Applying Trauma-Informed Design Principles to Therapeutic Residential Care Facilities to Reduce Retraumatization and Promote Resiliency Among Youth in Care

Abstract

Purpose: This conceptual paper connects the literature on the experiences and needs of youth in therapeutic residential care, trauma-informed frameworks utilized in these settings, and early research on trauma-informed design to facilitate an understanding of these connections and move towards developing a blueprint for trauma-informed design in residential settings for traumatized youth. Methods: A critical literature review drawing on trauma theory, trauma-informed care, evidence-based design, and trauma-informed design was conducted to inform the argument presented in this conceptual paper. Results: While many therapeutic residential care models engage trauma-informed care approaches to support staff in promoting healing environments for youth who have histories of complex trauma, the focus has remained on the psychosocial environment of care, and has yet to be systematically applied to the design of the built environment in which these programs are implemented. By applying the principles of trauma-informed care to the built environment, trauma-informed design has the potential to reduce retraumatization and promote resiliency among youth in care. Conclusions: Ultimately, this conceptual paper illustrates the value of further developing trauma-informed design principles to apply to settings that serve traumatized youth, such as therapeutic residential care facilities.

Almost by definition, children in therapeutic residential care (TRC) settings have often experienced at least one major traumatic event, and many have been exposed to direct and repeated violence throughout childhood, such as chronic abuse and neglect (Hummer et al., 2010). These early traumatic experiences can be compounded by system-generated trauma, the often stressful and emotionally overwhelming experiences that can occur as children move through the child welfare system, such as frequent disruptions in schooling, peer groups, and out-of-home placements (Hummer et al., 2010). While foster care or kinship care is typically preferred to placement in TRC as the least restrictive and most cost-effective option when children are removed from the home (Hawkins-Rodgers, 2007), children with complex trauma histories often present with significant developmental, emotional, and behavioral issues that place them at-risk at home or in the community (Holden & Sellers, 2019). As a result, many of these children are placed in TRC to address these complex clinical needs and promote social reintegration (Holden & Sellers, 2019).

While comparatively sparse in the context of residential care compared to other intervention settings, a few trauma-informed care (TIC) models have been successfully implemented in TRC settings over the last two decades to simultaneously address the pervasive impacts of complex trauma exposure on youth in care (YIC), while also seeking to foster positive developmental trajectories (McLoughlin & Gonzalez, 2014). The purpose of TIC is not to treat discrete symptoms related to traumatic experiences, but rather to direct the delivery of services in a way that understands, respects, and appropriately responds to the effects of trauma on an individual seeking care (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). For example, TIC program models emphasize respectful trauma screening and assessment prior to treatment, staff training to recognize the symptoms of trauma, and minimized use of procedures that have the potential to retraumatize individuals, such as physical restraint in mental health settings (SAMHSA, 2014). However, while many of these TIC program models utilize an ecological framework to address trauma-related challenges, the focus of these approaches has remained on the psychosocial environment of care, and has yet to be systematically applied to the design of the built environment in which these programs are typically implemented. As one researcher on the design of permanent supportive housing facilities for homeless individuals noted: “Most of the conversation for trauma-informed organizing focuses on the implementation of services…Missing from this framework is any sense of material space” (Huffman, 2018, p. 48).

The emerging field of trauma-informed design (TID) refers to the application of TIC principles to the design of the built environment. Much of the early work in this field has focused on the design of homeless services settings for adults, both in gray literature (Farrell, 2018; Grabowska et al., 2021; Wilson et al., 2020) and in empirical research (Bollo & Donofrio, 2021; Huffman, 2018; McLane & Pable, 2020; Rollings & Bollo, 2021). Yet there remains a distinct gap in the academic literature on the use of TID principles to support the design of facilities that serve youth who have experienced complex trauma. By connecting the literature on the experiences and needs of youth in care (YIC), current TIC frameworks utilized in TRC settings, and early research on the use of TID, this conceptual paper aims to facilitate an understanding of these connections and move towards developing a blueprint for TID of built environments that serve youth who have experienced trauma, such as TRC facilities. The following sections elaborate on critical issues, gaps in the existing understanding, and directions for future research.

Therapeutic Residential Care

Historically, therapeutic residential care (TRC) programs have been an important, albeit controversial, element of child welfare services (Pecora & English, 2016). The lack of a consistent definition and the interchangeable use of several terms to describe TRC (e.g. congregate care, group homes, residential care, etc.) has resulted in difficulties establishing evidence-based practices for use in these settings, with downstream impacts on policy development and the ability to obtain government funding to support the development of model TRC programs (Whittaker et al., 2014). The interchangeable use of terms can also mask important programmatic differences in levels and types of care (Whittaker et al., 2014). Finally, words like ‘congregate care’ tend to carry negative associations with historical abuse in residential settings for youth (Whittaker et al., 2014), which may prohibit understanding of how these programs have evolved over the last three decades to align with the principles of modern mental health practice and progressive child welfare (Whittaker et al., 2014).

TRC is considered a specialized subsegment of more generalized group care settings, with the added intention of delivering therapeutic treatment to youth struggling with significant mental and behavioral health issues (Pecora & English, 2016). For the purposes of this conceptual paper, the working definition provided by Whittaker, Del Valle, and Holmes (2014) will be utilized as the foundation for our investigation into the role of the physical environment of TRC settings:

‘Therapeutic residential care’ involves the planful use of a purposefully constructed, multi-dimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs in partnership with their families and in collaboration with a full spectrum of community based formal and informal helping resources. (p. 24)

By nature, TRC is ongoing, cutting across all contexts in which youth move throughout the day, including school, social, and clinical settings (Hodgdon et al., 2013). High-quality TRC ultimately aims to support youth in overcoming serious social, emotional, and behavioral challenges by establishing and promoting child safety, partnering with families and communities, promoting deep and meaningful relationships, and delivering quality, evidence-based interventions across these varied contexts (Whittaker et al., 2014).

Complex Trauma in Therapeutic Residential Care

Compared to the general population, young people living in TRC experience a disproportionately high level of emotional and behavioral problems (Burns et al., 2004), which can make placement in lower levels of care such as foster care more challenging (Holden & Sellers, 2019). It has been suggested that the experience of complex trauma may at least partially explain the severity of emotional and behavioral issues in YIC (Hummer et al., 2010). These children have often experienced at least one major traumatic event, which ultimately may have led to their placement in care, and many have histories of recurrent interpersonal trauma throughout childhood (Greeson et al., 2011). The experience of being placed in care can in and of itself compound the effects of these early negative experiences, and can be naturally disruptive to a child’s core attachment relationships and overall sense of safety in the world (Hummer et al., 2010).

Trauma is often categorized as either individual trauma or complex trauma. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines individual trauma as resulting from “an event, series of events, or set of circumstances that is experienced…as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (2014, p. 7). Alternatively, the term complex trauma is used to describe the dual issue of children’s exposure to early and repeated traumatic events – particularly those that occur within the context of the primary caregiving system – as well as the impact of this exposure on both immediate and long-term outcomes (Cook et al., 2005). Complex trauma typically involves the experience of child maltreatment – such as emotional abuse and neglect, sexual abuse, and physical abuse (Cook et al., 2005). Because this type of trauma occurs during critical developmental periods of childhood and is often embedded in the context of the child’s core attachment relationship, its subsequent impact on development can be profound (Arvidson et al., 2011). Collectively, these experiences can lead to a cascade of negative consequences across several domains of impairment, including (a) attachment; (b) biology; (c) affect regulation; (d) dissociation; (e) behavioral control; (f) cognition; and (g) self-concept (Cook et al., 2005). A growing body of evidence has subsequently linked the experience of complex trauma in childhood with many behavioral and psychological disorders in children and adolescents that can persist into adulthood (Cook et al., 2003).

To begin to understand the myriad ways in which complex trauma affects children in the present moment, one must understand the physiological and psychological changes that occur in the mind and body in response to acute stressors, and how these processes differ from those experienced under extreme or prolonged stress. Under normal stress conditions, the body’s response is mediated through allostasis, a generally adaptive and temporary process that controls the body’s response to a stressor (McEwen & Seeman, 1999). Acute stressors set off a chain reaction in the hypothalamic-pituitary-adrenal (HPA) axis, which results in the activation of the sympathetic nervous system and the secretion of stress hormones to prime an individual to respond to the threat, commonly referred to as the fight-or-flight response (McEwen & Seeman, 1999). Once the threat has been removed, negative feedback loops are engaged to turn off the HPA axis and stop the release of stress hormones, moving the body back to a state of balance (McEwen & Seeman, 1999).

When the processes for allostasis are persistently activated or dysregulated, termed allostatic load, the excessive demands on the system can permanently alter its ability to regulate stress responses (Carroll et al., 2013). Chronic dysregulation of the stress response system can be especially damaging when it occurs during childhood, as internal resources are diverted away from important developmental processes to support adaptation to the significant challenges the child faces in the present (van der Kolk et al., 2005). In the absence of a safe and supportive environment, children may struggle to develop effective internal coping strategies to self-regulate responses to stress, and may instead lean on more primitive and extreme fight-or-flight responses to even minor stressors (Briere, 2002). They may also struggle with re-calibrating this arousal response following the stressor’s removal (van der Kolk, 2003). The physiological implications of this adaptation have been linked repeatedly to several chronic health conditions that can persist throughout one’s life, including obesity, heart disease, and early death (Felitti et al., 1998; Zarse et al., 2019). The combination of exposure to childhood trauma and the resulting emotional dysregulation and loss of core competencies can also impact children’s ability to detect or respond to danger cues, and may lead to polyvictimization, or subsequent trauma exposure, later on (Finkelhor et al., 2007).

In addition to the devastating physiological and psychological effects that toxic childhood stress can have on developmental processes, the experience of repeated trauma in childhood has been associated with a marked inability to develop trusting relationships (Cook et al., 2003). This may be in part due to the fact that complex trauma often occurs within children’s core attachment relationships (Scheeringa & Zeanah, 2001). When caregivers can successfully respond to children’s physical and emotional needs, the developing child is provided with a foundational sense of safety, critical to their later ability to develop their own self-regulation strategies (Aideuis, 2007). Alternatively, caregiving relationships characterized by uncertainty can have widespread negative effects on a child’s sense of safety within other relationships and within the world (Hesse & Main, 2006). Without this foundational secure base to rely on, children are not able to develop the skills and competencies necessary to thrive as they grow older (Aideuis, 2007). Importantly, this distinction is where the clinical diagnosis for post-traumatic stress disorder (PTSD) tends to fall short in terms of accurately representing the pervasive negative impacts that complex trauma can have on key developmental processes. The diagnosis of PTSD does not address the pervasive loss of safety, trust, and self-worth, and subsequent difficulties in emotional and interpersonal functioning, which can occur when children’s early experiences are characterized by fear and violence instead of loving care (Osofsky, 2004).

The increasing recognition of these pervasive negative effects has required new directions for treatment for children who have experienced this type of trauma, approaches that are less about treating the discrete symptoms of PTSD – such as hypervigilance, numbness, and flashbacks – and more about addressing the ways in which early trauma exposure can reconstruct a child’s entire nervous system, leading to pervasive feelings of overwhelm and being ‘existentially unsafe’ in relationships and in the world (Burstow, 2003).

Trauma-Informed Care in Therapeutic Residential Care

Social service organizations address complex trauma through two pathways: (1) trauma-specific treatment and (2) trauma-informed care. Trauma-specific treatments directly address the effects of trauma and facilitate healing processes through interventions like psychoeducation, therapy, and medication (SAMHSA, 2014). Alternatively, trauma-informed care (TIC), typically applied at the agency or organization level, addresses trauma more broadly. SAMHSA (2014) describes a trauma-informed program, organization, or system as one that:

Realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by full integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. (p. 9)

While specific treatments for trauma are clearly indicated for many YIC, two major barriers exist in their successful implementation in TRC settings. First, existing trauma treatments were not developed for use in TRC, but rather for individual or group therapy contexts (Hodgdon et al., 2013). Because TRC delivers around the clock care and incorporates multiple contexts – including school, social, and clinical settings – trauma treatments designed exclusively for outpatient clinical contexts are less likely to deliver the same level of effectiveness when applied to TRC settings (Hodgdon et al., 2013). As an example, trauma-focused cognitive behavioral therapy (TF-CBT), one of the most frequently used evidence-based trauma treatments, is contra-indicated for youth who have current self-harming behaviors, lack familial support, or are at high risk for retraumatization, all of which are common features of YIC (Hodgdon et al., 2013). Additionally, the need to prioritize physical safety in TRC for both youth and staff, as well as a lack of sufficient funding to extend focus beyond this critical baseline, presents a second barrier to successful implementation of trauma-specific treatments in TRC (Hodgdon et al., 2013). Ultimately, these issues reiterate the need to integrate TIC approaches into TRC, extending application beyond the individual therapy context to entire systems of care.

Several trauma-informed, organization-wide frameworks have been empirically evaluated within TRC settings over the last two decades, incorporating the principles of TIC established by Fallot et al. (2008): (a) safety, (b) trustworthiness, (c) choice, (d) collaboration, and (e) empowerment. Three commonly referenced TIC frameworks that have been evaluated in TRC settings include the Sanctuary® Model, the Attachment, Regulation, and Competency (ARC) framework, and the Children and Residential Experiences (CARE) model (Bailey et al., 2018). With the flexibility to be applied as both a clinical intervention and at the organizational level, the Sanctuary® Model aims to establish an emotionally and physically safe environment – a sanctuary – with relational and environmental safeguards to prevent retraumatization and help youth build on strengths and develop core competencies to recover from early childhood trauma (Bloom et al., 2003). Studies evaluating the effectiveness of the Sanctuary® Model at the organizational level report significant positive effects on youth’s development of coping skills and on the therapeutic program environment (Rivard et al., 2005), including a reduction in the use of seclusion and improved patient and staff satisfaction (Bloom et al., 2003; Kramer, 2016; Rivard et al., 2005). The Attachment, Self-Regulation, and Competency (ARC) framework, also designed for application at both clinical and organizational levels, is grounded in attachment theory and guides organizational practices across skill areas in three primary domains of intervention: fostering safe relationships, supporting youth’s capacity for regulation of emotional and physiological experiences, and facilitating resiliency through the development of competencies (Kinniburgh et al., 2005). In residential treatment settings, application of ARC showed improvements in youth’s problem behaviors and post-traumatic stress symptoms, as well as a reduction in staff’s use of physical restraints (Kinniburgh et al., 2005). Finally, the Children and Residential Experiences (CARE) model is a principle-based program designed to enhance relational dynamics in TRC through targeted staff training, ongoing reflection, and data-driven decision-making (Holden et al., 2010). Utilizing an ecological approach, CARE aims to help agencies move away from past focus on maintaining compliance towards creating living environments that are developmentally enriching and promote a sense of normalcy (Holden et al., 2010). In a study evaluating the implementation of the CARE model in several residential care facilities over a three-year period, outcomes indicated that the implementation of the model led to a significant reduction in aggression towards staff, property destruction, and runaway behaviors (Izzo et al., 2016). Importantly, a recent study examining the impact of the CARE model on key outcomes in YIC found that successful implementation of the model improved relationship quality between children and direct-care staff, a critical component of successful TRC programs aimed at addressing complex trauma in YIC (Izzo et al., 2020).

Collectively, TIC frameworks implemented in TRC aim to support organizational change within agencies that work with trauma-exposed youth and families, creating trauma-informed environments in which trauma-specific treatments can be effectively implemented. While these models each aim to support YIC in unique ways, several common features exist among them. As with all TIC programs, an understanding of trauma theory and its application to therapeutic practices and settings is detailed as critical in all frameworks, both in reducing retraumatization and in promoting long-term resiliency and growth (Bloom et al., 2003; Holden et al., 2010; Kinniburgh et al., 2005). A recent report on trauma-informed residential care emphasized the universal theme of safety across all TIC models and frameworks (Johnson, 2017). Unique to TIC frameworks aimed at supporting youth who have experienced complex trauma is a focus on strengthening attachments and fostering positive relationships between youth and staff as well as among peers (Bloom et al., 2003; Holden et al., 2010; Kinniburgh et al., 2005). TIC program models for TRC often emphasize the attachment system as a critical foundation from which trauma-specific interventions can be meaningfully implemented (Arvidson et al., 2011). Finally, TIC frameworks for TRC emphasize creating opportunities for skill development to enhance youth competencies and reestablish normal developmental trajectories (Bloom et al., 2003; Holden et al., 2010; Kinniburgh et al., 2005). This promising evidence indicates the important role that TIC models can play in TRC.

While TIC frameworks for TRC provide an important starting point for considering the ways in which social service organizations can support YIC in recovering from complex trauma, several important barriers exist in their successful implementation in these settings. Because many of these models place a strong focus on staff training to create organizational change, organizational readiness and universal culture change is critical to successfully and sustainably implementing a TIC approach (Bloom et al., 2003; Rivard et al., 2005). While some agencies have successfully implemented TIC, inconsistencies in training and understanding of its application among staff can create significant variability in the degree to which agencies are able to fully embrace TIC models (Hummer et al., 2010). For example, one study found that while staff at a TRC facility generally supported the Sanctuary® Model, they questioned the relevance of the model to their individual roles, and viewed it as more of a management framework rather than a framework for supporting young people in TRC (Galvin et al., 2021). The issue of obtaining staff buy-in at all levels of the organization can be further complicated by the extremely high turnover that occurs in TRC facilities and the resulting need for ongoing training and funding support (Galvin et al., 2021). An additional criticism that many TIC frameworks face is the disproportionate focus on promoting an understanding of trauma theory and core principles among staff, as opposed to providing ways for practitioners to tangibly implement theory and principles into daily practice (Becker-Blease, 2017; Hanson & Lang, 2016).

Critically, the importance of promoting a therapeutic milieu and home-like environment is almost universally mentioned in the literature on the application of TIC frameworks to TRC settings (Bloom et al., 2003; Holden et al., 2010; Kinniburgh et al., 2005). The ‘therapeutic milieu’ describes an approach in therapeutic settings that “leverages all interactions in the living environment to achieve a beneficial emotional and behavioral experience for youth” (Huefner & Ainsworth, 2021, p. 324). The CARE principle of being ecologically oriented states that two of the most critical aspects of TRC are the physical and social features of the environment, given that it is easier to change or manipulate an environment than to demand that a child adapts to it when doing so many not be within their capacity (Holden et al., 2010). The Sanctuary® Model also prioritizes the creation of a physically and emotionally safe environment as the foundation for establishing a trauma-informed community (Esaki et al., 2013). However, while these broad conceptual descriptions provide an understanding of how critical the built environment may be in the successful implementation of TIC frameworks in TRC, they do not provide detailed guidance on how to meaningfully address environmental triggers and design trauma-informed spaces to better support the goals of TIC in TRC.

As described by Kopec and Harte (2020) in their chapter in Supporting and Educating Traumatized Students, the design of the built environment may be the critical missing piece in realizing a truly trauma-informed approach. The design of the physical environment surrounding TRC programs presents a unique opportunity to scaffold TIC principles in a meaningful way that is not subjected to the same internal changes and variability in staffing and training that have created long-standing issues for successful implementation of TIC approaches in TRC. In fact, the physical environment can provide a predictable and stable element that may help to buffer against the impact of these inconsistencies. Through an intentional, trauma-informed approach to the design of these environments, TRC settings can not only reduce the risk for retraumatization for YIC, but also promote positive therapeutic processes and long-term resiliency.

The Role of the Physical Environment in Therapeutic Residential Care

While design features of TRC facilities have yet to be systematically evaluated as a core feature of TIC approaches, the role of the physical environment has long been considered in the context of child development. Bronfenbrenner’s (1979) ecological theory for human development established that children develop through a series of dynamic transactions with their environments, directing critical developmental processes. While this theoretical framework has historically been applied to the psychosocial context of care, evidence suggests that the physical environment itself may play an important role in these processes (Evans, 2006, 2021). For example, specific characteristics of adverse environments, such as noise, crowding, and lack of access to nature, have been repeatedly linked to negative physical and mental health outcomes for young people (Evans, 2006).

Within TRC, the critical role that the environment of care plays in supporting therapeutic processes has also been well documented (Bettelheim, 1950; Rose, 1990). Because YIC often come from environments in which they were deprived of their basic needs, the physical environment of TRC settings represents a powerful symbol of ‘home’ in which they can develop the trust that their needs will be met (Barton et al., 2012). While it can be challenging to balance the need to promote safety and security while portraying a nurturing, home-like environment (Johnson, 2017), evidence suggests that this may be essential in supporting therapeutic goals and outcomes in TRC (Bailey, 2002). In his seminal work, Maier (1987) alluded to the importance of establishing rhythms of care that reflect what one would expect of a home environment through even minor design elements, such as creating flexible spatial boundaries. For example, staff in TRC may leave their office doors open while working on paperwork to signal to youth that they are still available if needed, while also giving youth space to interact with peers without feeling intruded upon (Maier, 1987). Beyond the symbolic importance of home-like environments in TRC, YIC may also present with established physiological and psychological vulnerabilities that may make them more susceptible to environmental pressures and conditions than children outside of the TRC context (Bailey, 2002; Robinson & Brown, 2016). Understanding these vulnerabilities may have important implications for how sensory features of the environment like lighting and acoustics are considered in the design of these settings. Ultimately, the goals of TRC can only be accomplished in an environment that establishes safety (both real and perceived), provides opportunities for youth to meet and overcome challenges through the development of skills and competencies, and supports youth in engaging in meaningful relationships and experiences (Holden & Sellers, 2019).

Reducing Retraumatization Through the Establishment of Physical and Emotional Safety

The role of the physical environment of TRC is to provide both a safe place away from exposure to violence at home and in their communities, as well protection from retraumatization within TRC settings by preventing institutional abuse and reducing unintended triggers (Whittaker et al., 2014). Especially in the context of historical abuses associated with group care settings, the consensus statement from the International Work Group on Therapeutic Residential Care established the guiding principle of TRC as to “first, do no harm” (Whittaker et al., 2014, p. 96). While TRC settings often require more intensive external measures of control than typical settings, such as staff utilizing physical restraint to prevent dangerous behaviors among YIC, a significant body of evidence points to the counterproductive and potentially catastrophic effects that these behavior management techniques can have on children who have experienced trauma (Muskett, 2014). For example, the physical restraint of a child may be incredibly triggering for those who have experienced traumatic situations in which they were physically immobilized, such as physical or sexual abuse (Bailey, 2002). Importantly, these measures may also harm the therapeutic relationship between staff and youth that is critical for supporting positive outcomes in TRC, and can inadvertently signal to youth that they do not have control over their behaviors, emotions, and experience (Bailey, 2002). Instead, modern approaches to TRC aim to support traumatized youth by promoting safe and supportive relationships between staff and youth, as well as among peers, with the physical environment playing an important role in symbolizing a message of care over control (Bailey, 2002). Promising case studies show that the use of design elements like warm wall colors, comfy seating, and overall aesthetic quality of a residential care setting can help to foster a sense of a warm and nurturing home (Rice et al., 2011).

The need to promote safety in TRC settings also extends beyond the symbolic. YIC who have experienced repeated childhood trauma may develop sensory sensitivities in response to these experiences that can subsequently impede their ability to establish an internal sense of safety, even in objectively safe environments (Robinson & Brown, 2016). Because traumatic experiences tend to heighten an individual’s awareness of their surroundings as a means of protecting and preparing them to respond with a specific action (e.g. the fight-or-flight response), features of the physical environment may become powerfully associated with a traumatic event (Robinson & Brown, 2016). The dissociation that often accompanies traumatic experiences can disrupt normal memory encoding processes, such that a narrative account of the experience may not be easily accessible or identifiable by the traumatized individual, and instead may present as fragmented physical sensations, images, or sensory experiences (van der Kolk, 2014). An example of such sensitivity might include being startled by loud noises, such as a door slamming. However, for children who experienced trauma at an early age, the implicit encoding of sensory features of the environment as traumatic memories may be even more pronounced, as the parts of the brain responsible for sequencing and providing context for such information are not yet fully formed (Briere, 2002). Broad sensitivities to environmental stressors may develop as a result, triggering unconscious and conditioned emotional responses to the physical environment long after the traumatic experience has ended (Briere, 2002; Robinson & Brown, 2016).

While it is possible that heightened reactions to environmental stressors in youth are rooted in specific traumatic memories, such as the color of a wall that was visible during harm or the sound associated with impending abuse, it is more likely that their early experiences of trauma have fundamentally shifted the ways in which they perceive and engage with the world around them in the present (Robinson & Brown, 2016). The ways in which children encode traumatic memories have clear implications for treatment, as talk therapy may be less effective for those who are not able to access narrative content to both describe and understand their experiences (van der Kolk, 2014). Alternatively, the role of the physical environment may become powerfully amplified for these children. As our primary source of sensory input, the built environment represents a feature of TRC that can be meaningfully altered to reduce retraumatization in these settings, helping to establish the necessary foundation for the important therapeutic work of TRC programs.

Research on children with autism spectrum disorder (ASD) may provide a useful foundation for considering how to modify the physical environment to support the sensory needs of YIC. A significant body of research has linked the role of altered perception and processing of sensory stimuli in autistic behavior (Mostafa, 2014). While the past focus of interventions for youth with ASD has been on helping them develop skills to better cope with the environment, evidence suggests that altering the stimulatory input coming from the physical environment, such as color, texture, lighting, ventilation, and acoustics, may help to address autistic behaviors before the sensory malfunction occurs, with positive effects on behavior and efficient development of skills (Mostafa, 2014). However, additional research is needed to understand how sensory needs may differ between youth with ASD and youth with complex trauma histories to be able to meaningfully address these challenges through the design of TRC settings.

Supporting the development of place attachment to the TRC setting may also help to promote a sense of safety in YIC. Grounded in attachment theory, place attachment describes the strong emotional bond that can develop between individuals and their environments (Low & Altman, 1992). An individual’s attachment to meaningful places can heighten their sense of safety, even in extremely stressful contexts like war zones (Billig, 2006). Research suggests that a regular pattern of positive experiences with a place become internalized, guiding future behaviors, and generating expectations about how the place may be able to meet one’s needs in the future (Magalhães & Calheiros, 2020) found that youth’s positive perceptions about their involvement in their care as well as their feelings of safety and security within their TRC program supported the development of place attachment to TRC. Considering the unique experiences of YIC, including displacement from their own home environments and the possible negative associations they may have with ‘home’ being the site of their trauma, facilitating place attachment with the TRC facility itself may play a crucial role in supporting positive outcomes during and following placement in TRC (Magalhães & Calheiros, 2020).

Providing Opportunities for Development of Core Skills and Competencies to Promote Resiliency

Only after children’s basic needs for safety are met can they begin to work towards building the skills and competencies necessary for healing and long-term recovery and thriving after TRC. The physical environment of therapeutic care can play an important role in providing youth with opportunities to meet and overcome challenges and gain core competencies that can support them in their treatment while in TRC and can later be translated to life outside of the care environment. For example, providing different seating options to facilitate small and large group gathering in common areas of TRC settings can support children’s development of positive relationships (Docherty et al., 2006), while providing opportunities to personalize their spaces – through display of special objects or including elements like chalkboards in their bedrooms – may support important identity development processes that are often interrupted in the aftermath of childhood trauma (Docherty et al., 2006). Involving youth in the design of TRC can serve the dual purpose of ensuring children’s voices are heard and their needs are met, while also helping them to establish a sense of ownership and accountability within the space (Docherty et al., 2006; Rice et al., 2011; Stevens, 2006). Involving youth and staff in TRC settings in post-occupancy evaluations (POEs) following design interventions can also support these processes (Docherty et al., 2006​).

Across settings serving traumatized youth, the consistent practice of providing a separate space for decompression illustrates its unique potential as an element of the physical environment that can support the development of self-regulation capabilities. Re-regulation rooms (Kopec & Harte, 2020) or stimulus shelters (Bailey, 2002; Robinson & Brown, 2016) provide a structured space for children to go when they are feeling overwhelmed. These rooms are specifically designed to promote a sense of safety and security, and offer children the ability to practice important emotion-regulation coping skills in moments of high stress. In residential settings, providing access to private bedrooms during the day can serve as a form of stimulus shelter (Bailey, 2002). Rather than continuing to reinforce unhelpful power dynamics, providing youth with the opportunity to remove themselves from stressful situations through therapeutic away spaces may help them to internalize a fundamental sense of trust and safety (McLoughlin & Gonzalez, 2014). While there remains work to be done in synthesizing these design principles into guidelines for traumatized youth, these examples provide strong evidence to support the potential impact of this work in supporting positive therapeutic outcomes of TRC.

Trauma-Informed Design in Therapeutic Residential Care

With this understanding of the complex needs and experiences of YIC, the current TIC frameworks that are being implemented in TRC to support youth in care, as well as the understanding of how the physical environment may contribute to positive and negative outcomes during and following placement in TRC, there are several bodies of literature that can be drawn upon to begin to develop trauma-informed design guidelines for use in TRC settings.

Insights from Evidence-Based Design in Healthcare Environments

The practice of evidence-based design (EBD) in healthcare has established that the physical environment can powerfully influence the physical and emotional health of patients and caregivers, and even the perception of overall quality of care (Liddicoat et al., 2020). Ulrich’s (2001) theory of Supportive Healthcare Design indicates that healthcare environments can promote healing by both eliminating stressful environmental features, such as loud noises and lack of natural lighting, as well as by including supportive environmental features known to alleviate stress and strengthen coping resources, such as providing access to nature and promoting social support through communal spaces. In the context of mental and behavioral health facilities, research suggests that design may be central to providing best-practice care, and can significantly influence factors such as engagement in the therapeutic process, emotion regulation, and aggressive behaviors (Liddicoat et al., 2020).

In a recent review of EBD in mental and behavioral health facilities by Aljunaidy and Adi (2021), the authors identified a significant body of literature on design for dementia and autism spectrum disorders, while design considerations for more common disorders, such as depression, anxiety, and stress-related disorders, were largely absent. It was suggested that the clearer linkage between the built environment and the reduction or elimination of problematic features associated with dementia (such as preventing disorientation during expected cognitive decline) and autism (such as reducing sensory overload) may at least partly explain this discrepancy (Aljunaidy & Adi, 2021). Disorders like PTSD may be overlooked due to their highly internalized presentation and symptomatology, as well as a general lack of understanding as to what types of physical environment features may provide relief (Aljunaidy & Adi, 2021). While important parallels may be drawn from overlapping features of certain psychological disorders, such as the sensory sensitivities associated with complex trauma and ASD, more work is needed to establish what features of trauma-related disorders are missing from the existing EBD knowledge base.

Without a formal diagnosis, complex trauma may present an even bigger challenge to designers in determining how the built environment may either hinder or support recovery processes. The pervasive nature of how complex trauma is imprinted on the mind and body may render youth unable to articulate their environmental needs or identify the ways in which the current environment could be modified to support them. Future work will need to establish a clearer understanding of both the needs of youth who have experienced complex trauma, as well as the environmental features or conditions that may hinder or support those needs, to develop appropriate design guidelines and objectives for facilities like TRC that serve traumatized youth.

Insights from Early Work in Trauma-Informed Design

Early work in the emerging field of trauma-informed design (TID) aims to respond to this gap in awareness on trauma-specific disorders and built environment solutions, incorporating the specific needs of individuals who have experienced trauma into EBD practice. While trauma-informed care (TIC) frameworks inform the delivery of social services in a way that recognizes the impacts of past trauma in the present moment, TID explores the application of TIC principles to the built environment (Bollo & Donofrio, 2021). In the seminal report by SAMHSA’s Trauma and Justice Strategic Initiative (2014), one of the ten implementation domains to consider when implementing a trauma-informed approach is the physical environments of social service organizations, such as mental health facilities and homeless shelters. Several questions are proposed by SAMHSA (2014) as areas to consider when evaluating the physical environment:

• How does the physical environment promote a sense of safety, calming, and de-escalation for clients and staff?

• In what ways do staff members recognize and address aspects of the physical environment that may be re-traumatizing, and work with people on developing strategies to deal with this?

• How has the agency provided space that both staff and people receiving services can use to practice self-care?

• How has the agency developed mechanisms to address gender-related physical and emotional safety concerns (e.g., gender-specific spaces and activities)? (p. 13)

In response to this guidance, the Committee on Temporary Shelter (COTS), an advocacy organization that seeks to provide long-term solutions to issues related to homelessness, developed the first known adaptation of TIC principles into trauma-informed design (TID) principles, building on the early work of Clarke (2009) in designing for dignity in hospital settings. These TID tenets include: (a) reduce or remove environmental stressors, (b) engage the individual actively in a dynamic, multi-sensory environment, (c) provide ways for the individual to exhibit their self-reliance, (d) provide and promote connectedness to the natural world, (e) separate the individual from others who may be in distress, (f) reinforce the individual’s sense of personal identity, and (g) promote the opportunity for choice while balancing program needs and the safety and comfort of the majority (Farrell, 2018). Table 1, adapted from Bollo and Donofrio (2021), illustrates the potential overlap between the principles of TIC and TID.

Table I.

Comparison Map of Trauma-Informed Care (TIC) Principles and Trauma-Informed Design (TID) Principles

	TIC Principles
TID Principles	Safety	Trustworthiness	Choice	Collaboration	Empowerment
Reduce or remove known adverse stimuli and environmental stressors	•
Engage the individual in a dynamic, multi-sensory environment			•
Provide ways for the individual to exhibit self-reliance			•		•
Provide and promote connectedness to the natural world	•		•
Separate individual from others in distress	•	•
Reinforce the individual’s sense of personal identity					•
Promote the opportunity for choice while balancing program needs and the safety/comfort of the majority		•	•		•

Adapted from Bollo and Donofrio, 2021, p. 8.

These principles have been expanded upon in several reports and white papers on the application of TID to homelessness services settings, permanent supportive housing, and domestic violence shelter design (Grabowska et al., 2021, Pable & Ellis, n.d., Wilson et al., 2020), broadening the reach of this early work to design practitioners outside of academia. In a report by members of Shopworks Architecture, Group 14 Engineering, and the University of Denver Center for Housing and Homelessness research, permanent supportive housing (PSH) facilities designed with these principles in mind included features like built-in nooks that individuals could climb into in public areas to provide a sense of privacy while still having access to social connection, carpeted staircases to limit the sound of footsteps, and the use of wooden materials to add a layer of warmth and deinstitutionalize the space (Grabowska et al., 2021).

Early academic research in this emerging discipline has begun to validate the potential for TID to support the goals of TIC approaches in settings serving adult populations who have experienced trauma (Bollo & Donofrio, 2021). Several published studies have explored the application of TID in permanent supportive housing (PSH) facilities: Bollo and Donofrio’s (2021) case study evaluation of TID in four PSH facilities, McLane and Pable’s (2020) study of the Westgate Program and Booth Center focusing on TID principles of personal empowerment and choice, and Huffman’s (2018) study of trauma-informed architecture at the Star Apartments. Rollings and Bollo (2021) subsequently published an integrative review evaluating design characteristics of PSH settings, detailing TID practices in their discussion, such as deinstitutionalization of aesthetics, optimizing access to natural lighting and nature, and creating opportunities for personalization. However, there remains limited peer-reviewed scholarship on the systematic application of TID in contexts outside of homeless service settings, particularly those that support traumatized youth.

Some work has begun to explore important developmental considerations in the design of institutional settings for children through a trauma-informed lens. In Marrow et al.’s (2012) implementation of a TIC approach in a juvenile justice center, environmental modifications were made as part of a multifaceted intervention with the intention of reducing trauma triggers, through installing features like noise-reducing panels and providing designated calm spaces for youth to practice emotion-regulation skills, which demonstrated positive effects on youth’s depression, anxiety, hope, and optimism (Marrow et al., 2012). Kopec & Harte (2020) incorporate trauma theory and knowledge of the important physiological changes that occur as a result of childhood trauma into recommendations for designing safe and supportive learning environments, including identifying and addressing probable triggers such as noise coming from adjacent classrooms, arranging classroom seating in a way that prevents students from feeling trapped, and using design to guide students experiencing a heightened stress response to safe spaces designated for the purpose of de-escalation (Kopec & Harte, 2020). This early work provides promising evidence to support adapting TID approaches to meet the unique needs of youth who have experienced complex trauma. However, more research is needed in this area to fully realize the potential of the built environment to promote recovery from complex trauma, particularly in TRC settings.

Future Research Directions

While early research in TID clearly illustrates the promising potential for a TID approach to support youth who have experienced complex trauma, more work is needed in this area to empirically validate these approaches and to understand the specific environmental features and conditions that may trigger youth or else serve as therapeutic supports in TRC. Much of the work that has been done to date has been published in gray literature and organizational reports. Empirical research is needed to validate these approaches and illustrate the impact of specific design interventions on complex trauma outcomes. There may also be important implications for the design of TRC facilities to support the unique developmental needs of adolescents, as the typical age of youth in residential care is 14 years and older. For example, adolescents may lean on peer relationships for companionship and intimacy needs, while relying on caregivers to meet safety needs (Papalia et al., 2007), with implications for how the built environment may support these relationships in unique ways. Additionally, it has been established that complex trauma can dramatically impact developmental progress, and thus the developmental stage of YIC and their subsequent environmental needs may not reflect that of normative peers outside of this environment (Cook et al., 2005).

The length of placement in TRC may also have meaningful implications for the design of these environments. Data from the Children’s Bureau indicates that youth typically spend a cumulative amount of eight months in a congregate care setting in the United States, though length of stay can vary from child to child and across states (Pecora & English, 2016). Magalhaes and Calheros (2015) found that the length of time spent in an institution was positively correlated with place attachment and subsequent positive associations of sense of self with TRC. With this understanding in mind, design features may be adapted to better support a sense of permanency in these temporary environments, such as through the establishment of daily routines like family meals in a homelike environment.

Finally, while research to date in EBD and TID approaches suggests there may be substantial benefit to considering how to design TRC facilities to better support children with complex trauma histories, a lack of appropriate funding – especially when compared to other medical and mental health facility types – may present challenges to implementing trauma-informed modifications to TRC environments. For example, in the U.S., it has been more than 40 years since TRC programs have received any significant government or private foundation funding for the development of model TRC programs (Whittaker et al., 2014). Even programs that do receive funding for environmental modifications may be limited in terms of their existing infrastructure. As an example, one TRC facility in upstate New York recently underwent a multi-million-dollar investment to redesign their entire campus. However, because the original campus housed army barracks, the redesigned campus clearly gives off this impression despite the significant investment made to redesign the facility. Given this perpetual funding issue, the potential for new TRC facilities to be designed with these TID principles in mind is unlikely, and design guidelines will need to consider lower cost modifications and ways to work with existing infrastructure to be meaningfully implemented in these settings.

Ultimately, this conceptual paper presents a foundational understanding of the complex needs of YIC, as well as an evaluation of current best practices and outstanding opportunities for the successful implementation of TIC in TRC settings. Critically, the physical environment of TRC has remained largely unexplored in the literature, despite evidence that this may be a key missing piece of current TIC approaches that can have profound impacts on youth and staff in these settings. Innovations in other fields, such as EBD in healthcare, illustrate the promise of design guidelines to support the identification of meaningful solutions and systematic application of design elements to support healing processes. While the important role that the physical environment can play in TRC has been established by some early work, particularly in relation to the symbolic representation of the ‘home’ and the necessity to establish physical safety for YIC, the development of synthesized TID guidelines for TRC in future research will support the systematic application and measurement of design interventions in these settings on key outcomes for YIC, reducing the risk for retraumatization in these settings, supporting critical therapeutic processes, and enabling long-term recovery and thriving for this vulnerable group of young people.

Declarations

Conflict of Interest

We have no known conflict of interest to disclose.