Evidence-Based Mental Health Treatment for Victims of Human Trafficking. Evidence-Based Treatment for Symptoms and Diseases Associated with Human Trafficking


Processing the psychological consequences of human trafficking requires long-term, comprehensive therapy.  Mental health therapy is typically based on one or more theories of psychological treatment, the most prominent being behavioral, cognitive, and psychodynamic.  Behavioral therapy focuses on increasing desired behaviors and decreasing problem behaviors through environmental manipulation.  Cognitive therapy works to change behaviors and feelings by altering how patients comprehend and understand significant life experiences.  Psychodynamic therapy explains behavior and personality as being motivated by inner forces, including past experiences, inherited instincts, and biological drives, and targets patients unconscious (APA, 2008).

Evidence-Based Therapeutic Treatment Options for PTSD
Cognitive Therapy
Aims to challenge dysfunctional thoughts based on irrational or illogical assumptions.
Cognitive-Behavioral Therapy
Combines cognitive therapy with behavioral interventions such as exposure therapy, thought stopping, or breathing techniques.
Exposure Therapy
Aims to reduce anxiety and fear through confrontation of thoughts (imaginal exposure) or actual situations (in vivo exposure) related to the trauma.
Eye Movement Desensitization and Reprocessing
Combines general clinical practice with brief imaginal exposure and cognitive restructuring (rapid eye movement is induced during the imaginal exposure and cognitive restructuring phases).
Stress Inoculation Training
Combines psycho-education with anxiety management techniques such as relaxation training, breathing retraining, and thought stopping. (Rauch & Cahill, 2003)

Over the years, research has found that complete psychiatric evaluations are preferable when working with victims of human trafficking.  Comprehensive psychological evaluations offer mental healthcare providers a complete understanding of patients psychological needs, including those related to prior traumatic experiences and presentation of co-morbidity.  Psychological evaluations can also assess patients functioning and availability of basic resources (e.g., food, shelter, clothing, income), both of which can have a significant impact on mental health as well as the benefits derived from treatment (Ursano et al., 2004).  Once patients have received a full psychological evaluation, scientific literature should be examined to determine the most effective evidence-based treatment options available for care.

Empirical evidence on the treatment of PTSD increasingly supports the use of cognitive-behavioral therapy that incorporates cognitive restructuring and exposure therapy (Rauch & Cahill, 2003; Ursano et al., 2004).  Cognitive-behavioral therapy combines cognitive therapy, including cognitive restructuring, with behavioral interventions such as exposure therapy, thought stopping, and breathing techniques.  When exposure therapy is introduced, patients confront their fear through progressively intense exposure to the anxiety-provoking stimuli until habituation is reached.  Exposure therapy can involve imaginal exposure, with confrontation occurring through thought only, or in vivo exposure, during which patients are exposed to the actual stimuli (Rauch & Cahill, 2003).  For example, medical professionals serving victims of sex trafficking cite provocative images of victims posted online during their victimization as a major factor in computer aversion (Williamson, Dutch & Clawson, 2008).  Exposure therapy for computer aversion might begin by having patients imagine and work through what it would be like to simply type on a computer.  The imaginal exposure would then slowly increase in intensity until patients were asked to imagine and work through what it would be like to find images of themselves online.  Exposure treatment relies on patients active engagement in challenging their automatic fearful assumptions and responses through an objective assessment of what results from exposure to feared stimuli (Otto, Smits, & Reese, 2004).

In addition to cognitive-behavioral therapy that includes cognitive restructuring and exposure therapy, eye movement desensitization and reprocessing and stress inoculation training have both been found to be effective treatments for PTSD (Bradley, Greene, Russ, Dutra, & Westen, 2005; Rauch & Cahill, 2003; Ursano et al., 2004).  Eye movement desensitization and reprocessing focuses on processing memories, and combines general clinical practice with brief imaginal exposure and cognitive restructuring.  During the imaginal exposure and cognitive restructuring phases, mental healthcare providers induce bilateral stimulation through rapid eye movement, bilateral sound, or bilateral tactile stimulation to decrease the vividness and/or negative emotions associated with the traumatic memories.  Stress inoculation training, on the other hand, combines psycho-education with anxiety management techniques such as relaxation training, breathing retraining, and thought stopping (Rauch & Cahill, 2003).  Cognitive-behavioral therapy, exposure therapy, and stress inoculation training have been found to be particularly successful in preventing the development of chronic PTSD as well as speeding recovery from PTSD when used with female victims of sexual violence (Rauch & Cahill, 2003; Ursano et al., 2004).

According to the American Psychiatric Association, randomized control trials do not support the effectiveness of psychological debriefing, or applying very brief intervention shortly after traumatic events, with patients presenting symptoms of PTSD (Rauch & Cahill, 2003; Ursano et al., 2004).  Psychological debriefing has actually been found to increase symptoms of PTSD in some settings (Ursano et al., 2004).  While the use of psychological debriefing is not supported, early supportive intervention, psycho-education, and case management have been found to facilitate victims continued utilization of mental health services (Ursano et al., 2004).

Cognitive-behavioral therapy is also at the forefront of evidence-based treatment for other anxiety and mood disorders (McIntosh et al., 2004; Otto, Smits, & Reese,, 2004; Weersing, Lyergar, Kolko, Birmaher, & Brent, 2006).  While many practitioners continue to employ psychodynamic therapy, family systems intervention, or a combination of techniques from multiple theoretical practicum, the effectiveness of these treatment options lack evidence-based support at this time (Weersing, Lyergar, Kolko, Birmaher, & Brent, 2006).  However, lack of evidence regarding other types of interventions does not necessarily mean they are ineffective, but rather that recommendations regarding the use of these treatment methods cannot be made based on current available research.

For individuals presenting with anxiety disorders, cognitive-behavioral therapy that combines psycho-education with exposure therapy and cognitive restructuring is especially beneficial in helping patients reevaluate automatic thoughts related to fears so they can eliminate dysfunctional thoughts and create new frameworks for interpretation (Otto, Smits, & Reese, 2004).  Cognitive-behavioral therapy, when offered by trained mental healthcare providers, has demonstrated long-term effectiveness (814 years) in patients suffering from anxiety disorders (McIntosh et al., 2004).

The most common diagnostic mood disorder among victims of human trafficking is major depressive disorder.  Effective, evidence-based treatments for major depressive disorder include cognitive-behavioral therapy and interpersonal psychotherapy (Karasu, Gelenberg, Merriam, & Wang, 2000; McIntosh et al., 2004; Weersing, Lyergar, Kolko, Birmaher, & Brent, 2006).  Unlike, cognitive-behavioral therapy, which targets dysfunctional thoughts while integrating behavioral interventions, interpersonal psychotherapy focuses on interpersonal relationships and the correlation between mood and interpersonal connections. The goal of interpersonal psychotherapy is to help patients improve their mood by seeking improvements in their interpersonal relationships (National Institute for Clinical Excellence, 2004).

Patients with substance-related disorders should be assessed to differentiate between use, misuse, abuse, and dependence.  Psychotherapy, sometimes coupled with pharmacological treatment, can be an essential part of treatment of substance-related disorders.  Evidence-based treatment includes cognitive-behavioral therapy, motivational enhancement therapy, behavioral therapy, 12-step facilitation, and psychodynamic/interpersonal therapy.  Additionally, self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies can also benefit individuals suffering from substance use disorders (Kleber et al., 2006).  Motivational enhancement therapy is a client-centered approach that induces motivation to create a personal decision and plan for change (Miller, 2003).  Twelve-step facilitation programs for a variety of substances are based on the theoretical framework that willpower alone is not enough to attain sobriety and that long-term recovery involves spiritual renewal and acceptance of a higher power (Nowinski, 2003).  When victims of human trafficking present with substance-related disorders, no matter what therapeutic method is used, treatment should focus on both the trauma and the consequential issues of victims drug abuse; if treatment only focuses on the consequential issues of victims drug abuse without addressing the underlying trauma that caused the drug abuse victims will be less likely to succeed in treatment and more likely to relapse (Alexander, Kellogg & Thompson, 2005).

While significant research has been and continues to be conducted regarding the treatment of various anxiety and mood disorders, there is a more limited understanding regarding the treatment of dissociative disorders.  According to the Mayo Clinic, treatment for dissociative disorders typically involves psychotherapy that incorporates various techniques, including techniques such as hypnosis, to trigger dissociative symptoms and help patients process their trauma.  Treatment can include cognitive therapy as well as art therapy, where expression through art can help individuals who may have difficulty expressing themselves through words (Mayo Clinic, 2007).

In the absence of research pertaining to the mental health treatment of victims of human trafficking, mental health professionals working with this population must educate themselves on the evidence-based research related to the treatment of common diagnoses and similarly marginalized populations to ensure proper provision of the best mental health care possible.  Mental health care providers should also educate themselves about effective pharmacological treatments for patients presenting with anxiety, mood, dissociative, and substance-related disorders.  Some evidence suggests that selective serotonin reuptake inhibitors can effectively complement the psychotherapeutic treatment of PTSD as well as other anxiety and mood disorders (Seedat et al., 2005; Ursano et al., 2004; Weersing, Lyergar, Kolko, Birmaher, & Brent, 2006).  Mental health care providers must remain up-to-date about new medications and research regarding pharmacological treatment to ensure proper coordination with psychiatrists and other medical providers, and to incorporate new scientific findings about medications.

Child Victims

Child victims of human trafficking require specialized attention by mental healthcare providers. The most common presentations for victims of child sexual exploitation are substance-related disorders, dissociative disorders, impulse control, conduct disorder, attention-deficit/hyperactivity disorder, antisocial personality traits, and most or all of the Axis IV psychological and environment problems.  Mood and anxiety disorders such as obsessive compulsive disorder and PTSD are also common; however, presentation for these disorders may be less overt due to self-medication and/or use of other survival skills (Alexander et al., 2005).  Some studies have found that concurrence of victimization and developmental milestones can exacerbate psychological consequences (Office for Victims of Crime, 1998).

Little is known about the presentation of PTSD in children.  Lack of information is due, in part, to the fact that identification of PTSD in children has been more recent than its recognition in adults (Pfefferbaum, 1997).  One study found that while children might initially respond to trauma through a fight or flight response, long-term trauma without relief can result in children responding through immobilization followed by dissociation (Perry, Pollard, Blakley, Baker, & Vigilante, 1995).  Some evidence suggests that girls are at higher risk for re-victimization than boys, while boys are more likely to develop aggressive behavior as a result of their victimization.  This evidence suggests the need for distinct, targeted treatment for boys and girls (Office for Victims of Crime, 1998).

Reviews of controlled trials for the psychological treatment of sexually abused children have found that the best treatment for these children is cognitive-behavioral therapy.  It is important to note that the majority of these studies have focused on younger children.  While studies of older children have not demonstrated such consistent findings, the results from cognitive-behavioral therapies remain more compelling than those associated with other therapeutic models (Putnam, 2003; Ramchandani & Jones, 2003).  As mentioned previously, other types of therapeutic interventions may be effective in treating children victims of sexual abuse; however, the limited number of randomized controlled studies investigating these models precludes thorough assessment of their efficacy and assurance they do no harm (Ramchandani & Jones, 2003).

While evidence suggests that a significant percentage of children who have been sexually assaulted may experience long-term psychological problems and/or a later onset of problems, it also shows that the majority of children do not benefit from long-term therapy (Putnam 2003; Ramchandani & Jones, 2003).  Therefore, therapy for these children must strike a balance between not being so short-term and symptom-driven that it misses children whose symptoms present later, and not being excessively long and keeping children in therapy beyond the point at which they benefit.

International Victims

Individuals ethnicity is often directly related to their world view and thus their experiences.  Ethnicity can affect how individuals seek assistance, define their problems, attribute psychological difficulties, experience their unique trauma, and perceive future recovery options.  Ethnicity can also directly influence patients outlooks on their pain, expectations of mental health treatment, and beliefs regarding the best course of treatment.  Many cultures do not differentiate psychological, emotional, and spiritual reactions from more physical reactions; rather, they focus on the impact of trauma on the body as a whole.  Additionally, cultural factors influencing individuals beliefs about threats and response to danger can play an important role in how individuals respond to violent crimes (Office for Victims of Crime, 1998).

Healthcare providers should remember that every culture has a distinct framework or perspective about mental health and, as a result, distinct beliefs about the benefits of seeking mental health services.  Counseling, in general, is a predominantly western practice and in some cultures folk healing, healing rituals, and secret societies are the commonly accepted forms of healthcare provision (Williamson, Dutch & Clawson, 2008).  Mental healthcare providers should familiarize themselves with the beliefs, values and practices of the various cultures of their patients so they are able to provide culturally competent care.

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