Co-authored with Kelly Kinnish
"Don’t give up on your client. When I first started therapy, I wouldn’t talk…every time, I wouldn’t talk for like the whole hour… some therapists would have given up…"
"The lady [prior therapist] tried to force things and just wrote stuff down…"
"Therapists should sit and listen…"
"What people don’t know when you’re going into therapy… you don’t know these people, you gotta gain trust first and then you talk about it. It’s not easy going in and like, this happened. It’s not easy."
These are just a few quotes from victims of the commercial sexual exploitation of children (CSEC)—also known as child sex trafficking—on their experiences receiving treatment for the trauma they experienced in their exploitation. For therapists, this is a challenging population to serve, but when therapists listen, they can often find the keys to successful treatment in the clients’ own words.
A very common challenge identified by therapists working with sexually exploited children and adolescents is difficulty engaging them in treatment. One reason for this difficulty is that these youth often have very high rates of prior involvement in our systems and have had many prior unsuccessful treatment experiences—their general distrust and disinterest is, frankly, understandable given their experiences! Another reason is that they often do not view their exploitation experiences as having been traumatic or see themselves as victims.
Regarding the first challenge, we suggest therapists make a point of asking clients about their previous therapy (what worked, what didn’t work, what they didn’t like, what made it difficult). This can help the therapist avoid the same pitfalls as the previous therapists. Also, when we have asked clients these questions, what we most often hear are failure in engagement basics. Clients don’t feel heard, respected, understood, safe, or that the therapist is “on their side.” So it is important that therapists working with CSEC be (or become!) really strong on the therapeutic fundamentals: A safe therapeutic space, nonjudgmental stance, establishing common ground, exploring client goals, etc.
Our second suggestion is to be very cautious about challenging a client’s perspective or beliefs about their exploitation experiences, especially their relationship with their exploiter, too early in therapy (“My boyfriend loves me and is the only one who keeps me safe”). It is possible early in therapy as part of psychoeducation to educate clients about CSEC/human trafficking broadly, that is, without necessarily addressing the specific experiences of the client. And there are some fantastic advantages to doing so, such as establishing a common language for talking about CSEC experiences and communicating comfort and a non-judgmental stance regarding these experiences. But it is not the goal of the psychoeducation component to convince a youth of their victimization. This is a potential engagement killer. There will be plenty of other opportunities to get there later in therapy once other skills and concepts are established. But you won’t get that chance if you force the issue too early. CSEC clients are often willing to acknowledge other traumatic experiences earlier in their life and sometimes (although less often) are willing to discuss other upsetting things that have happened during their period of exploitation (violence that they have witnessed or experienced). These are great places to start!
Judith Cohen, M.D. is a board-certified child psychiatrist and Medical Director, Center for Traumatic Stress in Children and Adolescents at Allegheny General Hospital in Pittsburgh. She is co-developer of Trauma-Focused Cognitive Behavioral Therapy described in Treating Trauma and Traumatic Grief in Children and Adolescents and Trauma-Focused CBT for Children and Adolescents: Treatment Applications. Kelly Kinnish serves as Clinical Director at the Georgia Center for Child Advocacy in Atlanta.