In 2021, there were an estimated fifty million people currently experiencing modern slavery (International Labour Organisation, International Organisation for Migration and Walk Free, 2022). Modern slavery includes human trafficking, which entails movement of people, either within or across countries, with the aim of exploitation (UKRI, 2023). Experiences of victims of trafficking during transit and on arrival to their destination can include sexual exploitation, forced (unpaid) labour, domestic work, forced crime and/or the removal of organs (Migrant Help, 2023). The journey undertaken may or may not be against the person’s will, but they may then be subsequently forced into activities under the influence of coercion.

The experience of being trafficked is isolating and intimidating (Mak et al., 2023), with consequent vulnerabilities to physical, mental, and sexual health conditions (Ottisova et al., 2016; Ottisova et al, 2018). Survivors often lack official identification (Hemmings et al., 2016) or legal permission to remain in their destination location, experience unstable socioeconomic conditions, and they may fear revictimisation and/or repercussions for loved ones (Altun et al, 2017).

There is a growing evidence base on the mental health, legal and other support needs of survivors of human trafficking. Their needs range from necessities, such as housing, to support for complex mental health and trauma related symptoms. Significant efforts have been undertaken to establish the treatment and support needs of survivors, as well as to develop suitable psychosocial interventions for human trafficking survivors.

The current blog summarises a realist review recently published in The Lancet Psychiatry about the different types of psychosocial interventions, which specific populations these interventions work with, and how and in what contexts (Mak et al., 2023).

Methods

The study employs Booth et al. (2019) guidelines for conducting a realist review. Based on the realist principle of explanation of causation and focused on theory-based synthesis, the authors have conducted the review in three phases- a scoping review, a systematic search, and a realist review.

1. A scoping review was conducted to hypothesize a Context-Mechanism-Outcome (CMO) configuration for developing an initial conceptual model for post-trafficking interventions. Essentially, the authors aimed to hypothesise “what interventions work for whom, in what circumstances, and how”.

CMOs are the building blocks of realist investigation. They are defined below:

• Contexts are the situations, populations, and circumstances in which an intervention, or parts of an intervention, operate.
• Mechanisms are how people respond to resources within an intervention and are the underpinning causal force for how interventions operate. They can take many forms, including social, material, emotional or technological.
• Outcomes are the outcomes of interest that are caused by the triggering of the mechanism. They do not necessarily refer to whether the intervention ‘works’ or not in the traditional sense, as they may not persist once the context has changed.

Feedback on suitability and relevance of the CMO model from professionals and survivors at NGOs supporting other survivors of human trafficking was incorporated. Testing CMO configurations’ hypotheses informed the next two phases of the study (Pawson et al. 2004).

2. A systematic search was conducted using PRISMA guidelines to search, screen and include relevant studies and extract data from them. Study characteristic data was extracted, along with component of interventions which was classified into the initial conceptual model developed in Stage 1. CMO configurations on these components were extracted and analysed qualitatively.
3. In the realist review, the authors “examined how interventions intended to modify or actually modified the context of trafficking survivors by triggering changes in resources and reasoning [mechanisms] and, as a result, affected their social and psychological outcomes.”

Results

The study included 41 articles. Most studies were conducted in high income countries, focused on interventions targeting survivors of sexual exploitation, included children and young population, and survivors were mostly women. In the pathways of care model developed in the authors’ scoping search, they categorised post-trafficking psychosocial interventions in four stages:

1. Identification (screening and identifying a person as a ‘victim’ of human trafficking)

Five interventions focused on using screening tools, training providers in interviewing and assessment, disclosure options and third-party interviews. Mechanisms in these interventions included improving understanding amongst providers about trafficking, providing a safe environment, and ensuring confidentiality of information for facilitating disclosure. These studies included training programmes, developing screening protocols at clinical settings, NGOs, community-based sites (for e.g., red light districts) and training community members to identify and report trafficked victims. Non-verbal disclosure effectively increased the reporting of victimisation.

2. Stabilisation (immediate needs for safety and sources of varied support)

Sixteen studies were identified in stabilisation stage. The interventions ranged from immediate crisis support, legal help, housing, and medical needs, referral system and dental and forensic assessments. These interventions aimed to be trauma-informed for realigning memories with resilience and strength. However, adherence to treatments was impacted by internal (e.g., rapport with the provider) and external barriers (e.g., language barriers). The psychological interventions in the stabilisation stage alleviated symptoms of PTSD, anxiety, depression, suicidality, and emotional disturbances.

3. Recovery (ensuring medium- and long-term functioning and autonomy)

With most studies included in this stage, the authors had hypothesized three areas in their initial concept model – rebuilding an autonomous life, psychological integration and pharmacological interventions. However, the authors identified studies only in the first two areas:

• Rebuilding an autonomous life: The key themes of interventions were support with interpersonal relationships, employability, education, empowerment, sexual health, avoiding revictimisation and reoffending.
• Psychological integration: This area involved grounding and integration of survivors’ traumatic memories. Interventions included psychoeducation about exploitation and its impact, trauma informed psychotherapies (cognitive behavioural therapy, eye movement desensitisation and reprocessing, and creative recreational approaches) and recreational activities. Some of the interventions were delivered by therapists from the same or different nationality as survivors’ or by community/social workers and were delivered in individual or group settings. The service providers required training and supervision. Staff turnover, burnout, and lack of sufficient access to providers in all regions were highlighted as barriers. The authors discuss the “sociocultural misalignment” between service providers’ and survivor’s backgrounds (specifically emotional expression, shame, and blame) – even tested interventions may not help people from all cultural backgrounds and ages. Reduced PTSD, depression, conduct and shame symptoms along with the improvement in survivors’ self-esteem, stress and cognitive capacities were common outcomes.

4. Reintegration (independent living in a safe community)

This is a difficult stage for several reasons, including stigma against survivors. Interventions addressed this by including recontacting loved ones, developing new ties with the local community, support for the family, legal and housing support and building vocational and financial capacity. Earning potential was noted crucial to improving survivors’ social status and likely successful reintegration.

Conclusions

Mak et al. (2023) concluded that the:

promising interventions were those that offered diverse opportunities for disclosure, adopted a trauma-informed care approach, aimed to build the long-term competencies of survivors, applied an integrated approach to the continuity of care, and fostered long-term social inclusion.

Strengths and limitations

The authors used realist methods to review how psychosocial interventions work (or do not work) for human trafficking survivors in different contexts. Beyond the limitations cited by the authors, there were some additional limitations.

• Firstly, stakeholder and survivor feedback were included in developing the initial conceptual model, however, the review could have benefitted from including them in the analysis or inviting their feedback in reporting the findings or as a commentary piece.
• Secondly, the final CMOs were reported, but not further tested within this study. They could be further explored and refined, for example, through interviews with survivors.

A strength of this review is that, although the authors did not use technical checklists to appraise the quality of the included studies (in line with guidance for realist reviews), they acknowledged methodological limitations and considerations of individual studies when specifically making inferences from that study.

Implications for policy, practice and research

For policy makers, the review spotlights the need for employing a dedicated workforce to support the trafficking survivors. There is also a challenge of applicability of interventions across setting and developing policy recommendations that are relevant for a range of varying global contexts – specific, locally relevant recommendations may be required.

There is a need to improve the training and supervision of specialist and non-specialist professionals working with trafficking survivors. Further training for non-specialist stakeholders and professionals who are in frequent and close contact with survivors, for example in camps or government accommodations, is also required. Survivors of trafficking are in contact with many organisations and sectors, and they may not disclose their experiences outright; therefore providing training which improves understanding of modern slavery should be a priority for all major psychological, housing, employment, welfare, and immigration support networks and organisations (among others).

The study findings imply dedicated interventions for specific needs at each stage of recovery are required. However, recovery may not be unidirectional, and survivors should be involved in decision making around their management plans, which could helpfully contribute to them “rebuilding an autonomous life”.

The review suggests exploring service providers’ and survivors’ views on the developed model of care. There is a need for testing interventions, specifically cultural adaptations, for feasibility, acceptability, and efficacy at each stage of the proposed care pathways models. Mechanisms of change as mediators for improving interventions for survivors of human trafficking also need to be studied.

Statement of interests

Shivangi Talwar is conducting her PhD research on improving treatments for adult survivors of childhood sexual abuse in South Asia. She is based at the Division of Psychiatry, University College London. There are no conflicts of interest.

Links

Primary paper

Mak, J., Bentley, A., Paphtis, S., Huq, M., Zimmerman, C., Osrin, D., … & Kiss, L. (2023). Psychosocial interventions to improve the mental health of survivors of human trafficking: a realist review. The Lancet Psychiatry, 10(7), 557-574. https://doi.org/10.1016/S2215-0366(23)00105-0

Other references

Global estimates of modern slavery: Forced labour and forced marriage. (2022). International Labour Organisation, Walk Free and International Organisation for Migration.

Modern slavery and human trafficking statement. (2022). UK Research and Innovation.

Slavery and human trafficking. (2023). Migrant Help.

Ottisova, L., Hemmings, S., Howard, L. M., Zimmerman, C., & Oram, S. (2016). Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiology and psychiatric sciences, 25(4), 317–341. https://doi.org/10.1017/S2045796016000135

Ottisova, L., Smith, P., & Oram, S. (2018). Psychological consequences of human trafficking: Complex posttraumatic stress disorder in trafficked children. Behavioral Medicine, 44(3), 234–241. https://doi.org/10.1080/08964289.2018.1432555

Hemmings, S., Jakobowitz, S., Abas, M., Bick, D., Howard, L. M., Stanley, N., Zimmerman, C., & Oram, S. (2016). Responding to the health needs of survivors of human trafficking: a systematic review. BMC health services research, 16, 320. https://doi.org/10.1186/s12913-016-1538-8

Altun, S., Abas, M., Zimmerman, C., Howard, L. M., & Oram, S. (2017). Mental health and human trafficking: responding to survivors’ needs. BJPsych international, 14(1), 21–23. https://doi.org/10.1192/s205647400000163x

Reach every victim of trafficking, leave no one behind. (2023). United Nations Organisation. Last accessed 2 August, 2023.

Booth, A., Wright, J., & Briscoe, S. (Eds.) (2018). Scoping and Searching to Support Realist Approaches. SAGE Publications Ltd, https://doi.org/10.4135/9781526451729

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