Treating the Hidden Wounds: Trauma Treatment and Mental Health Recovery for Victims of Human Trafficking. Core Components of Trauma Informed and Specific Services

03/15/2008

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.

In exchange for training on human trafficking, we have enlisted help from a group of psychologists to train our staff to ask questions that enable us to assess mental health needs without directly asking if the client needs mental health services. We ask questions about the trauma symptoms and then recommend someone that can help them, for instance, with the nightmares they are experiencing or the headaches they keep having. This helps us avoid the stigma associated with mental health services in some cultures.

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.

Interviewing techniques are very important when working with trauma survivors. Having the capacity to empathize with the victim, letting her take the lead, and treating her respectfully goes a long way to building trust and getting results.

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.

SAGE is a human rights non-profit survivor-run drug, mental health, and trauma treatment center in San Francisco, California. Its peer counseling model avoids a traditional approach to trauma treatment that positions service providers as clinically neutral authority figures. Rather, SAGE provides client centered supportive partnerships which address the social, political and economic contexts of client difficulties. SAGE combines the peer counseling with a host of other services, including alternative trauma treatments, such as acupuncture, art therapy, massage, healing touch, movement, and drama. SAGE also has a broad referral network which includes therapists specializing in Eye Movement Desensitization and Reprocessing (EMDR), an information processing therapy that integrates elements of many effective psychotherapies (psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies in structured protocols that are designed to maximize treatment effects (Shapiro, 2001), and willing to provide pro bono services.

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