Applying Telemental Health Services for Adults Experiencing Trafficking

Human trafficking, including sex and labor trafficking, forced labor, debt bondage, and other forms of involuntary and illegal servitude, is an egregious human rights violation. ¹ A substantial public health concern, human trafficking affects more than 40 million people globally. ² Several overarching public health responses to the human trafficking crisis have been developed; they emphasize (1) primary prevention, education, and outreach at the individual and community levels; (2) education of health care providers across health care settings to identify and assess people who are being trafficked; (3) interdisciplinary models of care; and (4) specialty clinics for people nationwide experiencing trafficking.^3,4 These responses also serve as guideposts for mental health care services development and provision for adults experiencing trafficking.

Indeed, adults experiencing trafficking have a variety of mental health symptoms and conditions, including posttraumatic stress, substance use, and mood and anxiety disorders. ¹ Despite the clear public health importance of human trafficking, empirical literature on effective mental health assessments and treatments is limited.^1,5-7 Various organizations recognize the need for research to better understand the risks, psychological impacts, and best practices for human trafficking identification and mental health assessment and treatment.^8,9 Mandated clinical trainings on human trafficking screening and related psychological services are increasing nationwide, and clinical systems, agencies, and institutions are developing recognition response protocols.^10-12

Barriers to Obtaining Mental Health Care Services

Barriers to identification, assessment, and treatment of people who are being trafficked abound across system, health care provider, and individual (ie, person being trafficked) levels.^1,13 At the systemic level, a nascent empirical literature, a limited number of scientifically based screening and assessment tools, inadequate organizational policies and procedures, and few mental health providers with specialized expertise and training are major barriers to clinical services delivery. ¹ At the mental health provider level, insufficient or minimal awareness and knowledge, misconceptions and implicit biases, and limited experience with complex clinical presentations impair accurate mental health assessment and treatment. ¹ At the individual level, safety concerns, physical ailments, financial difficulties, shame and/or stigma, cultural-linguistic barriers, lack of awareness or insight into symptoms, and general lack of knowledge of or trust in mental health providers pose substantial obstacles to the use of mental health care services.^1,13

For example, establishing initial contact and maintaining connections with mental health providers can be particularly challenging for people experiencing trafficking given their often dire life circumstances. Time and cost associated with health care services and transportation, childcare needs, limited medical leave or time off from work, and longer or nontraditional work hours are barriers to in-person services. ¹ People who are being trafficked may not have health insurance or access to money to pay for services; therefore, they might prioritize more acute or immediate health concerns (eg, injuries) over mental health care. Furthermore, they may be reluctant to disclose their trafficking or mental health history to medical providers, thereby impeding referrals to mental health care services. Thus, people who are experiencing trafficking require flexible health care solutions.

Leveraging Telemental Health

In concordance with the 21st Century Cures Act, ¹⁴ creating and accelerating mental health care access via technology and/or product development (eg, application [app]-based screening tools) have great potential to improve mental health care access for people who are being trafficked. The introduction of telehealth services to any health care system is likely to increase health care use while maintaining in-person contacts. ¹⁵ Telemental health interventions involve the use of available technologies (eg, videoconferencing, telephone, texting, web-based interventions, mobile phone technologies) to provide mental health care services. ¹⁶ As we move through a global pandemic,^16,17 which has accelerated the use of telemental health modalities, the importance of evaluating and integrating telemental health and remote delivery options to maintain socioecological models of care and uphold the public health response to human trafficking cannot be overstated. Indeed, telemental health is a promising pathway to improve treatment access by reducing barriers to care.

A well-established literature has documented the efficacy of telemental health interventions for posttraumatic stress disorder, depression, substance use, and anxiety-related conditions.^18-27 Randomized controlled clinical trials (RCTs) that have compared in-person modalities with telemental health modalities have found comparable outcomes.^18-33 An emergent literature has evaluated such interventions among trauma survivors, survivors of interpersonal violence (IPV), and individuals at risk for suicide.^28-32 The literature on telemental health care delivery for survivors of IPV is perhaps the most directly relevant to human trafficking, given the inherent safety risks and ongoing power/control dynamics common to both IPV and human trafficking. While telemental health interventions for IPV, broadly, have demonstrated feasibility, acceptability, and efficacy, ³¹ most studies have focused on computer-based screening, education, and safety decision aids. ³¹ Strengths of such interventions include instant and confidential access to resources and the ability to tailor such interventions to individual needs using limited to no human resources (eg, via interactive apps). However, more work is needed to establish comparable efficacy of telemental health, compared with traditional in-person modalities for IPV.^34-38 To our knowledge, no empirical research has focused on the use of telemental health for people being trafficked.

Adverse mental health consequences of human trafficking have been well-documented,^3-5,39 and telemental health interventions may be applicable to people experiencing trafficking across the lifespan. This commentary focuses on mental health care for adults who are currently being trafficked. Given the relative absence of empirical evaluations of telemental health interventions for people being trafficked, we discuss advantages and disadvantages of applying telemental health to assessment and treatment and consider the perspectives of patients and mental health providers. We enumerate future directions to advance evidence-based telemental health services for this population. We conclude by advocating for increased empirical and clinical attention to telemental health platforms as a potentially effective modality for traversing some identified obstacles to mental health care among people who are being trafficked.

Advantages of Telemental Health Services

Increasing Access

Telemental health may substitute for, or be a supplement to, in-person visits with mental health providers.^40,41 Furthermore, telemental health may offer treatment continuity for people experiencing trafficking, a population that is often transient. For people experiencing trafficking who may be considering fleeing from their traffickers or who need to relocate suddenly and do not know exactly where they will go or how they will get there, telemental health might be a helpful option. Such circumstances can make scheduling and attending regular in-person appointments very difficult. Indeed, telemental health modalities may provide people experiencing trafficking with safer and more convenient options for care access.

Telemental health modalities may circumvent traditional clinic hour and space barriers, offering the potential to provide extended-hours clinical care according to availability of mental health providers. To increase access, specialty clinics—equipped with the infrastructure, policies, and procedures to respond to the unique needs of people experiencing trafficking—may be required to enhance opportunities for patients who are being trafficked to initiate contact with treatment providers via telemental health. People who are being trafficked require integrated care, ¹ and treatment team providers may include physicians, psychologists, substance use counselors, social workers, and/or case managers. People experiencing trafficking may be able to meet with their entire treatment team via Health Insurance Portability and Accountability Act–compliant telemental health video platforms to integrate and coordinate care management.

Addressing Privacy Concerns

Telemental health, offered via web-based video, telephone, or text modalities, provides privacy that can reduce stigma associated with receiving mental health care services. Specialized hotlines or text lines, for example, can provide anonymity and confidentiality while providing support, education, and resources. Furthermore, language interpreter services may be readily used to join telemental health calls. People who are being trafficked may be more likely to seek care should services be available, without the need to travel or to provide traffickers with reasons for absence(s). For example, telemental health services may allow survivors of IPV currently residing in safe shelters, residential placements, or witness protection to remain in a confidential space and avoid becoming vulnerable to re-traumatization, retaliation, or triggers by physically seeking out health care providers. In addition, fear of going to health care professionals because of immigration status may be mitigated by increased access to telemental health providers. Furthermore, telemental health services may improve access to care and disclosures of trauma and trafficking histories or circumstances among patients experiencing IPV as a result of enhanced privacy.^28,29,42

Enhancing Efficiency for Mental Health Providers

For mental health providers, telemental health services offer built-in efficiency and boundaries, as log-ons and log-offs are at set times and visible to both provider and patient. Individual, group, and family services can be conducted via telemental health platforms, enriching the versatility of services that are provided and available. Intake mental health evaluations and ongoing assessments of functioning and risk can be conducted via telemental health.^31,43,44 Relatedly, telemental health modalities allow for continued remote access to patients for mental health providers who cannot get to the office (eg, inclement weather, COVID-19 quarantine), underscoring the continuity, reliability, and predictability of a trauma-informed approach.

Challenges to Use of Telemental Health Services

Technology Access and Ease of Use

Telemental health services require patient access to and familiarity with relevant technology. Potential challenges to telemental health services for people experiencing human trafficking include poor internet connectivity, financial costs of technology platforms, and maintenance. Certain subsets of people being trafficked may have access to mobile phones so that they can readily connect to traffickers or “clients” via such technology (eg, sex trafficking, theft rings, forced narcotics distribution), while access to mobile phones or technology may be uncommon in other trafficking scenarios (eg, agriculture, construction, manufacturing). Patients with traumatic brain injuries, limited educational attainment or literacy, or memory impairments resulting from trauma-relevant repression or cognitive disorders ⁴⁵ may not have the capacity to navigate the technology that telemental health requires. Finally, some people experiencing trafficking may be uncomfortable with using computers or mobile phones because such devices may have been used to coerce them into trafficking, thus representing a trauma-relevant cue.^46-48 Considerations of access to and sufficient proficiency with necessary modes of communication should be assessed carefully when considering telemental health services for adults experiencing trafficking.

Safety Concerns

People who are experiencing trafficking who choose telemental health modalities must navigate various safety concerns. Telemental health care may increase safety risks depending on the level of power, control, and intimidation exercised by the traffickers. ⁴⁶ Labor and sex traffickers may monitor the use of phones and communication and/or control access to identification and monies as a form of coercive control.^46-48 Indeed, traffickers’ coercion and control may prevent people who are experiencing trafficking from making contact with mental health providers.^46-48 People who are being trafficked may have to pay for their phones and service use or be indebted to their trafficker(s) to use cellular data. Traffickers may have access to individuals’ phones whereby they can learn the frequency and duration of calls or texts to health care providers or unknown numbers. Prepaid, disposable, or short-term–use mobile phones (eg, burner phones), purchased by people being trafficked or provided by clinical care settings, may be a solution to this level of tracing and supervision, although use of such concealed devices carries substantial risk of harm if the person’s behavior is discovered by the trafficker(s).

Risk Management

Risk management is a key consideration in the provision of telemental health services to adults experiencing trafficking because imminent risk may be a factor in any given contact. Informed consent for psychological services, in which patients’ identity and location are disclosed, may be especially risky for the individual experiencing trafficking, who may be apprehensive about disclosing identifiable information because of safety concerns or direct threats by the trafficker(s) about maintaining secrecy of identity and location. Thus, establishing transparent and mutually agreed-upon limits to confidentiality to ensure safety in cases of imminent risk to self or others is imperative.

Assessments of substance use and related hazardous behavior (eg, driving or providing care to young children while intoxicated), imminent violence risk, and suicide or homicide risk should be incorporated into each telemental health session. Following best-practice guidelines,^49,50 the use of patient-set passwords or specific patient-set code words for dangerous circumstances might be integrated into each call to allow mental health providers to verify patient identity, ensure confidentiality, and take action on behalf of the patient should imminent risk escalate during the call. Various considerations encapsulate the provision of telemental health services to populations experiencing trafficking, particularly with regard to risk management; extant guidelines can be referenced and adapted, as necessary, to the individual’s unique circumstances while upholding federal, state, and local (eg, clinic, hospital) policies.^48,51,52 In addition, mental health provider fatigue is a pertinent issue for clinical risk management and burnout prevention, especially for providers who might exclusively work in telemental health spaces independently and/or without substantive in-person contact with patients or colleagues.

Conclusions and Future Directions

Telemental health services have the potential to improve access to mental health care services among people experiencing trafficking and may help reduce the risk of re-trafficking among people who have exited trafficking.^1,5,10 It is important to explore the applicability of such modalities for people who have exited trafficking and for children and adolescents. Research is necessary to evaluate whether, how, and under what circumstances telemental health platforms may be effective and which subsets of this diverse and multifaceted population may benefit most.

The evaluation of social determinants of telemental health treatment initiation, access, and completion is necessary, as is the integration of person-centered, trauma-informed, culturally sensitive interventions.^48-52 Research assessing the use of telemental health services in real-world practice settings is crucial. Qualitative and mixed-methods methodologies should be considered in the context of preliminary acceptability and feasibility trials to evaluate comparisons of telemental health to in-person mental health care to hybrid models (ie, combination of in-person and telemental health) among people who have experienced trafficking and have transitioned to safe circumstances. Clinics or regions may implement evaluations, at the aggregate level, of the initial feasibility and clinical utility of telemental health services to inform larger-scale RCTs and/or implementation trials. ⁵³

Finally, research focused on comparing various types of telemental health delivery methods (eg, telephone, video, text) in improving dissemination and implementation of evidence-based services for human trafficking populations is critical. Consistent with trauma-informed care models,^51,52,54 patient preferences for telehealth versus in-person treatment should be elicited first. If telehealth is selected, then mode of delivery should be determined, as it is essential to provide choice. Future research should include qualitative studies (eg, interviews) to determine the telemental health needs, preferences, acceptability, and barriers to the use of telemental health among people being trafficked. Such information can meaningfully inform specialized telemental health guidelines and stimulate research on the efficacy of telemental health approaches for people experiencing trafficking. Offering explicit choices may facilitate empowerment, improve perceived controllability over care, and enhance trust in health care providers and health care and social service systems. Research on the effects of patient service choice on outcomes may be informative in creating specialized interventions tailored to the unique needs of this population. ⁵⁴

Overall, telemental health services originated in the need to increase dissemination and implementation of evidence-based services in low-resource and rural environments. ⁵⁵ By definition, people experiencing trafficking represent an understudied, underserved, and low-resource population that stands to benefit tremendously from policies and service modalities designed to target social determinants of health (eg, economic disadvantage) and address health disparities. This commentary is a call to action for clinicians and researchers to systematically evaluate the unexplored potential of telemental health platforms to improve the lives of people experiencing trafficking.^55,56