Psychologists’ Role in Treatment of Survivors of Human Trafficking: Training the Hands We Need on Deck
By Patrick Kerr, Ph.D.
Cancer InCytes Magazine - Volume 3, Issue 2, Winter 2014
Managing Editor: Danielle Fumagalli, M.A.
Human trafficking is a complex problem that must be addressed in a comprehensive manner. The needs of human trafficking survivors are equally complex, encompassing legal, medical, and psychological domains. Psychologists with appropriate training can contribute to addressing the unique mental health needs of trafficking survivors. At the recent conference of the American Psychological Association, specialized training on identifying, assessing, and working with human trafficking survivors was provided. This article summarizes the training from the first of three workshops on human trafficking at this conference.
Overview of Human Trafficking
Human trafficking refers to slavery as it occurs in the modern era. Estimates of the global and U.S. national prevalence of human trafficking vary widely. Global estimates range from 12 million to 27 million people currently enslaved, with an estimated 600,000 to 800,000 people trafficked across national borders annually (1). Rates in the U.S. range from 14,000-17,500 trafficked into the U.S. annually, with an uncertain number of people currently enslaved at any given time. Suffice it to say, the problem of modern slavery is substantial.
Slavery has been outlawed in the United States through a series of laws over the past two centuries, ranging from the thirteenth amendment of the U.S. Constitution, to the Mann Act of 1910, and most recently the Trafficking Victims and Violence Protection Act of 2000 (TVPA). One of the significant contributions of TVPA has been its inclusion of a pathway for survivors of human trafficking to receive psychosocial services (2). There is increasing recognition among researchers, clinicians, and advocates of the myriad unique health challenges faced by human trafficking survivors (3).
Over the past two decades, and especially since the passage of TVPA, a growing body of research has identified unique post-trafficking needs for survivors of human trafficking. Research on the short-term and long-term emotional and psychological consequences is in a nascent stage of development. The work that has been conducted thus far has found high prevalence rates of depression, anxiety, traumatic stress, and suicidality among human trafficking survivors (4). Thus, there is a clear need for psychological treatments that address the needs of formerly enslaved people.
Addressing the Psychological Welfare of People who Survive Human Trafficking
At the 2014 conference of the American Psychological Association (APA), one of the training sessions conducted (“What Psychologists Need to Know About Human Trafficking: Identification, Tools, and Resources”) reported the findings and recommendations of the APA Task Force on Trafficking of Women and Girls (5). This training provided an overview of multiple forms of trafficking; common behavioral, emotional, and cognitive responses to trafficking; and specific strategies for identifying, assessing, and treating human trafficking survivors.
Forms of Human Trafficking
All human trafficking revolves around the common components of force, fraud, and coercion. While multiple distinct forms of trafficking have been identified, each with a unique application of these components, TVPA categorizes trafficking into two broad primary categories: commercial sex trafficking and labor trafficking. Commercial sex trafficking constitutes the most common form of trafficking (accounting for approximately half of trafficking cases), and refers to situations in which people are forced into prostitution, pornography, or stripping. This is facilitated through a variety of methods, including false-front agencies and businesses such as employment, modeling, and marriage agencies that lure victims by fraudulently promising work, opportunities, and money.
Labor trafficking is distinguished from sex trafficking in that the forced or coerced work is not sexual in nature. Instead, labor trafficking is characterized by situations in which people are sold into and/or forced to work with little or no pay, experience abusive and inhumane treatment, and are physically and/or psychologically coerced into remaining in the situation. Labor trafficking occurs worldwide and across sectors (e.g., agriculture; manufacturing). Less common forms of trafficking include child soldier conscription, and human organ trafficking.
Risks for Human Trafficking Victimization
A confluence of micro and macro risk factors contributes to someone being a victim of human trafficking. Micro-level risk factors operate at the individual level, and include gender (up to 80% of trafficking victims are female); age (children are at higher risk); marginalization through oppressive and discriminatory experiences; history of traumatization and victimization; developmental, emotional, and cognitive factors; and immigrant status.
Macro-level factors operate at the system level. These factors are often referred to as “push factors” and “pull factors”. Push factors are those conditions that increase someone’s risk for being involved in situations with a high risk for trafficking. Push factors can be divided into economics (e.g., lack of employment opportunities, low wages, loss of financial or material resources, debt, and inadequate access to healthcare); violence (e.g., political instability, regional conflict/warfare, organized criminal activity); and oppression (e.g., discrimination based on race/ethnicity, gender, sexual orientation, or political affiliation). Pull factors are those that create a market for trafficked people. These factors can be divided into economics (e.g., demand for cheap production of products, demand for commercial sexual services) and policies (e.g., foreign policies that provide preferential treatment, protections, or opportunities to people of one region or nation over those from other nations or regions; domestic policies related to labor relations, support for economically disadvantaged people).
Common Victim Reactions to Human Trafficking Situations
Human trafficking reflects a unique form of traumatic experience in that it involves chronic trauma. Any single trauma is sufficient to cause someone to develop post-traumatic stress disorder (PTSD); repeated trauma in the context of slavery increases and complicates this risk. Traumatic experiences in human trafficking range from repeated physical assaults, to rape, to torture; human trafficking victim may both experience and witness these forms of violence, further complicating their traumatic stress. These types of chronic traumas from human trafficking lead to continuous autonomic nervous system arousal, which in turn leads to fear responses to neutral stimuli.
Fear responses, whether fight, flight, or freeze, are aimed at survival. In human trafficking, psychologists and other mental health professionals must be aware of a phenomenon known as “trauma-bonding”, in which a trafficking victim forms a symbiotic relationship with the trafficker. This can be thought of as a survival-oriented freeze response to the perpetual risk of violence experienced during trafficking. In this response phenomenon, protection of the trafficker (e.g., from arrest, from detection) or seeking the favor of the trafficker is a way of protecting oneself from additional physical and/or sexual abuse. While this is most commonly seen in sex trafficking, it may also occur in other forms of trafficking. Trauma-bonding leads to a distortion in perceptions of interpersonal relationships, and in one’s relationship to one’s own body. Therefore, a human trafficking victim may not see others who are trying to help them as being helpful or trustworthy, and may not learn to trust their own physiological responses to danger. The effects of the trauma-bonding phenomenon may be exacerbated by pre-trafficking risk factors, especially a history of abuse and interpersonal violence. When evaluating risk and planning treatment, considering the role of maladaptive views of interpersonal relationships created by repeated trauma from a trafficker is important.
Psychological Treatment of Human Trafficking Survivors
Human trafficking survivors may be difficult to engage in treatment for a number of reasons. First, no treatments have been developed or systematically researched for the treatment of trafficking-related trauma. While existing evidence-based treatments for PTSD (e.g., prolonged exposure, cognitive processing therapy) may be effective, much more work needs to be done in this area.
Second, psychological interventions require someone to engage in higher-order thought processes. However, the neurobiological consequences of chronic traumas during trafficking keep the lower brain engaged, thus impeding the cognitive process needed for change to occur.
Third, shame and mistrust are common responses to trafficking. Shame frequently leads to avoidance of engagement in services offered or rendered. Mistrust often originates from the messages the trafficker has communicated (e.g., authorities will deport you, arrest you, not believe you, harm you), and through learning experiences (e.g., no one has helped me in the past; law enforcement has arrested instead of helped me).
A compassionate attitude based on a thorough understanding of human trafficking is a critical component of providing services of any kind to human trafficking survivors. Recognition and validation of the inherent challenges and risks of escaping a trafficking situation is important. A pillar of treatment is that someone trustworthy be there when the victim exits the trafficking situation. Trust-building takes time, and requires that clinicians acknowledge the complexity of a decision to escape a trafficking situation.
Summary and Conclusions
Human trafficking affects millions of people worldwide, and is a growing problem for developed and developing nations alike. An effective response to human trafficking requires adequate healthcare, including mental healthcare, be available for trafficking survivors. Psychologists play a critical role in developing, researching, and implementing appropriate standards of care for treating survivors. Collaborative efforts across disciplines, including clinical psychology, are needed to enhance the post-trafficking care available for survivors.
Dr. Patrick L. Kerr is a clinical psychologist and Associate Professor in the Department of Behavioral Medicine and Psychiatry at the West Virginia University School of Medicine in Charleston. He is the director and co-founder of the WVU Dialectical Behavior Therapy Services Program. He also directs the Self-Injury, Suicide, and Emotion Regulation Research (SISTERR) Program.
[1.] International Labour Organisation (2012). ILO Global Estimate of Forced Labour: Results and Methodology.
[2.] Bales, K. & Soodalter, R. (2009). The slave next door: Human trafficking and slavery in America today. Berkeley, CA: University of California Press.
[3.] Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science & Medicine, 73, 327-335.
[4.] Oram, S., Stöckl, H., Busza, J., Howard, L. M., & Zimmerman, C. (2012). Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS medicine, 9(5), e1001224.
[5.] Sidun, N., Hume, D. Alejano-Steele, A., Burke, M., Contreras, M., Finckenauer, J. et al. (2014). Report of the APA Task for on Trafficking of Women and Girls. Washington D.C.: American Psychological Association.