Treating the Hidden Wounds: Trauma Treatment and Mental Health Recovery for Victims of Human Trafficking
By: Heather J. Clawson, Ph.D., Amy Salomon, Ph.D., and Lisa Goldblatt Grace, LICSW, MPH
Part of a larger project: Study of HHS Programs Serving Human Trafficking Victims
This Issue Brief is available on the Internet at:http://aspe.hhs.gov/hsp/07/HumanTrafficking/Treating/ib.htmhttp://www.icfi.com/markets/social-programs/
Printer Friendly Version in PDF format (10 pages)
- Study Overview
- Trauma and Its Impact
- Challenges in Meeting the Needs of Trafficking Victims who have Experienced Traumatic Abuse
- Trauma Informed and Specific Services
- Core Components of Trauma Informed and Specific Services
This is the third in a series of Issue Briefs produced under a contract with the Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE) to conduct a study of HHS programs serving human trafficking victims. Funded in the fall of 2006, the purpose of this exploratory project is to develop information on how HHS programs are currently addressing the needs of victims of human trafficking, including domestic victims, with a priority focus on domestic youth. This project also consists of reviewing relevant literature, and identifying barriers and promising practices for addressing the needs of victims of human trafficking, with a goal of informing current and future program design and improving services to this extremely vulnerable population.
This issue brief addresses the trauma experienced by most trafficking victims, its impact on health and well-being, some of the challenges to meeting trauma-related needs of trafficking victims, and promising approaches to treatment and recovery. While this issue brief touches on trauma across human trafficking populations, it has a special emphasis on trauma resulting from sex trafficking of women and girls.
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Recent trauma studies have deepened our understanding of trauma and its impact. They describe a complex range of post-trauma symptoms and identify the interactions of multiple factors as contributing to their seriousness (Briere & Spinazzola, 2005). For example, more serious symptoms are associated with histories of multiple victimizations, often beginning in childhood and resulting in disruptions of parent-child relationships (Ford & Kidd, 1998; Turner, Finkelhor & Ormrod, 2006). More profound impacts are also associated with co-occurring behavioral health problems, like substance abuse disorders, (Acierno, Resnick, Kilpatrick, Saunders, & Best, 1991) and with a range of other issues, like limited social supports, lower socioeconomic status, and stigma associated with particular traumatic events (Brier & Spinozzola, 2005).
Trauma exposure occurs along a continuum of complexity, from the less complex single, adult-onset incident (e.g., a car accident) where all else is stable in a persons life, to the repeated and intrusive trauma frequently of an interpersonal nature, often involving a significant amount of stigma or shame and where an individual may be more vulnerable, due to a variety of factors, to its effects (Briere & Spinazzola, 2005, p. 401). It is on this far end of the continuum where victims of human trafficking, especially sex trafficking, can be placed.
Most of the literature on trauma and trafficking focuses on the trafficking of foreign-born women and girls for commercial sexual exploitation. In addition to experiencing terrorizing physical and sexual violence, researchers report that victims often experience multiple layers of trauma including psychological damage from captivity and fear of reprisals if escape is contemplated, brainwashing, and for some, a long history of family, community, or national violence (Stark & Hodgson, 2003; Ugarte, Zarate, & Farley, 2003).
Additionally, the emotional effects of trauma can be persistent and devastating. Victims of human trafficking may suffer from anxiety, panic disorder, major depression, substance abuse, and eating disorders as well as a combination of these. For some victims, the trauma induced by someone they once trusted results in pervasive mistrust of others and their motives. This impact of trauma can make the job of first responders and those trying to help victims difficult at best.
In some cases, the exposure to trauma results in a condition referred to as Post-Traumatic Stress Disorder (PTSD). PTSD is a mental health diagnostic category created originally for war combatants and disaster victims but which also applies to victims of other traumas, including trafficking victims. For those that struggle with PTSD, the characterizing symptoms include intrusive re-experiencing of the trauma (e.g., flashbacks, nightmares, and intrusive thoughts), avoidance or numbing of trauma-related, or trauma-triggering, stimuli (e.g. avoiding certain places, people, and situations), and hyper arousal (e.g., heightened startle response, and inability to concentrate). For both adults and youth, once established, PTSD is usually chronic and debilitating if left untreated (Feeny, Foa, Treadwell & March, 2004).
Post-trauma responses like those outlined above reportedly contribute to problems with functioning, including difficulties controlling emotions, sudden outbursts of anger or self-mutilation (Briere & Gil, 1998), difficulties concentrating, suicidal behaviors (Zlotnick, Donaldson, Spirito, & Pearlstein, 1997), alterations in consciousness (dissociation), and increased risk taking. These post-traumatic symptoms and problems reflect those service providers often identify as common among the trafficking victims they work with. For some victims, in particular victims of sex trafficking, the use of alcohol and drugs to escape these emotional states is also a problem.
In addition to emotional problems, physical health problems can also predominate and result from the trauma of physical injury or indirectly through stress-related illnesses. For example, service providers report victims often complain of stomach pain, headaches, and other unexplained ailments. Given the impact of these trauma symptoms on the emotional and physical well-being of victims, it is not surprising that some victims of human trafficking experience difficulties obtaining and holding down a job, paying bills, and reintegrating back into society.
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Many of the health and social needs of trafficking victims stem directly from their experience with trauma and the brutal reality of unremitting threats or actual physical and sexual violence. Meeting these needs, in particular providing mental health treatment and trauma-informed services, is not without challenges. Service providers report the following barriers and challenges to getting victims help in dealing with their trauma.
Limited availability and access to appropriate mental health services. Issues of affordability and access to services, as well as responsiveness of those services to the complex needs of survivors, are common issues identified by service providers. Providers uniformly point to access to mental health services as a significant challenge for both international and domestic victims.
Survivor of human trafficking
For most victims, shame is seen as one of the greatest barriers preventing them from seeking mental health services. Providers note that the stigma associated with mental illness is an especially prominent challenge in engaging foreign-born and male victims in treatment.
For other victims, while providers report a willingness to seek help for physical health complaints, the underlying cause of the physical problems or symptoms the trauma often goes ignored and untreated.
For U.S. minor victims, barriers to accessing mental health services are linked primarily to the issues of confidentiality and concerns that someone will find out what has happened to them, lack of identification documents, lack of insurance, and system-related jurisdictional issues. For example, as one provider notes, it is often assumed that child welfare systems will provide mental health services for minors. Requirements to report minors to child protective services, however, do not necessarily result in access to treatment. If the abuse is not inflicted by a parent or legal guardian, the case is often seen as outside the jurisdiction of the system. In such cases the minors fall through the cracks and do not receive services they need. But there are still challenges even if a youth has health insurance or is served under the child welfare system. Most providers note that referral sources for mental health treatment or counseling are limited for youth, as well as for adults. In one community, the wait for a psychiatric referral for youth was up to seven months.
Once access to mental health or counseling services is obtained, many providers are unable to maintain the long-term treatment that many victims require. Providers report that insurance and/or funding restrictions often limit the number of sessions that a victim can receive. Furthermore, traditional therapeutic services are often ill-designed to respond to the needs of transient victim populations, in particular U.S. minor victims, who sometimes find it difficult to meet expectations for weekly appointments. Responsive mental health treatment requires considerable flexibility which may not be supported by existing systems of care. Therefore, while getting services in response to the immediate crisis is not viewed as a problem in most cases, helping a victim with long-term trauma recovery is a significant concern.
Victim service provider
Difficulty establishing trusting relationships with victims. For both law enforcement and service providers, getting victims to trust them and accept help is a huge obstacle. They acknowledged that while building trust takes time, time is something that often worked against both law enforcement and providers. Many of the services available for victims are described as time limited. For example, both domestic violence shelters and runaway and homeless youth programs, where most counseling services are offered on-site to victims, generally provide for short stays that do not allow adequate time to establish trusting relationships needed in order for a victim to open up and begin to address their trauma. The mistrust of victims often is due to their histories of betrayal from families, service systems, and in some cases, law enforcement and governments. But in addition, a victims mistrust is often compounded by fears that connections with law enforcement and/or service providers can compromise their physical safety (e.g., the trafficker will find them, they will be deported, or they will be sent back to an abusive home).
Mandated treatment efforts may be counterproductive when working with victims. In some communities, the only way to access mental health screening and treatment services is to be committed to a locked treatment facility. Having already experienced the loss of control to traffickers, this can make being in locked treatment facilities or detention centers seem particularly threatening, essentially re-traumatizing victims and frustrating their recovery.
Secrecy is a trademark of the women and girls involved in sex trafficking; victims may not define their experience as abusive, or attempt to escape. A complex web of coping strategies and harsh realities make it hard for some victims to seek and receive help. The shame and stigma of sex trafficking may lead them to conceal their involvement in prostitution, even in therapeutic relationships where success is dependent on frank disclosure and working through the trauma (Herman, 2003). In addition, if a victim does not define her experience as abusive, no matter how dangerous, she will not likely seek help or engage in recovery (Ugarte et al., 2003).
Foreign-born trafficking victims face additional barriers related to language, culture, and isolation. Lack of English skills for foreign-born victims limit their ability to access information about rights, services and options. Isolation due to these language barriers as well as cultural differences can be hard for any new immigrant but are particularly devastating for trafficking victims by reinforcing their captivity. (It should be noted that the isolation of domestic victims moved repeatedly throughout the country has some of the same effects.) Forming outside supports is critical in fighting the isolation and ultimately getting victims the help they need. Shifts in traditional Western professional treatment paradigms to more nontraditional interventions and support groups (which recognize oppression when working with people of low economic status and low power) have been noted as key to working with immigrant and refugee victims (Hotaling et al., 2003 p. 257).
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Given this range of challenges, what do we know about the way systems and services can best respond to the complex and multiple needs of trafficking victims? One especially useful framework characterizes two broad categories of service delivery: trauma informed services, appropriate for all systems of care in which victims may present; and trauma specific services, designed to treat the actual symptoms of physical or sexual abuse in specialty treatment programs (Harris & Fallot, 2001).
This framework is especially appropriate to working with trafficked women and girls since they are likely to present in a variety of systems of care for other than their trauma-related needs. Trauma informed services can promote a sensitive and relevant response regardless of where a victim seeks help, and can also improve the identification of victims. At the same time, trafficking victims are likely to need more specific and long-term trauma treatment. The distinction between trauma informed and trauma specific services can help providers better pinpoint where their services are located on the continuum and what it might take (including training, supervision, additional program components and networking) to create a more continuous and comprehensive system for victims of human trafficking.
Trauma informed services encompass two distinctly different things. According to Harris & Fallot (2001), to be trauma informed means, first, to know the history of past and current abuse in the life of your clients. This information allows for a more integrated and appropriate approach to meeting their needs. But second, to be trauma informed means to understand the role that violence and victimization play in the lives of most consumers of services and to use that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation in treatment. (Harris & Fallot, 2001, pp. 4-5) Trauma informed services are generally developed to treat primary problems other than trauma, by building capacity within those systems of care where survivors of trauma may present (i.e., homeless shelters, substance abuse treatment programs, the criminal/juvenile justice systems, mental health programs, medical programs, etc.). Regardless of the agency or systems primary mission, trauma informed services are committed to providing services in a manner that is welcoming and appropriate to the special needs of trauma survivors. Both the identification of victims, and successful treatment of their trauma, can be improved by having trauma informed services provided in multiple systems.
Trauma specific services, on the other hand, are likely to be found with specialty mental health programs or providers, although they clearly could be developed in other medical settings, homeless shelters, or other systems of care. They are generally accessed by referral to those doing the clinical work. A variety of trauma specific techniques are in the repertoire of these services. Among them may be grounding techniques to help manage dissociative symptoms; desensitization therapies to help make painful images more tolerable; and certain behavioral therapies which teach skills for coping with post-trauma effects (Harris & Fallot, 2001). These therapies can be delivered individually or in groups, and are often augmented by other complimentary approaches, including culturally relevant material.
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While the needs of individual trafficking victims with histories of trauma may vary considerably, the systems of care in which they are likely to present (child welfare; criminal justice; immigration; public health and behavioral health) can be better prepared to recognize their needs and help accordingly. Core components of a system of care responsive to the trauma-related needs of trafficking victims should include a set of core principles and practices based upon providers understanding that:
- Trauma is a defining life event with a complex course which can profoundly shape a victims sense of self and others;
- The victims complaints, behaviors and symptoms are coping mechanisms (their original sources of strength may no longer be effective), and requiring use of a relational, rather than individualized or confrontational, approach to their solution;
- The primary goals of services are empowerment and recovery (growth, mastery, and efficacy) which are prevention-driven and limited by survivor self-assessment and recovery needs; and
- The service relationship is collaborative, with victim and provider having equally valuable knowledge, the victim can be an active planner and participant in services, his/her safety ensured, a priority placed on choice and self control, and trust developed over time (Harris & Fallot, 2001).
Specific core components that are based on these beliefs and practices are listed below.
Review of agency policies and procedures to identify and remove any that are potentially unsafe and harmful to trafficking victims with histories of trauma. Internal reviews, using a trauma lens, can be especially helpful in identifying policies and procedures (e.g., strip searches, locked holding pens) which can be damaging to trafficking victims experiencing trauma disorders. Conversely, assessing the degree to which policies and procedures support a welcoming and agency-wide trauma informed perspective, within an overall planning process, can help clarify an agencys needs (for staff and training) and the role it expects to play within a comprehensive network of community services.
Education and training of staff, including those working directly with trafficking victims as well as other providers in relevant systems of care. Education of staff might include training on the complex interactions of trauma, substance use, emotional disorders and physical illness; multicultural education on specialized approaches to working with foreign-born victims; as well as basic safety issues in working with victims and approaches to treatment. Training should also include helping caregivers understand the experience of being trafficked, who is most vulnerable to trafficking, the techniques traffickers use to recruit victims, the impact on victims, and what a path to recovery can look like.
Key Characteristics of a Skilled Provider Working with Trauma-Survivors
- Understands that certain survivor behaviors are a response to trauma;
- Is knowledgeable regarding the mental health [and substance abuse] effects of violence and in particular, sexual violence;
- Is skilled and knowledgeable regarding trauma and trauma treatment;
- Is able to provide culturally competent services and seeks supervision regarding cultural issues;
- Is responsive to emergency mental health issues of clients
Modified list from Helping Sexual Assault Survivors with Multiple Victimizations and Needs: A Guide for Agencies Serving Sexual Assault Survivors (Davies, 2007), page 40
Screening for trauma in multiple settings. Identification is the first and necessary step in assuring victims get the help they need. In some cases, providers may be reluctant to ask sensitive questions early on in the relationship building process; however, not raising those questions at all can be more detrimental. For victims of sex trafficking, culturally sensitive screening that incorporates multiple references to sexual abuse has been considered beneficial in reframing the abuse and shifting responsibility to the perpetrators (Ugarte et al., 2003). Staff who conduct these screening will need adequate skills, supervision, and supports.
Victim service provider
Ensuring safety and meeting basic service needs. Establishing physical and psychological safety is considered a pre-requisite in working with trafficking victims with trauma histories. This may mean collaboratively assessing the current level of client safety and developing together plans to remain safe. It can also mean designing each component of service to prioritize safety. For example, an outreach and engagement activity under this rubric would prioritize safety and control by explicitly seeking permission to speak with a victim, asking about the amount of privacy he/she might want for an initial conversation, and following his/her lead on disclosure. Safety may also include working with a clinician who is respectful, non-judgmental, and allows the victim to explore his/her history in a safe and containing way. In addition and complementary to safety, providers emphasize several basic services that are critical components to comprehensively meeting the needs of individuals who have experienced trauma, including safe housing, life skills, health care, legal services, and vocational supports (Finkelstein et al., 2004). Developing multidisciplinary collaborative networks of programs across systems of care can help facilitate comprehensively addressing multiple needs.
Law enforcement officer
Building long-term, sustaining relationships and providing opportunities for regaining valued social roles. A critical part of trauma recovery and building new lives for trafficking victims involves the development of trusting, long-term relationships. This often needs to occur well before a victim is willing to engage in trauma specific treatment. These relationships are developed in some programs with care coordinators who assist with identifying and helping to meet a victims basic needs. Care coordinators are sometimes the link (through gentle and respectful suggestion) between basic services and mental health treatment, where needed. Other programs, working especially with immigrant women, emphasize relationship building through more natural and culturally familiar supports, including home visits, sharing a meal, etc. Helping victims connect with valued social roles, such as providing opportunities for peer leadership and community action are also noted by trafficking survivors and providers as opportunities to regain or reshape a victims sense of self and capabilities.
Access to trauma specific treatment services. In addition to the trauma informed strategies outlined above, providers working with trauma survivors must have access to a range of trauma specific interventions, including individual clinicians willing, available and culturally competent to work with victims of human trafficking, as well as groups designed to meet their often multiple treatment needs. Cognitive Behavioral Therapies have been most studied and therefore have the largest evidence-base supporting their effectiveness in reducing PTSD symptoms (Feeny et al., 2004; Foa and Rothbaum, 1998). In addition, evolving trauma-theory specific to complex trauma emphasizes that treatment should address developmental and relationship difficulties in addition to PTSD symptoms (Pearlman & Courtois, 2005).
Several treatment approaches have been developed for complex trauma specific to adolescents, using group therapy to address skills development, affect regulation, interpersonal connections and competence and resiliency building. These interventions all emphasize the relationship between symptoms and the traumatic experience, the development of concrete coping skills in managing symptoms, and the use of peer support groups to increase normalization, build healthy interpersonal relationship skills, and establish social supports (Cook et al., 2005). One program for sexually exploited teens emphasizes the importance that youth make the connection between their physical symptoms and mental health. Weaving mental health into other strategies, like art or music therapy, appear especially promising.
Providers also need to understand and assess the role that culture plays in resiliency and the importance of community resources as potentially mediating the trauma experience, especially for foreign-born victims. Individually-focused Western conceptualizations of trauma may miss the potential strengths inherent in culture and community to enhance engagement in healthy relationships and promote recovery (Tsoi Hoshmand, 2007; Argenti-Pullen, 2000; Burstow, 2003; Summerfield, 2004).
Making peer models and supports available. Given the challenges for trafficking victims in developing trusting relationships with professionals, there was wide acceptance among providers that successful programs need to incorporate peer-to-peer counseling and supports among their core components. Particularly for victims of human trafficking, where shame promotes secrecy, individuals can be most comfortable with peers who understand, and have lived, their own struggles. Both service providers and victims highlight the critical importance of non-judgmental, empathic peer support that allows trauma victims to successfully make the transition to a new life. Furthermore, peer led services can reduce or remove the cultural and language barriers that can get in the way of successful recovery. Structured peer support additionally offers the opportunity for survivors to develop a new identity as a valued and responsible member of a community. (Herman, 2003 p.11)
More and more programs for victims of human trafficking are starting to engage survivors in programming. This includes peer counsels assisting in program decision-making and peers providing group-mentoring/support to current clients. Peers are often individuals who graduated from the program. Interviews with survivors suggest that, when they are ready, involving them in the care of others can be beneficial to both the survivor and the victims they work with. Other programs have formed communities of survivors to serve as peer groups to assist other victims in rebuilding their sense of personal efficacy. Part of the success of these groups involves allowing the victims to set the agenda for meetings and focus on what is most important to them; which have included computer training, language classes, ethnic celebrations, and writing plays about their experiences.
Developing alternatives to traditional therapies. Alternatives to traditional therapies, especially those that build self-esteem, empowerment, and re-connection with self, are considered important adjunct services for this population. Art therapy, journaling, poetry and song writing, yoga, body work, drama, and outdoor physical activities are some examples of this strategy. Given the difficulty some victims have with self-soothing (an impact of trauma), it is not surprising that several programs use music as part of their therapy. Some programs report offering organized religious or spiritual activities to help victims connect to something that will last beyond the program timeframe. For several of the youth programs, engaging victims in decision making, providing leadership opportunities, and helping youth develop valued social roles is part of therapy. For adults, programs offered acupuncture, meditation, and a variety of other alternatives to traditional therapy within their agencies.
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Victims of human trafficking are especially vulnerable to the debilitating physical and psychological symptoms of trauma resulting from their repeated, intrusive, and long-term abuse. Providers working with this population, in particular with sexually exploited women and girls, emphasize that trauma recovery is critical to a victims ability to repair and regain her life. However, there are many challenges to meeting the trauma-related needs of
trafficking victims, especially since a comprehensive approach, which includes building basic supports and safety as well as treatment, often crosses multiple systems of care. Building trauma-informed and trauma-specific services offers the promise of identifying and responding to victims where they present (i.e., in other than the mental health system) with services that cover the spectrum of their needs. Building long-term, trusting relationships is at the heart of this work, which requires time and flexible models of engagement and treatment, including peer-to-peer work. In addition to group and individual trauma-specific counseling, a range of alternative therapies offer promise in helping victims build self-esteem, empowerment and re-connection with themselves and society. For foreign-born victims, promising models that recognize the limitations of individualized Western treatment and the healing potential of culture and community resources show promise.
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If you think you have come in contact with a victim of human trafficking, call the National Human Trafficking Resource Center at 1.888.3737.888. Outreach and education materials are available at www.acf.hhs.gov/trafficking.
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