Development of the Psychological Maltreatment Inventory

Alison M. Boughn, Daniel A. DeCino

 

This article introduces the development and implementation of the Psychological Maltreatment Inventory (PMI) assessment with child respondents receiving services because of an open child abuse and/or neglect case in the Midwest (N = 166). Sixteen items were selected based on the literature, subject matter expert refinement, and readability assessments. Results indicate the PMI has high reliability (α = .91). There was no evidence the PMI total score was influenced by demographic characteristics. A positive relationship was discovered between PMI scores and general trauma symptom scores on the Trauma Symptom Checklist for Children Screening Form (TSCC-SF; r = .78, p = .01). Evidence from this study demonstrates the need to refine the PMI for continued use with children. Implications for future research include identification of psychological maltreatment in isolation, further testing and refinement of the PMI, and exploring the potential relationship between psychological maltreatment and suicidal ideation. 

Keywords: psychological maltreatment, child abuse, neglect, assessment, trauma

 

In 2012, the Centers for Disease Control (CDC; 2012) reported that the total cost of child maltreatment (CM) in 2008, including psychological maltreatment (PM), was $124 billion. Fang et al. (2012) estimated the lifetime burden of CM in 2008 was as high as $585 billion. The CDC (2012) characterized CM as rivaling “other high profile public health problems” (para. 1). By 2015, the National Institutes of Health reported the total cost of CM, based on substantiated incidents, was reported to be $428 billion, a 345% increase in just 7 years; the true cost was predictably much higher (Peterson et al., 2018). Using the sensitivity analysis done by Fang et al. (2012), the lifetime burden of CM in 2015 may have been as high as $2 trillion. If these trends continue unabated, the United States could expect a total cost for CM, including PM, of $5.1 trillion by 2030, with a total lifetime cost of $24 trillion. More concerning, this increase would not account for any impact from the COVID-19 pandemic.

Mental health first responders and child protection professionals may encounter PM regularly in their careers (Klika & Conte, 2017; U.S. Department of Health and Human Services [DHHS], 2018). PM experiences are defined as inappropriate emotional and psychological acts (e.g., excessive yelling, threatening language or behavior) and/or lack of appropriate acts (e.g., saying I love you) used by perpetrators of abuse and neglect to gain organizational control of their victims (American Professional Society on the Abuse of Children [APSAC], 2019; Klika & Conte, 2017; Slep et al., 2015). Victims may experience negative societal perceptions (i.e., stigma), fear of retribution from caregivers or guardians, or misdiagnosis by professional helpers (Iwaniec, 2006; López et al., 2015). They often face adverse consequences that last their entire lifetime (Spinazzola et al., 2014; Tyrka et al., 2013; Vachon et al., 2015; van der Kolk, 2014; van Harmelen et al., 2010; Zimmerman & Mercy, 2010). PM can be difficult to identify because it leaves no readily visible trace of injury (e.g., bruises, cuts, or broken bones), making it complicated to substantiate that a crime has occurred (Ahern et al., 2014; López et al., 2015). Retrospective data outlines evaluation processes for PM identification in adulthood; however, childhood PM lacks a single definition and remains difficult to assess (Tonmyr et al., 2011). These complexities in identifying PM in children may prevent mental health professionals from intervening early, providing crucial care, and referring victims for psychological health services (Marshall, 2012; Spinazzola et al., 2014). The Psychological Maltreatment Inventory (PMI) is the first instrument of its kind to address these deficits.

Child Psychological Maltreatment
     Although broadly conceptualized, child PM experiences are described as literal acts, events, or experiences that create current or future symptoms that can affect a victim without immediate physical evidence (López et al., 2015). Others have extended child PM to include continued patterns of severe events that impede a child from securing basic psychological needs and convey to the child that they are worthless, flawed, or unwanted (APSAC, 2019). Unfortunately, these broad concepts lack the specificity to guide legal and mental health interventions (Ahern et al., 2014). Furthermore, legal definitions of child PM vary from jurisdiction to jurisdiction and state to state (Spinazzola et al., 2014). The lack of consistent definitions and quantifiable measures of child PM may create barriers for prosecutors and other helping professionals within the legal system as well as a limited understanding of PM in evidence-based research (American Psychiatric Association [APA], 2013; APSAC, 2019; Klika & Conte, 2017). These challenges are exacerbated by comorbidity with other forms of maltreatment.

Co-Occurring Forms of Maltreatment
     According to DHHS (2018), child PM is rarely documented as occurring in isolation compared to other forms of maltreatment (i.e., physical abuse, sexual abuse, or neglect). Rather, researchers have found PM typically coexists with other forms of maltreatment (DHHS, 2018; Iwaniec, 2006; Marshall, 2012). Klika and Conte (2017) reported that perpetrators who use physical abuse, inappropriate language, and isolation facilitate conditions for PM to coexist with other forms of abuse. Van Harmelen et al. (2011) argued that neglectful acts constitute evidence of PM (e.g., seclusion; withholding medical attention; denying or limiting food, water, shelter, and other basic needs).

Consequences of PM Experienced in Childhood
     Mills et al. (2013) and Greenfield and Marks (2010) noted PM experiences in early childhood might manifest in physical growth delays and require access to long-term care throughout a victim’s lifetime. Children who have experienced PM may suffer from behaviors that delay or prevent meeting developmental milestones, achieving academic success in school, engaging in healthy peer relationships, maintaining physical health and well-being, forming appropriate sexual relationships as adults, and enjoying satisfying daily living experiences (Glaser, 2002; Maguire et al., 2015). Neurological and cognitive effects of PM in childhood impact children as they transition into adulthood, including abnormalities in the amygdala and hippocampus (Tyrka at al., 2013). Brown et al. (2019) found that adults who reported experiences of CM had higher rates of negative responses to everyday stress, a larger constellation of unproductive coping skills, and earlier mortality rates (Brown et al., 2019; Felitti et al., 1998). Furthermore, adults with childhood PM experiences reported higher rates of substance abuse than those compared to control groups (Felitti et al., 1998).

     Trauma-Related Symptomology. Researchers speculate that children exposed to maltreatment and crises, especially those that come without warning, are at greater risk for developing a host of trauma-related symptoms (Spinazzola et al., 2014). Developmentally, children lack the ability to process and contextualize their lived experiences. Van Harmelen et al. (2010) discovered that adults who experienced child PM had decreased prefrontal cortex mass compared to those without evidence of PM. Similarly, Field et al. (2017) found those unable to process traumatic events produced higher levels of stress hormones (i.e., cortisol, epinephrine, norepinephrine); these hormones are produced from the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) regions in the brain. Some researchers speculate that elevated levels of certain hormones and hyperactive regions within the brain signal the body’s biological attempt to reduce the negative impact of PM through the fight-flight-freeze response (Porges, 2011; van der Kolk, 2014).

Purpose of Present Study
     At the time of this research, there were few formal measures using child self-report to assess how children experience PM. We developed the PMI as an initial quantifiable measure of child PM for children and adolescents between the ages of 8 and 17, as modeled by Tonmyr and colleagues (2011). The PMI was developed in multiple stages, including 1) a review of the literature, 2) a content validity survey with subject matter experts (SMEs), 3) a pilot study (N = 21), and 4) a large sample study (N = 166). An additional instrument, the Trauma Symptom Checklist for Children Screening Form (TSCC-SF; Briere & Wherry, 2016), was utilized in conjunction with the PMI to explore occurrences of general trauma symptoms among respondents. The following four research questions were investigated:

  1. How do respondent demographics relate to PM?
  2. What is the rate of PM experience with respondents who are presently involved in an open CM case?
  3. What is the co-occurrence of PM among various forms of CM allegations?
  4. What is the relationship between the frequency of reported PM experiences and the frequency of general trauma symptoms?

Method

Study 1: PMI Item Development and Pilot
     Following the steps of scale construction (Heppner et al., 2016), the initial version of the PMI used current literature and definitions from facilities nationwide that provide care for children who have experienced maltreatment and who are engaged with court systems, mental health agencies, or social services. Our lead researcher, Alison M. Boughn, developed a list of 20 items using category identifications from Glaser (2002) and APSAC (2019). Items were also created using Slep et al.’s (2015) proposed inclusion language for the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic codes and codes from the International Classification of Diseases, 11th edition (ICD-11) definition criteria (APA, 2013). Both Boughn and Daniel A. DeCino, our other researcher, reviewed items for consistency with the research literature and removed four redundant items. The final 16 items were reevaluated for readability for future child respondents using a web-based, age range–appropriate readability checker (Readable, n.d.) and were then presented to local SMEs in a content validity survey to determine which would be considered essential for children to report as part of a child PM assessment.

Expert Validation
     A multidisciplinary team (MDT) serving as SMEs completed an online content validity survey created by Boughn. The survey was distributed by a Child Advocacy Center (CAC) manager to the MDT. Boughn used the survey results to validate the PMI’s item content relevance. Twenty respondents from the following professions completed the survey: mental health (n = 6), social services (n = 6), law enforcement (n = 3), and legal services (n = 5). The content validity ratio (CVR) was then calculated for the 16 proposed items.

     Results. The content validity survey scale used a 3-point Likert-type scale: 0 = not necessary; 1 = useful, but not essential; and 2 = essential. A minimum of 15 of the 20 SMEs (75% of the sample), or a CVR ≥ .5, was required to deem an item essential (Lawshe, 1975). The significance level for each item’s content validity was set at α = .05 (Ayre & Scally, 2014). After conducting Lawshe’s (1975) CVR and applying the ratio correction developed by Ayre and Scally (2014), it was determined that eight items were essential: Item 2 (CVR = .7), Item 3 (CVR = .9), Item 4 (CVR = .6), Item 6 (CVR = .6), Item 7 (CVR = .8), Item 10 (CVR = .6), Item 15 (CVR = .5), and Item 16 (CVR = .6).

Upon further evaluation, and in an effort to ensure that the PMI items served the needs of interdisciplinary professionals, some items were rated essential for specific professions; these items still met the CVR requirements (CVR = 1) for the smaller within-group sample. These four items were unanimously endorsed by SMEs for a particular profession as essential: Item 5 (CVR Social Services = 1; CVR Law Enforcement = 1), Item 11 (CVR Law Enforcement = 1), Item 13 (CVR Law Enforcement = 1), and Item 14 (CVR Law Enforcement = 1).

Finally, an evaluation of the remaining four items was completed to explore if items were useful, but not essential. Using the minimum CVR ≥ .5, it was determined that these items should remain on the PMI: Item 1 (CVR = .9), Item 8 (CVR = .8), Item 9 (CVR = .9), and Item 12 (CVR = .9). The use of Siegle’s (2017) Reliability Calculator determined the Cronbach’s α level for the PMI to be 0.83, indicating adequate internal consistency. Additionally, a split-half (odd-even) correlation was completed with the Spearman-Brown adjustment of 0.88, indicating high reliability (Siegle, 2017).

Pilot Summary
     The focus of the pilot study was to ensure effective implementation of the proposed research protocol following each respondent’s appointment at the CAC research site. The pilot was implemented to ensure research procedures did not interfere with typical appointments and standard procedures at the CAC. Participation in the PMI pilot was voluntary and no compensation was provided for respondents.

     Sample. The study used a purposeful sample of children at a local, nationally accredited CAC in the Midwest; both the child and the child’s legal guardian agreed to participate. Because of the expected integration of PM with other forms of abuse, this population was selected to help create an understanding of how PM is experienced specifically with co-occurring cases of maltreatment. Respondents were children who (a) had an open CM case with social services and/or law enforcement, (b) were scheduled for an appointment at the CAC, and (c) were between the ages of 8 and 17.

     Measures. The two measures implemented in this study were the developing PMI and the TSCC-SF. At the time of data collection, CAC staff implemented the TSCC-SF as a screening tool for referral services during CAC victim appointments. To ensure the research process did not interfere with chain-of-custody procedures, collected investigative testimony, or physical evidence that was obtained, the PMI was administered only after all normally scheduled CAC procedures were followed during appointments.

     PMI. The current version of the PMI is a self-report measure that consists of 16 items on a 4-point Likert-type scale that mirrors the language of the TSCC-SF (0 = never to 3 = almost all the time). Respondents typically needed 5 minutes complete the PMI. Sample items from the PMI included questions like: “How often have you been told or made to feel like you are not important or unlovable?” The full instrument is not provided for use in this publication to ensure the PMI is not misused, as refinement of the PMI is still in progress.

     TSCC-SF. In addition to the PMI, Boughn gathered data from the TSCC-SF (Briere & Wherry, 2016) because of its widespread use among clinicians to efficiently assess for sexual concerns, suicidal ideation frequency, and general trauma symptoms such as post-traumatic stress, depression, anger, disassociation, and anxiety (Wherry et al., 2013). The TSCC-SF measures a respondent’s frequency of perceived experiences and has been successfully implemented with children as young as 8 years old (Briere, 1996). The 20-item form uses a 4-point Likert-type scale (0 = never to 3 = almost all the time) composed of general trauma and sexual concerns subscales. The TSCC-SF has demonstrated high internal consistency and alpha values in the good to excellent ranges; it also has high intercorrelations between sexual concerns and other general trauma scales (Wherry & Dunlop, 2018).

     Procedures. Respondents were recruited during their scheduled CAC appointment time. Each investigating agency (law enforcement or social services) scheduled a CAC appointment in accordance with an open maltreatment case. At the beginning of each respondent’s appointment, Boughn provided them with an introduction and description of the study. This included the IRB approvals from the hospital and university, an explanation of the informed consent and protected health information (PHI) authorization, and assent forms. Respondents aged 12 and older were asked to read and review the informed consent document with their legal guardian; respondents aged from 8 to 11 were provided an additional assent document to read. Respondents were informed they could stop the study at any time. After each respondent and legal guardian consented, respondents proceeded with their CAC appointment.

Typical CAC appointments consisted of a forensic interview, at times a medical exam, and administration of the TSCC-SF to determine referral needs. After these steps were completed, Boughn administered the PMI to those who agreed to participate in this research study. Following the completion of the TSCC-SF, respondents were verbally reminded of the study and asked if they were still willing to participate by completing the PMI. Willing respondents completed the PMI; afterward, Boughn asked respondents if they were comfortable leaving the assessment room. In the event the respondent voiced additional concerns of maltreatment during the PMI administration, Boughn made a direct report to the respondent’s investigator (i.e., law enforcement officer or social worker assigned to the respondent’s case).

Boughn accessed each respondent’s completed TSCC-SF from their electronic health record in accordance with the PHI authorization and consent after the respondent’s appointment. Data completed on the TSCC-SF allowed Boughn to gather information related to sexual concerns, suicidal ideation, and trauma symptomology. Data gathered from the TSCC-SF were examined with each respondent’s PMI responses.

     Results. Respondents were 21 children (15 female, six male) with age ranges from 8 to 17 years with a median age of 12 years. Respondents described themselves as White (47.6%), Biracial (14.2%), Multiracial (14.2%), American Indian/Alaskan Native (10.0%), Black (10.0%), and Hispanic/Latino (5.0%). CM allegations for the respondents consisted of allegations of sexual abuse (86.0%), physical abuse (10.0%), and neglect (5.0%).

Every respondent’s responses were included in the analyses to ensure all maltreatment situations were considered. The reliability of the PMI observed in the pilot sample (N = 21) demonstrated high internal consistency with all 16 initial items (α = .88). The average total score on the PMI in the pilot was 13.29, with respondents’ scores ranging from 1 to 30. A Pearson correlation indicated total scores for the PMI and General Trauma Scale scores (reported on the TSCC-SF) were significantly correlated (r = .517, p < .05).

Study 2: Full Testing of the PMI
     The next phase of research proceeded with the collection of a larger data sample (N = 166) to explore the item construct validity and internal reliability (Siyez et al., 2020). Study procedures, data collection, and data storage followed in the pilot study were also implemented with the larger sample. Boughn maintained tracking of respondents who did not want to participate in the study or were unable to because of cognitive functioning level, emergency situations, and emotional dysregulation concerns.

Sample
     Based on a power analysis performed using the Raosoft (2004) sample size calculator, the large sample study required a minimum of 166 respondents for statistical significance (Ali, 2012; Heppner et al., 2016). The sample size was expected to account for a 10% margin of error and a 99% confidence level. The calculation of a 99% confidence interval was used to ensure the number of respondents could effectively represent the population accessed within the CAC based on the data from the CM Report (DHHS, 2018). Large sample population data was gathered between September 2018 and May 2019.

Measures
     The PMI and TSCC-SF were also employed in Study 2 because of their successful implementation in the pilot. Administration of the TSCC-SF ensured a normed and standardized measure could aid in providing context to the information gathered on the PMI. No changes were made to the PMI or TSCC-SF measures following the review of procedures and analyses in the pilot.

Procedures
     Recruitment and data collection/analyses processes mirrored that of the pilot study. Voluntary respondents were recruited at the CAC during their scheduled appointments. Respondents completed an informed consent, child assent, PHI authorization form, TSCC-SF, and PMI. Following the completion of data collection, Boughn completed data entry in the electronic health record to de-identify and analyze the results.

Results

Demographics
     All data were analyzed using Statistical Package for the Social Sciences version 24 (SPSS-24). Initial data evaluation consisted of exploration of descriptive statistics, including demographic and criteria-based information related to respondents’ identities and case details. Respondents were between 8 to 17 years of age (M = 12.39) and primarily female (73.5%, n = 122), followed by male (25.3%, n = 42). Additionally, two respondents (n = 2) reported both male and female gender identities. Racial identities were marked by two categories: White (59.6%, n = 99) and Racially Diverse (40.4%, n = 67) respondents. The presenting maltreatment concerns and the child’s relationship to the offender are outlined in Table 1 and Table 2, respectively.

Reliability and Validity of the PMI
     The reliability of the PMI observed in its implementation in Study 2 (N = 166) showed even better internal consistency with all 16 initial items (α =.91) than observed in the pilot. Using the Spearman-Brown adjustment (Warner, 2013), split-half reliability was calculated, indicating high internal reliability (.92). Internal consistencies were calculated using gender identity and age demographic variables (see Table 3).

 

Table 1

Child Maltreatment Allegation by Type (N = 166)

Allegation f Rel f cf %
Sexual Abuse 113 0.68 166 68.07
Physical Abuse  29 0.17 53 17.47
Neglect  14 0.08 24   8.43
Multiple Allegations    6 0.04 10   3.61
Witness to Violence    3 0.02   4   1.81
Kidnapping    1 0.01   1   0.60

Note. Allegation type reported at initial appointment scheduling

 

Table 2

Identified Offender by Relationship to Victim (N = 166)

Offender Relationship f Rel f cf %
Other Known Adult 60 0.36 166 36.14
Parent 48 0.29 106 28.92
Other Known Child (≤ age 15 years) 15 0.09  58   9.04
Sibling-Child (≤ age 15 years) 10 0.06  43   6.02
Unknown Adult   9 0.05  33     5.42
Step-Parent   8 0.05  24   4.82
Multiple Offenders   6 0.04  16   3.61
Grandparent   6 0.04  10   3.61
Sibling-Adult (≥ age 16 years)   3 0.02   4   1.81
Unknown Child (≤ age 15 years)   1 0.01   1   0.60

Note. Respondent knew the offender (n =156); Respondent did not know offender (n =10)

 

Table 3

Internal Consistency Coefficients (α) by Gender Identity and Age (N = 166)

Gender n α M SD
 Female 122 0.90 13.2   9.1
 Male   42 0.94 13.5 11.0
 Male–Female    2 0.26   8.5  2.5
Age
 8–12 83 0.92 12.75 10.06
 13–17 83 0.90 13.69   9.01

Note. SD = Standard Deviation; M = Mean

 

Respondents Demographic Characteristics and PM Experiences
For Research Question (RQ) 1 and RQ2, descriptive data were used to generate frequencies and determine the impact of demographic characteristics on average PMI score. To explore this further in RQ1, one-way ANOVAs were completed for the variables of age, gender, racial identity, allegation type, and offender relationships. No significant correlations were found between demographic variables and the PMI items. On average, respondents reported a frequency score of 13.5 (M = 13.5, SD = 9.5) on the PMI. Eight respondents (5%) endorsed no frequency of PM while 95% (N = 158) experienced PM.

Co-Occurrence of PM With Other Forms of Maltreatment
     For RQ3, frequency and descriptive data were generated, revealing average age rates of PM reported by maltreatment type. Varying sample representations were discovered in each form of maltreatment (see Table 4). Clear evidence was found that PM co-occurs with each form of maltreatment type; however, how each form of maltreatment interacts with PM is currently unclear given the multiple dimensions of each maltreatment case including, but not limited to, severity, frequency, offender, and victim characteristics.

 

Table 4

Descriptive and Frequency Data for Co-Occurrence of PM (N = 166)

Allegation n M SD 95% CI
Sexual Abuse 113 13.04   9.01 [11.37, 14.72]
Physical Abuse   29 12.45 10.53   [8.44, 16.45]
Neglect   14 14.57 12.16   [7.55, 21.60]
Multiple Allegations    5 17.40   8.88   [6.38, 28.42]
Witness to Violence    3   7.67   5.03  [–4.84, 20.17]
Kidnapping    1 n/a n/a Missing

Note. CI = Confidence Interval; SD = Standard Deviation; M = Mean; n/a = not applicable

 

PM Frequency and General Trauma Symptoms
     For RQ4, Pearson’s correlation was used to calculate frequency score relationships between the PMI and TSCC-SF. There was a statistically significant relationship between the PMI and total frequency of general trauma symptoms on the TSCC-SF [r(164) = .78, p < .01, r² = .61] (Sullivan & Feinn, 2012). Cohen’s d, calculated from the means for each item as well as the pooled standard deviation, indicated a small effect relationship (d = .15) between general trauma and PMI frequencies (see Figure 1).

 

Figure 1

Correlation Between PMI and TSCC-SF General Trauma Subscale

Note. Scores were endorsed by respondents’ self-reports.

 

Child Suicidal Ideation Reports and the PMI
     Following a review of the findings of Thompson et al. (2005) and Wherry et al. (2013) that children who reported experiencing CM also experienced suicidal ideation, Boughn performed an additional two-way ANOVA that examined the effect of suicidal ideation on the PMI total score. A significant relationship—F(1, 164) = 49.52, p < .01, η2 = .23—between respondents’ PMI scores and thoughts of suicide was found. Respondents who did not report thoughts of suicide (59.0%, n = 98) indicated lower rates of PM (M = 9.37, SD = 7.97) compared to children who did report thoughts of suicide (41.0%, n = 68, M = 18.77, SD = 9.12). A preliminary review of this finding demonstrates the severity of PM’s impact on child victims.

Discussion

This study was designed with the aim of developing a tool to support accurate identification of PM among children and adolescents. Findings from its first large-scale implementation provide a foundational view to the occurrence of PM in terms of demographic characteristics, comorbidity of PM with other forms of abuse, and the relationship between PM and trauma. The analyses yielded both expected and unexpected results based on the extant research.

PM and Demographic Characteristics
Race
     There was no significant effect when exploring the data related to racial demographics and PM. The respondent sample closely reflected the geographical area’s known racial demographics at the time of the study, reflecting a population approaching 80% White with residents of all other known races below 5% for each racial group (U.S. Census Bureau, 2020). Although researchers (Dakil et al., 2011) anticipated children identifying as racial minorities would be included in the representation of CM reports, evidence from this study potentially reveals a greater than expected gap in reporting for minority-race populations (Bernard & Harris, 2018; Font & Maguire-Jack, 2015). This suggests that there may be additional, unidentified barriers influencing the reporting of maltreatment among minority-race populations.

Gender
     A lack of gender identity representation was evident in the data, consistent with prior research (Sivagurunathan et al., 2019). Respondents who self-identified with both male and female gender identities (1.2%) and as male (25.3%) were represented less frequently compared to female respondents (73.5%). This is not inherently a limitation of this study, as research shows that just 10% of males in the United States report their sexual abuse (Sivagurunathan et al., 2019). People who identify as male may face harmful cultural messages that enhance negative stigma for victims of abuse, causing increased feelings of weakness or vulnerability (Alaggia & Mishna, 2014). This finding may support claims that male trauma survivors feel stigmatized and report their experiences less frequently (Easton, 2012).

Additionally, children who identify outside traditional gender binary norms and definitions need more access to inclusive representation on screening assessments. Assessments like the TSCC-SF may be using antiquated gender- or biological sex–normed checkboxes, which leave certain groups underrepresented in research studies (Neukrug & Fawcett, 2015). These practices may present inaccurate findings, inadvertently reinforce discriminatory expectations, and generate inaccurate referrals. Non-binary youth encounter barriers that may compound their ability to effectively access supports in their daily life related to coming out, social violence, lack of peer and/or adult acceptance, discrimination, isolation, higher rates of suicide, and lack of representation in mainstream society (Bialer & McIntosh, 2016; Zimman, 2009). In this study, representation of non-binary respondents, specifically those who reported both male and female gender identities, was reported; this warrants further exploration to assess barriers among non-binary gender youth and their experiences with child PM (Bos et al., 2019).

Offender Relationships
     Frequency data for a child’s relationship with the offender were not found to be significant either for known offenders (M = 13.35) or unknown offenders (M = 11.2). In this study, 94% of the respondents already knew their offender (n = 156). This finding is consistent with previous research that has found that although child abduction and stranger danger are real phenomena, children are more likely to experience CM as a result of relationships with familiar individuals (Walsh & Brandon, 2011).

Co-Occurrence of PM With Other Abuse
     Only eight respondents (5%) endorsed no frequency of PM; the average total PM frequency rate for respondents in this study was 13.5 out of a possible 48, indicating extreme severity. In this study, we found evidence that PM is a co-occurring experience for children with open maltreatment cases, yet clinicians still lack formal, valid assessments to determine PM alone. Our findings support the National Children’s Alliance’s (NCA; 2016) call for clinicians to follow practice guidelines in accordance with state and national guidelines as they relate to mandatory reporting of CM concerns and determination of whether PM plus other forms of maltreatment may be present for child victims seeking services.

Comorbidity of PM and Trauma
     PM-related experiences on the PMI and general trauma symptoms from the TSCC-SF warrant discussion. The PMI illustrated a significant relationship with the TSCC-SF general trauma subscale (Briere & Wherry, 2016). More than half (61%) of the variance on the PMI was connected to general trauma symptoms, suggesting that higher rates of PM experiences may increase trauma-related symptoms. For example, previous researchers have found adverse childhood experiences and signs of trauma-related symptoms lead to serious mental health diagnoses, early mortality, and/or significant biological health risks in children (Tyrka et al., 2013; Vachon et al., 2015; Zimmerman & Mercy, 2010). Further exploration to determine if and how PM influences other trauma-related symptoms in children throughout their life span would expand upon the results of this study.

Suicidal Ideation
     Finally, our data revealed a significant effect between respondent endorsement of suicidal ideation and PMI total scores. PM experiences accounted for 23% of the variance for children who reported thoughts of suicide (41%, n = 68) compared to those who did not report thoughts of suicide (59%, n = 98). This finding is consistent with prior research exploring children’s experiences with maltreatment and suicidal thoughts (Thompson et al., 2005; Wherry et al., 2013).

Limitations
     This study has several limitations. First, by developing the PMI using national definitions, some regional and localized nuances were not considered. Second, data collected for this study were from a single Midwest CAC; thus, the data are limited in geographic generalizability. Third, the majority of respondents were White, and a more diverse sample would have been more representative of the region in which data were collected. Fourth, 99% of respondents identified as either male or female and may reflect an underrepresentation of non-binary or gender fluid youth in the results of this study. Fifth, this study relied heavily on quantitative data, which limited the ability to analyze each individual’s experiences with PM as they might describe from their unique perspectives.

Implications for Research and Practice
     The results of this study provide several areas for future research. While the PMI demonstrated good internal consistency across all items (α =.91), more research with diverse populations across the United States is needed. Research from other geographical locations may demonstrate how reporting patterns for PM interact with ethnicity, culture, and elements of social expectations (Spinazzola et al., 2014).

The initial results of this study indicate the PMI may be a useful tool for children to report PM experiences in CAC settings; however, future research at other CACs and similar treatment facilities is needed to determine the PMI’s true utility and scalability. Future analysis (i.e., exploratory factor analysis and confirmatory factor analysis) of the PMI may also identify factors and help refine the instrument.

More research with the PMI can expand researchers’ knowledge of PM and services needed to help children. Working with other CACs, child protection professionals, and the NCA may help bridge current gaps in interdisciplinary assessment and care and establish a stable and comprehensive understanding of PM (López et al., 2015). Furthermore, understanding how CACs are equipped to identify and handle PM cases may provide useful insights to help improve services for children in need. Although some CACs may have a variety of professionals working in specific roles, some CACs may be understaffed, causing staff to take on multiple and overlapping roles. It is important to understand if and how different combinations of trained professionals influence children reporting PM (Hart & Glaser, 2011; NCA, 2016).

More research with the PMI is needed for refinement and to ensure the instrument is not misused. Releasing the PMI at this stage to clinicians and researchers without a fully developed assessment manual may lead to inappropriate or ineffective administration of the PMI and potentially unethical practice that could place children at risk. Future research and refinement of the PMI may provide clinicians and researchers a reliable and valid tool that is grounded in consistent theory and practice.

Conclusion

The PMI was developed to assess child PM and offers researchers and clinicians useful findings. In supporting research (Arslan, 2017; Bernstein et al., 2013; Raparia et al., 2016), child PM is a serious and often harmful combination of experiences that requires professional intervention (APSAC, 2019). For children reporting PM experiences, the PMI may help mental health and other care providers determine which services are needed. Findings from this study suggest differences in demographic variables are minimal for PM. Overall PMI scores were correlated to the general trauma subscale on the TSCC-SF, and the PMI revealed higher rates of PM for children experiencing suicidal ideation. The findings are the beginning of a measure designed to illustrate the depth and frequency of PM for children. With the PMI, early PM intervention becomes possible for a once invisible form of maltreatment.

Conflict of Interest and Funding Disclosure
Data collected and content shared in this study
were part of a dissertation study, which was
awarded the 2020 Dissertation Excellence Award
by the National Board for Certified Counselors.
The Psychological Maltreatment Inventory (PMI)
items were not released in this publication to protect
victims of child maltreatment and to ensure future
publications can address comprehensive revisions
made to the PMI.

 

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Alison M. Boughn, PhD, NCC, LIMHP (NE), LMHC (IA), LPC-MH (SD), ATR-BC, QMHP, TF-CBT, is an assistant professor and counseling department chair at Wayne State College. Daniel A. DeCino, PhD, NCC, LPC, is an assistant professor and Interim Program Coordinator at the University of South Dakota. Correspondence may be addressed to Alison M. Boughn, Wayne State College, 1111 Main Street, Wayne, NE 68787, albough1@wsc.edu.

A Comprehensive Perspective on Treating Victims of Human Trafficking

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.