Posttraumatic stress disorder
First-line treatments for PTSD include several types of cognitive behaviour therapy, as well as Eye Movement Desensitisation and Reprocessing.37
There is ample evidence for the effectiveness of exposure-based treatments for PTSD. Most of the treatment programmes that have substantial empirical support for their efficacy fall under the cognitive-behavioural therapy umbrella, and they share two characteristics: 1) helping clients confront safe trauma reminders, either through discussions about the trauma, or through approaching trauma-related situations or images; and 2) aiming to disconfirm clients’ dysfunctional, unrealistic perceptions emerging from the traumatic experience.38 Traditionally, this is delivered in eight to twelve weekly sessions, lasting between sixty and ninety minutes each. Currently, structured trauma-focused behavioural therapy involving several sessions is considered to be most effective.39
Adaptations of exposure therapy for non-Western settings have been effective. Narrative Exposure Therapy (NET) has been evaluated across a range of studies in different populations.40 NET is an adaptation of exposure therapy that was designed for war-affected refugees; it involves recounting of the client’s life story, focusing particularly on the traumatic experiences that initiated PTSD symptoms. The therapist develops a record of the client’s life story in written form.41
Individual controlled trials have also shown effectiveness for Brief Eclectic Psychotherapy for PTSD;42 the same applies to Imagery Rescripting Therapy, provided that it is combined with other methods.43
Eye movement desensitisation and reprocessing (EMDR) is a structured intervention that asks patients to recall the most distressing image that represents the traumatic incident, along with associated negative cognition and bodily sensations.44 Whilst doing this, patients are asked to follow alternating eye movements or other bilateral stimulation, which have been shown to tax working memory and lower emotional arousal of the traumatic memory so that the trauma can be resolved.45 EMDR is routinely delivered as eight to twelve weekly, sixty to ninety minute sessions.46
Also, an increasing number of Internet treatments for PTSD exist, based on cognitive behaviour therapy. Generally, these programmes demonstrate beneficial effects. The major limitation of Internet treatment is that it requires access to computers and Internet technology, as well as literacy. Further, on the basis of the limited evidence currently available, programmes that include some degree of direct therapist contact result in better treatment outcomes than those without such contact.47
As yet, clinical experience has shown that both exposure-based methods and EMDR are mostly applicable and satisfactory in treating TPs, while EMDR also may be incorporated in another, exposure-based therapy. Treatment may also include psychopharmacotherapy; and often there is a need for support for social problems.
Frequently, however, there is an equal need to address manifestations of complex PTSD or personality-linked problems. While clinical experience suggests that such problems are not prominent in TPs who did not experience pre-trafficking/childhood abuse, this has not been scientifically established so far. A study currently being performed at the Equator Foundation looks into the prevalence of complex trauma and personality-linked problems in adult female victims of sexual exploitation, and seeks to identify an association with (amongst others) pre-trafficking abuse. In anticipation of expected outcomes, and based on clinical judgement, personality-focused methods are already included in the treatment package and are being researched as well.
Complex PTSD
The implementation of trauma-focused therapies for clients with complex PTSD may be very complicated. Yet, the issue is crucial, considering the multitude of traumas experienced, and the high prevalence of childhood abuse among TPs. As argued earlier in this chapter, the latter, in particular, may lead to the kind of personality-linked difficulties (great emotional instability, identity problems, lack of trust, interpersonal problems) listed under the domain of complex PTSD. Indeed, Cloitre et al. showed that although both adulthood and childhood traumatic experiences of complex trauma predict symptom complexity, cumulative trauma during childhood is by far the stronger contributor.48
Unfortunately, to date, there is only sparse evidence for effective treatments in complex PTSD related to child abuse. Effective first-line treatments for PTSD may be well established, but their generalisability to child abuse related complex PTSD is largely unknown.49 First-line PTSD treatments may not target all relevant pathology – such as poor affect regulation and interpersonal problems in TPs that are also child abuse victims. Bradley et al. (2015) showed that after cognitive behaviour therapy, approximately 40% of clients maintain their PTSD; and even among those who no longer have PTSD, the majority still suffer from significant residual symptoms.50 Abas et al. argue that treatment plans will need to take account of the chronic abuse experienced by TPs both before and during their exploitation, and must be tailored to individual needs. Their study also suggests that broad approaches to stabilising physical and psychological health and attending to social needs are likely to be needed before commencing trauma-focused psychological therapy.51
Van Minnen et al., however, suggest that prolonged exposure can be safely and effectively used with patients with all kinds of complicating (even severe) other mental health problems.52 According to these authors, the trauma-focused approach is often associated with a decrease in both PTSD and the co-occurring problem. In cases with severe comorbidity, however, they recommend to treat PTSD with prolonged exposure, while providing integrated or concurrent treatment to monitor and address the comorbid problems.53
Clearly, drawing conclusions based on the currently available empirical evidence for effective treatments in complex PTSD related to child abuse is problematic.54 It is therefore still unclear for clinicians whether complex PTSD clients are generally able to tolerate, and benefit from, commonly available first-line treatments as equally well as ‘simple’ PTSD patients, and opinions are divided on this issue. To optimise treatment outcomes, personalised treatments that are tailored to variations in symptom profiles, and that take into account patient preferences, are recommended.55
Conclusion
In terms of knowledge of the mental health needs of TPs, there is a need for evidence about personality-linked vulnerabilities. Similarly, there is a need for evidence on the effectiveness of trauma-focused therapy combined with a treatment focus on self-concept, affect-regulation, and interpersonal relations. Filling both gaps may result in treatment approaches addressing the mental health consequences of both the trafficking experience and aversive childhood experiences. Such approaches may not only help TPs overcoming current problems, but also appear to be relevant in preventing re-victimisation.
Notes
1 See Sarkar, K., Bal, B., Mukherjee, R., Chakraborty, S., Saha, S., Ghosh, A., and Parsons, S., “Sex-trafficking, Violence, Negotiating Skill, and HIV Infection in Brothel-based Sex Workers of Eastern India, Adjoining Nepal, Bhutan, and Bangladesh” (2008) 26(2) Journal of Health, Population and Nutrition 223–231; Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., Ciarrocchi, R.A., Johansson, A., Kefurtova, A., Scodanibbio, S., Motus, M.N., Roche, B., Morison, L., and Watts, C., “The Health of Trafficked Women: A Survey of Women Entering Posttrafficking Services in Europe” (2008) 98(1) American Journal of Public Health 55–59; McCauley, H.L., Decker, M.R., and Silverman, J.G., “Trafficking Experiences and Violence Victimization of Sex-trafficked Young Women in Cambodia” (2010) 110(3) International Journal of Gynecology & Obstetrics 266–267; Oram, S., Stöckl, H., Busza, J., Howard, L.M., and Zimmerman, C., “Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated With Human Trafficking: Systematic Review” (2012) 9(5) PLOS Medicine e1001224; and Turner-Moss, E., Zimmerman, C., Howard, L.M., and Oram, S., “Labour Exploitation and Health: A Case Series of Men and Women Seeking Post-trafficking Services” (2014) 16 Journal of Immigrant and Minority Health 473�
��480.
2 Oram, S., Stöckl, H., Busza, J., Howard, L.M., and Zimmerman, C., “Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated With Human Trafficking: Systematic Review” (2012) 9(5) PLOS Medicine e1001224.
3 See Bryant, R.A. and Harvey, A.G., Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment (Washington, DC: American Psychological Association, 2000); and Bryant, R.A., “Acute Stress Disorder as a Predictor of Posttraumatic Stress Disorder: A Systematic Review” (2011) 72(2) Journal of Clinical Psychiatry 233–239.
4 American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: Author).
5 Cloitre, M., “The ‘One Size Fits All’ Approach to Trauma Treatment: Should We Be Satisfied?” (2015) 6 European Journal of Psychotraumatology 10.3402/ejpt.v6.27344.
6 See ICD-11 –www.who.int/classifications/icd/revision/en.
7 Cloitre, M., Garvert, D.W., Weiss, B., Carlson, E.B., and Bryant, R.A., “Evidence for Proposed ICD-11 PTSD and Complex PTSD: A Latent Profile Analysis” (2013) 4 European Journal of Psychotraumatology 10.3402/ejpt.v4i0.20706.
8 Abas, M., Ostrovschi, N., Prince, M., Gorceag, V., Trigub, V., and Oram, S., “Risk Factors for Mental Disorders in Women Victims of Human Trafficking: A Historical Cohort Study” (2013) 13 BMC Psychiatry 204.
9 Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., Ciarrocchi, R.A., Johansson, A., Kefurtova, A., Scodanibbio, S., Motus, M.N., Roche, B., Morison, L., and Watts, C., “The Health of Trafficked Women: A Survey of Women Entering Posttrafficking Services in Europe” (2008) 98(1) American Journal of Public Health 55–59.
10 Hossain, M., Zimmerman, C., Abas, M., Light, M., and Watts, C., “The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women” (2010) 100(12) American Journal of Public Health 2442–2449.
11 Reid, J.A., “Risk and Resiliency Factors Influencing Onset and Adolescence-Limited Commercial Sexual Exploitation of Disadvantaged Girls” (2014) 24(5) Criminal Behaviour and Mental Health 332–344.
12 See Hossain, M., Zimmerman, C., Abas, M., Light, M., and Watts, C., “The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women” (2010) 100(12) American Journal of Public Health 2442–2449.
13 Kiss, L., Pocock, N.S., Naisanguansri, V., Suos, S., Dickson, B., Thuy, D., Koehler, J., Sirisup, K., Pongrungsee, N., Nguyen, V.A., Borland, R., Dhavan, P., and Zimmerman, C., “Health of Men, Women, and Children in Post-trafficking Services in Cambodia, Thailand, and Vietnam: An Observational Cross-sectional Study” (2015a) 3(3) Lancet Global Health 154–161.
14 See Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., Ciarrocchi, R.A., Johansson, A., Kefurtova, A., Scodanibbio, S., Motus, M.N., Roche, B., Morison, L., and Watts, C., “The Health of Trafficked Women: A Survey of Women Entering Posttrafficking Services in Europe” (2008) 98(1) American Journal of Public Health 55–59; Cwikel, J., Chudakov, B., Paikin, M., Agmon, K., and Bel-maker, R., “Trafficked Female Sex Workers Awaiting Deportation: Comparison With Brothel Workers” (2004) 7(4) Archives of Women’s Mental Health 243–249; and Tsutsumi, A., Izutsu, T., Poudyal, A.K., Kato, S., and Marui, E., “Mental Health of Female Victims of Human Trafficking in Nepal” (2008) 66(8) Social Science & Medicine 1841–1847.
15 See Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., Ciarrocchi, R.A., Johansson, A., Kefurtova, A., Scodanibbio, S., Motus, M.N., Roche, B., Morison, L., and Watts, C., “The Health of Trafficked Women: A Survey of Women Entering Posttrafficking Services in Europe” (2008) 98(1) American Journal of Public Health 55–59.
16 Zimmerman, C., Oram, S., Borland, R., and Watts, C., “Meeting the Health Needs of Trafficked Persons” (2009) 339 British Medical Journal b3326.
17 Abas, M., Ostrovschi, N., Prince, M., Gorceag, V., Trigub, V., and Oram, S., “Risk Factors for Mental Disorders in Women Victims of Human Trafficking: A Historical Cohort Study” (2013) 13 BMC Psychiatry 204.
18 See Hossain, M., Zimmerman, C., Abas, M., Light, M., and Watts, C., “The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women” (2010) 100(12) American Journal of Public Health 2442–2449.
19 Kiss, L., Pocock, N.S., Naisanguansri, V., Suos, S., Dickson, B., Thuy, D., Koehler, J., Sirisup, K., Pongrungsee, N., Nguyen, V.A., Borland, R., Dhavan, P., and Zimmerman, C., “Health of Men, Women, and Children in Post-trafficking Services in Cambodia, Thailand, and Vietnam: An Observational Cross-sectional Study” (2015a) 3(3) Lancet Global Health e154–161.
20 See Kiss, L., Yun, K., Pocock, N., and Zimmerman, C., “Exploitation, Violence, and Suicide Risk Among Child and Adolescent Survivors of Human Trafficking in the Greater Mekong Subregion” (2015b) 169(9) JAMA Pediatrics e152278.
21 See Tsutsumi, A., Izutsu, T., Poudyal, A.K., Kato, S., and Marui, E., “Mental Health of Female Victims of Human Trafficking in Nepal” (2008) 66(8) Social Science & Medicine 1841–1847.
22 Hossain, M., Zimmerman, C., Abas, M., Light, M., and Watts, C., “The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women” (2010) 100(12) American Journal of Public Health 2442–2449.
23 Abas, M., Ostrovschi, N., Prince, M., Gorceag, V., Trigub, V., and Oram, S., “Risk Factors for Mental Disorders in Women Victims of Human Trafficking: A Historical Cohort Study” (2013) 13 BMC Psychiatry 204.
24 See Hossain, M., Zimmerman, C., Abas, M., Light, M., and Watts, C., “The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women” (2010) 100(12) American Journal of Public Health 2442–2449.
25 See, further, Brewin, C.R., Andrews, B., and Valentine, J.D., “Meta-analysis of Risk Factors for Posttraumatic Stress Disorder in Trauma-exposed Adults” (2000) 68(5) Journal of Consulting and Clinical Psychology 748; Ehlers, A. and Clark, D.M., “A Cognitive Model of Posttraumatic Stress Disorder” (2000) 38(4) Behaviour Research and Therapy 319–345; Ozer, E.J., Best, S.R., Lipsey, T.L., and Weiss, D.S., “Predictors of Posttraumatic Stress Disorder and Symptoms in Adults: A Meta-analysis” (2003) 129(1) Psychological Bulletin 52; and Weiss, E.L., Longhurst, J.G., and Mazure, C.M., “Childhood Sexual Abuse as a Risk Factor for Depression in Women: Psychosocial and Neurobiological Correlates” (1999) 156(6) American Journal of Psychiatry 816–828.
26 See Pereda, N., Guilera, G., Forns, M., and Gómez-Benito, J., “The Prevalence of Child Sexual Abuse in Community and Student Samples: A Meta-analysis” (2009) 29(4) Clinical Psychology Review 328–338.
27 See, further, Kendler, K.S., Bulik, C.M., Silberg, J., Hettema, J.M., Myers, J., and Prescott, C.A., “Childhood Sexual Abuse and Adult Psychiatric and Substance Use Disorders in Women” (2000) 57 Archives of General Psychiatry 953–959; Collins, N.L., Guichard, A.C., Ford, M.B., and Feeney, B.C., “Working Models of Attachment: New Developments and Emerging Themes”, in Rholes, W. and Simpson, J.A. (eds.), Adult Attachment: Theory, Research, and Clinical Implications (New York, NY: Guilford Press Publications, 2004), pp. 196–240; and Murphy, S., Elklit, A., Hyland, P., and Shevlin, M., “Insecure Attachment Orientations and Posttraumatic Stress in a Female Treatment-seeking Sample of Survivors of Childhood Sexual Abuse: A Cross-lagged Panel Study” (2016) 22(1) Traumatology 48.
28 See Yehuda, R. and LeDoux, J., “Response Variation Following Trauma: A Translational Neuroscience Approach to Understanding PTSD” (2007) 56 Neuron 19–32.
29 See Ein-Dor, T., Doron, G., Solomon, Z., Mikulincer, M., and Shaver, P.R., “Together in Pain: Attachment-related Dyadic Processes and Posttraumatic Stress Disorder” (2010) 57(3) Journal of Counseling Psychology 317–327.
30 Ehlers, A. and Clark, D.M., “A Cognitive Model of Posttraumatic Stress Disorder” (2000) 38(4) Behaviour Research and Therapy 319–345.
31 See, further, Brewin, C.R., Andrews, B., and Valentine, J.D.,
“Meta-analysis of Risk Factors for Posttraumatic Stress Disorder in Trauma-exposed Adults” (2000) 68(5) Journal of Consulting and Clinical Psychology 748; Ozer, E.J., Best, S.R., Lipsey, T.L., and Weiss, D.S., “Predictors of Posttraumatic Stress Disorder and Symptoms in Adults: A Meta-analysis” (2003) 129(1) Psychological Bulletin 52; and Hebenstreit, C.L., Maguen, S., Koo, K.H., DePrince, A.P., “Latent Profiles of PTSD Symptoms in Women Exposed to Intimate Partner Violence” (2015) 180 Journal of Affective Disorders 122–128.
32 See, for example, Laban, C.J., Gernaat, H.B.P.E., Komproe, I.H., van der Tweel, I., and De Jong, J.T.V.M., “Postmigration Living Problems and Common Psychiatric Disorders in Iraqi Asylum Seekers in the Netherlands” (2005) 193 Journal of Nervous and Mental Disease 825–832.
33 See, further, Bryant, R.A. and Harvey, A.G., Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment (Washington, DC: American Psychological Association, 2000); Bryant, R.A., “Acute Stress Disorder as a Predictor of Posttraumatic Stress Disorder: A Systematic Review” (2011) 72(2) Journal of Clinical Psychiatry 233–239; and Bisson, J., Brayne, M., Ochberg, F., and Everly, G., “Early Psychosocial Intervention Following Traumatic Events” (2007a) 164 American Journal of Psychiatry 1016–1019.
34 Kornør, H., Winje, D., Ekeberg, Ø., Weisaeth, L., Kirkehei, I., Johansen, K., and Steiro, A., “Early Trauma-focused Cognitive-behavioural Therapy to Prevent Chronic Post-traumatic Stress Disorder and Related Symptoms: A Systematic Review and Meta-analysis” (2008) 19(8) BMC Psychiatry 81.
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