Counseling Survivors of Human Trafficking

Description of Human Trafficking

Human trafficking, which encompasses both labor and sex trafficking, occurs within the United States and across the globe. Labor trafficking refers to the recruiting, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion (Trafficking Victims Protection Act; U.S. Department of State, 2018). Sex trafficking is a specific type of human trafficking characterized by scenarios in which commercial sex acts are induced by force, fraud, or coercion, and/or in which the person induced to perform sex acts is not 18 years of age. Although rates of human trafficking were difficult to determine (Fedina, 2015), in any given year, it was estimated 20.9 million people globally were exploited through labor trafficking and 4.5 million people were victims of sex trafficking (International Labour Organization, 2012). Given these estimates, counselors must be prepared to work with survivors of labor and sex trafficking.

Identification/Assessment Strategies

Counselors may assess clients for possible signs of trafficking including instances in which clients are under 18 years of age and providing commercial sex acts, have a controlling older partner, work excessively long or unusual hours, or have few personal possessions (Polaris, 2016). A more extensive list of possible red flags can be found on the Polaris and National Human Trafficking Hotline websites. Because offenders trafficking drugs are beginning to traffic people (Litam, 2017; Shelly, 2013), counselors should assess clients with current or past substance use disorders to determine whether they have fallen into a drug debt or debt bondage. Debt bondage is a cycle through which traffickers obtain and maintain control by forcing victims to provide services in exchange for food, transportation, clothes, drugs, housing, and work-related supplies (de Chesnay, 2013).

Children exploited via sex trafficking may be absent from school or miss periods of time while being sold in other communities (Williamson & Prior, 2009). Counselors need to learn more about how human trafficking influences schools, possible indicators of child trafficking, and how to address and prevent exploitation of children. A wide variety of assessment tools have been developed to help individuals across a variety of settings identify survivors of sex and/or labor trafficking. The following section provides a brief description of the Comprehensive Human Trafficking Assessment Tool, Adult Human Trafficking Screening Tool and Guide, and Trafficking Victim Identification Tool. Counselors must be knowledgeable about the definition and possible indicators of human trafficking to use assessments effectively. Additionally, the following resources provide a framework for types of questions that may be helpful for identifying survivors of human trafficking. Prior to screening individuals for signs of trafficking, it is essential that counselors establish a sense of safety, trust, and rapport.

Resources:

Polaris https://polarisproject.org/human-trafficking/recognize-signs

National Human Trafficking Hotline https://humantraffickinghotline.org/human-trafficking/recognizing-signs

Comprehensive Human Trafficking Assessment Tool

The Comprehensive Human Trafficking Assessment Tool (National Human Trafficking Resource Center, 2011) is used to identify and assist potential victims of labor and sex trafficking. The Comprehensive Human Trafficking Assessment Tool includes general trafficking, sex trafficking specific, labor trafficking specific, and network specific assessment questions. The tool additionally outlines important assessment tips and questions necessary to conduct comprehensive safety checks in person or over the phone.

Counselors can determine which types of assessment questions or whether a combination of questions may be most effective in determining whether individuals may be trafficked. The general trafficking assessment consists of 34 open and closed ended questions related to fraud, coercion, debt-monetary, and force. The sex trafficking specific assessment consists of nine open and closed ended questions that address general areas related to sex trafficking such as whether individuals have ever felt pressured to engage in sex acts against their will, whether they were required to meet a nightly quota, and whether they felt forced to engage in sex acts with friends or business associates for favors or money. The labor trafficking specific assessment outlines ten open and closed ended questions about whether individuals felt they were paid fairly, worked normal hours, were able to take breaks, felt threatened, or were providing labor due to force, fraud, or coercion. In cases where counselors have determined whether individuals are survivors of sex and/or labor trafficking, the network/controller specific assessment questions may be used to supplement the general trafficking questions. Each of the questions in the network/controller specific assessment include open and closed ended questions. The network/controller specific assessment includes nine questions about domestic servitude, 11 questions associated with pimp-controlled sex trafficking, 12 questions related to intimate partner and inter-familial trafficking, fourteen questions about commercial front brothels, 13 questions related to residential brothels, 11 questions about labor trafficking in agriculture, four questions associated with labor trafficking in the service industry, and nine questions regarding labor trafficking in sales crews, The Comprehensive Human Trafficking Assessment Tool is provided at no cost by the National Human Trafficking Resource Center and the Polaris Project. Counselors who use the Comprehensive Human Trafficking Assessment Tool must be familiar with the definition, process, and components of human trafficking to accurately assess responses. It is important to emphasize that a single question alone is not sufficient to substantiate a case of human trafficking. Additionally, questions from the Comprehensive Human Trafficking Assessment Tool must be individualized for each client and for the program. Counselors must be sensitive to the immediate needs of each individual and be prepared to connect clients with resources available at their place of employment or within their communities such as safe and stable housing, ongoing counseling, case management, and/or legal support.

Resource:

Comprehensive Human Trafficking Assessment Tool: https://humantraffickinghotline.org/resources/comprehensive-human-trafficking-assessment-tool

Adult Human Trafficking Screening Tool

The Adult Human Trafficking Screening Tool (AHTST) and Guide was developed by the Administration for Children and Families and the National Human Trafficking Training and Technical Assistance Center for use within the public health setting (National Human Trafficking Training and Technical Assistance Center, 2018). The AHTST consists of eight closed-ended, minimally invasive, short questions designed to reflect elements of force, fraud, and coercion. The questions outlined in the AHTST should be integrated into screening conversations in which counselors are simultaneously building rapport and trust. The AHTST and Guide were developed using data from interviews with subject matter experts across the public health, behavioral health, health care, and social work sectors. The Adult Human Trafficking Screening Tool and Guide includes additional relevant resources including a description of human trafficking indicators and a flowchart for identifying adults at risk for human trafficking.

Resource:

Adult Human Trafficking Screening Tool and Guide: https://www.acf.hhs.gov/sites/default/files/otip/adult_human_trafficking_screening_tool_and_  guide.pdf

Trafficking Victim Identification Tool (TVIT)

The Trafficking Victim Identification Tool (TVIT) was created by the Vera Institute of Justice (2014) and yields valid and reliable scores for identifying victims of sex and labor trafficking. The TVIT is offered in long and short versions. The long version consists of eight screening background questions, five questions related to personal background, nine questions about migration history, 12 questions associated with work history, and 19 questions regarding living and working conditions. The short version includes five demographic questions, four questions related to migration history and 16 questions associated with working/living conditions. Both scales use a binary format (yes/no) with opportunities for clarification and follow-up questions throughout the assessment. For example, if individuals indicate that yes, they had felt pressured to touch someone or have had unwanted physical or sexual contact with another person, the TVIT prompts users to gather more information (“if you feel comfortable talking about it, could you tell me what happened?) Both long and short versions include a post-interview assessment to be completed by the interviewer where nonverbal indicators of past victimization, indicators that responses may have been inaccurate, likelihood that clients are trafficking victims, reasons for ratings, and service referrals can be documented. The Vera Institute of Justice offers both the user guide and TVIT tools in English and Spanish. The TVIT and manual content was validated based on research conducted by the Vera Institute of Justice and the National Institute of Justice. The TVIT is the first validated instrument to screen human trafficking victims across a variety of clinical and forensic settings. It requires examiners to have preliminary knowledge of human trafficking to best assess responses.

Resource:

Trafficking Victim Identification Tool:

https://www.vera.org/publications/out-of-the-shadows-identification-of-victims-of-human-trafficking

Intervention Strategies

A paucity of research exists which specifically focuses on the efficacy of evidence-based treatment for human trafficking survivors (de Chesnay, 2013; Levine, 2017; Williamson, Dutch, & Clawson, 2008). Current intervention strategies for trafficked clients are borrowed from evidence-based interventions originally designed for post-traumatic stress disorder, survivors of domestic violence, and torture (Jordan, Patel, & Rapp, 2013; Salami, Gordon, Coverdale, & Nguyen, 2018). Cognitive behavioral therapy, exposure therapy, eye movement desensitization and reprocessing (EMDR), and stress inoculation training represent evidence-based treatment options for individuals who experience post-traumatic stress disorder, such as human trafficking survivors (Williamson, Dutch, & Clawson, 2010). It is important to remember that human trafficking survivors require individualized treatment (Litam, 2017). Counselors should be prepared to use a variety of trauma-sensitive interventions to empower clients to develop trustworthy relationships, overcome challenges, decrease rates of self-harm, and remove themselves from dangerous situations. Clients may not believe or understand that they have been trafficked (Clawson & Dutch, 2008), or may feel as though they are helping their boyfriend or girlfriend by selling commercial sex to earn money (Litam, 2017). Thus, counselors must be mindful of avoiding stigmatizing labels or language that may promote feelings of shame in clients. Counselors are encouraged to seek supervision, consult with colleagues, and engage in regular self-care routines to avoid experiencing burnout, secondary trauma, and compassion fatigue when working with this population. Of note, emerging research has posited that post-traumatic stress disorder is an inadequate diagnostic construct for defining the “chronic and repeated traumatic exposures” experienced by sex trafficking survivors (Levine, 2017, p. 7). Instead, Disorders of Extreme Stress (DESNOS), or complex PTSD, has been proposed for inclusion in the ICD-11 (Hyland et al., 2017; Sachser, Keller, & Goldbeck, 2016). Treatment for DESNOS in sex trafficking survivors have not been conducted (Levine, 2017). The following section outlines several categories of evidence-based interventions that may be useful when working with human trafficking survivors.

Creative Interventions

Creative-based interventions may empower individuals with trauma, such as trafficked survivors, to embrace the excitement and challenges of making healthy choices. Counselors can incorporate creative art therapies and expressive interventions to decrease symptoms of trauma in children (van Westrhenen & Fritz, 2014) and adults (Shouten, de Niet, Knipscheer, Kleber, & Hutschemaekers, 2014). A systematic review of six controlled studies identified art therapy as an effective modality in the treatment of adults with symptoms of post-traumatic stress disorder and major depressive disorder (Shouten et al., 2014).

Counselors can incorporate the use of creative and expressive interventions using mandalas, music, dance, and a structured or free drawing to promote openness with clients while providing a sense of structure.

Resources:

Lowenstein, L. (2011). Favorite therapeutic activities for children, adolescents, and families: Practitioners share their most effective interventions. Retrieved from https://www.lianalowenstein.com/e-booklet.pdf

Cognitive Behavioral Therapy

Clients with a history of sex trafficking may benefit from cognitive behavioral therapy due to an internalization of derogatory labels and negative beliefs about themselves and others (Hickle & Roe- Sepowitz, 2014). Because many trafficked survivors struggle with feelings of guilt and shame about their trauma experiences, cognitive behavioral therapy may be an effective modality to modify maladaptive cognitions (Salami et al., 2018). Trauma-based cognitive behavioral therapy with children and adolescents (Keeshin & Strawn, 2014; Racco & Vis, 2015) and adults with histories of trauma and post-traumatic stress disorder are effective (Wagner, Rizvi, & Harned, 2007). Future areas of research should investigate the efficacy of cognitive behavioral therapies with trafficked survivors to standardize appropriate treatment methods for this unique population.

Resources:

EMDR Institute, Inc.: http://www.emdr.com/what-is-emdr/

Trauma Focused Cognitive Behavioral Therapy

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based modality designed for children, adolescents, and non-offending caregivers that uses structured sessions designed to teach coping skills

and process the trauma narrative (Levine, 2017). TF-CBT is a widely used and evidence-based modality to support traumatized chilren and their non-offending caregivers (Diehle, Opmeer, Boer, Mannarino, & Lindauer, 2014). Existing studies have identified TF-CBT as an effective treatment for counseling sexually exploited youth (Cohen, Mannarino, & Kinnish, 2017; Kenny, Helpingstine, & Weber, 2019). A review of

meta analyses, qualitative reviews, and clinical studies indicated TF-CBT was an efffective treatment modality in reducing post-traumatic stress disorder symptoms in children and adolescents (Cary & McMillen, 2012; Gillies, Taylor, Gray, O’Brien, & D’Abrew, 2012; Ramirez de Arellano et al., 2014). TF-CBT has been identified as an evidence-based treatment that may benefit human trafficking survivors (Altun, Abas, Zimmerman, Howard, & Oram, 2017). More research is needed to determine whether TF-CBT is effective for trafficked youth in the United States and internationally (Cohen et al., 2017).

Altun, S., Abas, M., Zimmerman, C., Howard, L. M., & Oram, S. (2017). Mental health and human trafficking: responding to survivors’ needs. British Journal Psychology International, 14(1), 21-23. http://dx.doi.org/10.1192/S205647400000163X

Cary, C. E., & McMillen, J. C. (2012). The data behind the dissemination: A systematic review of trauma- focused cognitive behavioral therapy for use with children and youth. Children and Youth Services Review, 34, 748-757. http://dx.doi.org/10.1016/j.childyouth.2012.01.003

Clawson, H. J., & Dutch, N. (2008). Addressing the needs of victims of human trafficking: Challenges, barriers, and promising practices. Retrieved from https://aspe.hhs.gov/system/files/pdf/75471/ib.pdf

Cohen, J. A., Mannarino, A. P., & Kinnish. K. (2017). Trauma-focused cognitive behavioral therapy for commercially sexually exploited youth. Journal of Adolescent Trauma, 10, 175-185. http://dx.doi.org/10.1007/s40653-015-0073-9

de Chesnay, M. D. (2013). Psychiatric-mental health nurses and the sex trafficking pandemic. Issues in Mental Health Nursing, 3, 901-907. http://dx.doi.org/10.3109/01612840.2013.857200

Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., & Lindauer, R. J. L. (2014). Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: what works in children with posttraumatic stress syndromes? A randomized controlled trial. European Child and Adolescent Psychiatry, 24, 227-236. http://dx.doi.org/10.1007/s00787-014-0572-5

Fedina, L. (2015). Use and misuse of research in books on sex trafficking: Implications for interdisciplinary research, practitioners, and advocates. Trauma, Violence, and Abuse, 16, 188-198. http://dx.doi.org/10.1177/1524838014523337

Gillies, D., Taylor, F., Gray, C., O’Brien, L., & D’Abrew, N. (2012). Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database of Systematic Reviews, 12, 1-110. http://dx.doi.org/10.1002/14651858.CD006726.pub2

Hickle, K. E., & Roe-Sepowitz, D. E. (2014). Putting the pieces back together: A group intervention for sexually exploited adolescent girls. Social Work with Groups, 37, 99–113. http://dx.doi.org/10.1080/01609513.2013.823838

Hyland, P., Shevlin, M., Elklit, A., Murphy, J., Vallieres, F., Garvert, D. W., & Cloitre, M. (2017). An assessment of the construct validity of the ICD-11 proposal for complex posttraumatic stress disorder. Psychological Traumatilogy, 9(1), 1-9. http://dx.doi.org/10.1037/tra0000114

International Labour Organization. (ILO). (2012). New ILO global estimate of forced labour: 20.9 million victims. Retrieved from http://www.ilo.org/global/topics/forced-labour/publications/ WCMS_182004/lang--de/index.htm

Jordan, J., Patel, B., & Rapp, L. (2013). Domestic minor sex trafficking; A social work perspective on misidentification, victims, buyers, traffickers, treatment, and reform of current practice. The Journal of Human Behavior in the Social Environment, 23, 356–369. http://dx.doi.org/10.1080/10911359.2013.764198

Keeshin, B. R., & Strawn, J. R. (2014). Psychological and pharmacologic treatment of youth with posttraumatic stress disorder. Child and Adolescent Psychiatric Clinics of North America, 23, 399-411. http://dx.doi.org/10.1016/j.chc.2013.12.002

Kenny, M. C., Helpingstine, C. E., & Weber, M. (2019). Treatment of a commercially sexually abused girl using trauma-focused cognitive behavioral therapy and legal interventions. Clinical Case Studies, 18(1), 18-35. http://dx.doi.org/10.1177/1534650118800809

Lahad, M. (2000). Darkness over the abyss: Supervising crisis intervention teams following disaster. Traumatology, 6, 273–293. http://dx.doi.org/10.1177/153476560000600403

Levine, J. A. (2017). Mental health issues in survivors of sex trafficking. Cogent Medicine, 4(1), 1-13. https://dx.doi.org/10.1080/2331205X.2017.1278841

Litam, S. (2017). Sex trafficking in America: What counselors need to know. The Professional Counselor, 7(1), 45-61. http://dx.doi.org/10.15241/sdal.7.1.45

National Human Trafficking Resource Center. (2011). Comprehensive Human Trafficking Assessment Tool. Retrieved from https://humantraffickinghotline.org/resources/comprehensive-human-trafficking- assessment-tool

National Human Trafficking Training and Technical Assistance Center. (2018). Adult Human Trafficking Screening Tool and Guide. Retrieved from https://www.acf.hhs.gov/sites/default/files/otip/adult_ human_trafficking_screening_tool_and_guide.pdf

Nijdam, M. J., & Olff, M. (2016). Erasing memory traces of trauma with eye movement desensitization and reprocessing therapy. European Journal of Psychotraumatology, 7, 1-3. http://dx.doi.org/10.3402/ejpt.v7.32545

Polaris. (2016). 2015 NHTRC annual report. Washington: DC. Author. Retrieved from https://humantraffickinghotline.org/resources/2015-nhtrc-annual-report

Racco, A., & Vis, J.-A. (2015). Evidence based trauma treatment for children and youth. Child and Adolescent Social Work Journal, 32, 121–129. http://dx.doi.org/10.1007/s10560-014-0347-3