Spotlight (2015) Movie Analysis
This movie is about a team of reporters from the Boston Globe and their investigation into allegations of
sexual abuse of children in the Catholic Church. The movie describes an investigative process that
started with investigating one priest, Father John Geoghan, accused of molesting more than 80 boys,
and led to the realization that decades of abuse by over 80 priests had occurred and that senior
members of the Church were involved in a cover-up.
Answer the questions below, referring to lectures, as well as, other readings.
1. Discuss grooming techniques described by victims. Describe scenes in which victims refer to the
pornographic cycle, and describe messages the priests said to victims that were enticing and
threatening.
2. In the scene in which a journalist (Sacha Pfeiffer) interviews Father Ronald Paquin, the priest
justifies his actions by claiming that, “Sure, I fooled around. But I never raped anyone and I
never felt gratified myself. . . .” Paquin also claimed that he had been raped by other boys and
by a priest when he was a child. Relate this information to the textbook’s discussion of the
definition of sexual abuse, and to research on perpetrators’ history of victimization and trauma.
3. Discuss parents’ and families’ relations with priests that allowed the children access to the
priests.
4. The chief editor at the Boston Globe, Marty Baron, wants proof of systemic abuse by the Boston
Archdiocese. What does he mean? Besides the Church, describe how other systems (e.g.,
journalism, criminal justice) contributed to the continued abuse by priests.
Child Sexual Abuse
Child sexual abuse is any interaction
between a child and an adult (or another
child) in which the child is used to sexually
stimulate the perpetrator or observer.
Sexual abuse can include both touching
and non-touching behaviors.
Child Sexual Abuse
Statutory Rape (California Penal Code 261.5 PC):
When any person engages in sexual intercourse
with a person under the age of eighteen
Physical force may or may not be used, but other
forms of coercion may be used to engage the
children and to keep the secret. Persuasive,
manipulative tactics are used to “groom” the
children.
Myth or Fact?
Child sexual abuse is a rare
experience.
Myth or Fact?
A child is most likely to be
sexually abused by a stranger.
Myth or Fact?
Preschoolers do not need to
know about child sexual abuse
and would be frightened if
educated about it.
Myth or Fact?
Child sexual abuse is always
perpetrated by adults.
Myth or Fact?
Talking about sexual abuse with a child who
has suffered such an experience will only
make it worse.
Myth or Fact?
Children who are sexually abused will
never recover.
Out of Darkness, Into Light: Child Sexual Abuse
http://www.pbs.org/vide
o/wlrn-documentaries-
out-darkness-light-child-
sexual-abuse/
Characteristics of Victims
• Age of CSA victims – varies from infancy to 18
with most cases between 12-14 years of age
• Gender of CSA victims-females are more
likely to be victims
• Race of CSA victims are heterogeneous
• Socioeconomic status (SES) – varies but
children in lower SES are more vulnerable
• Potential for self-blame among victims of CSA
Family Violence Across the Lifespan, 3rd Edition
© 2011SAGE Publications
Characteristics of Child Sexual Abuse Perpetrators
• Age of perpetrators is often between 30
and 40 years – a significant number are
under 18 years of age
• Gender of perpetrators are likely to be
males (93%) than females (about 7%)
• Race of perpetrators are heterogeneous
• About 30% have been victimized by sexual
abuse as a child
Family Violence Across the Lifespan, 3rd Edition
© 2011SAGE Publications
Signs of Sexual Abuse
• Increase in nightmares, sleeping difficulties, withdrawn
behaviors, angry outbursts, anxiety
• Pain while urinating or having bowel movements, indicating
infection
• Symptoms of genital infections (e.g., offensive genital odors)
• Physical trauma (abrasions or lesions) to the genital area
• Begins wetting the bed and having accidents
• Masturbates excessively or engages in persistent sexual play
with friends, toys, or pets
• Initiating sophisticated sexual behaviors (not developmentally
appropriate for child’s age)
▪ Trauma symptoms
Dynamics and Consequences Associated With
Child Sexual Abuse
• Dynamics of Child Sexual Abuse
• Usual Progression
• Grooming
• Child Pornography
Factors That Increase Trauma Experienced by
CSA Victims
• Long duration of abuse
• Poly-victimization
• The severity of the abuse
• Abuse by someone who is a parental figure or trusted acquaintance
• Abuse that involves invasive forms of sexual activity
• Negative reactions by significant others to the disclosure of abuse
Family Violence Across the Lifespan, 3rd Edition
© 2011SAGE Publications
National Child Traumatic Stress
Network Child Sexual Abuse
Committee. (2009). Caring for Kids:
What Parents Need to Know about
Sexual Abuse. Los Angeles, CA &
Durham, NC: National Center for
Child Traumatic Stress.
Los Angeles Clergy Abuse
Use of Anatomically Detailed Dolls in the
Interview
Arguments in favor of the use of anatomically
detailed dolls
Arguments against the use of anatomically
detailed dolls
Child Behavior with Dolls Normal Questionable Abnormal
Undressing the Dolls
Looking at Dolls’ Genitals
Touching Dolls’ Genitals
Touching Dolls’ Anal Area
Touching Dolls’ Breasts
Avoiding Dolls
Placing Dolls on Top of Each Other Lying Down
Showing Dolls Kissing
Showing Vaginal Penetration
Showing Anal Penetration
Showing Oral-genital Contact
Showing Genital-Genital Contact
Showing Fondling/Digital Penetration
Ratings of Behaviors with Anatomical Dolls for Children Ages 2 – 6 years
CSEC stands for commercial sexual
exploitation of children which is
defined as the sexual abuse of
children for monetary gain. Sexual
exploitation includes pornography,
physical abuse, prostitution, and
child trafficking (Albanese, 2007).
What Is CSEC?
Sex Trafficking: The New American Slavery
https://www.cnn.com/2015/07/20/us/sex-trafficking/index.html
Who buys a trafficked child for sex? Otherwise ordinary men.
https://www.usatoday.com/story/opinion/nation-
now/2018/01/30/sex-trafficking-column/1073459001/
• Approximately 300,000 children are at danger of
getting involved in sexual exploitation in the
United States every year (Adams, Owens, &
Small, 2010).
• Average age of entering into the prostitution is
between 12 to 14 years old (Reid & Jones, 2011).
• Recent studies show that pimps/traffickers
control the majority of CSEC victims in the
United States (Reid, 2014).
Statement Of Problem
• Brannigan and Van Brunschot (1997) found that, in comparison to their
peers, youth who were engaged in prostitution reported more negative
characteristics in their parental home lives, more physical and sexual
abuse, parental alcohol or drug abuse, and unstructured families.
Abusive history and CSEC
• Lloyd (2011) revealed that 70–90%
of young women who are engaged in
prostitution have experienced sexual
abuse in their past.
• Children who have a history of neglect and
physical abuse often demonstrate insecure
attachment style (Egeland & Sroufe, 1981).
• Chronic consequences of childhood sexual
abuse in victims is linked to behaviors and
symptoms of adults who have insecure
attachment styles (Alexander, 1992).
Abusive history and attachment style
• Damaged view of self and others leads to losing the
sense of control and action in relationships. Victims
of maltreatment believe that other people are not
trustworthy and the whole world is a hazardous place
(Herman, 1992).
• Shame-based beliefs make victims feel unloveable, so
they think people cannot care about them (Carnes,
1997).
• Insecure attachment styles are related to
experiencing negative relationships and emotions
(Beech & Mitchell, 2005; Shaver & Clark, 1994;
Shaver & Hazan, 1993).
Consequences Of Damaged Attachment
Saba Borjianboroujeni examined the pimping relationship through
the lens of attachment theory for her master’s study.
To examine the nature of the pimping relationship between sex
traffickers and victims, this study implemented semi-structured
interviews with fifteen participants.
CSEC Research Study: Dr. Ulibarri and Dr. Ulloa
Participants were stakeholders who work
with CSEC victims including law enforcement
officers, service advocates, and educational
specialists that include CSEC survivors.
Each interview last between 45 to 60
minutes and were conducted by Dr. Ulloa
and Dr. Ulibarri.
Template analysis (TA) is a process in which we can organize and
analyze textual data based on the themes (King 1998; King et al.
2002).
The transcriptions of semi-structured interviews with 15 CSEC
stakeholders revealed six themes that continued to resurface during
the analysis of the data.
Data Analysis
• 14 out of 15 participants referred to having a history of abuse as a
significant risk factor
• Broken families, participant #13 stated “if you really want to get down to
the nitty-gritty umm what really makes them at risk in that trauma is going
back to childhood and doing more prevention more on developing safe
healthy families and reducing childhood trauma.”
• Participant #14 also said “sexual abuse is obviously also one of the risk
factors, so when people are sexually abused they get a lot of attention,
and they think that’s love and attention.”
Theme 1: Abusive History
• 12 participants referred to negative self-image as a characteristic found in victims.
• Participant #6: “I already had that mentality of prostitution, yeah um, it stayed
with me, I had no worth, I had no direction, I had no purpose other than to serve
others for there were nothing for me. And that grow into my adult life and there I
was.”
Theme 2: Self-image
• Participant #4: participant #8 referred to low self-worth as a consequence of early
sexual abuse, “I think the girls who have victimized early on, they take on all kinds
of other issues that come around them like drug abuse is one big one, then the
emotional health, they have a very low sense of self-esteem and they don’t, they
feel they deserve everything wrong. They really truly believe they deserve just
junk, they are not worth anything.”
• Participant #1: “Because they’ve been hurt I guess for lack of a better word
so many times and deceived umm so many times that you can’t do anything
to me that somebody else hasn’t already done so shut the “f” up, you
know? So that takes time to break that.”
• Participant #6: “As far as my relationships go with friends, I had them I
wanted them I didn’t know how to interact with them, I didn’t know how, I
didn’t know how I can actually be that open to anybody about what my
inner trouble was, what my hidden trauma was, what I was going through at
home, what my secrets are, how do you trust anyone with that and carry
out with me through my adult life.”
Theme 3: Other image
• 14 out of 15 participants talked about how victims did not have someone to
bond with.
• Participant # 12 said, “That is a manipulation and she’s seeking that, an
unhealthy attachment because she just doesn’t have a healthy attachment
from her home life. Because these children seek for a sense of belonging
and attachment to love.”
Theme 4: Unhealthy attachment
• Trauma bonding theory states that in an abusive relationship, power imbalance and
extreme intermittent maltreatment lead to the development of a strong emotional
attachment in the victim (Dutton & Painter, 1993).
Theme 5: Trauma bonding
• Participant #10 described pimps’ behavior as, “you and I don’t understand that but
they do they know that they have a place to stay at night. They have someone that
maybe beats them up during the day and loves them at night but they would have
been removed from that, they don’t have anything.”
• Participant #10 stated, “They [pimps] want to disorient that female. They want to
get her to another area. They take her here and move her to Orange County. She
doesn’t know Orange County. They’re gonna get her out of the city that they don’t
have any way to contact anybody. They don’t feel safe. There is no running away.”
• 7 participants mentioned that pimps know that girls are at risk for
developing trauma bonding toward them and that they know how to play
their roles to form this bonding.
• Participant #10 said, “You pick that right victim who doesn’t have any self-
esteem that has had issues in her life and you give them this opportunity
the pimp give her this opportunity, within two days they are able to get
that little girl to go out and sell herself.
Theme 6: Trafficker’s strategies
• Responses from stakeholders in the present study support the existence of
trauma bonding between CSEC victims and pimps.
• Participant #14 said, “I think some of the protective factor would be some
adult connection be it a teacher, a sports coach, the lady down the street, a
young adult, maybe somebody that they trust.” (prevention tool)
• Ten participants mentioned that having an attachment to a special someone
could be a protective factor. For example, participant #14 said, “I think some
of the protective factor would be some adult connection be it a teacher, a
sports coach, the lady down the street, a young adult, maybe somebody
that they trust.” (intervention tool)
Some Discussion Points
Extra Credit for CFD537
Spotlight (2015) Movie Analysis
Worth up to 10 points
This movie is about a team of reporters from the Boston Globe and their investigation into allegations of
sexual abuse of children in the Catholic Church. The movie describes an investigative process that
started with investigating one priest, Father John Geoghan, accused of molesting more than 80 boys,
and led to the realization that decades of abuse by over 80 priests had occurred and that senior
members of the Church were involved in a cover-up.
Answer the questions below, referring to lectures, as well as, other readings.
1. Discuss grooming techniques described by victims. Describe scenes in which victims refer to the
pornographic cycle, and describe messages the priests said to victims that were enticing and
threatening.
2. In the scene in which a journalist (Sacha Pfeiffer) interviews Father Ronald Paquin, the priest
justifies his actions by claiming that, “Sure, I fooled around. But I never raped anyone and I
never felt gratified myself. . . .” Paquin also claimed that he had been raped by other boys and
by a priest when he was a child. Relate this information to the textbook’s discussion of the
definition of sexual abuse, and to research on perpetrators’ history of victimization and trauma.
3. Discuss parents’ and families’ relations with priests that allowed the children access to the
priests.
4. The chief editor at the Boston Globe, Marty Baron, wants proof of systemic abuse by the Boston
Archdiocese. What does he mean? Besides the Church, describe how other systems (e.g.,
journalism, criminal justice) contributed to the continued abuse by priests.
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
https://www.tandfonline.com/action/journalInformation?journalCode=wwat20
https://www.tandfonline.com/loi/wwat20
https://www.tandfonline.com/action/showCitFormats?doi=10.1080/02703149.2016.1205908
https://doi.org/10.1080/02703149.2016.1205908
https://www.tandfonline.com/action/authorSubmission?journalCode=wwat20&show=instructions
https://www.tandfonline.com/action/authorSubmission?journalCode=wwat20&show=instructions
https://www.tandfonline.com/doi/mlt/10.1080/02703149.2016.1205908
https://www.tandfonline.com/doi/mlt/10.1080/02703149.2016.1205908
http://crossmark.crossref.org/dialog/?doi=10.1080/02703149.2016.1205908&domain=pdf&date_stamp=2016-10-03
http://crossmark.crossref.org/dialog/?doi=10.1080/02703149.2016.1205908&domain=pdf&date_stamp=2016-10-03
https://www.tandfonline.com/doi/citedby/10.1080/02703149.2016.1205908#tabModule
https://www.tandfonline.com/doi/citedby/10.1080/02703149.2016.1205908#tabModule
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 paola_contreras@williamjames.edu One Wells Avenue Newton, MA
02459, USA; Diya Kallivayalil dkallivayalil@challiance.org 1493 Cambridge Street Cambridge, MA 02139, USA.
© 2017 Taylor & Francis Group, LLC
http://dx.doi.org/10.1080/02703149.2016.1205908
mailto:paola_contreras@williamjames.edu
mailto:dkallivayalil@challiance.org
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
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.
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).
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, 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.”
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 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.
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.
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.
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
http://dx.doi.org/10.1186/1471�244x-13�204
http://dx.doi.org/10.1177/097185240701200106
http://dx.doi.org/10.1080/03906701.2010.511886
http://dx.doi.org/10.1080/03906701.2010.511886
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.
http://dx.doi.org/10.1037/0021�843x.109.1.69
http://dx.doi.org/10.1002/jclp.20015
http://dx.doi.org/10.2979/meridians.12.1.208
http://dx.doi.org/10.1177/1077801210367643
http://www.globalslaveryindex.org/report/#view-online
http://dx.doi.org/10.1016/j.beth.2011.04.001
http://dx.doi.org/10.1002/jclp.21959
http://dx.doi.org/10.1016/s0160�2527(97)00016�2
http://dx.doi.org/10.1016/s0160�2527(97)00016�2
http://dx.doi.org/10.1177/1473325011435257
http://dx.doi.org/10.1177/0020872813505630
http://dx.doi.org/10.1632/pmla.2012.127.4.835
http://dx.doi.org/10.1632/pmla.2012.127.4.835
http://dx.doi.org/10.1177/1077801209335493
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
http://dx.doi.org/10.1002/imhj.20033
http://dx.doi.org/10.1016/j.ijgo.2009.06.002
http://dx.doi.org/10.1080/08974451003641081
http://dx.doi.org/10.1080/08974451003641081
http://dx.doi.org/10.1080/08974451003641321
http://dx.doi.org/10.1016/j.ejpoleco.2008.11.002
http://dx.doi.org/10.1016/j.ijgo.2010.11.009
http://dx.doi.org/10.1016/j.ijgo.2010.11.009
http://dx.doi.org/10.1300/j015v26n03_06
http://dx.doi.org/10.1177/1077801204268607
http://dx.doi.org/10.1177/1077801204268607
http://dx.doi.org/10.1300/j189v02n03_03
http://dx.doi.org/10.1037/a0022645
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.
http://dx.doi.org/10.1177/1363461507081635
http://dx.doi.org/10.1016/j.ijgo.2012.08.019
http://dx.doi.org/10.1016/j.ijgo.2011.03.005
http://dx.doi.org/10.1016/j.ijgo.2011.03.005
http://dx.doi.org/10.1177/1077559509355315
http://dx.doi.org/10.1177/0886109912475172
http://dx.doi.org/10.1002/cpp.636
http://dx.doi.org/10.1007/bf02116830
http://dx.doi.org/10.1353/hrq.2004.0021
http://dx.doi.org/10.1177/1077801205274450
http://dx.doi.org/10.2105/ajph.2009.173229
http://dx.doi.org/10.1016/s0924�9338(13)77248�1
http://dx.doi.org/10.1016/s0924�9338(13)77248�1
http://dx.doi.org/10.1002/(sici)1099�0852(199705)6:2<94::aid-car310>3.0.co;2-i
http://dx.doi.org/10.1002/(sici)1099�0852(199705)6:2<94::aid-car310>3.0.co;2-i
http://dx.doi.org/10.1111/j.1468�2435.2012.00777.x
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
http://dx.doi.org/10.1007/s12117�005-1035�7
http://dx.doi.org/10.1080/02703140802145540
http://dx.doi.org/10.1080/08164649.2011.606602
http://dx.doi.org/10.1080/08164649.2011.606602
http://dx.doi.org/10.1007/s12117�010-9107�8
http://dx.doi.org/10.1007/s12117�010-9107�8
http://dx.doi.org/10.1111/j.2044�8309.2011.02061.x
http://dx.doi.org/10.1001/jama.300.13.1551
http://dx.doi.org/10.1080/10481885.2012.701140
http://dx.doi.org/10.1007/s11524�013-9837�4
http://dx.doi.org/10.1177/1524838012440340
http://dx.doi.org/10.1177/1524838010390709
http://dx.doi.org/10.1111/1468�2397.00063
http://dx.doi.org/10.1002/cpp.659
http://dx.doi.org/10.1080/09658211.2012.680962
http://dx.doi.org/10.1521/psyc.2005.68.2.95
http://dx.doi.org/10.1521/psyc.2005.68.2.95
http://dx.doi.org/10.1002/jts.2490030110
http://dx.doi.org/10.1016/j.ijgo.2010.04.016
http://dx.doi.org/10.1177/1077801207301614
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
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.
http://dx.doi.org/10.1080/13575270802268059
http://dx.doi.org/10.1177/0886260512469102
http://dx.doi.org/10.1177/0002716214521556
http://dx.doi.org/10.1177/0002716214521556
http://dx.doi.org/10.5820/aian.1901.2012.37
http://dx.doi.org/10.1002/acp.1689
http://dx.doi.org/10.1080/08974451003641172
http://dx.doi.org/10.1002/jcop.20225
http://dx.doi.org/10.1002/jcop.20225
http://dx.doi.org/10.1111/j.1750�8606.2008.00035.x
http://dx.doi.org/10.1080/08974451003641065
http://action.web.ca/home/catw/attach/CATW%20Comparative%20Study%202002
http://action.web.ca/home/catw/attach/CATW%20Comparative%20Study%202002
http://dx.doi.org/10.1080/08974451003641206
http://dx.doi.org/10.1016/j.avb.2012.02.005
http://dx.doi.org/10.1177/0886109910364362
http://dx.doi.org/10.1177/1557085106294845
http://dx.doi.org/10.1177/0734016806290136
http://dx.doi.org/10.1111/0735�2751.00089
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
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
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
http://dx.doi.org/10.1353/hrq.2007.0011
http://dx.doi.org/10.1016/0145�2134(81)90050�8
http://dx.doi.org/10.1093/infdis/jir540
http://dx.doi.org/10.1080/08974451003641438
http://dx.doi.org/10.1023/b:jots.0000048959.29766.ae
http://dx.doi.org/10.1037/0033�295x.107.3.411
http://dx.doi.org/10.1016/j.socscimed.2007.12.025
http://dx.doi.org/10.1037/a0024929
http://dx.doi.org/10.1037/a0024929
http://www.uncjin.org/Documents/Conventions/dcatoc/final_documents_2/convention_%
http://www.uncjin.org/Documents/Conventions/dcatoc/final_documents_2/convention_%
http://www.justice.gov/crt/about/crm/trafficking_newsletter/tvpaanniversaryreport
http://www.justice.gov/crt/about/crm/trafficking_newsletter/tvpaanniversaryreport
http://dx.doi.org/10.1007/s10508�006-9044�4
http://dx.doi.org/10.1111/j.1545�5300.2010.01305.x
http://dx.doi.org/10.2105/ajph.86.11.1607
http://dx.doi.org/10.1177/00030651040520042001
http://dx.doi.org/10.1300/j059v18n02_03
http://dx.doi.org/10.1080/19361520802702191
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.
http://dx.doi.org/10.1093/rsq/hdr007
http://dx.doi.org/10.1093/rsq/hdr007
- The Experiences of Trafficked Women and Girls
Vulnerabilities
Trafficker’s Psychological Coercion Tactics
The Relational Consequences of Human Trafficking
Traumatic Bonding
Trafficking-Specific Marginalization, Stigma, and Abuse
Shame and Mental Health Symptoms
Psychotherapy Vignettes with Survivors of Trafficking5
Maria: Secrecy, Shame, Stigma and Self-Identification
Diane: Control and Shame
Li: Agency, Vulnerability, and Revictimization
Discussion of Case Vignettes
Recommendations for Psychotherapists and Conclusions
Notes
References