articles

Aftercare for Survivors of

Human Trafficking
Becca C. Johnson
This article examines aftercare services needed for victims of human trafficking,
including the importance of mental health services. Aftercare services must be
provided in a trauma-sensitive way which encourages all involved in service
provision to understand complex traumasymptoms and behaviors, possible
outcomes, reasons for silence as well as victim thoughts, beliefs and feelings.
Therefore, both breadth of knowledge and sensitivity are needed in the provision of
aftercare services for those exiting a life of victimization. Trauma-specific therapy,
the key role of the social worker, and scriptural mandates are also presented.

n the fight against human trafficking, organizations and ministries

that focus on prevention, policies, laws and their enforcement, lessening the demand, victim identification, as well as rescue, are needed.
Once victims are identified and rescued, however, our fight against human
trafficking is not over. Follow-up care is needed to help victims on their
journey towards recovery and restoration.
For the purposes of this article, the term victim is used to describe
those having been traumatized. It references what was done or happened
to them. However, the term survivor is preferred and more applicable as
it describes the persons strengths and resiliency in overcoming such horrendous experiences as human trafficking and sexual exploitation.
Though law enforcement or those in victim identification may feel
successful when a perpetrator has been apprehended or a rescue has taken
place, those in social services know that our job of assisting the victim
down the long road to recovery has just begun.
The term aftercare is used to refer to the services provided victims of
human trafficking. After they have been rescued, they need carethus,
aftercare. The focus of aftercare is to bring practical help, as well as hope
and healing, to those devastated by trauma.
Social Work & Christianity, Vol. 39, No. 4 (2012), 370389
Journal of the North American Association of Christians in Social Work

Aftercare for Survivors of Human Trafficking

The provision of these aftercare services, however, must be comprehensive and provided in a trauma-sensitive manner. All of those providing
aftercare services should have a foundational understanding of the types,
complexity, impact, and possible symptoms of trauma. Without this foundation, victims may easily be re-traumatized, feel violated, invalidated,
rejected, unsafe, misunderstood, helpless, and hopeless. Without this foundation victims may discontinue essential services needed in their recovery.
Therefore, both breadth of knowledge and sensitivity are needed in
the provision of aftercare services for those exiting a life of victimization.
This article examines both the services needed for victims, as well as the
importance of providing these in a trauma-sensitive way, including traumafocused care. The important role of the social worker is also discussed.
Aftercare Services: Meeting Practical Needs
For the Lord your God is the great God He defends the cause
of the fatherless and widow and loves the alien, giving him food
and clothing. (Deuteronomy 10: 17a, 18, NIV).
Aftercare services must first meet the basic human needs of food clothing and shelter. Comprehensive aftercare for victims of human trafficking
generally includes a variety of services. Which services are needed depends
on the individuals needs, nationality, language skills, gender, age, housing
situation, and the type of trafficking. For example, a female domestic minor
who has been sexually exploited will have different needs than an adult
male, labor-trafficked, foreign national without documentation, family, or
English language skills.
Once removed from the trafficking context, the practical assistance
needed for survivors of human trafficking may include many or most of
the following:

Housing

Food and clothing

Medical care

Health education

Dental care

Legal &/or immigration
services

Protection by the criminal
system

English language learning,
Literacy, &/or Interpretation

Independent living skills

Educational opportunities
Vocational training

Job placement

Transportation

Human rights education

Help taking care of family
in the homeland if foreign
national

Economic assistance

Physical Safety

Repatriation (foreign nationals wanting to return to their
homeland)

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Reunification (some survivors
may wish to be reunited with
their families)

One anti-trafficking organization providing comprehensive

aftercare, including extensive legal
assistance states:

victims cannot become survivors without a social service advocate to ensure access to benefits and services and
to provide supportive counseling, validation, and normalization; a shelter or housing program to ensure basic necessities
are provided; and finally, critical legal services that assist
victims in navigating complex criminal, civil, immigration,
and other legal proceedings that ultimately deliver the
person to full status and work authorization.(Client Services Program, Coalition to Abolish Slavery and Trafficking
website, www.castla.org/client-services-program)
As we look specifically at the needs of victims of sex trafficking, we
realize that their needed services can represent the convergence of many
different social service agencies. There are those agencies and ministries that
focus solely on helping those with experiences related to domestic violence,
sexual assault, child abuse, crisis pregnancy, runaway and homeless youth,
human rights, and gender and racial equality, many of which include legal
advocacy, financial help and assistance in identifying and acquiring needed,
related services. Sex trafficking victims would qualify for many of these
services. They usually need most of these agency-focused services due to
the multiplicity of their trauma experiences.
Figure 1: Human/Sex Trafficking Victim Needs:
A Merging of Various Service Agencies

(Johnson, 2011)

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Aftercare Services: Meeting Emotional Needs

While attending a large, national anti-human trafficking conference, I
attended a seminar on the key to successoffered by an aftercare agency on the
key. This agency believed that the key to victim restoration was in providing
job training and placement. While I agree that job skills and income are
important for financial independence and self-esteem, this focus does not
address the emotional impact of the victims traumathe betrayal, abuse,
threats to bodily integrity, fears, and deprivations experienced.
Meeting the practical needs of those rescued from human trafficking
is essential and obvious, yet victims also need emotional or mental health
services. They need assistance working through the emotional aftermath of
their trauma and in planning for their future. Providing for practical needs
is incomplete when not coupled with the provision of specific services that
focus on trauma recovery and meet victims emotional needs.
Accordingly, to the list of aftercare services above we add:
Mental health serviceindividual counseling, group therapy,
psychoeducation, anxiety management, and additional supportive
therapies (art, music, equine)
Safety planninghow to keep and stay safe (both physically and
emotionally)
Future planningdeveloping goals for the future
The director of a residential program for minors rescued from sex trafficking once shared with me that she originally thought that providing for
basic, practical needs, along with a loving, caring environment was all that
was needed. As she became more aware of the devastating, long-term effects
of trauma, she realized the necessity of having not just trauma-informed
but trauma-specific services. She now feels that it is essential to provide
quality, trauma-focused therapy for rescued victims.
Why is Emotional Healing Important? Understanding Trauma
It helps us to understand the importance of including services that
encourage emotional healing by taking a look at what many human trafficking victims experience. Our empathy increases as we get a glimpse at
the horror of their situations.
Traumatic experiences can be dehumanizing, shocking or
terrifying and often include betrayal of a trusted person
or institution and a loss of safety. [Trauma is a] psychologically wounding experience that induces powerlessness,
fear, recurrent hopelessness and a constant state of alert
(National Center on Trauma-Informed Care).

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Trauma Events Continuum

The following diagram offers a way to view trauma on a continuum.
Trauma reactions are generally more severe as one moves up the arrow,
with trauma symptoms becoming more pronounced and recovery services
and support requiring more time. Individuals may, of course, experience
the trauma in different ways and degrees regardless of where it falls on the
continuum. Ones trauma reactions depend on a variety of factors including
age, gender, life experiences, culture, religious beliefs, support system, and
more. This diagram focuses on trauma events rather than individual trauma
experiences such as divorce, death of a loved one, medical procedures.
Figure 2: Trauma Events Continuum

(Johnson, 2011)

Single impersonal traumatic events happen once and would include

such things as natural disasters and accidents as well as acts of human
negligence. Single interpersonal trauma refers to single events that are
committed person to person, whether known or unknown, such as robbery, assault, and rape. Multiple interpersonal with a single perpetrator
would refer to ongoing child abuse, neglect or domestic violencemultiple
trauma experiences with a known assailant. Multiple interpersonal with
multiple perpetrators refers to those who have experienced a variety of
traumatic events at the hands of several or many different abusers. This last
category describes well what victims of human trafficking and especially
sex trafficking experience. Rape, violence, torture, assault, humiliation,
abuse, degradation, confinement, threats, isolation, and more are all a part
of human trafficking.

Aftercare for Survivors of Human Trafficking

This multiplicity and prolonged traumatic exposure is examined in the

literature on complex posttraumatic stress disorder (Courtois, 2004; Sar,
2011; Schwecke, 2011). In her article, Understanding Complex Trauma,
Complex Reactions, and Treatment Approaches, Christine Courtois
(2004) writes:
Complex traumatic events and experiences can be defined
as stressors that are: (1) repetitive, prolonged, or cumulative, (2) most often interpersonal, involving direct harm,
exploitation, and maltreatment including neglect/abandonment/antipathy by primary caregivers or other ostensibly
responsible adults, and (3) often occur at developmentally
vulnerable times in the victims life, especially in early
childhood or adolescence, but can also occur later in life.
This multiplicity of trauma events (generally referred to as complex
trauma) leads to a complete sense of instabilitymentally, emotionally,
physically, socially and spiritually. The world becomes unsafe, unstable,
uncertain, and unforgiving. The victims life is controlled, crazy and confused. She/he is left with an inability to cope, to overcome, or to find help
or hope. This is illustrated in the following diagram.
Figure 3: Complex Trauma

(Johnson, 2011)

Complex trauma, that of multiple and/or prolonged traumatic events,

results in emotional dysregulation, loss of safety and the ability to detect or
respond to danger cues (Herman, 1992). Victims suffering from complex
trauma often experience depression, anxiety, self-hatred, dissociation, substance abuse, despair, and somatic ailments. They are also at higher risk for
self-destructive and risk-taking behaviors, re-victimization, and experience
difficulties with interpersonal and intimate relationships (Courtois, 2004).

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Trauma Symptoms
Researchers (Cook, Blaustein, Spinazzola, & van der Kolk, 2003) have
identified and categorized key features of complex trauma symptoms and
behavioral characteristics in seven domains. They are listed here with a
brief summary of some of their key components:
Attachmentdifficulties with relationships, boundaries, trust, affect
attunement.
Biologyincreased medical problems, somatization.
Affect or emotional regulationdifficulty identifying, expressing
and/or controlling emotions.
Dissociationalterations in states of consciousness, amnesia,
depersonalization and derealization.
Behavioral controlpoor impulse control, eating and substance use
problems, aggressive, oppositional, compliant, self-destructive.
Cognitionproblems with perceptions, understanding, sustained
attention.
Self-conceptlow self-esteem, guilt and shame.
In reviewing the list, it becomes apparent that most of the symptoms
are emotional-mental-social in origin, rather than biological. Those rescued
from human trafficking, especially sex trafficking, experience many of these
symptoms. Without focused, intentional counseling, many will continue
to live a life overcome by these negative outcomes.
The Silence Compliance Model
It is difficult for most to understand victim silence. People often ask,
Why dont they just tell someone? When I co-led a support group for
mothers of minors who had been abused, the most common question asked
was Why didnt my child speak upwhy didnt he/she tell me? The
Silence Compliance Model (Johnson, 2010) categorizes the many reasons
victims seem to comply with their abusers or traffickers. Overlap exists
but the model serves to help in our understanding of the dynamics of the
silencing power of captive or abusive situations such as human trafficking.
Coercion: Victims are scared due to:
Cruelty, brutality, torture
Threats of harm to self and/or loved ones
Threats of deportation and/or arrest
Withholding of food and other necessities of life
Withholding of drugs (traffickers may encourage or cause addictions and then use it to control victims)
Victim is unable to identify any solutions, help, support, or escape

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Collusion: Victims are in survival mode due to:

Dependence: Emotional, drug, and/or financial
Threats and/or brutality
Isolation
Feeling helpless
Brainwashing leads to experiencing confusion and uncertainty
about what is/isnt real or true
False sense of love and belonging
Captive Compliance: Victims might display positive perspectives
and behaviors in support of their captor (also referred to as the
Stockholm Syndrome)
Contrition: Victims feel shame and feelings of:
Culpability, guilt, and self-blame
Remorse and regret
Worthlessness
Hopelessness
Family dishonor or duty
Stigmatization (negative stereotyping)
Rejection and abandonment
The Silence Compliance Model addresses the key issues facing victimscruelty, captive compliance and culpability. Victims are scared, in
survival mode, and/or filled with immobilizing shame. This silence is
reinforced by the many thoughts, beliefs, and feelings victims hold, such
as those listed here:
What Victims Often Think and Believe:
Its my fault. I am to blame.
I am a bad person (unworthy).
I should have known better or tried harder.
Im so stupid.
People use and abuse me, even those who say they love or care
about me.
Dont feel.
I gotta be tough and not let things bother me.
I cant trust anyone, not even myself.
Love hurts.
This is what I deserve.
Its helpless (the situation).
Im hopeless.
This is as good as it gets.

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Victim Reality: Common Feelings from an Uncommon Experience

(Johnson, 2012):

Doubt-filled
Distrusting
Dependent
Dissociative
Dream-less
Depressed
Discouraged
Devastated
Dejected
Damaged-goods
Disregarded
Demoralized
Down-trodden

Demeaned
Disposable
Dehumanized
Defiled
Devalued
Deceived
Dirty
Desperate
Disconnected
Destroyed
Detached
Dumb
Dead

Research confirms that victims of trauma are much more likely to be

re-victimized (van der Kolk 1989; van der Kolk, Roth, Pelcovitz, Mandel,
& Spinazzola, 2005; Yehuda, Spertus, & Golier, 2001). This is why intentional, trauma-focused care is essential. Without help and healing, they
are more likely to be re-traumatized and more prone to live a guilt-ridden,
anger-controlled, shame-filled life.
Advocating for Trauma-Focused Emotional Healing
If we meet the practical needs of victims without helping them work
through the emotional impact and aftermath (illustrated below), observations and experience show that there is a high risk of recidivism as individuals return to former or new positions of victimization or continue to
live a life filled with shame.
Figure 4: Importance of Emotional Healing
and the Dynamics of Recidivism

(Johnson, 2008)

Aftercare for Survivors of Human Trafficking

As we advocate for the inclusion and importance of services focused

on meeting emotional needs, we find less recidivism and more emotional
healing and wholeness. I consider that success. With focused emotional
care, the victim can go from a shame-filled to a hope-filled life.
After hearing about the impact of trauma, it can be tempting to think that healing is impossible, but it is possible
for survivors to find relief from the emotional, physical,
and behavioral reactions that often follow a traumatic
experience. Quality care, including the unconditional love
of caregivers, trauma-focused counseling, medical care,
and opportunities for the future all empower survivors to
overcome the trauma they have experienced (International
Justice Mission, (2010), p. 15).
A Biblical Mandate
In the Bible, in Matthew 25 verses 35-36, we read:
I was hungry and you gave me something to eat,
I was thirsty and you gave me something to drink,
I was a stranger and you invited me in,
I needed clothes and you clothed me,
I was sick and you looked after me,
I was in prison and you came to visit me.
This is aftercare. In these verses we are encouraged to provide for the
basic human needs of food, drink, shelter and clothing. Yet we are also to
look after the sick and visit the imprisoned. Jesus calls us to offer both
practical and emotional help.
I was sick and you looked after me. Looking after the sick includes
the emotionally injured, as well as the physically ill. Victims of human trafficking are emotionally wounded. They feel sick, heartbroken, confused,
fearful, ashamed, overwhelmed, numb, guilt-ridden, insecure, betrayed,
and angry. They need someone to look after them so they can get better.
Victims may not know or understand what is wrong but they definitely
need others to help them navigate the road to healing.
I was in prison and you came to visit me. Visiting the imprisoned
includes those held captive by past traumas and present fears. Human
trafficking victims have been held captive by traffickers in literal or virtual prisons, generally under horrible emotional and physical conditions.
Kept in locked rooms or coerced and manipulated into believing there is
no escape, they feel helpless and hopeless. They have not been allowed
many of the freedoms we take for grantedthe freedom to speak, share
an opinion, believe as we choose; the freedom to go and do what we want;

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the freedom to choose what we will and will not do, and so much more.
Once freed, many continue to be imprisoned, not by the trafficker, but by
their fears and/or inability to access needed help.
Trauma Sensitive Care
When providing holistic services for those rescued from modern-day
slavery, it is imperative that those services be provided in a way that is sensitive to the issues and concerns related to trauma. Trauma-informed care
is an approach to engaging people with histories of trauma that recognizes
the presence of trauma symptoms and acknowledges the role that trauma
has played in their lives (National Center for Trauma-Informed Care).
Trauma-informed care is critical, especially when working with survivors
who have experienced the devastation of complex trauma (Elliott, Bjelajac,
Fallot, Markoff, & Reed, 2005; Harris & Fallot, 2001).
While the term trauma-informed is commonly used, I prefer to use
the phrase trauma sensitive to reflect engagement of the heart as well as
the mind. This means that all aspects of the services demonstrate awareness
of traumas impact and aftermath on victims and seek to be sensitive. This
sensitivity minimizes the triggering of negative memories that can cause
additional traumatization.
Trauma-sensitive care reflects a commitment by all involved to treat
victims experiences gently and with emotional as well as physical safety in
mind. This means that all personnel and volunteers in contact with survivors are well trained and understand the impact of trauma on individuals,
communities, and cultures. Agency policies and guidelines reflect cultural
as well as trauma awareness and are developed with a heightened sensitivity
of how decisions might be perceived and how they affect survivors.
For example, as we interact with and engage victims, we become aware
of what and how we communicate, how body language and gestures might
be perceived, who should/should not interface with victims, and much
more. All of those providing services to victims, whether in an ongoing
or infrequent capacity, should be trauma-informed, aware and sensitive
whether driver, teacher, cook, nurse, or administrator.
Trauma Aftercare Staff Checklist
The following checklist (Johnson, 2010), originally developed for a
home for sex trafficking survivors, presents a possible set of desired and
required personal and professional behaviors and characteristics for all
staff members. The first requirement is that each staff member be traumainformed and therefore, trauma-sensitive.
For effective aftercare services, staff must:

Aftercare for Survivors of Human Trafficking

1. Be trauma-sensitive (knowledgeable about trauma symptoms and concerns).

2. Strive to be emotionally (and spiritually) mature.
3. Address and deal with any personal biases or prejudices
(race, religion, age, gender, status/class).
4. Address ones own past abuse/trauma(s).
5. Be patient, gracious, genuinely empathetic and caring.
6. Unconditionally love and accept the victims.
7. Be encouragers, seeking a positive, strengths-based environment.
8. Encourage survivors to participate in decisions that affect
them and to make their own choices (guide, but dont
decide).
9. Engage in programs and services and get to know the survivors personally.
10. Model healthy relationships (e.g., communication and
listening skills, conflict resolution, anger and stress management).
11. Understand and assist victims in developing emotional
control (affect regulation skills).
12. Be able to recognize and understand victims emotions (affect attunement skills), providing an opportunity for them
to observe and learn appropriate emotional responses.
13. Believe in the value of human worth, dignity and equality.
14. Believe that healing is possible.
15. Have a positive perspective regarding counseling/therapy
and be supportive of trauma therapy program.
16. Know and execute ones role and duties responsibly and
professionally.
17. Follow all agency and governmental guidelines, policies,
and regulations.
18. Know and consistently implement agency behavioral management skills.
19. Seek to maintain staff unity.
20. Know the signs and symptoms of vicarious trauma, seeking
preventative practices.
21. Be prayerful, Holy Spirit dependent, and God-honoring.
Trauma-Focused Care
While everyone involved in service provision is to be trauma-sensitive,
those with direct, ongoing contact, which focuses specifically on dealing
with and healing from traumas impact, provide what is called trauma-spe-

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cific or trauma-focused care. This trauma-focused care is done professionally

and thoughtfully, with great concern for the individuals emotional safety. In
trauma-specific care, Therapy is targeted directly towards identifying, processing, grieving, resolving and integrating traumatic experiences (Smith,
2010). Those who provide services that focus directly on traumas impact
are not just trauma-aware, but also trauma-trained. Trauma-focused care
includes individual and group therapy, including adjunct therapy programs
(such as art, music, drama, dance, play, and equine therapy)all focused
on facing and defeating traumas negative impact on the individual.
Trauma-Focused Therapy
When asked to develop and supervise the counseling program at
an aftercare center for young girls rescued from sex slavery in Cambodia, I decided to re-research trauma therapy models (even though I had
been a licensed therapist for almost 20 years). While there are numerous
therapeutic modalities that focus directly on trauma, it was important to
find a model that could be adapted both for those of other countries and
cultures and for those with limited education and training in social work
or counseling psychology.
In searching for a counseling modality meeting those criteria and appropriate to individuals with multiple trauma experiences, Trauma-Focused
Cognitive Behavioral Therapy (TF-CBT) stood out as a promising approach.
Comparative studies on therapeutic methods indicated CBT to be preferred
or best practices for working with sexual abuse and PTSD victims, as well
as other related conditions (Saunders, Berliner,& Hanson, 2004; Kaufman
Report, 2004). In addition to its empirical support, TF-CBT felt intuitively
comfortable and was similar to what I had been doing in therapy for years.
An implementation manual states, Many therapists are already using and
including many TF-CBT components and activities but may not have labeled
or conceptualized them as such (Child Sexual Abuse Task Force, 2004).
That summarizes well how I felt when first studying TF-CBT. It made
sense with what Id already been doing but added a few important missing
components and put them all in a best practices sequence.
A year after the initial training and implementation, the rescue home
director reported that the counseling program was effective, going very
well, and that the use of the TF-CBT was key to the girls recovery.
Many have shared their relief and thankfulness at having a wellresearched model, a road map of sorts, to help those suffering from the
effects of human trafficking. TF-CBT provides this model and thereby brings
hope and help to helpers and victims alike.

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Trauma-Focused Cognitive Behavioral Therapy

TF-CBT was developed by Judith Cohen, Anthony Mannarino,
and Esther Deblinger. For a thorough understanding of this therapeutic
model, read their book Treating Trauma and Traumatic Grief in Children and
Adolescents (2006). It provides specific information on the development,
components and implementation of the TF-CBT model. Additional training is provided online (http://tfcbt.musc.edu/) and professional training
workshops are offered in various locations followed by opportunities for
supervision. Refer also to their recently published book, Trauma-Focused
CBT for Children and Adolescents: Treatment Application (2012). TF-CBT
has been used in individual, family, and group therapy and in office-based,
residential and school-based settings.
Trauma-focused cognitive behavioral therapy, an intervention based
on learning and cognitive theories, strives to reduce negative emotional
and behavioral responses and correct unhealthy beliefs and attributions. It
combines trauma-sensitive interventions with cognitive behavioral therapy.
The authors state, TF-CBT has proven to be effective in improving PTSD,
depression, anxiety, externalizing behaviors, sexualized behaviors, feelings of
shame, and mistrust. (National Child Traumatic Stress Network (NCTSN)
TF-CBT Fact Sheet, 2004). Positive results were obtained and maintained
over time in several studies using the TF-CBT with youth who have experienced multiple traumas (Cohen, Deblinger, Mannarino, & Steer, 2004).
The developers of this therapeutic approach use the acronym PRACTICE to present the components of this treatment model (Cohen, Mannarino, Deblinger, 2006, p. 45):
P
R
A
C
T
I
C
E

Psychoeducation and parenting skills

Relaxation skills
Affect expression and regulation skills
Cognitive coping skills and processing
Trauma narrative
In vivo exposure (when needed)
Conjoint parent-child sessions
Enhancing safety and future development

Victims and caregivers are provided knowledge and skills related to

processing the trauma, managing distressing thoughts, feelings, and behaviors, and enhancing safety, caregiver skills, and communication (NCTSN
Fact Sheet, 2004).
Among its components, TF-CBT assists victims in understanding
trauma, dealing with the negative effects (physiologically and psychologically), developing helpful responses, differentiating feelings and thoughts,
facing fears, telling ones story, and setting future goals. Survivors are en-

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couraged to overcome the debilitating effects of the trauma and to put it

in perspective as part of their life story, not as what defines it.
In using the TF-CBT, Ive conceptualized it like the construction of
a house. The foundation, provided in a non-intrusive, trauma-sensitive
way, includes, psychoeducation, caregiver skills training, body awareness
and relaxation skills, and affective and cognitive skills (including affect
identification and regulation, cognitive-behavioral techniques such as corrective maladaptive thinking and more). These components are typically
presented in a more general, less personal, way in order to minimize the
potential of re-traumatization.
The construction of the house is the building of the healing process
that incorporates the trauma narrative and correction of unhealthy or
inaccurate cognitions. Sharing the trauma with another person, facing
residual phobias, and making future safety plans and goals are also a part
of this building process.
The effectiveness of TF-CBT is supported by outcome studies
and recognized on inventories of model and promising treatment programs.... TF-CBT is an evidence-based treatment
approach for children who have experienced sexual abuse
or similar traumas. Despite the impressive level of empirical
support for TF-CBT and an established publication track
record, many professionals remain unaware of its advantages
(Child Welfare Information Gateway, 2007, p. 1).
Adaptations for Sex Trafficking Victims
In order to use the TF-CBT for sex trafficking victims, I felt a few minor
adaptations were needed while keeping to the integrity of the model. First,
I put it into a user-friendly version (i.e. less psychological terminology),
and then, since I was utilizing the model overseas with those of limited
training, I felt a need to re-name the steps. This did not change the model
but made it more understandable. For example, Psychoeducation became
Learning; Affective Expression and Modulation became Feeling; Cognitive Coping and Processing became Thinking; Trauma Narrative became
Sharing; In Vivo Mastery became Living Free; and Enhancing Future
Safety became Living Safe and Well.
During that year, we continued to make a few small adaptations considering the responses from trauma victims (multiple trauma-sex trafficking victims), the staff (their level of knowledge and training), and cultural
concerns. These adaptations maintained the integrity of the model, while
at the same time, enabling it to be a more useful tool for this population.
The following describes a few of the other modifications.

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Psychoeducation is a foundational component of any trauma therapy.

Survivors are presented information about stress, abuse, trauma, and other
related topics. This information facilitates the normalization and validation
process as victims realize their thoughts, feelings and behaviors are not
crazy nor their experiences uncommon. When working with victims of
sex trafficking, in addition to these suggested topics, we also provide psychoeducation on sexual exploitation, sex education, coercion, and trauma
bonding, along with any other relevant, helpful information.
While TF-CBT encourages the inclusion of parents in the therapy
process, this is not always possible with trafficking victims as the parents
are often the perpetrators of the trauma or are unavailable due to their own
abuse or other circumstances. Since many of the programs and agencies
providing aftercare for victims of sex trafficking are residential, the parental
or caregiver role is incorporated into staff training for all personnel, with
special focus on the house parents (e.g. house moms). The residential
program provides the consistency of environment needed in behavioral
management and in demonstrating unconditional love and acceptance
that is, if all staff are well-trained and supportive of the therapeutic goals.
In the Trauma Narrative (telling ones trauma story), a key component of TF-CBT, I found it helpful to delineate two different sub-steps
specifically for victims of sex trafficking. Victims are encouraged to share
traumatic experiences that were done to them. While this is the focus of
trauma narratives, we found it also important to encourage victims to share
about traumatic experiences they may have perpetrated or done to others.
In human trafficking, especially in the sex trade, many victims are
coerced, manipulated, forced, or brainwashed into engaging others in
sexual acts. Some victims, out of habit, control, and/or anger, are abusive
to others. For example, Bottom Bitches, those put in charge of the other
girls in the stable, often must physically enforce the pimps rules. One
survivor shared how she had to hold another girl down while the girl was
being raped for the first time. Another shared of having to recruit other girls
and force them into sexual activities. While the trauma narrative focuses
on what has happened or been done to the victim, we found it necessary
to also encourage the girls (at some point in the therapy, often later) to
bravely share what they did, either by force or choice, to others.
Examples include:
Having to hold someone down while he/she was being raped
and/or abused
Having to watch someone be tortured (or killed)
Being forced/threatened to do sexual or other abusive acts on
other people
Performing abusive acts on others (not by force, but habit,
choice, and/or anger)

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Enjoying and participating in the abusive activities

Having to recruit and train a new girl (with or without deception)
In order to transition to this part of the sharing process I developed a
longer list of possible activities (examples) in which one may have engaged
while a victim of exploitation. This helps to normalize the experience and
provides a starting point to discuss this deep, shame-laden part of their
trauma experience.
I advocate the use of the TF-CBT with victims of human trafficking,
especially victims of sex trafficking, because I have heard many wonderful
stories from aftercare workers and therapists. In Cambodia the girls are
smiling again, in Kenya, mothers shared how they thought their children
were being drugged because they were seeing such positive changes in them,
and in the USA, the director of a residential program for minor sex trafficking victims said the girls are making great progress using the TF-CBT.
While I began my journey in aftercare overseas, in recent years I have
also been involved in encouraging, supporting, and training here in the U.
S. After sharing these adaptations with other therapists, the response has
been overwhelmingly affirming. One therapist shared, Now it makes much
more sense to me and I want to use it. Another, who works primarily with
sexual abuse victims, expressed that the incorporation of the two parts of
the trauma narrative (what was done to them and what they may have done
to others) is also applicable and important in working with victims from a
variety of trauma situations. Another organization, International Justice Mission, providing human trafficking and sexual abuse victim aftercare in various
locations, observed the use of this adapted TF-CBT and now incorporates its
use around the world with their global partners who provide victim services.
The Role of the Social Worker: Bridging the Gap
The role of the social worker is fundamental to the success of aftercare
services, whether residential or outpatient programs. It is the social worker,
often in the important and supportive role of case manager, who assesses
victim needs, assists in determining client goals, identifies needed resources
and services, and then provides follow-up to see that they are obtained.
Social workers are in a unique and important position to ensure that
both practical as well as emotional aftercare services are provided. It is the
social worker, with knowledge and training in holistic human needs and
social services, that provides the essential perspective. The social worker,
as case manager, ensures that all needed services, whether practical or emotional, are identified and provided in ways that are trauma-sensitive. The
social worker, as therapist, provides needed emotional restoration through
trauma-focused therapy. These roles are vital in the survivors journey of
healing and wholeness.

Aftercare for Survivors of Human Trafficking

While therapy is but one piece of the puzzle in the restoration process,
the case manager is often the one who sees all of the needed puzzle pieces
and makes certain they are put together in a way that doesnt re-traumatize
victims.
Conclusion
In Psalm 82:4 we read: Rescue the weak and needy; deliver them
from the hand of the wicked.
This verse is especially applicable to the problem of modern day
slaveryhuman trafficking. We are to rescue the victims, the weak and
needy. By doing so, we remove them from the hand of the wickedthose
traffickers, buyers, facilitatorsall who use and abuse people, disregarding
Gods perspective on human worth and dignity. Once rescued, we must help
provide the needed practical, as well as emotional, support that encourages
self-efficacy, choice, and decision-making.
Once rescued, it is important to assist with the immediate and practical
needs of survivors. It is important to provide food, clothing and shelter,
legal, medical and dental care, and education or vocational training. But
that is not enough. We also need to provide comprehensive, intentional
opportunities for emotional healing.
Those ministries and organizations whose programs focus on rescues
must be diligent to ensure that adequate resources, personnel, and facilities
are available to provide appropriate and comprehensive aftercare. Rescuing the traumatized without providing the needed follow-up services can
lead to further victimization. Without appropriate individualized help,
many victims return to their trafficked life, even more convinced than
before that help and hope are unattainable. Without proper follow-up care,
victims can go deeper into despair and depression. Aftercare is to be both
comprehensive and sensitive, including opportunities for trauma-focused
interventions. Survivors need assistance in identifying their needs and help
in accessing needed services.
Our Biblical mandate is to rescue the weak and needy, to speak up
and to defend the rights of the destitute and the needywhich includes
victims of human trafficking.v
Speak up for those who cannot speak for themselves, for the
rights of all who are destitute. Speak up and judge fairly, defend
the rights of the poor and needy(Proverbs 31:8-9).

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Becca C. Johnson, Ph.D. is Director of US Aftercare for Agape International

Mission (AIM) and an Aftercare Associate with International Justice Mission
(IJM). She is Consulting Psychologist for Access Freedom and Agape Restoration Center and provides training for aftercare staff of organizations working
with victims of human trafficking, sexual abuse, and exploitation. Address:
1116 Key Street #213, Bellingham, WA 98229. Email: RJohn448@aol.com.
Phone: (360) 312-7708.
Key Words: aftercare, complex trauma, human trafficking, prostitution,
sex trafficking, sexual exploitation, silence compliance model, TF-CBT,
trauma, trauma-focused care, trauma-informed, trauma-sensitive

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