NEW RESEARCH: Trauma intervention in exit recovery programs for women affected by commercial sexual exploitation.

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By HerSpace CEO & Founder, Emily Hanscamp

View original article here: http://community.borderlands.org.au/index.php/joomlaorg/browse-by-issue/196-issue/issue-52


As a practicing social worker with 8 years’ field experience, currently practicing as a Mental Health Social Worker and trauma counsellor, I have engaged with over 100 girls and women affected by commercial sexual exploitation (CSE) in Melbourne, Mumbai and Manila. I have been struck by the impact of trauma in their lives and the lack of services available to support them in addressing it. My observations in this regard are mirrored in the research. For programs to be effective in supporting women to heal, recover and exit CSE, the academic literature suggests that resulting trauma must be addressed (Abas et al., 2013; Hom & Woods, 2013; Macias Konstantopoulos et al., 2013; Rafferty, 2013). My experience and the insights of the literature prompted me to explore whether any programs supporting women affected by CSE that include trauma interventions exist anywhere in the world and, if so, whether they have been evaluated with appropriate evidence.

Violence and abuse that is equivalent to torture mark the vast majority of women’s experience of prostitution and these experiences prevent women from freely choosing to enter and exit the industry (Cecchet & Thoburn, 2014; Devine, 2009; M. Farley, Baral, Kiremire, & Sezgin, 1998; Harvey, 2008; Johnstone-Petty, 2010; Kurtz, Surratt, Kiley, & Inciardi, 2005; Le, 2014). Physical assault, rape, murder and verbal harassment are reported by women in the sex industry throughout the UK, Norway, the US and Canada, where M. Farley et al. (1998) found 76% of women surveyed meeting criteria for Post-Traumatic Stress Disorder (PTSD) and mortality rates for women in the sex industry 40 times higher than the national averages in these countries. In the US, depression and anxiety are reported by women accessing services at the extremely high rate of 96.7%, PTSD at 93.3% and complex PTSD at 63.3% (Long, 2014). Symptoms of PTSD and other psychosocial issues suffered by women include depression, anxiety, nightmares, self-harming behaviours, dissociation, learned helplessness, internalized blame, helplessness, decreased self-esteem, feelings of fear, horror, anger, guilt and shame, alongside numerous psychological, emotional and social issues (Buonaugurio, 2014; Cecchet & Thoburn, 2014; Hernandez, 2014; Hom & Woods, 2013; Hossain, Zimmerman, Abas, Light, & Watts, 2010; Min, Lee, Kim, & Sim, 2011; Sloss, 2003; Valera, Sawyer, & Schiraldi, 2000; Warshaw, 2010). These symptoms compound existing structural barriers to exit and increase the risk of re-entry and re-trafficking post exit (Buonaugurio, 2014; Cecchet & Thoburn, 2014; Devine, 2009; Hom & Woods, 2013; Jobe, 2010; Johnstone-Petty, 2010; Kelly, 2005; Nelson, 2009; Roe-Sepowitz, Hickle, & Cimino, 2012; Warshaw, 2010).

In addition, a policy context surrounding sexual exploitation is necessary to understand the lived experience of victim-survivors and programmatic approaches in response. Globally, a variety of different jurisdictions exist framing policy for this issue; CSE is legal or illegal, criminal or de-criminalised, the Nordic model offering an alternative where purchasing sex is criminal and its selling de-criminalised. Only the latter model embeds exit programs in policy, all other frameworks offering no legislated responses to support victim-survivors. Due to the variance in policy frameworks, documenting this issue from a prosecution and legal standpoint becomes virtually impossible. Examples of this include an Australian parliamentary inquiry into sexual servitude in 2004, estimating between 300 and 1000 women trafficked into Australia annually and a UK report estimated between 142 and 1420 women trafficked into the UK annually (Kelly & Regan, 2000). The lack of consensus regarding the extent of the issue may provide an explanation for minimal efforts put into developing and implementing programs to address CSE.

Based on the evidence of high levels of psychological issues symptomatic of trauma consequent of sexual exploitation, scholars and practitioners alike have made strong recommendations that therapeutic interventions be incorporated into exit recovery programs to address these impacts (Abas et al., 2013; Arnstein, 2014; Hossain et al., 2010; Johnson, 2012; Leidholdt, 2013; Sloss, 2003). Scant evidence as to whether the recommendations are being implemented in programming exists, however, and whether therapeutic interventions are being analysed as to their impact in women’s lives (Bruhns, 2014; Buonaugurio, 2014; Harvey, 2008; Hom & Woods, 2013). In this article, I document the extent of therapeutic interventions present within exit recovery programs and identify if their impact has been assessed.

Most literature focuses on describing the psychosocial impacts of CSE including trauma, PTSD, violence and sexual assault, physical, sexual and mental health problems and risk factors for mental health diagnosis (Abas et al., 2013; Acharya, 2014; Hom & Woods, 2013; Le, 2014; Mayfield-Schwarz, 2007; Nelson, 2009; Oram, Stöckl, Busza, Howard, & Zimmerman, 2012; QuADArA, 2008). A less extensive group of works develops advise for CSE-sensitive and specific services; they recommend avoiding a focus on exit as the main goal; a multi-systemic approach; welfare provision; rehabilitation and reintegration services; targeted prevention strategies and residential facilities for minors (Clawson & Goldblatt Grace, 2007; Cusick, Brooks-Gordon, Campbell, & Edgar, 2010; Hanley, 2004; Shigekane, 2007; Thorburn, 2014). Factors associated with causes, risks, prevention, recovery and exit are also extensively examined (Bruhns, 2014; Hu, 2011; Shigekane, 2007) as-well as service utilization and barriers to engagement (Hanley, 2004; Kurtz et al., 2005; Sloss, 2003). Some articles offer specific practice examples, such as music therapy, integrative therapy and peer-led models (Hotaling, Burris, Johnson, Bird, & Melbye, 2004; Napoli, Gerdes, & DeSouza-Rowland, 2001; Rabinovitch, 2004; Schrader & Wendland, 2012).

Like the present study, a number of works offer an overview of programs and interventions; of the 8 articles, 6 relate solely to sexual trafficking, not incorporating a broader view of the issue as suggested by the term CSE, a framework encompassing all legal and illegal aspects of the local and international ‘sex industry’. A single study examines a program for sex-trafficked minors and only one research report assesses services for victims-survivors of CSE as is the intent of the present study. In the latter study, Wilson, Critelli and Rittner (2015) focus on a review of trans-national responses to CSE throughout the US and India, highlighting the lack of literature on existing interventions and the need to evaluate efficacy.

Given the documented interconnections between all aspects of the ‘sex industry’ and sex trafficking, showing how one fuels and perpetuates the other (Farley, 2007), it is surprising that more literature about programs for all CSE survivors (and not just trafficking victims) is available and no analysis as to why the sole focus on trafficking exists. I wonder whether it relates to the common perception I encountered when working in the field that – compared to trafficked women – those identified as ‘functioning’ in other facets of the ‘industry’ are perceived as having ‘decided’ to be in their respective positions and therefore being less in ‘need’ and ‘worthy’ of service support. Trying to move beyond these perceptions, this study examines services for women in all facets of CSE, based on the premise that all women should have access to services regardless of their more specific circumstances.

Similar to the present study, the 8 studies provide information about services around the world, mostly focusing on the US; NGO activity against trafficking globally includes repatriation, reintegration, accommodation, counselling, outreach, legal, financial and vocational training (Tzvetkova, 2002). Almost no literature on existing interventions in programs in the US and India is available nor any evaluation of their efficacy (Wilson et al., 2015). Post exit services, residential services, economic empowerment, rehabilitation programs, peer-support models, behaviour modification and trauma-focused intervention are amongst services found in Indian and US surveys (Wilson et al., 2015). An analysis of Nigerian social rehabilitation programs comparing government, social welfare and faith-based models found a combination of faith and social welfare models most effective (Aborisade & Aderinto, 2008). In South-East Asia, Hu (2011) claims trafficking after-care services need to more intentionally incorporate the cultural value of community and connectedness. Finally, a study based in Melbourne, Australia found young people engaged in ‘commercial sexual activity’ access services that meet their immediate needs, such as obtaining clean needles and condoms (Hanley, 2004).

Research documenting community and economic development programs offered to women in the sex industry mostly discuss their sex-work harm reduction aspects, including microenterprise and skill-based income-generating programs alongside HIV prevention and risk reduction education (Sherman, German, Cheng, Marks, & Bailey-Kloche, 2006). Microenterprise programs are most common throughout developing countries and are especially effective in slums, one study in a Kenyan slum reporting that two-thirds of participants set up operational businesses and 50% stopped sex work (Odek et al., 2009). Community development responses are most often applied to the commercial sexual exploitation of children and little has been written on programs for women.

Studies of programs in the US include Long’s (2014) review all sex trafficking services in the US, who found few programs providing direct services sensitive to the needs of survivors; 73% of services offered on-site counselling including Dialectical Behavior Therapy, Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) and Trauma Focused Cognitive Behavioral Therapy, but Long (2012) did not provide any program description or analysis of impact. She did find, though, a significant lack of mental health professionals trained to understand human trafficking and its impacts (Long, 2014). A review of aftercare services for international sex trafficking survivors in the US highlighted how few services for trafficking survivors exist. Macy and Johns (2011) reviewed all services for international sex trafficking survivors in the US, finding them lacking; they recommend a trauma-informed approach and a continuum of care, to address survivors’ changing needs, moving from recovery to independence. Focusing on rehabilitation and reintegration for victims-survivors of trafficking in the US, Shigekane (2007) provided recommendations to address cultural barriers preventing survivors seeking help and for the provision of culturally-appropriate services. A review of rehabilitation centres across the 50 states of the US found 10 rehabilitation centres for Domestic Minor Sex Trafficking survivors aged 11 or older, 5 offering information about their services, listing housing, medical and health, legal, substance abuse, mental health, job and life skills training (Twigg, 2012). The rehabilitation centres did not mention the provision of trauma services and no specific information about their mental health supports.

Whilst the 8 articles review exit recovery services globally, few discuss CSE, focusing on sex trafficking only and none offering a focus on therapeutic interventions specifically. To address this gap, this review examined documented examples of exit-recovery programs in the academic literature and surveyed them for recorded evidence of therapeutic trauma interventions for women affected by commercial sexual exploitation.

Programs supporting women, girls and children affected by CSE are described in the literature as rehabilitation, repatriation, rescue, exit or residential treatment programs and are referred to as ‘Exit Recovery Programs’. Among practitioners, this term refers not only to programs for women exiting CSE, but also those recovering from and/or surviving in it. In relation to interventions addressing psychosocial impacts, the terms counselling, therapy, psychological and mental health support and trauma intervention were all understood as indicating some form of trauma intervention; therefore, articles about CSE programs containing these terms were all included in the present sample.

Limitations

This scoping study sourced data from academic sources through online search engines, and is therefore limited in that undocumented CSE treatment programs have not been included. It was not possible within the scope of the current study with its resource and time limitations to conduct field research, which is recommended for any future studies extending the findings of this research. A second limitation is the extent to which each program was described in the literature. As many programs were not outlined in detail, it may be they have therapeutic components but these simply were not included within their descriptions. Finally, since the time documents were written, programs mentioned may have changed, expanded or concluded their services. These final two limitations could be addressed through field research, which would gain up-to-date and detailed insight into programs.

Method

Program Search

I selected a number of key terms to search the literature, covering all variations of the areas of the topic, including the population group, the issue of CSE, impacts of CSE and programs addressing impacts. There were a total of 17 terms used to create various combinations and searches with all combinations were conducted in each search engine. I examined reputable social science search engines including ProQuest, EbscoHost, Taylor and Francis, Informit, Wiley Online Library, Contemporary Women’s Issues and Google Scholar.

The criteria for inclusion as a ‘program’ for analysis are that mention is made in the title or abstract of all of the following:

  • Population: Women, girls, females or children;
  • Issue: Mention of issue of CSE and/or its impacts;
  • Program: A specific program approach to addressing impacts of CSE.

Of course, if the examined article did NOT include reference to therapeutic intervention or its evaluation, this would not mean that the program in question would fail to undertake such activity.

Results

The searches resulted in 19 articles responding to the 3 above sample criteria in relation to a specific program; of the 19, 9 referred to a program without a therapeutic component, 5 included some form of therapeutic intervention and of these ,4 had been assessed for impact in women’s lives.

Among the 9 articles found describing exit-recovery programs for women affected by CSE, 3 examples of training programs for professionals working to support adolescent and minor victims of sex trafficking were found (Arnstein, 2014; Christian, 2014; Cohu, 2012). Programs focused on supporting law enforcement, criminal justice, social services and youth shelters (Christian, 2014), training professionals directly treating adolescent girls (Arnstein, 2014) and offered holistic prevention to the Los Angeles County Department of Children and Family Services (Cohu, 2012). Arnstein (2014) collaborated with staff at the STOP-IT program (see below) in Chicago developing a training manual.

Residential programs in the US for minors victims of sex trafficking are scarce, with five examples cited in the Clawson and Goldblatt Grace (2007) review including Educational and Mentoring Services (GEMS), Transition to Independent Living (TIL), Standing Against Global Exploitation (SAGE) Safe House, Children of the Night and Angela’s House. Programs had between 6-24 beds with a length of stay of 3-6 months but with flexibility, some claiming 18 months being the necessary time to begin rebuilding women’s lives. High security, safety planning provision and female staff were core components of the program structure and both SAGE and GEMS prioritise hiring staff that are survivors themselves. Services offered included trauma-informed care, medical screening, life and job skills training and youth development and education programs. All services agree trauma-informed care and ongoing mental health services are necessary, listing cognitive behavioural therapy (CBT), dialectical behavioural therapy (DBT) and eye movement desensitization and reprocessing (EMDR) as examples. It remains unclear, however, whether residential programs themselves provided these programs, simply stating that they agree on the ‘need for’ them; I thus assume that the residential programs do not directly provide such treatments as yet.

Exit programs for ‘sex workers’ in the UK focus on the provision of accommodation, court diversion and drug treatment in early phases of support. Street-based sex workers are the main beneficiary group, though programs are intended for all sex workers (Cusick et al., 2010); having attempted to contact indoor sex workers, they found that the latter were particularly difficult to reach and often rejected services, leading services to focus on street sex workers. From my own field experience, whilst indoor sex workers may at first appear to not be in need of services or ‘reject’ them, when an ongoing relationship can be build, they will be more able to trust, open up and, in fact, admit to needing support. I have learned from women I counselled that they need to ‘put a brave face on’ in the brothel environment and cannot show weakness due to the pressures put on them by brothel owners, managers and madams and the bullying that can occur between co-workers. It is true that street sex workers are easier to reach due to their visibility and their needs are more overt; however, this does not render indoor sex workers in lesser need of support and there is no information available about any planned or intended service improvements benefitting indoor sex workers.

Further relating to the UK programs, only 6 of 26 services listed ‘exiting services’ as their current focus, the remainder describing their approach to intervention as harm reduction (Cusick et al., 2010). Sex worker choice was foundational to all projects and Cusick et al. (2010) suggest that the UK government focus on exiting is an ineffective approach to intervention, recommending that exit services to be offered within a wider, more holistic service approach.

Two services offering practical intervention and training/educational support were found; firstly, providing comprehensive services to survivors of human trafficking, the STOP-IT program in Chicago aims to support women to exit exploitation (Wirsing, 2012). STOP-IT also provides outreach and training to local community professionals. The program addresses ‘common needs’: support, legal assistance, safe housing, education, documentation, employment, health, child care, transport, safety planning and material aid in partnership with other services. Wirsing (2012) does not provide an analysis of the program concerning its impact in the lives of service users and without evidence base it remains impossible to ascertain the success of this program and its approach. Secondly, Rajan (2013) interviewed former residents of the SAANLAP shelter home 5 years, capturing their experience before, during and after sex trafficking in Kolkata India. This shelter home provided vocational training and education while women waited for their trial dates to testify against madams and traffickers. Women described feelings of despair, hopelessness, self-loathing shame and suicidality during trafficking and post-rescue. Though these emotional effects of trauma were described as persistent, devastating and causing physical health issues, SAANLAP did not have any mental health services and therapeutic interventions. Rajan (2013) suggests that post-rescue services in developing countries can become more effective by replicating the mental health services of developed countries. From my own experience working in the field in the Philippines and India and having visited SAANLAP myself, I would echo Rajan’s (2013) suggestion. Working in an anti-trafficking organization in the Philippines in 2010, its shelter homes contracted a single psychologist, available one day a week for 100 residents. The women’s collective in Mumbai I worked with from 2009-2014 did not offer any therapeutic services, focusing on education, training and harm minimisation interventions. Women who were supported into alternative livelihood options would often fall back into work in the red light area, along with drug and alcohol addiction and, as a practitioner observing this, I wondered whether unaddressed trauma, due to lacking therapeutic support, could be related to recidivism.

Survivor-led peer models are also key to programs discussed in the literature. The prostitutes’ empowerment, education and resource society (PEERS) in Canada has been developed, managed and staffed solely by survivors offering services for those in the ‘sex trade’ regardless of their intentions to remain or exit (Rabinovitch, 2004). This model is based on the belief that for trust to be built, it is essential that staff are survivors themselves, understanding their experience, culture and challenges in a personal way (Rabinovitch & Strega, 2004). PEERS has identified a number of key areas needed for success: choice, capacity building, harm reduction and trust, a key being to hold no judgment or expectations concerning the choice of women who receive services. PEERS has a significant impact with 86% of service users eventually exiting the sex trade and moving on to alternative training, education and employment programs for which women are paid an hourly wage; the service is based on a harm reduction and relational approach, offering 3 month pre-employment and life skills training programs and an education program regarding myths and stigma associated with the sex industry and risks, dangers and long-term effects of being involved, and how to access support. PEERS also runs Community Empowerment Vision workshops for Indigenous women.

The PEERS program subscribes to a strengths-based philosophy, seeing women as skilled and resilient and steers away from all pathologising, intentionally not having a focus on therapy (Rabinovitch & Strega, 2004). However, Wilson et al. (2015) question if peer-based models are applicable in all socio-cultural settings, due to low literacy levels, combined with discrimination and stigma characteristic of women in the sex industry, most relevant to developing countries; they also highlight the lack of empirical evidence to prove the effectiveness of the peer-model. Rabinovitch (2004) highlights the risks for survivor staff, who are responsible for attaining program funding. In order to do so they need to tell and re-tell their stories to justify the program, which has implications for dissociation and posits the story of prostitution as their main identity. From my own practice experience, I have been able to build trust and rapport with women survivors, supporting them in their exiting journey whilst not being a survivor of CSE. I therefore also critique this model, not only because it can have re-traumatising impacts for survivors, but also because it negates the resources, skills and experience of all non-survivor practitioners, excluding them from this approach. There is of course a unique set of skills and knowledge that comes with personal experience and I believe it necessary to have the voices of survivors and service participants active in program development and implementation; however, I do not think an either/or approach should apply.

Another key example of peer programs is the Durbar Mahila Samanwaya Committee (DMSC), a community-based organisation made up of Sonagachi red light area sex workers (Jana, Dey, Reza-Paul & Steen, 2014). It was established out of an STI and STD prevention project in Kolkata, representing over 66,000 sex worker members in 49 branch committees. The DMSC run 32 educational activities in homes and schools, a cooperative savings scheme, 51 clinics and have 33 self-regulatory boards (SRBs). As a result of these efforts, significant reductions in sexual health issues have been documented. The DMSC established a prevention program for minors and women coerced into sex work, setting up community vigilance approaches to regulate entry into sex work, identify abuses and respond to coercion, implemented through the SRBs. The 15 years’ work of SRBs was reviewed and results found over 80% of successful rescues reported in West Bengal and conducted by SRBs and a decline of over 90% of the proportion of minors in Sonagachi red light area. The claim of this article and program is that sex workers themselves are more effective at intercepting the trafficking, coercion and exploitation of minors and unwilling women than regulatory bodies and other organizational efforts. This program makes no mention of steps following intercepting minor and coerced women and does not have a therapeutic component. I believe future research and reports should address how NGOs and government entities can learn from this model and collaborate with the DMSC, given the high success rates of their approach. I do not think it a sustainable or even ethical solution for sex-worker-run organisations to be the main group responsible for prevention, given the numerous challenges already facing this group and the weight of such responsibility.

Exit and recovery programs with a therapeutic component for women affected by CSE

Therapeutic interventions were listed amongst the services offered to victims of sex trafficking in the US; Long (2014) surveyed 30 organisations for services provided finding 29 offered counselling and 46.2% had the goal to incorporate more mental health services in future. Services reported using Trauma Informed Therapy, forms of Cognitive Behavioural Therapy; Dialectical Behaviour Therapy, Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) and Seeking Safety. Similarly, Twigg (2012) interviewed people at 4 rehabilitation centres, one of which articulated a trauma-informed model of treatment, the others describing strengths-based work, social work, empowerment and feminist therapy-based models. Services addressed immediate as well as ongoing needs, including life skills and job skills training and long-term housing. Neither study provided detailed descriptions of therapeutic programs or evaluative insight into the impacts or effectiveness of counselling.

In South-East Asia, narrative, cognitive, play and art therapy were used to address trauma in aftercare services (Hu, 2011), but only very minimal information about program content and no evaluation or analysis concerning effectiveness are mentioned. Music therapy in an aftercare centre for young girls in Cambodia was cited by Schrader and Wendland (2012), but program impact or effectiveness is not documented; the program involves music therapists from abroad training local practitioners and includes little information on work done with victim-survivors.

Two residential programs with a therapeutic component were found; the Mary Magdalene Home is the only organization in Alaska that specializes in dealing with women who have been sexually exploited. The program provides ‘a platform of physiologic, safety, social, and esteem needs support’ for women exiting prostitution (Johnstone-Petty, 2010); data concerning the perceived social and health needs of women at the Home identified nutrition, ability to shower, access to feminine hygiene products, homelessness, the experience of abuse, safety for children, employment and finance, spirituality, relationships, self-esteem, stigma and counselling. The study does not provide an analysis or description of the Home itself, but Johnstone-Petty (2010) observes that the program lacks evidence-based program strategies to support this population. A residential prostitution-exiting program in a southwestern state in the US is cited by Roe-Sepowitz et al. (2012), who surveyed women attending the program in their research. The program provided housing, employment, education assistance, weekly individual counselling and a psycho-education trauma-focused group called ‘Esuba’. The authors were interested to learn what influenced successful completion of the program and found that non-completers were more likely to report greater symptoms relating to trauma. They advise to incorporate trauma interventions into the residential program as well as other support programs. The findings of this study align with the outcome of Rajan’s (2012) research and my previous observations regarding the need for interventions to address trauma symptoms and decrease the risk of women returning to CSE.

Exit and recovery programs for women affected by CSE with a therapeutic component that have been analysed for impact in women’s exit and recovery pathways

Very few programs incorporated therapeutic interventions; of the 19 programs analysed, only 4 had undertaken any kind of evaluation or assessment of their therapeutic interventions. While, as mentioned, this probably underestimates the number of programs incorporating therapeutic intervention and the number undertaking evaluation, it still can be suggested that the impact of therapeutic intervention is understudied in the exit-recovery service sector. A total of 4 examples of programs addressing therapeutic needs and which have been evaluated for impact in women’s exit and recovery pathways from CSE were identified; they include a clinical psychology program in East London; the Healing Emotional Affective Responses to Trauma (HEART) model in a residential setting in the US; Integrative Therapy with a detailed case study of impact in a female ‘prostitute’s’ life; and Esuba, a psycho-educational trauma and abuse intervention group program. These will now be described in more detail.

The clinical psychology program for commercial sex workers in East London operates out of a sexual health outreach service ‘Open Doors’ and its first year of operation was documented by Stevenson and Petrak (2007). A Clinical Psychologist was made available for all users of the sexual health service, offering psychological support at dedicated sessions on Fridays and initial consults during outreach four times a week. Attending outreach allowed the psychologist to introduce herself, build rapport and break down stigma. Unlike numerous other services documented, Open Doors mainly reaches out to indoor premises and was problematic for street-based workers due to the lack of confidential space, something the report suggests needs more development. During its first year, 29 women were referred to the service, the majority of whom met the psychologist on outreach before attending a scheduled session; 7 referred themselves and another 7 did not attend the first session.

Presenting issues in sessions included problems related to sex working, depression/anxiety/not coping, complex and sexual health related needs and immigration and legal problems. Issues relating to sex working included violence, being unhappy in the job, exiting, fear of exploitation and self-confidence related to job options; depression and anxiety about unwanted pregnancy, assault, weight issues, self-identity, post-traumatic symptoms and loss and bereavement were all significant concerns for women. Complex needs and sexual health issues included substance misuse, dual diagnosis, sexual health concerns, sex addiction and negation of condom use. Interventions applied by the clinical psychologist included motivational interviewing, Cognitive Behavioural Therapy, Therapeutic witnessing and Solution Focused Therapy drawing on Strengths-Based approaches. Stevenson and Petrak’s (2007) study does not provide in-depth insight as to the impact of psychological services in women’s lives but documented its aim to do so in future; no additional studies can be found as yet. The study does provide valuable insight into effective tools of engagement with women for therapeutic services and the diverse range of women’s psychosocial needs requiring intervention.

The second case, the HEART model (Healing Emotional Affective Responses to Trauma) provides an emotional and spiritual framework for dealing with trauma based on Christian values and beliefs and therapeutic techniques (Jones, 2014). The model reconnects with memories of trauma and pain in order to re-live memories in a safe environment. The therapists use creative imagery to re-process trauma, which, they argue, allows emotions surrounding memories to lessen and be replaced by healthy coping skills. The aim is for women to be able to live with trauma without needing to engage in unhealthy coping mechanisms and move toward wellbeing. Jones (2014) captured the lived experiences of 8 service participants in a residential facility in the US, who had received counselling within the HEART model for up to 3 months. Participating women reported the model supported them to work through memories and emotions to move toward connecting to and accepting the past, engage in forgiveness of self, God and others and share a safe and non-judgmental space with the counsellor where they could share freely. Participants were able to build on coping skills, think more clearly, move forward with their lives, recognize triggers, manage impulses and cope with feelings instead of ‘numbing’ them. In particular Gestalt empty-chair work therapy, Rogerian non-directive counselling and Art Therapy approaches were mentioned. Overall, the safe, supportive, non-judgmental relationship with the counsellor was important to all participants. Jones (2014) did not conduct any pre- or post-therapy measures, however the first-hand account of women’s experiences indicate the HEART model’s effectiveness at addressing trauma in a number of ways. I have also seen Gestalt empty-chair work and Rogerian non-directive counselling resonate with survivors in my own practice, approaches that allow for a feminist approach where choice, rights and options can be given back to women as they receive therapy and moving intervention away from diagnostic, directive approaches that may lead to women feeling judged, stigmatized and pathologised.

Integrative Therapy is the third example of a therapeutic program with documented impacts, Napoli et al. (2001) providing a descriptive case study offering rich insight into first-hand experience of this therapeutic trauma intervention. The therapy is a type of psychological counselling designed to address the major after-effects of psychological abuse, being the dissociation from the body and self, powerlessness, low self-esteem, mistrust and fear of intimacy. The aim of this therapy is to re-create a connection between conscious choices and experiential awareness of body, sexuality, and emotional reactions. Napoli et al. (2001) claim traditional talk therapies are not successful due to the distorted reality consequent of dissociation. Integrative Therapy draws on body work (breathing, muscle relaxation), visualization and guided imagery to reintegrate memories and reconnect to physical body and emotions, support to deal with intense emotions, teaching techniques for self-protection and nurturing and the therapeutic impact of a safe environment with the therapist. The technique also uses letter writing, journaling, script changing, genograms and guided storytelling.

The case study presents the direct voice of ‘Bonnie’, sharing that the therapy validated and affirmed her experience, creating a strong rapport and allowing her to engage in therapy (Napoli et al. (2001). Bonnie was able to express how, through her experience of childhood abuse, her need for love and attention was not met; she understands how her dissociative self-harming behaviour expressed through prostituting herself had evolved. Through a guided process of visualizations, she re-processed memories of abuse, calling it ‘wrong’ and bringing in her adult-self to advocate for her child. She developed the capacity to love and stop abusing herself, as abuse had previously been confused with love; she describes feeling empowered, as she was able to use these visualizations as a tool independently from her therapist to make decisions that were self-protective. Bonnie was able to leave street prostitution and attributes this to Integrative Therapy.

The first-hand experience of Bonnie is a rare and valuable example of the lived experience of therapeutic intervention in a survivor’s life. Napoli et al. (2001), however, only captured a single case, premising their article on the assumption that prostitution is an individual choice. They offer no analysis of the social and systemic factors surrounding and oftentimes limiting women’s agency to choose. Further, the context within which therapy is provided is not clarified, lacking information about the nature of the broader program or organization or whether it was delivered privately. As well, there’s no information about the therapist and whether one of the authors is involved in the therapy, nor about the duration of therapy and whether there’s ongoing support post-therapy; these details would be useful to understand wider applicability of this program. An evaluation including additional participants with before and after measures would provide valuable insights about the impact of the intervention. Whilst I agree that, on their own, traditional ‘talk therapies’ are rarely effective when deep-seated trauma is present, in my experience, providing intervention such as psycho-education, interpersonal skill training, problem-solving skills and motivational interviewing can be effective in conjunction with non-verbal approaches. The journey of recovery is multi-faceted and complex, relating to cognitive, emotional, physical and social healing and the therapeutic response must accordingly draw on a number of tools to respond to each facet.

Finally, the ‘Esuba’ program is a psycho-educational trauma and abuse intervention group-program that follows three stages of trauma recovery: emotional and physical safety, remembrance and mourning and reconnection (Ward & Roe-Sepowitz, 2009). Esuba is founded on the facilitation of safe relationships between group facilitator and survivors, the authors conducting a quasi-experimental study to research the experiences of 29 participating women in a Southwestern state in the US. The psycho-educational component informs women of the impacts of abuse and the safe environment fostered by group facilitators allows women to share their experiences of these impacts in the healing process. The program involves 12 weeks of 2-hour sessions, offering definitions, scenarios and the legal frameworks relating to abuse, identifying and working through misconceptions about themselves and their experiences, such as self-blame and the internalization of a victim mentality. Impacts on relationships, self-perception, decisions and coping skills are discussed and through role plays, skits, ice breakers and true-and-false activities, their strengths and resilience are explored. Feedback is encouraged to bear witness to the pain and experiences of others. Safety is established with group members being able to offer feedback to other group members but only if it is supportive and expressed with positive regard. Grounding activities are incorporated to prevent group members leaving the group feeling vulnerable or dissociative and to avoid possible issues with sleep, focusing and controlling emotions, which may increase risk of self-harm, drug use or the desire to flee the program. The Ward & Roe-Sepowitz (2009) study found the Esuba program to be an effective intervention in decreasing trauma symptoms among all participating women. This group-therapeutic intervention offers a multi-faceted approach including psycho-education, bodywork techniques such as grounding, creative approaches like role-plays and a trauma-informed approach focusing on trust and safety among participants and with staff. Agreeing with the need for multi-faceted approaches addressing emotional, social, physical and mental aspects, I appreciate why this program was effective in addressing women’s complex trauma symptoms.

Discussion

There is a great amount of literature providing evidence of deep-seated psychosocial issues consequent of CSE in the lives of affected women and recommended interventions to address this trauma; it is, therefore, important to reflect on why so few programs implement the recommendations. Throughout the literature, service providers frequently comment on the lack of resources, program design and appropriately trained and qualified professionals needed to provide therapeutic programs. These are interconnected issues, as without funding, programs cannot be piloted, tested and developed and professionals have no opportunities to learn and apply new skills. In the 140 articles relating to this topic including in my search, none explored reasons for the dearth of programs, the literature only identifying the need for them and the minimal resources available.

Based on my experience, there are two possible reasons for the challenges in acquiring funding; first, exiting CSE is a complex, convoluted process and the necessary therapeutic trauma interventions are no quick-fix services; rather, they are long-term endeavours, the results of which are difficult to quantify (Baker, Dalla, & Williamson, 2010). It might take several months or even years of support for a woman to recover and heal and the journey is unlikely to be linear; rather it is a complex process with ups and downs, as past experiences are integrated, re-processed and new plans for the future made and acted upon. It is difficult to argue the efficiency of such approaches as inner healing is challenging to quantify, whilst material aid and harm minimization programs display more immediate and quantifiable results. Second, the complex social structures surrounding women’s lives, and the issues of sexual exploitation and the ‘sex industry’ themselves; to address these issues, their reality must first be accepted and understood and this may be confronting for many groups, communities and individuals. As to the need for trauma interventions specifically, the first step toward resourcing and supporting these programs is appreciating the psychologically and emotionally damaging nature of CSE in women’s lives. Social and political discourse surrounding this issue frames many forms of CSE, such as prostitution and sex work as a ‘profession’ (in many countries legitimate and legal) and the choice for ‘customers’ to ‘consume’ its ‘professional’ ‘services’ (Rabinovitch & Strega, 2004). Such framing does not align with the acceptance of trauma consequent of this ‘work’, as no legitimate profession, properly regulated, is acceptably causing such horrific violence, abuse and damage in a person’s life. If services were to be established to address them, this would have legislative and policy implications for government, possibly prohibiting the business of the sex industry as a non-legitimate commercial enterprise.

Given the above complexities, it might be obvious why the many recommendations for trauma intervention continue to be ignored, resource limitations restricting design and implementation of therapeutic programs. Given the harrowing impacts of CSE on millions of women globally, it is all the more important that resources be available to address it and services be supported in their challenging efforts to engage and walk alongside the women affected.


 

Link to original article: http://community.borderlands.org.au/index.php/joomlaorg/browse-by-issue/196-issue/issue-52/127-trauma-intervention-in-exit-recovery-programs