post-traumatic stress disorder - The Professional Counselor

A Comprehensive Perspective on Treating Victims of Human Trafficking

Mar 9, 2020 | Volume 10 - Issue 1

Kathryn Marburger, Sheri Pickover

Providing treatment to survivors of human trafficking requires mental health professionals to understand complex layers of multiple traumas. These layers include an understanding of how trafficking occurs; what gender, ages, sexual orientations, life circumstances, and ethnicities are most at risk to be trafficked; the lasting impact of trafficking on human development, mental health, and family relationships; and the stigma victims face from their own families, communities, and mental health providers. These survivors suffer from physical ailments and post-traumatic stress disorder, and they are at high risk for developing comorbid disorders such as depression and addiction disorders. Integrated treatment options to alleviate these concerns, including cognitive behavioral therapy, trauma-focused therapy, ecologically focused therapy, and family therapy, are presented.

Keywords: human trafficking, trauma, post-traumatic stress disorder, addiction disorder, sexual orientation

Human trafficking is often referred to as modern-day slavery and is found in every corner of the globe (Cecchet & Thoburn, 2014; Department of Homeland Security [DHS], n.d.; Gerassi, 2015; Hardy et al., 2013; Hodge, 2014; Litam, 2017; Polaris, n.d.-b; Sanchez & Stark, 2014; Zimmerman & Kiss, 2017). The United Nations defines trafficking as:

the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or
use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or
of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the
consent of a person having control over another person, for the purpose of exploitation. (Office of the
High Commissioner for Human Rights, 2000, article 3, para. 1)

The International Labour Office (2017) has estimated that 40.3 million people are victims of modern-day slavery throughout the world. This means that one person in every 1,000 is being victimized through modern-day slavery. Offering high rewards with minimal risk, human trafficking is a profitable and fast-growing criminal enterprise. Human trafficking profits surpass illegal arms trafficking and are second only to drug trafficking (Busch-Armendariz et al., 2014; Greer & Davidson Dyle, 2014; UNICEF USA, 2017). The International Labour Office (2014) has estimated that the profits from human trafficking are $150 billion a year, of which $99 billion comes from sexual exploitation.

The DHS reported that the crime of human trafficking is often hidden in plain sight in both legal and illegal industries; victims can be any gender, sexual orientation, age, and nationality, including documented or undocumented immigrants (DHS, n.d.; Rothman et al., 2017). However, statistics on human trafficking within the United States are lacking (DHS, n.d.; Gerassi, 2015; Miller-Perrin & Wurtele, 2017; Varma et al., 2015), and a uniform system of collecting data to identify victims currently does not exist, which increases the difficulty of obtaining accurate data (Gerassi, 2015; Miller-Perrin & Wurtele, 2017). Additional factors that contribute to the underreporting of human trafficking include legal and social services that are not readily accessible to victims, fear of punishment from traffickers, and fear or distrust of law enforcement. Moreover, some victims may not even recognize themselves as being the victims of human trafficking (De Chesnay, 2013; Miller-Perrin & Wurtele, 2017).

Human trafficking is a crime that inflicts complex layers of trauma on victims and survivors. The goal of this article is to provide mental health professionals with a systemic view of this crime from various perspectives so that they can implement wraparound-focused treatment plans. The perspectives adopted include how individuals become trafficked, sociocultural factors, the impact on the victims’ development and mental health, family relationships, and the stigma victims face from communities and their families. Having knowledge of these complex factors will allow mental health professionals to devise trauma-sensitive approaches to treat survivors of human trafficking. For the purpose of this paper, the term victims refers to individuals who are actively under the control of the trafficker, and the term survivors refers to individuals who are no longer being exploited.

Sexual exploitation and forced labor are two of the most common forms of human trafficking (Busch-Armendariz et al., 2014; De Chesnay, 2013; Greer & Davidson Dyle, 2014; Hodge, 2014; Martinez & Kelle, 2013; Miller-Perrin & Wurtele, 2017; U.S. Department of State, 2017). Human Rights First (2017) reported that 19% of human trafficking victims are trafficked for sex, and yet sex trafficking accounts for 66% of trafficking profits worldwide. Sex trafficking includes a wide variety of traditionally accepted forms of labor, including commercial sex, exotic dancing, and pornography. It is a form of oppression placing men, women, and children throughout the world at risk of sexual exploitation (Litam, 2017; Polaris, n.d.-a; Zimmerman & Kiss, 2017).

Traffickers treat victims’ bodies as resources to be used and repeatedly sold for money or goods such as pornography, cigarettes, drugs, clothing, and shelter (Busch-Armendariz et al., 2014; Greer & Davidson Dyle, 2014; Litam, 2017; Miller-Perrin & Wurtele, 2017; Sanchez & Stark, 2014). International trafficking often receives more attention; however, most trafficking occurs domestically within the same country (Martinez & Kelle, 2013; Zimmerman & Kiss, 2017). Furthermore, trafficking does not have to include crossing a state line, nor does it necessarily involve moving locations (Busch-Armendariz et al., 2014). Domestic minor sex trafficking is flourishing in every region, state, and community in the United States (Countryman-Roswurm & Bolin, 2014), with Midwestern cities showing increased rates of recruitment; such cities have access to several highways to transport victims to destination cities, including Detroit, Chicago, and Las Vegas, where demand for sexual exploitation is highest (Litam, 2017).

Sex trafficking has been linked not only to escort and massage services, strip clubs, and pornography, but also to major sporting events, entertainment venues, truck stops, business meetings, and conventions (Busch-Armendariz et al., 2014; Hardy et al., 2013; Litam, 2017). As long as demand exists, the opportunity for traffickers to sell victims is limitless. The internet increases the convenience and reduces the risk for traffickers and consumers. For instance, although Backpage.com was shut down by the U.S. government in 2017 for participating in and profiting from sex trafficking advertisements, and other websites like Craigslist began to censor and remove sex advertisements (Anthony et al., 2017; Leary, 2018; Peterson et al., 2019), numerous websites are used by traffickers not only to lure victims but also to advertise and sell to consumers. These websites include Eros.com, Bedpage.com, and social media platforms such as Instagram, Facebook, Twitter, Tinder, and Grindr (Jordan et al., 2013; Litam, 2017; Moore et al., 2017; O’Brien, 2018). The physical and psychological abuse victims experience from both traffickers and consumers leaves victims traumatized (Graham et al., 2019; Greer & Davidson Dyle, 2014; Litam, 2017; Moore et al., 2017; Zimmerman & Kiss, 2017).

The Victims of Trafficking

One out of every four victims of human trafficking is a child (International Labour Office, 2017), and these children are often found in the child welfare and juvenile justice systems, and runaway and homeless youth shelters (Moore et al., 2017; U.S. Department of State, 2017). In 2016, it was estimated that one out of six runaways was a victim of sex trafficking and 86% had been in foster care or social services when they ran away (Polaris, n.d.-a). Runaway youth are usually approached by traffickers within 48 hours of living on the street (Jordan et al., 2013). Traffickers recruit runaway or homeless children into trafficking rings, exposing them to extreme forms of abuse that result in many being killed from the violence inflicted or from diseases acquired through sexual abuse (Litam, 2017).

Sex trafficking is prevalent throughout the world, affecting men, women, children, families, and communities. Individuals also are trafficked for various other purposes, including domestic service, agricultural work, commercial fishing, the textile industry, construction, mining, factory work, and petty crime (U.S. Department of State, 2017; Zimmerman & Kiss, 2017). Although men have been confirmed to be victims in all areas of trafficking, they are disproportionately subjected to forced labor, whereas women and children account for the majority of sexually exploited victims (International Labour Office, 2017). Although trafficking occurs in all parts of the world and can affect anyone, several factors increase the risk of trafficking, including gang activity, a history of childhood abuse, and poverty. Substance abuse also plays a key role (De Chesnay, 2013; Moore et al., 2017; O’Brien, 2018).

Addiction

Substance abuse within families is a risk factor for children becoming the victims of trafficking (Hardy et al., 2013; Miller-Perrin & Wurtele, 2017). Parents or other family members with an addiction can force youth into sexual exploitation, selling or trading them to support their drug addiction (De Chesnay, 2013; Litam, 2017). Traffickers often force substance use on victims in order to control and sexually exploit them (De Chesnay, 2013; Gerassi, 2015; Hodge, 2014; Hom & Woods, 2013; Litam, 2017; Moore et al., 2017). Substance abuse also may be a way for trafficking victims to cope with the abuse they endure (Miller-Perrin & Wurtele, 2017).

Trafficking victims who engage in substance abuse usually experience detrimental personal outcomes, including an increased likelihood of engaging in high-risk behaviors (i.e., unprotected sex), infection from needles, and overdosing (Gerassi, 2015; Zimmerman et al., 2011). They often commit drug-related crimes for their trafficker and are therefore at risk of arrest and conviction for prostitution and drug offenses (Litam, 2017; Miller-Perrin & Wurtele, 2017; Zimmerman et al., 2011). Arrests, drug charges, substance abuse, and violent clients can trap trafficking victims in a vicious circle of re-traumatization by their traffickers, their potentially abusive consumers, and the criminal justice system (Gerassi, 2015; Zimmerman et al., 2011).

Impact on Physical and Mental Health

A concern for children who fall prey to sex trafficking is the impact these experiences have on their development. Not only are victims affected by educational deprivation, but trafficking also causes serious harm to their psychological, spiritual, and emotional development (Miller-Perrin & Wurtele, 2017; Rafferty, 2008; Sanchez & Stark, 2014). Child victims suffer from an increased risk of several emotional problems such as guilt, shame, anxiety, hopelessness, and loss of self-esteem (Miller-Perrin & Wurtele, 2017; Rafferty, 2008). Some of the mental health consequences for child victims include depression, dissociation, post-traumatic stress disorder (PTSD), eating disorders, somatization, poor attachment, antisocial behaviors, substance use disorders, self-harm, and suicidality (Kiss et al., 2015; Miller-Perrin & Wurtele, 2017; Rafferty, 2008). Furthermore, because of the exposure to the violence and sexual assault linked to trafficking, child victims have been found to be at higher risk of sexually transmitted infections, reproductive health problems from unsafe abortions, fractures, genital lacerations, malnutrition, and dental problems (Miller-Perrin & Wurtele, 2017).

Trafficking poses significant risk to child victims’ long-term mental health. Survivors trafficked in childhood report a high prevalence of mental health problems such as depression, anxiety, and PTSD. These mental health problems also affect adult victims (Hom & Woods, 2013; Oram et al., 2016). Among women who have survived trafficking, there are increased rates of anxiety and stress disorders, disassociation, depression, personality disorders, low self-esteem, suicidal ideation, and poor interpersonal relationships (Sanchez & Stark, 2014). Additionally, somatic symptoms such as headaches, fainting, and memory problems are commonly reported among women who are victims of trafficking (Oram et al., 2016). A high prevalence of sexually transmitted infections has been reported in both men and women (Hom & Woods, 2013; Oram et al., 2016; Sanchez & Stark, 2014). Borschmann et al. (2017) found high rates of self-harm among adult victims of human trafficking.

Pregnancy is a common occurrence for trafficked women (Bick et al., 2017; Gerassi, 2015; Hom & Woods, 2013; Oram et al., 2016; Sanchez & Stark, 2014). Several barriers to maternity services have been identified for pregnant victims, including traffickers preventing women from seeking care and the victims feeling reluctant because they might not have valid documents (Bick et al., 2017). Additionally, children and family members are often used by traffickers to threaten and coerce victims, which further isolates victims and distances them from their families (Hardy et al., 2013; Hodge, 2014; Juabsamai & Taylor, 2018; Sanchez & Stark, 2014).

Sex trafficking often involves the exploitation of victims by force, and the brutal nature of the crime can cause complex mental health problems for victims (Gerassi, 2015; Greer & Davidson Dyle, 2014; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). Victims endure high levels of trauma, and survivors show increased rates of depression, anxiety, PTSD, and substance use disorders (Gerassi, 2015). The goal of traffickers is to physically and psychologically break victims down into subservience (Hodge, 2014). Not only are victims forced to engage in humiliating sexual acts and use substances, but traffickers also use recurrent beatings, rape, and even murder as tactics to control their victims (De Chesnay, 2013; Gerassi, 2015; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). Victims may believe that the traffickers have their best interests in mind and develop significant bonds with their traffickers, similar to Stockholm syndrome, and may be reluctant to escape (De Chesnay, 2013; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). In addition, victims of sexual exploitation have not only endured physical and emotional abuse from their traffickers, but there also is a strong correlation with childhood abuse (Gerassi, 2015; Miller-Perrin & Wurtele, 2017). However, issues of physical and mental health tend to be exacerbated by issues of economic deprivation and racial inequality. These factors may act as a catalyst for putting individuals more at risk of human trafficking (Greer, 2013).

Multicultural Considerations

Sex traffickers often target vulnerable individuals, including runaway and homeless youth; victims of domestic abuse or sexual assault; victims of war; and individuals who experience social discrimination, including gender, racial, ethnic, and socioeconomic inequality (Anthony et al., 2017; Miller-Perrin & Wurtele, 2017). For example, LGBTQ homeless youth account for 20% of the homeless youth population in the United States, yet 58.7% of homeless LGBTQ youth are victims of sex trafficking (Martinez & Kelle, 2013). Martinez and Kelle (2013) further noted that this figure is significantly higher than the 33.4% of the heterosexual homeless youth. Furthermore, LGBTQ youth are more than seven times more likely to experience acts of violence than their cisgender peers (Anthony et al., 2017). Trafficking often affects victims of poverty. Studies of sexual exploitation and domestic sex trafficking also have reported higher rates of violence against women of color, especially African American women, and undocumented immigrants (Gerassi, 2015; Zimmerman & Kiss, 2017).

Finally, individuals with intellectual disabilities are at risk because of an unfamiliarity with sexual activities and an inability to understand the nature of sexual abuse and exploitation (Reid, 2018). As a result, such individuals are at a higher risk of becoming victims of trafficking (Greer & Davidson Dyle, 2014; Hodge, 2014; Miller-Perrin & Wurtele, 2017; Reid, 2018).

Returning Home

Women who have been victims of trafficking have often been found to come from abusive households (Gerassi, 2015; Hom & Woods, 2013; O’Brien, 2018; Oram et al., 2016). As a result, once victims are free from their traffickers, they have often been found to not only lack social support but also lack basic needs such as shelter and financial support (Hom & Woods, 2013; Le, 2017; Oram et al., 2016). Reconciliation with supportive family often plays a key role for trafficking survivors; however, because of stigma, some victims are met with shame and judgment from their families and are not welcomed (Hom & Woods, 2013; Juabsamai & Taylor, 2018; McCarthy, 2018; Zimmerman & Kiss, 2017).

Unfortunately, it is not uncommon for victims to be exploited by someone they know and love. Oftentimes a trafficker is a family member, intimate partner, friend, or acquaintance (Gerassi, 2015; Hardy et al., 2013; Hom & Woods, 2013; Le, 2017; Miller-Perrin & Wurtele, 2017; Moore et al., 2017), which further complicates survivors’ ability to establish trusting relationships. Moreover, law enforcement may charge adult victims with prostitution. Not only is the victim caught in legal limbo, but they are re-victimized by law enforcement (Sanchez & Stark, 2014). Finally, female survivors who socialize with men after being freed from their traffickers have reported being triggered with memories of their abusive experiences, further affecting their ability to develop healthy, stable relationships and social support (Hom & Woods, 2013).

Victims of human trafficking have often been robbed of their identities, had their self-esteem demolished, and already experienced physical and psychological abuse before they became victims of human traffickers. Once they leave their traffickers, survivors have a variety of immediate, short-, and long-term needs that must be addressed to help promote resiliency while they are reintegrating into the community (Busch-Armendariz et al., 2014; Graham et al., 2019; Hom & Woods, 2013; Le, 2017; McCarthy, 2018; O’Brien, 2018; Twigg, 2017). Immediate needs include ensuring safety; finding medical care, food, shelter, clothing, and counseling; and acquiring identiﬁcation, language interpretation services, and legal and immigration assistance (Busch-Armendariz et al., 2014; Graham et al., 2019; Hom & Woods, 2013; McCarthy, 2018; Polaris, n.d.-a; Twigg, 2017). Education, employment, and establishing friendships have been identified as vital ongoing needs to successfully alleviate stress while reintegrating into the community (Hom & Woods, 2013; McCarthy, 2018; O’Brien, 2018; Polaris, n.d.-a; Twigg, 2017). However, it is important to note that survivors are often met with substantial challenges while seeking basic services. For instance, many programs may be underfunded or ill-equipped to handle the high demand for services (Polaris, n.d.-a). This reaffirms the crucial need to meet survivors with empathetic and nonjudgmental attitudes to help prevent re-victimization and a return to traffickers (Anthony et al., 2018; Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018).

Family support can provide survivors with significant protection while reintegrating into the community. Reconnecting with family typically increases the likelihood of a sustainable return process (McCarthy, 2018; Twigg, 2017). However, reconciliation might require a careful approach, as the process can be met with difficulties, including stigma, dysfunctional family environments, or the family’s direct involvement with the victim’s trafficking (Le, 2017; McCarthy, 2018; Twigg, 2017; Zimmerman & Kiss, 2017). In some cases, shame within a cultural context is a prohibitive factor for many to return to their families because of the association with prostitution or having been trafficked (Hom & Woods, 2013). As a result, it is necessary to provide comprehensive, culturally sensitive interventions for trafficking survivors (Hodge, 2014; Hom & Woods, 2013; Le, 2017; McCarthy, 2018). Family continues to be essential to survivors’ sense of identity, and, upon return, cultural beliefs and values that previously formed their self-concept remain influential to survivors (Le, 2017). Many women have noted that marriage and children play an integral role in successfully reintegrating into their community and gaining acceptance from family members (McCarthy, 2018). However, issues of economic deprivation and racial inequality act as a barrier to successful community reintegration and put an individual at higher risk for trafficking (Greer, 2013).

This brief literature review has confirmed that victims of human trafficking suffer from a wide array of mental health concerns, including PTSD, depression, anxiety, and substance abuse, and from stigma associated with being victims of human trafficking. Mental health treatment should address these complex concerns and provide for comprehensive assessment and treatment planning.

Treatment Challenges

Working with trafficked clients poses a series of challenges for counselors because an intervention modality specific to sex-trafficked survivors has yet to be developed (Hopper et al., 2018; Jordan et al., 2013). Treatments are borrowed from evidence-based interventions initially developed for PTSD, domestic violence, and captivity, and a holistic approach is essential (De Chesnay, 2013; Hom & Woods, 2013; Jordan et al., 2013). Four essential practices for providers include ensuring safety and conﬁdentiality, engagement of trauma-informed care, performing a comprehensive needs assessment, and delivery of comprehensive case management that coordinates physical and mental health and legal services. As a result of the multiple traumas trafficking victims endure, the path to restoring wellness is often long and complex, requiring additional time and patience from mental health counselors (Hodge, 2014; Hom & Woods, 2013).

Mental health counselors should conduct a needs assessment to identify the physical, emotional, and spiritual needs of trafficking survivors (Hodge, 2014; Hom & Woods, 2013). Survivors are often in need of medical treatment, as traffickers do not bother with preventative care or what they may consider minor treatment and only allow victims to seek treatment when a condition interferes with earning money (De Chesnay, 2013). Similarly, survivors are often resistant to seek help from mental health providers because of fear of physical violence or threats of retaliation from their traffickers if they disclose their circumstances (De Chesnay, 2013; Hodge, 2014; Litam, 2017). Survivor-centered approaches are recommended initially to acknowledge and validate the survivor’s experience, give the survivor control, and build a sense of safety and trust (Hodge, 2014; Hom & Woods, 2013; Twigg, 2017).

However, after months or years of abuse, trafficking survivors often need a wide array of services to meet their distinctive needs (Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018; Polaris, n.d.-a). The U.S. government has enacted several policies to help victims of trafficking, including the Victims of Trafficking and Violence Protection Act of 2000, which allows victims who have been trafficked from abroad to be issued visas, enabling them to reside in the United States (Davy, 2016; Hodge, 2014). Survivors need to be met with nonjudgmental attitudes, acceptance, understanding, and genuine concern, and they should be slowly encouraged to take on risks associated with leaving their traffickers (Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018). Providing survivors with emotional support and encouragement opposes the isolated world created by their trafficker. Survivors have explained that street outreach programs can play an essential role in establishing contact, allowing victims to become aware of the resources available and begin breaking down the sense of isolation (Hom & Woods, 2013). Additionally, it is vital to empower survivors so that they can understand they are in control (Anthony et al., 2018; Hodge, 2014; Hom & Woods, 2013; Twigg, 2017). Research on resiliency has found creativity, humor, flexibility, and movement are important factors in improving self-esteem, prosocial behaviors, and hope among traumatized individuals (Litam, 2017).

Evidence-Based Treatment
Counselors working with trafficking survivors should be equipped to use several trauma-sensitive interventions to assist with the individual needs of each survivor (Busch-Armendariz et al., 2014; De Chesnay, 2013; Hardy et al., 2013; Hodge, 2014; Hom & Woods, 2013; Litam, 2017; Miller-Perrin & Wurtele, 2017; Twigg, 2017). Trauma-sensitive interventions recognize safety as the foundation for working with individuals to end self-harm, develop trusting relationships, overcome obstacles, leave dangerous situations, and promote wellness (Hopper et al., 2018). Although it may be painful for trafficking survivors to verbalize their traumatic experiences, creative therapies offer alternative methods of communication and expression (De Chesnay, 2013; Litam, 2017).

Although evidence-based practices for treating sex-trafﬁcking survivors are not widespread, counseling techniques exist that have been shown to be effective with child sex abuse victims, including trauma-focused cognitive behavioral therapy and dialectical trauma-focused cognitive behavior therapy (De Chesnay, 2013; Twigg, 2017). Similarly, participating in group counseling can empower survivors of sex trafficking and provide them with an opportunity to share their experiences, generating a sense of community and support (Hopper et al., 2018). Peer support has been noted to be a vital component of intervention, both as a motivating factor to remain in treatment and as help in the prevention of survivors returning to their traffickers (De Chesnay, 2013; Litam, 2017; Twigg, 2017). Furthermore, discussing stigmatized topics within group settings can help reduce shame, as it is common for trafficked survivors to feel that no one else has gone through similar situations (Hickle & Roe-Sepowitz, 2014; Litam, 2017). Having a setting to address the shame can help survivors recognize the commonality of their experiences and build support (Countryman-Roswurm & Bolin, 2014; Litam, 2017).

Family Therapy

As human trafficking affects individuals, families, and communities, it is necessary to adopt treatment models that engage families and communities as well as individual-based treatment models. Twigg (2017) found that survivors require and benefit from therapeutic support in order to achieve successful family and community reunification. However, like individual treatment, family therapy models specific to human trafficking survivors do not exist, but current family therapy models developed around trauma could be adapted for use with human trafficking survivors. Apsche et al. (2008) developed Family Mode Deactivation Therapy, a cognitive behavior family therapy model for use with youth and families in residential treatment that uses ongoing assessment and community skill development to reduce the behavioral symptoms associated with trauma. The researchers found this model reduced recidivism more effectively than a non–family-based approach. Hughes (2017) developed an attachment-focused family treatment for children who have experienced developmental trauma. This two-phase treatment provides therapy to a caregiver first, then transitions to joint sessions to reframe the trauma experience.

Similarly, using ecologically based family therapy with individuals involved in sex trafficking has been found to improve outcomes for sobriety and depression (Murnan et al., 2018). Agani et al. (2010) recommended the use of the linking human systems community resilience model, which is based on transgenerational and ecosystemic structural family therapies. This model focuses on identifying the strengths of community and family members, bringing them together to encourage their competency and using community leaders to solve problems. Other novel approaches to working with survivors of crime include the Family Group Project, which involves group therapy aimed at recreating a family environment to re-integrate survivors into the community (Allen et al., 2015).

A Survivor’s Story

Research provides one perspective on the plight of human trafficking victims and survivors, but a first-person account provides insight to the worldview of an actual survivor. One of the authors met with a human trafficking advocate in order to gain further perspective on the needs of survivors. The advocate, who requested that the author provide no identifying information beyond her gender, disclosed during the interview that she was a survivor who had been trafficked by her husband. Her trafficker had been blackmailing a John, a term commonly used for an exploitive consumer. She was arrested during a raid and remained in jail for 3 months because she refused to say anything. She explained that it took her a year to build up the strength and courage to testify in court because her trafficker blackmailed her. He threatened to tell her family about the exploitative acts and substance use, which he forced her to engage in. He would say, “Do you really want your family to know what you have been up to?” However, once her family was notified of her predicament, she reported that her family members provided emotional support. She explained that it was through their support she was able to come forward and testify.

Although she came forward and testified against her trafficker, she was not viewed as a victim, and she was charged with prostitution. As she explained, advocates are trying to change the legislation and work with police in her local area so that human trafficking victims are not charged with crimes. For instance, not only was she charged with prostitution, but she also had to pay the John $3,000, the money her trafficker had stolen from him. Despite never having seen the money, she was ordered to repay it and was placed on a repayment schedule. Even more disheartening, her trafficker made a plea deal and did not have to repay any money and the charges of trafficking were dropped. All these events provide an example of how the legal system can re-victimize a survivor. Although she had been the victim of trafficking, which stigmatized her, she also was told that she owed money to someone her trafficker had stolen from, thus re-victimizing her.

The charge of prostitution remained on her record and became something she had to explain to potential employers. With the support of her family and by attending therapy, she was able to rebuild her life. She had a bachelor’s degree in social work when she met her ex-husband and was able to obtain her limited license. She decided to pursue a master’s degree and was once again faced with the challenge of disclosing the charge on her record and reliving the trauma of explaining what happened. The first university she applied to denied her application, and this placed her in a deep depression; however, she was accepted at another university and after graduating became an advocate for survivors of human trafficking. She also shared that although it took time to be able to trust someone again, she has established an intimate relationship and will soon be married.

Conclusion

Counselors treating a human trafficking survivor need to develop a wide-ranging view of assessment, treatment, case management, support, advocacy, and termination from counseling. Human trafficking survivors suffer from a complex variety of developmental, mental health, and social issues that require counselors to not only engage the individual in treatment, but also to act as an advocate against stigma within their family and the community.

The myriad of issues faced by these individuals, from navigating the criminal justice system, coping with multiple layers of physical and emotional trauma, overcoming substance abuse, overcoming family and community alienation, coping with dual stigmas of human trafficking and mental health diagnoses, to finally reintegrating into daily work and life, require counselors to be vigilant in the assessment process. Counselors need to consider assessment an ongoing extensive process that should occur throughout every session and focus not just on mental health needs, but also on physical health and basic needs, and career support. Counselors will need to assess risk of the individual returning to the trafficker and have referrals ready to help the client stay safe. Human trafficking survivors will need a counselor able to quickly identify short-term crisis needs during long-term treatment.

When entering the treatment phase, counselors need to research multiple treatment modalities that may not directly relate to human trafficking but may support the client. For example, a counselor will need to navigate working with substance use, trauma, family issues, and career concerns. Counselors will need to widen their view of their role within the therapeutic relationship. Human trafficking survivors may require case management services more than long-term counseling when first entering care, yet the need to build a strong therapeutic relationship is paramount for ongoing treatment. The counselor should consider taking on the case management role as needed to promote consistency in the treatment process. As an advocate, the counselor will need to engage multiple individuals and systems into the treatment process to ensure comprehensive care. Counseling skills aimed at engaging families, law enforcement personnel, legal personnel, and medical professionals in treatment are essential for treating survivors. Counselors would also benefit from strength-based approaches with this population, as research indicates survivors most benefit from being able to identify their own qualities of self-protection and resiliency, which empowers their recovery process. This empowerment also allows for a supportive termination process, ensuring that the survivor has ongoing access to a support network in order to facilitate long-term recovery.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Kathryn Marburger is a graduate student at the University of Detroit Mercy. Sheri Pickover, PhD, LPC, is an associate professor at Central Michigan University. Correspondence can be addressed to Sheri Pickover, 195 Ojibway Court, Mt. Pleasant, MI 48859, picko1s@cmich.edu.

Assessment and Treatment of Brain Injury in Women Impacted by Intimate Partner Violence and Post-Traumatic Stress Disorder

Mar 30, 2018 | Volume 8 - Issue 1

Trish J. Smith, Courtney M. Holmes

Intimate partner violence (IPV) is a public health concern that affects millions of people. Physical violence is one type of IPV and has myriad consequences for survivors, including traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). It is estimated that as many as 23,000,000 women in the United States who have experienced IPV live with brain injury. This article overviews the intersection of TBI and PTSD as a result of IPV. Implications for counselors treating women impacted by IPV suggest counselors incorporate an initial screening for TBI and consider TBI- and PTSD-specific trauma-informed approaches within therapy to ensure best practices. A case study demonstrating the importance of the awareness of the potential for TBI in clients who experience IPV is included.

Keywords: intimate partner violence, traumatic brain injury, post-traumatic stress disorder, PTSD, public health

In 1981, the U.S. Congress declared October as Domestic Violence Awareness Month, marking a celebratory hallmark for advocates and survivors nationwide (National Resource Center on Domestic Violence, 2012). Since this time, similar social and legislative initiatives have increased overall awareness of gender inequality, thus influencing a decline in women’s risk for intimate partner violence (IPV; Powers & Kaukinen, 2012). Recent initiatives, such as a national briefing focused on brain injury and domestic violence hosted by the Congressional Brain Injury Task Force, continue to call increased attention to the various intersections and implications of this national public health epidemic (Brain Injury Association of America, 2017). Unfortunately, despite various social advocacy movements, IPV remains an underrepresented problem in the United States (Chapman & Monk, 2015). As a result, IPV and related mental and physical health consequences continue to exist at alarmingly high rates (Chapman & Monk, 2015).

IPV refers to any act of physical or sexual violence, stalking, or psychological aggression by a current or previous intimate partner. An intimate partner is an individual with whom someone has close relations with, in which relations are characterized by the identity as a couple and emotional connectedness (Breiding, Basile, Smith, Black, & Mahendra, 2015). An intimate partner may include but is not limited to a spouse, boyfriend, girlfriend, or ongoing sexual partner (Breiding et al., 2015). Physical violence is the intentional use of force that can result in death, disability, injury, or harm and can include the threat of using violence (Breiding et al., 2015). Sexual, emotional, and verbal abuse are often perpetrated in conjunction with physical violence in relationships (Krebs, Breiding, Browne, & Warner, 2011).

Heterosexual and same-sex couples experience IPV at similar rates (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015). Researchers estimate that more than one in every three women and at least one in four men have experienced IPV (Sugg, 2015). These rates likely underestimate the true prevalence of IPV, given that populations with traditionally high incidences of abuse (e.g., poor, hospitalized, homeless, and incarcerated women) may not be included in survey samples (Scordato, 2013; Tramayne, 2012). Additionally, fear and shame often serve as a deterrent to reporting abuse (Scordato, 2013). Although both men and women are victims of IPV, women are abused at a disproportionate rate (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015) and have a greater risk than men of acquiring injury as a result of physical violence (Scordato, 2013; Sillito, 2012). Data have shown that 2–12% of injuries among women brought into U.S. emergency departments are related to IPV (Goldin, Haag, & Trott, 2016), 35% of all homicides against women are IPV-related (Krebs et al., 2011), and approximately 22% of women have experienced physical IPV, averaging 7.1 incidences of violence across their lifespan (Sherrill, Bell, & Wyngarden, 2016). IPV is a pervasive relational problem that creates a myriad of complex mental and physical health issues for female survivors (Sugg, 2015). One health issue commonly experienced by female survivors of IPV is post-traumatic stress disorder (PTSD; Black et al., 2011).

PTSD and IPV

A Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnosis of PTSD is based on the client’s exposure to a dangerous or life-threatening stressor and consists of the following symptomology: intrusion of thoughts or re-experiencing of the event, including flashbacks; avoidance of experiences or thoughts related to the stressor; negative alterations in cognition and mood; and changes in reactivity, including hypervigilance or hyperarousal. According to Bourne, Mackay, and Holmes (2013), flashbacks are the hallmark symptom of PTSD and involve a process in which the individual dissociates and feels as though they are re-experiencing the traumatic event through involuntary, vivid, and emotional memories. Although PTSD symptoms may occur immediately after a traumatic event, symptoms may have a delayed onset in which the full range of symptoms can manifest even 6 months after the event, showing only partial symptom criteria in the preceding months (Utzon-Frank et al., 2014).

Experiencing IPV increases risk for developing PTSD (National Center on Domestic Violence, Trauma, and Mental Health, 2014). In a national sample of 9,000 women, 62% who experienced some form of IPV reported at least one PTSD symptom (Black et al., 2011). Women who experience IPV are almost three times as likely to meet criteria for PTSD when compared with those who have not had such experiences (Fedovskiy, Higgins, & Paranjape, 2008). Although PTSD is a common manifestation of IPV, another condition, traumatic brain injury (TBI), also is prevalent in survivors (Sherrill et al., 2016). The symptomology of TBI mirrors that of PTSD, rendering the clinical tasks of appropriate diagnosis and treatment planning especially difficult (McFadgion, 2013).

TBI and IPV

TBI is defined as a change in brain function caused by an external force (e.g., strike to the head or strangulation; Murray, Lundgren, Olson, & Hunnicutt, 2016). Symptoms include headaches, dizziness, fatigue, difficulty concentrating, irritability, and perceptual difficulties with noise and light (Zollman, 2016). Other symptoms can include problems with attention, memory, processing speed, decision making, and mood (Jeter et al., 2013). Professionals can use computerized tomography (CT) scans to find contusions, hematomas, diffuse axonal injury, and secondary brain injuries, which aid in the medical diagnosis of TBI (Currie et al., 2016). Although CT is widely used in assisting with the identification of TBI, a final diagnosis is most often made in a clinical interview with the patient, treating physician, and if feasible, those who observed the violent incident or responded to it (Zollman, 2016). Violence that causes TBI may or may not leave internal or external physical evidence of trauma (e.g., bruising, scarring); thus it is crucial that assessment and screening attempts take place beyond neuroimaging technology and are included as a part of a comprehensive evaluation (Joshi, Thomas, & Sorenson, 2012).

Researchers indicate that over 60% of women, with estimates as high as 96%, who experience IPV sustain injury to the face or head areas, including attempted strangulation (McFadgion, 2013; Sherrill et al., 2016; St. Ivany & Schminkey, 2016). Acquired TBI through IPV can complicate the therapeutic treatment of women (Murray et al., 2016). Brain injury shares similar symptomology with PTSD, increasing likelihood for misdiagnosis, complications with care, and long-term brain damage (McFadgion, 2013). Additionally, TBI and PTSD are often comorbid diagnoses, and those who survive physical trauma and incur a TBI suffer negative mental health impacts such as depression, anxiety, and suicidal ideation (Smith, Mills, & Taliaferro, 2001).

PTSD and TBI have an extensive impact on brain functioning (Boals & Banks, 2012; Saar-Ashkenazy et al., 2016). Individuals with PTSD experience daily cognitive failures in memory, perception, and motor function (Boals & Banks, 2012; Saar-Ashkenazy et al., 2016). Other researchers have shown that PTSD negatively impacts brain functioning on multiple levels, including stimuli recognition, and overall cognitive functioning (Saar-Ashkenazy et al., 2016). Similarly, individuals with TBI may experience physical, sensory, cognitive, and social difficulties as a result of their brain injury (Brain Injury Association of Virginia , 2010). Given the overlapping symptoms of PTSD and TBI, and the overall impact on functioning, it is critical for counselors to consider these factors when diagnosing and treating women who have experienced IPV.

In sum, IPV is a widespread public health issue with a multitude of negative consequences related to human functioning. Incidences of TBI in women who have experienced IPV cannot be overlooked. A framework for mental health counselors that includes awareness of the overlapping symptoms between two likely outcomes of IPV and their manifestation is crucial for successful case conceptualization and treatment.

Counseling Implications

PTSD and TBI have extensive impact on human functioning, and it is critical that counselors examine appropriate responses and considerations for therapeutic treatment of female survivors of physical violence resulting from IPV. Clinical considerations should be incorporated into initial screening, therapeutic approaches, and communication with clients.

Screening and Assessment
McLeod, Hays, and Chang (2010) suggested that counselors universally screen clients for a current or past history of IPV. Based on the literature, survivors of IPV face various challenges when seeking services and either reporting or disclosing abuse, including: self-blame for the abuse; fear of the perpetrator; internalized shame; lack of acknowledgement of the level of danger; perception that community services are not helpful; lack of housing, child care, and transportation; access to money; and lack of educational opportunities (Fúgate, Landis, Riordan, Naureckas, & Engel, 2005; Lutenbacher, Cohen, & Mitzel, 2003; McLeod et al., 2010; Scordato, 2013). Minority populations experience additional challenges, including fear of prejudice and systemic oppression (Scordato, 2013). Thus, counselors carry the responsibility to broach screening with all clients. With an intentional screening for IPV, counselors are able to further identify TBI as a result of physical violence in IPV to ascertain medical and related concerns. Given the statistical probability that a woman who experienced physical IPV sustained past injury to the head or neck, initial screening is critical (Murray et al., 2016). The Pennsylvania Coalition Against Domestic Violence (PCADV; 2011) provides a guide based on a classic TBI screening called HELPS. The guide asks questions in the context of IPV, including if the person has ever been: (a) hit on the head, mouth, or other places on the face; (b) pushed so hard the head strikes a hard or firm surface; (c) shaken violently; (d) injured to the head or neck, including strangulation, choking, or suffocating that restricted breathing; and (e) nearly drowned, electrocuted, or intentionally given something allergic. These questions serve as a guide in detecting if the survivor has acquired TBI; however, they should not be used in place of a medical assessment (PCADV, 2011).

The Brain Injury Association of America (2015) describes symptoms of TBI as including: headaches, dizziness, lack of awareness of surroundings, vomiting, lightheadedness, poor attention and concentration, fatigue, and ringing in the ears. Impairments involving functions related to memory, decision making, and processing speed may be indicators of brain injury (Jeter et al., 2013). Recognizing TBI allows for the appropriate response in treatment, including identifying necessary medical consultations and referrals.

Therapeutic Approaches to IPV

After the brain is injured, a recovery process involving three stages is prompted, including: cell repair, functional cell plasticity, and neuroplasticity (Villamar, Santos Portilla, Fregni, & Zafonte, 2012). Zasler, Katz, Zafonte, and Arciniegas (2007) described neuroplasticity as the process in which spared healthy brain regions compensate for the loss of functioning in damaged regions. Kimberley, Samargia, Moore, Shakya, and Lang (2010) suggested that repetition of activities is required to induce neuroplasticity, or recovery of the brain.

Researchers have shown that certain techniques in talk therapy can aid in the recovery of the brain, serving to benefit both the treatment of PTSD as well as the alleviation of symptoms in TBI (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011). For example, Chard et al. (2011) compared two therapies: (a) cognitive processing therapy (CPT), a form of cognitive behavioral therapy effective in treating PTSD; and (b) an alternate version of CPT, CPT-cognitive only (CPT-C), which omits the writing and reading of one’s trauma narrative and instead emphasizes cognitive challenging and rehearsal. Both approaches were applied to a sample of 42 male veterans who met criteria for PTSD, had history of TBI, and were compared across four groups based on severity and treatment approach (Chard et al., 2011). In addition to speech therapy two to three times a week and a psychoeducation group 23 hours a week, CPT-C individual sessions and group sessions were each held twice a week as a part of a residential treatment program (Chard et al., 2011). Chard et al. identified a significant main effect across PTSD and depression measures for both groups, indicating CPT-C as a plausible treatment for clients with TBI.

Another therapeutic approach includes CRATER therapy, which is an acronym that encompasses six targets for therapy: catastrophic reaction, regularization, alliance, triangulation, externalization, and resilience (Block & West, 2013). The first target, catastrophic reaction, is based on targeting the explosive reaction that is in response to overwhelming environmental stimuli; regularization is the therapist’s approach to establishing a regular daily routine for the client (e.g., sleep–wake cycle, meal times); alliance is the relationship between the professional and survivor; triangulate is the relationship expanded beyond the client to include a family member or friend; externalize negates self-blame; and resilience promotes the use of effective coping skills (Block & West, 2013). The individual’s family members and friends are specifically targeted in the approach to account for ecological validity and provide support. Block and West (2013) stated, “CRATER therapy targets the formation of a good working alliance, teaches the survivor to perform skills without cues from the provider and integrates both cognitive and therapy interventions” (p. 777). Overall, this theory infuses cognitive restructuring into individual psychotherapy and assists the client in developing effective coping strategies.

In addition to the implementation of specific therapeutic approaches in counseling, the counselor can incorporate management strategies to accommodate survivors’ brain injury symptoms in counseling sessions. For example, a client who takes longer to complete tasks and answer questions because of an impaired information processing speed can be accommodated by the counselor doing the following: (a) allowing extra time for responses, (b) presenting one thing at a time, and (c) not answering for them during the lapse in response time (BIAV, 2010). The PCADV (2011) also recommends speaking in a clear and literal sense as well as providing tasks in short increments. If memory is impaired, the counselor can make it a point to repeat information as necessary, encourage the use of external memory aids (e.g., journals, calendars), and give reminders and prompts to assist with recall (Block & West, 2013). In the case in which the client shows poor self-monitoring skills and lacks adherence to social rules or consistently dominates the dialogue in sessions, the counselor can provide feedback, encourage turn-taking, and gently provide redirection of behavior (BIAV, 2010). Implementing techniques that involve feedback and redirection also can decrease chances of oversharing that might re-traumatize the survivor (Clark, Classen, Fourt, & Shetty, 2014). Utilizing compensatory strategies such as these can ensure the accessibility and efficacy of counseling sessions to survivors with TBI.

Therapeutic Communication With IPV Clients
Aside from specific counseling approaches and management strategies, several considerations can be made by the counselor to ensure an informed response in communication and chosen interventions. Building a therapeutic relationship, including instilling hope for possible change, is especially useful with complex PTSD diagnoses (Marotta, 2000). Additionally, researchers suggest that receiving social support is a resiliency factor in trauma recovery (Shakespeare-Finch, Rees, & Armstrong, 2015; Zhou, Wu, Li, & Zhen, 2016). However, data suggest that women with brain injury, when compared with male counterparts, experience more negative alterations to social and play behavior, including more exclusion and rejection in social situations (Mychasiuk, Hehar, Farran, & Esser, 2014). Mychasiuk et al. (2014) indicated that group therapy or other social types of interventions related to social support building and safety planning may be contraindicated until these specific challenges can be addressed in individual counseling.

Counselors should be aware of the cyclical nature of abusive relationships that can result in multiple brain injuries over time (Murray et al., 2016). Additionally, counselors should understand complex PTSD, which is associated with prolonged exposure to severe trauma; alterations to affect and impulses, self-perception, interactions with others, and increased somatization; and medical problems (Pill, Day, & Mildred, 2017). Consideration of the potential impact that cumulative brain injuries and prolonged trauma have on health outcomes is critical for effective clinical intervention (Kwako et al., 2011), as myriad aspects of a woman’s ability to identify and understand her situation may be negatively impacted. A critical skill for women in violent relationships includes the need to account for, and effectively assess, one’s physical environment at the time of abuse. A client can take the following precautions to protect herself from future violence: (a) making herself a smaller target by curling up into a ball in a corner, (b) avoiding wearing scarves or necklaces that can be used in strangulation attempts, (c) guarding her head with her arms around each side of her head, and
(d) hiding guns or knives (PCADV, 2011). Furthermore, it is imperative that the counselor actively assist in the safety planning process given that head injury and trauma often impair cognitive processes such as a person’s ability to plan and organize (PCADV, 2011). Initiating the safety planning process as a psychoeducational component of treatment could serve to counter shame and self-blame for the survivor, ensuring that a trauma-informed approach and best practices are maintained (Clark et al., 2014).

Ethical Implications
Client cases that include current or past IPV are often fraught with numerous ethical considerations (McLaughlin, 2017). Perhaps the most pervasive ethical issue is the responsibility of mandated reporting. Counselors must be aware of the intricacies of such responsibility and understand the limits of reporting as it pertains to survivors of IPV (American Counseling Association, 2014). Clinicians should become skilled at assessing for violence in relationships so that reporting can occur if one of the following situations arise: abuse of children, older adults, or other vulnerable populations; duty to warn situations; or risk of suicide. The responsibility to report must be discussed with clients during the informed consent process and throughout treatment (American Counseling Association, 2014, B.1.d).

IPV presents additional complications for treatment providers. Researchers suggest that more than 50% of couples in therapy report at least one incident of physical aggression against their partner (O’Leary, Tintle, & Bromet, 2014). Despite this implication, counselors fail to adequately assess for violence or intervene when violence is present. Once a thorough assessment has taken place, clinicians can evaluate the most appropriate and safe course of treatment for each individual and the couple together. Treatment options include continued couples work (when appropriate), separate individual therapy, or group work that may include anger management or other behavioral-change strategies (Lawson, 2003).

Counselors working with survivors of IPV should expect to regularly determine how to “maximize benefit and minimize harm” for each client (McLaughlin, 2017, p. 45). Counselors may find themselves working with clients who want or need to stay in the relationship or those who want or need to leave the relationship. Each situation is complicated with a variety of personal factors such as level of violent threat and access to financial and other types of resources. Individual assessment in collaboration with the client to determine the best therapeutic strategy is necessary (McLaughlin, 2017).

Finally, counselors may hold overt or covert personal biases toward IPV clients and violence against women. Counselors should evaluate personal feelings toward both victims and perpetrators of IPV prior to working with them and throughout the course of treatment. McLeod et al. (2010) developed a competency checklist for counselors to assist in necessary self-reflection and self-evaluation of their level of competency when working with this population. Finally, counselors should understand the critical nature of supervision and consultation and seek it out when necessary (McLaughlin, 2017).

Case Study

The following case study is a hypothetical case based loosely on the first author’s experience as a counselor in a domestic violence shelter. The case and treatment description are meant to provide a general overview of how counselors might implement an overarching lens of screening and treatment when working with survivors of IPV.

A 48-year-old Caucasian woman sat across from her counselor, elated as she described the sense of relief she felt to finally receive counseling support during what she explained to be the worst time of her life. In disclosing several accounts of physical, sexual, and emotional abuse, she described times in which her ex-partner had blackened her eye, broken bones, and strangled her. Knowing the various causes of TBI in IPV, the counselor started a conversation about the possibility of brain injury. The client denied going to the emergency room to be assessed for injuries, a process that would have likely detected contusions or swelling of brain tissue. The absence of medical treatment was not surprising to the counselor, given the numerous barriers that often leave survivors of IPV without medical attention, including fear of further harm. Knowing this, the counselor was careful in her communication so as to not suggest blame or judgement for the client’s decisions to not seek past medical assistance. The counselor proceeded to ask questions related to whether or not the client perceived any changes to physical or cognitive functioning in comparison to life before her abusive relationship, with focus on memory, attention, and learning experiences. The client found it very difficult to answer these questions in detail, indicating that her memory was potentially impaired because of either PTSD or brain injury. A neutral, yet warm and understanding, therapeutic stance was critical for the counselor to keep the client engaged in the therapeutic process.

Following the detection of probable TBI, the counselor provided psychoeducation to promote awareness on the nature of the injury as well as referrals to various local and state resources. The counselor and client then discussed the client’s experience of PTSD symptoms and how these symptoms could mirror the symptoms of brain injury. Education is a recommended strategy when working with clients with PTSD (Marotta, 2000). The counselor knew that helping the client to differentiate between the two would help her monitor and document symptoms for the journaling homework that would eventually be assigned to her. At this time, the counselor provided the client with a handout with a t-chart comparing PTSD and TBI symptoms, knowing that a concrete, visual representation might be a helpful accommodation. For her journaling homework, the counselor instructed the client to record the following: symptom type, duration, intensity, and any contextual details. This recording would benefit the client in multiple ways, including increasing personal awareness and attention to symptoms, indicating the necessity of additional referral sources, and providing a record for discussion with future medical professionals.

At the beginning of the next several sessions, the counselor followed up on the client’s journaling homework. During these check-ins, the client reported times of forgetfulness, difficulty with attention, and problems staying organized and making decisions. One particular incident allowed the counselor and client to actively probe through differences between PTSD and TBI when the client reported a time in which she “zoned out” while running errands. They explored the event, discussing duration and contextual details. It was in this conversation that the client mentioned a glass item having fallen nearby and shattering loudly just moments before she “zoned out.” From this detail, especially noting the infrequency of her zoning out day-to-day, the counselor discussed the likelihood of it being trauma-related, connecting it to the many nights of domestic disturbances with her abuser that ended in various household items being destroyed. On the other hand, the counselor associated her increased forgetfulness, headaches, and a distorted sense of smell with possible manifestations of brain injury. The counselor recommended that the client call the state’s brain injury association to learn about medical providers who had extensive experience treating TBI.

Noting shattering glass as one of her triggers, the counselor and client discussed what she could do after perceiving this stimulus to reorient to the present. Grounding techniques such as deep breathing were discussed. To address forgetfulness, the counselor implemented compensatory strategies that included shorter responses and questions, utilization of the present time frame, and repetition of responses provided by the counselor. To encourage further assessment and treatment, the counselor followed up on the client’s contact with experienced TBI medical professionals.

Clients may be involved in both individual and group counseling simultaneously. However, group counseling may be contraindicated for women who have experienced a TBI until social and relational challenges can be addressed in individual counseling (Mychasiuk et al., 2014). Therefore, before recommending entry into a counseling group, the counselor first assessed the client’s day-to-day interactions with individuals and how her social network changed before and after sustaining TBI. This assessment allowed the counselor an opportunity to both gauge the appropriateness of group therapy and identify possible barriers to group that might be assisted with accommodation. With careful consideration and assessment, counselors can maximize the use of group therapeutic factors such as interpersonal learning, socializing techniques, and imitative behavior.

Conclusion

PV is a prevalent public health issue that impacts the development of a wide range of mental and physical health diagnoses, in which PTSD and TBI are two pervasive complications that often affect survivors of IPV. Recent initiatives, such as the national briefing hosted by the Congressional Brain Injury Task Force, are indicative of the work still needed to properly address this underrepresented national issue (Brain Injury Association of America, 2017). Counselors should understand the intersectionality of PTSD and TBI and how such experiences can complicate treatment. This article has provided several suggestions for counselors to improve their clinical practice to better accommodate survivors of IPV, including screening and assessment techniques, therapeutic approaches, and communication suggestions. Counselors should be aware of the need to adopt specific therapeutic approaches and strategies in counseling that compensate for cognitive impairments so as to avoid gaps in the delivery of services and adhere to best treatment practices. Counselors also are required to abide by ethical codes and guidelines and are urged to continually seek supervision and consultation when working with this population to ensure that the various aspects of this complicated category of violence are thoroughly considered.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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Trish J. Smith is a resident in counseling and a senior client services advocate at Safe Harbor Shelter in Richmond, Virginia. Courtney M. Holmes, NCC, is an assistant professor at Virginia Commonwealth University. Correspondence can be addressed to Trish Smith, Safe Harbor Shelter, P.O. Box 17996, Richmond, VA 23226, trish@safeharborshelter.com

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