Establishing trust and hope

From the first contact with a survivor of trafficking, every interaction offers an opportunity for the therapist to build a sense of trust and safety (Witkin and Robjant, Reference Witkin and Robjant2022), and also with the interpreter if one is present (for advice on working with interpreters, see Costa, Reference Costa2022). ‘Create the illusion of time’ (Witkin and Robjant, Reference Witkin and Robjant2022; p. 4) to allow the survivor to describe their experiences at their own pace. Wherever possible, the same clinician (and interpreter) should provide both the therapy assessment and the intervention. Allow for extra time or sessions at every stage of the intervention, to facilitate the development of a trusting relationship; it is common for additional information to be disclosed later on in therapy, once trust is established.

Survivors have endured serious psychological and/or physical abuse, yet it is common for them to blame themselves and feel shame, which can inhibit them from speaking openly or being able to fully recognise the crime that has been committed against them. It is important to take a human rights approach in this work, whereby the therapist can sensitively name the survivors’ experiences as a criminal violation of their human rights to try to reduce consequences such as a sense of isolation, self-blame and shame (Regner and Witkin, Reference Regner, Witkin, Klotz, Bielefeldt, Schmidhuber and Frewer2017).

Throughout the assessment process, it is important to instil hope and to support the survivor to contemplate their goals for therapy, and their life more broadly. Making decisions or thinking about areas of strength can be difficult for people who have survived trafficking. Therefore, the therapist should scaffold these conversations carefully and ensure a person’s existing resources and strengths are acknowledged and developed during therapy. Goals should be revisited throughout therapy to see if additional ones should be added as the person develops more confidence in identifying and articulating their needs and wishes.

A holistic and ‘whole life’ perspective

Take a holistic and a ‘whole life’ perspective throughout assessment and treatment, rather than focusing only on the survivor’s current symptoms or most recent experiences. Early life or previous experiences and circumstances such as abuse, sexual violence, health issues, poverty, or marginalisation may have resulted in a survivor’s vulnerability to trafficking or exploitation (for information about pre-trafficking vulnerabilities, see the NRM Handbook (OSCE/ODIHR, 2022)). Additionally, there may be a range of current social problems that perpetuate a survivor’s vulnerability to exploitation, such as homelessness, destitution or debt, or legal issues for which referral to appropriate agencies may be required (OSCE/ODIHR, 2022). Survivors may also be struggling with co-morbid health problems as a direct or indirect result of their trafficking experience, for example, physical disability/illness (including chronic pain or effects of long-term malnutrition); sexually transmitted infections; head injuries; and substance misuse (see Oram et al., Reference Oram, Abas, Bick, Boyle, French, Jakobowitz, Khondoker, Stanley, Trevillion, Howard and Zimmerman2016). Such issues may not have been disclosed previously, so it is important to investigate whether the survivor has been offered adequate support, and to what extent they have been able to engage with what has been offered. Research suggests that survivors may struggle to access, engage with or optimally benefit from healthcare or therapy services if their holistic needs are not also attended to (Brady et al., Reference Brady, Chisholm, Walsh, Ottisova, Bevilacqua, Mason, von Werthern, Cannon, Curry, Komolafe, Robert, Robjant and Katona2021; Williamson et al., Reference Williamson, Borschmann, Zimmerman, Howard, Stanley and Oram2020).

For some survivors, cultural or personal differences in their understanding of mental health problems or perceptions of talking therapy can be a barrier to engagement (Kinnish and Hopper, Reference Kinnish, Hopper, Dryjanska, Hopper and Stoklosa2024). These topics should be raised openly and sensitively by the therapist, and interventions should be adapted in line with the survivor’s own beliefs, values and experiences. CBT and other psychological models developed in European and North American populations can be presented as one way of looking at survivor’s difficulties. This is to avoid presenting such models as the only source of knowledge, thereby invalidating other helpful cultural knowledge and values. Terms such as ‘psychoeducation’ can infer that there is one way of understanding and managing distress. Therefore, interventions or strategies can be better described as possible tools in addition to those that survivors have discovered themselves and already use. For example, CBT strategies to manage dissociation can be suggested as one possible approach (see Chessell et al., Reference Chessell, Brady, Akbar, Stevens and Young2019). For further information on culturally adapting CBT see Beck (Reference Beck2016) and Beck and Naz (Reference Beck and Naz2019).

Developing treatment plans that acknowledge the lasting impact of trafficking

Diagnosis can be useful to guide which CBT model to consult when planning treatment. Research indicates that survivors of trafficking have high rates of complex post-traumatic stress disorder (PTSD) (Evans et al., Reference Evans, Sadhwani, Singh, Robjant and Katona2022; Jowett et al., Reference Jowett, Argyriou, Scherrer, Karatzias and Katona2021; Ottisova et al., Reference Ottisova, Smith and Oram2018), PTSD, anxiety and depression (Oram et al., Reference Oram, Khondoker, Abas, Broadbent and Howard2015) and suicidal ideation (Oram et al., Reference Oram, Abas, Bick, Boyle, French, Jakobowitz, Khondoker, Stanley, Trevillion, Howard and Zimmerman2016).

Survivors of long-term exploitation may not meet the full criteria for a diagnosis of PTSD, for example if they have not experienced a ‘Criterion A’ type trauma as stated in the DSM-5. However, being subjugated, commodified, and controlled for long periods of time violates a person’s basic needs, human rights and dignity; a survivor’s resulting psychological needs cannot always be neatly explained or compartmentalised within existing diagnostic frameworks. Survivors may present with clusters of symptoms from different disorders that do not meet one specific diagnostic threshold, yet the symptoms and impact on the survivor may still be significant. For example, a survivor might present with some symptoms of PTSD, such as hypervigilance or hyper-arousal in the absence of clear re-experiencing symptoms but might simultaneously engage in excessive rumination. Survivors might also present with mixed or sub-diagnostic threshold symptoms for other common disorders such as depression, generalised anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), eating disorders or complex grief reactions.

This can make it challenging for clinicians to identify one clear treatment plan from the established evidence-based models. Combined with the other barriers to service access and engagement (outlined above), it can mean that survivors miss out on the therapeutic support that they need to overcome their psychological difficulties (Kinnish and Hopper, Reference Kinnish, Hopper, Dryjanska, Hopper and Stoklosa2024). Therefore, therapists and services may need to formulate a survivor’s presentation, and offer treatment in a more flexible way, rather than focusing only on diagnosis-driven treatment decision making.

Survivors of trafficking may have become used to minimising or ignoring their own needs, and/or acquiescing to the demands of others, to the extent that they struggle with interoception (‘listening’ to their body), a known difficulty amongst survivors of trauma (Leech et al., Reference Leech, Stapleton and Patching2024). As a result, they may not engage in daily activities that support their health and wellbeing (for example, not being able to identify hunger or physical health issues). Suppressing or ignoring these needs may have been an adaptive coping response during their trafficking experiences. Where necessary, treatment plans should support survivors to identify and meet their own needs through establishing a healthy routine that addresses any potential risks of self-neglect. Behavioural activation (Martell et al., Reference Martell, Addis and Jacobson2001) principles and techniques may provide an accessible structure for survivors to begin addressing their basic daily needs and routine.

Some survivors may find the emphasis on collaboration in the therapeutic relationship unfamiliar, or even uncomfortable. Where this presents a barrier to a person engaging in a structured therapeutic intervention, address this directly and think with the client about how you can facilitate their meaningful participation during therapy. It may also be helpful to consider alternative ways to engage with clients or alternative sources of support such as skills-based, creative, educational or community activities or groups (for example, see Robert and Argyriou, Reference Robert and Argyriou2021). Exposure to collaborative methods of working during therapy can gradually support a person to build trust and mutually supportive relationships with others, which can improve their quality of life and potentially facilitate reducing their risk from others.

Survivors can struggle with making autonomous decisions and may need more time and support to consider their options and make informed decisions about their care. Obtaining informed consent for treatment should be seen as an ongoing process, regularly revisited by the therapist to facilitate the client’s understanding and active engagement in their care (OSCE/ODIHR, 2022). Space should be made for exploration of ambivalence, worries or questions the person has about seeking help.

Risk assessment and safeguarding

The ongoing safety of the survivor must be at the forefront of any assessment. It is important to maintain up-to-date knowledge of organisational and legal safeguarding policies and procedures, as well as the local and national pathways for access to formal identification and protection, support and re-dress (see ‘the four NRM pillars’, as outlined in the NRM Handbook; OSCE/ODIHR, 2022). Beyond the standard clinical assessment of risk, consider the survivor’s ability to keep themselves (and their dependents) safe from the risks of potential harm or re-exploitation, which can be elevated for this population (Oram et al., Reference Oram, Khondoker, Abas, Broadbent and Howard2015). Do not assume that the survivor has a comprehensive knowledge of their rights and entitlements in their current context (e.g. access to healthcare); this may be something you need to help them research or learn about. Moreover, when supporting the survivor to access other organisations, do not merely signpost; try to actively introduce the survivor to the service (e.g. via a clinical letter or a joint visit) and troubleshoot any barriers before assuming a survivor will be able to access another service (see ‘Provision of ‘bridged’ referrals to other professionals and services’ in the NRM Handbook; OSCE/ODIHR, 2022). Joined-up care and multi-agency collaboration is essential to effectively safeguard trafficking survivors; it is helpful to build co-operative working relationships with appropriate local anti-trafficking or survivor care organisations. Be transparent about professional duties and the limits of confidentiality and how a survivor’s data will be stored or shared and facilitate the survivor’s inclusion in care and risk management plans as far as possible.

Some traffickers may pose an ongoing threat to survivors and some survivors may even continue communicating with, or feel compelled to return to their trafficker. This can be for a multitude of reasons, including an emotional connection to the trafficker (Gerassi, Reference Gerassi2015). Evidence indicates that family members, friends or romantic partners are frequently involved in the recruitment stage of trafficking (Counter Trafficking Data Collaborative, n.d.). Even beyond pre-existing relationships, survivors may feel ‘bonded’ to their trafficker (sometimes referred to as ‘traumatic bonding’ or ‘Stockholm syndrome’) and continue to protect the trafficker at the expense of their own wellbeing or safety long after they have escaped (Casassa et al., Reference Casassa, Knight and Mengo2022). Survivors may experience ongoing confusion about the intentions of their trafficker(s) and the trafficker’s interpersonal manipulation can cause difficulties when the survivor attempts to form new relationships (Baldwin et al., Reference Baldwin, Fehrenbacher and Eisenman2015).

Other survivors may fear the consequences of not returning to their trafficker (e.g. due to threats against themselves or their family and/or because of debt bondage). Debt bondage is a method of exploitation where the person is convinced that they have incurred an exorbitant debt that they must repay, e.g. falsely incurred ‘expenses’ during the trafficking period, or a loan subject to excessive inflation rates. This can be levied against the victim’s family (in their absence), causing the survivor to feel responsible and fear reprisals against their family. While debt bondage should always be considered false and illegal, the survivor’s belief that they must repay the debt can endure, and can create risks of re-trafficking or exploitation. Provide clear messaging about the illegitimacy and illegality of the alleged ‘debt’, but balance this with acknowledging the genuine threat of harm that the survivor might be facing if the debt is not repaid. In some cases, it can help to consider with the survivor what exactly the ‘debt’ is supposed to be for, to help them to disengage from the belief that it is owed. However, it is important to bear in mind that if the client believes that they or their family are at direct risk for not paying a ‘debt’, even ‘proving’ the invalid basis of the debt may not resolve the risk of them returning to the trafficker in order to repay it, or reduce real risk to them or their family. Survivors may also have financial obligations to family, which can lead to them returning to their trafficker or force them into another exploitative working environment. Where necessary, seek specialist or safeguarding support from local agencies.

Trafficking survivors might have difficulty recognising or asserting their rights, and even beyond exploitative working environments may be more vulnerable to entering into other exploitative situations, such as ‘survival’ or abusive relationships, or survival prostitution; this risk increases if the person is experiencing poverty, dangerous living conditions or homelessness (OSCE/ODIHR, 2022). Directly discuss the survivor’s interpersonal relationships (past and present). Even when a survivor reports a relationship as being positive for them, it is important to closely consider any potential unidentified risks with this relationship (OSCE/ODIHR, 2022) and attend to how the survivor identifies potential risks (or positive strengths) in a relationship.

Attend to the survivor’s pre-trafficking history along with past and current vulnerabilities to develop a shared formulation of risk and protective factors, which also includes proactive and practical strategies and relational connections, that facilitate their safety (OSCE/ODIHR, 2022). Risk assessment should include an agreed plan for follow-up if the survivor misses any appointments, such as contacting a mutually trusted person (who should be agreed with the survivor and appropriately ‘vetted’ at the outset). Safe receipt of correspondence should also be discussed, including, for example, whether the receipt of post is secure at their accommodation and whether texts and emails are received and managed directly by them. Risk assessments with survivors of trafficking need to be comprehensive and regularly reviewed, as circumstances may change rapidly.

Trauma memory processing: a focus on guilt, shame and disgust

Survivors presenting with symptoms of PTSD can be offered existing evidence-based trauma-focused interventions (National Institute for Health and Care Excellence, 2018) such as trauma-focused CBT (Ehlers and Clark, Reference Ehlers and Clark2000), narrative exposure therapy (NET; Schauer et al., Reference Schauer, Neuner and Elbert2011) or eye-movement desensitisation and re-processing (EMDR; Shapiro, Reference Shapiro2018).These interventions can be adapted to the additional needs of trafficking survivors (e.g. Robjant et al., Reference Robjant, Roberts and Katona2017; Brady et al., Reference Brady, Chisholm, Walsh, Ottisova, Bevilacqua, Mason, von Werthern, Cannon, Curry, Komolafe, Robert, Robjant and Katona2021). Due to service or other constraints, it may be necessary to collaboratively prioritise processing memories that cause the most distressing symptoms, although therapy will need to be extended if the survivor has a number of traumatic experiences requiring attention.

Individuals who have been subject to prolonged trauma (and particularly sexual violence) may present with significant symptoms of dissociation (Schauer and Elbert, Reference Schauer and Elbert2010). Therapists will need to be aware how to identify and support survivors in managing symptoms of dissociation, and will need to adapt the pace of sessions and treatment accordingly. Survivors may also experience strong somatic or sensory re-experiencing symptoms such as physical sensations (e.g. the pain of being raped (Macdonald et al., Reference Macdonald, Salomons, Meteyard and Whalley2018)) or olfactory or gustatory intrusions (e.g. Vermetten and Bremner, Reference Vermetten and Bremner2003). These intrusions may cause acute feelings of distress or shame and may not be voluntarily disclosed. Therefore, therapists should ask the survivor directly about their sensory experiences in relation to traumatic events. Further detailed guidance on the delivery of therapy for survivors of sexual violence can be found in Young et al. (Reference Young, Akbar, Brady, Burrows, Chessell, Chisholm, Dixon, Ellison, Grey, Hall, Khan, Lee, Michael, Paton, Penny, Roberts, Rouf, Said, Soubra, Steel, Stich, Vann, Wells and Bartholdy2025).

Addressing the survivor’s feelings of guilt or beliefs about their own responsibility for being trafficked is an important aspect of therapy. Many survivors blame themselves for having fallen victim to the trafficker and their deception; they may also blame themselves for other events related or subsequent to the trafficking, such as harm that has come to family members. Acknowledging the existence of other survivors with similar experiences of exploitation and sharing information about the common methods of traffickers can begin to alleviate the individual’s feelings of responsibility (see ‘Traffickers methods of operation’ in the NRM Handbook, OSCE/ODIHR, 2022) Moreover, existing cognitive re-structuring techniques such as those exploring how responsibility is ‘distributed’ amongst the perpetrator(s) or other people involved can also be used to good effect with trafficking survivors (see Young et al. (Reference Young, Chessell, Chisholm, Brady, Akbar, Vann and Rouf2021) and Young et al. (Reference Young, Akbar, Brady, Burrows, Chessell, Chisholm, Dixon, Ellison, Grey, Hall, Khan, Lee, Michael, Paton, Penny, Roberts, Rouf, Said, Soubra, Steel, Stich, Vann, Wells and Bartholdy2025) for further explanation as to how these techniques can be applied in practice).

Exploring ‘typical’ psychological reactions to such abuse, can help to de-stigmatise the survivor’s own responses, and reduce feelings of shame. Shame can also be addressed through interactions in the therapeutic relationship (see Contreras et al., Reference Contreras, Kallivayalil and Herman2017) as well as specific compassion focused cognitive therapy exercises (Lee and Jones, Reference Lee and Jones2012). Research suggests that anger can be suppressed during severe traumatic experiences (Schauer and Elbert, Reference Schauer and Elbert2010); and facilitate connection with, and expression of, any feelings of anger during therapy, which can help the client to feel empowered and able to acknowledge the violation of their human rights (Schauer et al., Reference Schauer, Robjant, Elbert, Neuner, Ford and Courtois2020).

To address feelings of disgust, begin by sharing information about the biological function of disgust, and exploring the disgust-related memory in detail, including the client’s thoughts and beliefs connected with this experience (for detailed information on addressing disgust in therapy, see Jones et al., Reference Jones, Brake, Badour, Tull and Kimbrel2020).

Imagery, including imagery re-scripting techniques (Holmes et al., Reference Holmes, Arntz and Smucker2007) can be a helpful tool for addressing feelings of shame, guilt and disgust. The development of images should always be led by the survivor’s own ideas, but examples can include the survivor being de-contaminated (Jung and Steil, Reference Jung and Steil2013), the trafficker being shrunk or otherwise disempowered, the survivor being able to fight back, protect or defend themselves, or (for those who have a religious faith), ‘divine intervention’. These alternative images and restructured appraisals can also be integrated into any ‘updates’ used within trauma-focused cognitive therapy, where appropriate (Grey et al., Reference Grey, Young and Holmes2002).

Addressing low self-esteem

By identifying the psychological impact of trafficking, therapists can help survivors to reflect on their beliefs about themselves and their broader sense of identity. Helping survivors to identify with whom the responsibility for the trafficking belongs (as outlined above) can also reduce the survivor’s negative beliefs about themselves. Introducing strategies to increase the person’s assertiveness (Hagberg et al., Reference Hagberg, Manhem, Oscarsson, Michel, Andersson and Carlbring2023), self-efficacy (Bandura, Reference Bandura1977), self-esteem (Fennell, Reference Fennell2016) and self-compassion (Lee and Jones, Reference Lee and Jones2012), can help survivors to develop or reconnect with adaptive coping strategies. Even relatively simple activities such as a ‘positive qualities log’ can be implemented to good effect. Bear in mind that different cultures may have different perspectives about self-esteem, or terminology associated with this. Explore the client’s understanding and perceptions of self-esteem and use language that is relatable for them. These techniques can be crucial for supporting survivors to function more autonomously and safeguard themselves against potential future risks.

Addressing the impact of psychological control

As explained above, survivors may have complex feelings towards their trafficker, including feelings of dependence, love and gratitude (Casassa et al., Reference Casassa, Knight and Mengo2022) as well as fear, anger or disgust. If the survivor has ambivalent feelings, it is important to acknowledge (rather than dismiss) these, and encourage curiosity about why these feelings might exist. Invite the survivor to collaboratively explore the psychological impact of grooming, manipulation, control and deceit that they have experienced (Baldwin et al., Reference Baldwin, Fehrenbacher and Eisenman2015), and consider how their interpersonal relationships, personal characteristics or vulnerabilities were manipulated by the trafficker to gain power and control over them. The therapist can draw on academic literature and resources developed for people who have faced human rights abuses with similar consequences (Contreras et al., Reference Contreras, Kallivayalil and Herman2017; Grey and Young, Reference Grey and Young2008). For example, the Baldwin et al. (Reference Baldwin, Fehrenbacher and Eisenman2015) paper outlines domains from such as Biderman’s (Reference Biderman1957) framework, and highlights how traffickers use isolation, induce weakness and exhaustion, remove a person’s autonomy, but also offer occasional indulgences (amongst other tactics) to control and manipulate their victims. Asking survivors directly for their experiences across these domains may help to elicit a shared formulation about the psychological impact of trafficking and help the survivor to have a broader view of their trafficker’s motivations and behaviour.

The relational and deceptive nature of trafficking can leave survivors with confused or complicated feelings about their trafficker. One tool that can facilitate the survivor developing a new perspective on their experiences is the ‘Power and Control Wheel’ (Domestic Abuse Intervention Project, n.d.). This tool was designed to facilitate exploration of control within domestic violence but can be readily adapted to explore similar issues in trafficking. The therapist should guide the survivor through each section of the wheel and identify specific examples of abuse and the impact of this abuse on the survivor’s feelings, behaviour and resulting beliefs about themselves. This conversation can then move on to discussing the ongoing impact of this abuse, how these power and relational dynamics may be repeated (or at risk of being repeated) in current relationships, and how the survivor can develop strategies to help them build safe and supportive relationships in the future.

It may also be helpful to consider how the chronic abuse the survivor endured may have led them to experience ‘learned helplessness’ (Anyaegbunam et al., Reference Anyaegbunam, Udechukwu and Nwani2015; Hopper and Hildago, Reference Hopper and Hidalgo2006; Seligman, Reference Seligman1972) or ‘mental defeat’ (Ehlers et al., Reference Ehlers, Clark, Dunmore, Jaycox, Meadows and Foa1998) which can contribute to ongoing feelings of worthlessness and lack of agency. These concepts should be introduced tentatively; consider the impact of language and terminology on the survivor and hold in mind the context of chronic control and subjugation that led to the person developing these difficulties.

Control through exploitation of ritualised oath ceremonies

The exploitation of a person’s religious or spiritual beliefs for purposes of control is reported by survivors from different countries and cultural backgrounds (Chisholm et al., Reference Chisholm, Mark, Unigwe and Katona2024); however, it is particularly common amongst those trafficked from West African countries, where it may be referred to as juju or voodoo (Garcia, Reference Garcia2013). These traditional ceremonies are often exploited by traffickers to instil fear and ensure that ‘an enduring psychological bond is formed between the trafficker and the victim that is not dependent upon their physical proximity’ (OSCE, 2013; p. 68). Ritual ceremonies can be frightening; the meaning for the survivor might also change over time as they begin to comprehend the extent of the betrayal and exploitation they have endured. Ceremonies exploited for the purposes of trafficking may be used to threaten harm, illness or death of the individual or their loved ones if the terms of the oath are violated, which often includes secrecy about the oath itself, meaning survivors may struggle to disclose or describe it (Cherti et al., Reference Cherti, Pennington and Grant2013; Ikeora, Reference Ikeora2016; Wilson, Reference Wilson2021; Witkin and Robjant, Reference Witkin and Robjant2022).

Survivors may hold a strong belief in the omnipresence and omnipotence of their trafficker that may continue long after leaving the direct control of a trafficker (Ikeora, Reference Ikeora2016), or completion of trauma-focused treatment (Wilson, Reference Wilson2021). It is neither necessary nor helpful for the therapist to confront or challenge the nature of the survivor’s spiritual beliefs, which may be supportive and helpful in some areas of their life but have been exploited by the trafficker for the purposes of controlling the individual. Explicitly discuss the motivations of the trafficker in exploiting their spiritual beliefs to create fear and control them and explore whether flexibility can be introduced into the survivor’s beliefs, for example about the omnipresence of the trafficker, the negative consequences of violating the oath, and the credibility or validity of the trafficking-related oath specifically.

A starting point can be to refer to examples where other survivors have spoken out without ill consequence (Wilson, Reference Wilson2021), for example, by sharing anonymised composite accounts (e.g. in Millett-Barrett, Reference Millett-Barrett2019) or news articles about this topic (e.g. Nwaubani, Reference Nwaubani2018). Consulting sympathetic (and well-informed about the context of trafficking) religious or community leaders can also facilitate evidence gathering to support these conversations (Wilson, Reference Wilson2021).

Guided discovery techniques (to challenge the seemingly omnipotent power of the trafficker and the oath), and reassurance from trusted others can reduce fear and shame but this often provides only temporary relief for the survivor’s anxieties. Beliefs about the power of the trafficker are often closely linked to the individual’s low self-esteem and feelings of helplessness and powerlessness relating to their broader trafficking experiences. Spending time focusing on the survivor’s strengths, values and beliefs throughout therapy can be crucial to helping them regain their sense of autonomy and self-efficacy, including in relation to the power of the oath. Imagery techniques (as outlined above) can also be a useful therapeutic tool to provide a ‘felt sense’ of protection from the traffickers perceived power.