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Abstract Background Human trafficking is a form of modern slavery that involves the forced movement of people internally within countries, or externally across borders. Victims who are trafficked for sexual exploitation are subject to repeated, multiple trauma, and high rates of mental health problems including posttraumatic stress disorder PTSD have been found.
Methods In this retrospective audit, we record the results of NET to treat 10 women who had been trafficked for sexual exploitation who were diagnosed with PTSD. Results All 10 women completed the therapy and experienced a reduction in PTSD severity scores at posttreatment, with improvements that were maintained or further improved at 3-month follow-up.
General distress was also significantly reduced following treatment. Conclusion Although limited by sample size and retrospective design, this audit demonstrates that NET is a feasible treatment for PTSD in this population and warrants further evaluation in a randomized controlled trial. Further adjunctive interventions may also be necessary to treat the additional psychological problems experienced by this population.
People who have been trafficked have frequently encountered extreme violence and psychological abuse during their enslavement 3. Although in its infancy, research into the mental health impact of trafficking has consistently found high rates of mental health problems, most commonly depression, anxiety, and posttraumatic stress disorder PTSD 4 — 8. A number of factors are likely to contribute to this, including the interplay between genetic predisposition and environmental factors such as pre-migration experiences, experiences within the trafficking situation, and the post-release context, including access or otherwise to therapeutic interventions.
In a study of trafficked women returning to Moldova 4 , several risk factors for mental disorders were identified, including childhood sexual abuse, unmet needs, and lack of social support post-trafficking. Exposure to violence prior to the trafficking experience was also linked with PTSD, depression, self-harm and anxiety in trafficked children, and adolescents attending post-trafficking services in Thailand, Cambodia, and Vietnam 9.
Experiences that occur within the trafficking situation also contribute to subsequent mental health problems. Longer periods within the trafficking situation in which they were sexually exploited are associated with greater post-trafficking mental health problems among trafficked women returning to Moldova 4 and among survivors of trafficking for sexual exploitation in the USA 6.
Similarly, women who were trafficked for at least 6 months were twice as likely to experience higher levels of anxiety or depression This may be explained by increased exposure to violence or sexual exploitation over time. Some studies have shown a specific relationship between events that occur during the trafficking experience and mental health problems. For example, sexually exploited women in Nepal were shown to have higher rates of anxiety, depression, and PTSD than those who were victims of non-sexual exploitation In a study assessing mental health problems in women accessing post-trafficking services in a range of countries, sustaining physical injuries and sexual violence were linked to higher rates of depression, anxiety, and PTSD In a study of 1, trafficked men, women, and children, several factors threats, severe violence, poor living conditions, long working hours, and unfair loss of pay were linked to increased likelihood of developing symptoms of depression, anxiety, and PTSD 5.
Survivors who had the most marked subjective feelings that their freedom was restricted while they were being trafficked had increased rates of anxiety 10 and double the overall risk of poor mental health 5 than those who felt less restricted. Although mental health problems among victims of trafficking have been shown to be high, recovery without treatment is rare, particularly in those who have developed PTSD Where there is comorbidity, recovery often does not occur even when rehabilitation has been attempted 7.
This is unsurprising given the multiplicity of trauma that victims of trafficking have experienced 2 , which often includes trauma prior to the trafficking situation. In keeping with this, there is evidence from the wider non-trafficking literature that PTSD is more common among those who have experienced multiple trauma 12 and recovery is less likely There is a paucity of research into clinical interventions for the treatment of victims of trafficking.
Much of the literature in this area proposes principles by which interventions should be delivered rather than describing treatment trials. Such trials are in any case challenging because of the many other adversities that survivors of trafficking often also experience. Those who have been trafficked across borders face immigration insecurity.
Many seek asylum in the same country in which they have escaped their captors. This may increase their fears about the possibility of being recaptured.
Victims of trafficking may also experience significant stressors related to their insecure immigration status such as further incidents of imprisonment for example, for having used false documents while under the control of traffickers , or of immigration detention.
Research has consistently demonstrated that a long asylum determination procedure and other post-migration adversities contribute to mental health problems 14 — Immigration detention has also been shown to be associated with mental health problems Given the high rate of PTSD among victims of trafficking, an evidence-based treatment for PTSD should be available and be provided to those victims who meet diagnostic criteria for this condition.
Narrative exposure therapy NET 18 is a short-term evidence-based treatment for PTSD that was specifically developed for victims of multiple trauma and may therefore be worthy of evaluation in the context of trafficking-related PTSD.
In NET, an individual is taken through their entire autobiography. Both traumatic and positive events are identified and understood within the wider sociopolitical context in which they occurred.
The majority of time in therapy is spent carrying out a detailed exploration of, and exposure to, traumatic events experienced chronologically and in context. The therapist guides the exposure through the event in a much more directive manner than is usual in other therapies.
Contextual information is integrated into the memory for the trauma during the exposure, in order that the autobiographical memory is completed.
The detailed account of the autobiography is transcribed by the therapist and is given to the client at the end of therapy. It provides a written acknowledgment or testimony of their experiences, including both traumatic events and positive events, within the context in which they occurred.
Narrative exposure therapy was initially developed for use in low income countries in contexts of ongoing insecurity and high likelihood of exposure to further trauma. Subsequently, it has been shown also to be effective among asylum seekers and refugees in high income countries. Several trials have now demonstrated its efficacy among diverse populations, including former child soldiers 19 , asylum seekers in Germany who had experienced war and torture 20 , and individuals with comorbid BPD These populations have in common a high prevalence of PTSD resulting from experience of multiple traumas, which in some cases includes developmental trauma.
In the light of the above, and particularly because of the multiple traumas to which victims of human trafficking have usually been subjected, NET was therefore chosen in this pilot study as an appropriate treatment for women trafficked for sexual exploitation who suffered from PTSD. Victims of trafficking for sexual exploitation are likely to experience high levels of shame.
In NET, shame is considered to be one of several emotions that are likely to occur during sexual violence including rape. Shameful events are treated in the same way as any other traumatic event. The close attention and empathic response of the therapist is thought to allow the individual feeling shame to connect with another compassionate person as they go through the exposure to this event.
Rather than experiencing the response that they expect being rejected and socially excluded , the client instead experiences empathy and compassion. In NET, the therapist is not neutral, but rather is an advocate for the Human Rights of survivors The therapist facilitates the expression of emotions that the survivor was not able to experience and express at the time. In our collective clinical experience, this often enables the client to take a position of acknowledging the abuse of their Human Rights.
Anger is a powerful antidote to shame. Many victims of trafficking have had their trust betrayed by traffickers who may have initially engaged in romantic relationships with their victim, prior to exploiting them. In our clinical experience victims of trafficking often continue to hold ambivalent feelings toward their trafficker and may develop new relationships with abusive partners, or experience further exploitation by others.
In order to help the victim to recognize and acknowledge the exploitation that they have been subjected to by the person who trafficked them, and to attempt to increase the interpersonal safety of the victim in the present and future, an emphasis on attending to the possible motivations of the traffickers was included during the NET sessions.
Materials and Methods Participants The participants were clients of the Helen Bamber Foundation, a charity that provides specialist psychological therapy as part of a holistic model of care to victims of trafficking among others. Ten female victims of trafficking for sexual exploitation were treated using NET. All clients of the Helen Bamber Foundation who are offered therapy are asked to complete the measures described below as a means of evaluating outcome.
All female victims of trafficking who meet diagnostic criteria for PTSD and who live in London where the center is based are offered psychological therapy. The case series described represents a retrospective audit of the first 10 female victims of trafficking who received treatment with NET. All of the participants were provided with information about the therapy and associated risks and benefits. All provided written consent to receiving treatment. Those who declined treatment with NET were offered alternative interventions and could still access the other services offered by the Helen Bamber Foundation.
Nine out of the 10 participants had insecure immigration status at the time of starting treatment; 5 of the women were from Albania, 4 were from different African countries, and 1 woman was from China. The women were aged between 18 and All had experienced multiple traumatic events during childhood and in the context of the trafficking situation. All had been subjected to multiple sexual assaults as well as severe physical abuse in the trafficking situation.
Six out of 10 were treated with the help of professional interpreters. Where necessary, the PDS interviews were conducted with the help of an interpreter. Since language and literacy issues meant that participants were not able to complete the questionnaires themselves, the therapist administered the PDS as an interview by reading the questionnaire to the participant.
Where necessary, participants completed the CORE with the help of an interpreter. Procedure All clients provided consent to participate in both the diagnostic interviews and the treatment.
Following the initial diagnostic interview, all were offered NET. They completed the same measures at the end of treatment and at a 3-month follow-up.
Treatment fidelity was maximized through close case supervision by the first author, who has considerable experience in delivering NET and training others to apply the approach. Results All clients completed 10—19 sessions of treatment, depending on the number of traumatic events that they had experienced.
Three, Bonferroni-corrected, paired samples t-tests were conducted for post hoc comparisons between conditions.