Spotlight (2015) Movie Analysis

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=wwat20

Women & Therapy

ISSN: 0270-3149 (Print) 1541-0315 (Online) Journal homepage: https://www.tandfonline.com/loi/wwat20

Psychotherapy in the Aftermath of Human Trafficking: Working Through the Consequences of Psychological Coercion

Paola Michelle Contreras, Diya Kallivayalil & Judith Lewis Herman

To cite this article: Paola Michelle Contreras, Diya Kallivayalil & Judith Lewis Herman (2017) Psychotherapy in the Aftermath of Human Trafficking: Working Through the Consequences of Psychological Coercion, Women & Therapy, 40:1-2, 31-54, DOI: 10.1080/02703149.2016.1205908

To link to this article: https://doi.org/10.1080/02703149.2016.1205908

Published online: 03 Oct 2016.

Submit your article to this journal

Article views: 2620

View related articles

View Crossmark data

Citing articles: 7 View citing articles

WOMEN & THERAPY 2017, VOL. 40, NOS. 1–2, 31–54 http://dx.doi.org/10.1080/02703149.2016.1205908

Psychotherapy in the Aftermath of Human Trafficking: Working Through the Consequences of Psychological Coercion Paola Michelle Contrerasa,b,c, Diya Kallivayalila,b, and Judith Lewis Hermana

aHarvard Medical School, Cambridge, Massachusetts; bCambridge Health Alliance, Cambridge, Massachusetts; cCounseling Department, William James College, Newton, Massachusetts

ABSTRACT Shame and mistrust are factors that complicate a trafficking survivor’s readiness to benefit from services offered by multi- disciplinary providers. Shame is understood as one of the consequences of the trafficker’s coercion. Experiences of coercion and resulting shame later complicate trust building with psychotherapists. Through case studies of psychotherapy work in a public hospital, the authors describe how trust and shame issues are worked through. The psychotherapist facilitates the survivor’s work towards restoring a sense of humanity and dignity.

KEYWORDS Exploitation; human trafficking; psychological coercion; psychotherapy; sex trafficking; shame; slavery; trauma; trust

Human trafficking is a human rights violation and crime committed by a trafficker who exploits another person through the use of force, coercion, or deception, or a combination of these methods (Trafficking Victims Protection Act of 2000, 2000; United Nations, 2000). The U.S. Congress enacted the TVPA in 2000 to prevent trafficking, protect victims,1 and prosecute traffickers. In the first years after passage of the TVPA, prosecutions were the central focus (Haynes, 2004). However, growing difficulties in identifying victims of trafficking (Jahic & Finckenauer, 2005) and persuading survivors to collaborate with prosecutions (Hepburn & Simon, 2010) resulted in increased attention to victim-centered issues in each TVPA reauthorization (Pollock & Hollier, 2010; United States Department of Justice, Civil Rights Division, 2010).

Despite increased public awareness of human trafficking, providing health services to survivors still presents significant challenges (Busch-Armendariz, Busch Nsonwu, & Heffron, 2014; Macy & Graham, 2012; Shigekane, 2007). The relational consequences stemming from the trafficker’s use of psycho- logical coercion cause invisible harms (Farley, 2003; Kim, 2011) that keep trafficked persons “hidden in plain sight” (Herman, 2003).

A comprehensive approach to work with survivors of trafficking is one that combines ecological (Harvey, 1996) and relational psychotherapies (Tummala- Narra, Kallivayalil, Singer, & Andreini, 2012), along with evidence-based

CONTACT Paola Michelle Contreras [email protected] One Wells Avenue Newton, MA 02459, USA; Diya Kallivayalil [email protected] 1493 Cambridge Street Cambridge, MA 02139, USA. © 2017 Taylor & Francis Group, LLC

treatments adapted to address mental health symptoms associated with traf- ficking (Hossain, Zimmerman, Abas, Light, & Watts, 2010). Psychotherapy can help the survivor reduce symptoms, and concurrently overcome feelings of shame and reclaim the basic trust lost on account of the abuses perpetrated by the trafficker (Herman, 2011). To conceptualize our approach, this paper will review (a) the psychological experiences of trafficked people; (b) the rela- tional consequences of human trafficking; and (c) clinical vignettes of our work with trafficked women at the Cambridge Health Alliance.2

The Experiences of Trafficked Women and Girls

In order to treat the relational consequences of human trafficking, first it is necessary to understand the dynamics that characterize human trafficking (Farley, 2004; Leidholdt, 2013; Raymond et al., 2002).

How are people trafficked? The typical human trafficking narrative portrayed in the media (Baker, 2014; Denton, 2010) and case law (Srikantiah, 2007) is extreme and not representative of the diversity of trafficking experi- ences. For instance, Srikantiah’s iconic victim is always a woman. Human trafficking is gendered when it is attributed to vulnerabilities construed and stereotyped as inherent female traits (e.g., passive, weak, gullible), rather than as a crime that stems from the chronic marginalization of women and other vulnerable groups. In consequence, men and transgender persons trafficked into the sex industry and for other forms of labor are made especially invisible (Denton, 2010). It also becomes more difficult to identify female human trafficking offenders because they are automatically assumed to be victims (Demir & Finckenauer, 2010).

Srikantiah’s (2007) female iconic victim is abducted, beaten into sub- mission and then locked away and exploited. She is trafficked for sexual exploitation (rather than for domestic servitude or other forms of labor); she is a “good” witness who cooperates with law enforcement; and she does not escape trafficking on her own but is rescued by others. She is one who is worthy of relief and support. In clinical settings, however, the narrative is different. Survivors report perpetrations that typically involved high levels of psychological coercion, which is more difficult to identify than the physical violence emphasized in the literature.

Vulnerabilities Converging complex experiences that unfold over the lifespan contribute to the trafficking of vulnerable people (Reid, 2012). Individual experiences, such as childhood sexual abuse, are a central risk factor for later vulnerability to sex trafficking (Brannigan & van Brunschot, 1997; Macías Konstantopoulos et al., 2013; Silbert & Pines, 1981; Widom & Kuhns, 1996). Other individual experi- ences include family participation in the sale of their children to traffickers

32 P. M. CONTRERAS ET AL.

(Falb et al., 2011; Itzen, 1997; McCauley, Decker, & Silverman, 2010), and pressure to support the family economically (see, for example, Acharya, 2008; Bales, David, Datta, & Grono, 2013; Clawson, Salomon, & Goldblatt Grace, 2008; Schauer & Wheaton, 2006). Societal attitudes that affect an indi- vidual’s self esteem, such as the cultural objectification of women and girls (Cacho, 2014; Farr, 2005; Gozdziak & Bump, 2007; Macías Konstantopoulos et al., 2013) also contribute to sex trafficking. Finally, the demand from sex buyers for trafficked persons—commonly for women and girls—is a powerful and often overlooked contributor to the proliferation of sex trafficking (Ali, 2009; Farley, MacLeod, Anderson, & Golding, 2011; Hunt, 2013).

Stressors such as poverty and lack of economic opportunity compound indi- vidual vulnerabilities (Jac-Kucharski, 2012). For international victims of traf- ficking, civil unrest and political uncertainty in the country of origin may render people vulnerable to a trafficker’s ruse (Jac-Kucharski, 2012; Raymond et al., 2002). Contextual stressors such as localities with high rates of organized crime, patriarchy, and pimping culture increase violence against women, including human trafficking (Reid, 2012). For instance, Lydia Cacho (2014) describes the Mexican “macho codes” that objectify women. She notes that even women who participate in criminal organizations develop misogynist attitudes.

A finding consistently present across studies on sex trafficking is that most victims were at a disadvantage on account of contextual stressors, adverse and traumatic experiences such as sexual abuse, individual vulnerabil- ities, or a combination of all of these. These disadvantages may leave people with no choice other than to accept a trafficker’s offer to prostitute (Castillo, 2012). Some survivors of sex trafficking describe it as, “The choice made by those who have no choice” (Farley, 2006, p. 102). A disadvantaged victim, a predatory trafficker, a locality burdened by crime, poverty, or other stres- sors, and demand for trafficked people, together make for a scenario that increases the effectiveness of a trafficker’s psychological coercion (Kim, 2011).

Trafficker’s Psychological Coercion Tactics Psychological coercion begins when the trafficker feigns a well-intentioned relationship, as a friend, protector, parental figure, or potential partner (McCauley et al., 2010; Raphael, Reichert, & Powers, 2010). The victim may or may not have known the trafficker prior to this approach (Williamson & Prior, 2009). A young person’s need for love and belonging or other emotional and relational needs (Reid, 2012) may increase her vulnerability to a trafficker’s typical lures—grooming behaviors such as providing for the most basic needs (e.g., food and shelter) or offering expensive gifts and trips (Pierce, 2012).

After the trafficker gains the victim’s trust, physical violence and other more severe psychological coercive tactics follow. These may include threats of violence to the victim (Gupta, Reed, Kershaw, & Blankenship, 2011) and to family members (Acharya, 2008; DePaul University College of Law,

WOMEN & THERAPY 33

2005; Hossain et al., 2010); forced substance use (Silverman et al., 2011); deprivation of movement (Di Tommaso, Shima, Strom, & Bettio, 2009; McCauley et al., 2010); withholding food and money and then offering these in exchange for having unprotected sex with sex buyers (Decker, Mack, Barrows, & Silverman, 2009); controlling basic body functions such as sleep- ing and use of toilets (Choi, Klein, Shin, & Lee, 2009); and subjecting victims to other abuses recognized by Amnesty International (1973) as methods of torture. Some traffickers utilize very subtle psychological coercive tactics throughout. For example, in two studies victims reported that traffickers threatened to end a feigned romantic relationship (Petrunov, 2014; Raphael et al., 2010), thus directly manipulating the need for love and belonging that traffickers use to lure many people into trafficking (Reid, 2012).

Central to establishing control for traffickers is social isolation, degradation, and the control of bodily functions. Lange (2011) described this level of per- petrator control as “intimate terrorism” (Lange, 2011). It becomes the fertile breeding ground for humiliation, degradation and shame, and prevents victims from gaining a sense of mastery over their experiences, an issue pertinent to the survivors of many forms of trauma (Andrews, Brewin, Rose, & Kirk, 2000; Talbot, Talbot, & Tu, 2004). Mansson and Hedin (1999) identified feelings of shame that stem from the trafficker’s coercive control as one of the major challenges for women attempting to leave situations of sexual exploitation.

The Relational Consequences of Human Trafficking

Numerous studies have documented severe health (Acharya & Clark, 2010; Miller, Decker, Silverman, & Raj, 2007; Muftic & Fin, 2013) and mental health consequences of trafficking. Most commonly noted are depression, post-trau- matic stress disorder (Abas et al., 2013; Farley et al., 2003; Howard et al., 2013; Rafferty, 2008; Tsutsumi, Izutsu, Poudyal, Kato, & Marui, 2008; Zimmerman et al., 2003), and substance abuse (Macy & Johns, 2011; Shigekane, 2007; Vaddiparti et al., 2006). Although fewer studies focus on the relational conse- quences of human trafficking, several authors (Baker, Dalla, & Willamson, 2010; Brunovskis & Surtees, 2012; Clawson et al., 2008; Fuchs Ebaugh, 1988; Gajic-Veljanoski & Stewart, 2007; Lange, 2011; Sanders, 2007) specifi- cally identify shame and mistrust as obstacles to engaging in various types of services (e.g., legal, case management, vocational rehabilitation).

Traumatic Bonding

Several authors describe victims’ difficulties in breaking away from the trafficker, and providers’ frustration in response to victims who return to traf- fickers (Raphael et al., 2010; Reid, 2010; Shigekane, 2007). Studies on domestic violence and hostage situations (Cantor & Price, 2007; Carpenter, 1985) and

34 P. M. CONTRERAS ET AL.

victims of incest (DeYoung & Lowry, 1992) have found that acts of kindness alternated with physical violence and/or psychological coercion contribute to a type of traumatic bonding, which makes it psychologically challenging for the victim to break free from the perpetrator. The trafficker’s grooming beha- viors are similar to the behaviors of batterers and other perpetrators. There- fore, traumatic bonding is likely an issue to contend with in cases of human trafficking. Reid (2010) noted that traffickers use a mixture of reward and punishment, “…freedom and bondage, acceptance and degradation, to produce intense loyalty and trauma bonding to the trafficker” (p. 158). Gender differences may make women more vulnerable than men to traumatic bonding. Women in particular may respond to a traumatic event with an increased need for relationships (David & Lyons-Ruth, 2005; Mawson, 2005; Taylor et al., 2000), a behavior coined as the “tend-and-befriend” response (Taylor et al., 2000). In times of high stress, fight-and-flight responses are typically the pri- mary response for both genders. However, female biological systems that stimu- late attachment and caregiving behaviors may increase a woman’s tendency to seek social bonds for mutual protection in times of stress. A biological response intended to protect a woman from further harm during and after a traumatic experience may also make her more vulnerable to bonding with a trafficker.

Cacho’s (2014) interviews with trafficked women in Mexico described the tactics of organized crime networks intended to increase a victim’s bonding with traffickers. Cacho interviewed Lorena Martins, the daughter of an Argen- tine sex trafficker operating in Mexico. Ms. Martins denounced her father and helped local authorities gather information to prosecute him. “Breaking girls” was the term the trafficking ring used to refer to the process of sex trafficking. The trafficking ring’s ruse basically consisted of recruiters who identified Mexican girls that had been victims of domestic violence or rape. The traffick- ers became father figures that provided these vulnerable girls with shelter and jobs. The women and girls developed positive feelings towards the traffickers for giving them these opportunities. To lure women from other countries the traffickers promised women jobs and paid for their airfare to Mexico. After the women arrived in Mexico, the traffickers took their passports with the excuse of processing their immigration status. Once the women felt comfort- able, Cacho’s interviewee described that the trafficker’s gradually broke their promises: “Their immigration turn[ed] problematic and they [were] placed in a situation of distress” (p. 127). The combination of the trafficker’s help and care in the beginning of the trafficking experience, followed by withdrawal of those resources, ultimately resulted in the women’s coercion into prostitution.

Trafficking-Specific Marginalization, Stigma, and Abuse

Marginalization and stigma that affect women post-trafficking exacerbate all forms of mental health distress and contribute to shame and mistrust

WOMEN & THERAPY 35

(Sallman, 2010; see also Surtees, in this issue). Sallman cautions that mistrust exhibited by a woman with a history of prostitution (trafficked or otherwise), “…may be an effect of stigma, rather than an indicator of a client’s unwilling- ness to cooperate in treatment” (p. 13).

Historically, law enforcement has compounded the stigma and marginali- zation of prostituted people. Law enforcement officers still commonly identify sex trafficking victims as criminal offenders and arrest them for prostitution (Cross, 2013; Halter, 2010; Lange, 2011). Most concerning are the extreme forms of police brutality and violence, including sexual violence, documented towards women in prostitution (Williamson, Baker, Jenkins, & Cluse-Tolar, 2007). These abuses have contributed to victims’ deep mistrust towards law enforcement (Herman, 2005).

A recent cultural shift to less stigmatizing terminology and language may help to reach women who have remained invisible and locked into painful cycles of exploitation (Herman, 2003). Essentially, yesterday’s prostitute is today’s victim of sex trafficking.3 Though the shift has engendered consider- able controversy (American Psychological Association Task Force on the Trafficking of Women and Girls, 2014; Worthen, 2011) it is a much welcomed shift from disparaging language4 that marginalized people in prostitution (Montgomery-Devlin, 2008; Reid, 2010; Williamson & Prior, 2009). Sex traf- ficking then is the preferred term to refer to all forms of coerced prostitution, even among women identified (by self or others) as consenting sex workers (Farley, 2004; Farley et al., 2003; George & Sabarwal, 2013; Raphael et al., 2010; Reiger, 2007; Skilbrei, 2010).

Shame and Mental Health Symptoms The important role of shame and secrecy with trafficked persons has also been well documented (Clawson et al., 2008; Herman, 2003). Herman (2011) deconstructs shame as a relational experience of perceiving, imagining, or being subjected to another’s scorn and derision. Scheff (2000) (as cited in Lewis, 1971), explains that shame arises in response to threats to social bonds. More recent relational psychoanalytic theories describe the intersub- jective aspects of shame and how it is co-constructed and recreated in the patient–therapist dyad (Levine, 2012). Psychotherapy that addresses trust and shame issues directly can therefore be particularly helpful to trafficking survivors.

Shame has a significant association with general stress reactions (Pinto- Gouveia & Matos, 2011), and with PTSD, especially when the trauma exposure includes high levels of emotional and verbal abuse and experiences of subordination and isolation (Beck et al., 2011). In one set of studies, traumatic memories about shaming experiences amplified the intensity of depression (Matos & Pinto-Gouveia, 2010) and were a significant predictor of paranoid ideation and dissociation (Matos, Pinto-Gouveia, & Duarte, 2012).

36 P. M. CONTRERAS ET AL.

Trauma scholars have recommended that a central component of therapy be devoted to enabling survivors to talk about their feelings of shame in a manner that facilitates mastery and dignity (e.g., Cloitre, Cohen, & Koenen, 2006; Herman, 1992; Herman, 2011). Because shame interferes with the therapeutic alliance (Black, Curran, & Dyer, 2013; Pettersen, 2013), attending to issues of shame in psychotherapy would likely improve treatment outcomes (Cândea & Szentágotai, 2013). Therapy that builds strong relational bonds between the caregiver and the survivor’s shamed self is required to help the survivor develop a capacity for self-care and self-compassion (Harman & Lee, 2010; Pettersen, 2013; Pinto-Gouveia & Matos, 2011), and to allow for the mutual and relational negotiation of shame states (Leerning & Boyle, 2013). Pettersen (2013) for instance, has argued that “Since nurturing the emerging self is the focus in healing shame, the method must be relational and not behavioral” (p. 691).

Psychotherapy Vignettes with Survivors of Trafficking5

We propose that a psychotherapy approach focusing on building trust with the survivor in the first stages of treatment can greatly benefit the survivor, and at the same time increase the likelihood that s/he will remain open to engaging with other professionals (e.g., attorneys, case managers, advocates). Evidence- based psychotherapy interventions developed specifically to work with survi- vors of human trafficking are currently unavailable (Macías Konstantopoulos et al., 2013; Macy & Johns, 2011). Although evidence-based treatments can address mental health symptoms that may result as a consequence of human trafficking (e.g., PTSD, depression) (Clawson et al., 2008; Hardy, Compton, & McPhatter, 2013; Williamson, Dutch, & Clawson, 2010), these interventions do not sufficiently address the prominent relational needs of this population.

Through case studies we will discuss the complex themes that arise for trafficking survivors in psychotherapy, with particular attention to issues that surface after acute psychosocial stressors have been addressed. Specifically, we will discuss how the therapist might help the patient work through the intensified trust issues and shame.

Maria: Secrecy, Shame, Stigma and Self-Identification

Maria, a 20-year-old woman from Central America, was sold into prostitution by her family to pay back debts owed to local gangs. Maria faced substantial childhood adversity. Her family was extremely abusive. Both parents beat her and her siblings, hitting them with brooms, with television cables, with any- thing at hand. Her father was frequently incarcerated for gang involvement. The family moved constantly because of fear of reprisals from other gangs. They often sheltered other gang members and there were firearms and guns in the house. Maria noted, “We lived with thieves, with drug dealers, but to

WOMEN & THERAPY 37

me that was normal.” Maria’s younger brother became gang-involved at age 14 and was murdered at age 17 while he was in prison.

When Maria was 16, her mother sent her to work in a bar to help the family financially. The bar turned out to be a brothel where Maria was forced to have sex with at least 10 men a night. The bar took her earnings and Maria rarely received more than $3 a night. The brothel owner told her that her family knew she was prostituting and did not want her back. They threatened her and said she would regret trying to escape. Many sex buyers were extremely violent. Maria became depressed and suicidal; on two occasions she swallowed pills in an attempt to die.

One day the brothel owner told Maria she could “make a fortune” working for him in a New York brothel. Maria believed the brothel owner and agreed to travel to New York. A smuggler crossed her over the border on foot. In New York, an associate of the brothel owner she worked for in Central America coerced Maria into prostituting without pay in his brothel. He threatened to report her to immigration and law enforcement if she did not comply. Maria eventually escaped the brothel.

I [DK] met Maria a few years after she escaped, when she entered psycho- therapy. She worked at a dry cleaners and had a child with her live-in partner. She sought treatment because her symptoms were interfering with her func- tioning and parenting. She slept poorly, had nightmares, and felt depressed. She was tormented by memories of her murdered brother. She had deep shame about her involvement in prostitution. Her partner and his family did not know her history. She said, “I’m good at keeping secrets but I wish I had a pill to help me forget everything I have gone through.”

“In my family,” Maria explained, “Drugs and criminals were considered normal. However, we were told to keep everything secret. When my father was in jail, we were told to tell people he was away working in another city.” She understood her family’s sending her to the brothel as follows: “My mother would cry and say to me, it’s your job to take care of your younger sisters. We never had any money and I think my parents stole sometimes to feed us. I thought I could help my sisters by working but once I was there, I didn’t know if any of the money was going to them.” The habit of secrecy and her fear of being stigmatized led her to withhold her past from her new family. Maria explained, “I just let them think I had a good family back home. I don’t think they could ever understand my past and I don’t want them not to trust me or think badly of me, or think this will make me a bad mother. So I keep everything inside.”

Diane: Control and Shame

I [PMC] met Diane when she was 24 years old and her primary care physician referred her for individual psychotherapy. Diane grew up in the United States

38 P. M. CONTRERAS ET AL.

with working class Irish-Catholic parents who struggled with alcoholism and mental health problems. Diane’s father was violent when he drank. She described him as a “weekend drinker.” She stated, “From a very young age I learned that when Friday rolled around someone would get hurt.”

When Diane was seven years old her mother fled with the children and hid them at an uncle’s home. Diane expressed relief to be far away from her violent father. However, her relief was short lived, as her uncle soon began to sexually abuse her and her brother. When Diane talked about her history of sexual abuse she prefaced it with, “I’ll say it quickly and once, and then I never want to talk about it again.” After several months of twice-weekly psychotherapy Diane’s trust increased. She disclosed that her uncle took pornographic pictures of her and her brother. She stated, “Sometimes he made us [Diane and her brother] be sexual with each other.” She and her brother became distant as adults. She noted, “We hate each other; I think it’s because we remind each other about what happened.”

Diane struggled in school. She was aggressive with peers and teachers. At age 12 she was hospitalized after she attempted suicide by cutting her wrists. She had been secretly cutting since age 10. Diane met with “too many” mental health providers. She stated, “It was one provider after the other, they changed them all the time, I’d start talking to one and when I was starting to feel okay with that person they switched me to work with someone else.”

At age 15, Diane met an older girl at a residential program who told her she should leave home, “She made me realize my family was bad. I told her everything that happened to me because she seemed so strong and with it. I wanted to be like her.” Diane’s new friend, Daisy, offered her shelter. She told Diane she had a boyfriend, “She said that her boyfriend had a job and an apartment and told me he helped her out after she left home because her father raped her.”

Diane was discharged from the residential program to her mother’s home. Hospital staff referred her to therapy but Diane refused to attend. Problems with her mother escalated, “We fought constantly and I kept thinking the girl from the program would help me out. I was trying to find an excuse to run. I felt horrible being with my family, I felt dead there and I just wanted to run.”

One week after her discharge, Diane ran away from home and called the girl she met at the program. “Daisy told me where to meet her. She reassured me I would be safe with them.” Daisy introduced Diane to her boyfriend, Ryan. “Ryan was really nice and I was jealous she had such a nice boyfriend. We went to his apartment and it was so laid back. We watched television; he ordered pizza and gave me beer. I got drunk fast because I didn’t really drink.” Diane said she blacked out, and when she awoke, she realized something had happened. “I knew someone had put something in my drink and I thought someone raped me. I didn’t say anything or cry or nothing because I didn’t want to risk my chances of staying with them. I thought maybe I had done

WOMEN & THERAPY 39

something wrong, so I shut my mouth. That was how much I didn’t want to go back home.”

Daisy took Diane shopping the first week. Ryan gave them a credit card and Daisy encouraged Diane to buy clothes she disliked. “It was stuff I would never wear, I was a tomboy and she kept insisting I buy tight clothes.” Despite these warning signs, at the end of the first week, Diane explained that Daisy and Ryan felt like the family she had always wanted. Ryan gave her a fake ID and Daisy helped her search for jobs. When Daisy talked to her about pros- tituting, Diane said it felt like she had come up with the idea on her own. She stated, “Daisy told me that she loved Ryan so much that when they were out of cash she had sex with other men for money. I thought I wanted to do the same. I wanted them to let me stay.”

Ryan sexually exploited Diane for the first time a week shy of her 16th birthday. Ryan took her to a hotel room where she had sex with a much older man. Ryan kept the man’s payment. Countless experiences of sexual and physical violence followed. Diane thought about leaving but felt trapped. She started to drink heavily and one of Ryan’s friends, Mark, who later became Diane’s trafficker, gave her cocaine that she quickly became addicted to. Diane described that her feelings about her experiences changed con- stantly. She stated, “It was a time of big highs and lows, sometimes I felt so excited that I had all this money, we’d buy cool stuff and then other times, I thought I was in hell. I remember one morning I couldn’t walk because I hurt so badly and going to the hospital just wasn’t an option.”

Diane remained with Mark and two other traffickers until she was twenty. She moved between three different states. After a hospitalization due to a heroin overdose, Diane checked herself into a substance abuse program. She noted, “A counselor there spent a lot of time with me and she convinced me to help myself.” In the substance abuse program, she learned that Mark and Ryan had been arrested. Diane returned to her mother’s home and continued to prostitute solo via the internet.

Initially, Diane did not understand why Mark, Ryan, and other traffickers were prosecuted. She stated, “I was there because I wanted to, I know they did bad stuff, they hurt some of the girls, they let some of the guys [sex buyers] do disgusting stuff, but if I put someone in jail, I’d put my uncle in jail.”

Li: Agency, Vulnerability, and Revictimization

Li is a 26-year-old woman who fled a country in East Asia to escape her abusive husband who nearly killed her. She had distant relatives in New England who promised her work in a restaurant. She travelled by air to the United States on a tourist visa. She was forced to leave her 9-year-old daughter behind with her abusive husband.

40 P. M. CONTRERAS ET AL.

Immediately after she started to work at the restaurant, her boss physically and sexually abused her and threatened that authorities would deport her if she reported him. He also abused other employees. Li thought that if others tolerated him, there would be no hope if she went to the police. She was forced to have sex with men in the back of the restaurant, and her boss kept her earnings. Li noted, “I was so isolated and had no one I could reach out to. I felt no one would believe me and fight for me and I was so scared to go to prison or be sent back.” Eventually, however, Li called the police, who helped her escape.

I [DK] met Li when she was applying for legal status and living in a women’s shelter. She hoped to obtain legal status and reunite with her daughter. Shelter staff helped her find work at a cafe and she made friends there and at the shelter. However, in a session a few months later, she tearfully reported that she had decided to leave this job, because someone had promised her a better job selling health products: “Staff is so angry because I didn’t tell them. They think I am really ungrateful.” Through a mutual friend, a woman from her community had contacted Li and said that she was a doctor at a local hospital. The woman told Li she could earn more money selling health products. “She said I could make more money to support my daughter when she came.” The job did not exist. The woman did not pay Li and told her she owed money for the products she had given her. The woman harassed Li and threatened to report her to local authorities; she implied that she had connections “with the high levels of the police.” Eventu- ally, Li borrowed money to pay her, and after that the harassment stopped. Li explained, “I kept thinking I could trust her because she was a doctor and she was from my people. Why would someone from my own community hurt me like this? I was so scared. I was already involved with the police, and I didn’t want to make any more trouble. Maybe they would not let me bring my daughter here.”

Discussion of Case Vignettes

Did Maria, Diane or Li self-identify as “trafficked?” Each understood her experience based on the social context in which she was born and raised. Although Maria understood she was forced into prostitution, she told her story in terms of her life experiences rather than as a victim of human traf- ficking (Reid, 2012).

Similarly, Li understood her predicament in terms of “bad things” causing one event to lead to another. She also identified moments when she had some control and when she did not. In her mind, her struggles started with an abusive marriage. She also identified attempts to escape or improve her situation. Although she did not use the words prostitution’ or trafficking,’ she felt strongly that she was abused, used, and controlled by her traffickers.

WOMEN & THERAPY 41

She recognized harms largely through her physical symptoms as a direct consequence of her traumatic past. She almost never discussed her sexual exploitation.

Only after several years of psychotherapy could Diane think of herself as a survivor of trafficking. Her first disclosure was fraught with intense feelings of anger and shame, “I wanted to do the things that I did. I don’t want to think of myself as a victim. I wasn’t weak like some of the other girls.”

Herman (2003) noted that the shame and stigma of prostitution leads vic- tims to conceal their experiences even in relationships, such as a therapeutic one, where disclosure is fundamental. Shame perpetuates psychological isolation with memories of victimization. Psychotherapy is meant to develop a larger and more textured narrative, where understanding about the impact of traumatic experiences will encourage self-compassion. But survivors withhold information about their victimization until assured they will not be judged.

Maria’s shame about her family and her past kept her isolated, at a distance from the people who cared about her—her new family, her legal team, and her co-workers. Her legal team pressured her to disclose her experiences to deter- mine whether her case was appropriate for asylum or trafficking remedies. Maria’s narrative was not linear, however; it emerged piece by piece. With reluctance and shame, she disclosed parental abuse and prostitution last. Her lawyers were frustrated that she did not disclose these facts earlier. They felt she was working against her interests and theirs in their efforts to represent her. Challenges with disclosure became central in Maria’s legal case. Her legal team asked, “How does being a victim of this kind of trauma explain why victims don’t tell the whole story? How can the trauma be dealt with so that they can better participate in their case?” Maria’s response highlighted that her mistrust in providers ran deep. Maria noted, “If my own family did not take care of me and mistreated me, why would I expect professional people who don’t even know me to believe and understand me?”

Diane had a similar disclosure pattern. Her presenting problems were depression, substance abuse, and family conflict. Initially, she discussed “domestic abuse” problems with her “ex-boyfriend.” In her first month of treatment, she attended all appointments. She talked briefly about a sexual abuse history and her struggles to curb alcohol and drug use, cutting, and symptoms of depression. After she first revealed sexual exploitation, she missed the following session. Diane reengaged after numerous outreach attempts. In the following sessions long and awkward silences filled the room, which revealed the shame she was experiencing. Diane described her shame state in these words: “When I talk about having sex with all those guys, I don’t want to look up at you.” In this phase of Diane’s psychotherapy, it became routine to talk about the moment-by-moment experience of her feelings, thoughts and mental states. Diane also talked about her struggles in relationships. Trafficking shifted from being “the bad choice that I made,” to “exploitation,”

42 P. M. CONTRERAS ET AL.

and at the end of one session Diane said, “I saw a TV show about it. Trafficking. I think that’s what happened to me.”

These cases illustrate important themes pertinent to working with traf- ficked persons. For Tummala-Narra et al. (2012), common assumptions about the term trafficking “…can often obscure the actual context of the human experience, the circumstances that result in people’s vulnerability to being abused and exploited, choices that people may have made that resulted in harmful outcomes, the effects of poverty and the complexity of the familial, social and political environment that shape a person’s life trajectory” (p. 22). Understanding the context of vulnerability for each victim highlights the multiple factors that contributed to later experiences of sex trafficking.

In Maria’s case, family violence and abuse, her family’s expectation that she parent and provide for younger siblings, poverty, and rampant gang violence in her community contributed to her becoming a victim of trafficking. Shame and secrecy further prevented her from seeking or even envisioning outside supports. Her case also highlights complex issues that discourage self-identification as a victim. Fear of deportation, fear of reprisal against family, lack of rights, misinformation, and fear of repressive police regimes are some of the factors that discourage self-identification (Lange, 2011).

How does a trafficked woman understand her experience? Maria under- stood her prostitution as forced and stemming from poverty, violence, and family abuse. Diane identified as a prostitute by choice. In therapy she needed to talk about the exploitation as her choice. She needed to feel that I [PMC] understood her point of view. Diane frequently said, “I was strong, never weak like the other girls,” before she could trust me enough to reveal the riveting fear and vulnerability she also experienced. Diane needed to feel strong and in control before she could be vulnerable. It took nearly 2 years of twice- weekly psychotherapy for Diane to make these shifts. Maria’s and Diane’s stories also illustrate the complexity of mapping trafficked persons’ experi- ences onto legal notions of how experiences should be told, rather than how the survivor can tell her experience.

Li’s case highlights how trust issues can become an obstacle for services. The shelter staff expressed frequent frustration that increased Li’s shame. One staff member said, “We told her that the way to slowly build herself up was to stay at this job, but she didn’t follow our advice and she didn’t even tell us that she had just left that job. It’s like she’s stuck in this role of being a victim. She’s one of the lucky ones who got out, and yet she keeps making bad decisions like this and still expecting us to help her.”

Survivors of trafficking will usually have numerous basic needs that require immediate attention: food, clothing, housing, legal status, means for travel. Basic resources are often dispensed by non-mental health providers: shelter staff, child protective agencies, social services law enforcement and legal agencies among others. Providers manage the important and complex task

WOMEN & THERAPY 43

of administering scarce resources—who receives them, for what purpose, for how long. Inherent in the exchange is the provider’s position of power (see, for example, Halter, 2010). A provider has the power to ascribe an identity of deserving or undeserving survivor. For example, a provider may be more inclined to think positively of the survivor who willingly submits to the provider’s service plan. Providers may also mistrust or infantilize victims and judge them as “easily duped” (because the survivor was tricked by the trafficker) and as having “poor judgment.” A survivor’s autonomy and initiat- ive may be met with provider opposition. When Li rejected a housing option, for example, providers felt reluctant to continue working with her. I [DK] explored Li’s reasons for declining the housing referral. She explained that the unit was too far from her community, with which she had just started to reconnect. Li wanted to stay close to important social resources. However, she also worried a great deal about disappointing providers—“I want them to see me in a good light.”

What emerged over time in psychotherapy as Li discussed both the housing referral and leaving the cafe job was the continued economic adversity that Li faced and her sense of isolation from her community. The isolation was mag- nified at the shelter where she felt misunderstood, struggled to understand the rules, and felt that the staff assumed her English was much better than it was. She coped with a sense of lost time and believed that the job selling health products would enable her to improve her financial situation more quickly than the cafe job. She also believed that a woman from her own community would be more likely than shelter staff to help her facilitate her financial goals, and she fell prey to the well intentioned relationship discussed earlier. Li also struggled to understand that other options, such as housing referrals and jobs, would not be forthcoming if she did not take them when they were available. She discussed her fear of being far away from her community and from people who spoke her language, as she had no family to turn to for advice or support. She also articulated her anxieties in talking with anyone she perceived as administrative, as it reminded her about her court case.

Recommendations for Psychotherapists and Conclusions

Trust building with survivors of trafficking is essential to decrease feelings of shame. The psychotherapist working with trafficked persons also needs to build trusting relationships with other providers attending the survivor (see, for example, Arredondo, Shealy, Neale, and Winfrey (2004) frame for psychologists on consultation and interprofessional collaboration). Health, social services, and legal providers may look to psychotherapists for guidance on perplexing survivor behaviors. Consultation requests may pose challenges for psychotherapists accustomed to the bounds of conventional psycho- therapy practice (e.g., 50-minute sessions, minimal collateral contact).

44 P. M. CONTRERAS ET AL.

The cases of Maria, Diane, and Li highlight the importance of making long term treatments available for survivors of human trafficking. Brief treatments may help decrease targeted symptoms of depression or PTSD, but addressing the survivor’s relational and identity challenges will require a strong thera- peutic relationship that is consistent (e.g., with the same provider), predictable, and sustained over a long period of time (see for example, Leichsenring & Rabung, 2008; Wilczek, Barber, Gustavsson, Åsberg, & Weinryb, 2004).

With regards to working with collateral service providers, psychotherapists should use their knowledge base to answer provider questions as best they can. Therapists should routinely request consent from their survivor patients to be in touch with their other service providers. This will, of course, bring up issues of trust and shame; the patient must trust the therapist enough to believe that the therapist will advocate on her behalf, and will not disclose con- fidential information. It may be helpful for the therapist to discuss these con- cerns explicitly, and to explain why a network of provider trust is so important.

Crucial to trust building with providers is remaining available for consultation and encouraging discussion of challenging issues. It is equally important for the psychotherapist to not make promises (to survivors or to other providers working with survivors) that cannot be fulfilled, even if this is done with benevolent intentions.

In clinical practice, we recommend routine screening for sexual exploi- tation, using behaviorally specific language rather than emotionally loaded terms. For example, rather than asking “have you ever been trafficked or engaged in prostitution,” we suggest questions such as “have you ever had to trade sex for food, clothing, shelter, money, drugs, or other basic needs?”

Psychotherapy can function as an alternative relational model, one that seeks actively to show respect for the patient’s dignity, not to dehumanize or marginalize, while also acknowledging the inherent power imbalance in the relationship. Rather than a relationship built on promises and then coercion—as occurs in human trafficking—psychotherapy can be a freely cho- sen relationship that is built on mutuality and earned trust. This will require critical thought and consideration about the inherent power imbalances present in the psychotherapy relationship and in general health services (Pril- leltensky, 2008). We strongly encourage psychotherapists working with traf- ficked women to use treatment approaches that consider issues of power in therapy (see for example, Davies & Frawley, 1994; Harvey, 1996; Herman 1992; Jordan, 2008). We also recommend that therapists who are engaged in treating survivors seek additional education on issues of human trafficking, as new research information becomes available.

Human trafficking survivors have experienced coercion techniques that effaced their volition. These experiences may compromise the survivor’s ability to regulate relationships with healthy boundaries (Herman, 1992), with resulting vulnerability to repeated victimization. The survivor may be

WOMEN & THERAPY 45

particularly vulnerable with authority figures who appear to offer care and protection. Risk of revictimization also applies to exchanges between provi- ders (e.g., medical, mental health, legal) and patients, where the expert role automatically ascribes more power to the provider (French & Raven, 1959).

Misuse of power by psychotherapists and other providers will often start with a strong desire to help. The multiple needs of trafficking survivors and the complications to exit/escape trafficking may be met with the provider’s intensifying desire to assist. If left unexamined, what started as a desire to help is prone to transform into a need to rescue. The risk for the survivor is that the provider’s need to rescue can become more important than the patient’s needs. Moreover, in order to complete the dynamic, the provider will need the client to take on the role of the powerless victim that requires rescue. The pro- vider may insist that the survivor consult with him/her about life decisions indirectly related to their care. An “unconscious habit of obedience” (Herman, 1992, p. 111) may initially push the survivor to comply automatically. How- ever, at some point, survivor patients may resist a passive role by engaging in behaviors—healthy or unhealthy—that counter treatment recommendations. Providers may respond by exercising power afforded by their positions in ways that reenact the coercive aspects of the abuse. For example, they may initiate procedures for an involuntary hospitalization even though the level of risk warranted for such restrictive measures does not exist. Therefore, providers of trafficking survivors need supportive spaces of reflection where the potential for these and other coercive dynamics can be considered, examined, countered, and ideally prevented.

Reid’s (2012) findings show that multidimensional and complex factors contribute to the trafficking of women and girls. The survivor’s understanding of her experience of trafficking will shift and evolve over time, for example from identifying as a prostitute by choice, to trafficked victim, and finally to survivor. The psychotherapist who can hold all these realities will help the survivor make meaning of her experiences. Therefore, psychotherapy sui- ted to the needs of sex trafficked women will be first and foremost one that can attenuate the polarized discourses about trafficking and prostitution: legal, feminist, or abolitionist (as described by Castillo, 2012; Worthen, 2011). At the very least, the psychotherapist must have the ability to detoxify any language that could potentially shut down the survivor’s comfort in acknowledging and accepting the complexity of all of her experiences. The psychotherapist should strive to help the survivor construct her own story of survival, a story that may change over time as the survivor comes to terms with the depths of her experience. Making space for the survivors’ changing narratives will be essential in order to resolve overwhelming feelings of shame.

The different points of view on human trafficking—feminist, legal, abolitionist, and media-driven—are honest attempts of communities of people to understand, and hopefully eradicate, this terrible crime, which brings us to

46 P. M. CONTRERAS ET AL.

our last point. Professionals have a deep and personal need to make sense of something as sinister as trafficking. Explanations and theories help filter these poignant and terribly painful experiences. Yet no matter how strong the buffer, working with this traumatized population carries the potential of impact on the therapist (Figley, 1995; McCann & Pearlman, 1990). Support from colleagues in the form of consultation and supervision is essential. Theories that recognize the impact of witnessing will be most helpful (see, for example, Kennedy & Whitlock, 2011; Weingarten, 2010).

In conclusion, the psychotherapist can help counter the consequences of human trafficking by guiding the survivor through a process that will relieve the shame related to her experiences, and rebuild the basic sense of trust that has been destroyed. The psychotherapist will need to navigate relationships across several disciplines, maintain a critical thinking stance regarding different perspectives about human trafficking, consider the inherent power imbalances of the psychotherapist–patient relationship, and find ways to regulate the impact of bearing witness.

Notes

1. Even though we use the terms “victim” and “survivor” interchangeably, we recognize the survivor status of all women with histories of trafficking including those that are currently trapped in trafficking; have escaped, left, or been rescued from trafficking; those who returned to trafficking or were re-trafficked; and those who permanently exited trafficking.

2. The Cambridge Health Alliance (CHA) is a public hospital and teaching hospital of Har- vard Medical School. CHA is committed to providing a variety of health and mental health services to diverse and underserved populations.

3. Related terms include: sexual exploitation; commercial sexual exploitation of children (CSEC); domestic minor sex trafficking (DMST); and modern day slavery.

4. In Montgomery-Devlin’s (2008) study, providers used several terms—some that suggested the victim was to blame—to describe child victims of trafficking exploited through por- nography, prostitution, and/or stripping. Terms included, “ … child prostitute, juvenile delinquent, sexually exploited youth, commercially sexually exploited youth, sex trafficking victim, and prostituted youth” (p. 155).

5. Names, demographics, and other identifying information of clinical cases have been altered to ensure privacy.

References

Abas, M., Ostrovschi, N. V., Prince, M., Gorceag, V. I., Trigub, C., & Oram, S. (2013). Risk factors for mental disorders in women survivors of human trafficking: A historical cohort study. BMC Psychiatry, 13(1), 1–11. doi:10.1186/1471–244x-13–204

Acharya, A. K. (2008). Sexual violence and proximate risks: A study on trafficked women in Mexico City. Gender, Technology and Development, 12, 77–99. doi:10.1177/097185240701200106

Acharya, A. K., & Clark, J. B. (2010). Health consequences of trafficking in Mexico: Findings from Monterrey city. International Review of Sociology, 20(3), 415–426. doi:10.1080/ 03906701.2010.511886

WOMEN & THERAPY 47

Ali, M. (2009). Assessment of the demand-supply interface of trafficking and commercial sexual exploitation. In C. Aghazarm & F. Laczko (Eds.), Human trafficking: New directions for research (pp. 73–94). Geneva: International Organization for Migration.

American Psychological Association Task Force on the Trafficking of Women, & Girls. (2014). Report of the task force on trafficking of women and girls. Washington, DC: American Psychological Association.

Amnesty International. (1973). Report on torture. London: Gerald Duckworth & Co. Ltd. Andrews, B., Brewin, C. R., Rose, S., & Kirk, M. (2000). Predicting PTSD symptoms in victims

of violent crime: The role of shame, anger, and childhood abuse. Journal of Abnormal Psychology, 109, 69–73. doi:10.1037/0021–843x.109.1.69

Arredondo, P., Shealy, C., Neale, M., & Winfrey, L. L. (2004). Consultation and interprofessional collaboration: Modeling for the future. Journal of Clinical Psychology, 60(7), 787–800. doi:10.1002/jclp.20015

Baker, C. N. (2014). An intersectional analysis of sex trafficking films. Meridians, 12(1), 208–226. doi:10.2979/meridians.12.1.208

Baker, L. M., Dalla, R. L., & Williamson, C. (2010). Exiting prostitution: An integrated model. Violence against Women, 16(5), 579–600. doi:10.1177/1077801210367643

Bales, K., David, F., Datta, M., & Grono, N. (2013). The global slavery index. Walk free foundation. Available at http://www.globalslaveryindex.org/report/#view-online

Beck, J. G., McNiff, J., Clapp, J. D., Olsen, S. A., Avery, M. L., & Hagewood, H. (2011). Exploring negative emotion in women experiencing intimate partner violence: Shame, guilt, and PTSD. Behavior Therapy, 42, 740–750. doi:10.1016/j.beth.2011.04.001

Black, R. S. A., Curran, D., & Dyer, K. F. W. (2013). The impact of shame on the therapeutic alliance and intimate relationships. Journal of Clinical Psychology, 69(6), 646–654. doi:10.1002/jclp.21959

Brannigan, A., & Van Brunschot, E. G. (1997). Youthful prostitution and child sexual trauma. International Journal of Law and Psychiatry, 20, 337–354. doi:10.1016/s0160–2527(97) 00016–2

Brunovskis, A., & Surtees, R. (2012). Coming home: Challenges in family reintegration for trafficked women. Qualitative Social Work, 12(4), 452–474. doi:10.1177/1473325011435257

Busch-Armendariz, N., Busch Nsonwu, M., & Heffron, L. C. (2014). A kaleidoscope: The role of the social work practitioner and the strength of social work theories and practice in meeting the complex needs of people trafficked and the professionals that work with them. International Social Work, 57(1), 7–18. doi:10.1177/0020872813505630

Cacho, L. (2014). Slavery inc: The untold story of international sex trafficking. Berkeley, CA: Soft Skull Press.

Cândea, D-M., & Szentágotai, A. (2013). Shame and psychopathology: From research to clinical practice. Journal of Cognitive and Behavioral Psychotherapies, 13(1), 101–113.

Cantor, C., & Price, J. (2007). Traumatic entrapment, appeasement and complex post- traumatic stress disorder: Evolutionary perspectives of hostage reactions, domestic abuse and the Stockholm syndrome. The Royal Australian and New England College of Psychiatrists, 41, 377–384.

Carpenter, E. (1985). Traumatic bonding and the battered wife. Psychology Today, 19(6), 18–18. Castillo, D. A. (2012). On the line: Work and choice. PMLA, 127(4), 835–844. doi:10.1632/

pmla.2012.127.4.835 Choi, H., Klein, C., Shin, M-S., & Lee, H-J. (2009). Posttraumatic stress disorder (PTSD) and

disorders of extreme stress (DESNOS) symptoms following prostitution and childhood abuse. Violence against Women, 15, 933–951. doi:10.1177/1077801209335493

Clawson, H. J., Salomon, A., & Goldblatt Grace, L. (2008). Treating the hidden wounds: Trauma treatment and mental health recovery for victims of human trafficking. Washington,

48 P. M. CONTRERAS ET AL.

DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating survivors of childhood abuse: Psychotherapy for the interrupted life. NY: Guilford.

Cross, A. L. (2013). Slipping through the cracks: The dual victimization of human-trafficking survivors. McGeorge Law Review, 44(2), 395–422.

David, D. H., & Lyons-Ruth, K. (2005). Differential attachment responses of male and female infants to frightening maternal behavior: Tend or befriend versus fight or flight. Infant Mental Health Journal, 26(1), 1–18. doi:10.1002/imhj.20033

Davies, J. M., & Frawley, M. G. (1994). Treating the adult survivor of childhood sexual abuse: A psychoanalytic perspective. New York: Basic Books.

Decker, M. R., Mack, K. P., Barrows, J. J., & Silverman, J. G. (2009). Sex trafficking, violence victimization, and condom use among prostituted women in Nicaragua. International Journal of Gynecology and Obstetrics, 107, 151–152. doi:10.1016/j.ijgo.2009.06.002

Demir, O. O., & Finckenauer, J. O. (2010). Victims of sex trafficking in Turkey: Characteris- tics, motivations and dynamics. Women & Criminal Justice, 20(1–2), 57–88. doi:10.1080/ 08974451003641081

Denton, E. (2010). International news coverage of human trafficking arrests and prosecutions: A content analysis. Women & Criminal Justice, 20(1–2), 10–26. doi:10.1080/08974451003641321

DePaul University College of Law. (2005). In modern bondage: Sex trafficking in the Americas. Chicago, IL: International Human Rights Law Institute.

DeYoung, M., & Lowry, J. A. (1992). Traumatic bonding: Clinical implications in incest. Child Welfare, 71(2), 165–175.

Di Tommaso, M. L., Shima, I., Strom, S., & Bettio, F. (2009). As bad as it gets: Well-being deprivation of sexually exploited trafficked women. European Journal of Political Economy, 25, 143–162. doi:10.1016/j.ejpoleco.2008.11.002

Falb, K. L., McCauley, H. L., Decker, M. R., Sabarwal, S., Gupta, J., & Silverman, J. G. (2011). Trafficking mechanisms and HIV status among sex-trafficking survivors in Calcutta, India. International Journal of Gynecology and Obstetrics, 113, 86–87. doi:10.1016/j.ijgo. 2010.11.009

Farley, M. (2003). Prostitution and the invisibility of harm. Women & Therapy, 26(3–4), 247–280. doi:10.1300/j015v26n03_06

Farley, M. (2004). Bad for the body, bad for the heart: Prostitution harms women even if legalized or decriminalized. Violence against Women, 10(10), 1087–1125. doi:10.1177/ 1077801204268607

Farley, M. (2006). Prostitution, trafficking, and cultural amnesia: What we must not know in order to keep the business of sexual exploitation running smoothly. The Yale Journal of Law and Feminism, 18, 102–136.

Farley, M., Cotton, A., Lynne, J., Zumbeck, S., Spiwak, F., Reyes, M. E., … Sezgin, U. (2003). Prostitution and trafficking in 9 countries: Update on violence and posttraumatic stress disorder. Journal of Trauma Practice, 2(3–4), 33–74. doi:10.1300/j189v02n03_03

Farley, M., MacLeod, J., Anderson, L., & Golding, J. M. (2011). Attitudes and social character- istics of men who buy sex in Scotland. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 369–383. doi:10.1037/a0022645

Farr, K. (2005). Sex trafficking: The global market in women and children. Portland, OR: Worth.

Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. London: Brunner-Routledge.

French, J. R. P., , Jr., & Raven, B. H. (1959). The bases of social power. In D. Cartwright (Ed.), Studies in social power, (pp. 150–167). Ann Arbor, MI: Institute for Social Research.

WOMEN & THERAPY 49

Fuchs Ebaugh, H. R. (1988). Becoming an ex: The process of role exit. Chicago: University of Chicago Press.

Gajic-Veljanoski, O., & Stewart, D. E. (2007). Women trafficked into prostitution: Determi- nants, human rights and health needs. Transcultural Psychiatry, 44(3), 338–358. doi:10.1177/1363461507081635

George, A., & Sabarwal, S. (2013). Sex trafficking, physical and sexual violence, and HIV risk among young female sex workers in Andhra Pradesh, India. International Journal of Gynecology & Obstetrics, 120(2), 119–123. doi:10.1016/j.ijgo.2012.08.019

Gozdziak, E. M., & Bump, M. N. (2007). The care of unaccompanied undocumented children in federal custody: Issues and options. Protecting Children, 22(2), 67–83.

Gupta, J., Reed, E., Kershaw, T., & Blankenship, K. M. (2011). History of sex trafficking, recent experiences of violence, and HIV among female sex workers in coastal Andhra Pradesh, India. International Journal of Gynecology and Obstetrics, 114(2), 101–105. doi:10.1016/j.ijgo. 2011.03.005

Halter, S. (2010). Police conceptualizations of girls involved in prostitution in six U.S. cities: Child sexual exploitation victims or delinquents? Child Maltreatment, 15(2), 152–160. doi:10.1177/1077559509355315

Hardy, V. L., Compton, K. D., & McPhatter, V. S. (2013). Domestic minor sex trafficking: Practice implications for mental health professionals. Journal of Women and Social Work, 28(1), 8–18. doi:10.1177/0886109912475172

Harman, R., & Lee, D. (2010). The role of shame and self-critical thinking in the development and maintenance of current threat in post-traumatic stress disorder. Clinical Psychology and Psychotherapy, 17, 13–24. doi:10.1002/cpp.636

Harvey, M. R. (1996). An ecological view of psychological trauma and trauma recovery. Journal of Traumatic Stress, 9, 3–23. doi:10.1007/bf02116830

Haynes, D. F. (2004). Used, abused, arrested and deported: Extending immigration benefits to protect the victims of trafficking and to secure the prosecution of traffickers. Human Rights Quarterly, 26, 221–272. doi:10.1353/hrq.2004.0021

Hepburn, R., & Simon, R. J. (2010). Hidden in plain sight. Gender Issues, 27, 1–26. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Herman, J. L. (2003). Hidden in plain sight: Clinical reflections on prostitution. Journal of

Trauma Practice, 2(3–4), 1–13. Herman, J. L. (2005). Justice from the victim’s perspective. Violence against Women, 11(5),

571–602. doi:10.1177/1077801205274450 Herman, J. L. (2011). Post traumatic stress disorder as a shame disorder. In R. L. Dearing &

J. Price (Eds.), Shame in the therapy hour, (pp. 261–275). Washington, DC: American Psychological Association.

Hossain, M., Zimmerman, C., Abas, M., Light, M., & Watts, C. (2010). The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. American Journal of Public Health, 100, 2442–2449. doi:10.2105/ajph.2009.173229

Howard, L. M., Oram, S., Mckenzie, C., Abas, M., Broadbent, M., & Zimmerman, C. (2013). Human trafficking and mental health. European Psychiatry, 28(1), 2579–2580. doi:10.1016/ s0924–9338(13)77248–1

Hunt, S. (2013). Deconstructing demand: The driving force of sex trafficking. The Brown Journal of World Affairs, 18(2), 1–12.

Itzen, C. (1997). Pornography and the organization of intrafamilial and extrafamilial child sexual abuse: Developing a conceptual model. Child Abuse Review, 6, 94–106. doi:10.1002/ (sici)1099–0852(199705)6:2<94::aid-car310>3.0.co;2-i

Jac-Kucharski, A. (2012). The determinants of human trafficking: A U.S. case study. International Migration, 50(6), 150–165. doi:10.1111/j.1468–2435.2012.00777.x

50 P. M. CONTRERAS ET AL.

Jahic, G., & Finckenauer, J. O. (2005). Representations and misrepresentations of human trafficking. Trends in Organized Crime, 8(3), 24–40. doi:10.1007/s12117–005-1035–7

Jordan, J. (2008). Recent developments in relational-cultural theory. Women & Therapy, 31(2–4), 1–4. doi:10.1080/02703140802145540

Kennedy, R., & Whitlock, G. (2011). Witnessing, trauma and social suffering: Feminist perspectives. Australian Feminist Studies, 26(69), 251–255. doi:10.1080/08164649.2011. 606602

Kim, K. (2011). The coercion of trafficked workers. Iowa Law Review, 96(409), 409–474. Lange, A. (2011). Research note: Challenges of identifying female human trafficking victims

using a national 1–800 call center. Trends in Organized Crime, 14(47), 47–55. doi:10.1007/ s12117–010-9107–8

Leerning, D., & Boyle, M. (2013). Managing shame: An interpersonal perspective. British Journal of Social Psychology, 52, 140–160. doi:10.1111/j.2044–8309.2011.02061.x

Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. The Journal of the American Medical Association, 300(13), 1551–1565. doi:10.1001/jama.300.13.1551

Leidholdt, D. A. (2013). Human trafficking and domestic violence a primer for judges. The Judges’ Journal, 52(1), 1–12.

Levine, L. (2012). Into thin air: The co-construction of shame, recognition, and creativity in an analytic process. Psychoanalytic Dialogues, 22, 456–471. doi:10.1080/10481885.2012.701140

Lewis, H. B. (1971). Shame and guilt in neurosis. New York: International Universities Press. Macías Konstantopoulos, W., Ahn, R., Alpert, E. J., Cafferty, E., McGahan, A., Williams,

T. P., … Burke, T. F. (2013). An international comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 90(6), 1194–1204. doi:10.1007/s11524–013-9837–4

Macy, R. J., & Graham, L. M. (2012). Identifying domestic and international sex-trafficking victims during human service provision. Trauma, Violence & Abuse, 13(2), 59–76. doi:10.1177/1524838012440340

Macy, R. J., & Johns, N. (2011). Aftercare services for international sex trafficking survivors: Informing U.S. service and program development in an emerging practice area. Trauma, Violence & Abuse, 12(2), 87–98. doi:10.1177/1524838010390709

Mansson, S-A., Hedin, U-C. (1999). Breaking the Matthew effect – On women leaving prostitution. International Social Welfare, 8, 67–77. doi:10.1111/1468–2397.00063

Matos, M., & Pinto-Gouveia, J. (2010). Shame as a traumatic memory. Clinical Psychology and Psychotherapy, 17, 299–312. doi:10.1002/cpp.659

Matos, M., Pinto-Gouveia, J., & Duarte, C. (2012). Above and beyond emotional valence: The unique contribution of central and traumatic shame memories to psychopathology vulnerability. Memory, 20(5), 461–477. doi:10.1080/09658211.2012.680962

Mawson, A. R. (2005). Understanding mass panic and other collective responses to threat and disaster. Psychiatry: Interpersonal and Biological Processes, 68(2), 95–113. doi:10.1521/ psyc.2005.68.2.95

McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149. doi:10.1002/jts.2490030110

McCauley, H. L., Decker, M. R., & Silverman, J. (2010). Trafficking experiences and violence victimization of sex-trafficked women in Cambodia. International Journal of Gynecology & Obstetrics, 110(3), 266–267. doi:10.1016/j.ijgo.2010.04.016

Miller, E., Decker, M. R., Silverman, J. G., & Raj, A. (2007). Migration, sexual exploitation and women’s health. Violence against Women, 13(5), 486–497. doi:10.1177/1077801207301614

WOMEN & THERAPY 51

Montgomery-Devlin, J. (2008). The sexual exploitation of children and young people in Northern Ireland: Overview from the Barnardo’s beyond the shadows service. Child Care in Practice, 14(4), 381–400. doi:10.1080/13575270802268059

Muftic, L. R., & Fin, M. A. (2013). Health outcomes among women trafficked for sex in the United States: A closer look. Journal of Interpersonal Violence, 28(9), 1859–1885. doi:10.1177/0886260512469102

Petrunov, G. (2014). Human trafficking in Eastern Europe: The case of Bulgaria. The ANNALS of the American Academy of Political and Social Science, 653, 162–182. doi:10.1177/ 0002716214521556

Pettersen, K. T. (2013). Sexual abuse within the family: A study of shame from sexual abuse within the context of a Norwegian incest center. Journal of Child Sexual Abuse, 22, 677–694.

Pierce, A. (2012). American Indian adolescent girls: Vulnerability to sex trafficking, inter- vention strategies. American Indian and Alaska Native Mental Health Research, 19(1), 37–56. doi:10.5820/aian.1901.2012.37

Pinto-Gouveia, J., & Matos, M. (2011). Can shame memories become a key to identity? The centrality of shame memories predicts psychopathology. Applied Cognitive Psychology, 25, 281–290. doi:10.1002/acp.1689

Pollock, J. M., & Hollier, V. (2010). T visas: Prosecution tool or humanitarian response? Women & Criminal Justice, 20(1–2), 127–146. doi:10.1080/08974451003641172

Prilleltensky, I. (2008). The role of power in wellness, oppression, and liberation: The promise of psychopolitical validity. Journal of Community Psychology, 36(2), 116–136. doi:10.1002/ jcop.20225

Rafferty, Y. (2008). The impact of trafficking on children: Psychological and social policy per- spectives. Child Development Perspectives, 2(1), 13–18. doi:10.1111/j.1750–8606.2008.00035.x

Raphael, J., Reichert, A., & Powers, M. (2010). Pimp control and violence: Domestic sex traf- ficking of Chicago women and girls. Women & Criminal Justice, 20(1–2), 89–104. doi:10.1080/08974451003641065

Raymond, J. G., D’Cunha, J., Dzuhayatin, S. R., Hynes, H. P., Rodriguez, Z. R., & Santos, A. (2002). A comparative study of women trafficked in the migration process: Patterns, profiles and health consequences of sexual exploitation in five countries (Indonesia, the Philippines, Thailand, Venezuela and the United States). N. Amherst, MA: Coalition against Trafficking in Women. Retrieved from http://action.web.ca/home/catw/attach/CATW%20Comparative %20Study%202002.pdf

Reid, J. A. (2010). Doors wide shut: Barriers to the successful delivery of victim services for domestically trafficked minors in a southern U.S. metropolitan area. Women & Criminal Justice, 20(1–2), 147–166. doi:10.1080/08974451003641206

Reid, J. A. (2012). Exploratory review of route-specific, gendered, and age-graded dynamics of exploitation: Applying life course theory to victimization in sex trafficking in North Amer- ica. Aggression and Violent Behavior, 17, 252–271. doi:10.1016/j.avb.2012.02.005

Reiger, A. (2007). Missing the mark: Why the trafficking victims protection act fails to protect sex trafficking victims in the United States. Harvard Journal of Law & Gender, 30(1), 231–256.

Sallman, J. (2010). Living with stigma: Women’s experiences of prostitution and substance use. Journal of Women and Social Work, 25(2), 146–159. doi:10.1177/0886109910364362

Sanders, T. (2007). Becoming an ex-sex worker: Making transitions out of a deviant career. Feminist Criminology, 2, 74–95. doi:10.1177/1557085106294845

Schauer, E. J., & Wheaton, E. M. (2006). Sex trafficking into the United States: A literature review. Criminal Justice Review, 31(2), 146–169. doi:10.1177/0734016806290136

Scheff, T. (2000). Shame and the social bond: A sociological theory. Sociological Theory, 18(1), 84–99. doi:10.1111/0735–2751.00089

52 P. M. CONTRERAS ET AL.

Shigekane, R. (2007). Rehabilitation and community integration of trafficking survivors in the United States. Human Rights Quarterly, 29, 112–136. doi:10.1353/hrq.2007.0011

Silbert, M. H., & Pines, A. M. (1981). Sexual child abuse as an antecedent to prostitution. Child Abuse & Neglect, 5(4), 407–411. doi:10.1016/0145–2134(81)90050–8

Silverman, J. G., Raj, A., Cheng, D. M., Decker, M. R., Coleman, S., Bridden, C., … Samet, J. H. (2011). Sex trafficking and initiation-related violence, alcohol use and HIV risk among HIV-infected female sex workers in Mumbai, India. Journal of Infectious Diseases, 204(5), 1129–1234. doi:10.1093/infdis/jir540

Skilbrei, M. (2010). Taking trafficking to court. Women & Criminal Justice, 20(1–2), 40–56. doi:10.1080/08974451003641438

Srikantiah, J. (2007). Perfect victims and real survivors: The iconic victim in domestic human trafficking law. Boston University Law Review, 87(1), 157–211.

Talbot, J. A., Talbot, N. L., & Tu, X. (2004). Shame-proneness as a diathesis for dissociation in women with histories of childhood sexual abuse. Journal of Traumatic Stress, 17(5), 445–448. doi:10.1023/b:jots.0000048959.29766.ae

Taylor, S. E., Cousino Klein, L., Lewis, B. P., Gruenewald, T. L., Gurung, R. A. R., & Updegraff, J. A. (2000). Biobehavioral responses to stress in females: Tend-and-befriend, not fight-or- flight. Psychological Review, 107(3), 411–429. doi:10.1037/0033–295x.107.3.411

Trafficking Victims Protection Act of 2000. (2000). § 7101, 22 U.S.C. (b)(2). Tsutsumi, A., Izutsu, T., Poudyal, A. K., Kato, S., & Marui, E. (2008). Mental health of female

survivors of human trafficking in Nepal. Social Science & Medicine, 66, 1841–1847. doi:10.1016/j.socscimed.2007.12.025

Tummala-Narra, P., Kallivayalil, D., Singer, R., & Andreini, R. (2012). Relational experiences of complex trauma survivors in treatment: Preliminary findings from a naturalistic study. Psychological Trauma: Theory, Research, Practice, and Policy, 4(6), 640–648. doi:10.1037/ a0024929

United Nations. (2000). Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime. Retrieved from: http://www.uncjin.org/Documents/ Conventions/dcatoc/final_documents_2/convention_% 20traff_eng.pdf

United States Department of Justice, Civil Rights Division. (2010). Report on the tenth anni- versary of the Trafficking Victims Protection Act. Retrieved from: http://www.justice.gov/ crt/about/crm/trafficking_newsletter/tvpaanniversaryreport.pdf

Vaddiparti, K., Bogetto, J., Callahan, C., Abdallah, A. B., Spitznagel, E. L., & Cottler, L. B. (2006). The effects of childhood trauma on sex trading in substance using women. Archives of Sexual Behavior, 35(4), 451–459. doi:10.1007/s10508–006-9044–4

Weingarten, K. (2010). Reasonable hope: Construct, clinical applications and supports. Family Process, 49(1), 5–25. doi:10.1111/j.1545–5300.2010.01305.x

Widom, C. S., & Kuhns, J. B. (1996). Childhood victimization and subsequent risk for promiscuity, prostitution, and teenage pregnancy: A prospective study. American Journal of Public Health, 86(11), 1607–1612. doi:10.2105/ajph.86.11.1607

Wilczek, A., Barber, J. P., Gustavsson, J. P., Åsberg, M., & Weinryb, R. M. (2004). Change after long-term psychoanalytic psychotherapy. The Journal of the American Psychoanalytic Association, 52(4), 1163–1183. doi:10.1177/00030651040520042001

Williamson, C., Baker, L., Jenkins, M., & Cluse-Tolar, T. (2007). Police-prostitute interactions: Sometimes discretion, sometimes misconduct. Journal of Progressive Human Services, 18(2), 15–37. doi:10.1300/j059v18n02_03

Williamson, C., & Prior, M. (2009). Domestic minor sex trafficking: A network of under- ground players in the Midwest. Journal of Child and Adolescent Trauma, 2, 46–61. doi:10.1080/19361520802702191

WOMEN & THERAPY 53

Williamson, E., Dutch, N. M., & Clawson, H. J. (2010). Evidence-based mental health treatment for victims of human trafficking. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

Worthen, M. (2011). Sex trafficking or sex work? Conceptions of trafficking among anti- trafficking organizations in Nepal. Refugee Survey Quarterly, 30(3), 87–106. doi:10.1093/ rsq/hdr007

Zimmerman, C., Yun, K., Shvab, I., Watts, C., Trappolin, L., Treppete, M., & Regan, L. (2003). The health risks and consequences of trafficking in women and adolescents: Findings from a European study. London: London School of Hygiene & Tropical Medicine (LSHTM).

54 P. M. CONTRERAS ET AL.