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By Lindsey Phillips

August 2021

Jenna Hershberger, a licensed associate professional counselor, was working on a crisis response team for a regional human service center in North Dakota when she received a call from a young woman reporting physical abuse. The woman was forthcoming about her medical complaints but not the state of her mental and emotional health. Hershberger could tell there was more to the woman’s story, so she asked to meet her in real life to discuss things further. The woman agreed.

During their in-person meeting, , a therapist at the Village Family Service Center in Fargo, North Dakota, noted signs of potential sex trafficking. “Her presentation was really concerning. She was very tearful,” Hershberger recalls. The woman also kept mentioning how her “friends” had forced her to do things while she was under the influence of substances. The more the woman shared, the more convinced Hershberger grew that the people being referenced were human traffickers, not friends. When Hershberger asked where the woman was staying, she revealed that she was currently homeless.

After talking for a while, the woman finally acknowledged that she had been forced into sex trafficking and wanted to get out. She was scared and didn’t know what to do. Fortunately, Hershberger did. She found the woman a safe shelter for the night and helped her locate mental and physical health services.

“I’m in North Dakota … [where] prevalence rates [of human trafficking] are lower, yet it’s still happening,” says Hershberger, a member of the �ֲ���ý. “The tragedy where I am and in Midwestern, rural areas is that people just seem to say, ‘Well, this doesn’t happen here.’”

Jared Rose, a licensed professional clinical counselor and supervisor with a private practice, , in Toledo, Ohio, has also encountered a “that doesn’t happen in my community” mentality when it comes to human trafficking. He began working in anti-trafficking about 15 years ago when someone involved in an anti-trafficking organization in Toledo approached him because of his work with the LGBTQ+ community and with people infected with, affected by or at risk for contracting HIV, both of which often intersect with trafficking. When conducting trainings in rural Ohio counties, Rose has heard law enforcement say, “That’s not happening here.” This statement makes Rose cringe because he knows firsthand from his work with individuals who have been trafficked that it is happening.

Human trafficking, in fact, is more common than we think. The International Labour Organization that approximately 40.3 million people were in modern slavery globally in 2016. Sometimes people incorrectly assume that human trafficking is a problem only in developing countries, but the National Human Trafficking Hotline 63,380 survivors of human trafficking in the United States from 2007 to 2019.

Rose, an �ֲ���ýmember who wrote an �ֲ���ýfact sheet on human trafficking awareness for school counselors in 2019, finds that too many counselor clinicians also remain unaware of the definition and . “You could have the epitome case sitting in front of you,” Rose says. “And if you don’t even know what trafficking is, you’re going to miss it.”

Recognizing the Signs

The U.S. Department of Homeland Security human trafficking as the use of force, fraud or coercion to obtain some type of labor or commercial sex act. Rose, of counseling at Bowling Green State University, advises counselors to stay alert to signs of force, fraud or coercion with clients. “Take note of who they are with and where the power and control lie,” he says. For example, is someone else benefiting — often financially — from the client’s actions? Does someone else seem to be in charge or making all the client’s decisions for them?

Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, also looks for visual signs such as bruising, scarring or branding. Individuals who are being or have been trafficked are often branded with “ownership” tattoos with the name of their trafficker or with symbols such as a star or cowboy hat. Because sex acts place a lot of strain on the body, survivors often discuss medical complaints such as dental issues, migraines or urinary tract infections, she adds.

Clients who have been trafficked “may appear overly compliant and submissive, or they might appear really abrasive and abrupt,” Hershberger points out. Counselors must recognize “that those strategies were adaptive at one time but they’re not right now.”

As it relates to falling victim to trafficking, Rose notes that the No. 1 risk factor for children is being unhoused. He prefers the term unhoused to runaway, he explains, because children are often abandoned or “thrown out” by their families. “Within a matter of two to three days of being out of the home, kids are approached [by traffickers], and one-third of those [unhoused] kids are going to get trafficked,” he says. “So, that piece of being unhoused — couch surfing, staying at a shelter, living on the street or whatever the case may be — puts them at significantly higher risk.” Children who are already vulnerable may easily fall prey to an adult who shows them attention or what they initially perceive as support, he adds.

Other risk factors include lower socioeconomic status, past trauma (sexual, physical, emotional, verbal or spiritual), being differently abled, substance use, and belonging to a racial or sexual minority group, Hershberger says. Given the complex trauma that these individuals experience, they often present with comorbid disorders such as substance use, bipolar and severe depression, she notes.

Counselors may overlook or miss signs of trafficking when they take the client’s circumstances or presenting issues at face value, notes , an associate professor of counseling at North Carolina Agricultural and Technical State University. For example, if a client is homeless or doesn’t have any identification, counselors may start to talk about the emotions, behaviors and social systems surrounding the client’s chronic homelessness and help them come up with a plan to find a more stable environment. But in doing this, clinicians may miss the larger picture, stresses Dunlap, a licensed clinical mental health counselor with in Greensboro, North Carolina. Perhaps the client was forced into sex trafficking after being taken from their home or fleeing an unsafe environment.

“There’s a lot of different risk factors. There’s a lot of different things to look for. There’s a number of populations that we are particularly concerned about, but at end of day, it all boils down to vulnerability,” Rose says. For that reason, he stresses that counselors need to be cognizant of that vulnerability piece in connection with their clients.

Sometimes counselor practitioners worry that they won’t be able to recognize the signs that someone has been trafficked, Rose says, but he reassures them they know how to read interpersonal reactions. They know when someone is looking to another person for answers. They notice when people’s stories do not match up.

Counselors also need to consider what a trafficking survivor might look like in their particular clinical setting, Hershberger says. For example, if a counselor is doing crisis work, they might have someone who is in denial about being trafficked or confront a situation that appears to be domestic violence.

The office setting may determine the likelihood of a practitioner encountering an individual who is currently being trafficked or who has gotten out. Counselors who work in public health settings or hospitals are more likely to see individuals who are currently being victimized when these individuals come in for a medical issue such as testing for a sexually transmitted disease or injury from abuse, Rose notes. Counselors working in private practice or at a community agency will typically see these clients after they have been extricated, he says.

Establishing trust and safety

People who have been trafficked may find it difficult to trust others. Before thinking about clinical treatment plans, counselors need to establish a sense of safety and a healthy therapeutic rapport with these clients, Hershberger stresses. These individuals have experienced “complex trauma in the sense that it’s repeated for long duration and often comes from people who should be caregivers,” she explains, “so it makes it really hard for survivors of trafficking to trust us. We need to be really authentic because survivors will pick up on it if [we’re] not.”

Hershberger, president of the North Dakota Association for Counselor Education and Supervision, advises clinicians to maintain an open-door policy with survivors of human trafficking, especially when they are working on engagement with the client. People who are dealing with significant trauma may be more prone to canceling sessions, so adhering to a policy of termination after two missed sessions will not help build engagement and rapport with these clients, she cautions.

Counselors’ innate desire to help clients heal can sometimes be an impediment to build-ing this relationship. Rose sees counselors who want to dive right into the trauma work before first building strong therapeutic and strategic foundations, which can take a long time. “The minute we try to push too much — even if our best intentions are there — is when someone can have [a negative] reaction” and feel that the counselor is forcing them to do something they don’t want or are not yet ready to do, he says.

Rose has also witnessed the inverse: clients who get frustrated when counselors don’t jump straight into the trauma work. When this happens, he explains to clients that although they may feel ready, their whole system may not be. To further illustrate the point, he compares trauma work to a physical wound: “If I start poking around at a wound and you don’t trust me yet or your entire system isn't ready to allow that yet, you’ll immediately pull back and you’re not going to want me to go near it,” he tells clients. “And the same [thing] is happening cognitively and emotionally with trauma. If we start poking around and you’re not ready, then it’s going to fall apart on us.”

The need for clinical trauma care

Rose asserts that counselors are in a prime position to provide clinical psychotherapy and trauma-focused work. Rose is an executive member of the Lucas County Human Trafficking Coalition, and he was awarded the Social Justice Leader Award from the Human Trafficking and Social Justice Institute in 2017.

Mental health services geared toward survivors of trafficking are great at managing clients’ symptoms through art or expressive therapy or group work, but Rose finds this is often where their treatment ends. “It has to be more. It has to be evidence-based trauma work,” he stresses. “We can’t just treat symptoms. We have to treat the whole person, and we have to treat the trauma.”

“Folx that have been labor trafficked have all sorts of layers of trauma damage. … Sex traffic victims have all of the symptoms of domestic violence, emotional abuse, physical abuse, sexual abuse — all rolled into one very unpleasant package,” he continues. “And expressive therapy is not going to treat that trauma; it’s going to treat the symptoms. If we really want to help folx, we have to go deeper, and that’s where counselors really need to come into play.”

Rose, a certified therapist in eye movement desensitization and reprocessing (EMDR), recommends that counselors use an evidence-based trauma treatment that follows a triphasic approach that a) establishes a foundation, b) reprocesses and works through the trauma and c) plans for the future. Rose often uses EMDR when he’s working with this population because he finds it helpful to treat the root cause of the trauma. He also recommends trauma-focused cognitive behavior therapy, especially when working with children and adolescents.

Take the relational approach

Hershberger points out that traffickers differ from other sexual offenders (who are often described as socially awkward and desire a sense of belonging) in that they are often socially intelligent, charismatic and good at forming relationships. They gain the trust of vulnerable individuals by initially fulfilling their need for love, connection and belonging, she explains. For example, the trafficker could be the first person in the individual’s life to recognize and celebrate their birthday or give them special attention, such as taking them to get a manicure.

These acts can cause some survivors to form bonds with and defend their traffickers — a condition often referred to as Stockholm syndrome. Hershberger and Dunlap point out that something similar sometimes happens with individuals who experience domestic violence. “Survivors will often defend their trafficker because they didn’t have that sense of belonging or that family growing up. So, this is the first time they’re experiencing that — along with horrible kinds of trauma — but it’s hard for them to differentiate that,” Hershberger explains.

According to Hershberger, these trauma bonds illustrate survivors’ desire for human connection. Traffickers thwart this connection by exploiting this desire for their own gain.

“Human sex trafficking is the ultimate anti-relationship,” argues Hershberger, who recently presented on this topic at ACA’s Virtual Conference Experience. Survivors of sex trafficking have been forced “to exist in a world absent of authentic, growth-fostering relationships,” she explains. Thus, she recommends that counselors use a relational-cultural approach with this client population to foster an authentic growth-fostering connection.

To explain this approach, Hershberger presents Marie, a fictional client: When she was 14 years old, Marie lived in an abusive home where her mother’s boyfriend molested her. So, Marie was excited when Jake, a 24-year-old man, approached her and promised a better life as his “girlfriend.” He bought her nice things and told her she was “amazing in bed.” One day, he told Marie some money hadn’t come through at work and asked if she would help him by having sex with a few guys. When she resisted, he beat her until she complied. He forced her into sex trafficking, and she was having sex with as many as 10-15 men a night. (See Hershberger’s 2020 article, “,” published in the Journal of Creativity in Mental Health, for a more detailed discussion of this case study.)

Following a relational-cultural framework, Marie’s counselor first establishes a sense of safety and trust, and they are authentic, empathetic and consistent in their interpersonal interactions, Hershberger says. So, if the counselor makes a mistake by showing up late for session, they own that mistake, apologize and ask Marie how they can make up for it.

Marie may have internalized negative beliefs or self-blame such as “I’m only good for my body and others’ use” or “I’m not worthy of being loved.” The counselor can help Marie first identify and name these beliefs, and then they can work together to challenge these negative beliefs. The therapeutic relationship further challenges Marie’s distorted thinking about herself and relationships, Hershberger notes, and models what a healthy relationship entails.

To challenge Marie’s belief, the counselor could use self-disclosure and tell Marie, “I experience you as a creative, confident individual who is worthy of being loved.” Hershberger recommends that counselors use the client’s own words when reflecting positive attributes to help the client identify and own their strengths.

As Hershberger points out, traffickers try to keep victims in a constant state of uncertainty about their environment, safety or identity. So, the counselor’s role is to identify moments or thoughts that are unclear, such as Marie’s negative perception of her self-worth, and help her add clarity to them.

Hershberger names bibliotherapy and narrative therapy as useful approaches for empowering survivors of trafficking and helping them find their own voice. For example, the counselor could ask Marie what name her trafficker gave her and the name she wants to use moving forward. Then, Marie could journal about this new identity and the qualities associated with it.

The counselor could also add in creative techniques such as collage or relational imagery. For example, Hershberger once had a client who identified with the image of a wounded deer because they too had been hurt and abandoned. The wounding paralleled their own trauma around the physical abuse they had experienced while being trafficked. Later, Hershberger used this image to help the client think about what they wanted their future identity to be and to create a collage of their strengths.

The therapeutic relationship becomes a healthy relationship — one that is safe, dependable and empowering and that counters the disconnection and uncertainty survivors experienced when they were trafficked, Hershberger says.

Preparing to work with this population

The best way to understand what is going on with human trafficking in a specific area is to get involved and volunteer in the community, Rose says. One place to start is joining or attending meetings of local, regional or state trafficking coalitions and task forces. “You can learn more about what agencies are providing services for this population,” he says. “They need to know where mental health providers are, and you need to know where additional services are for survivors.”

Rose advises counselors to approach these partnerships with an attitude of wanting to learn and help. Communities don’t respond well to people who think they know what is best or have all the right answers, he says. Instead, inform these organizations of the crucial skills they may be missing. Counselors have “the clinical piece that a lot of these places need and strive for,” Rose notes. “There’s a lot of social workers, nurses and different helping professionals, but clinical mental health treatment may not be what they have.”

In addition to attending monthly meetings of North Dakota’s trafficking task force, Hershberger prepared to work with this population by reading case examples and familiarizing herself with these tough stories. She also reached out to other clinicians in the field to hear about their experiences. As she points out, “It’s one thing to hear terminology, but it’s another thing to hear somebody’s story.”

Rose and Dunlap recommend that counselors limit their caseloads (if they have that option) when working with this population. “You can’t hear the thing of nightmares for three, four or eight hours a day and expect to be OK by 6 or 7 o’clock at night,” Rose says. Both he and Dunlap, an �ֲ���ýmember who researches and works with youth with disabilities, survivors of human trafficking and criminal populations, have had to learn how to balance their clinical schedules better. They intentionally leave time between these difficult sessions so they can reflect, reenergize and regroup before seeing their next client.

Counselors must also remember that not every client-counselor relationship is the right fit, Rose says. For example, someone may refer a female survivor of sex trafficking to him because of his expertise in EMDR, but if she has been abused by men her entire life, she may not want to work with Rose regardless of his qualifications and reputation as a counselor.

“These clients have had people treat them really poorly their entire lives,” he points out. “Part of that therapeutic relationship is recognizing maybe I’m not the best counselor for every person I want to help, and that’s OK. Just giving [clients] that freedom and autonomy will help them along in their journey. They don't have to work with me to fix the problem.”

Rose reminds counselors there are other ways to help serve this population without working directly with clients. Counselors can get involved in local agencies that work on human trafficking, provide education and trainings, or work on prevention, he says.

Hershberger understands how difficult it can be when counselors must refer a client. Because she was part of a crisis response team when she met the woman who was a survivor of human trafficking, she wasn’t able to continue working with her. The woman was referred to another clinician who worked for the human service center. “That was hard,” she recalls. “I couldn’t stay with her, and having that continuity of care would have been nice.”

Hershberger did have a chance to meet with the woman a few months later. With the help of her new counselors, she was making progress toward creating healthier relationships.

Paige Dunlap, a licensed clinical mental health counselor in Greensboro, North Carolina, once worked with an agency in Detroit that assisted individuals who no longer wanted to be engaged in gang activity. In sharing their stories, some of the group members disclosed that they had been directly or indirectly involved in trafficking other individuals. After recovering from the initial shock of hearing that, Dunlap started to think and educate herself about ways counselors could help perpetrators of trafficking.

“We as counselors don’t really talk about this hidden population” of perpetrators, she says. “We don’t know too much about them.”

Often people’s biases can cloud their judgment about these individuals. The more Jenna Hershberger, a licensed associate professional counselor in Fargo, North Dakota, researched and worked with cases of sex trafficking, the more she discovered the dichotomous thinking attached to it: People consider traffickers to be “bad” and survivors to be “good.” But it’s more complicated than that, she says.

“In the literature, we see that traffickers and survivors experience the same kinds of childhood traumas, such as sexual, emotional, physical and spiritual abuse,” she explains. But for individuals who become traffickers, “there is a distortion that happens in the way that they respond to the trauma.” Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, acknowledges this is an area of research that mental health professionals do not fully understand yet. But initial clinical findings, as well as Hershberger’s own professional experience, indicate that traffickers often seem to have empathy deficits and endorse trafficking myths such as “people like this way of life.”

Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University, says that traffickers and victims of trafficking often get enmeshed in that world for similar reasons. “There is a need for belonging in all of these individuals,” she says. Both groups often lack support systems, have limited work opportunities and are tempted by the promise of a “better” life, she explains.

Once individuals get involved in trafficking, it becomes difficult for them to leave, Dunlap points out. “It becomes almost an institutionalization for them too. … They don’t know how to function outside of that.”

“Getting those individuals into your office to do this hard work is really going to be tough,” she admits. “If you’re a counselor and you do happen to have these clients, the last thing they need is for your own biases to be stopping them from getting help, because they’re doing good just to be there.”

Hershberger hopes counselors continue to research ways to better help both the survivors and perpetrators of human trafficking. In doing so, she encourages counselors to consider a larger question: How as a society are we creating spaces in which people don’t know what a healthy relationship looks like so that they’re seeking out this subculture for a sense of belonging?