SOAR to Health and Wellness for Behavioral
Health Professionals – March 23, 2017 Webinar>>Leilani Funaki:
Hi Everyone, I want to thank you for joining us for our SOAR webinar, to stop, ask, observe, and respond.
I’m Leilani Funaki with the National Human Trafficking Training and Technical Assistance
Center, we’re once again happy to have all of you with us today. Just as we get going
here, if you could take a moment and let us know if you can hear the audio. If you can
hear me speaking, that’s great. If for some reason you can’t hear me, go ahead and type
no in the chat box, which is located to the right of your screen. Once again, if you can’t
hear me, type no here. Great. Glad to hear that you can. In the meantime should you have
any technical difficulties during the webinar this chat box is where you can reach us and
let us know that you can’t hear something or if you have a question, this is a great
place to post that. Additionally, if you need extra help, you
can email Wendy Labrecque, our technical support specialist today, email located on the screen
([email protected]), as you can see. Today’s session is going to be recorded and it will
be available on our website within the next few days. Before we get started, one more
thing to make you aware of, down here you can see my green arrow pointing to the files
to download box. There are a few handouts we’ll share throughout the webinar today.
The first one that we need to make you aware of is the SOAR handout, it describes requirements
you need to meet to earn continuing education credits today and discloses any conflicts
of interest that may come from those who are involved in the creation of the training.
And once again, if you have any questions, please use the chat box and we are very excited
to have you here with us today. To get us going we’re going to introduce Beth Benning
from the office on trafficking and persons, and I’ll let her take it from here.>>Beth Pfenning:
Thanks, I’m Beth Pfenning, Program Specialist with Office on Trafficking in Persons, OTIP.
On behalf of the Department of Health and Human Services and the National Human Trafficking
Training and Technical Assistance Center I want to welcome you to this afternoon’s SOAR
to Health and Wellness training. Before we turn over to our presenters, I want to briefly
provide you all with background on the training we’re about to take. In September 2008, the
HHS Office of the Assistant Secretary for Planning and Evaluation sponsored a symposium
on the unique health needs of trafficked persons, one of the main conclusions of that symposium
was that training for health care, for behavioral health, social services and public health
fields on this issue was vitally important to increasing victim identification and ensuring
that the surface delivery we provide is trauma informed. The importance was further reinforced
by the Federal Strategic Action Plan on Service Victims of Human Trafficking in the U.S. In recognition of the vital role and to align
with the agency’s mission, the administration for children and families and office on women’s
health designed training in 2014 which has gone through piloting and enhancements, informed
by training feedback that we’ve received to date, but most importantly the expertise of
trafficking survivors, social service providers and health care professionals through two
national technical working groups. So, we have four sections for today’s training that
align with SOAR, an acronym for stop, observe, ask, and respond. As Leilani mentioned, if
you have questions throughout today’s training submit them to everyone through the chat box
and Leilani will work to compile those to address during our breaks. We’ll be offering
two short 5 minute breaks after the stop and ask section. Administrators will come back
on at that time and let you guys know when we’ll be restarting the webinar. As a friendly
reminder, we have CEUs and CMEs available for those who stay and complete the form which
will be sent out electronically after this training. And I do want to briefly turn it
over to Makini and Elisabeth to introduce themselves before we move along.>>Makini Chisolm Straker:
Hi. This is Makini Chisolm Straker. I am an emergency medicine physician in New York,
and really excited to talk to you today. I actually helped develop the SOAR content and
I will be talking after Elisabeth, so I will pause and let her introduce herself so that
it will just transition quite nicely I think.>>Elisabeth Corey:
Hello, everyone. My name is Elisabeth Corey, and I am a survivor of family controlled sex
trafficking and abuse. I am also a trauma expert and I’m a life coach for complex
trauma survivors. I was also involved in the original SOAR team and I’m happy to be here
presenting to you today>>Beth Pfenning:
Thank you guys. Before we delve in, we want to get an idea of the geographic diversity
of our participants today. If you wouldn’t mind taking a few seconds to look at the map
we have before you and tell us where you’re from. Awesome, a lot of people in the Pacific
Northwest. Columbus, Spokane, yep. North Carolina, great. Terrific. Thank you guys so much. I
did briefly want to mention prework we sent as part of your training registration, homework
but you did not have to turn it in. We did want to mention that handout is available
in the files to download pod that Leilani pointed out earlier. Makini will address key
components today but this handout was designed for you to think through your local safety
net and who among these key stakeholders we feel are integral to this continuum of care
are you already working with or could you be partnering with, so we’re going to ask
you to keep that in mind as we embark on today’s training. And with that I’ll turn it over
to Elisabeth. Thank you.>>Elisabeth Corey:
Thank you so much. I am really happy to be here today talking with you. We’re going to
start off by discussing course objectives. So let’s get started by making sure we understand
why we’re here today. These are the course objectives which you see in front of you.
And what you will be able to accomplish by the end of this training session. It will
enable you to describe the types of human trafficking in the united states, recognize
possible indicators of human trafficking, demonstrate how to identify and respond to
potential trafficking victims, respond appropriately to potential human trafficking in your community,
and share the importance of human trafficking awareness and responsiveness with others in
your work environment. I think I’m supposed to be changing the slides. There we go. So
next we’re going to be taking a pulse check here. We just wanted to kick off with a couple
of quick questions about your experience with the subject. If you guys could take the poll
that you see below the slide. Right here the two questions are could you identify a potential
victim of trafficking, and also have you ever encountered a potential victim of trafficking.
We want to see a little bit about what your current understanding of trafficking is. I see what’s coming in here, looks like for
identifying a potential victim of trafficking, we’re somewhere between 60 and 70 percent
saying yes, they could. So that’s a really good high number. And have you ever encountered
a potential victim of trafficking is also coming in. Looks like between 60 and 70 percent,
a little closer to 60 percent. So that’s really helpful that it seems like a lot of you have
some exposure to trafficking victims thus far, this will be helpful and I expect lots
of participation today. So let’s move on to the next slide here. So in the past, we’ve
typically thought of human trafficking and molded our response to it basically coming
from a perspective of law enforcement. While this perspective is important, we now realize
human trafficking is really a public health issue that affects individuals, families and
communities, and also across entire generations. This graphic here shows terms related to public
health and human trafficking. You can answer in the comments section, what I’d like to
know, which of these public health issues relate to your day-to-day work, if you could
answer in the comment section and I’ll read some of them out. Counseling, social services,
trauma, my favorite topic, infectious disease, ER nurse, outreach, social systems, women’s
health, trauma, school, social worker, health care, RN, this is great. We have
a lot of different concepts represented here today. Counseling, mental health, community
health, integrated health care. Workforce development. Thank you guys so much for participating.
I appreciate it. Women advocacy. Okay. So thank you all. You know, one of the primary benefits of looking
at human trafficking as a public health issue is the emphasis on prevention. That is, looking
at systemic issues that cause people to be vulnerable to human trafficking in the first
place because trafficking doesn’t happen in a silo. It is often one component in a series
of traumatic or violent experiences over the course of a lifetime. And recognizing these
risk factors is critical to prevention. So moving on, so now we’re going to be talking
a little bit about prevention approaches. In this slide, we’re talking about the primary,
secondary, and tertiary prevention approach that can be applied to human trafficking.
So there are examples at each level here that are provided on the slide, and I encourage
you guys to read through those. But the public health prevention approach does the following.
It focuses on prevention, interrupting violence and changing social norms. So that is really
think very, very critical because what we’re trying to do is get at this from the foundation
of where it is starting. It also recognizes the social and economic
determinants of health and well-being that may lead to trafficking. It focuses on identifying
protective and risk factors. It encourages culturally specific prevention and intervention
efforts, engages all essential community stakeholders who can play a role in addressing human trafficking.
It builds community capacity and includes community members, in a development of policies
and practices. And it recognizes human trafficking along the spectrum of interrelated violent
and systemic inequities. So as we move through each section of SOAR, please keep these things
in mind. Next we’re going to talk about the SOAR framework. The SOAR framework was developed
by the U.S. Department of Health and Human Services. As Makini mentioned earlier, she
was involved in the creation of it, and so was I. I think we were on two different teams
when we were developing it, but definitely both of us were involved. This framework provides
a quick mental reference for professionals like you to keep in mind the best way to help
pro potential victims of human trafficking. There are four things when interacting with
patients or clients you need to remember. You need to, first, stop. So becoming aware of the nature and scope
of human trafficking is stop. Observe, which is to recognize verbal and not verbal indicators
of human trafficking. Then ask, identify and interact with potential human trafficking
victim. And respond, this is responding appropriately to a potential human trafficking victim. So,
we’re going to be starting with stop. What are the objectives for stop? First off, we want to distinguish between
some of the most common misconceptions and realities of human trafficking, so important
because many of us have an understanding that may be based on things we learned in the media
or in other places that this is not the reality. Also, recognize the potential for interactions
with human trafficking victims on the job is a lot higher than you think. Explain the
legal definition of human trafficking based on the TYPA, the trafficking victim’s protection
act that we’ll be discussing. Identify the use of force, fraud, or coercion against potential
human trafficking victims, or minors, who have signs of abuse or neglect. Identify common
risk factors for victims of sex and labor trafficking. And identify common relationships
between traffickers and victims, that particular part is one of my favorite talking points. So, before we begin working through the framework,
let’s make sure you understand your role in dealing with potential human trafficking victims.
There are two main ways that you can help stop human trafficking. The first one is to
identify potential victims and respond appropriately. This does include treating, referring and
reporting when mandated by state laws or tribal ordinances. The second, work with others in
your profession to develop protocols for your workplace on how to help potential victims.
This is often overlooked until it is needed, and so this is something that we’ll be talking
about today and I really encourage you to begin working on that. So, next we’re going
to be discussing a case study. And we’re going to be reading this to you today. Then we’re
going to be talking about a few questions from this case study.>>Leilani Funaki:
For those who would like to follow as we read the case study, it’s available for download
here in the files to download box as well. So this first case study is about Liza. As
an 11 year old I was one of six foster kids sold, my foster mother needed to get money.
No one in the system knew what was going on. When we ran away the police would return us
and we felt like we had no recourse since no one believed us when we said we were being
hurt. By the time I was 12 I left for good and was on my own. Met a guy on the street
who said he would take care of me and I believed him. In actuality, he was a pimp and sold
me to men for money. He had me moving around on a circuit, Chicago, Detroit, Indianapolis
and back to Chicago again. At first he treated me nicely, long enough to get me to do what
he wanted. Then he turned mean and if I didn’t make enough money he beat me mercilessly. I learned quickly how to keep my head down
and make my daily quota. During this time, I was beaten, burned, raped, and assaulted,
sometimes by my trafficker, sometimes by the guys who were buying me. Some wounds were
treated by grandmother of one of the pimps who had been a nurse for 30 years. She had
set up a basement, had a setup in the basement, pimps bought us when we were seriously injured.
Sometimes I went to a local neighborhood clinic, health clinic, no one ever asked what happened
to me. And if they did, I lied because I was afraid of my pimp. I knew he would beat me
if I told anyone what was going on. To this day I have physical, mental, and emotional
issues as a result of that time on the streets.>>Elisabeth Corey:
Thank you so much, I appreciate that. So let’s talk about, for a few minutes, about what
was just read. This case study for Liza. If you could, comment in the comment section
the answers to these questions. The first one, if Liza came into your office or emergency
department how would you proceed? Kara says if follow-up questions. Thank you, Kara. Brittany
says complete, sorry, I’m not supposed to be saying names. Sorry about that. Complete
an assessment alone, no adults or caregivers. Assess for safety immediately. Ask questions
about her family history. Yes, explain my role and what I can do to help her consider
her options. I see call the police, if they could be of help. Try to speak to her alone.
Make sure that we’re in private room even if she came in with someone. Okay. That’s
great. I think there’s a few really important things that you’re bringing out here. One
of which is the need to separate from whoever they came in with, who might be likely to
be a trafficker. So I think that’s a really good understanding to have going into this.
And also this idea of explaining who you are and what you are doing, and also building
rapport. Those are really important things that we need to do, when we have a suspicion
about somebody potentially being a trafficking victim. Assess for safety. Explain my role.
Offer support. Also a really good understanding of what needs to happen. Yes, someone is saying
her age is important. That is also  that is very important because more than likely
the protocols are going to change based on the age. So let’s look at the second question here.
What indicators would alert you that she might be a victim of human trafficking? Untreated
STDs. Absolutely. Seems fearful of authority figures. That’s a really good one. Types of
injuries. Being reluctant to talk, unwillingness to make eye contact. Suspicion stories. Yes,
especially stories that have gaps or don’t seem to really make a lot of sense. Attempting
to hide what is going on, and the story keeps changing, as we just said. Yes, language barriers
are also something to be on the lookout for. Never allowed alone, that’s a big one. And
that’s why the separation can be such a critical component of the protocol. Physical injuries,
difficult to engage in conversation, uneasiness, and nervousness. Yes, a person accompanying
her speaks for her, definitely. We’re going to talk more about that as well. And the next
one is similar to that, overbalance of caregiver, friends who present to appointment, yes, and
then another really good one here is attempting to protect the abuser. So all right. So those
are some really, really good examples. I think you guys have been through this before. So
thank you so much for your amazing answers. And then the last question that we have here
today is what questions would you ask? Do you feel safe? Do you want to get out? Do
you feel safe in your current living situation? Do you need help? Are you in the life? Are
you trading sex for anything? Yes, asking what her immediate needs are. I think that
one is really important because many times we’re so focused on trying to help her get
out of a potential dangerous situation that we don’t think to start with something as
basic as needs, so I think that’s a really good one there. How can I help you? How do
you think I can help you, that’s an interesting spin on it too, because many times trafficking
victims don’t think you can help them? They really are very convinced that that’s not
going to happen. What do you need today? So, yes. The focusing in on needs I think
is a great way to go because that gets into that place of sort of being able to build
rapport. You know, trust is a really tricky thing. We’re going to talk some about that
today. And  but if you can build some rapport, you can potentially meet a need, that’s starting
you off on the right track. So thank you guys for all of your really, really good answers
today. So we’re going to move on to the next slide now. So what do we mean by human trafficking?
This is tricky. You know, we’ve been defining human trafficking for a while now, and it’s
important for us to understand the definition as we move forward into identifying people,
we really need to know where we’re coming from here. So, how would you know whether
or not Liza might be a potential victim of human trafficking? Well, you know, to be clear,
let’s talk about what we actually mean. According to the Federal Strategic Action
Plan on Services to Victims of Human Trafficking in the United States, human trafficking is
a crime involving the exploitation of someone for the purpose of compelled labor or commercial
sex act through the use of force, fraud, or coercion. We’ll talk more about force, fraud,
and coercion in a little bit. According to the U.S. Department of State, a commercial
sex act means any sex act on account of which anything of value is given to or received
by any person. Okay. Where a person younger than 18 is induced to perform a commercial
sex act, it is a crime regardless of whether there is any force, fraud or coercion. So
that’s a very important point that we all need to keep in mind. And that’s one of the
reasons that the age, as you mentioned earlier, the age can be important from the perspective
of protocol and also identification. Let’s take a second to look at some common trafficking
misconceptions and realities. So we’re going to start with the first one here, tell me
your answer, true or false, trafficking must involve movement across state or national
borders. I’m seeing a lot of correct answers here. Yes, it absolutely is false. Someone
else said not smuggling, that’s a really important distinction, right? I think this is one of
the most common misperceptions that I hear of when I talk with people who don’t know
much about trafficking, they immediately assume that there must be some kind of crossborder
activity, and in reality trafficking does not require transportation. A person may be trafficked within his or her
own neighborhood, although transportation may be involved as a control mechanism to
keep victims in unfamiliar places. It is not a required element of the trafficking definition.
So human trafficking is not synonymous with forced migrations that involve border crossing.
Next, men, women, boys, and girls of any age, nationality, socioeconomic status, ability,
race, and ethnicity are trafficked. Once again, all of these correct answers coming through.
Yes, this is true. Unfortunately, you know, within the media and other places, there are
often situations where stereotypes of what a trafficking victim looks like are put out
there. But this is very true. You know, trafficking is not specific to certain demographic or
populations, there are trends, human trafficking, but in the end human trafficking with cross
all of these things. So it’s important to understand that. The next one, victims will
ask for help if they need or want it. False, false, false, false. And a “not always. “A
couple not always, yes. And I think, you know, for this one, it’s
really important to understand that the answer is false. Victims of human trafficking often
do not immediately seek help, or self-identify as victims of a crime. And this can be for
a variety of reasons. And that includes that they are afraid of violence against themselves
or their loved ones. They have loyalty to the trafficker. They probably have been told
not to trust anybody else, and that includes you, of course. You know, they are blaming
themselves for what happened. They may be embarrassed. They may hold shame about what’s
happening because they blame themselves. Or, you know, they have been given specific instructions
by traffickers regarding how to behave when talking to law enforcement or medical community
or social services. It is important to avoid making a snap judgment about who is or who
is not a trafficking victim based on first encounters because trust takes time to develop,
as I was talking about a few minutes ago. Trust is very complicated, with trafficking
victims and survivors. So continue trust building and patience when interviewing is often required
to uncover the full experience of what that victim has gone through. And then the final
true/false question here, health care and social service professionals need to recognize
signs of trafficking and respond appropriately. Yes. Lots of trues coming in. That would be
true. You know, it is not health care or social service professional’s job to make a determination
as to whether a person is actually being trafficked. But it is important that you be able to identify
potential trafficking victims because you may be the first person to be able to provide
help for them. So thank you guys for your participation on those. We’ll move to the
next slide. Okay. This is an important slide, and we do
need to understand that, you know, research has shown that victims of trafficking are
highly likely to come into contact with someone in the health care system. It is not something
that is not showing up in the health care system. That is so important for us to understand.
A 2011 study interviewed four national survivors of sex and labor trafficking to investigate
how many of them encountered health care professionals while being trafficked. Fifty percent encountered a health care professionals
during the time they were trafficked, yet none were identified as a victim of trafficking
during these encounters. In addition to that, a 2014 study where researchers interviewed
survivors of domestic sex trafficking and found almost 88 percent had encountered one
or more health care professionals sometime during the period in which they were being
trafficked. Again, none of them were identified as a victim of trafficking, as a result of
these encounters. And I just wanted to add from my own personal experiences as a family
control trafficking survivor that most of my interactions with nonabusive adults was
through the medical or teaching profession. There was also some interaction with social
workers. So while some families who traffic do have doctors in the trafficking networks
that they run, I believe the medical community in some form is likely to see almost all familycontrolled
victims. That’s really important to know. Now let’s talk about the type of interactions
or the type of professionals that they may be interacting with. First off, you know,
as we have seen victims of human trafficking encounter variety of health care professionals
while actively being trafficked, this graph is based on an anonymous national health care
survey of human trafficking victims in 2014. The respondents were victims of sex and/or
labor trafficking. A total 173 patients surveyed, 117 saw a clinician while being trafficked,
some saw multiple practitioners during the trafficked time. The emergency department
was definitely the most common that human trafficking victims were interacting with,
55.6 percent. Followed by primary care it’s a 44 percent, OBGYNs at 26.5 and dentists
at 26.5. With that being said, emergency department personnel are highly likely to encounter an
individual being trafficked. In a previous study, the findings of the 2012 study indicated
that although 27percent of the staff understood human trafficking was a problem, and was even
a problem among their emergency department population, only 19 percent felt confident
or very confident they could identify a victim of human trafficking. And within that, less
than 3percent had been trained on potential victim identification. Which is one of the
reasons why SOAR exists, and I think it’s really important for us to understand why
we need this type of training. So this lack of training increases the chances
that a person being trafficked will go unidentified. Or even worse, in some cases, be blamed, judged
or misunderstood which will make them less likely to come forward in the future. In addition,
victims of other crimes such as domestic violence, child abuse and sexual assault may also be
victims of human trafficking. Which may not be recognized by the health care provider.
This is really important to understand the connection, between other forms of interpersonal
violence and trafficking. Many times we might identify somebody because they are victim
of child sexual abuse, only to find out later on they are also being trafficked. So let’s
talk a little bit more about the meaning of human trafficking and how that breaks down
within the trafficking victims’ protection act of 2000 which is also record to as the
TYPA. The TYPA provides a framework to identify potential trafficking victims and help them.
So there’s several different parts. There’s the action. There’s the means. And there’s
the purpose. Okay. And in a court of law, one of each of these elements needs to be
proven for a successful prosecution. So in other words, we do not need to be recruiting
harbor and transporting and providing, so to speak, you have to be doing one of these
things. The exception to this particular structure is when we’re talking about minors. When minors are induced into commercial sex,
it is considered human trafficking, regardless of the means which means we don’t have to
prove force, fraud, or coercion, when somebody is under the age of 18. So to clarify, we
want you to understand the legal definition, but we know it’s not your role to make legal
determinations. Okay. Your job in the health and social services field would be to use
this framework to help you to recognize signs of trafficking and connect patients to resources.
While this  another important opponent, this is the American legal definition. However,
human trafficking is a global problem. You might also hear it referred to as trafficking
in persons, or tip, it occurs in every country in the world including the United States.
It is a marketdriven criminal industry fueled by demand for labor services and commercial
sex acts. It can affect anyone, however it often affects those who are more vulnerable.
So that’s critical to understand. Next slide. Let’s talk about force, fraud, and coercion
here. These are the means. And they are very important for us to comprehend when we begin
looking at trying to identify victims of trafficking. So what are we talking about here? Once again,
remember that only one of these needs to be met. So if you find that somebody is, you
know, undergoing some form of fraud, then you don’t need to also prove force. So that’s
really critical to know. In the case of a minor, once again, you don’t need to prove
any of these things, if they are being forced, induced to perform a commercial sex act. So,
here let’s talk about  let me do it this way, instead of reading this part to you.
Can you think of some examples for each definition? If you could, just take a moment to type in
some examples for each definition and we’ll talk a little bit about that. Yes, forcible
rape, or beating. Definitely rape, kidnapping, force. Removal from family and support system,
yes. And in some cases, that’s certainly force or physical coercion, but that could also
be psychological coercion. Threatening to hurt a family member, that is a huge one.
Psychological coercion. Fraud, visa fraud, offering them a job, a contract, and then,
you know, it’s not in their own language so they sign it, and it really is something completely
different. So yes, so workers who are told they will have a job, and then when they get
there their papers are taken and forced to work, good examples of fraud. Also keeping
money or belongings that they were promised. Forced drug use is certainly an aspect of
physical coercion. As well as psychological coercion. Yes. Yes, I know that in my own
family a really big one for me that I faced was the threat of homelessness. So it wasn’t
that I was necessarily going through any kind of force or, you know, physical threats, so
to speak, but there was a lot of psychological sort of financial abuse that was put before
me, and so that sort of kept me motivated to do what I was told. Yes, yes, and then
I see one about the Stockholm syndrome, abuser threatening to withdraw emotionally, yes,
there can be huge connections between the victim and the trafficker, and that can absolutely
play into the psychological coercion, definitely. Yes gaslighting, yes, that’s something I talk
a lot with my clients about. We can spend a lot of time feeling very, very confused
about what reality really is, so yes, thank you for bringing up gaslighting. Manipulation
is a huge psychological coercion tactic, so thank you guys so much for your answers there.
We’ll move into the next slide here and talk about vulnerable populations. I see that Leilani
put up a comment, the slides are available in the files to download box, which is right
underneath. We’ve been getting quite a few questions whether or not this will be available
so I want to put that out there real quick. So, when it comes to human trafficking, remember
that we have many different vulnerable populations. And while there are some that are considered
more vulnerable than others, there are certainly populations that have been, you know, highly,
in some cases even stereotyped to be the main vulnerable population, it’s important for
us to understand all of the populations. And so I’m going to highlight just a couple
of them here. Children, definitely, are at the particular risk for section and labor
trafficking. And then child you know, child labor traffic cases identified in agriculture
work, restaurants, pedaling and begging rings, something for us to keep in mind. Those from
the lesbian, gay, bisexual, transgender or questioning communities may be at high risk
for exploitation, especially if they are thrown out of their houses for being gay, bisexual
or transgender. Because homelessness becomes an issue for them, many times they will trade
sex for food, clothing, shelter. And they can be targeted for trafficking. Homelessness
for anyone, especially under the age of 18, is a huge, huge vulnerability, and so we have
to be aware of that as well. And traffickers do often prey on racial and ethnic minorities,
undocumented immigrants, indigent, poor, persons with disabilities, often reluctant to seek
help from authorities. Native American population are an important population to understand
they are highly vulnerable here, that includes American Indian, Alaska native, native Hawaiians,
and Pacific Islanders. These populations face the same challenges
as other vulnerable populations, but they have the unique risk factors including inadequate
law enforcement, which means that crimes can go unreported. They are also dealing with
generational trauma. And I want to spend just a moment on intergenerational trauma because
I think it is often overlooked when it comes to trafficking. I think we have to really
understand that intergenerational trauma has a huge effect on vulnerability for trafficking.
Things like slavery, the holocaust, and war are huge components to intergenerational trauma
that can last for hundreds and hundreds of years and leave certain populations very vulnerable
to other forms of trauma as well. So let’s go to the next slide here. We’re going to
talk for a second about ace. Ace is actually one of my favorite studies that’s out there
right now because trauma is complicated, but the adverse childhood experiences study which
actually came out through the centers for disease control and prevention and Kaiser
Permanente has done such a good job getting us a better understanding of how we’re being
impacted by trauma, okay? And every  when you take this particular test, which is really 
it’s a 10question test, I like to tell people it’s the only test I ever got the perfect
score on. But it’s talking about childhood maltreatment, family dysfunction, as well
as current health status or linking it to current health status, which is what’s so
amazing about this. What it does for us is it asks questions that really sort of simplify
the traumatic impact that people are facing in their lives today and it really has done
wonders to get us a better understanding of how trauma is impacting the life of adults
today. But one of the other things that’s helping us understand is how trauma creates
vulnerabilities for things like further exploitation, including trafficking. So I’m a huge fan of the ace study. And
if you haven’t looked into it or taken it, I recommend you go and take the 10question
test. It really looks at three types of aces, including abuse, neglect, household dysfunction.
If you get an opportunity to do that, please do take it. So another quick pulse check here,
which vulnerable populations are you most likely to encounter during your workday? If
you guys could take the poll here we’ll get an idea for what you’re seeing. I’m seeing
a real high likelihood for you to be seeing individuals with childhood abuse and neglect.
Also children involved in the foster care and juvenile justice systems. Those are very connected. And then I’m also
see runaway and homeless youth, Native Americans and Hawaiians, foster care and juvenile justice
system coming in second, hugely vulnerable populations. I know within the survivor community
there are very few of us who did not experience some kind of childhood experience and neglect,
even before we were trafficked. Okay. Let’s move to the next slide. This is probably my
favorite slide of all the slides. It’s the reason that I love this slide, because there
is a huge stereotype about human trafficking and the nature of the relationship between
the trafficker and victim. And here is the thing. It is not  you know, there’s this
sort of stereotype out there that the trafficker is some kind of stranger who pulls up in a
white van and takes children off playgrounds. And while that can happen, I think we have
to understand that most of the time victims and traffickers have a relationship, and in
the case of this particular study, which was done by the covenant house, in New York, they
are a service provider for homeless youth in New York. And so they did a study, so this
is mainly focused on domestic minor sex trafficking victims, and mainly U.S. Citizens here. But what the study found was really a striking
relationship between traffickers and DMST victims, the most striking being 36percent
of the children in the study were trafficked by their parents or immediate family members.
I think it’s just so important that we understand the reality of the relationship between them.
The other I think really striking finding that they had here is that we’re looking at
27percent being trafficked by their boyfriends. Of course, boyfriend can be a term that sometimes
is used to refer to a trafficker, but, you know, meaning in this case we’re meaning any
romantic partner whatsoever. I think we have to know this is happening because when we
know this, when we can understand that just because somebody walks into a clinic with
somebody who is a legitimate family member, that does not mean they are not being trafficked.
So really critical that we know that. So we’re going to finish up here with the stop section,
and, you know, I think that just to review a couple key points here before I pass off,
I think actually we’re going to break and then to Makini, is just we have to understand
the human trafficking definition being that we’re working with an action, force, fraud
and coercion. The means is force, fraud, and coercion. And a purpose. The health care professionals
have an opportunity to recognize signs of trafficking and become a first line of appropriate
response. The TYPA defines human trafficking. Trafficking does not require transportation
of victims. Victims do not self-identify or seek help and appearance of consent does not
disqualify. Common atrisk factors and traffickers often have personal relationships with victims
prior to exploitation. I appreciate your amazing participation and comments. Thank you so much.
And I will pass this off to Makini and also I think a quick break.>>Leilani Funaki:
Yeah, this is Leilani again. We’ll take a fiveminute break before we move on to the
next section, observe, of the training. Let’s plan to be back here at 2:00 p.m. Eastern
Time. We’ll take a fiveminute break and start the training at 2:00 P.M. Eastern time. [Recess]>>Leilani Funaki:
Welcome back to the training. We’re going to end the break and turn over to Makini,
to talk about the observed section of the training. Makini, it’s all yours.>>Makini ChisolmStraker:
Awesome. Thank you. As I said at the beginning during the introduction, I’m an emergency
medicine professor and physician in New York. So my clinical experience is going to be a
little bit different but for the next session we’re going to talk about what trafficking
looks like, or might look like, when you’re working clinically. And some indicators are
going to be pretty specific to people providing physical medical care, and so some of those
are sort of caveats for you. But we are going to focus on the verbal and nonverbal indicators.
So first we should talk about what the barriers are for a patient or a client to be identified.
What the barriers are on our end as providers. And then what it mike look like clinically
when we’re seeing a case. Okay. So just what are your thoughts? Sounds like a lot of you
have experience. There was like 70 percent in both boxes who knows how to identify trafficking
and who has seen trafficking. What does it look like for you with respect to barriers,
difficulties for patients or clients in disclosing to you? First response, fear unknown or prior
bad experience with practitioner, a lot of fear, fear of punishment, language, that’s
a really important one. So as we’ve discussed already, you know, trafficking doesn’t require
that you’re not from the U.S., but certainly if you don’t speak the language that can be
quite a problem. We’ll talk a little bit more about that. False feeling of being in control
is really important, sense of agency that people who are being victimized may feel,
we might identify as victims, but they may not feel that way so there would be no reason
for them to disclose. Shame or guilt. It’s going fast now. Patients believe it’s their
fault and they will get in trouble or deported. Also not recognizing that there is a concern,
so trauma normalized. Right, if that’s what you’ve seen your whole life, that’s what love
looks like for you why would you think there’s anything to say. Lack of access, lack of trust,
trust in the system, great, those are  the list could go on for 12 years. Addiction,
substance abuse, no one will believe them. You see a lot of things you’re putting in
the box here on the list, and this list is not exhaustive. But I do encountered that it’s important for
us to touch on a few of the big ones. As Elisabeth pointed out earlier, it’s not our job to facilitate,
to get a disclosure. It is our job to make it a place someone feels they can disclose,
however, but we’re missing it. We’re not recognizing it. Sometimes that’s, you know, part of that
is because on the patient or client end feel of shame or guilty, there is the feeling of,
you know, wanting to please your provider, that’s a very natural dynamic that happens
in these relationships. But people very much feel like this is my fault. I’m ashamed of
what has happened or what I’ve been doing. Particularly when we haven’t made it easy
for someone to disclose. We haven’t necessarily set up the system in
which we work to facilitate someone telling us something bad is happening to them. Lack
of awareness they can been victimized, people talk about that. Sense of agency in my experience
I’ve seen particularly with youth, so adolescents who in general think they are in control;
despite what we want them to think. They might feel like this is a choice. You know, I’m
choosing this. I’m in control of these decisions, so they don’t feel like they are being victimized,
they don’t feel like victims. Not necessarily understanding they have rights. Some victims
or people who are victimized might feel like, well, this is it. This is  like life is hard,
and this is my hard knock life, and it is what it is. There is no recourse. Not having
control of their id or records, it’s hard to  it might be hard for them to come forward
if they have no proof, right, or can’t speak the common language, we’ll talk about language
barriers. It’s important language barrier is on the patient end, client end, also on
our end, right? So I work in an emergency department, so I always can get the language
that the person is speaking, as long as I can figure out what language it is, through
the interpreter lines. But if you work in a private office or clinic those are not free.
The hospital is paying and they are expensive. If your system doesn’t have the capacity to
pay for that, language will be a barrier. They can’t talk to you. They can’t tell you.
If they are afraid of being deported, foreign born and don’t call their experience trafficking
so they don’t know that they qualify as a trafficking victim, under the law, and b,
they don’t necessarily realize that they don’t have to be deported. They have options. They
may have experienced trauma bonding with the trafficker or with other people who are being
victimized. And so trauma bonding, we should talk about a little bit, essentially that
quote/unquote good relationship, the person starts to feel good feelings with the person
that has been hurting them or causing them, you know, whatever harm this is. And so this
person may have a true and honest relationship, that is, you know, familial, for example,
might be a romantic relationship, or maybe it became a relationship in which they felt
bonded to this person after a period of time. Some of that is just survival, right? If you’re in a bad situation, in order to
survive, the person who is hurting you sometimes you need to bond with them just, a, you can
keep going and, b, so they will let you keep living. Mandatory  fears of mandatory reporting,
that’s a pretty important one. People are worried, they come to  they seek care and
think, oh, well, I don’t want to tell someone XYZ because I know that will result in having
to report me, whether or not that’s true is a different story but they feel that. We talked
about people feeling like the shame or guilt, feeling complicit in the illegal act. Not
all trafficking takes place in illicit or illegal industries, even labor trafficking.
You can be  a form of labor trafficking might be being forced, defrauded or coerced into
participation in drug trafficking. Drug trafficking is illegal, of course, and
so that person might feel like they are participating in an illegal activity, regardless of whether
or not they want to. They may feel like, well, this is my fault. I’m committing a crime so
I can’t say anything. Really importantly, big one, people are afraid they are going
to get hurt, someone they care about is going to get hurt if they say something. That’s
a major one also kind of in the definition of trafficking. Limited literacy and education.
It just makes it hard to communicate if they are not able to grasp  we can’t grasp what
they are saying and they can’t explain comfortably. Distrust of provider or anyone in sort of
an authority figure or format. Partially because, you know, the trafficker has told them arguably
one lie, that they had a good job for them, things were going to be okay, that this is
all normal. After that, a lot of things were true. So if you do XYZ, I will hurt your sister,
I will XYZ this bad thing will happen. At some point you stop testing because you don’t
want bad things to keep happening. So then you don’t trust anyone. You only trust that
one person who told you the one lie once. And then feelings of hopelessness and helplessness,
I mean, that one happens in a lot of forms of interpersonal violence and traumatization
that you just kind of give up. You just go through the motions of life at that point,
and these are all things that can prevent someone from disclosing to us. What about
how  what we are unable or that we fail to recognize? How have you guys seen that play
out in your clinical experiences? You can just type into the chat box as you’re doing
now, yeah. Huge one, thank you. Lack of awareness and education. You can’t find what you’re
not looking for. A lot of people put that in already. Too many patients, not enough
time. That’s really true. I work in an emergency department. That is almost always true. Typical
bad teenager, we’ll talk about that for sure, but feel like, eh, yet another kid not listening,
and not doing the right thing. There’s nothing you can do, right? So I never want to ask
a question about something that I can’t actually I don’t want to find a diagnosis I can’t do
anything about because then what? All I’ve done is tell someone bad news and said, well,
good luck. If you have time to follow up, but time is the issue, label, lack of awareness,
limited resources, you can’t promise someone housing, right, if you don’t know that’s really
possible. Doesn’t happen in my community. People feel like this is a New York or something.
This doesn’t happen in my town of Indianapolis. Yeah, I does. Our own language barriers, minimizing,
believing the person that is speaking for the victim, that’s a really important one,
right? We should all be speaking with our clients
and patients at some point one on one at least once. Feeling obligated to report or call.
We’re going to talk about that one. Job overload, yeah. So you guys have hit on a lot of things
on this box, on this slide. Of course, none of this is exhaustive either. Some of this
is a major one that we all talked about, the first thing you said was lack of knowledge.
We don’t necessarily know the laws, and so we’re going to talk about some of those today.
People are worried about HIPAA, right. I don’t want to break my patient’s confidentiality;
I don’t want to get in trouble. Lack of trauma informed care training so we don’t know how
to ask the question. We don’t know what to do when we get the information. Misidentification
of the case. So that one’s really important. Especially we see in sex trafficking, people
commonly mislabel with partner violence or sexual abuse, of a child, and these are not
always the right terms to be using. Which means we mislabel if we mislabel or
misidentify the case we might hurt that person’s chances of getting appropriate referrals and
resources. That’s a big deal. Attitudes we talked about, someone had written in before
the typical bad teenager, so you see a 16 or 17yearold, 15yearold coming in relatively
decked out, the newest fancy iPhone and what not, fancy whatever, and they feel like, you
know, they have been around the block a while, they know what’s up. They don’t need to listen
to you. So then we sort of take that on also. We reflect that back and say, well, just a
bad kid, give them the med and let’s go and don’t dig deeper. Lacking access to neutral
professional interprets, checking off boxes, in this area of electronic medical records
and, you know, people are  you’re paid based on how many clients you see, not the quality
of care you provide necessarily. So you just want to see the 30 patients you
need to see that day. Just to keep the lights on and pay your staff, it makes it hard to
get to know what’s happening with your patient. That being said, we also assume it will be
too time consuming or complex. It does take more time, not as much as I think people might
imagine up front. Patient is unresponsive or tells us a story, you can tell when they
give you a story, you’re like you practiced that, that’s not exactly the truth, or they
are not participating. I can’t make someone tell me something. Lacks information on good
referral options so I don’t know who I’m supposed to call so I’m not going to try
to identify the thing. Or we attribute behaviors to harmful cultural stereotypes. So that kind
of goes along with the bullet that’s next to it, has prejudicial attitudes. Sometimes
we think, oh, these people from this place who do these things, this is why they do these
things and so it’s their culture and I’ll leave it at that. That’s the dangerous thing
for us to do, to just chalk it up to someone’s culture, to their beliefs or belief system
when they are being harmed. Right? Or just decide not to get involved because we don’t
want to get involved. And that happens unfortunately quite a bit too. So as behavioral health professionals,
so again, emergency medicine doc, I’m going to say we in a different way today. Emergency medicine is a specialty in medicine
but in some ways also I have to do a little bit of everything. I work in a community emergency
department, and so I don’t have a psychiatrist. We don’t have social workers at night or weekends.
In some case I have to fill in a lot of other roles that, you know, I didn’t go to social
work school, for example. I’m not a psychiatrist. I’m not a psychologist. So the ways in which
behavioral health professionals can help in at least three ways in fighting trafficking,
number one, recognizing trafficking when it shows up in our settings, and offering assistance.
If the patient or client is ready to receive. Again, as Elisabeth said, our job is not disclosure,
that’s not my aim and goal in life. But I need my patient or my client to feel like
this is a place they can tell me, they can come back and tell me, and that I will help
them in any way that is within my ability. Another way is serving or working in organizations
you work specifically with people being trafficked, who may be trafficked, working on promising
practices for rehabilitation, integration, prevention, prevention comes into the third
bullet. Talking to vulnerable populations as a form of prevention, there are many forms
of prevention, Elisabeth talked about a few earlier. You know, primary, secondary and
tertiary. But it has to be all of our responsibilities to, you know, find one way if we can to participate.
And we’ll talk about that response a little bit later in a few  sorry to say it, in an
hour or two. I know that sounds far in the future. So let’s talk a little bit about some
indicators, the things that we look for, or that we might see as behavioral health professionals,
when we might encounter a patient or client who is being trafficked. And what questions
might you ask to find out, you know, what have you asked in the past and what are you
thinking about now that you might ask to find out if a person is being victimized by trafficking.
So we see, you know, someone’s not speaking for themselves, not telling us information.
We talked about someone else in charge of their identity, documents. It seems pretty
clear that someone else is in control. Signs of selfharm. As a behavioral health
provider you might see cutting. We see cutting every day, not terribly uncommon, one way
we see people hurting themselves I would say that another form of selfharm is substance
use, not always, sometimes it’s actually a form of control the trafficker uses. But it
can also be a way of hurting yourself, knowingly hurting yourself. Bruises or other signs of
abuse. Again, you might not see that clinically if you’re not seeing patients, right, in the
way that you’re having them disrobe or something but might notice you shake their hand and
they have a bruise on their arm, right? I always ask my patients, oh, how did that happen,
just something in a way that’s a little bit maybe nonjudgmental, but also indicates that
I care and I’m paying attention, right? Emotional exhaustion, submissive or fearful
demeanor, potentially recent arrival from another country. It’s the United States, people
are coming in every day. So that most people who are arriving in the United States probably
are not being trafficked, right? But it’s something to pay attention to. Oh, what brings
you to the U.S.? How did you get here? Those kinds of questions might be useful. What are
the questions you’ve asked when you started to wonder if someone was being trafficked,
what else did you ask to delve in a little bit? I see a lot of folks are typing so I’m
going to give you guys a chance. Have you been forced into behaviors you did not want
to do? Yeah, so that  I start to get into that when I feel confident something’s up,
this person is not in control of how they are living. Multiple trips to the emergency department.
That’s great. Because we have frequent flyers, right? Those of us who work in the E.D. know
that lingo. Frequent flyers has a negative connotation in the E.D… This might be their
call for help. Tattoos and branding. This one is difficult if you’re not actually physically
examining a patient but you may see those, we’ll talk a little bit about that in the
coming slides. I have asked if the patient had to do anything for friends, boyfriend,
family that make them up comfortable to pay the bills or rent. That’s really important.
Some people feel like I’m doing this because XYZ who I care about loves me, and we need
this to get by, it’s a great way to normalize the behavior, soften the question, but also
sort of open that conversation. Keeping them isolated. That’s important in the sense that
you want someone to feel like they have the opportunity to disclose. If the person that’s with them is their trafficker
or a fellow person who is being trafficked, or they are at the E.D., like there’s 30 people
around, they are not going to tell you. I’m not going to tell you. It doesn’t really facilitate
disclosure about a lot of things. You want them to have the opportunity to speak was
as a clinician or if you need an interpreter one on one. Who helped you get the tattoo?
I ask, tell me about your tattoo. I find that there’s three reasons people have them. One,
they are excited to tell you about. They want to tell you, oh, my grandmother and I were
so close and there’s that great story. Or, you know, I was drunk and I made a poor choice
and they are embarrassed but not the worst story. There’s the one where someone made
them get it. Someone’s age, so seeing a 14yearold asking to be tested for STIs, you get concerned.
In New York state, that’s not going to be every state but in New York state 12 and up
are allowed to receive reproductive health care without parental or guardian approval
or consent or involvement. So of course we want to prevent people from getting or spreading
or having sequelae from STIs but we want to know why are not you safe, why are you getting
so many STIs? And we’re sometimes  we take back the patient for imaging, that’s great.
Someone pointed out in the E.D. it can be difficult to separate the patient or the client
from the person that’s accompany them, their visitor. In the E.D., I like to pull rank
and say, hospital policy, because it is, every patient gets examined alone, or gets whatever
it is alone. You know, worst to worst, security always
wins. I will always win as a clinician. You will leave if you are not a patient. But not
everyone here in our session today works in a place where they have that luxury, so some
of us have to rely on some other finagle. Some folks might try we have to go for imaging,
we can’t get a picture of you too, I play it off like that. That’s a great way to do
that. So here are red flags we’ve talked about quite a bit. I’ll touch on a few we haven’t
talked about. Frequent treatment for STIs and injuries, so people having a long history
of chlamydia, herpes, syphilis, et cetera, HIV, that’s a lot of stuff. They keep coming
back to get treatment that’s concerning. Unusually high number of sexual partners, unusual might
be different for you than it is for me but if you somehow get to that part of the history,
that’s something to pay attention to. Along those lines, multiple pregnancies, or terminations
of pregnancy, exposure to toxic chemicals, and that person is not able to protect themselves,
they don’t have proper protective equipment, that’s how they got their injury, for example.
So toxic chemicals but also, you know, got your finger stuck in the slicer working at
the construction site, dental issues, as we saw Elisabeth talked about one studies, dentists
are seeing probably more than we would have imagined or remembered. We talked about some issues. Weight loss and
malnourishment is important, in it the age of obesity people who are thin in a concerning
way we should be alarmed either medically and if not medically then socially because
either they have something truly medically wrong or don’t have access to food and that’s
not okay, especially in a country like the united states where  there are people hungry,
not because the country doesn’t have food so we should ask questions there. Respiratory
issues, exposure to toxic chemicals, for folks that don’t have access to meds, frequent,
or multiple suicide attempts. In behavioral health, you’ll see some of that in the physical
health, you’ll see some of that, but in behavioral health you might here contradicting stories.
I look to reword stories and offer it back. One way to show I’m listening, but two to
see if they are actually listening or going along to get along. I might say the story and change one word
so instead of tripping forward they fell backwards or something, if they don’t correct me I start
to get a little concerned. They are not focusing or concentrating. These things are not clear
signs that it’s trafficking, right, something that makes you want to pay more attention
but in behavior health it’s difficult because this could also be a sign of a diagnosis they
also carry like schizo effective disorder or ADHD, maybe they are on the autistic spectrum.
It’s not a clear slam dunk of trafficking but things to pay attention to. Folks who
don’t know when or where they are, but don’t in other ways have altered mental status,
doesn’t seem like a medical problem, not delirium, just weird. You came to the hospital, came
to my clinic, why don’t you know how to get here, where you are, why don’t you know the
month? If they are trying to protect that person who it seems like is hurting them,
so that trauma bonding we talked about. We talked about some of the minimizing of the
abuse, guilt, and shame, suicidal ideations, being really, you know, timid or fearful in
your presence of telling you the story. Social services, which does play along a bit with
behavioral health, we might see things like they are absent from school a lot, grades
are falling, they are withdrawn in school, they go to the nurse a lot because they are
stressed out. It seems like there’s an increase or they
are not just experimenting with substances, they are like using them. Their attire is
changing. For example, you might see that a kid who seemed to be dressing like the way
kids dress, and age appropriate way, might be dressing in a bit more quote/unquote adult
ways or that are not appropriate for the weather, like it’s cold out, why are you wearing a
mini skirt, for example. Age inappropriate romantic partner might be I’m 16 going on
17 but I’m dating a 40yearold. That’s a problem. We should be paying there, not just
saying, you know, oh, kids. A change in their friends, right? So kids usually  they have
their cliques but when it seems like the clique is changing for a child, we’re paying attention,
you might notice that is affecting other things in their life or they are running away lot.
I want to come back to being absent from school or grades falling. That doesn’t always turn
out to be the case. I think Elisabeth, would you want to tell a little bit about your story
here and how that played out or did it play out for you?>>Elisabeth Corey:
Sure, yes. Thanks, Makini. Basically, I just wanted to throw up a caution flag, when it
comes to using failing grades as the only indicator of kind of school performance. Well,
that being an indicator for trafficking, because in the case of most of the familycontrolled
trafficking survivors, including myself, people that I work with on a regular basis, they
found that school was a place that they could thrive when their family like was so chaotic,
and so many times in the school environment familycontrolled trafficking victims continue
to do very well because it’s kind of that one place where the rules make sense and they
can thrive and feel good about themselves. Of course, there are instances where the grades
may shift dramatically in one direction or another, or of course there are other indicators
you could look for. What I would just warn against is if have you somebody who is meeting
other indicators but yet they seem to have good grades, don’t use that as a reason to
not look at them as a possible trafficking victim.>>Makini Chisolm-Straker:
Thanks, Elisabeth. Yeah, I think it’s  just to reiterate or echo that point, it’s important
everything is not going to line up. If they have, you know, four things but something’s
the opposite of one of the things on this bullet that doesn’t make it not trafficking.
If you’re concerned about it, you have to have more conversation and ask about it. In
the public health realm, I won’t go through all of them but things to think about when
you’re seeing someone, you’ll generally have a little bit more information than just what’s
happening with their behavioral health. You might know they have tuberculosis or something
like that. You’re probably going to see a lot of history of physical abuse, sexual abuse,
emotional abuse, emotional and verbal abuse. Remember that abuse and maltreatment in childhood
is not just something that is done to you but also things that are not done for you.
So neglect, right? Not receiving the medical care or food that
you need to grow and be healthy, not receiving the love, the actual affection that a child
actually needs to grow and develop. These things are important. And so it’s not just
the active things that are done but also the things that are I guess you could say actively
not done. Things that you might pay more attention to in the behavioral health sector, we talked
about substance use, being a way people might harm themselves. I would also really caution
folks to understand that substance use disorders sometimes precede trafficking and make you
vulnerable, a way someone can exploit an individual. But they can also be used or created. So in
labor trafficking, I’ve had patients who were basically given uppers, so they could
stay up, right? If you could work 18, 20 hours a day, you’re way more profitable to me as
a trafficker than if you’re working an 8hour day. Similarly, these are not mutually exclusive,
right, so you could also be on upper and be sex trafficked and vice versa, but I’ve
also seen people being sex trafficked on quote/unquote downers, to keep you complacent but also helps
sort of numb, numb and dull that pain, not necessarily even just the physical pain but
the emotional pain. But once you develop a physical dependence on the substance, it’s
real. You have a substance use disorder. You will
do what you need to do to make your quota, you will do what you need to do to get right,
stay right, be right. And that means getting the drug. And once the trafficker knows they
have a physical hold on that, they are running the show. Emotional, these are hard because
you’re seeing these things anyway, right? Irrespective of whether the person is being
trafficked, that’s why you’re seeing the patient, something is wrong emotional or behaviorally.
So these are not  I don’t want you to necessarily dig for trafficking with every client or patient
you’re seeing but just be aware these things are in some ways even harder with trafficking
because there’s another layer adding to and making this work. In complex trauma we see
all of these other it’s not just anxiety, not just depression, not just PTSD, it’s all
these things and they are interacting together and it makes it really hard to manage, especially
if the person is in their situation. They don’t know they are in a situation. You don’t
know they are in a situation. These symptoms are never going to get better if they are
not readied to leave their situation because of trauma bonding or trying to protect themselves
or someone. It can be hard to manage these things from a clinical perspective. So it’s
just important to keep in mind as you try to care and provide care. I think we’re just
going to breeze through physical signs, just because you’re not generally seeing these
patients from this perspective. But it’s just important if you look at these sort of outer
signs, outer parts of the body, you might actually see, right? You might see someone’s forearms depending
on the weather, wearing shorts or a skirt, unusual injuries or bruising. You could see
burns. Tattoos are frequently fairly well hidden or like hidden in hard parts of the
body you wouldn’t see as someone, as behavioral health specialist, accidentally. Tattoos might
be a bit odd. So, you know, there is certainly Marvin the Martian tattoo because they love
Marvin the Martian or have a heart or something like that, or a phrase in Latin, but then
there’s like the crown that says daddy, that’s a bit odd. I ask my patients about all their
tattoos, just because I can’t possibly know all the trafficking tattoos. But the tattoos
are a way traffickers are branding their property, the same way that farmers used to and maybe
still do brand their cattle, so when their cattle wander off someone can claim them.
Similarly it’s a sign to other traffickers, back off, this is mine. And then we talked
a bit about some other stuff. So besides seeing a little bit about chronic illness, I won’t
talk about this slide, but chronic illness and pain is also quite difficult because from
a behavioral health perspective sometimes it’s somatization, the not a medical things
causing XYZ but sequelae of being trafficked, months ago, years ago, still having pain from
XYZ. Sometimes you have chronic pain because you were doing something when you were being
trafficked that resulted in you having chronic back pain, arthritis, whatever it is. It’s
hard to always know which one is somatization and which one is not, it’s really important
for behavioral health specialist to work in conjunction with medical team so we have to
have a really collaborative relationship. We talked a bit about substance use already,
so I won’t say too much more about this outside of the fact that as behavioral health professionals
we’re already taking care of folks who have substance use disorders. What are the kinds
of questions that you guys ask when you’re taking care of someone who you’re worried
about trafficking maybe, you’re worried about interpersonal violence, and you know there’s
substance use, what do you guys  what are the questions that you ask? I’m just waiting for folks to type, sorry.
There’s lots of people typing now. Okay. So one person says I usually ask about coping.
Are you using the substances to cope? What are the difficult  what are you having difficulty
coping with? That’s a great point and question. We talked about how substances are used to
manipulate people being trafficked. But also, you know, people who are being trafficked
might use them independently, quote/unquote, in order to cope with their circumstances.
When did you first use them, what are the circumstances? Try to understand is it a manipulation
thing, is this how you’re being  is this the way you’re being forced or coerced into
trafficking versus, you know, was it something you started out with and someone took advantage
of it? If they ask me if they want help. Yes, if they are not ready to quit, it’s not time
for them. When was your first use? How did you spend your day? I like that question.
How do you spend your day? What do you do all day? That question I think is important because,
one, it indicates that you care about them as a person and you recognize they are not
just a patient. Most people would not identify themselves first as a patient even though
when we walk in, we identify them as, this is my patient soandso. And if you have an
idea about how someone’s spending their day, if they are spending their day scheming how
to get more substances we know there’s a problem, right? If you’ve ever been given drugs without knowing,
roofies, for example, or when you refused it, so against your will. If they are under
21, are you using alcohol? How do you get your alcohol? That’s really important. I would
add to that what alcohol are you using? Because there are people who don’t have the means
or are under age, you can get alcohol, it doesn’t have to be from a liquor store. You
can have an alcohol problem and they are medically even more dangerous because they are immediately
more lifethreatening alcohols, that’s another thing to add. And what do we do when we identify
substance misuse and substance disorders? The first thing is figure out where they are
in their readiness. Are they ready to quit? Do they want help? If they want help we should
connect them with services that are appropriate. If they are not ready for help it might be
worth talking a bit more about some questions you guys brought up, why are you using, when
did you start using, how does it help you cope, what does your day look like, to help
bring them to the realization this may not be the best course of action. Referring people
who you suspect of being trafficked to appropriate service provider, creating holistic treatment
plans. Your treatment plan for helping someone quit meth, for example, won’t work if meth
is how they are being controlled by their trafficker and they are not ready to leave
their trafficking situation, right? So a plan that is not just focused on the substance. And information on human trafficking resources
to all clients, we’ll talk more about, you know, these actions during the respond section
so I don’t want to give away all my stories. But I’ll tell you about how I provide that
information in a section or two. And then if we start thinking about, you know, how
did these  how does trafficking affect people who are victimized by trafficking, people
really experience a lot, a lot of mental health illness. PTSD, depression, and anxiety are
some of the most common ways, but they are not, again, as we said before, they are not
independent of each other. It’s not just PTSD. Just depression. Just anxiety. Just selfharm.
These things all sort of work together for this complex trauma that makes it complex
and complicated to treat, so what I’d like to do is have us go through a case study,
and then talk a little bit about some of the things that  talk in the chat box, talk about
what we’ve talked about so far with our s and o. We’re going to read the case study
for Priya.>>Leilani Funaki:
And once again if you’d like to download Priya’s case study and read along with me it is available
there in the files to download box. This one says my sister and I were sent to the U.S.
by our parents to work for Meriwether, a landlord who emigrated to the U.S. He convinced our
parents we would attain the American life. I was 15, Asha was 17. When we arrived we
found Meriwether did not have honest intentions. He raped us. And forced us and many other
women and girls he trafficked from our home country, into sexual servitude, to work in
his restaurants and to work in cleaning and maintenance on his rental properties. We were
all brought to the U.S. with fraudulent visas, all girls from poor families, and we were
dependent on him for food, clothing, shelter, and employment. In November 1999, my sister
Asha was found dead in one of Meriwether’s apartment rentals, although Meriwether was
eventually arrested, I was able to escape the situation, I continue to suffer major
mental health issues due to my victimization. I sought psychiatric care for fear, suicidal
ideation, and depression. I feared he would come to rape, beat, and kill me. It’s been
several years since the case resolved, I am still under psychiatric care.>>Makini Chisolm-Straker:
Thank you. So in the chat box, really quickly, what are the barriers that came between Priya
and her service providers? How are the ways what are the barriers that influenced how
you’re thinking about this case? How do you think these barriers could have been overcome,
basically what are your thoughts? And after that I want to answer the questions in the
chat boxes. Some barriers, economics, age, lack of documentation, language, visa, fear,
money, power, you guys are doing great. System support, trust beyond culture, lack of resources,
lack of social support, families in other countries so social capital, right? Who are
you going to get help from? Fear she would be exposed. Homelessness. Lack of insurance,
yeah, that’s a fair concern as well. Okay. Really quickly, I want to  there were four
questions. One is there specific lingo associated with traffic? Yes. And it can be regional. So I’m in New York. Doing a study can covenant
house, New Jersey, their lingo is different in New Jersey. So it’s important to learn
the lingo in your area. Folks may say “in the life. “I use the language my patient is
using, I try to mirror what they are saying so when we first start talking I use pretty
generic language, things I try to avoid are sort of valued or judgmental sounding terms
like pimp or trafficker, or really an epidemic sounding terms like that. Is there a concern
if you force removal of the trafficker you won’t see the patient again? So generally
speaking, I will force removal if I’m worried about the safety of myself or my patient or
patients or staff. Because in that moment, my job again is, in that moment, none of us
survive this moment nothing else matters. I usually try finesse. I believe in honey
over vinegar first. Usually, people want to avoid a scene. Most times, people will try
to avoid the scene and go along to get along and will step out. I offer them a back end.
You’ll be invited back in. I’ll come get you. Visiting hours are over for the next 45 minutes
so you can come back. And more awareness of trafficking, centers more awareness, is it
more dangerous for folks to get help? Not yet. I don’t think so. You guys are here but
there’s still a general lack of awareness. I don’t think traffickers are totally on to
that. More information on the tattoos, sure. So most people who are trafficked are not
tattooed or are not branded. Tattoos are specific. And so there is  I can’t give you all the
tattoos that exist, that are going to indicate trafficking. I really would start with can
you tell me more about your tattoo, and listen. That’s going to be the most helpful thing.
And it is 2:45, so really quickly we’ll summarize. I think you all did really well with the explaining
the barriers to preventing proper recognition of trafficking. Patient barriers include fear,
distrust, shame, talked about all of that. Provider barriers, you also talked about in
that last slide. Unawareness of signals, misclassification, uninformed attitudes. And when providers are
aware of the common indicators of trafficking, we’re able to generate a quicker response,
more efficient and effective response to potential trafficking cases so well done. Are we on
a break now again?>>Leilani Funaki:
No, we’re going to go ahead and ask Elisabeth to cover the next section and we’ll take one
break after that.>>Elisabeth Corey:
Okay. Thank you guys. Thank you, Makini. That was really awesome. I learned. So, we’re going
to talk about the ask section now. And let’s go to the next slide here. So we have several
objectives in the ask section. One of which is to commit to treat a potential victim using
victimcentered treatment best practices. So this is really going to be focused on the
traumainformed care approach. Second is to identify the elements needed to establish
a safe environment. And the third objective is apply these victimcentered interview techniques,
and one of the tools we can use to look at that is the trafficking victim identification
tool. There are also other interviewing tools available. So, the victimcentered approach
is really geared towards making sure that the victim’s needs and concerns are considered
above all also where that is possible. All professionals involved in human trafficking
cases must advocate for the victim. Avoid activities that cans on ostracize the victim
or mirror the trafficker, that can happen in certain environments whereas Makini was
talking about when you’re in the medical community and you have to see all these different patients,
sometimes you have to keep going and unintentionally we can limit the victim’s choices, and in
their own recovery process. So this does require to us have patience,
empathy and compassion for the individual. And that is not just you but everybody else
who is involved in it. What we’re trying to create here is autonomy, as much for the victim
as the environment you’re working in will allow. If the environment won’t allow autonomy
for the victim, it’s about changing that, right? We want to start creating a better
environment for potential victims of human trafficking. So what do we mean by trauma?
Okay. In short, trauma is an experience that overwhelms one’s ability to cope. I think
it’s really important we say it that way, because one thing that trauma is not defined
by is a particular experience or event. Okay. Because an event could affect one person in
one way, and another person in a completely different way. So we really want to focus
on how is the individual coping with the particular traumatic experience in their case. Okay.
Anyone can be affected by trauma. Individuals, families, or communities. As a matter of fact,
I often talk with my clients about the fact that they have the microtrauma that’s affecting
them but there’s also this macrotrauma which is affecting the community within win they
are part of, or also within the family they grew up. Vulnerable populations, especially
children, girls and women, youth, LGBT, persons with affected by trauma. I think that’s true,
we also have to open our eyes to the fact that trauma is everywhere. And I actually don’t shut up about this, in
my own work, we have to bring home the fact that so, so many of us are walking around
having experienced something that overwhelms our ability to cope, whether it was when we
were children or whether it was a more extreme event when we were an adult. We have experienced
some form of trauma. So traumainformed care falls under the umbrella of the victimcentered
approach. And a traumainformed approach can be implemented in any type of service setting
or organization. And is distinct from traumaspecific intervention or treatments designed specifically
to address the consequences of trauma and facilitate healing. Traumainformed practices
can and should be used in an organization, absolutely. There’s no doubt about it. Everybody
needs to be doing this. And here are some of the ways that organizations and providers
can implement a traumainformed care approach. Okay. First, reflected principles of a traumainformed
approach throughout the organization’s policies, program design, services, and environment.
This is really critical that if we’re going to start pushing for traumainformed approach,
that we’re doing it as a part of the culture within the organization, and it should be
affecting everything. That means when you’re working with the employees in the organization,
they should be approached with a traumainformed you know, they should be managed in traumainformed
policies and procedures, not just something that applies to clients or patients or people
you see on a daily basis. Foster the core principles of safety, voice, and choice. So
obviously we talk a lot about safety. We talked about safety in the last section
when it comes to separation. Voice being allowing this person to speak and say what their needs
are and choice being that autonomy that I was speaking of a few minutes ago. Establishing
trusting respectful and collaborative relationships. Somebody that I worked with the past coined
this phrase I love, transformative relationships. When we can create a transformative relationship
with somebody we’re working with, that means we’re showing them a different way to relate
than what they have experienced in the past. And that can be life changing for somebody
and show them that maybe, just maybe, my relationships in the past, something was actually wrong
with them. When we can show them there’s another way to relate to a human being it can be incredibly
powerful for that person to understand what’s been going on in their lives. No, it won’t
happen in five minutes, but it can happen if we put in the time and the patience and
energy to do it. Establish and maintain transparency in action and interactions. Transparency is
key because I’m telling you from my only personal experience there’s nothing like trauma
to create hypervigilance on a mass scale. And so I think it’s important for us to understand
that if we’re not transparent, there is nobody like a trauma survivor to figure out we’re
not being transparent. They live for it. They look for it, notice it, see the signs, and
pick up on everything. The hypervigilance goes on long way to helping them survive but
can be a bit of detriment when something who is trying to help them is not transparent
and they immediately stop trusting that person. And last, sharing information in ongoing and
consistent manner, so that’s about being there for them consistently and not just every once
in a while because more than likely, trafficking survivors, as well as other times of complex
trauma survivors, are really used to being given attention for a little while and then
having that attention sort of go away. So don’t be that person, because if you cannot
be that person, you’re moving into that transformative relationship I was talking about earlier.
So, what are the six principles of traumainformed approach? We talked about a few of these already.
But traumainformed care promotes maximized healing and minimized retraumatization in
the delivery of a broad range of services. And this could be any services. Certainly
behavioral health, substance use, housing, vocational employment, domestic violence and
victim assistance and peer support. So this approach is going to support, and it’s not
just the physical safety but the emotional safety, for victims and staff. And you really
want to look at, as we were talking about earlier, being able to provide information
about trauma to victims in a trustworthy and transparent way. Okay. I work with a lot of
people, the way that I’ve named my organization has trauma in the title, I worked with people
who said when they first found out about me they were like, well, I didn’t know whether
or not to come to you because I didn’t think I had trauma, right? And so a lot of this is about educating the
individual as to what their experience is. Actually, that their experiences are in fact
traumatic in nature. And that they do have trauma. That can be incredibly helpful for
them because if they understand they have trauma, it can also help them to understand
how they can get help for it. We also talk about peer support here. And I cannot underestimate
the power of peer support. There is nothing like having somebody nearby who really, really
gets what’s happening to you on a deep, deep level, because they are two of the most powerful
words in healing and establishing relationships with people, sorry, two of the most powerful
phrases are “I believe you” and “me too. “There is something about having somebody say, I
know exactly what you’re talking about, that happened to me too, that is incredibly healing
for people who suffer from trauma, so peer support is incredibly important. I think it’s also important for us to connect
potential victims to crucial support networks like we were saying, peer support is one of
those. But also other types of support networks that help them to foster interpersonal relationships
than grow that really gets down to this idea of sort of collaboration. Collaboration with
both people that are trying to help but also people that are not involved in the helping
process, just to kind of gain relational experience, which is really difficult for trauma survivors.
Empowerment, voice and choice, we talked about this before, the idea of shared decision making
is important, or making decisions together, we’re not making decisions for you. And then
of course bringing in an understanding of cultural historical and gender considerations
as well, especially if you’re working in a community where you have a particular culture
and culture is particularly vulnerable to trauma and trafficking, maybe even culture
that has experienced tremendous amount of intergenerational trauma. It’s important to
understand how that plays into the traumainformed approach. I also just wanted to mention a
couple other things. We really need to change the paradigm from what’s wrong with you to
what has happened to you. I would say one of the things that I hear most from my clients
when they come to me is I’m not like everybody else, something is wrong with me. And I am always  the first thing I tell them,
no, this is not about something being wrong with you. This is about what has happened
to you. And there is so much relief and so much healing that can come from such a simple
concept, but we have to be able to bring that to them and let them know that, no. No, there
is not anything wrong with you. That’s not what this is about at all. So we’ll move to
the next slide. Okay. We’re going to play a video here in just a second. But before
we do that, I wanted to just very quickly give you a brief understanding of my own story
before we start this. And the person who is going to speak in the video and I, our stories
are actually fairly similar, interesting, because it’s not that common of a story, let
me put it this way, it’s a very common story but not a story that gets told a lot. Let
me say it like that. But I had a lot of experiences when I was growing up with medical doctors,
and every time I was in any kind of medical setting, my parents would do all of the talking
for me. The  I experienced quite a few as a toddler, urinary tract infections, and my
mother would always excuse those away as being caused by bedwetting. And so their goal, my parents’ goal in this
whole experience, was to avoid pelvic exams for me when I was a child. And they would
do that at all costs. But when I was 8 years old, I was actually taken to a doctor by a
neighbor because my parents were out of town, and I was suffering from yet another urinary
tract infection. The doctor did a pelvic exam and immediately called the police. So this
was really the only experience in my entire childhood where I had an adult actually come
to understand and recognize what was happening to me and tried to do something about it.
However, my experience was not good. I ended up in a room with a whole bunch of different
adults, who were all very, very concerned, but the way I understood what was happening
around me was that they were all mad at me because they were concerned, they weren’t
talking to me, weren’t paying attention to me. They were having this adult meeting while
I was sitting in the room as an 8yearold, I was taken out of my house and put in foster
care. I saw this as a punishment. Nobody really ever explained to me what was actually happening,
except, you know, my parents had already made it clear that, you know, this would be the
most horrible situation ever. Unfortunately, when I was in foster care, I was raped by
my foster care brother in a home that seemed more like a hotel for kids. So it wasn’t really
the right foster care environment for any child to be in. There really was no food preparation.
There was no taking care of the children. So I changed my story so I could go home.
And honestly, the CTS workers were disappointed, even expressed being angry with me, and in
the end because I did that, the judge shamed me at 8 years old. That was my experience
with services at the time that I was growing up, and you’re going to hear sort of similar
story here in just a minute, in the video, or some very similar things that went on.
And I think it’s important when we listen to these stories to really take in what can
be done to treat children in a more traumainformed way and so we’re going to watch the video
now and then on the back end of that I will ask you some questions.>>Female Speaker:
Most people even today think that trafficking and exploitation happens in third world countries,
not in the United States of America, and certainly not in Kentucky, but it does, and I’m proof
that it does. I grew up in a town in Kentucky and I in a middle class home. I have an older
sister, and my parents divorced in my late teens. I was an avid swimmer. It was my life
and something I enjoyed doing. It was a passion of mine. And I always enjoyed art, from the
time I was very young, art class was my favorite subject in school. I was trafficked beginning
as a very young child. It was pretty much always a part of my life, all of my life,
up until I escaped when I was eighteen. My trafficker was somebody that had my complete
trust and the complete trust of my family, and therefore it made it very easy to gain
access to me, to exploit me. There were quite a few moments in time when I was trafficked
that, you know, the opportunity for intervention arose. When I was a young child I had chronic
reoccurring vaginal infections that was treated by my pediatrician. Then in middle school I contracted oral an
sexually transmitted disease, in which I was treated by an ear, nose and throat doctor,
both physicians were wonderful and very caring, but not one physician or health care worker
ever asked whether I was being sexually exploited, not once. Both doctors knew my family. And
so I think that they may have dismissed that thinking no way could a child from a middle
class home be being exploited. Another case where I see an opportunity that was missed
for an intervention was I was in middle school, somebody reported that I was being sexually
abused. I had to go down to child protective services. Prior to going to my interview I
was coached by my trafficker on what to say and how to deny the abuse. He told me not
to talk too much, and to know that the CPS was not my friend. I distinctively remember
him saying, do you know what they want to do? And I said, no. And he said that they
want to take you away if you say anything, for good. You’ll be locked up, taken away
from your family, your friends, and your pets. You will go to jail, and everybody will know
what you did. By the time I got there and walking into the office, in which I was interviewed
by a CPS worker, I walked in there feeling guilty, feeling ashamed, and not at all seeing
the social worker who was interviewing me as somebody that could help me, who was there
to rescue me and bring me to safety. I saw her as the enemy. And I answered her questions,
denying that I was being abused. And left there with no  there was no followup. And
I left, and trafficking continued.>>Female Speaker:
So let’s talk about a couple of questions regarding this particular video. And you can
answer in the chat box here. But what red flags should the providers have seen? And
you’re right, it is heartbreaking, absolutely. The current vaginal infection, especially
at that age, absolutely, absolutely. Oral STD in a child. No doubt. Those are huge signs.
Timidness or fear  I can’t say that word today  fearfulness, exhibited during interviews
and flat out denial, yes, concern expressed about  yes, the fact the concern was even
expressed at all, you know, that’s a really important thing to point out is that, yes,
it can happen and people are just trying to get back at somebody or being retaliatory
in nature, but it’s actually pretty rare in the scheme of things. If there’s a concern,
it’s something that needs to be looked at very seriously. So, yes. So the next question,
what questions could the providers or social worker have asked? And do recall she was trafficked
at a minor and is now speaking from her past experience. While you’re typing, the like the comment
about providers making assumptions about parents being good parents, yes. We do have a habit
of doing that. Or even this idea that what happens in the family stays in the family,
that’s another really popular one. So questions. Is anyone hurting you? What do you think my
role is? That’s a great one. What is the relationship to the person you are with? And then who do
you spend most of your time with? Scrolling by really quick, I’m trying to read these.
What have others told you about what is supposed to happen today? That’s really, really good.
Suspect that it was not the parents who brought the child to cps, oh. Did anyone tell you
what to tell me or tell you not to talk? Yes, that one, you know, that may get the right
response and also could be direct to the point that they won’t answer it. I don’t know but
I think it depends really on the child. But I think generally this idea of, oh, what were
you told was going to happen today can be really helpful because, you know, contrary
to popular belief when children lie, the stories can get a little amok and askew, and we can
pick up on that kind of thing so I think that’s a really good question. Ooh, who do you talk
to when you feel scared? Excellent. I can’t imagine that most of us who have been through
conflict trauma perpetrated by the family would have an answer for that, honestly, which
is a red flag in and of itself. So, and then the last question that I wanted to ask you
guys here is what could the social worker have done differently? While you’re answering that I’ll say somebody
is also talking about disclosing what happens or talking about what happens after disclosure.
That’s another really good one that I see here. So what could we have done differently?
Better followup. Absolutely, no doubt about it. Explaining their role. Following up. I
think that that’s really a key point, is this idea of following up because it’s very rare
that you’re going to gain the trust from any child who has been abused or trafficked the
first time you talk to them. So following up, establishing multiple points of contact
with this child, expressing to them really what you’re expressing to them is that you’re
not going anywhere. And that you are going to continue to be, you know, consistently
involved can be incredibly helpful and another person is saying tell her you can always call
me later, give her the number, yes. Yes. So in reaching out to her school that’s another
really good one. I know in some cases where family is potentially involved in the trafficking,
sometimes the first place cps workers will go is the school. So thank you guys so much
for those comments. Appreciate it. So let’s talk a little bit about trust. And when we’re
talking about building trust, I would say that out of all those things that I have worked
with in my clients, by the way all my clients are adults, the number one issue people are
facing and have been facing most of their lives is trust and the lack of it. And so
let’s talk about kind of a building that trust, because we have to kind of work towards creating
the kind of relationship that a child can feel that they can trust us. So, you know, being a key component to identifying
potential victim of trafficking as it says here and it does require a tremendous amount
of patience in order to do that. We need to see the potential victim as an individual
and treat them with dignity and respect. And so one of the ways that we’re going to build
trust with them is honesty. As I said earlier, when we are not honest, they can tell and
they can tell me quicker than the average person because they are often in a hypervigilant
state and noticing details maybe others won’t notice. We do need to understand incremental
disclosure. That is how cases unfold. This is often something that I’ve spoken to law
enforcement about. I think we have to be really understanding when it comes to this concept,
because many times either because of the beliefs that have set in like the beliefs around whether
or not they believe they are at fault, to blame, or believe the trafficker is going
to help them, is in love with them, whatever it might be, those types of beliefs will make
it difficult to get any kind of significant disclosure the first time we work with somebody.
And what will often happen is as a person gets more and more comfortable with you, disclosure
will get more and more detailed, and will provide more and more information to you.
It is not that they are necessarily lying the first time. It’s that they are still trying
to figure out the story for themselves, and what it looks like in reality to them. And
when we have had traumatic experiences, our reality is often shifting on a regular basis
as we heal, as we feel safer, as we begin to uncover our own memories in some cases
which memory loss is very common with trauma. So it’s very important that we can maintain
an understanding for incremental disclosure and why it happens. The use of openended questions,
we don’t want to appear like we’re guiding them towards an answer. We want them to be
able to answer us as they see fit. This comes back to this idea of autonomy. And then practicing
reflective listening. So, you know, they say something to us and
instead of us going, let me tell you the next thing I need to tell you, we repeat back to
them what they are saying to us, that can really be powerful and helping them to not
only understand that we’re listening but also to make sure that we have interpreted what
they’ve said to us correctly. So these are all very powerful techniques for building
trust with a client. So that’s and if you guys have any other thoughts on building trust,
that you think are not brought up here, please feel free to put them in the comment section
and I’ll try to mention a couple as we go. I see one here, agree, blaming cps, yes, it
does. And I do a lot of work with memory recovery and I will tell you that people come to me
when they first come to me, they may not even know half of what happened to them. Literally,
it is not in their cognitive memory anymore. We have to be conscious that this is actually
a very typical trauma response, when we’re working with people, and it may take time
before they even know the full story, let alone telling it to us. So thank you for that. And another comment
here, normalizing their experience. Yes, yes, yes. I often say, you know, it’s not  I’ll
say to clients sometimes, you know, I’m not telling you this to minimize your experience,
I’m telling you this to let you know that I also feel the same way, right? So allowing
them to normalize it can be so, so helpful in their healing. Thank you. So creating a
safe space, and this gets in a little bit more to this idea of the physical environment.
But also how the interview is actually accomplished. Some of the best practices for establishing
trust and safety are, you know, trust is essential for disclosure, building trust is a top priority,
if you’ve not established it your victims will continue to be misidentified and mistreated,
that is absolutely a guarantee. So one way we can build trust is in a safe space, the
safe space is both the physical safe space and emotional, secure, and consistent space.
So, we want to make sure to pay attention to the physical space, in which we’re holding
a conversation with the patient. Consistency is best achieved, definitely by meeting regularly
with the patient but also in the same place. And also, is this place sort of a traumainformed
space, so can others overhear what they are saying, is it a comfortable space, looking
for things like that can be very helpful. It is essential that you clearly articulate
who you are and above all demonstrate your respect for the patient. So a few things to
keep in mind. Environment, right, is it a pleasant welldecorated
temperaturecontrolled welllit room, right? Where privacy can be ensured. Frequency, as
we’ve been talking about, they are not going to reveal information to you one time. There’s
going to be incremental disclosures that happen so regular visits is really important. Trust
killers, try to conduct these visits or, you know, don’t do it when you’re rushed, let’s
put it that way, because when you’re rushed or you’re tired or you’re out of patience
there’s a really good chance the people that you’re working with, victims you’re working
with, are going to notice it almost immediately. And they are going to respond to that. They
are going to respond and say, here is one more person who don’t have the time for me,
right? Make sure you start the conversation, not by immediately going into a bunch of questions
in regards to the case or the facts of the case. But really getting to know the person
and telling them at the beginning how you’re going to interact with them, that you know,
you’re not blaming them for the situation, and have conversation with them. And also
wear appropriate and actually  well, I believe it’s always appropriate to say something about
yourself. You don’t have to give away massive details, but when we can open up to the individual
who we’re working with, it can really help them to feel like they can trust us too. So,
okay. So next we’re going to talk a little bit about the separation protocol, because
it is critical that every provider have a separation protocol. And of course this may
come as no surprise, we need to have it prior to needing it. This is why we need to work
on protocols now. The plan must be established ahead of time, as I said, separation plan
allows provider to examine our question patient or client privately in a safe environment.
Like Makini talked about earlier, she gave a lot of good strategies for how she makes
that work in her environment, of course it’s going to be different in every environment.
But it’s important that we have something in place. And then criteria, strict criteria, should
be set for when and when not to intervene once a patient or client has been identified.
You know, if a decision is made to proceed with an intervention, a clear procedure must
be determined in advance that includes notification of internal and external security officials
because as Makini talked about earlier, in an emergency department, it may be a little
more security focused already, that’s not always available in every type of setting.
So we have to be prepared for that. And we have to be prepared that traffickers can be
armed and violent, and there is a danger in this work. So we have to address that within
the protocol. And in addition, the staff of your agency may be exposed to some level of
danger, so it is critical to work through safety component of any intervention. And
really getting input from local and federal law enforcement and hospital security if you
work in a hospital setting. So maybe if you could just take a minute here to share any
experiences you’ve had with separating potential trafficking victims. You can put those in the comment section.
I see a few people typing here. We use xray and urine collection to get the patient alone,
really good examples. We’ll say we need to do a physical exam alone. Inpatient setting,
have team page when or checking in on patient when potential abuser left the room for any
reason, that’s a good one too. These are great. Thank you. And so another person is saying
here the program she works with is for women and they have a rule about no men being allowed
in sessions or to sit in a waiting room, rationale is based on safety and comfort, that definitely
can help with separation right up front. So thank you. I appreciate your examples. So
let’s move on here to tool for action. One tool that can be used when you are doing interviews
with clients is something that’s called the trafficking victim identification tool, or
TVIT, it’s sometimes referred to. Because interviewing trafficking victims,
we’ve been talking about this a lot, it’s not easy at all. We’re not going to have this
immediate rapport with the person. They are not going to trust us immediately. This is
going to take time. But a tool like TVIT can help us to bring  to basically have some
ideas. You know, one of the things I’ve heard about TVIT from people in the medical
community, it’s way too many questions. I don’t think anybody expect you to realistically
ask every question but it’s a great way to get an understanding of the questions that
can be asked, and many times hospital settings have told me they have taken the questions
and integrated that with their existing questions, that they already ask patients and been able
to take the questions that work best for their environment so I recommend something like
that. But if you’re  if you ask traffickingspecific questions, when red flags are raised, this
can be beneficial, really being able to identify the victims. So, some questions to start off
with for the safety check is to say, asking things like, is it safe for you to talk with
me right now? Do you feel like you are in any kind of danger while speaking with me
at this location? Or is there anything that would help you to feel safer while we talk? So these kind of get to the place of the establishing
that initial safety or establishing whether or not it’s there at all. So and then one
other thing you can do is if this is a safety check, check in by phone, remind the individual
he or she is free to hang up at any point during the conversation, if they feel somebody
may be listening in. You can ask questions like how can we communicate if we get disconnected?
Would I be able to call you back or leave a message, right? Because obviously the safety
concern is there. If someone comes on the line what would you like for me to do? Hang
up, identify myself as a person or a friend? Are you in a safe place, can you tell me where
you are? Are you injured? Would you like me to call 911? These are all questions that
can really kind of help with bringing in the safety. You know, and getting a solid understanding
of whether or not you can really go forward with asking any additional questions. So what
can the TVIT tool and questions help you with? They can help you with developing trust and
demonstrating respect. Also maintaining confidentiality and understanding
the effects of trauma and victimization, but also setting up the interview. So the questions
cover the following topics. First of all, personal background and demographics. Migration
in the United States and work and living conditions. This tool is available online for free. You
can download it. So it’s something that I definitely recommend looking into. There’s
a link at the bottom of this PowerPoint slide as well. Okay. This slide, what would you
do? Let’s start up here with what would you do if you see that the patient or client has
bruises on their face and arms, and an unusual tattoo or brand at the top of their breast?
Anybody want to put in a comment, answer that one? Okay, ask them if they are alone about
the injuries. Ask about them. I see several people typing. If the client is a minor, notify
child protection. I see another one, that’s an interesting tattoo, tell me about it. Yes.
Ask about the patient’s background and work toward inquiry about the tattoo in everyday
activities, yes, repeating what they say, finding common areas to identify victims,
yes, that’s right on par. Assure them you keep  you will keep their confidence, but
ask about their tattoos. Can you tell me about your tattoo, that’s great? And so what would you do or ask next? Let’s
say they answer you. I give you an answer that is suspicious, what would you do or ask
next? Yes, continue to ask followup questions. If they deny concern, circle back to questions
after building some more rapport. Absolutely. It’s an interesting one. How did you afford
your tattoo? Continue to maintain rapport, right. You know, if nothing else, if they
are not sharing anything else with you, keep building the rapport and asking questions
about them and trying to build the trust with them. Right. Okay. And what would you do if
she tries to leave the room in the middle of a meeting? Let her know that she can connect
with me whenever she is ready, right. Ask her not to but reassure her that she can always
come back. These are really important points because
it shows she can have an unconditional experience. She needs to go now but you will still be
there later. People in this kind of an environment are not used to being treated in an unconditional
way at all. So I think that will have a very a big effect on them to know that, to know
that this is unconditional, if she walks out there’s always an opportunity for her to come
back. So not going to ask the last one because we talked a lot about separation already.
I would like to finish up here, just with the section summary. This section was to focus
on applying traumainformed techniques and also building trust when you’re working with
potential victims. Also discuss conducting a safety check and using the trafficking victim
identification tool to assist with interviewing. And Makini is saying we’ll talk more about
it in response, also we’re going to talk a lot more about these types of things. I think
we’re going to break now. Leilani, are you there?>>Leilani Funaki:
Yep, and that’s right, we’re going to take another fiveminute break so we’ll be back
here at, oh, let’s do 3:37 eastern time. I’ll write that in the chat here, so fiveminute
break, we’ll be back to start again at 3:37 eastern time. Thank you. [Recess]>>Leilani Funaki:
We’re back from our break and we’re going to get started with respond, fourth and final
session, and Makini will handle that for us. I’ll turn it back over to her.>>Makini ChisolmStraker:
Awesome. I’m ready. I hope you’re back in your seats and had a good stretch. Respond,
what to do. We talked about what to do because asking questions is an action, separating
potential traffickers or victims, visitors from our patients, that’s an action. It is
a response. But what to do now when you think that this person might be trafficked, that’s
on your differential and it’s pretty high up there in your top two or three. Right now
we’re going to talk about referrals, like how do you refer someone locally. Using the
CLAs standards to provide appropriate care, culturally and linguistically appropriate
services. Defining the role of NGOs and governmental organizations in addressing trafficking. How
to apply SOAR to a real place study, we’ll go through one of those. We’re going to talk
about basic elements needed for response protocol meaning institutional protocol, not your individual
practitioner response. And we’ll talk about the qualities of advocate for human trafficking
awareness to work with management and peers, so taking what you’ve learned today, what
you will continue to learn, and how to work with management and peers, I can tell you
I’ve been in the antitrafficking field for 12, going on 13 years now, and there is always
more to learn about how to communicate and work effectively with your peers, because
you’re educating them about trafficking. Just because. Because you’re educating them, because you
have a patient, and that’s like when emotion can run a little bit high. So first, you guys
had some homework, you may or may not remember that. But we do this regularly, right? Excuse
me. Not just for patients who are trafficked, but for all of our clients because as we remember,
our patient or client is not just a patient or client, it’s not just what our skill set
is not their own set of needs. Their needs and identity is bigger than what we can provide
individually. What do we need to do to make successful referrals? And what additional
action should we take after we provide service or care for someone? So if you guys could
enter into the chat box and you can refer to the quote/unquote homework that you did
before, the prework that you did. What do you need for successful referral to take care
of patient or client, identify some of those needs, because the patient or client told
you and you recognize, what steps do you need to do next? So evidence, the person who wrote
evidence, can you say more about what you mean? Agency capacity. I think that’s referring
to the agency for which you work so that’s important, yes. Make sure the patient or client
is okay with the referral, yes, arguably one of the most important steps, the first step
to everything is that your patient is involved. Number one, because it’s your patient’s body,
your patient’s life, your patient’s choice. Number two, because if they are being victimized
in a way that is trafficking or exploitation or something you may be the first person in
a long time that has respected their autonomy and ability to make decisions for themselves. Number three, we have to understand that the
person sitting in front of us is the best and most informed about their life. What we
think might be a good idea might not be safe for that person. That’s really important.
If the person is not ready for the change, the change will never work. We all remember
that. Well, there’s so many comments in here. Check referrals regularly to make sure they
are still valid and accepting refers, that’s huge. How many times have you referred someone
and it got awkward when you realized, oh, they went out of business. They have moved.
I work at a community hospital, and it’s a community hospital, and so our EMR is not
always up to date. Sometimes I have to remember and ask the nurse, hey, did that doc retire?
I don’t want to refer them, doesn’t make you look good or trust they can come to you for
help. Background information, if it’s through the division of vocational rehab, connect
with support services, before I evaluate them as a psychologist, access to resources, always
do a handoff, so that’s important. If you’re going to make a referral for a need, for example,
for housing or substance abuse treatment, or dental services, whatever it is. You want
to make sure you have your patient or client’s permission, first. And I would talk about
how much that client or patient wants the other person to know. Right? If you’re referring
them for dental care, the dentist may not need to know they are a survivor of trafficking,
right? They may need to know these fillings are awful, horrific and need to be fixed,
versus if they need housing someone may need to know their trafficking situation because
safety becomes an issue then, right? And so you want to have the threeway handoff where
you can introduce the clients to the person or the agency. So those are some really good
points. Thank you all for bringing all of those up.
There’s so much more, of course, right? If the patient or the client allows, it is very
helpful, extremely helpful, to talk to the national human trafficking resource center
for assistance and referrals. There are a few reasons I do this. Number one is that 
I live in New York City. I know most of the resources that are available to me. Sometimes
someone needs something that I’m not 100percent sure exactly how they can get that. That’s
one great way for me to find out pretty quickly and pretty specifically. Number two, you can
have them speak are a survivor who has been there. I’m not a survivor of trafficking and
can never say to someone who I think might be a survivor, I know what you’re going through.
While it’s important for, as Elisabeth talked about, share what you’re comfortable share
and what’s safe and appropriate to share, it’s also important to not lie, right? I don’t
know what they are going through. I have ideas, I might be able to imagine, I might have served
patients and have friends and family that know but that’s not the same thing. For them
to be able to talk to someone on the other side now can be extremely important. It’s
also really valuable because you can do quote/unquote anonymous reports. They don’t have to give
their name or anything like that to get information. After identifying someone or thinking, you
know, suspecting there’s trafficking because, again, we’re not making the final determination
as clinicians, we want to make sure that if someone’s ready to leave their circumstances
we have a plan for their basic emergency needs, right? Like everyone needs to be able to eat
and have shelter and a safe place to stay, if they have medical needs, safety and security
is accounted for. As well as if, for example, they are a parent or older sibling, they are
responsible for someone else, they are not going to go unless they have a plan for that
person too. They may need legal assistance down the line, something else to keep in mind.
And then national human resource traffic center can be helpful with these things. HIPPA, people
get concerned when they are reporting or giving a tip to the resource center, they are worried
about HIPAA. Again, you don’t need to give anyone’s name, date of birth, nobody is looking
for a sosh. The most useful thing would be for you to say what you’re concerned about,
right? You have to say we’re worried about this trafficking, for example. But it’s really
important to remember that HIPAA is made to protect your patient. And if your patient
gives you the permission to disclose, you’re not violating HIPAA. Okay? We’re trying to
protect our patient’s privacy and their safety, but if they give you permission, you can do
that. So there are also times in which protecting someone’s safety overrides HIPPA. There are times when we are required to report
by law, as mandated reporters. Reports of child abuse and neglect, child maltreatment,
human trafficking does not fall into the realm of child maltreatment in every state and so
it’s important to know your state laws. I can share if there’s some time at the end,
I can try to find a link to an article that came out on U.S. laws, pretty comprehensive,
mandated reporting about trafficking. But it’s important to remember that that’s going
to be out of date like all the time, every year, because laws keep changing because the
law, legislation, is finally starting to catch up with what we know in public health, right?
But you may also have to disclose or report by law because, for example, again in New
York if a patient comes in with a gunshot wound, I have to report that. An injury by
stabbing, I have to report that. When and how I do it, I can finesse a little,
but I’m not trying to lose my license, right? And that is the law. The law is also there
not just to protect my patient but to protect the safety of others as well. So if your patient
agrees to disclosures, that becomes a little bit I guess easier for us, but honesty is
really important for us to try to be up front with patients and clients so we know where
they are ready as well for the reporting to happen. In the event of an emergency, and
I know I work in the emergency department, most things in there are not emergencies,
but like a lifethreatening emergency you’re worried about the safety of your staff, your
patient, yourself, or your patient asks you to call, again, HIPAA does not apply when
all of those things are happening. So it may be that I say I need police right now because
we need help right now. HIPAA is ultimately going to be validated because that patient
might still be there when the police show up, but if I’m worried that, you know, someone
is physically endangering my staff at the clinic where I am, I’m not going to  I
don’t know krav maga, I’m not taking anyone down. We need help so it’s important to remember
that. We talked a little bit already about mandated reporting requirements but what do
you do when you are a mandated reporter and a 14yearold comes in and you, from what you’re
understanding, they are being forced into a labor trafficking situation. And they say 
you call the police, I’m leaving, what are you going to do? Or you have an adult, right,
that comes in with a gunshot wound, a few E.D. folks here, they don’t want you to call
the police, what are you going to do in these circumstances? Oh, you can type into the chat
box, sorry. Don’t talk out loud. I can’t hear you. While you’re typing, there’s a comment
here, do you have any questions, do you have any tips on provider safety, safely and sharing
your contact info? So if you’re sharing with the national human trafficking resource center
I comfortable doing that. If I’m sharing with a patient, I have business cards that
are my trafficking work business cards, and I have my business cards for work. I will give them my health care card, if they
say they are comfortable with that, and on it, if they are not ready to leave the situation,
I will write the phone number to the national human trafficking resource center, the hotline
and tell them what the number is, are you comfortable taking this card so if someone
finds it, it looks like, oh, call the hospital for your results or whatever. That’s one way
to do it. Sorry, I want to get some responses. You’re in this situation, mandated reporter,
it’s getting awkward. Wait, going too fast. You could call someone else while explaining
the logic, so it’s really important to explain why you’re doing what you’re doing. Mandated
to call cps, after they leave. My first job is the care of the patient. Right?
In front of me. If they can’t stay, I can’t make them. It doesn’t matter how old they
are. I will tell my patients the truth. I’ll say, look, I have to make this call. Where
are you on the readiness scale? We have a conversation. If they are not ready, I say,
okay, look, I don’t get paid extra to make this hard on you. I’m here to provide care.
Here is what we’ll do. We’ll do what you need. And many people are being discharged, I’ll
make the call after you go. It can be difficult, it’s really hard, to swallow, especially when
it’s a child. When it’s a minor. That can get quite difficult. But if they are going
to just walk out, you can’t physically restrain them. I call the officer trained specifically
for the cases, not nine one one, get to know your contact, that’s really important because
not everyone is trained in a traumainformed way that Elisabeth wonderfully talked about,
especially outside held care settings and behavioral health and social work settings.
Most people have no idea what traumainformed care is. And law enforcement is unfortunately
not  they are not all trained on this, right? Most of them are not. So I want to make sure
I get the person that knows what they are doing. My first call, I work at an institution,
is social work, is they know more folks than I do, they know all the changes that have
happened, they make this call all the time. And they can help me navigate. I think it’s
really important that it’s a team effort. It shouldn’t just be you trying to figure
all of this out. That’s really important. It does get complicated. And do you have to
sort of do some finagling sometimes to make it work. Also really important to making it work is
making sure you’re meeting or patient or client where they are. That might mean meeting them
in the language of Russian or meeting them in the language of Korean. I don’t speak those
languages so I have to use an interpreter. They can’t reach  nothing I tell them, nothing
I can offer them, can be  is accessible to them if they don’t know what I’m saying.
You also want to be respectful of their beliefs and what they hold important, right? So for
some people, it’s not  the individual is not important, for example. From where they
are from, the community that they are from, the family that they are from, the collective
is more important. What’s better for the safety and the wellbeing of your family? For them,
it might be, I’m suffering, yes, bad things are happening to me, but I think this is better
for my family for XYZ reasons. You have to meet them where they are and try to help them
figure out how to best navigate their situation so their family is safe and getting what they
need, as much as possible. Questions, do most institutions have a plan set in place when
trafficking is suspected? No. Most do not. But you will be the one to do that. That is
why we’re so glad you guys are on this call today. Most places don’t. Part of the reason
is we need a champion which we’re going to talk about. But getting a protocol put in
place is  it’s not an easy lift but not impossible with the right stakeholders being engaged.
This is the number to the National Human Trafficking Resource Center (1 (888) 373-7888). I want
to make sure everyone has that. It’s something that the U.S. way that we break
up the phone number is the first three and the four. I always remember one triple 8,
37, 37, triple 8, triple 8. It’s important to remember how ever you can. You can also
check them out online. They have lots of information. They have tips on how to report to trained
law enforcement, they also have technical assistance and training, and information about
data and statistics where you are. Importantly these are statistics that are essentially
convenient samples, not, you know, random sampling, this is not representative. This
is who has called them. So if you think about it, right, 63 to 65percent
of rapes, for example, are not reported according to FBI, the FBI report in I think 2013 or
something like that. So a lot of people are not going to come forward because they don’t
know they are victims, they are ashamed, for all the reasons we talked about. It’s going
to be biased sampling but more than to have a general idea to help with protocol with
the buyin, we’re the fourth most common state, I’m in Ohio, that’s the state with the fourth
most common number of calls to the trafficking center, right? So really important that you
know that phone number in your heart and by heart. Oh, and someone lives in Ohio. They
have coalitions that create protocols for the community, is that common in other states?
I wish that it was. That you can be a model, Ohio. So we’re getting a little close to the
end, I want to make sure we have time for lots more questions so let’s do this one more
group exercise. We’re going to go through the case, we’re going to go through a case,
and we’re going to go through SOAR and we’re going to talk about common risk factors, indicators,
what we’re going to ask, what sort of victimcentered techniques and what we’re going to do. Should
I pass to Leilani for a second?>>Leilani Funaki:
Yeah, I’m ready with this. So for the last case study it’s in the files download area
if you want a copy to read as I share this with you. This is for Barbara. I grew up in
a suburb in northern Virginia, molested at my home for the first time by my father when
I was 8yearold old, running away at 12 to get away. Police always brought me back and
my parents didn’t seem to know what to do with me. I spent time in the detention center,
reform schools, in hospital centers for children with problems. My mother was in complete denial.
I tried to tell her once what was happening but she couldn’t believe me or she didn’t
want to. They put me into the juvenile justice system and child welfare system. Eventually
my parents’ rights were taken away, I kept running away to Washington, D.C. and before
long people noticed me. One day a woman picked me up, I was around 13. She took me back to
her apartment and told me I could stay with her and began to groom me for prostitution.
She told me the man in her apartment was her boyfriend, now I believe he was a trafficker. When I was 14 they told me to Moses, another
pimp, vicious around smart with money women under his control, sold me to anyone and everyone.
He had a quota, hard to make, if I didn’t make it he would take out a wire coat hanger
and whip me. I did whatever he wanted me to do for fear he would beat me again. I walked
the tracks around certain hotels, arrested many times, but pimp never bailed me out.
He didn’t want to spend the money. I would sit in jail until they let me out. Around
that time I also started using drugs that were given to me. At first I used them to
numb the pain but quickly became addicted to heroin. With all the beatings, violence
and abuse I became tough, but somewhere inside me I was able to protect a small little place,
a place that loves life, loves animals, and years later when I was helped to leave the
life, I told someone what happened to me and she couldn’t believe it. She kept saying,
you don’t seem like all that happened to you. The emergency department was my doctor during
the years I was on the street. Even though I was obviously a minor during the first years,
no one asked me what happened to me or what was wrong. Ultimately, one caring person in
the drug rehab center realized there was something more going on. Saw I needed help and asked
questions and found me services for what happened to me. It wasn’t until years later I understood
I was a trafficking victim.>>Female Speaker:
Thanks, Leilani.>>Female Speaker:
[affirmative]>>Makini Chisolm-Straker:
I’m going to move the slides back for a second so everyone can see what we’re going
to try to do in the next few minutes. You have all that back story, but where I want
you to focus is on the methadone clinic, where we are right now, drug rehab center, Barbara
comes every day, five AM, stands in line to get her methadone. And that’s where we’re
working right now. What are some of the risk factors that Barbara in talking to her a little
bit you hear her story, what are the risk factors for trafficking are you recognizing?
You can put your answers in the chat box. History of substance abuse, your first slide,
you’re at the methadone clinic. Good. Prior abuse, frequent runaway, child abuse, juvenile
justice system. Using the drugs to suppress something. We all use substances for something.
There’s a reason behind it, so what is that reason in previous history of neglect. Oh, methadone, so someone has a question,
what is methadone? For folks with an opioid use disorder, they can be put on methadone,
a longacting opioid that doesn’t really provide the high per se but keeps people from experiencing
the withdrawals, which is why people keep using, right, because of the physical dependence
in addition to everything else. And so there are  it’s a legal drug when it’s prescribed
by certain providers, only certain providers can provide methadone. Other risk factors,
sexual assault in the home, living on the streets. Good. Okay. So what are the physical
and mental indicators of trafficking in this scenario? Again, you’re at the drug rehab
center and you’re hearing Barbara’s story. What are some of the signs? Some of you mentioned
a lot of stuff already. History of running away. Using methadone to numb herself, so
using a drug to numb yourself is a good mental indicator, indicator of sort of a mental illness
of substance abuse disorder. Physical injuries, yeah, if you’re hearing her story you’re going
to suspect she’s got some old injuries existing. How would you apply victimcentered interview
techniques to this case? So you’re at rehab. And so you take an extra interest in someone.
How did you get her to tell her story? What did you ask her? What brings you here? That’s
a really good question because I think the first obvious answer they are going to say
is methadone, but that’s a deeper question too. Why are you here? Why do you need methadone?
Tell me about your journey? That’s another really nonjudgmental valueless
sort of way of asking what’s going on in your life without making it seems like what’s wrong
with you, right? Another way to rephrase that is what brings you here today or what happened
to you? Not what’s wrong are you, right? Where are you from? I like that question. Hey, tell
me your story. Not, you know, it’s not so accusatory. To what service providers would
you refer Barbara? She didn’t even know she was a survivor of trafficking. She didn’t
even know that term, right? She learned that years after it happened. What service providers
would you refer her to now? Oh, someone while you’re typing someone else said let
her know you believe her. That’s really important. In some ways I think people want to be complimentary
and say you don’t seem like that happened to you, meaning you don’t seem broken and
hopeless. At the same time it implies I don’t believe
what you’re saying, these things sound horrible and you seem fine, so it’s really important
to thank people for sharing and trusting you with their story, but also let them know that
you  now that you know, you know this happened, this is not as extreme as, you know, the movies
would have us make it. So some folks would say I’d refer her to a traumainformed therapist.
A physical checkup, mental health counseling, sequelae of trafficking can continue for years,
primary care physician, peer support, yes. It’s so good  we all have experienced something
and there’s nothing like talking to someone else. It’s a shorthand you can have with that
person you can’t have with someone else. They have been there so they know where you’re
going. Great, you’ve done great. Stick with me a little bit longer. You’ve had some really
good questions about protocols, I want to get you on the path. Protocols can be a little
bit of a heavy lift. They are not built in a week. They are not built in a month. You’re
going to have to teach people about trafficking. Kind of like you’re getting sort of a quick
oneonone today. What do they do when they identify it, how to talk to folks. What’s
a good plan for when people are ready to leave and when they are not ready to leave? Mandatory
reporting, really important is the referral process because, again, we can’t solve everyone’s
problems from the one place where we’re standing. They are going to need so much more. It takes a community and village to raise
a child, right? It’s going to take a communities and village to support people who have been
victimized. And followup or followthrough procedures, really importantly I know this
because I work in the emergency department, and I never want to see someone again, right?
My goal is that you never have another emergency in life. But that doesn’t mean you don’t still
need help, so I always have to have a followup plan for someone. Sometimes when I can’t make
a followup plan I have to admit them to the hospital. So it’s really important for us
to have a followup plan for this protocol process, and I would remind us all as well
that something that’s not on this bullet point, on this slide, a bullet missing is that we
need to constantly  someone said check on the referrals and check on the protocol and
make sure the process is working. It might be that things changed or something
just doesn’t work here, we thought it would. There are protocols in place so please don’t
reinvent the wheel. That’s so much work, and it might not work. There’s no reason to learn
through failures what others already are that failure for you. Lots of protocols are already
in existence, and there’s websites you can check out that will be able to guide you quite
a bit on developing your protocol. Really importantly, you need buyin from not just,
you know, your colleagues and your peers but the people with the power. So if you’re not
on this list, I’m not on this list, then you have to kind of get the ear of the people
on this list and get the buyin of them. So if you’re at an NGO, for example, you want
your executive director on board. If you’re working in an emergency department or a hospital,
you need a hospital administrator, nursing director, recognizing not just one of these
people, all of these people, because again it’s the protocol not just one person solving,
you know, the problems of many. It’s all of us working together as a team that are going
to come together and do this. So I do still want to leave time for some questions. So
just a really quick summary, strong advocacy for people, victimized by trafficking, begins,
just begins, by using the SOAR, stop, ask, respond, and act, to encourage a comprehensive
adoption of awareness with all people who work at your site. So not just your nurses,
not just your physician assistants, not just your social workers, not just you, but think
about your housekeeping staff and your TCA and techs, and receptionist or clerk who greets
people, are they greeting people in a traumainformed way, not what’s wrong with you but what brings
you in, what happened to you? Make sure you know your local referral network
because you have to call for help. Networks vary by region as local knowledge but these
are your greatest assets in getting someone the care they need. Quick story, a couple
weeks ago I had a colleague email me really quick, hey, we have a case of a young girl
we think is being trafficked, she wants out but has nowhere to go, what can we do. They
forgot maybe I put a list of resources in the electronic medical records system, they
had to click on a box. I said hey, I’m across the street, I’ll come over. The fact my
colleagues felt comfortable enough to ask me, you know, like that referral process is
an informal one but just knowing someone I was then able to talk to social work and say,
hey, call soandso because I know them there, tell them I sent you. It makes all the difference.
Things go a little bit faster sometimes if you make connections before you need to use
them. Nongovernmental agencies, social services, we have to work together in order to serve
people who are victimized by trafficking or anything else, social determinants are not
whether or not you have access to your insulin, that’s not the first determinant. The first is where you were born and who raised
you, and what access you had to what things you needed, and those all come in with law
enforcement and NGOs and social work, et cetera. And then it’s really important to identify
the elements needed for the development of protocols before you try to build a protocol.
And knowing who the appropriate advocates with authority are, so you got to have friends
in high places. Or make those friends, in order to make sure your protocols are not
just developed but implemented, monitored, evaluated, reassessed, and then revised, as
needed. So that being said, hopefully you feel comfortable that by the end of today,
maybe you’re not an expert, but you can describe the times of trafficking in the united states,
labor and sex, and pick a field and it should fall into one of those. Recognize some indicators
of trafficking, demonstrate how to identify and respond to potential trafficking victims,
and respond to trafficking victims and respond appropriately in your community, share the
importance of being aware, share your awareness with others in your work environment because
we are trying to make this exponential as you can see, pay it forward by telling others.
So right now our last pulse check, how many of you feel like you could recognize someone
who might be victimized by trafficking if they walked into your clinic, your office,
your NGOs, your hospital, your E.D. today? Oh, a lot of you are filling out  all of
you feel like you could identify someone. Many of you recognize that you have encountered
someone so over 70percent. All of you are going to tell somebody, and that’s really
the most beautiful thing. You’re going to tell somebody. Let’s see. Are there any questions
that I didn’t answer, Leilani, or that  I don’t want to scroll too far and get lost?>>Leilani Funaki:
We did have one question that was asking if brands on women, are they typically above
the breast, is that the same for males, referring back to talking about tattooing, that sort
of thing.>>Makini Chisolm-Straker:
Thank you. Brands are not typically anywhere. They are typically anywhere they want the
the trafficker wants them to be. Some places I think it’s fair to say are sort of  people
will tell you are common are the back of someone’s neck, in the axilla, armpit region, on the 
like the rib cage area. I’ve also seen tattoos in the inner thigh, on the inside of someone’s
wrist. Depending what they are, they are sort of discreet, like they are not totally obvious,
even if they are like on someone’s wrist, that they are a brand. It just seems like
any other joe schmo tattoo. The tattoos that are hidden on  I find them when I’m doing
a physical exam, for example, someone comes in, maybe a pelvic exam, I find them that
way, or if I’m listening to their lungs because they come in with a cough, I might
find them that way. They have to take off their shirt or whatever, zip their zippered
hoodie for the chest xray so there’s nothing typical and again tattoos are really not that
common. But they are concerning when you find them. So some folks are typing in where they
also see them, on the next with gangs, upper thigh, behind the ear are common. Looks like
other folks are typing. Any other questions? I don’t want to take up all your time. I understand
immediate intervention would be the most necessary when identifying victims, what are the longterm
modalities, PTSD, that’s a big question when we’re out of time. Yes, longterm needs are
poorly resourced, I mean shortterm needs, so are longterm. I would suggest lots more
reading. There’s a textbook to get you started on references. Leilani, let me know what I
can and can’t  if I can put that in the email chat maybe.>>Leilani Funaki:
Yeah, certainly. We can also send out any resources you have as an email followup after.>>Makini Chisolm-Straker:
That would be the easiest. Again, I don’t want to talk too much out of turn because
I’m not a longterm health care provider, right? So I can’t tell you all the modalities,
but I can suggest some reading. What path would you  oh, wait. I’m sorry, I want to
scroll up a little.>>Elisabeth Corey:
Makini, it’s Elisabeth. I wanted to throw out there that one of the modalities that
I have found most helpful with my clients is something known as interfamily systems
work, and it’s really a powerful technique. It is something that people need to be certified
in using, but it really does help when you’ve got clients who are significantly dissociative
after a significantly long period of complex trauma.>>Makini Chisolm-Straker:
Thank you, Elisabeth. You’re definitely more qualified to talk about it than I am. So someone
asked how we can get  what path I would encourage if you’re interested in epidemiology at public
health, well, we’re numbers, data. We’re an evidencebased driven field. So learn lots
and then where you realize you can’t learn more because no one has asked that question,
research. Because we need research and evidence in order to provide highquality effective
and efficient care. Is there human trafficking continuing education mandatory for E.D. physicians?
Not yet. Not all over the U.S. In New York, Governor Cuomo made it required but at this
point there’s no teeth because there’s no money and there’s no  it’s not tied to anything.
For example, in other words to maintain my license I have to recertify my knowledge about
child maltreatment every however many years it is. I don’t have to do that for trafficking
yet. We’re getting there. It would be very helpful if you’re interested and affiliated
with a professional organization, government doesn’t make nearly as much change as quickly
as your professional organization. So you are with the American public health association,
or the American nursing association, or American academy  anything, really, that’s where to
start getting your policy statements written, just because those it’s a faster machine than
a larger governmental machine which takes more time. If the government is going to make
a role they have to find a way to enforce it. Your licensing body can say you’re no
longer licensed if you don’t get XYZ. I’m going to turn it over to Leilani. We could
talk forever about this. Thank you all so much.>>Leilani Funaki:
Thank you, Makini. So we want to thank all of you for attending today’s training. I know
this is a topic that there’s a lot of questions you have about it, a lot more information
you’d like to receive. Once more, I posted a few times that NHTTAC offers free assistance,
we’re here and available if you need additional help for like customized training for your
organizations, if you want to know more about what you can specifically do in your field,
to address human trafficking, please do reach out to us. Our website is there in the chat
box (https://www.acf.hhs.gov/otip/training/nhttac). Email ([email protected]) us, you can give us
is a call (844-648-8822). Once again, we offer free customized training and technical assistance
that way. The second piece of information that you need to be aware of is that we’ll
be sending you an evaluation link right after this webinar, if you want to earn continuing
education credits you do need to complete that evaluation. You’ll have a week to do it so we’ll send
you the email this afternoon and you’ll need to have that completed by March 30th in order
to earn any kind of continuing education credits for today’s webinar. We’re grateful you attended
the training. Hopefully it was helpful to you and you’re able to take this information
and implement it back into your organizations. If you have any questions, please do email
us at [email protected] org. Again, you can look at our website (https://www.acf.hhs.gov/otip/training/nhttac),
give us a phone call (844-648-8822), we’re here, and we are more than happy to answer
your questions. Thank you. [end of transcript]

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