexual abuse, long term
domestic violence, and human trafficking.

14. THE H.E.A.R.T. MODEL
The Model is designed to address both Cognitive (thoughts)
and Emotional (feelings) schemas connected to traumatic
events and to deal with sensory triggers by resolving
internal conflict that includes but is not limited to:
•Self blame Victimization
•Shame Emotional Disregulation
•Self-Esteem Guilt
•Personal Identity

15. THE H.E.A.R.T. MODEL
The HEART Model follows a standardized Three
Phase Model of Treatment using 7-10 stages.
The Three Phase Model is standard treatment
for Dissociative Disorders as approved by the
International Society for the Study of Trauma
and Dissociation (ISSTD).

16. The Three Phases are…

17. PHASE 1
1. Initial Phase, rapport building, safety issues, confidentiality,
crisis stabilization, orientation to therapeutic process,
boundary issues, system mapping.

18. PHASE 2
2. Uncovering memory, processing affect; cognitive
restructuring; fusion and/or some integration; most of the
therapy work around memories, affect regulation, cognitive
distortions, and life stabilization

19. PHASE 3
3. Final integration(s), relearning to live as a single personality,
relational sexual issues, spiritual issues, closure.

20. H.E.A.R.T.MODEL FORTRAUMA
•Create a safe environment-Therapeutic Alliance (Phase 1)
•Reconnect to memory.- Dealing with Implicit Memory (Steps 2-9=Phase 2)
•Anchor to memory.
•Process affect.-Dealing with difficult feelings and emotions
•Negotiate between adult and inner child.-Resolution of Cognitive Distortions
•Forgiveness of self.
•Awareness of God.-Resolution of Spiritual Distortions
•Process possible distortions of God.
•Forgiveness from God.
•Merging of split parts.
•Infilling of God.
•Return with new insight and life. (Phase 3)

21. MAJORTRAUMA DISORDERS OFTRAFFICKING SURVIVORS
•Borderline Personality Disorder – 72% co-morbidity with Physical
and Sexual Trauma in Early Childhood.
•Post-Traumatic Stress Disorder – co-morbid up to 85% of the time
with Early Childhood Trauma.
•Dissociative Disorder (O.S. or Unspecified)
•Dissociative Identity Disorder- 97% as a result of Early Childhood
Sexual Trauma before the age of 8 yrs old.
•Substance Use/Abuse Disorders- 69-73% co-morbidity with Trauma
•Eating Disorders- 63% co-morbidity with Trauma.

22. ESTIMATEDLENGTH OFTREATMENT FORTRAUMA DISORDERS
•Borderline Personality Disorder: 18-30 months for
stability and self regulation. (M.Linehan, D. Savinsky)
•Post-Traumatic Stress Disorder: 24-36 months
•Dissociative and Dissociative Identity Disorder: 2-10
years. (International Society for the Study of Trauma and Dissociation)

23. CURRENT H.E.A.R.T. RESEARCH
Over the course of two years, we have discovered the adolescent population
of those who have been trafficked show the most significant response to
treatment at 18 to 24 months for symptoms such as PTSD and anxiety.
Depression symptoms reduce significantly at the 6-9 month marker.
These preliminary results point to long-term care for adolescents of
commercial sexual exploitation as the best practice for treatment. Our
preliminary research shows symptoms in adolescence become heightened 2-
4 months into residential care and begin to reduce around 6 months.
Following these initial markers, adolescent girls show marked decrease over 2
years in negative symptomology as well as self-reported development of
interpersonal skills and relationship building.

24. RESEARCH
Over the past 5 years, research with the model in
treatment programs and homes for survivors of Human
Trafficking with both Adults and Adolescents have
shown four very specific trends:
1. A decrease in symptoms of PTSD
2. A decrease in symptoms of depression and anxiety
3. An increase of personal resiliency
4. An increase in positive God image

25. ARCHITECTURAL DESIGN
Survivors of Early Childhood Sexual Abuse and Human
Trafficking come into treatment with a number of
issues and problems that Architectural Design of the
treatment/home facility can assist in addressing. These
issues include but are not limited to:
•Safety
•Trust
•Comfort
•A Sense of Peace

26. THERAPEUTIC DESIGN
When in the process of Therapy and Recovery, the same
issues as listed above (along with other emotional and
environmental situations) arise that the facility design can
aid in the therapeutic milieu to allow for effective healing,
resilience, and restoration.
•Mood- Color, line, design
•Anger- safety areas
•Spirituality- chapel, quiet room, gardens, walkways

27. THERAPEUTIC DESIGN(CONT.)
Homelike- interactive space, open common areas, easy line of
sight, modernized kitchen, space in living areas and bedrooms.
Safety (safe edges of rooms, furniture, house design), security
measures, minimal isolative areas, lack of‘hiding places’.
Spacing of buildings
Counseling and Group areas

28. The Design of a Treatment Facility and/or Residential Treatment Home
can make all the difference in clients having a smooth transition to
treatment and success in the therapeutic process. We would like to shift
this discussion to Design and how to make this home environment that
is conducive to treatment a reality.

29. RESEARCH
MarcSchweitzer,M.Arch.,AIAArchitect,PatientExperienceSpecialistStaffordKingWiese Architects

30. Person
Centered
Healing
Environment
Survivors
Therapy
Model
Design Theory
Research
Evidence

31. January 11, 2016
Environmental Design in Support of A Trauma Recovery Program for
Female Adolescent Victims of Sex-Trafficking:
A Courage House for Courage Worldwide, Inc.
MARC SCHWEITZER, AIA, M.Arch., CAREN CUPP, M.Arch., and JENNY WILLIAMSON, Founder and CEO Courage
Worldwide
ABSTRACT
The current paper presents the concepts behind the design of a homelike facility on a secluded campus for long-term
residential care for exploited adolescents, specifically females ages 11-17, who have been victims of commercial sexual
exploitation. The treatment model is innovative in that it is a long-term treatment and housing solution with no pre-
defined maximum length of stay. Integral to the model is the assumption that the built environment has direct and
indirect effects on mental health.(1) This paper presents the research behind the design thinking and specific design
elements to create a homelike environment. Research indicates the positive effects of a familiar homelike environment. to
be: support of a healthy, coherent life view; lowering of resident and staff stress levels and restoration from fatigue;
facilitating personal control; and supporting socially supportive relationships. The result is that residents are more
trusting and accepting of treatment. Research on the direct correlation between the homelike character and specific
residential design elements to the success of treatment will be forthcoming when the model site, Courage House
Northern California is operational.
RESEARCH

32. Source: 2009 Survey of Design Research in Healthcare Settings.
Ellen M.Taylor, AIA, MBA, EDACThe Center for Healthcare Design.
• Popular toolsto evaluate
design strategies during
planning and design
Research

33. EBD Features“Always”
Used in Healthcare Settings
Nurturing,
Therapeutic,
and Reduces
Stress
Source: 2009Survey of Design Research in Healthcare Settings.
Ellen M.Taylor, AIA, MBA, EDACThe Center for Healthcare Design.
Research

34. SURVIVORS - DESIGN CONSIDERATIONS
• Safety
• Rural Campus
• Community
• Family
• Privacy
• PersonalChoice
• Spirituality

35. • Safety
• Trust
• Comfort
• A Sense of Peace
• Homelike
• Spirituality
THERAPY - DESIGN CONSIDERATIONS

36. A HEALING ENVIRONMENT

37. Healing Environment
a. Participation& Control
A HEALING ENVIRONMENT
a. Participation& Control
b. Connections
a. Participation& Control
b. Connections
c. Healing Encounter
a. Participation& Control
b. Connections
c. Healing Encounter
d. StressReduction

38. “Unless peoplecan, in some way, create,
manage, change, or participatein activities
thataffecttheir lives, dissatisfaction,
alienation, and even illness are likely
outcomes.”
S.LeonardSyme,PhD.ProfessorEmeritus,Epidemiologyand
CommunityHealth,UC BerkeleySchoolofPublicHealth
Environment, Peopleand Health, Annual Review of Public Health 1983, Lindheim, R, SymeS. Leonard
New Design Parameters for Healthy Places, Places,Vol 2, No. 4 1985, Lindheim, R, Syme S. Leonard
A HEALING ENVIRONMENT
Participation & Control

39. Connections
• Social Relationships
Environment, Peopleand Health, Annual Review of Public Health 1983, Lindheim, R, SymeS. Leonard
New Design Parameters for Healthy Places, Places,Vol 2, No. 4 1985, Lindheim, R, Syme S. Leonard
3
A HEALING ENVIRONMENT
• Status
• Nature
• LifeCycle
• Culture & Society
• Place

40. A HEALING ENVIRONMENT
Four Ingredients of a Healing Encounter

41. “... design may reduce
aggression(in psychiatric
facilities)by minimizing
stressorse.g. noise, foster
control and privacy, and
provideexposure to …nature”
Ulrich, R.S., Bogren, L., & Lundin, S.Toward a DesignTheory for Reducing Aggression
in Psychiatric Facilities. 2012
Stress Reduction
0
20
40
60
80
100
120
RESTRAINTS MEDICATIONS
ENFORCEMENT
OLD NEW

42. APPLICABILITY
RESEARCH
ResearchChallenges

43. Stronger Research
a. Safety
b. SpiritualHealth
c. Community
d. Turf
e. Privacy
f. Sensory Complexity
g. Minimizebarriers
h. Views of nature
i. Naturaldaylight & Light
j. Art, music
k. Physicalactivity
SUMMARY
Schweitzer, M., Cupp, C.,Williamson, J. Environmental Design in Support ofTrauma Recovery. 2016

44. Weaker Research
a) Home-like setting
b) Experiencing Nature
c) Beauty
d) Quiet & Solitude
e) Variety of spaces
f) Color
g) Crafted interiors
Schweitzer, M., Cupp, C.,Williamson, J. Environmental Design in Support ofTrauma Recovery. 2016
SUMMARY

45. a. Safety
“Safety, isn’t imprisoning
childrento keep them from
running; it’s convincing them
thatthey don’t have to run at
all.”
SanDiegoUnion-Tribune

46. a. Safety
“The organization
of the cottages
supportsthe
feeling of safety.”
Dr. Benjamin Keyes
Developer of the H.E.A.R.T. model ofTraumaTherapy

47. b. SpiritualHealth
Heilemann, T., & Santhiverran, J.(2011). How do female
adolescents cope and survive the hardships of prostitution?
A content analysis of existing literature. Journal of Ethnic and
Cultural Diversity in Social Work, 20: 57–76.

48. [A] sense of coherenceis necessaryfor
good emotional and physicalhealth.
Antonovsky,A
Spirituality is centralto the healing
communityand to the achievementof
healing and total health.
JennyWilliamson
Antonovsky,A. Unraveling theMysteryof Health- How PeopleManage Stress and
StayWell. Jossey-Bass Publisher. San Francisco: 1987.
b. SpiritualHealth

49. “The image of village-houses,
a neighborhood underlies the
new movement…”
Frank Pitts, President, ACHA
c. Community

50. d.Turf
Likeabandoned lots in a neighborhood,
“orphan”building and campusspaces are
sitesfor anti-social and negativebehaviors.
Shepley, M.The Location of Behavioral Incidents in a Children’s Psychiatric Facility.
Children’s Environments, 12(3),352–361. 1995.
Perkins, E., Prosser, H., Riley, D., &Whittington, R. Physical Restraint in aTherapeutic
Setting: A Necessary Evil? International Journal of Lawand Psychiatry, 35, 43–49. 2011

51. e. Privacy
“Providingindividualbedrooms(with
privatebathrooms) may be the most
importantdesignintervention for reducing
stressand thereby aggressionin psychiatric
settings.”
Ulrich, R.S., Bogren, L., & Lundin, S.Toward a DesignTheory for Reducing Aggression
in Psychiatric Facilities. 2012

52. f. Sensory Complexity
Avariety of spacesand“multiple sensory
retreats”in a building are important for
emotionaland cognitivefunctioning
Orians,et.al. 1992
Orians, G.H., Heerwagen, J.H. Evolved responses to landscapes. In Barkow J., Cosmides,
L,Tooby, J. IEds.).The Adapted Mind: Evolutionary Psychology and the Generation of
Culture. Oxford University press, 98-121. Oxford & NewYork: 1992.

53. Victims…should be supported and invited
toparticipatemeaningfully in decision-
making…empoweringsurvivors as
engagedparticipantsin the process
The CaliforniaEvidence-BasedClearinghousefor ChildWelfare
g. MinimizeBarriers

54. g. MinimizeBarriers
Maximize communications
Deemphasize Hierarchy

55. Views of nature foster rapid reduction of
stress, lower anxiety and anger, and
increase positive moods.
Ulrich,et.al.1991
Ulrich, R.S., Zimring, C., Zhu, X., DuBose, J., Seo, H-B, Choi,Y-S,
Quan, X. & Joseph, A. A Review of the Research Literature on
Evidence-Based Healthcare Design. Health Environments Research
and Design. 1(3), 101-165. 2008.
h.Views of Nature

56. Higherlevels of daylight
exposure reduce depression
and improvemood.
Ulrich,et.al.2008
Ulrich, R.S., Zimring, C., Zhu, X., DuBose, J., Seo, H-B, Choi,Y-S,
Quan, X. & Joseph, A. A Review of the Research Literature on
Evidence-Based Healthcare Design. Health Environments
Research and Design. 1(3),101-165. 2008.
i.Daylight

57. k. Physical Activity

58. Regulation minimums questioned
• Allow 2 children per bedroom
CATitle 22, Division6, Chapter 5 Group Homes,Section 84087
REGULATIONS
Notable Challenges
Regulation minimums questioned
• Allow 2 children per bedroom
Regulatory requirements questioned
• Secure, locked
• No cellphones, internet access
• Minimumof toilet fixtures
• Outdoor activity space separation by age (physical or time)
• Fencearound outdoor activity space

59. Research
Resources
Contact: marc_schweitzer@skwaia.com
916.930.5909

60. LEARN MORE

61. Planetree Visionary Design Network
http://www.healthdesign.org/search/articles
PubMed (US National Library of Medicine National Institutes of Health
https://www.ncbi.nlm.nih.gov/pubmed/
The Center for Health Design Knowledge Repository
http://www.healthdesign.org/search/articles
Building Research Information Knowledgebase
https://www.brikbase.org
American Society for Healthcare Engineering (ASHE)
http://www.edra.org/
Environmental Design Research Association (EDRA)
http://www.edra.org/
Design Research Resources

62. • VA Mental Health Facilities Design Guide, Department of
Veterans Affairs, OCFM, October 2014
Add weblink
• Design Guide for the Built Environment of Behavioral
Health Facilities, David M. Sine, James M. Hunt, National
Association of Psychiatric Health Systems
www.naphs.org/quality/design-guide-for-the-built-environment
Guidelines

63. • Design Research And Behavioral Health Facilities,”Mardelle M. Shepley, Samira Pasha, The
Center for Health Design, July 28, 2013
https://blogs.cornell.edu/healthyfutures/files/2016/01/shepley-pasha-behavior-265fa8a.pdf
• Literature Review: Commercial Sexual Exploitation of Children
Southern Area Consortium of Human Services; Harbert, Anita and Tucker-Tatlow, Jennifer;
Academy for Professional Excellence at San Diego State University School of Social Work;
February 2014
https://theacademy.sdsu.edu/wp-content/uploads/2014/12/sachs-csec-lit-review-02-2014.pdf
• A Review of the Research Literature on Evidence-Based Healthcare Design.
Ulrich, R.S., Zimring, C., Zhu, X., DuBose, J., Seo, H-B, Choi, Y-S, Quan, X. & Joseph, A. Health Environments
Research and Design. 1(3), 101-165. 2008
Add weblink
• Healing Spaces: Elements of Environmental Design That Make an Impact on Health.
Schweitzer, M., Gilpin, L., Frampton, S. The Journal of Alternative and Complementary Medicine, 10
(Supplement 1), pp. S-71-S-83. 2004.
Add weblink
Literature Reviews

64. • Schweitzer, M, Gilpin L., Frampton S., Healing Spaces: Elements of Environmental Design That Make an Impact on Health
The Journal of Alternative and Complementary Medicine 2004; Vol. 10, Supplement 1: S71-S83
• Evans Gary W. The Built Environment and Mental Health. Journal of Urban Health: Bulletin of the New York Academy of
Medicine; 2003; 80(4): 536-555
• Karlin, Bradley E and Robert A. Zeiss. Best Practices: Environmental and therapeutic issues in psychiatric hospital design:
Toward best practices. Psychiatric Services, 57, October 2006
• Frampton, S, Gilpin L. et.al. Putting Patients First, 1st 2nd and 3rd Editions. Wiley???
• Environmental Design in Support of A Trauma Recovery Program for Female Adolescent Victims of Sex-Trafficking.
MARC SCHWEITZER, AIA, M.Arch., CAREN CUPP, M.Arch., and JENNY WILLIAMSON, Founder and CEO Courage Worldwide
• Lindheim, R, Syme Leonard S., Environments, People, and Health. Ann. Rev. Public Health; 1983; 4:335-59
• Lindheim, R. New Design Parameters for Healthy Places. Places, 1983; Vol 2, Number 4
• Ulrich, R, Bogren, Lundin, S. Toward a Design Theory for Reducing Aggression in Psychiatric Facilities. Paper submitted
to the conference ARCH 12: ARCHITECTURE / RESEARCH/ CARE / HEALTH, Chalmers, Gothenburg, November 12-14, 2012
• The Location of Behavioral Incidents in a Children’s Psychiatric Facility; McCuskey Shepley, Mardelle; Children’s
Environments: 12(3), 352-361; 1995
Design References

65. PRESENTER
Caren Cupp, M.Arch.
DirectorofDesign,StaffordKingWieseArchitects

66. EDAC:8 stepsfor an evidence-baseddesignprocess
ProjectContext

67. 1. Define EBD Goals & Objectives
Provide a safe and secure environment
Provide a homelike environment
Encourage a sense of community
Support treatment & recovery
Encourage spiritual well-being
1

68. Find Sources of Relevant Evidence
Support Treatment & Recovery:
• provide healing environment with spaces
for multiple modes of treatment,
• encourage participation and evoke a sense of trust
Encourage Spiritual Well-being:
• support the whole person- body mind and spirit
• provide refuge with space for prayer, meditation,
solitude, including cultural and religious
preferences
• develop meaning through a connection to place
and the natural order
• provide cognitive relief and restoration through
access to nature
Provide a safe and secure environment:
• prevent/reduce incidents,
• reduce aggressive behaviors,
• secure campus
Provide a Homelike environment:
• reduce stress with a non-institutional setting,
comfort, privacy
• restore identity through choice,
• control over environment and personal
expression
Encourage a Sense of Community:
• promote a positive peer environment
and a sense of belonging to encourage
long-term stays
Focus on Patient-Centered research:
2

69. 3. Criticallyinterpret relevant evidence
Translate proven research to the behavioral health context:
•Emotional response to the healing environment (reducing stress, reducing negative behaviors)
•Evaluate relevance of setting, patient age/demographics, diagnosis, treatment
•Prioritize potential benefit to patient treatment and recovery
•Carefully consider the fundamental premise underlying the emotional responses
3
Much of the research in the general HC setting is based on an emotional
response to the environment that contributes to healing.

70. Translate proven evidence tothe behavioral health context:
Consider EBD elements proven to contribute to healing through a positive
emotional response
Shame------------------  opportunities for ownership/nurturing--  Pride
Self-esteem-----------  allow areas for self-expression-------------  Identity
Victimization---------  allow control over ones environment---- Empowerment
Mistrust----------------  provide safe and secure environment---- Trust
Self blame/Guilt-----  spiritual well-being, connection to--------  Forgiveness of self
nature, the natural order, place
Distorted Emotion EBD Benefit/ Restored EmotionEBD Element
Apply premise to support behavioral health (trauma) modes of treatment

71. Createand innovate EBD Concepts
How do you define the concept of home for a
person who has only negative associations with
the concept?
4
86% had no father in their home
14% had fathers, where all but
one was their perpetrator
75% raised in poverty and on
welfare
85% reported sexual abuse and
domestic violence in their homes
70% reported being homeless
75% reported that CPS had been
involved

72. Developa hypothesis
How do you proceed when the notion of home
evokes negative emotions? Or worse, horrible,
painful and traumatic associations?
.
5

73. Redefine the concept of home:5. Hypothesis:
Allow for Control:
Participation in/ Management of one’s
environment. Provide opportunities to
Nurture
Personal expression:
within a highly ordered environment
Provide choice:
Vary types of space; group,
intimate, private , open,
secure,
5
Cottages

74. Cottage Gardens
Redefine the concept of home:5. Hypothesis:5

75. Cottages
Redefine the concept of home:5. Hypothesis:5

76. The Courage House
survivors can see that
they, like those before
them, can succeed in
recovering.
The wall creates a
feeling of connection to
a larger community of
Courage House
graduates.
Caren Cupp, Design
Director
How do you redefine the concept of community, for a group who’s
behavioral issues prevent many benefits of group activities?
5. Hypothesis:5 Building Courage

77. Design Hypothesis
Finding Hope5. Hypothesis:5

78. Design Hypothesis
Spirituality is centralto
the healing
communityand to the
achievementof
healing and total
health.
JennyWilliamson
Finding Hope5. Hypothesis:5

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QUESTIONS?
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Questions?