Human trafficking is a crime and a violation of human rights, but for counsellors, psychotherapists and other mental health professionals, it is perhaps better described as a form of chronic interpersonal trauma. The lives and relationships of trafficked people and their children, families and communities can be profoundly damaged by the process, which involves the recruitment and movement of people by means such as deception, coercion and abuse of vulnerability, for the purposes of exploitation.1
Women, men and children are trafficked across and within international borders for exploitation in forced prostitution and forced labour in settings as diverse as domestic work, construction and agriculture. This article details the psychological risks encountered by trafficked women and the consequences for their mental health and wellbeing, and provides guidance on working therapeutically with this population.
Psychological risks encountered by trafficked women
Outlining the range of risks encountered by trafficked women, the leading trafficking researcher, Professor Cathy Zimmerman, described how ‘women are physically beaten to force them to have sex, raped as a psychological tactic to intimidate them into future submission, isolated to disable them psychologically, and economically deprived to create a reliance on traffickers’.2 Other risks and abuses are likely to include psychological abuse and entrapment, including threats to women and their loved ones, manipulation of intimate and familial relationships, and lies, deception and blackmail; coerced use of drugs and alcohol; restrictions on movement, time and activities; usurious charges for travel documents and basic necessities, including food, clothing, housing and healthcare; confiscation of identity, visa and travel documents; and high-risk living and working conditions. These abuses typically occur repeatedly, in combination, and over a prolonged period, giving rise to symptomatology similar to that observed among victims of torture.3 In many cases, trafficked women also experience hardship, deprivation, and violence from partners, family members and others, both prior to recruitment and during the recruitment and journey phases of the trafficking process.4,5 These experiences are likely to have long-term psychological impacts additional to those endured during their exploitation.
Psychological consequences of human trafficking
Over the past two decades, studies conducted in the UK (see Box 1), mainland Europe, and Southeast Asia have highlighted the high prevalence of depression, anxiety, post-traumatic stress disorder (PTSD) and suicidal ideation among trafficked women in contact with shelter services.5–7 Exposure to repeated, prolonged or multiple forms of interpersonal trauma prior to and during trafficking may not only lead to a risk of developing PTSD, but also to the development of a qualitatively different post-traumatic response: complex PTSD (CPTSD).9,10 In addition to symptoms relating to re-experiencing, avoidance and hyperarousal, complex PTSD includes symptoms relating to affect dysregulation, negative self-concept and relational difficulties. Emotional, somatic and behavioural dysregulation may manifest in a variety of ways. Trafficked women may, for example, have difficulty recognising, managing or expressing their emotional states,8 or may feel distress physically (for example, through headaches, stomach aches, back pain or fatigue) or feel disconnected from their physical state.4,11,12 Women may also present with dysregulated or impulsive behaviours, including substance abuse, self-harm, eating disorders and sexual risk-taking. It is useful to think of these behaviours as adaptive coping strategies that can be replaced with other, safer strategies through psychotherapeutic support.15
Experiences of abuse, exploitation and commodification can also impair trafficked women’s self-perception, self-esteem and relationships with others. Trafficked women frequently blame themselves for what happened to them, feeling they are responsible for having accepted a dubious offer of work, having ‘agreed’ to do the work that they were trafficked into, or having failed to find a way to free themselves.5 Such feelings can extend beyond women’s appraisals of their circumstances to become verdicts on themselves, with feelings of worthlessness, shame and contamination common.11 Particularly where women have experienced prior interpersonal violence, trafficking experiences may serve to reinforce or confirm previously held core beliefs about worthlessness or failure. These beliefs may therefore be very entrenched and require long-term therapeutic input to overcome. Women who continue to experience symptoms of PTSD, such as dissociation, flashbacks and hypervigilance, may feel as though their sense of self is fragmented and that they are a ‘different person’ to the one they were before the trauma. This may be compounded by the fact that the nature of traumatic memories means that intentional recall of events is poorly organised, lacks coherence and can feel disconnected from events before and after.13
Shame and mistrust may be especially pronounced among women forced into prostitution and may lead survivors to conceal experiences within therapeutic as well as intimate relationships, perpetuating women’s psychological isolation.14 Many women expect that they will be labelled, blamed and stigmatised for what has happened to them and anticipate difficulties reintegrating into their families and communities.
Such fears may be justified: family and community members may react negatively, or even violently, to women who have experienced trafficking or may not want to acknowledge women’s experiences of abuse and exploitation. In this context, mental health professionals must attempt to balance efforts to challenge unhelpful beliefs and perceptions with an awareness of the family and community dynamics that may be counterproductive to recovery. Feelings of mistrust, abandonment and betrayal may be an issue, particularly where the manipulation of intimate relationships was used as part of trafficking schema or where there was extensive interpersonal abuse.3 Women may encounter relationship difficulties at either end of a continuum, with some women entering quickly into new relationships, having difficulty recognising maladaptive relationships, and displaying high-risk sexual behaviours, and other women employing overly rigid boundaries, avoiding social contact and peremptorily rejecting others.15
Working therapeutically with trafficked people
Much of the therapeutic work with trafficked people will require the same key therapeutic skills as working with any vulnerable population, including paying careful attention to the therapeutic relationship, ensuring a thorough assessment and formulation, and taking into account environmental and systemic factors that may impact on engagement and progress in therapy. However, there are particular features that the therapist may need to be sensitive to or aware of when working with trafficked women. Women who are not from the UK and who may have been prevented from using health services may not understand how the system works and what support is on offer. There may also be cultural differences in the understanding of mental health and issues related to the gender of healthcare professionals and interpreters.16 Therefore, it may be necessary to spend substantial time at the beginning of an assessment on issues around confidentiality, the purpose of assessment and therapy, and exploring the woman’s understanding and expectations. Wherever possible, professionals should allow for extended consultations.17
Professionals should also be aware that narratives of the trafficking experience are likely to emerge piecemeal, with accounts becoming more coherent as a relationship of trust is established and women feel able to speak more fully about their experiences. Multiple factors mitigate against women’s willingness – and abilities – to provide an account of their experience. Many women still fear harm to themselves and their families if they disclose information about their experiences long after they have escaped from exploitation; a study of survivors of trafficking conducted as part of the PROTECT research programme (see Box 1) found that four-fifths of women reported ongoing fear of their traffickers.4 Others’ fears may include risk of illness or death if they talk about their experiences following ritualised violence in ‘Juju’ ceremonies performed by traffickers, or detention or deportation due to irregular immigration status or misinformation from their traffickers.3 Feelings of guilt, shame and mistrust may also be powerful inhibitors to disclosure. As noted above, women may hold strong negative beliefs about their responsibility for events and about their own worth. Among the key roles for mental health professionals is to assure women that what happened to them was not their fault, to reinforce that they are not responsible for the behaviour of their traffickers, to help them to build their confidence and self-esteem and help them plan for the future. Initially, it may be necessary for the therapist to verbalise this explicitly to help build trust, but later in therapy it is useful to find ways to elicit this from women themselves, in their own words. This theme may need substantial elaboration and emphasis in therapy, as shame and guilt are likely to permeate many of the woman’s experiences. In addition, trauma frequently disrupts the recall of the details and chronology of events, leading to accounts that may seem inconsistent and confused. Questions about traumatic experiences may trigger painful flashbacks and dissociation, and traumatised individuals are likely to actively avoid talking about such experiences for this reason. Supporting women to develop coping strategies, such as grounding techniques, early in therapy can help to reduce the sense of current threat and provide a safe environment in which to build a narrative around traumatic experiences.
Hopper describes the key components of trauma-informed assessments when working with trafficked women as safety planning, needs assessment and goal setting, exploration of trauma history and vulnerability to trafficking, and assessment of strengths and coping strategies.15 Mental health professionals working with trafficked people should be mindful of the need for careful and ongoing risk assessments and safety planning, including the risk of re-trafficking. Patients should be seen without companions present and with an independent interpreter.17 Risk assessments should include contact with the trafficker and their associates, and threats to the survivor and her loved ones.15 Particularly in cases in which many traffickers have been involved in a network, it can be difficult for women to comprehend the nature and extent of their deception and betrayal.3 Women may remain in contact with, or even take advice from, the person they trusted even after escaping the network, placing them at further risk of harm. Risk assessment should also include history of violence and current suicidal ideation or plans.
Unmet needs impact significantly on mental health.6 Meeting some of these needs can contribute to building a trusting relationship, as well as to enabling women to begin attending to their emotional needs. Commonly reported needs include shelter and basic necessities; medical and dental care; interpretation, translation, and education to improve language skills; and, financial needs.4 Ongoing stressors may include legal stressors (immigration, civil and criminal justice), poverty and social isolation. In some cases, where there are multiple ongoing stressors, it may not be appropriate to begin therapy, particularly treatments for symptoms of PTSD, which require significant emotional commitment and may exacerbate symptoms in the short term. Research indicates that a key barrier to engagement with mental health services for trafficked people is instability due to both immigration status and housing.16 This can include people changing locality within the UK and potentially returning to their home country, which impedes therapy. If a person is moving within the UK, it can be very useful to provide a detailed written assessment for future practitioners to ease the transition to another care team.16 Goal-setting can be a novel way of thinking about the future and an intervention in itself; spending time on this and ensuring that small steps can be taken towards realistic goals can help build a sense of progress and hope.
Taking a history can provide not only factual information about what led to a woman being trafficked, but also an understanding of the woman’s perceptions of her situation. This can be used to provide education and reduce the risk of re-victimisation. If planning to provide therapy, the history may also give early indications about some of the woman’s appraisals of the trauma and the theme of cognitions around this – for example, self-blame or hopelessness – which can contribute to a formulation of her current mental health needs. The extent of information obtained about the conditions of the trafficking experience itself should be limited, so as to be appropriate to the purpose of the assessment and the psychological state of the survivor. An assessment of trafficked women’s strengths and coping strategies is a necessary counterpoint to the assessment of vulnerabilities, risks and needs. Existing external resources can be used in developing a network of support, gaps can be targeted through support planning, and therapeutic interventions can build on identified internal strengths.15 Using a strengths-based and solution-focused approach to assessment and therapy can help women to develop a positive self-identity and begin to move away from unhelpful narratives of shame and worthlessness.
Following assessment, decisions will need to be made about the most appropriate form of support. This will depend on a range of factors, including any ongoing risks, the woman’s current immigration status and housing situation, the amount of social support she has, and her readiness to engage in a therapeutic intervention. Initial interventions may include increasing social support, developing coping strategies to deal with stress, improving sleep, and behavioural activation to increase activities that provide a sense of pleasure or achievement. Where women are able and willing to commit to ongoing therapy, evidence-based treatments for PTSD, such as trauma-focused cognitive behavioural therapy and eye movement desensitisation and reprocessing (EMDR), can help to reintegrate traumatic memories and reduce symptoms.7,18 For women with multiple and complex traumatic stress experiences, narrative exposure therapy (NET) can be used to transform fragmented reports of events over a long period of time into a more coherent narrative.19 These therapies require a significant emotional commitment, and women therefore need a clear understanding of what therapy will entail, as well as sufficient resources to manage the intensity of the work. Throughout therapy, practitioners need to ensure ongoing risk assessment and be aware of changes in the woman’s circumstances and needs that may impact on engagement.
Escape from situations of human trafficking cannot be equated with recovery from its harms. Trafficked women experience multiple risks prior to, during and after their exploitation, and many months and even years after regaining their freedom, they report a high prevalence of mental distress and of emotional, somatic and behavioural dysregulation. Therapeutic work with trafficked women demands that mental health professionals draw on skills in trauma-informed assessment and support, including attention to the historical and ongoing risks experienced by trafficked women and to their strengths, coping strategies and readiness to engage. Through this process, trafficked women can be supported to overcome their experiences of trauma and abuse and reclaim their sense of self.
Dr Siân Oram is Lecturer in Women’s Mental Health at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London. She has a particular interest in human trafficking and domestic violence, and previously managed a programme of research to inform health service responses to human trafficking. Twitter: @sianoram
Dr Jill Domoney is a Research Clinical Psychologist also at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London. Her research interests include developing and evaluating psychosocial interventions relating to the perinatal period and to domestic violence; she has also published research on mental health service responses to victims of human trafficking.
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