Mike Dubi, Ed.D., LMHC, Editor
Jeanne Thomas, MBA, Associate Editor
Winter 2018, Vol. 1, No. 4
Hello and Happy Holidays to all our Canadian members, and our US and worldwide members too. I am writing this from Beautiful British Columbia (see right). Catching a few days before the next session of courses start on January 7, 2019.
More than ever before, the study and understanding of
is a crucial tool for all those in the helping professions.
The Need for Trauma Training and Certification:
We hear from you that administrators and funders often require trauma-certified clinical staff. Since 2009, the International Trauma Training Institute (formerly International Association of Trauma Professionals) has responded to that need by ensuring that mental health professionals have the tools to identify and treat trauma, and to refer clients to those who specialize in specific areas of trauma if they so need.
Further, many agencies who employ non-clinical front line staff see the need for trauma informed care. Agencies need to create, within their structure, a treatment framework that helps both their clinical and non-clinical employees to recognize, understand and respond to the effects of trauma.
To address this need,
ITTI has developed a 2-hour
Trauma-Informed Care Basics
online training. It is designed to meet the needs of schools, agencies, and management, as well as professional and non-professional staff.
Click here for details.
Next Cycle of Trauma Trainings:
We at ITTI look forward to working with you as we continue to create and develop new trainings. Best holiday wishes to all.
Mike Dubi, ITTI President
Human Trafficking and Trauma
Kristen Erin Eldredge
As the concept of trauma becomes increasingly more integrated into the training of mental health professionals (MHPs), one type of trauma that is still not as widely explored is human trafficking (HT). This article will offer a brief introduction into some of the key elements of HT and considerations for mental health treatment of survivors.
Definition of Human Trafficking
A variety of terms are utilized to describe human trafficking, including modern day slavery and commercial sexual exploitation of children. The U.S. Government, via the Trafficking Victims Protection Act of 2000 (reauthorized most recently in 2013) defines two categories of human trafficking: sex trafficking and labor trafficking. Sex trafficking is defined as the use of “recruitment, harboring, transportation, provision, obtaining, patronizing or soliciting of a person for the purpose of a sex act” or in which the person being induced to perform the sex act is a minor. Severe forms of sex trafficking include the elements of force, fraud, or coercion (22 USC § 7102 (9-10)). Labor trafficking is defined as the “recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery” (22 USC § 7102 (9B)). The key elements of these definitions include the actions of what is done (e.g. recruiting, harboring, etc.), means (e.g. force, fraud, coercion), and purpose (labor or commercial sex acts).
Risk Factors and Identification
The characteristics of those who are at risk for human trafficking are diverse. Trafficking can occur to persons of any age, gender, sexual orientation, ethnicity, or nationality, though there are particular risk factors that may make an individual more vulnerable. These include but are not limited to: previous history of abuse and neglect, family conflict, poverty, minimal education, populations who commonly experience discrimination (e.g. ethnic, sexual minorities), being a runaway or throwaway (i.e. kicked out), and homelessness (Klatt, Cavner & Egan, 2014).
Understanding these risk factors can be extremely helpful when attempting to identify who is, or has been, trafficked. However, this is no easy process regardless of how well we understand the risk factors. There are several common barriers to identifying trafficking victims but primarily it is extremely difficult for the trafficked individual to self-identify. While being trafficked, the force, fraud, and coercion the individual experiences serves to intimidate and silence the victim. It is common for traffickers to threaten to harm or kill victim’s family members, destroy victim’s reputations, and even to kill the victim. Sexual and physical violence is common, as is maintaining control through drug addiction (Busch-Armendariz, Nsonwu, & Heffron, 2018). Sadly, these threats are often driven home by forcing the victim to witness these actions being perpetrated against others.
Immediate Treatment Needs
The treatment needs of survivors of human trafficking, especially minors, is significantly different from survivors of other forms of trauma and violence (Havlicek, Huston, Boughton, & Zhang, 2016). For MHPs providing treatment to these survivors, it is important to assess where the survivor is in their recovery to establish the most appropriate treatment. An individual who has very recently survived a trafficking experience will benefit most from an extensive, interdisciplinary case management approach (Busch-Armendariz et al., 2018), focusing initially on crisis management, emergency housing, food, clothing, urgent medical care, and locating safe family or support people (Gibbs, Walters, Lutnick, Miller, & Kluckman, 2015). Additional components of this initial stage include connecting the survivor with mentors and beginning to access benefits and resources. The next component of the case management approach introduces initial mental health care, which often includes substance abuse treatment given the high rates of substance abuse in HT. General medical care, the securement of longer term-housing and/or reintegration into the family system, education or employment assistance, and connections with the community are also key elements in this stage of healing (Gibbs et al., 2015).
Extended Mental Health Treatment Needs
Survivors of HT require long-term mental health care. Even after the initial crisis intervention is addressed, the effects of the complex trauma (CT) inherent in HT are profound and long-lasting. CT consists of traumatic exposures that are repetitive or ongoing over a long period of time, resulting in a cumulative impact. Herman (1992) illuminated the distinct nature of CT, highlighting how chronic exposure to abuse, violence, or other traumatic experiences, especially in a relational context, results in symptomatology distinct from PTSD. Therapy for HT survivors should conceptualize treatment from a CT perspective. The survivor is likely to experience the usual post-traumatic stress disorder (PTSD) symptoms of re-experiencing, avoidance, hyperarousal, and negative symptoms, yet they may also experience the symptoms of complex PTSD. Complex PTSD symptoms include: 1. Changes in emotional regulation (e.g. depression, emotional lability), 2. Changes in consciousness (e.g. amnesia, dissociation), 3. Changes in the perception of oneself (e.g. shame, feeling inhuman), 4. Changes in the perception of the perpetrator(s) (e.g. trauma bonds), 5. Changes in relationships with others (e.g. isolation, distrust / overly trusting), 6. Changes in meaning systems (e.g. loss of faith; Herman, 1992), and 7. Somatic issues (e.g. health issues; Boon, Steele, & van der Hart, 2011; Korzinski, 2013). While numerous modalities exist to treat CT, consensus among experts is that treatment should be based on a multi-stage approach, typically including at least three distinct stages: safety and stabilization, working through traumatic memories, and resolution and reconnection (Courtois, Ford, & Cloitre, 2009).
Since every HT survivor’s experience will be unique, so too will be their mental health treatment. However, there are common elements of trafficking that will subsequently be central themes to the therapy. A few of these themes will be described here, though it should be noted that this discussion provides a mere glimpse into the issues that arise in treatment of HT survivors.
Money and Power
The primary motivation of traffickers is to exploit individuals to obtain money and/or power (Polaris, 2018). The objective is to keep the trafficked person producing income. In other criminal enterprises, such as drug or arms trafficking, traffickers have to replenish their supplies and risk getting caught with illegal products. In HT, the person is used over and over again and the trafficker can easily “explain” the relationship with the person if caught (i.e. this is my relative). In the therapeutic setting, MHPs must be mindful of circumstances that may lead to the survivor feeling that they are once again being exploited for another’s gain. Unfortunately, what may feel benign to MHP could feel like re-exploitation to the survivor. For example, given the growing interest in HT among the professional community, therapists who use a client’s story or the privileged relationship with the survivor to gain professional clout may communicate to the client that, once again, they are only valued for their role as a trafficking victim.
Debt bondage is a form of financial control which involves traffickers holding victims responsible for the “expenses” of their trafficking (e.g. clothing, food, housing). These charges are grossly inflated and inconsistently set to the extent that the individual will never be able to escape the debt required to be paid in order to achieve freedom (Busch-Armendariz et al., 2018). In mental health treatment, payment is a necessary component. Even if the MHP is able and willing to provide pro bono services, this may be triggering to the survivor. Especially in relation to money, survivors will be hypervigilant about hidden rules, incurring debt, and having the MHP ultimately hold the financial charges over them in another form of control. For this reason, establishing a consistent, written, mutually agreed upon and reasonable fee for service is essential. The MHP should both communicate and model transparency about the financial side of therapy, letting the client know that there will be no hidden charges or obligations of any kind.
Distorted Relationships and Trauma Bonds
A trauma bond is an emotional attachment that a victim develops towards the trafficker as a result of experiencing both abuse and care from the trafficker. The grooming and recruitment efforts of trafficking capitalize on this phenomenon, as many traffickers initially offer love, acceptance, and protection to their victims (Rosenblatt, 2014). This type of bond (also known as Stockholm Syndrome) in a complicated and distorted relationship can lead survivors to blame themselves for the abuse, protect the perpetrators, and have a difficult time leaving the abusive relationship (Middleton, Sachs, & Dohary, 2016). Even for MHPs, this concept can be confusing and frustrating, especially given how deeply it is ingrained into the survivor’s worldview. Therapists will need to become educated on the concept, remain nonjudgmental, and resist trying to create a dynamic where the survivor feels they have to choose between loyalty to the MHP versus loyalty to the trafficker.
Sadly, despite the tireless efforts to eradicate and prevent human trafficking, this issue is not likely to go away. MHPs should seek education, training, and supervision on this topic to ensure that survivors are protected from re-exploitation and can experience healing and recovery in a safe and healthy therapeutic setting.
Boon, S., Steele, K., & van der Hart, O. (2011).
Coping with trauma-related dissociation
. New York: W. W. Norton & Company.
Busch-Armendariz, N.B., Nsonwu, M., & Heffron, L.C. (2018).
Human trafficking: Applying research, theory, and case studies.
Thousand Oaks, CA: Sage Publications.
Courtois, C.A., Ford, J.D., & Cloitre, M. (2009). Best practices in psychotherapy for adults. In C.A. Coutois & J.D. Ford (Eds.),
Treating complex traumatic stress disorders
(pp. 82–103). New York, NY: Guilford Press.
Gibbs, D.A., Walters, J.L.H., Lutnick, A., Miller, S. & Kluckman, M. (2015). Services to domestic minor victims of sex trafficking: Opportunities for engagement and support.
Children and Youth Services Review, 54,
Herman, J.L. (1992b).
Trauma and recovery: The aftermath of violence from domestic abuse to political terror.
New York, NY: Basic Books.
Rosenblatt, K. (2014). Determining the vulnerability factors, lures and recruitment methods used to entrap American children into sex trafficking.
Sociology and Criminology, 2(1),
About the Author
Dr. Kristy Eldredge
) is a Licensed Professional Counselor in Denver, Colorado where she works with adult survivors of complex trauma and human trafficking. She is also an Associate Professor in the online Clinical Mental Health Counseling Master’s degree program at the Chicago School of Professional Psychology.
Great Expectations: A Closer Look at Birth, Trauma, and Mental Health
Amanda Harrington, M.A.
Andy Brown, Ed.D.
Three women were in the third trimester of their low risk pregnancies. One found herself preeclamptic and in an emergency cesarean section three weeks before her due date. Another delivered vaginally, but she was stripped of her choice and dignity by the nurses and physician on call and the use of forceps was a physically and psychologically intense experience. The third woman went into labor naturally but suddenly experienced a major medical complication that required emergency sedation and surgery. These are real experiences of women who recently gave birth. In the end, each of these women walked out of the hospital with a newborn in tow and little physical complication aside from the birth itself. Happy salutations on the phone and social media would report “mom and baby doing great!”, but the reality is, each of these women would also walk away from the hospital with a heavy emotional burden not so easily shared.
When labor and delivery is portrayed in America, the most common depiction is a linear progression that starts with the water breaking at an inopportune time and ends with a shiny new baby being handed over to the smiling parents. Other than some shouted obscenities and sweat, the whole ordeal is relatively neat and is over in a few short hours. The reality, however, is that the birth process rarely ever happens in this neat linear progression. It is messy, raw, intimate, and often the most vulnerable state a woman will ever find herself experiencing. She is often in extreme pain, as well as being emotionally and physically naked for hours or days. In fact, though birth may be a natural part of life, research has recently acknowledged that for many women the emotional and physical toll it takes can have serious, lasting effects on overall wellbeing and functioning (Ayers, 2014).
Birth Stories: The Unedited Truth
For some, the vulnerability of the birth process is empowering, and their stories evoke a sense of strength and kinship to the generations of mothers before them
(Tatano-Beck & Watson, 2016). For many others, however, the story is one of unanticipated violation, pain, shame, and fear (Simpson, & Catling, 2016). Studies show that up to a third of women felt they or their child were in immediate danger during childbirth, with half of those mothers reporting continual serious negative emotional responses even after the threat of danger had passed (Boorman, Devilly, Gamble, Creedy, & Fenwick, 2014). More often than not, the dire elements of a child’s birth story are heavily edited and sterilized. The notion exists that hardship, panic, and pain of a difficult delivery are often washed away with baby’s first bath. It is true that birth is a miraculous and natural part of life, but it is also true that for hundreds of thousands of women, the emotional and physical toll taken will result in serious, lasting detriment to their overall wellbeing and functioning (Ayers, 2014).
This is expressed out of fear of not appearing grateful; fear that in their first test of motherhood, they have failed. For these mothers, their stories often go untold while their internal narratives remain steeped in anxiety, distress, and guilt
(Fenech, & Thomson, 2014).
Birth Experiences, Mental Health, and Overlooking the Elephant
Most of these women will not seek help for their postnatal distress. Of those who do, many may find themselves focusing on their current functioning for a potential diagnosis of postpartum depression or psychosis. It is further unlikely that any meaningful discussion about the birth will occur, rather, the discourse concerning haywire hormones, lack of sleep, and life adjustments will ensue. These are certainly pertinent concerns, but what if mental health professionals are missing a critical component making them blind to the elephant in the room? Rigid diagnostic thinking may prohibit them from recognizing the link between the intense emotion and fear surrounding the physical experience of birth and the client’s current functioning.
What if they don’t recognize the mountain-sized elephant they are overlooking is actually trauma?
Zubernis and Snyder (2016) point out that for most mental health practitioners, “trauma” continues to be associated closely with military combat veterans for males and sexual assault for females, so it is easy to see how this component may be overlooked when working with postpartum women. It may be incorrectly assumed that an event so commonplace and enveloped in happiness cannot be traumatic. Unfortunately, this does not paint a complete picture of trauma, and the lack of awareness and research equates to countless families suffering under this oversight.
Traumatic Birth Experiences: Who, What, Why?
Just as it is with more traditionally recognized trauma events, such as combat, assault, and natural disasters, it is acknowledged that most women who experience a traumatic birth will go through acute periods of distress, mourning, and anxiety. While most mothers resolve their birth issues at an acceptable level, a smaller group will go on to experience significant emotional and psychological maladjustment (Greenfield, Jomeen, & Glover, 2016). Anywhere from 5.6% (Creedy, Shochet, & Horsfall, 2000) to as high as 32.1% (Maggioni et al., 2006) of women who experienced a traumatic birth go on to develop Post Traumatic Stress disorder (PTSD), and 13% to 19% of women develop postnatal depression (PND) (O’Hara & McCabe, 2013). More recent studies show that these rates are varied and probably conservative as the limited classification and wording of the DSM-IV criteria used in older studies. These may have excluded women who experienced significant trauma for other reasons than safety and fear, such as feeling violated, stripped of dignity, and intense emotions, such as shame, guilt, and anger (Boorman et al., 2014).
There is no technical definition of what constitutes a traumatic birth experience, but an overview of literature suggests that a fundamental element involves a significant discrepancy between the birth experience that was expected and the birth experienced in reality (Boorman et al., 2014). The traumatic element typically involves the mother experiencing an intense level of negative emotion, most often fear, during the birth process, Common examples involve serious medical complications that pose a threat to the lives of the mother and baby, such as eclampsia, uterine rupture, and low fetal heart tones and often require undergoing emergency cesarean sections or using forceps and vacuums to deliver the baby (Greenfield, Jomeen, & Glover, 2016). However, even relatively uncomplicated labors and deliveries can be perceived as deeply traumatic. For example, when women whose care providers and birth place policies stripped them of autonomy, control, collaboration, or connection, they tend to report their birth experiences as traumatic, even when neither the mother nor the baby’s life had been in imminent danger (Byrne, Egan, Mac Neela, & Sarma, 2017; Reed, Sharman, & Inglis, 2017). Additionally, the literature revealed that women with a history of anxiety and depression, trauma, and sexual abuse were far more likely to report traumatic births, develop subsequent symptoms of mental health deterioration, and to find increased difficulty recovering from the symptoms as compared to women without a history of mental health (Turkstra et al., 2013).
Implications and Treatment
Women who experience a traumatic birth experience and are unable to resolve the emotional and psychological implications often go on to exhibit symptoms that align in many ways with clinical diagnoses of PTSD, such as re-experiencing, hyper arousal, mood dysregulation, and avoidance of the stimuli (Fenech & Thomson, 2014).
Additionally, without resources to work through their experiences and emotions, the literature points to powerful feelings of insecurity, guilt, and shame. This can be linked to depression and anxiety and significantly impeded bonding with infants and partners (Boorman et al., 2014; Simpson & Catling, 2016).
There are stunningly few studies on the options and efficacy of treatments for mental health issues related to traumatic birth experiences. However, increased awareness in the past decade has put the issue on the research horizon. In one mixed methods study, researchers sought to determine the efficacy and experiences of treatment using Eye Movement Desensitization and Reprocessing (EMDR) for women who had been identified as continuing to experience significant symptoms related to their traumatic birth experience (Sandström et al., 2008). The study suggests that this treatment intervention shows significantly promising results in aiding women to process their experiences and decrease their PTSD symptomology, such as intrusive thoughts, hyperarousal, and re-experiencing of events. It is important to mention that women who were currently pregnant were less receptive and more likely to terminate the process early. There is also some evidence to suggest that providing guided debriefing sessions and specific support following a traumatic birth event (TBE), may aid in decreasing the intensity and prevalence of symptoms. For example, the Australian intervention Promoting Resilience in Mothers’ Emotions (PRIME) worked well in mitigating the symptoms for identified mothers who had a traumatic birth experience (Turkstra et al., 2015). The intervention was implemented by trained midwives and allowed women a debriefing framework that helped to identify and process the distressing elements of the labor and delivery. It focused on developing realistic perceptions and creating simple plans of support and resources, and was found successful, especially for mothers who did not have a history of mental health issues (Turkstra et al., 2015).
Addressing the Elephant
Review of the literature revealed the bulk of knowledge and understanding relates to the prevalence, symptoms, and predictive factors surrounding mental health and traumatic birth experiences (Grekin & O’Hara, 2014). Though this is valuable information, the studies were almost exclusively undertaken and published by medical and health care related professionals and journals. This left large gaps in areas that are typically undertaken by the mental health field concerning how perceptions, coping strategies, specific interventions, and cultural implications play a role in effectively treating women struggling after a traumatic birth experience
(Simpson, & Catling, 2016). Keeping this in mind, it would appear that the first step in closing the gap involves increasing awareness that birth can be a silently prevalent source of trauma for women across generations and culture. There are few events in a woman’s life that are as universally transformative as birthing a child. It seems logical to address and accordingly treat the ‘elephant in the room’ of trauma that define these women’s experiences.
Ayers, S. (2014). Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care.
Boorman, R. J., Devilly, G. J., Gamble, J. A., Creedy, D. K., & Fenwick, J. (2014). Childbirth and criteria for traumatic events.
Byrne, V., Egan, J., Mac Neela, P., & Sarma, K. (2017). What about me? the loss of self through the experience of traumatic childbirth.
Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: Incidence and contributing factors.
Fenech, G., & Thomson, G. (2014). Tormented by ghosts from their past': A meta-synthesis to explore the psychosocial implications of a traumatic birth on maternal well-being.
Greenfield, M., Jomeen, J., & Glover, L. (2016). What is traumatic birth? A concept analysis and literature review.
British Journal of Midwifery
Grekin, R., & O'Hara, M. W. (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: A meta-analysis.
Clinical Psychology Review, 34
Graaff, L. F., Honig, A., Pampus, M. G., & Stramrood, C. A. (2018). Preventing post-traumatic stress disorder following childbirth and traumatic birth experiences: A systematic review.
Acta Obstetricia Et Gynecologica Scandinavica,
Maggioni, C., Margola, D., & Filippi, F. (2006). PTSD, risk factors, and expectations among women having a baby: A two-wave longitudinal study.
Journal of Psychosomatic Obstetrics & Gynecology
Reed, R., Sharman, R., & Inglis, C. (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions.
BMC Pregnancy and Childbirth, 17.
Sandström, M., Wiberg, B., Wikman, M., Willman, A., Högberg, U., Medicinska fakulteten, Samhällsvetenskapliga fakulteten. (2008). A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth
. Midwifery, 24
Simpson, M., & Catling, C. (2016). Understanding psychological traumatic birth experiences: A literature review.
Women and Birth, 29
Archives of Women's Mental Health
Turkstra, E., Creedy, D. K., Fenwick, J., Buist, A., Scuffham, P. A., & Gamble, J. (2015). Health services utilization of women following a traumatic birth.
Archives of Women's Mental Health, 18
Zubernis, L., & Snyder, M. (2016).
Case conceptualization and effective interventions: Assessing and treating mental, emotional, and behavioral disorders
. Thousand Oaks, CA: Sage.
About the Authors
spent a decade as an educator until she graduated in 2016 with a MA in Mental Health Counseling. She is currently pursuing a Ph.D. in Counseling Education and Supervision at Capella University.
Andy Brown, Ed.D.
is a professor, clinician and VP of ITTI. He lives in Clayton, NC. He can be reached at
UPCOMING TRAUMA TRAININGS
Courses Leading to Certification
All courses are NBCC approved
January 7 - February 17, 2019
- Clinical Trauma Professional (CTP), 13 CE hours
- Anger Management Treatment Professional (AMTP), 13 CE Hours)
- Child & Adolescent Trauma Professional (CATP), 13 CE Hours
- Clinical Trauma for Social Workers, 13 CE Hours (this course is also NASW approved #886782500-1939)
January 7 - March 3, 2019
- Sex Offender Treatment Provider (SOTP), 24 CE Hours
Additional Trauma Courses
All courses are NBCC approved
January 7, 2019
- Trauma-Informed Care Basics (TIC), 2 CE Hours
January 7 - February 17, 2019
- Attachment & Trauma (AT), 13 CE Hours)
- Neurobiology for Mental Health Professionals (NB), 13 CE Hours
- Preparing Forensic Assessments (PFA), 13 CE Hours
- Clinicians in the Courtroom (CIC), 13 CE Hours
- Victimology (VIC), 13 CE Hours
- Treating Sexual Addiction (TSA) 13 CE Hours
- Neurobiology of Addictions (NA), 13 CE Hours
International Trauma Training Institute (ITTI, LLC)
8051 N. Tamiami Trail - Box 4
Sarasota, FL 34243