Meeting the mental health & psychosocial needs of sexually exploited women in the Greater Mekong sub-region: a mixed methods study enhancing the training development of human trafficking aftercare workers

Meeting the mental health & psychosocial needs of sexually exploited women in the Greater Mekong sub-region: a mixed methods study enhancing the training development of human trafficking aftercare workers

Human trafficking, also regarded as modern day slavery, is an international human rights problem. This problem has been acknowledged by 154 countries through their ratification of the UN Trafficking Protocol. The Protocol calls for a comprehensive response to human trafficking including a non-binding or ‘soft’ obligation of
member states to provide post-trafficking protection and assistance. One aspect of protection and assistance is the provision of mental health and psychosocial support.
Due to the non-binding nature of the obligation, the development of these services has been relegated to a lower priority and remains largely under-researched. This
state of affairs is more pronounced in the Greater Mekong Sub-region (GMS) which lacks a strong mental health sector resulting in services predominately being provided by non-professional workers.

Research literature has documented high rates of posttraumatic stress disorder (PTSD), depression, and anxiety in trafficked populations. Findings have
recommended the adaptation of evidence-based approaches to treating trauma as a means of developing high quality mental health and psychosocial support services.
Furthermore, past research has recommended that these services be culturally relevant. Thus a thorough understanding of how cultural values affect the way
trafficking trauma is experienced by the women and communities is required. This extends to the way affected women and communities respond and cope. A review of
current training curriculums also reflects a gap in resources addressing the mental health and psychosocial support needs of trafficked women in the GMS, especially in
addressing the core elements of trauma counseling.

The purpose of this study was to respond to the mental health and psychosocial aftercare needs of trafficking victims by evaluating their needs and the current
services available in the GMS (excluding China). This study sought to obtain compelling evidence-based insights into the experiences, challenges, and needs of trafficking victims. It further investigated the training and professional development needs of non-professional aftercare workers within this context. This study was
designed to conduct rigorous practice-based research that determined the extent to which there is a need to enhance training curricula for the professional development
of trafficking aftercare workers in the GMS.

A number of aspects related to mental health and psychosocial support needed investigation to support the development of a culturally relevant mental health and
psychosocial training curriculum. This study sought to answer the following research questions related to the experiences of trafficked women in the GMS (excluding
China):

Research Question 1: What are the experiences and challenges affecting trafficked and sexually exploited women from the GMS?
Research Question 2: What cultural contexts and characteristics are related to the trauma experience of trafficked women in GMS?

The following questions were related to the application of the results of Research Questions 1 and 2 to the training of aftercare workers:

Research Question 3: What are aftercare workers presently doing to support the mental health and psychosocial needs of trafficked women from GMS?
Research Question 4: What training have aftercare workers who are providing services to those in and from the GMS already received?
Research Question 5: What needs do aftercare workers who are providing services to those in and from the GMS have for further skill development in providing mental
health and psychosocial support?
Research Question 6: What are the preferred learning methods and approaches of aftercare workers who are providing services to those in and from the GMS?

In order to address the research questions, an exploratory, sequential mixed methods design using a pragmatic approach was adopted. The research consisted of two phases: 1) a structured, but open-ended interview, which, in addition to developing a deep understanding of the experiences and challenges of trafficked women, provided data for the development of the next phase; 2) an online survey translated into the five languages of the GMS. The samples included professionals with experience in aftercare settings who would have been in positions to observe the experiences, challenges, and aftercare of sexually exploited trafficked women.

A Causal Layered Analysis and a thematic analysis were applied to the qualitative data, and descriptive frequency and correlation analyses were applied to the quantitative data. The results of the research phases were applied to the development of a practice-based solution in the third phase. This involved the development of an enhanced, evidence-based, culturally relevant training curriculum and a concept note.

Research findings included the development of a conceptual understanding of the cultural contradictions inherent in the GMS that make women vulnerable to sex trafficking and affect their experiences post-trafficking. The contradictions include the ‘push factors’ of poverty; the obligation of children, especially daughters, to support the family; and the monetary value of sex that make women more vulnerable to trafficking. The ‘rejection factors’ that cause a trafficked woman to be stigmatized
by family and community post-trafficking include their having broken social mores, being viewed as ‘bad’ or ‘contagious,’ and being viewed as a failure for not
successfully supporting their families. Finally, the cultural ‘repression/isolation factors,’ that result in isolating a trafficked woman and preventing her from getting
support, include not talking about her experiences to avoid shaming her family, not talking because it is a cultural norm to remain silent about feelings and bad experiences, and talking about these would reveal that the woman had done
something ‘bad’ to have brought this experience upon themselves.

Research findings related to the experiences and challenges as well as related to cultural dimensions included:

• how trafficked women understand their trafficking experiences and the accompanying violence in terms of ‘meaning making’;
• the role of coercive violence, and the concept of willingness and choice (or lack thereof), on the part of the women in the trafficking experience as it applies to the cultural context of the GMS;
• the networks of cumulative harm, relationships of trust, and attachment affected by the trafficking experience;
• the impact on developing learned helplessness through repeated violence (pre-, during, and post-trafficking), male entitlement and female submission, as well as beliefs about karma, fate, and destiny; and
• the exploration of culturally relevant means of expressing the emotional and psychological impact of trauma in GMS cultures, based on the reactions to trauma developed by the National Organization for Victim Assistance in its
Community Crisis Response Team Training curriculum.

Research results related to aftercare workers and their training indicated that while many aftercare workers have regular training and supervision, most have been
trained informally. Results were mixed as to whether services are currently meeting needs, but there was consensus that training is needed. Training interests include: counseling; mental health and psychosocial support for individuals and groups; supervision and mentoring; and cultural relevance. Contradictory to the expectations
of the collective culture of the GMS, respondents indicated an interest in expert-led training strongly balanced with facilitated learning among participants.

This study contributed to methodological development of the Causal Layered Analysis (CLA) beyond the futures discipline by applying it to understanding the current context of human trafficking. It increased the reliablity of the CLA
framework by utilizing a five-step process to systematically analyze the data. The need for further clarification of the CLA terminology was identified relating to the fourth layer, myths and metaphors. The results of this study proposes that in an Asian
context identifying ‘proverbs and sayings’ better described the ‘myths and metaphors layer.’ Assessing whether culturally embedded sayings are myths after the proverbs
and sayings have been elicited made methodological sense. It might be a more effective approach to identifying the stories and narratives connected to the worldviews and transformational influence.

Methodologically, the use of a mixed methods design advanced its use in the exploratory research of complex problems and firthered a systematic approach to
analysis. The utilization of mixed methods research designs in resolving practicebased issues better informs proposed solutions. This is due to the resulting ability to
triangulate findings and the depth and breadth of research insights associated with qualitative and quantitative strategies of enquiry.

This study contributed to professional practice through the development of a conceptual framework for the cultural transposition of practice from one cultural
context to another. It further contributed through the development of an enhanced training curriculum for the training of aftercare workers and through the formulation
of a concept note for prospective donor agencies.

Future research is needed in a number of areas related to: a) studies located in associated disciplines related to ‘idioms of distress,’ b) evaluations of mental health
and psychosocial methods, c) assessment of what training non-professionals need, and d) research building on the results of this study related to cultural dimensions
that include the cultural transposition process, the exploration of the myths and metaphor layers of the CLA, and questions specific to the experiences of trafficked
women as mediated by culture.