Between Poverty and Trauma – A Shelter Management Manual for Migrant and Trafficked Women and Girls

BETWEEN

POVERTY & TRAUMA

A shelter management manual for migrant and trafficked women and girls and the reintegration of trafficked survivors

BETWEEN

POVERTY & TRAUMA A shelter management manual for migrant and trafficked women and girls and the reintegration of trafficked survivors

This is a project by The Strategic Initiative for Women in the Horn of Africa (SIHA Network) in collaboration with the Good Samaritan Association.

Compiled by: Abebaw Minaye (PhD) School of Psychology Addis Ababa University

Illustrations by Mwesigwa Bhengie Design & Print by Revolve Tack Ltd

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TABLE OF CONTENTS Preface Principles in Using the Manual

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SESSION 1: INTRODUCTION 1.1. Experiences during trafficking and

Post return 1.2. Services returnees need 1.3 Screening and assessment guide

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SESSION 2: PHASES IN SUPPORTING VOTS SESSION 3: GENERAL CARE PROVISION PROCEDURES IN SHELTERS 3.1. General services 3.2. Service philosophy 3.3. Security and safety assessment 3.4. Harm reduction 3.5. Ethical considerations in the general

Care work SESSION 4: VICTIMS CASE MANAGEMENT 4.1. Concept of case management 4.2. Generic skills 4.3. Case work practice skills 4.4. Smart practices guides for

Responsible case management 4.5. Ethical principles in case

Management SESSION 5: ETHICS AND CODES OF CONDUCT IN SHELTER SERVICES 5.1. Introduction 5.2. Codes of conduct in assessment and intervention 5.3. Codes of conduct in client treatment, institutional policy and professional behavior

2 6 7 10

15 16 17 18 21 22 24 25 26 27 31 32

36 37 39

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SESSION 6: MEDICAL AND PSYCHIATRIC CARE 5.1. Physical health problems 6.2. Mental health problems 6.2.1. Types of mental illnesses and

Possible medical and

Psychological treatments

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SESSION 7: COUNSELLING AND PSYCHOSOCIAL ASSISTANCE 57 7.1. Conception and objectives of counseling 58 SESSION 8: RECREATIONAL ACTIVITIES FOR VICTIMS SESSION 9: BASIC SKILLS TRAINING 9.1. Life skills training 9.2. Business skills planning 9.2.1. Entrepreneurship 9.2.2. Starting and improving one’s

Business (siyb) 9.3. Employment opportunities 9.3.1. Proper use of resources and financial education

66 70 71 75 75 76 80 81

SESSION 10: SUPERVISION, MONITORING AND FOLLOW-UP 86 10.1. Concept and role of supervision 87 10.2. Creating a productive workplace culture 88 10.3. Standard supervisory tasks 89 10.4. Styles of supervision 90 10.5. Monitoring and follow-up 92 SESSION 11: SELF-CARE FOR STAFF 11.1. Burnout 11.2. Burnout self-exam 11.3. Practicing self-care to reduce

Burnout

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95 96 97 98

FOREWORD This manual has been developed by SIHA to respond to the growing needs within the Horn of Africa to establish shelters for women and girls whose lives and well-being are at risk. The manual is also inspired by the experiences of women and girl domestic workers and migrant domestic workers and women who have been victimized due to their poor employment conditions and further victimized by the societal and cultural stigma leading to them becoming traumatized and struggling with poor mental health and stigma. Additionally, this manual will serve women survivors of sexual violence and women whose existence is threatened by social norms and religious fundamentalism.

The production of this manual would not have been possible without the support and collaboration of Good Samaritan Association (GSA), an organization that runs a women’s shelter considered to be one of the leading shelters in Addis Ababa, Ethiopia. The GSA Shelter mostly focuses on the provision of support to women survivors of trafficking and women domestic worker returnees to Ethiopia who would have previously migrated to the Arab and Middle-Eastern countries to seek employment and provide support for their families. Majority of these women experience severe torture and abuse by their employers and return to their homes with serious mental health issues and trauma.

The hazards around the domestic work are largely due to the fact that the work occurs within private and isolated spheres. The households in the Gulf countries are highly isolated territories; leaving the workers extremely vulnerable to all forms of abuse. The challenges in and around the human rights violations and abuses perpetrated against migrant women domestic workers from Africa have several layers including their race, gender and area of work.

As SIHA, we hope that women organizations and government agencies working with women and girls across the region will benefit from this publication and will consider the importance of women’s temporary shelters as a critical establishment to support masses of poor women subjected to torture and violence due to their employment and /or social and economic conditions. Having a shelter in addition to psycho-social support services will aid women in regaining their self-esteem, and heal and reclaim back their ability to function within society. This manual shows the importance of considering the impact of discrimination, repression and abuse on the mental health of women particularly poor and marginalized women and girls who perform marginal jobs and, migrant women and girls who are more subjected to torture and abuse and very much in need of safe spaces to regain their mental health.

Hala Alkarib Regional Director – SIHA Network

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PREFACE There are different methods that may be used to provide support to victims of trafficking (VOT).

Examples include repatriation of victims, returning victims to their original place and re-unifying them with family when available, referring them to service-giving organizations, connecting them to law enforcers and others. One other method of providing support to VOT is preparing a shelter to accommodate beneficiaries and provide them the required services. When providing a shelterbased service, the management of the facility is a critical issue. Shelters provide various services such as basic accommodation (food, bed, clothes, sanitation‌etc.), health (within the shelter and outside the shelter), psychosocial services (counseling and therapeutic services including life skills training), economic services (entrepreneurship training, short term skill training for specific jobs, searching for employment possibilities, providing grants for small business, and financial education) and social services (reunification with family and referral to social service organizations like woreda social affairs or women and youth affairs bureaus).

A competent shelter service requires a clear idea of how to manage the shelter in a coordinated fashion. Central to the shelter management process is having staff members who clearly understand their own role, the objective of the shelter, their clients’ needs and the concept of shelter management, in general. The very purpose of this curriculum material is to build the capacity of staff working in shelters and to empower them with the diverse components of shelter service and knowledge of how to provide the services. This curriculum material is meant to guide the training of GSA’s shelter staff on how to provide its clients with a complete and coordinated shelter service from admission to reintegration and even post reintegration follow-up.

Dear Shelter worker,

You are a person engaged in assisting victims of trafficking.

This material has been developed to help you support the recovery, rehabilitation and reintegration of VOT at Good Samaritan Association (GSA). GSA has developed an operational manual that sets its standard of provision with regard to accommodation, medical, psychosocial, and life skills trainings for its clients. This module has ten sections beginning with an introduction of the services you will provide at GSA and ending with the follow-up you will conduct once the rehabilitated women are reintegrated into their communities.

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General Objectives of the Curriculum Material After going through this curriculum material, you will be able to: 1. Identify the criterion used to assess trafficking cases 2. Articulate the needs of trafficking victims at each phase in the reintegration process 3. Explain the general care procedures in assisting victims 4. Apply the suggestions in case management for optimal service for VOT reintegration 5. Describe the possible medical and psychiatric problems victims of trafficking face 6. Provide proper counseling for VOT 7. Appreciate the role of recreational activities in the rehabilitation of VOT 8. Discuss the basic skills VOT need for better adjustment during the reintegration phase 9. Adhere to the ethical principles in providing psychosocial support for victims 10. During shelter supervision and post reintegration supervision, demonstrate skills for better follow-up procedures to ensure sustainable outcomes 11. Apply self-care measures to reduce burnout among psychosocial shelter workers

Dear Shelter worker,

I want to assure you that if you thoroughly go through the contents of this curriculum material, you will enhance your understanding about the various components of care provision for VOT. This, in turn, will help you provide professional support that will make a viable contribution in healing the cognitive, emotional and behavioral problems of VOT. This healing will promote wellbeing and will improve psychological, economic, and social functioning at the individual, family and community level.

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This curriculum material is prepared to: • Provide shelter staff with a high standard of training •

Help psychosocial care providers in their professional development by supplying them with resource materials for learning effective service provision for VOT

•

Assist shelter staff in improving their customer service skills

•

Improve service provision for shelter clients (VOT) by increasing individual staff member’s knowledge and skills

•

Ensure that shelter staff interact with clients at a high standard of dignity, safety, service quality and respect

•

Offer GSA a resource material that complements its shelter management efforts

Principles in Using the Manual

Dear Shelter worker,

If you want to benefit the most from this material, it is imperative that you reflect on the questions presented throughout the document. The most important way to make this material relevant is by relating the experiences of the clients with whom you are presently dealing with those you have already integrated. Think of your clients who have successfully reintegrated and also those who still have lingering problems with reintegration. The key principles of this training material are: Participation, appropriateness, relevance, respectfulness, and behavioral orientation. In each section, check to see if the contents, exercises and examples fit with the activities you are doing to empower your clients and give them the best service

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possible.  

Session 1: Introduction

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SESSION OBJECTIVE Dear Shelter worker, After successfully completing this session you, will be able to: • • • •

Recognize the key indicators for identifying VOT Understand both the physical and mental health implications associated with victims of trafficking Recognize the psychological responses that VOT display which relate to their traumatic experience List the services that VOT need upon return and throughout the reintegration process

1.1. Experiences during trafficking and post return Pre-session Question Dear Shelter worker, 1. What do you think are the problems that trafficking victims face during trafficking?

2. What are their reactions to the problems faced?

3. What are some of the experiences they have?

4. What do you think are the critical needs they have?

Experiences during Trafficking After painstaking discussions, the UN Palermo Protocol to Prevent, Suppress and Punish Trafficking in Persons Especially Women and Children (2000) defined trafficking as follows: Trafficking in persons is the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion of abduction, of fraud, of deception, of the abuse of power of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person for the purpose of exploitation. Exploitation shall include, at a minimum the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs. The consent of a victim of trafficking in persons to the intended exploitation set forth above shall be irrelevant where any of the means set forth above have been used. (p.2)

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Dear Shelter worker,

Trafficking is a serious crime. Around the world, close to 45 million individuals live trafficked lives. Ethiopia has its fair share of cases. Many Ethiopians are trafficked to the Middle East, South Africa, Europe and neighboring African countries like Djibouti and the Sudan. Human trafficking has a devastating impact on the human rights of its victims. There are several international conventions and protocols against trafficking that Ethiopia has ratified.

Ethiopia has also enacted local anti-trafficking and anti-smuggling laws. All of them clearly state that trafficking is a criminal act tantamount to slavery and punishable by up to 20 years in prison. Unfortunately, trafficking laws are poorly enforced due to the complex nature of the problem and the poor capacity of policing bodies. Trafficking negatively affects the general health, physical wellbeing and psychological health of its victims.

The following are some examples of general health problems VOT may face: 1) Infectious diseases such as HIV/AIDS and parasites 2) Reproductive health problems 3) Injuries, scars, bruises or physical trauma from overwork or physical abuse in domestic settings 4) Effects of chemicals used for cleaning 5) Illness resulting from poor sanitation and/or contaminated food or water 6) Heat stroke or exhaustion 7) Musculoskeletal trauma from awkward posture, repetitive movement, and/or heavy lifting 8) Kidney and gastric infections related to overwork and working for long hours standing up

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Victims may exhibit the following physical symptoms: • • • • •

Aches and pains - headaches, backaches and stomach aches Sudden sweating and/or heart palpitations Changes in sleep patterns and appetite Greater susceptibility to colds and illnesses - weakened immune system Increased use of alcohol or drugs, and/or overeating

Some of the psychological symptoms victims typically exhibit include: • • • • • • • • • •

Shock and fear Disorientation, cognitive confusion and intrusive thoughts of the trauma Irritability and restlessness Nightmares and flashbacks of the events Attempts to avoid anything associated with trauma Tendency toward isolation and feelings of detachment Difficulty trusting and/or having feelings of betrayal Feelings of helplessness, panic and loss of control Diminished interest in everyday activities Loss of a sense of order or fairness in the world; expectations of doom and fear of the future

Trafficking survivors experience compounded stress related to acculturation, having to learn a new language, exposure to varying forms of religious or spiritual practices, new foods, different conceptualizations of family and community and their relationship with money. In fact, survivors’ experiences are multifaceted and hence, poly-victimization, also known as complex trauma, occurs.

Poly-victimization refers to the experience of multiple victimizations of different types, such as sexual abuse, physical abuse, confinement and salary denials. Research shows that the impact of poly-victimization is much more powerful than multiple events of a single type of victimization.

The types of physical and psychological abuse that human trafficking victims experience often lead to serious mental or emotional health consequences.

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Mental Health Issues Reported by Trafficking Survivors Depression, hopelessness, feelings of sadness and unhappiness, sudden or inexplicable crying Inability to plan for the future

Fear of being alone, fear of strangers and feelings of distrust

Sleeplessness, sleep disturbances and nightmares Stress-avoidance, anxiety, phobias and panic attacks

Feeling inferior to others and fear of rejection

Denial, memory loss, difficulty concentrating

Obsessions and compulsions

Anger, aggression, irritability, mood changes

Hallucinations or delusions

Changes in appetite or eating patterns, eating disorders Exhaustion and constant fatigue

Somatization/psychosomatic symptoms

Isolating behavior

Numbness

Alcohol, drug - substance abuse

Low self esteem

Recurrent or intrusive memories of abuse

Sexual problems, including lack of sexual desire or hyper sexuality

Self-harm and suicidal thoughts

Feelings of fear and insecurity

Post-return problems of VOT Victims are not free from the problems they have faced even after returning to their homes and communities. Among the main problems and difficulties that women VOT face upon their return are the following: • •

•

•

•

Lack of adequate clothing, appropriate accommodation and food Continued psycho-social effects from the trafficking experience o Trauma - depression, mistrust of self and others o Health/Medical problems - scars and other bodily trauma from physical harm Family and social reintegration problems o Breakdown of family relationships o Stigmatization o Rejection by families and communities o Feelings of shame Financial difficulties o Coming home empty-handed o Being in debt bondage o Inadequate savings Employment and skill related problems o Lack of local job opportunities and support to start and sustain a viable business o Lack of skills – for those below the age of 18, difficulties of returning to a normal school environment due to the interruption of studies Between Poverty and Trauma

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Legal issues o Not knowing how to file complaints against exploitation and abuse o Not knowing how to follow legal proceedings

1.2. Services Needed by Returnees Dear Shelter worker,

What do you think are some of the critical needs that returnees have? Please give examples by using cases on which you are currently working or cases you supported previously.

Once a trafficked person has exited an exploitative situation, they may require support to return and reintegrate into their community. Removal from an exploitative situation does not guarantee that the trafficked person’s trauma has ended. Understanding the experiences that they have endured is vital in developing a better framework to assist returnees to recover and decrease the likelihood of re-trafficking. The essential services that shelters provide can help trafficking victims recover and move toward reintegration into society. It is important to note that no two shelters are alike in terms of location, size, cost, length of stay and the population that the shelter serves.

Victims have the best chance of recovery when they are provided with interdisciplinary care in a secure environment. Sadly, there are very few facilities in Ethiopia that fit this description and capacity is limited. GSA is one of these few facilities in Ethiopia. At this juncture, it is essential to realize that some victims may decline assistance if their families are not supportive. Victims also may not understand the benefits of the services being offered to them. Declining to seek assistance may also be due to limited accessibility, distrust of service providers and a belief that assistance is inappropriate. On top of this, some victims may think that accepting assistance leads to stigmatization. Some trafficked people may not even consider themselves victims. So, it should not be assumed that all women who have been trafficked consider themselves victims, detest their captors, or wish to escape and go home. Many women are in ambiguous circumstances in which they may have contradictory and uncertain feelings. For example, some women may regard their experience as the consequence of a poor decision for which they are/were obliged to fulfill the terms of a contract. Some women may see their trafficking situation as only temporary, a situation in which they intend to earn enough money to pay off debt and support a family at home. Some women may not perceive their work setting as abusive. These complexities can make it hard to approach women, establish trust, gain their cooperation, acquire truthful responses, and to fully comprehend their decisions and actions. Having comprehensive curriculum material that helps to understand these challenges with regard to available services will greatly improve the competency of caregivers and the services they provide. If approached in a sensitive and nonjudgmental manner, many women benefit from having the opportunity to tell their story. If these women feel that they are respected and that their welfare is a priority of the shelter and of the psychosocial shelter workers, they will share accurate and intimate details of their experience.

The factors affecting the security and well-being of a woman who has been trafficked are also the same factors that affect disclosure.

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1.3. Screening and Assessment Guide

Proper screening and assessment plays a pivotal role when offering meaningful services to help rehabilitate any vulnerable group in a shelter. Effective and efficient service requires evidencebased practices. Services for VOT are not an exception. Having evidence enhances informed decision-making in service delivery. Case managers have to use sociological, psychological, legal, medical, and epidemiological factors to determine the characteristics of the problems in terms of economic, biological, legal, educational, philosophical, religious, and spiritual ramifications.

Dear Shelter worker,

What are the criteria you use to screen clients who come to GSA? Asking the right questions will help you determine if the person in front of you is a victim of trafficking and someone who needs your help.

Key Screening Questions • • • • • • • • • • • • • •

Can you leave your job or situation if you want?

Can you come and go as you please?

Have you been threatened when you try to leave?

Have you been physically harmed in any way?

What are your working or living conditions like?

Where do you sleep and eat?

Do you sleep in a bed, on a cot or on the floor?

Have you ever been deprived of food, water, sleep or medical care?

Are you being paid?

Do you have to ask permission to eat, sleep or go to the bathroom?

Are there locks on your doors and windows so that you cannot get out?

Has anyone threatened you or your family?

Has your identification or documentation been taken from you?

Is anyone forcing you to do anything that you do not want to do?

In your assessment questions, be aware of selected indicators like evidence of mental, physical or sexual abuse, physical exhaustion, heightened sense of fear or distrust, inability to or fear of making eye contact and inability to provide a local address or information about parents. Once these indicators are observed, you can use the list of criteria in the table below as a standard screening for someone who has suffered trafficking.

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S. N 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

A person is considered to be a victim of trafficking if he/she: Is made to work against his/her will Is unable to freely leave his/her work environment Is unfamiliar with the local language/culture where he/she is working Does not know his/her home or work address Is forced to work under inhumane conditions Has no or only partial access to his/her earnings Works excessively long hours over long periods without compensation - has no days off Is forced to live in crowded or substandard accommodations Has tried to escape but has been returned Has had the costs for transportation to the destination paid for by facilitators and must now repay these costs by working or providing services Shows signs that his/her movements are being controlled Is distrustful of the authorities or is threatened with being handed over to the authorities Is not in possession of his/her passport or other travel or identity documents because those documents are being held by someone else Has limited or no social interaction because he/she is restricted by someone Has limited or no contact with family or with people outside of his/her immediate environment Shows signs of injuries that appear to be the result of assault or sexual abuse. Further, it is revealed that such injuries are inflicted frequently.

Suffers injuries that appear to be the result of the application of control measures Is sick and has had no access to medical attention for a prolonged time Seems fearful and prefers others to speak on his/her behalf when addressed directly Acts as if he/she was instructed by someone as to what information to make available Shows fear or anxiety because of someone controlling him/her or forcing him/her to do something unwanted Is subjected to violence or threats of violence against family members or loved ones when he/she tries to leave the working situation Is under the perception that he/she is bonded by debt or cultural bondage (e.g. witchcraft bond).

Questions for Reflection

Dear Shelter worker, Are the criteria you are using at GSA similar to those listed above?

What is new in this list compared to the GSA criteria? What is missed in the above list that is included in the GSA criteria? Which of the above do you think do not work for Ethiopian trafficking cases?

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Session 2: Phases in Supporting VOT

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SESSION OBJECTIVES After completing this session, shelter staff that participated in the training will be able to: • • •

Discuss the major procedures in rehabilitation and reintegration Elaborate on the considerations before reintegration Explain the factors affecting successful reintegration

Pre-session Questions

Dear Shelter worker, What do you think about how best to support survivors of trafficking?

How do the needs of clients and type of support and activities you provide differ at the different phases? Can you give an example of a case in which a victim’s needs changed from the time of admission to the facility to the time of the post reintegration follow-up procedure?

The care work associated with survivors of trafficking is not a one-shot activity but rather it encompasses a spectrum of activities. The needs and activities of the victims differ greatly from the time of admission to the time of reintegration. The objectives of the support also differ at each stage. First, upon admission, the service and need is related to accommodation, food, clothing and shelter. Medical service is the next provision. Accommodation and medical support are central for recovery to begin. Secondly, victims need psychosocial support, mainly counseling and recreational activities. This contributes to rehabilitation. Rehabilitation requires that the victims learn life skills like communication, decision-making and problem solving. The third objective is reunification. For reunification to occur, survivors must develop entrepreneurial, IGA/vocational, financial and educational skills which will help with job placement. This leads to successful reintegration. Reintegration is the process by which a returning migrant is reintroduced into the ‘economic and social structure of their origin community to be self-sufficient and able to earn his/ her own livelihood’. Reintegration requires the socio-economic inclusion of trafficking survivors through access to a reasonable standard of living, opportunities for personal and economic development, and access to social and emotional support. Reintegration is complete when the returned person becomes an active member of the economic, cultural, civil and political life of a country. Reintegration will help VOT to reconnect with children, husbands, parents, relatives and neighbors. Beyond the physical act of returning, reintegration involves unification with the social environment. This is a long-term socio-economic solution to allow the VOT to be reinserted into society and have a normalized life minimizing the risks of re-traf¬ficking. Better reintegration helps the individual victims, their families and their local community. Reintegration requires follow-up that includes activities of supervision and field visits for sustainability of outcomes. Follow-up and aftercare are as important as reintegration assistance (Ezeilo 2009). So, recovery, rehabilitation, reintegration and sustainability are the major goals of the shelter service. These four goals finally make clients fully functional in their economic, social, and psychological life.

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Scholarly Summary of the Three Phases in Service Provision for Survivors 1.

2.

3.

Provision of basic service - This includes addressing basic health needs, housing, creating a secure environment, and family support in the form of mediation.

Assessment/recovery/education services - This includes psychological assessment, counseling, psychotherapy, life skills, formal or informal education, and community education.

Reintegration service - This includes family assessment, vocational training, seed grants, legal aid and follow-up visits.

Components of Reintegration Assistance There are six components of reintegration. The precise form each care component takes depends upon many things including the country/culture, organizational philosophy, priorities and resources.

1. Proper and safe housing - accommodation, food, clothing, and security 2. Preventing stigmatization - awareness and sensitization campaigns 3. Health/medical care 4. Psychological services - counseling for the client, family reconciliation efforts‌etc.

5. Social services - material and economic assistance, advocacy to link the client to whatever support networks already exist in the community, family relations 6. Job and education - skills training, entrepreneurship skills, assistance with job placement, financial literacy, formal schooling opportunity, literacy, life skills 7. Legal support and assistance

Dear Shelter worker,

Which of the above services are well delivered at GSA and which services at GSA require significant improvement?

Factors to consider before reintegration is undertaken: 1.

2.

3.

The best interest of the victim considering his/her age and sex Security situation, disability status, and medical condition of the victim Respect for the victim’s human rights and dignity throughout the process

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4.

5.

6.

7.

8.

Obtaining the victim’s informed consent before reintegration The cultural/religious values of the victim Developing an individualized reintegration plan for each victim Family tracing as well as family and community preparedness to receive the victim Availability of other service providers in the area that can assist the returned victim

Reintegration challenges include: • • • • • •

Failure to address predisposing conditions Family situation Social acceptance Physical health Lack of infrastructure Insufficient or inappropriate skills

Factors affecting successful reintegration: • • • • • • • • • •

Family and community environment Collaboration between institutions offering reintegration services for VOT Handling difficult cases Matching services with VOT needs Financial sustainability for shelters of VOT Education, professional training and employment of VOT Psycho-social counseling Financial support for VOT Medical services Legal assistance for VOT

The following flow chart demonstrates the steps to be followed in supporting victims from admission or opening of a victim’s file until their full reintegration and closure of a victim’s file.

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Chart 1: Flow Chart of the Entire Reintegration Process Victim case file

Individual and situational reintegration

Victim can return

Family/community preparation

Inform and prepare victim for return

Logistical arrangements including travel documentation, co operation with organizations at the destination, safety precautions, etc

Victim cannot return

Identify other options and inform the victim. These options include: • extended stay in the country/shelter; • Integration • reintegration • referral to appropriate service providers

Travel

Victim arrives home or to host community

Link VOT to locally available services

Follow-up and support

Closure of victim’s case file

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Session 3: General Care Provision Procedures in Shelters

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Dear Shelter worker,

This session provides you with relevant information concerning general care for survivors. General care includes: general services, service philosophy, core guides in practice, safety assessment and harm reduction.

Session objectives

Within the general framework of service provision in this section, you are expected to: 1. Demonstrate essential care procedures helpful in improving the quality of the client’s life from the time of emergence from the atrocious world of the trafficked life until reintegration 2. Know broader contextual issues that help survivors to recover, rehabilitate and reintegrate 3. Assist clients to start changing their self-perception so that they see themselves as survivors rather than victims. Help to restore the client’s sense of identity and move them from a state of depression and fear to a state of awareness of self and others 4. Support the clients in recognizing their own vulnerability as well as their own resiliency 5. Use basic harm reduction and safety procedures to reduce causalities

3.1. General Services Given the challenges that clients faced during trafficking and upon return, the general support services for trafficked victims should include the following activities: • • •

• • •

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As recovery s often a long process, continuous psychosocial counseling and health services are needed.

Provision of career counseling guidance in accordance with local labor market demand and individual returnee’s aspirations and potential.

Training on income generating activities so that returnees become self-sufficient and will avoid re-trafficking. This may include small-scale savings and credit schemes by setting up Self-Help Groups as well as vocational skills training and business skills. For those without primary school, non-formal education will be provided prior to vocational skills training.

Through networking and collaboration with employers’ groups, job placement services will be provided to successful graduates of vocational skills training. For those successful graduates who desire to set up their own small business, small grant seed money will be provided as appropriate.

Opportunities for clients to meet with others who have shared the same experiences. Strong peer networks will help with readjustment and reintegration.

Provision of legal assistance for filing complaints against exploitation and abuse.

Continuous provision of referral services based on information on the kinds of assistance available for returned migrants including training programs and employment services.

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Post Reading Question

Dear Shelter worker, What services are available at GSA? Are they similar to those listed above? What different services are obtainable at GSA? Dear Shelter worker, In fact, not every shelter provides all types of services directly. Many activities and services are arranged by the project’s network. Shelters often function as reception centers and offer individualized programs of social protection tailored to the needs of the women in the shelter. The following chart summarizes the services offered in shelters.

Chart 2 Direct Assistance Provided to VOT in Shelters Identified victim of trafficking

Needs assessment for direct assistance

Physical care • Shelter • Clothing • Food • Sanitary Pads, etc

Health care • Medical examination • Testing • Surgery • Medication • Reviews

Psychosocial support • Trauma therapy • General counselling

Legal assistance • Immigration services • Criminal investigation • Prosecution • Civil claim for damages

Other services • Life skills • Education • Vocational training

3.2. Service Philosophy Effective shelter services are guided by a service philosophy. Here are the guidelines: a. b.

Set forth a logical approach for how services, support, activities, and interventions will empower and meet the needs of service recipients.

Ensure that services are strengths-based, person or family-centered, culturally and linguistically sensitive, and trauma-informed.

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c.

Lead the development and implementation of program activities and individualized services based on the best available evidence of service effectiveness.

In addition to the above service philosophy, the following general core practices guide our responses to human trafficking survivors. ᴥ Create a safe space for communication ᴥ Establish rapport and trust ᴥ Identify precipitating problems ᴥ Help the client identify, cope with and express feelings ᴥ Respect differences and avoid assumptions ᴥ Help survivors explore their options and consequences of those options ᴥ Protect survivors’ confidentiality always ᴥ Provide affirmation and moral support ᴥ Support the survivor’s decisions

Reflection Questions

Dear Shelter worker, To what extent are the services at GSA guided by the abovementioned service philosophy? Are the above core practice guides followed at GSA? Is there something missing at GSA? If so, why is it missed?

There are four principle elements of care that you need to closely follow. They are: attentiveness, responsibility, competence, and responsiveness.

Attentiveness recognizes that the needs of others must be identified in order to care for them.

Responsibility is described as a personal sense of duty, separate from the sense of obligation imposed on individuals by society.

Competence is having the appropriate skills and knowledge base to provide support.

Responsiveness is stated as an acute recognition and commitment to provide care in instances of vulnerability and inequality. Responsiveness is like empathy with an action component, wherein caregivers can identify with the care receiver and duly respond.

3.3. Security and Safety Assessment Safety is of the utmost priority for any shelter. Due to the trauma they have experienced, VOT are often mental unstable and may harm themselves and shelter staff. Regular assessments are crucial to maintain a safe environment and to take corrective action after a critical incident. Results of periodic assessments must be shared with shelter staff and clients. Supervisors must orient new staff to safety and security procedures. Below are some sample security assessment issues that can be used by GSA to examine existing safety and security measures. These sample security

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assessments must be discussed by staff, both frontline and management, to ensure a safe shelter environment.

a.

Threat Potential

b.

Creation of Behavioral Contracts

c.

Clothing

It is vital to assess the overall threat potential of your clients. It is also absolutely essential to individually assess every client for the possibility of violence. As bench marks, you will need to review incident reports at GSA for the last two years to see how often violence or threats of violence occurred. If these reports are not available, consider developing a system to ensure that future reports are retained and accessible. The only reliable indicator of a client’s potential for violence is a history of violence. Check whether the violent incidents were verbal or physical in nature.

If a client’s behavior escalates to the point of verbal threats or physical violence, the shelter staff need to set firm limits that clearly define behaviors that will not be tolerated and that will lead to consequences such as discontinued services. As indicated in GSA’s operational manual, the rules must be handed to clients at sign-in and be posted in visible locations around the shelter. These rules serve as a behavioral contract between the client and GSA. The contract must be written with details of inappropriate behaviors that will result in clear and specific consequences. The client must sign this contract. For some clients, signing a contract at the time of admission might be difficult as their state of mind may be compromised by their trafficking ordeal.

Appropriate clothing can help reduce the risk of harm to shelter staff in an escalating or threatening situation. You should always be comfortable in your attire. You must be aware that some clothing can pose a personal risk when dealing with potentially dangerous clients in violent situations.

Check if there is anything that you wear that might cause you injury if attacked? Here is a checklist: ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ

d.

Earrings Can they be grabbed easily?

Ties\Scarves\Necklaces Are they choking hazards?

Glasses Can they attract clients to harm you?

Clothing Can you move comfortably and quickly?

Shoes Can you move quickly in them?

IDs and Laminated Badges If they are worn around the neck, they should be on break-

away chains or straps, otherwise, they can be used to choke the wearer.

Physical Surroundings

What are possible weapons in your work place? Is furniture arranged so that staff and clients have clear access to exits? Scissors and letter openers should be stored in desk drawers, not on top of desks. Chairs should be heavy enough to reduce the chance that they will be thrown. Coffee pots and full mugs should be placed out of client reach. When dealing with an agitated client, it is important to provide an easy exit. When you sit in an office or interview room, make sure that you are not trapped by a desk and can reach the door rapidly and easily.

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e.

Procedures and Planning

The staff’s ability to maintain self-control and work as a team can determine how well they will handle an escalating or emergency situation. Helpful suggestions for staff emergency plans are: • Create code words indicating a need for help - Many dangerous sites make use of code words or code-phrases. For example, a red card may be used to show that there is a violent incident in progress. All staff should agree and drill on the code phrase.

• Have the police hotline number handy and ready to use – This reduces the time required to call for help.

• Have a formal review and clearly document incidents - After a violent incident, review the incident with the staff members involved. Evaluate the response in terms of teamwork and the interventions used. This will help develop skills for future incidents. A properly written incident report must be documented so that staff members may read it to evaluate their response to the incident and make needed improvements. A clear and concise report can protect individuals or an agency from the misrepresentation of facts by others.

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Dear Shelter worker,

It is very important that you are aware that VOT often attempt to harm themselves and others. This fact has been well documented in various shelters. One client stood on top of a fence in an attempt to run away from the shelter. Luckily, she was intercepted and rescued by the cooperative efforts of shelter staff. A client in another shelter, climbed onto a roof to commit suicide but again, the staff was able to calm her and bring her down to safety. Another victim of trafficking would hit herself with any available object, scratch her face, eat Vaseline or hair ointment and drink urine. Other clients have thrown items in attempts to harm shelter staff. A nurse was seriously wounded after someone threw a container at her.

3.4. Harm Reduction Overview

Harm reduction-based treatment starts by working with individuals “where they are at� regarding their problem which may involve drug or alcohol abuse, sexual behavior or mental instability. This treatment approach does not require a person to abstain in order to receive treatment. In fact, the first step to recovery may not be abstinence. Sometimes, the first step is to assist the person to evaluate how their behavior harms themselves and those in their community. Asking a client to leave the shelter or refusing admission to a person with a problem behavior does not assist that individual to alleviate their problem. Abstinence based treatment does not work for everyone.

This belief forms the harm reduction philosophy. In terms of sobriety, for example, denying care when it is needed is not a good motivator and visits to the hospital emergency room and to jail may be very costly. This program accepts that clients may have difficult and challenging behaviors but as long as staff and other clients are not threatened, services will never be denied.

Dear Shelter worker,

Is admission to GSA restricted? If so, what are these restrictions?

Are the restrictions based on problem behaviors?

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A harm reduction treatment model provides an opportunity to engage those individuals who are behaving in ways that cause themselves and their community harm but yet are not capable of or interested in stopping their behavior suddenly; cold turkey. Harm reduction recognizes that any movement in the direction of reduced harm, no matter how small, is a positive step. It is vital to note that harm reduction and abstinence are not in conflict. A harm reduction program often precedes abstinence and a harm reduction philosophy may accompany abstinence-oriented treatment. For instance, a substance abuse treatment program can decide to use a harm reduction approach with users who relapse while in treatment.

Three Keys to the Harm Reduction Approach a.

b. c.

Don’t Judge: Work to develop a non-judgmental relationship with clients. If a client can follow the rules of the shelter, offer them care and treatment rather than disapproving of their behavior. Your tone of voice, actions, and overall communication should not be judgmental.

Step-By-Step: Present the idea that clients can take steps to reduce harm and little by little, their health will improve.

Reduce Assumptions: Do not assume that you understand what is harmful in a client’s life. Let the client know that you are there to work with them to reduce the harm. If you have witnessed a pattern of harmful behavior, do not assume that the client knows it is a harmful pattern. Ask how they feel about what is going on in their lives. The success of your conversations depends not only on what you say but how you say it. People who are hurting themselves usually feel guilty and angry about their behavior. Sometimes these feelings are externalized and individuals can become angry with others who suggest that the behavior is harmful. People who feel guilty and annoyed with themselves have difficulty trusting others and may respond angrily. The most important thing is to create a trusting relationship that allows you to present harm reduction information.

3.5. Ethical Considerations in General Care Work When providing any sort of service to clients, it is vital to remember ethical principles. Ethical issues are even more important when working with vulnerable groups like trafficking survivors.

Ethical concerns pop up at every stage of support from admission until case closure. Ethical issues also appear in every kind of service offered in a shelter. Below are ten pertinent guiding principles to ethically safe care service.

1.

Do no harm

Treat each woman as if the potential for harm is extreme until there is evidence to the contrary. Do not offer services that will make a woman’s situation worse in the short or long term such as interfering in family or marital relations, punishing them for misbehaving or sharing confidential information to a third party.

2. Know your client and assess the risks

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Learn the risks for each woman’s case (specific mental health risks, physical health risks, or family and social relationship problems) before providing a given service. Each case has unique characteristics.

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3. Adequately select and prepare interpreters and co-workers

Weigh the risks and benefits associated with employing interpreters or other co-workers and develop adequate methods for screening and training new staff. Sometimes, interpreters may not be competent and may provide wrong interpretation. All interpreters must have a professional license. Interpreters may use their linguistic connection with a victim to lure the victim back into trafficking. Without invading a client’s privacy, it is a good idea to check phone records and other communication that a client has with people outside of the shelter.

4. Ensure anonymity and confidentiality

Protect a client’s identity and confidentiality throughout the entire interview and service.

5. Get informed consent

Make certain that each respondent clearly understands the content and purpose of the interview and the intended use of the information solicited.

6. Listen to and respect each woman’s assessment of her situation and risks to her safety

Recognize that each woman will have different concerns, and that the way she views her concerns may be different from how others might assess them.

7. Do not re-traumatize a woman

Do not ask questions intended to provoke an emotionally charged response. Be prepared to respond to a woman’s distress and highlight her strengths.

8. Be prepared for emergency intervention

Be prepared to respond if a woman says she is in imminent danger. For example, she may be suicidal, she may contemplate harming others, or she may have serious health issues including high blood pressure, heart disease or diabetes.

9. Put information collected to good use

Use information in a way that benefits an individual woman or that advances the development of good policies and interventions for trafficked women at GSA.

10. Prepare referral information

Do not make promises that you cannot keep. If asked, help with referrals.

Note: Getting informed consent is possible in two ways: either orally or in written form. If a victim is mentally unstable or is a minor, her legal guardian may be requested to give consent.

Likewise, if a victim is mentally incapacitated and cannot give accurate information about her family and relatives, the shelter has to depend on the credibility of the referring institution.

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Session 4: Victims Case Management

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Dear Shelter worker,

Within this major session, five sub-sessions are covered: the concept of case management, generic skills in case management, practice skills in case management, smart practice guides in case management, and ethical principles in case management.

Session Objectives

By the end of this session, trainees will be able to: • Describe the concept of case management • Effectively apply generic skills in case management • Explain the practice guides for responsible case management • Appreciate the ethical principles in effective case management

4.1. Concept of Case Management The general care work we discussed above is meant to apply to every case. Although there are some commonalities in the problems affecting all of the trafficking survivors, each survivor has her own unique character, unique needs, unique family and community situation that necessitates individualized case management. For example, each client differs in age, level of vulnerability, mental and physical health, level of education, family situation, financial capacity, marital status, economic need (type of job sought), legal need…etc.

Dear Shelter worker,

Please add other individual differences that are essential for individualized service to the above list.

The National Association of Social Workers (NASW) defines case management as the ‘collaborative process of assessment, planning, and facilitation for options and services to meet an individual’s complex needs’ (NASW, 2005). A case is an individual situation that will require interpretation, balanced risk taking, and decision making in difficult situations. While there are overarching principles and frameworks within which decisions are made, in the final analysis, the case for each girl must be considered on its own merit, as there are seemingly infinite variations in the details of their cases and lives. Some of the broad goals of case management include:

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• • • •

Enhancing developmental, problem-solving, and coping capacities of clients Creating and promoting effective services that provide individualized care for people Linking people with systems that provide them with resources, services and opportunities Improving the scope and capacity of the delivery system to address different needs

Case management is a provision of comprehensive victim-centered services to trafficking sufferers. The case manager performs multiple roles including point person, victim advocate, and facilitator of communication in order to help the victim navigate complex criminal justice and social service systems. Providers should create a case management plan and review it at each meeting with a client. Effectiveness of case management depends on a case manager’s ability to establish a trusting relationship with the trafficking victim. The case manager must also identify and access local, state, and federal resources to address the victim’s needs. So, a comprehensive plan is needed which requires the following actions: • Collaborative planning between clients and workers • Considering the impact of the characteristics of client systems on the planning process • Defining goals and objectives and their importance in planning Focusing on planning to generate and use as many potential solutions as possible • Delineating a step-by-step approach for constructing actual plans

Assigning A Case Manager

The first step in case work is identifying a primary case manager. There may be different agencies involved in case management and delivery of direct service assistance based on the characteristics and needs of victims. It is helpful to identify a primary case manager for each victim in order to alleviate confusion for the victim and to streamline communication between various service providers and law enforcement agencies. Case management systems can have numerous benefits if implemented effectively as has been demonstrated in criminal cases involving domestic violence, young offenders and offenders with mental health issues. Case management requires the coordination of structures and processes involved in addressing the needs of the client. Case coordination allows for information to be exchanged between members of different institutions: mental health workers, social workers, medical staff, police and prosecutors. Case management is often coordinated through victim service providers at nongovernmental organizations, but it may also be coordinated through public agencies such as child protection agencies. It is effective when done in partnership.

4.2. Generic Skills Case managers use generic social work processes to carry out case management activities. Core functions include outreach, assessment, planning, linking, advocacy, monitoring and evaluation.

A. Outreach

Outreach heightens awareness of the program using public speech, newspaper articles, brochures and pamphlets. Outreach includes contact with key people such as local leaders, religious leaders, teachers, lawyers, nurses and physicians, basically, anyone who can possibly advocate for client support.

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B.

Staffing If clients, themselves, can be involved with the staffing process, it will contribute to feelings of ownership and empowerment within the program.

C.

Linking Clients with Resources Case managers offer technical assistance to clients with respect to availability, benefits, eligibility requirements, application procedures and other vital information concerning resources. This requires: • Being familiar with the resources and having firsthand information to draw upon • Planning for emergency situations and anticipating the types of crises clients are likely to experience • Creating new resources where none exist • Coordinating the services of multiple providers

D. Advocacy Case managers must try to encourage social service organizations to be more responsive to the unmet needs of clients. Questions to ask: • Is the resource available?

• Is the resource accessible?

• Is the provider willing to make necessary accommodations?

• Will the resource be adequate?

E.

Monitoring and Evaluation (Discussed in detail in session 10) • Initial and ongoing assessments are necessary to identify each victim’s accomplishments and strengths as well as current or new service priorities.

4.3. Case Work Practice Skills Dear Shelter worker,

The core activities in case management are: establishing goals, beginning and guiding subsequent meetings, examining the problem, client perspective & situations, and working & evaluating skills. Details of each of these four skills are presented below.

i.

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Establishing Goals

One of the case manager’s tasks is to help clients to identify a general goal and then move on to develop measurable, attainable, positive and specific (MAPS) smaller objectives to help them to work toward the main goal.

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Effective goals are those that are: • Stated as accomplishments • Stated in clear and specific terms • Stated in measurable or verifiable terms • Realistic - have a reasonable chance of success • Adequate - if achieved, the situation will improve • Consistent with a client’s value and cultural system • Time specific - includes a time frame for achievement

MAPS - may consider the following • Increase from a given beginning point to an endpoint • How much do you want to raise your performance?

• When your performance is satisfactory, what will you do to perform even better?

• How much more time do you need to work and to grow?

What Goals Should Clients Set? • Obtaining concrete services such as financial assistance, employment, health care, or housing • Making important life decisions, resolving crisis, relieving immediate distress, or removing barriers to change • Modifying structures in social systems such as family, organizations or community by changing communication patterns, behaviors, roles and rules • Working toward future aspirations through planning for growth and change

Dear Shelter worker,

If you want your clients to think about goals, use open-ended questions that are focused on the future. a. At the end of our work together, what do you want your life to be like? b. When the problems that brought you here are solved, what do you want to do? c. When you leave GSA, what might other people see you doing that you are not doing now? d. Tell me about the picture of what you want your family to be like? e. Let’s pretend that these problems are solved. What differences will you notice in your life?

Guide your clients to make their goals related to MAPS. Encourage your clients to think carefully about their goals and to describe them clearly.

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Questions social workers can ask to identify a client’s strengths: • • • • • • •

ii. a. b. c. d. e. f.

What are the outstanding qualities of this client and how does this client demonstrate power?

How and with whom does this client successfully build attachment?

What special or unique characteristics distinguish this client from others?

What skills does this client possess?

What resources are in place to support this client?

In what ways does this client contribute to the social and physical environment?

How has this client been able to adapt to change?

Beginning Subsequent Meetings

Ask client where he/she would like to begin Summarize previous meeting if any Identify tasks for the current meeting Ask client about progress Ask client about homework Ask client about problems

In meetings with clients, one of the roles of the shelter worker is to listen carefully to the implicit and explicit communication of the client and to elicit alternative proposals. During listening, good observation is important. Try to notice: • Facial expressions (tears, mouth turned down …etc.)

• Eye movement and eye contact • Body position and movement • Breathing pattern • Muscle tone • Gestures • Skin tone changes In meetings, dialogue with clients should focus on solutions. This requires asking questions such as: • What have you been doing to solve your problem?

• What works even for a little while?

• What are you learning about your situation?

• Is there anyone who seems to be coping with a similar issue? What are they doing?

• Are there ever times when things just seem to be going better for no apparent reason?

• What have you discovered about yourself as you work on this issue?

• Do you remember a time when this problem did not exist?

• Tell me what was going on then?

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iii. Examining Problems or Challenges - Client Perspectives and the Situation a.

b.

c.

Problems or challenges- This requires posing questions about previous attempts to solve the problem, the history of the problem (s), and the severity of the problem (s).

Client Perspective – The shelter worker should ask the client questions about personal strengths, about the feelings surrounding the problem, and about the effects of the problem on health, sleep and the ability to function at school or work.

Situation - The shelter worker should ask the client questions concerning the effects of the problem on other people, available social support and about the positive and negative aspects on the environment.

iv. Working and Evaluating Skills

Good case work with clients requires using effective skills such as rehearsing action steps, reviewing action steps, educating, advising, responding with immediacy, reframing, using contracts, recording progress, evaluating and establishing outcomes. In casework, using contracts to bring about positive change is absolutely essential. A contract is an outline of agreed upon relations between the shelter worker and the client. Creating a contract uses many skills including identifying an issue in collaboration with the client, reflecting on the issue, clarifying the issue, establishing goals, identifying action steps, developing an action plan, planning for evaluation and summarizing the social work contract for the client.

In supporting an individual’s case, it is vital to understand the ‘stages of readiness’ for change.

1. Pre-contemplation - The client does not even know she has a problem behavior 2. Contemplation - Client begins to think that she has a behavioral problem to work on 3. Preparation - Client develops plan to deal with the problem 4. Action - Client takes relevant actions to reduce or eliminate the problem 5. Maintenance - Client sustains the action he/she is taking to avoid possibility of relapse 6. Termination - Client terminates actions as the problem is solved These stages are not linear. A client may vacillate between stages particularly during relapse.

Ingredients for Effective Case Management • Establishing a hopeful relationship with the client • Assessing client strengths and needs • Developing, in partnership with the client, a service plan to achieve desired outcomes • Locating, linking, and following up with needed services and support • Monitoring, coordinating, and adjusting services and support to achieve desired outcomes • Providing crisis prevention and intervention services and support • Advocating for the client The ability to implement an effective case management system will depend on the capabilities, resources and priorities of the institutions involved in handling human trafficking cases. In order to implement successful case management, case managers receive training on the following:

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a. b. c. d. e. f. g. h. i.

Engaging individuals and families Basic counseling skills Determining when and how to conduct safety assessments Conducting assessments using standardized instruments Community programs and how to access services Mainstream benefits programs, including eligibility requirements Providing case advocacy Shelter possibilities Family reconnection skills

4.4. Smart Practices for Responsible Case Management •

• •

•

• •

•

•

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Identify appropriate services: Few service providers offer a comprehensive array of in-house services to all types of trafficking victims. To address the victim’s needs, diverse service providers are needed as Task Force partners. Use your Victim Services Committee to map out potential needs and identify appropriate resources and then, locate appropriate resources and services to address the victim’s needs and goals.

Understand the limitations of each service provider’s response capacity. For example, service providers that work with adult victims may not be equipped to assist children.

Remember that “needs assessment” is not a static step, but rather an ongoing process of engagement. As one set of needs is met, another may be identified as the victim’s case moves through the entire support process.

Protection of victims’ rights and informed consent. Get consents signed and remind the client verbally if you want to share information with an outside agency. It is important for victims to be aware that they have choices and control over their story and personal information.

Monitor circumstances that may impact the victim’s safety. Safety planning should be conducted at every meeting with a victim.

Clinical case conference reviews: Case conferences should be held to review progress, needs, as well as any barriers to safety or self-sufficiency experienced by victims. It also makes sense for the victims to be a part of these meetings, as it increases their understanding of roles and allows all to hear their needs, concerns and confusion. Case conferences can provide the opportunity to identify service gaps and strategize possible referrals to new providers to ensure comprehensive victim assistance.

Communicate and follow up with outside professionals. Advocate on behalf of the client as needed to help reduce barriers and to monitor and evaluate the effectiveness of the intervention in meeting the client’s needs and achieving their goals.

Regular case coordination meetings and use of a case team. Depending on the complexity of the case, the case manager, and other workers may meet on a regular basis. These meetings can help ensure that a client’s needs are being met and provide accurate updates about the

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case status to everyone involved. In order to protect confidentiality, it is critical to clearly define what can and cannot be shared with the various participants in the case. Using a case team is important to ensure that victims do not fall through the cracks of the multiple systems involved in their treatment and care.

A final note for good case management: Have a referral pathway whereby organizations giving diverse services are identified, mapped, and a networked system is created. Clients could be provided with a brochure that clearly maps out what each organization provides in terms of accommodation, health support, psychological support, economic support and legal support.

For example, the Ethiopian Women Lawyers Associations gives legal aid for vulnerable women, Women In Self Employment (WISE) provides business and entrepreneurial skills as well as financial education, Government Technical and Vocational Education Colleges give skills training…etc.

Those giving physical services (accomodation and health)

Those offering economic support (IGA, employment skill training)

Those giving social services (counseling and life skills training)

Those giving legal support

4.5. Ethical Principles in Case Management In case management, some overall ethical principles of direct assistance are: Respect for and protection of human rights, non-discrimination, self-determination and participation, individualized treatment/care, comprehensive approach to assistance, and best interest of the victims. Focusing on clients’ rights and adhering to the following principles are crucial for effective case management.

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• • • • • • • • • •

To participate as a collaborative partner in the change process To receive culturally sensitive treatment To have an equitable share of societal resources To view challenges from one’s own perspective To participate in gathering and analyzing information To set one’s own goals To resist what social workers want to impose To choose from among the various alternative interventions To collaborate on the evaluation process To help determine time frames and know costs involved

An essential ethical consideration in case management is being careful not to cross boundaries.

Warning signs that show that you, as a staff member, might be crossing boundaries are: 1.

2.

You spend much more time with one client than others.

You spend time with a client when you are ‘off duty’ meeting them for lunch, dinner, or after work.

3. A client stays late or makes special arrangements to be around you when you are working.

4. You feel you are the only one who really understands the client and you feel other staff members are just critical or jealous of your relationship with the client.

5. You become defensive if someone questions your interaction or relationship with a client.

6. You discover that communication between you and a client has become overly familiar or flirtatious.

7. A client does not want to interact with other staff. She waits for you to get what she needs.

8. You think a lot about the client when you are not at work.

9. You begin to view a client as your personal client and other staff members need to call you for help when working with this client.

Service agencies assisting trafficked women frequently decline requests from journalists and researchers to interview women in their care. It is considered unethical.

Post-Session Questions

Dear Shelter worker, Think about two cases on which you’ve worked, one that you think was effectively managed and another that was poorly managed. Which case management practices were used well? Which case management practice was missed or used improperly? What new guide or skill have you learned in this session?

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Here is a sample ‘Case Process’ at Good Samaritan Association: • Receive the client at the airport, police station, IOM, or other institution.

• Welcome them.

• Introduce them to the shelter staff and the institution.

• Open a case file.

• Calm them.

• Ensure access to a shower and provide food and water.

• Help them settle and get some rest.

• If they are restless, aggressive and unsettled, give them medicine such as Diazepam.

• Follow up on symptoms for 3-4 days and transport to the hospital when necessary.

• If admitted to the hospital, make sure to follow up with the medical team.

• Once the client has recovered in terms of health, ask them about their other needs.

• Give them life skills training.

• Give them job skills as needed in collaboration with organizations offering such trainings.

• Reunite them with family.

• Follow up their activities back in their home community.

Below is a case story and how it was managed by the Organization for the Prevention and Rehabilitation of Street Children.

Case story Bubu (Pseudonym) was born in southern Ethiopia, in the Wolaita zone. She is 15 years old and came to Addis with her uncle. He helped her get employment as a domestic worker. She was working in a good situation. She was happy because her female employer was good. One evening, Bubu’s uncle came to her employer’s house and told her that her mother had come from the countryside to Addis and wanted to see her. The uncle took Bubu far away from her employer’s home. Because she was longing to see her mother, Bubu didn’t notice that she and her uncle had traveled a long distance. She did not know where they were going. Her uncle took her to a garbage dump where there was no one around. When she asked him where her mother was, he told her to wait for a bit. He kept her waiting there until midnight. Then, the uncle raped her. He threatened her with a dagger telling her that if she told anyone, he would kill her and bury her. He told her that no one would ever find him. He went away and left her there alone. She fainted and when she regained consciousness, she found herself bleeding. She immediately went to her employer’s home. When Bubu’s employer saw her, she was stunned and asked Bubu what had happened. Bubu told her employer everything about being raped and threatened. The employer felt sad and informed the police. The police took Bubu to OPRIFS.

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OPRIFS did the following when managing the above case: • • • • • • • • • •

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Shelter staff received her and welcomed her.

Shelter staff admitted her.

She was taken to Ghandi Hospital (Addis Ababa) to get a medical diagnosis.

She was returned to the shelter and was made to wash her body and change her clothes.

She was given new clothes, shoes, soap, and other basic needs (bed and food).

She received several counseling sessions using different techniques.

She received non-formal education.

She received legal counsel.

When she finished with legal proceedings, she participated in recreational activities.

Finally, she was reunited with her family in the southern part of Ethiopia.

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Session 5: Ethics and Codes of Conduct in Shelter Services

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Session Objectives By the end of this session you will be able to: • Discuss the codes of conduct to be upheld by shelter staff at GSA • Identify codes of conduct related to assessment, client treatment, and professional behavior • Understand the standard codes of ethics to be upheld by shelter staff

5.1. Introduction Ethics are a system of moral principles shared by a group. These principles define fair treatment and good behavior. Within the shelter system, these principles provide standards, which define the code of conduct making sure that everyone is treated humanely, fairly, and compassionately. Ethical principles help shelter workers demonstrate consistent professional behavior that leads clients to trust the facility. Shelter work is not easy. Ethical guides help professionals act in a consistent and dignified manner. A code of conduct, on the other hand, indicates what must be done and what must not be done; the dos and don’ts that must be obeyed otherwise consequences ensue.

In relation to a code of conduct, shelters must have policies that prohibit: corporal punishment, the use of aversive stimuli, withholding nutrition, inflicting physical or psychological pain, the use of demeaning, shaming or degrading language or activities, forced physical exercise to eliminate behavior, punitive work assignments, punishment by peers, group punishment or discipline for an individual’s behavior and unwarranted use of invasive procedures and activities as a disciplinary action. Below, you will find an example of a standard code of conduct.

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Code of Conduct

This Code of Conduct is a set of behaviors to establish and specify relations between staff and shelter residents. Not all behaviors and circumstances can be foreseen. This Code is meant to give staff knowledge of appropriate behavior between residents and staff. Any questionable situations that arise between staff and residents that do not seem covered in this code of conduct should be addressed with a supervisor to obtain clarification and guidance.

1. Staff will always treat residents with respect and dignity. No client should be a victim of verbal, emotional, or physical abuse by a staff member.

2. Staff will behave in accordance with all applicable safety policies and procedures.

The safety of all residents and staff is of the utmost importance.

3. Staff must refrain from alcohol or drug use while on duty. They should never come to work under the influence of alcohol or drugs.

4. Staff must refrain from any relationship with a client that could be viewed as unprofessional. Inappropriate types of relationships include, but are not limited to: • Sexual relationships • Business relationships • Sale or use of drugs and alcohol • Gambling • Financial Assistance (acting as a payee or conservator) • Personal relationships outside of the work environment 5. Staff will always apply rules and regulations fairly and equitably to all residents.

6. Staff will not provide favors for, or accept favors from, residents.

7. Staff will never give or take money from a resident.

8. Staff will not use any language that is offensive or discriminatory.

9. Staff will dress in a way that reflects positively upon their role as professionals working in a shelter.

10. Staff will refrain from any communication with clients that may be interpreted as sexual or flirtatious, including inappropriate jokes, self-disclosure, or touching.

11 When in doubt about any course of action or behavior with residents, staff should consult their supervisor.

I, _________________, have read and understood this Code of Conduct to be followed by all staff in the shelter. I further understand that this code does not include all foreseeable circumstances that I may face in working with shelter clients, and that I will seek supervision anytime I have questions about appropriate professional behavior.

Signature---------------------------------- Date-----------

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Dear Shelter worker,

Evaluate the fit between the code of conduct at GSA and the one given above?

What is there in the GSA code that is not indicated in the above table? What is new in the above table that is not included in the GSA code of conduct? Which of the behaviors listed in the above code of conduct are difficult for you to abide by?

5.2. Code of Conduct in Assessment and Intervention Assessments and interventions should be understood in the context of counter-trafficking.

Regardless of the expected variety of settings and circumstances in which assessments and interventions are conducted, the following ethical standards must be respected: a. Informed consent of the person, or their legal representative, is unconditionally required and must be endorsed for any kind of assessment and intervention. b. Keep the assessment and intervention procedures short, simple, paced, and appropriate to the physical, intellectual and emotional condition of the person. c. Strict confidentiality should be ensured regarding archiving and transfer of information and documents from one helping site to another. Information includes referrals, patient files and specimen code numbers. In this regard, security, such as locked facilities, safe locations and security staff is essential. d. Avoid any replication of assessment procedures including re-interviewing or re-examining the client for the same factual data. e. The use of psychological tests, standardized diagnostic instruments and interventions such as psychological counseling, should be entrusted to professional helpers with adequate training. f. Have private rooms for interviewing, examination and treatment. g. Provide access to in-person or telephone interpreters to meet VOT language needs. h. Find out about an individual’s literacy and then ensure that information is conveyed and understood at the correct level. Some people respond better to information communicated using visual aids. i. Don’t make rapid or negative assumptions about an individual’s reaction or behavior. j. Consider possible cultural, social or personal reasons for an individual’s reactions. k. Recognize that an individual’s understanding of their trafficking experience is in the context of their own religion and cultural beliefs and is important to recovery.

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Specific principles that service providers for the homeless share: • • • • •

Individuals have the right to safe shelter, adequate food, and sanitary conditions.

Residents have the right to make their own choices and those choices should be respected.

However, shelter workers must let clients know the consequences of those choices.

Residents deserve to have services provided competently and fairly.

All clients deserve the same quality of service. No one should receive special treatment.

Shelter residents should be treated with warmth and friendliness to decrease alienation and despair, and to increase their chances of obtaining the services they need.

5.3. Codes of Conduct in Client Treatment, Institutional Policy and Professional Behavior Dos and Don’ts to show respect for each client 1. Do welcome and introduce yourself when meeting clients for the first time. Make eye contact and greet them warmly. Introduce yourself even before you ask them for their names as this communicates that you are interested to know them as a person beyond identification purposes.

2. Do put the client’s needs above your own while on duty. Never make a client wait for service when it isn’t necessary. Stop social conversations with other staff when a client needs attention.

3. Don’t wait for a client to come to you. When you see a client with an obvious need, approach them and help them. By anticipating a client’s needs, you show them that they are important.

4. Don’t use your power as a shelter employee to demean, humiliate, or judge a client.

5. Don’t discuss a client’s business in public areas where other client’s may overhear.

6. Do finish dealing with one client’s concerns or needs before attending to another’s.

7. Do show concern for a client’s personal belongings. Showing that you understand that a client’s belongings are important to them communicates an overall sense of respect.

8. Do show tolerance for differences. These differences may be religious, political or cultural.

9. Don’t blame or reprimand a client in front of other residents.

10. Do treat all clients equally. Do not show favoritism.

11. Don’t take it personally. Not reacting emotionally to a client’s anger helps to calm the situation.

12. Do enforce policies and procedures equally with all clients. You are more likely to gain the respect of clients if they see that your actions are fair and balanced and that you treat everyone the same.

13. Don’t promise a client something you cannot deliver. If you make a commitment to a client, even a small one, live up to it! Most clients have a difficult time trusting “the system” if and when promises are not kept. In unavoidable instances when a commitment or service cannot be provided even after it was promised, do not try to make excuses but rather take responsibility and apologize.

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Here is an example of a code of ethics to be signed by shelter staff.

Code of Ethics

The following ethical standards provide a consistent level of care. All shelter staff members are responsible for upholding these standards in their daily work providing quality service to shelter guests.

• The welfare of shelter residents is the guiding principle for all shelter staff in performance of their duties.

• Residents have the right to a shelter that is safe and sanitary.

• Residents deserve to be treated with basic human dignity and respect.

• Residents have an expectation of privacy and confidentiality. Information about a shelter resident shall not be given out without their permission.

• Residents have the right to make their own decisions. They should expect the staff to respect those choices, and to have the consequences of those choices clearly explained.

• Residents deserve to be treated courteously and fairly.

• No client should face discrimination based on race, religion, ethnicity, nationality, sexual orientation, gender identity, age, political beliefs or disability.

I, ________________________________, have read and understood the Code of Ethics listed above. I agree to abide by these ethical standards in my work as part of the shelter staff team.

Name _____________________________________Date_______________

Dos and Don’ts to show respect for the institution, its policies and procedures 1. Do maintain a clean and orderly environment. The shelter is not only a workplace, but also a home.

2. Do treat your co-workers with respect. Keep personal conversations with other staff to a minimum while in a client’s presence. Never share personal information about other staff with clients.

3. Don’t interrupt other staff’s interactions with a client. Unless there is urgent need, allow other staff to fully concentrate on the client with whom they are working. If you must interrupt, do so respectfully and say, “Excuse me, I am sorry to interrupt, but...”

4. Don’t blame the institution, your co-workers, or supervisors in front of clients. When staff members wish to complain, criticize, or suggest improvements, they should do so in staff meetings, directly with their supervisors or by filing a grievance.

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5. Do know the policies and procedures of your facility and follow them consistently. This tells clients that staff can be relied upon to carry out their duties and enforce rules and regulations in a consistent, competent, and fair manner. This also allows you to be a resource for clients.

6. Do know emergency procedures and respond immediately to ensure a client’s safety. It is the responsibility of all staff members to know the facility’s emergency protocols.

Dos and Don’ts to taking responsibility for one’s professional behavior 1. Do be aware of your professional limitations. Do not attempt client interventions you are not trained or authorized to provide. Seek supervision if you are unsure.

2. Do take on self-improvement and educational activities. Take advantage of opportunities for training within the shelter system. Use these opportunities for professional development.

3. Don’t blame others for your mistakes. Own your errors and take responsibility to correct them. Staff members who learn from their mistakes show responsibility and trustworthiness and are good role models for clients and other staff.

4. Don’t lose control of your emotions in front of clients. Seek help from peers or your supervisor when you feel overwhelmed. This is not a sign of weakness.

5. Do pay attention to how you present yourself in your demeanor, dress and hygiene. Our standards of behavior, dress, and cleanliness are a model for clients.

6. Don’t let your personal affairs interfere with your professional duties. For example, don’t keep a client waiting while you finish a personal telephone call. This is rude and shows a lack of interest in your client.

7. Do your job even though no one is watching or reminding you.

8. Don’t let dangerous situations or interactions go unattended. If staff members are aware of drug dealing, intimidation or extortion within the shelter, they need to respond immediately to maintain the safety of clients and other staff.

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Session 6: Medical and Psychiatric Care

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Session Objectives After completing this session you will be able to: • Describe the common physical and mental health problems VOT experience • Identify the health services VOT need for better rehabilitation and reintegration • Outline the steps in supporting VOT who experience mental health problems • Discuss possible treatments for VOT who experience mental illness

Dear Shelter worker,

The complicated abuse and exploitations including beating, insult, degradation, rape, painful journey, overwork, hazardous work, denial of food and medication, salary denial, confinement, extortion…etc. that happen at the various stages of migration and trafficking, often lead to mental and physical health problems that necessitate medical and psychiatric intervention. Several studies on trafficking survivors have documented that they are much more vulnerable to mental illnesses than their non-migrant counter parts. In this section, physical and mental health is addressed. Four major mental health problems are examined along with possible medications and therapies. Post-traumatic stress disorder is a major focus. Treatments for PTSD include intervention and cognitive behavior therapy as well as cognitive processing therapy. Psychiatric nurses and counselors will have in-depth knowledge of mental illnesses. Facility staff members are not expected to understand mental illness in great detail but should have some knowledge in this area. If you want to learn more, please seek out books on clinical psychology, psychiatry, counseling psychology and DSM V.

6.1. Physical Health Problems Dear Shelter worker,

Please list the kinds of physical health problems experienced by clients at GSA particularly upon arrival? Which kinds of physical illnesses do you see more frequently? Which illnesses are difficult to handle? Are there overlaps between physical and mental illnesses?

In human life, health is the most critical consideration. That is why the first thing people ask you after a few days of separation: “How are you?” If your health is poor, your education, economic situation, social relations, political and even religious and spiritual life will be compromised.

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Following admission to the shelter, the first thing staff members need to do is to check the client’s health. VOT may suffer from several physical and psychological issues all at the same time because they have often been forced to live and work in dangerous conditions. Many of the clients have experienced harsh traveling conditions and severe beatings. They complain of headaches, bruises, scars, broken bones, lost teeth, cigarette burns, stomach ache, skin disease, dehydration, cardiovascular or respiratory problems, fatigue, weight loss, chronic back issues, weak eyes, neurological issues, gastrointestinal problems, hemorrhoids, hearing impairment, malnourishment, infectious diseases like tuberculosis or pneumonia and overall poor health. Many of the women have been sexually abused through rape, prostitution and sexual exploitation. The physical effects of this sexual abuse include HIV infection, pregnancy, pelvic pain, rectal trauma, urinary difficulties, botched or unsafe abortions, fistula and infertility resulting from chronic untreated sexually transmitted diseases. Because most victims do not have timely access to health care, by the time they reach a clinician, it is likely that health problems are complicated.

Health services include, as needed: a. General medical check b. Clinical services for mental health problems c. Medication management and/or monitoring d. Appropriate information including pregnancy prevention, family planning, safe and healthy relationships as well as prevention of HIV/AIDS and other sexually transmitted diseases Human trafficking is a global public health problem. Health care providers are one of the few professionals likely to interact with trafficked women and girls. Health care professionals should be especially vigilant to identify trafficking victims in emergency rooms and psychiatric inpatient units. As health care professionals frequently encounter human trafficking victims and work to promote the well being of citizens, they are in the perfect position to serve as liaisons and providers of treatment and care for this population. However, health care professionals may not be adequately trained in recognizing, evaluating, and managing human trafficking victims. They may not be sensitive to victims’ needs, or they may fear the emotional burden of caring for human trafficking patients. Health care professionals may lack the skill to know how to ask about patients’ specific experiences in being trafficked. For instance, undressing for a physical examination in the presence of multiple team providers can be extremely traumatizing for trafficking victims. These women may not be able to tolerate the treatment setting and may not subsequently return for further treatment.

Dear Shelter worker,

The role of the shelter worker may involve accompanying clients when they go for medical treatment. When clients have an appointment with a physician who is a stranger to them, it may be very helpful and less traumatic to have you, the shelter worker, present as someone who is familiar and knows the story. If available, the shelter nurse can also be important in this capacity. Follow-up by shelter staff may help clients stick to their prescribed medical and drug treatment.

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Dear Shelter worker,

VOT in the shelter must recognize that the horrors they lived through are likely to affect their health. Shelter staff should never undermine a client’s pain. VOT may have somatization, a process by which psychological distress is expressed through physical symptoms. Shelter staff members need to be empathetic rather than judgmental if they are to help their clients with somatization.

6.2. Mental Health Problems A trafficked individual’s risk of mental disorder appears to be influenced by multiple factors including pre-trafficking abuse, duration of exploitation, violence and restriction on movement while trafficked, unmet needs, and lower levels of social support following trafficking (Ottisovaet al, 2016). Psychological distress, including shame, guilt, stigma, disrupted identity development, entrapment, religious discrimination, and cultural isolation can exacerbate psychiatric and medical conditions. Social stresses, like family and community expectations also may worsen a client’s psychiatric condition after return. Psychological violence experienced by victims of human

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trafficking results in high rates of post traumatic stress disorder, depression, anxiety, maladaptive behaviors such as suicide and alcohol or drug abuse as well as a multitude of somatic symptoms.

Causes of mental illnesses experienced by trafficking returnees are mainly rooted in acculturative stress, expectation failure and identity crisis.

In their work with survivors, shelter staff notice that VOT are less stable, more isolated and have higher levels of fear and severe trauma. A significant number of trafficking survivors have a history of psychiatric issues. The World Health Organization (WHO) clearly articulates that there is no health without mental health, showing that mental health is critical for healthy functioning in any area of life.

Addressing the mental health needs of VOT requires the collaboration and integration of medical and psychiatric service providers. After the patient is medically stabilized (physical health), the mental health team (psychiatrist, psychologist, social worker, physician, nurse) should evaluate the patient for the presence of thoughts or behaviors that are potentially dangerous to self and/ or others, mood disorders, personality disorders, substance use disorders, as well as a history of trauma/abuse or neglect. If any of these are present, there is need for admission to an inpatient psychiatric unit for acute psychiatric stabilization. If the patient is not medically stable, then the psychiatric consultation team should continue to follow the patient alongside the primary medical and surgical teams. Patients should be educated about available services and pharmacological and psychotherapeutic treatments, and this process should be carefully documented. Every effort should be made to prevent the possibility of further traumatization both when the client is in the hospital or in the shelter.

Steps in supporting VOT who might be experiencing mental health problems: a. Diagnosis and assessment b. Identify the root causes. c. Identify appropriate services - check if there is something medically wrong and if not, begin with debriefing of experiences. d. Begin with counseling, as pharmacological interventions are likely to have side effects. e. If counseling and therapy are not helping to cure the emotional or cognitive problems, proceed to pharmacological treatment.

Dear Shelter worker,

As many problems are inter-related, meaningful improvements in mental stability are often the direct result of the physical treatment that the client is receiving as well as the shelter accommodation, the safe physical environment, the better diet and the psychiatric and psychological interventions.

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6.2.1. Types of Mental Illnesses and Possible Medical and Psychological Treatments There are four broad categories of mental illness. Depending on the kind of disorder, different types of psychological or medical treatment may be required.

Dear Shelter worker,

It is important to restate that the information included in this curriculum gives an overview of the types of mental illnesses a shelter client may have. The information found in this document should not be used to diagnose or treat a client’s mental illness; such detailed information is available in the DSM V manual. At this point, the purpose of the curriculum is to provide you with tips to notice the major mental health problems that trafficking survivors or clients may have. You will then be able to decide whether to refer a client to a mental health center or in mild cases, to offer counseling right at the shelter.

Dear Shelter worker,

Try to notice which types of problems are common among your clients. If you want more details on mental illness, please read clinical psychology, psychiatry or counseling psychology books.

A. Thought Disorders

Thought disorders are often called psychotic disorders and this term covers a wide range of mental illness. If a client is experiencing a thought disorder, their thinking will be: a. Non-Linear - Not Straightforward. For example, the client may think that events are connected, when actually they are not. b. Delusional- Strange beliefs and thoughts. A client may believe that others wish to do her harm when if fact, there is no danger. Clients may believe they are at the center of a worldwide conspiracy and that they are the only person who knows about it. They may feel that their thoughts can be overheard, taken from their head without their permission, or that their thoughts are not their own but come from a supernatural entity or an international figure.

They may believe that ordinary events have special meaning only for them. c. Hallucinations - The person experiences events that others do not see, hear, or perceive.

These experiences may seem real. An individual may hear her name being called, hear voices say unpleasant things about her, or hear strange sounds within usual noises. A client may experience visual hallucinations; such as seeing things that others do not. Different clients may have different emotional reactions ranging from acceptance to irritation to terror.

People experiencing hallucinations may seek to blot them out with alcohol or other drugs because the visions are so terrible. d. Suicidal- Suicide and self-harm are significant risks for people with thought disorders. Shelter workers need to remain alert for these behaviors and be prepared to take appropriate action.

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Case example

A young client insisted that her female employer had a Vimto like juice ready to poison her. Saint George came to her every day and told her not to drink the juice because it was poisonous. One day, she was so thirsty and hungry that she drank the Vimto that her employer gave her. After drinking the Vimto, she went insane. She ran from the house still wearing her kitchen costume. She left all of her belongings behind. Then, she was stranded down the road and something came into her ear and told her in a whisper, “Your whole family is dead. There is no one left for you. What are you doing here?”

Dear shelter worker,

Which of the above thought disorders is the young client experiencing?

Treatment

Dear Shelter worker,

Accurate assessment and diagnosis may have implications for the course of treatment. If possible, begin with counseling as counseling has little or no disturbing side effects. As for medications, anti-psychotics or neuroleptics, they can be helpful, though they often have significant side effects. Medications can make a person feel physically worse, even as they help the person to control their behavior. Cognitive Behavior Therapy is used in psychosis and helps patients develop coping strategies, make behavioral changes, and change unhelpful patterns of thinking. CBT reduces the severity of symptoms and decreases the duration of hospitalization.

Dear Shelter worker,

For proper use and details about CBT, it is better to refer to counseling and clinical psychology resource materials. Below are some suggestions when treating individuals with thought disorders.

Dos and Don’ts when working with a person who may have a thought disorder 1. Don’t try to argue with a person having a disordered thought or belief. Direct confrontation reduces the possibility of an effective and supportive relationship. Instead, help the person explore how the belief controls their behavior. Do use this belief in a constructive way to help them meet basic needs and continue to reside safely at the shelter.

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2. Don’t question the hallucinations by saying, “Where? I don’t see anything.” Attempt to determine if a client has hallucinations. If their attention seems to wander or they are responding to an event you do not perceive, say, “I wonder what you are seeing or hearing right now?”

3. Do attempt to reassure a person who seems to be anxious. If a client seems disoriented, upset, or is responding in a way that does not seem connected to their surroundings, ask if they know where they are, what day it is, and how you can help them.

4. Do ask for assistance if a person seems to be disoriented, non-responding, or if their responses do not make sense. This is especially important if you have had previous experience with this client and their behavior seems out of the ordinary or is worse. They may have a medical condition that has become an immediate problem or a mental health condition that has gotten worse and requires treatment or even a crisis response. Your responsibility may be to refer this client to another staff member for assessment to determine the sort of help needed.

Example

A client comes into the shelter whose awful smell is offending others. However, she refuses to shower because she has objects such as toy guns and bits of string hung from her body. She tells you that these items contain a lot of power and that if she takes them off, she might not be able to move. Instead of telling her that this is not true, suggest that she can keep the objects close by the shower while she washes so that she can still ‘pick up’ on their power. Let her know you will make sure that nobody steals the objects while she is in the shower.

B.

Personality Disorders

Personality disorders affect a person’s ability to relate to other people. They are sometimes termed ‘characterological’ disorders. They may be severe enough that the person is unable to get along with others. People with personality disorders may: • Have difficulty making or maintaining close relationships • Have difficulty with self-image or feel that they are ‘special’ and rules should not apply to them • Personalize and misinterpret the meaning of others’ communication • Exhibit poor impulse control • Use drugs or alcohol / cut or burn themselves • Have difficulty considering the feelings of others around them • Have difficulty with emotional stability

Treatment:

Medications are not likely to work here. Behavioral therapy and psycho-education may be helpful. For details on behavior therapy and psycho-education, you can read resources in clinical psychology and counseling psychology.

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Dos and Don’ts when working with a person who may have a personality disorder 1. Don’t try to argue or coax them out of their feelings.

2. Do try to validate what they are feeling. Knowing someone is listening to them reduces frustration.

3. Do use gentle humor if possible to ‘talk them down’ from an emotional peak.

4. Don’t make fun of them or their feelings.

5. Do set limits around what you will and won’t do and what the shelter can and cannot do.

Clarity and consistency are necessary.

6. Do respect their intelligence. People with personality disorders are often very intelligent.

7. Do communicate with your co-workers about the client so that everyone is on the same page regarding the client’s behavior. This helps eliminate situations where the client might split staff by giving different information to different staff members.

C.

Mood Disorders

Mood disorders affect a person’s sense of well-being. People with mood disorders may be primarily depressed. They might be happy and then sad, and not know why their mood has changed. When the symptoms of the mood disorder become stronger, they may be less able to control their behavior. People with certain mood disorders may be unable to respond appropriately to social situations. Substance abuse and mood disorders often go hand in hand. People sometimes use substances, especially alcohol, to ‘level themselves out’. Clients with mood disorders may: • Make hasty/impulsive decisions like getting married after knowing someone for only a very short time • Experience bursts of energy that last for days at a time during which very little sleep is needed • Have little energy and feel like they cannot get out of bed - may require a lot of sleep • Be grandiose, self-important, and demanding • Feel that nobody understands the situation • Have periods where they feel sad and worthless • Feel as if they has no control over their feelings • Feel shame about what was done or said • Act like the life of the party; outgoing, energetic, charming and confident Medications like anti-psychotics can help to stabilize moods. Because there are many forms of mood disorders including bipolar and mania, there are multiple treatments as well. These medications may have side effects, which can be serious. Behavioral therapy, and support services such as spiritual, family and peer support can be used.

Dos and Don’ts when working with a person who may have a mood disorder 1. Do monitor for increasing symptoms. Mood disorders usually start small and then worsen.

2. Do let them know you are concerned about them by saying, “Alemitu, I’m worried that you seem to be needing less and less sleep these past few days. That doesn’t seem like you.”

3. Don’t try and tell someone who seems to be depressed or down “it’s all in your head” and that “you can feel better if you want to.”

4. Do listen for signs that a client feels so hopeless that they might be suicidal or considering hurting themselves.

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5. Do discuss with a supervisor or mental health professional when you think a client at the shelter is having a mood-related problem.

D. Trauma Disorders

Trauma is an experience that overwhelms the victim’s psychological and biological coping mechanisms. Trauma occurs when internal and external resources are inadequate to cope with stigma, poverty and threat. Trafficking victims experience stress, depression, fear, physical abuse, physical health problems and violence, all of which negatively affect emotional stability. Trauma may be the result of a single event such as a natural disaster or witnessing/experiencing a violent act, or it may be the result of a series of ordeals. Most trafficking victims face many traumatic experiences, most of which are untreated. Trauma affects how victims see themselves (“I am helpless,” “worthless”), their worldview (the world is dangerous, no one can protect me), and relationships (“I cannot trust anyone”). These beliefs affect how victims respond to services and lead to feelings of helplessness, shame, humiliation, shock, denial and disbelief. Trauma disorders limit a person’s ability to respond to their environment in productive ways. Trafficked women, who have been physically or sexually abused are more likely to develop trauma disorders, PTSD is common among human trafficking victims. PTSD symptoms may result from trafficking or pretrafficking life events. People with trauma disorders may relive the traumatic event in nightmares or have intrusive recollections, and may startle easily. They may also have other responses that can make life difficult, including feelings of being numb, difficulty communicating their feelings and problems in relationships.

PTSD associated symptoms and the percent of trafficked women who rank these symptoms as severe: Symptom

%

Recurrent thoughts/memories of terrifying events

75%

Feeling as though the event is happening again

52%

Recurrent nightmares

54%

Feeling detached/withdrawn

60%

Unable to feel emotion

44%

Jumpy, easily startled

67%

Difficulty concentrating

52%

Trouble sleeping

67%

Feeling on guard

64%

Feeling irritable, having outbursts of anger

53%

Avoiding activities that remind them of the traumatic or hurtful event

61%

Inability to remember part or most of the traumatic or hurtful event

36%

Less interest in daily activities

46%

Feeling as if they don’t have a future

65%

Avoiding thoughts or feelings associated with the traumatic events

58%

Sudden emotional or physical reaction when reminded of the hurtful events

65%

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Individuals with histories of traumatic physical and/or sexual abuse have increased risk for the development of dissociative disorders. Dissociative disorders are characterized as a ‘disruption in the usually integrated functions of consciousness, memory, identity, or perception’ (APA, 2005, p.

519). Some victims may simply not be able to recall certain events or details of events. Substance related disorders are often found to be co-morbid in victims of human trafficking. (International Organization for Migration, 2006; Zimmerman, 2003). While a few victims of trafficking reported prior substance addictions, most victims who reported alcohol and drug abuse said they began using after they were in their trafficking situations. Some victims reported using alcohol and drugs to help them deal with their situations however, others, reported being forced or coerced to use drugs or alcohol by traffickers (Raymond et al., 2002; Zimmerman, 2003).

Treatment of PTSD Among Trafficking Survivors Using a Trauma-Informed Approach Trauma-informed services are a crucial part of a victim’s recovery (Clawson, Salomon, & Grace, 2008). Trauma-informed care plays an important role in service delivery by providing a framework for accommodating the vulnerability of trauma victims. In trauma-informed care, treatment is guided by a practitioner’s understanding of trauma. Trauma-informed care should include a commitment to empowerment, victim safety, and recognition of the impact of multiple traumatic events across the course of an individual’s life. For patients suffering from multiple traumas, the therapist and patient should work together to determine the most traumatic event for the patient. For those patients who have difficulty assessing which trauma currently causes them the most distress, the therapist should inquire about the patient’s current symptoms related to each event and evaluate the severity of each symptom cluster to determine which trauma should be processed first. A focus on the most traumatic event will allow patients to learn coping skills to help decrease current trauma symptoms related to that event, and help patients practice and learn how to manage trauma in general. A trauma-informed approach is one that involves recognizing the signs and symptoms of trauma. Consider the following during service delivery: safety, trustworthiness, transparency, peer support, collaboration, empowerment, voice, choice and cultural, historical, and gender issues.

Trauma-informed therapy recognizes the signs, symptoms and the widespread impact of trauma on victims and understands potential paths for healing. As in the victim-centered approach, priority is for the victim’s safety and security. While everyone’s experience of trauma may be different, it is important to understand how trauma taxes an individual’s coping resources. It is imperative that care-workers understand trauma and how it affects victims’ responses to services.

The shelter worker should avoid victim re-traumatization thus increasing the safety of all, and increasing the effectiveness and efficiency of interactions with victims. Professional training in trauma and trauma-informed care is essential and strongly encouraged.

Smart Tips for Building and Utilizing a Trauma-Informed Lens • Build long-term, sustainable relationships to regain valued social roles.

• Provide access to trauma-specific treatment services.

• Use group therapy to address skills development, to affect regulation, to strengthen interpersonal connections and for competence and resiliency building.

• Make peer models and supports available.

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• Engage survivors in programming. • Develop alternatives to traditional therapies.

Other Therapeutic Approaches Cognitive Processing Therapy (CPT) helps in cognitive restructuring to change feelings of hopelessness regarding one’s self and the world. CPT changes maladaptive perceptions, which, in turn, lead to increased activity levels and reduced apathy and fearfulness. Survivors of human trafficking may hold strong feelings of guilt and shame about their experiences. Cognitive Processing Therapy (CPT) is an appropriate treatment strategy to promote cognitive changes with regard to guilt and shame. Also, Psycho-Education (PE) may be helpful for patients with low literacy levels and physical disabilities because patients do not need to write down an account of their trauma. For patients who have difficulty recounting details of their trauma experience, CPT may not be an appropriate approach as being able to produce a detailed account of the trauma suffered is a necessary part of the treatment. PE should be used for these patients. Given the nature and extent of the trauma that human trafficking victims experience, it may initially be difficult for them to talk about their trauma experience, leading them to avoid and possibly drop out of therapy. Therefore, treatment approaches that do not require a detailed trauma account may be best at the onset of therapy.

For depressive disorders, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are first-line treatments and are empirically supported. CBT focuses on challenging and restructuring maladaptive cognitions to effectively change dysfunctional patterns of thinking and reduce distress. The premise of IPT is that psychological well-being stems from appropriate interactions and communication with others. Therefore, IPT aims to decrease psychological distress through strengthening and creating new interpersonal relationships. Trafficking victims who abuse alcohol or drugs must deal with their substance abuse issues as well as the emotional disorders that are associated with their trafficking experiences. Victims of trafficking may develop substance dependencies as a means of coping with their horrific experiences. Traffickers may also use substances to enslave their victims.

Human trafficking survivors are a heterogeneous population with diverse experiences and thus, their mental health needs and treatment needs will differ greatly. Consideration needs to be given to individual characteristics that may impact treatment. Factors such as cultural background, level of acculturation and language should be considered and explored, as these factors may give rise to different treatment needs. It is recommended that therapists individualize and tailor elements of treatment to best suit patient needs and also, consider patient treatment preferences. For example, the use of interpreters may be warranted when working with individuals who speak a different language so that the individual feels safe and supported. Use of interpreters can aid the disclosure process and allow the patient to feel a sense of cultural connectedness. However, by having an additional person in the room, a client may fear stigma and judgment and thus, may not disclose as readily. Because of issues of fear, safety and mistrust, human trafficking victims may not seek help and may go untreated. It is imperative that patients feel safe and welcomed. To this end, and before patients can engage in any meaningful treatment, mental health professionals need to be sure that they are using a therapeutic style that is characterized by empathy, genuineness and warmth. To establish an appropriate treatment progression, therapists should carefully monitor and report the impact, progress, and outcomes of treatment. Obviously, it is important for mental health professionals to firstly consider their patients but health care providers should also be

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aware of their own emotional and professional needs. To reduce burnout and secondary trauma, mental health professions should aim to be mindful of their own emotional reactions to hearing about patient trauma and be proactive about seeking support, engaging in self-care practices, and seeking out consultation whenever needed. Although our recommendations focus on the use of cognitive approaches in the treatment of psychological symptoms for human trafficking victims, therapists should also consider incorporating exposure-based interventions and other therapeutic approaches such as relaxation techniques whenever relevant. For example, patients with PTSD, including human trafficking victims, often have persistent sleep difficulties and nightmares. These negative sleep patterns may affect a patient’s level of fatigue and psychological wellbeing as well as bring about a resurgence of symptoms. Therefore, incorporating sleep therapy or nightmare exposure and re-scripting therapy into treatment may help improve long-term patient outcomes.

When appropriate, supportive group treatments may be useful for patients.

Dos and Don’ts when working with people who may have experienced significant trauma 1. Don’t expect to discuss central traumatic events in the shelter environment. Traumatic experiences are often deeply disturbing and difficult for the person to share with others.

2. Do remain supportive and accepting.

3. Do recognize that although individuals with trauma disorders don’t always respond the way you wish them to, they are not lashing out at you personally.

4. Don’t raise your voice if a client does not seem to understand what you have just said.

Instead, approach them quietly and gently.

5. Do validate the person’s experience. If a shelter client tells you of a traumatic event, say, “Given what happened to you, it’s understandable that you feel that way.”

6. Don’t blame the client or suggest the she is somehow at fault. Do not blame the victim!

7. Do make eye contact. If the person becomes upset at eye contact, stop making it.

8. Do recognize that a first-time shelter client may find the experience traumatizing and take extra time when dealing with that person. Traumatized people may need things explained to them several times before they fully understand them.

Triggering Re-traumatization Gaps in both the criminal justice and victim services systems can re-traumatize survivors. Key triggers to re-traumatization include: feeling a lack of control, experiencing unexpected change, feeling threatened or attacked, feeling vulnerable or frightened and feeling shame.

Providing culturally appropriate and trauma-informed mental health treatment can be challenging.

Some of the commonly reported barriers and challenges to helping victims with their trauma include: • Limited availability and access to appropriate mental health services • Difficulty establishing trusting relationships with survivors • Co-occurrence of trauma and substance abuse or addiction • Victims with long histories of poly-victimization • Victims who choose not to label their experience as abusive • Cultural, linguistic barriers and isolation from home community

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Dear Shelter worker,

All interaction with a victim is based on creating a situation in which the victim feels safe, understood and makes his or her own choices. Do you often do this? What are the indicators for this? Can you give examples? PTSD and depression are the most common of the four mental disorders that trafficking survivors experience.

What treatments for these two disorders worked best for you? What interventions have you used that have actually had poor outcomes or even worsened a client’s behavior?

Note Dear Shelter worker, PTSD and depression are given more attention in this section because these two mental illnesses are the ones most often experienced by trafficking survivors. To help you conceptualize the entire mental health process, I have developed the following simple model.

Perceived stressors: Include major life events (both positive and negative), dally routiness and other predisposing issues. We also call these risk factors

Symptoms: Worried, frustrated, loss of appetite, irritability, feel bad about self, anhedonia

FIDO-C

(Frequency, intesity, duration, on set and context

Result

Impairment in functioning: career, home, school, social relations, personal life, spirituality, marriage, etc

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Possible supports: Protective factors such as personal resilience, mindfulness, support to improve their family relations, friendships, spirituality..etc.

Session 7: Counselling and Psychosocial Assistance

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Dear Shelter worker,

Mental health outcomes, illness or wellbeing, are a product of how we think and the relationships we have with others. Trafficking affects how we think and how we relate to others. So, two major interventions to help clients are 1) to develop more positive thought processes and 2) to form healthy relationships with others including family, friends, neighbors, and other community members. This calls for counseling. By and large, the central support system for victims of trafficking and domestic violence is counseling. Unless a mental health issue is biologically rooted and medication is necessary, counseling is highly recommended and is the best method for helping to heal relationship problems. Counseling is preferred because it has limited, or no significant side effects compared to medication.

Session Objectives Dear Shelter worker, After going through this session, you will be able to: • Develop the role of counseling in rehabilitating VOT • Describe the types of counseling and therapy best suited to VOT • List key considerations during counseling • Identify qualities required of a counselor

7.1. Conception and Objectives of Counseling The term “psychosocial” refers to the dynamic relationship between psychological and social elements affecting human development. The concept of psychosocial is closely linked to the concepts of “well-being” or “wellness”. Most definitions of psychosocial assume that psychological and social factors are responsible for the wellbeing of people. Humanitarian agencies have come to prefer the term “psychosocial well-being” over narrower concepts such as “mental health”, because it points explicitly to social and cultural as well as psychological influences on well-being.

The term psychosocial implies a very close relationship between psychological and social factors.

The psychosocial wellbeing of an individual is defined with respect to three core domains: human capacity, social ecology, and culture/values. Psychological factors include emotions and cognitive development; a person’s capacity to learn, perceive and remember. Social factors refer to a person’s capacity to form relationships with other people and to learn and follow culturally appropriate social codes. Human development hinges on social relationships. Forming relationships is a human capacity as well as a human need, a factor that becomes especially relevant in humanitarian work.

Psychosocial care and support are interventions and methods that enhance a person’s ability to cope in his or her own context and to achieve personal and social well-being. The psychosocial

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support approach was developed for helping people in situations of emotional distress. It includes various activities that protect people in stressful and difficult situations and provides them with positive human relationships to help restore their sense of self-respect and ability to overcome anxiety and despair. The specific objectives of psychosocial support programs are to reduce the impact that stress and emotional distress have on individuals and to strengthen individuals coping mechanisms for the healing process. Psychosocial interventions seek to ameliorate the effects of negative thoughts and behavior through facilitating activities that encourage positive interaction between thought, behavior, and the social world.

General Concept of Counseling Counseling entails the following:

ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ

Helping a person who has experienced social or psychological problems like trafficking The counselor and the client have a special yet professional relationship It requires good listening skills The counselor is professionally trained and if possible, certified.

It is characterized by confidentiality It is based on the willingness and consent of the client, in this case, the survivor The counselor/counselee relationship is based on equality and dignity Helping the client to see her strengths Counseling is a support meant to show the positive side of life Counseling helps the client make meaningful decisions

Understanding what counseling is, and what it is not:

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Counseling is not giving advice

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Counseling is not probing the client or soliciting information

Counseling is not giving information, though giving information may be part of it Counseling is not deciding for the client but helping the client to examine alternatives to make her own decision Counseling is not judging or blaming the victim for her behavior or decision Counseling is not preaching or teaching the client Counseling is not giving promises that cannot be fulfilled Counseling is not arguing with the client Counseling is not imposing attitudes on the client

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Post-session Questions

Dear Shelter worker, Which of the above actions have you been mistakenly doing in counseling? Which of the above suggestions do not make sense to you? Which of the suggestions is difficult to implement?

Objectives of Psychosocial Counseling The major goals of counseling are to help clients change behaviors, improve psychological health, enhance their capacity to make informed decisions, improve relationships and improve assertiveness. For most victims, counseling sessions deal with problem solving strategies and coping mechanisms. Main concerns for clients during counseling sessions:

ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ ᴥ

Restoration of emotional stability and physical wellbeing Personal safety and protection The need to contact family members and return to the community Response available from family and community for possible return and reintegration Where and with whom they will live Establish or rebuild coping mechanisms and decision-making skills Build confidence to competently function economically and socially Help develop mental and social resources to realize potential

Help formulate practical solutions according to needs and circumstances Finally, counseling is meant to empower these women and to encourage them to make informed decisions competently and independently.

Types of Counseling Counseling can be provided both at an individual and group level. Counseling can also be oriented to social support such as spiritual counseling, family counseling or peer counseling. There are many types of individual counseling; psychoanalytic approach, behavioral therapy, cognitive therapy, cognitive behavior therapy (CBT) and its related cognitive processing therapy (CPT), rational emotive therapy, client-centered therapy, logo therapy, trauma focused counseling, psycho-education, eye movement desensitization re-processing (EMDR), positive psychology, eclectic approach, mixed model…etc. Each of these is rooted in major theoretical formulations.

Each approach requires specific procedures and skills. Depending on the situation of a client, each type of counseling has its own advantages and limitations.

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Dear Shelter worker, Presenting you with a detailed explanation of every type of counseling is beyond the scope of this curriculum material. Let’s have a look at cognitive behavior therapy (CBT) on its own. This therapy involves: • Facing disordered and irrational thoughts and feelings • Encouraging a client to have positive thoughts about her internal feelings • Identifying the client’s level of feelings • Using systematic desensitization • Helping clients to stop irrational thoughts • Providing trainings for clients on social skills • Giving assignments to be done by the clients The recommendation in the mental health field is to have an integrated care approach where psychiatrists, psychologists, social workers and nurses all work together. An integrated care approach is multifaceted, interdisciplinary and inter-professional. It aims to provide greater service accessibility, patient and service provider education and coordination as well as improved quality of care. VOT need support, validation, and a sense of safety as they deal with physical, emotional, and psychological wellness. Translators and language services as well as culturally and gendersensitive treatment teams should be made available. Providers need to be aware of patients’ potential resistance to accessing care.

Peer counseling is one of the preferred treatment methods as it avoids a traditional approach to trauma treatment that positions service providers as authority figures. Peer-to-peer counseling when offered by survivors, who are now working in shelters, is a wonderful source of support for victims. Victims are often more comfortable with empathetic peers who understand them and who have lived through similar painful circumstances. Peer-to-peer mentoring is also a way to help survivors build a new identity and remove feelings of isolation. Client-centered supportive partnerships that address social, political, and economic difficulties are indeed worthwhile.

Dear Shelter worker, The number and frequency of counseling sessions needed depends on the severity of a client’s problems. You will meet victims who have dealt with horrific situations such as physical and emotional abuse, having a child taken away or killed, and being raped by fathers or other family members. Other victims have dealt with less severe situations such as salary denial or frequent insult. The severity of the victim’s experience will dictate the number of sessions needed for rehabilitation. Literature shows that most clients will require between 6 and 10 counseling sessions. When using CBT, fifteen sessions is the norm. In some cases, as few as 4 or 5 sessions may work if the issue is well sorted, specific and focused. In other cases, clients may have to explore deeper problems, which may take months or even years to work through. The only thing that is clear is that most problems will not have a quick fix. As to the length of a session, individual counseling often lasts 50-55 minutes. Relationship counseling may last 75-85 minutes.

Considerations During the Counseling Service

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Ask questions about the client’s experiences and feelings

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Help the client to prioritize problems Give shape and structure to the counseling service – set goals

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Identify issues concerning health, family relations, community re-unification concerns, career concerns etc.

Identify the role of the client and the counselor Provide sufficient and relevant information to help the client make proper decisions

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Establish a good relationship with the client to build trust

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Improve the client’s coping and problem-solving skills

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Follow up, evaluate and write a report

Encourage the client to speak about the problem and provide emotional support Arrange the place and time for counseling sessions Paraphrase, elaborate, examine and summarize the client’s statements and experiences Validate the client’s experience Estimate the level of the client’s problem Prepare an action program for the counseling session Fix the next appointment – day, time and venue Identify relevant resources Ask the client about the topic being discussed at the end of their last appointment Help the client to examine diverse life alternatives and help to generate solutions together with the client Align counseling with other services working in collaboration with nurses, case managers… etc.

Dear Shelter worker,

To what extent do counselors at GSA implement the above activities? Is there something you think is missing from the above list that should be added? Which of the suggestions is not meaningful?

Behaviors required of counselors

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Respects self and others Is humble Is patient and has emotional self-control Can maintain confidentiality Listens a lot and speaks less Accepts behavioral differences among people Has balanced thoughts and reserves judgment Is truthful and does not give false promises Is a positive thinker and is soft-hearted Has sufficient knowledge about the topic/issue Can share feelings and be empathetic

Dear Shelter worker,

Which of these qualities do you think you possess?

Which ones should you work on?

Sample Case Story ( Lubaba is a pseudonym) Lubaba is 25 years old. Both of her parents died when she was young. Since there was no one to help her, she dropped out of school after grade five. She had no job opportunities in her hometown so after discussing it with her brothers and sisters; she decided to migrate to Saudi Arabia. Her brothers contributed the money (5,000 ETB) for her journey to Yemen. When she disembarked from the boat in Yemen after crossing the Gulf of Aden, gangsters raped her and she lost her virginity. She travelled 20 days on foot from Yemen to the border city of Jizan in Saudi, helped by only one elderly, adult man. The man found her employment in a household in Jizan.

The man secretly dealt with her employer and began to take her salary month after month for a year. Eventually, she left this house because two of the sons of her employers raped her. She found employment in another house in Jizan. After working for three months, she feared that the man might take her salary so she went to Jidda and found another job. After working for eight months in Jidda, the police caught her. Before deportation, she had a health screening. After the health test, everyone began treating her as a despicable person because she was HIV positive. She is not sure who infected her.

Lubaba said she had heard about the plight of trafficked women before her migration but her situation in Ethiopia was dire so she just said, “Let me go and if I die, let me die.” She says that anyone who migrates particularly by getting smuggled does not have peace.

The smugglers beat us in addition to gang raping. Rapists made us stand naked and used gloves to insert their hands into our vaginas to search us. Asked why they searched their vaginas

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she said they suspected us of hiding money and mobile phone. They said that Habesha are shrewd. After searching, they again had sex with us. In the presence of 30 or 40 other males, they forced us undress while threatening us with their knives and razor blades. They made us sit and stand up several times while we were not even wearing our pants and bras. We did not refuse because we did not want to lose our lives. We gave the money we had and we also got raped.

Now, Lubaba says that she is not a normal person. She merely exists. She is living on the outskirts of a small town renting a house for 20 ETB and baking injera for people. Her monthly salary is 25 ETB. She described how her third employer degraded her.

One day my female employer told me to boil water. The water boiled a lot and I said, “What is it for ma’am?” She said to let it go because she wanted it very hot. I reduced the heat. She said, “Why did you reduce the heat?” I reduced the heat to save energy. She made me enter the bathroom and she shaved my hair with that hot water. I said, “Why did you do that to me?” She said, “You Habesha’s have a stinky smell and you are never without disease. We get diseases from you. You bring HIV to us. You also come with hunger.”

There is a lot of temptation to migrate but now that I have tried it I will never do it again even if they tell me to go again because I have seen the pain. I have tasted the bitterness. I have picked up my poison (the disease). People who have not experienced it say, “Let’s go and die.”

They are getting ready to leave. They will be going.

With regard to what affects her most, she said, All will be forgotten and pass away but I very much feel acquiring the disease (AIDS). Yes, that is what I feel most. Money, you get it and lose it but what can you do with the disease? I can do nothing with this disease. This is what I feel. I am not so upset about not bringing money home or the labor that I have exerted.

She also feels the discrimination because of her zero-status here in Ethiopia.

Here they discriminate and take you as despicable. When they see me, they cover their mouths. They assume that baking will transmit the disease. About Habesha’s, they say, “Riha” (dirty/filthy) in Arabic...weee (Amharic tone to express grievance) they make us suffer much… as to me I am tempted…but just that was also better for me…at least I will get some money, something to eat but here…my tea room was being frequented…but if someone says she has the disease (AIDS), they consider you despicable as if the disease will be transmitted by any means.

Dear Shelter worker,

What are Lubaba’s issues? Can you prioritize her issues?

Discuss how you might counsel this woman? What support does she need?

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Dear Shelter worker,

Do you think recreational activities are luxuries that only rich people can enjoy? Do you think they are too expensive? Do you think they are meant only for entertainment? If you said yes, I think you are wrong. In fact, recreational activities are vital for everyone and they don’t have to cost a lot. Activities are not merely meant for entertainment but rather, have significant healing effects particularly for traumatized individuals.

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Session 8: Recreational Activities for Victims

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Session Objectives

After completing this session, you will be able to: • Explore the possible recreational activities appropriate for VOT • Properly manage recreational activities involving VOT • Ensure the safety of recreational activities offered to VOT

Role of Recreation in Rehabilitation

Art therapy and music therapy are frequently used to help survivors build connections between their physical symptoms and mental health. It is good to combine counseling with a host of other services including alternative trauma treatments such as art therapy, massage, healing touch, movement and drama.

Dear Shelter worker, Can you list the recreational activities available for VOT at GSA? Do you think they are adequate?

What activity should be added?

There are many traditional and modern recreation possibilities such as checkers (dama), chess, hide-and-seek, volleyball, tickler (enqoqlish), puzzles, story-telling, presentation of speeches, fairy tales, folklore, reading comic books, drawing, painting, listening to music, composing drama, role playing and visiting attractions…etc.

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Dear Shelter worker,

Please add more activities to this list. There are so many options!

It is important to carefully plan all activities and ensure that they are included in the weekly schedule of events at the shelter.

Sample Recreational Activities 1. Physical exercise and breathing - This is important for both physical health and to reduce anxiety. If it is safe and if they have the strength, clients may be encouraged to do simple wrestling as it develops strength, resilience and identity.

2. Folk dance to selected music either traditional or modern 3. Tree of life exercise - Pretend to be a tree where you sit with legs and hands folded. Slowly unfold arms and legs upward and outward to grow into a tree. Shrink in winter, blossom in the spring, grow fruit in summer and harvest in autumn. Tell clients to attach their life developments across these stages.

4. Guided Imagery - Close your eyes and meditate on a landscape – one that you like – maybe it is familiar from your childhood or adulthood or maybe you are inventing it. Walk through the landscape looking around it.

5. Draw a picture of a tree – Place your picture near where you think it is in relation to other trees – create the ‘Forest of the Group’.

6. Relaxation exercise – Play gentle music while you sit or lie comfortably and reflect on your journey in life.

7. Mime - Copy voices of animals, celebrities…etc.

8. With a partner, create a problematic situation from which you must plan an escape. Then, with a partner, play a trust game in which you close your eyes while your partner takes you on a ‘blind walk’. This trust exercise establishes safety again after the ‘escape’ theme, which is a major topic for these women and raises questions such as: What am I escaping from?

Myself? My situation? My oppressors? Who is a trusted supporter? Family? Shelter worker?

Local officer…etc.

As survivors get rehabilitated and stabilized, they will also start to engage in work activities such as cooking food, preparing coffee, cleaning and other activities that hopefully, will give them a positive sense of well-being.

An important message at this juncture is to be cautious with materials used for recreational activities. These materials could be used to self-harm or to harm other clients and staff at the shelter.

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Dear Shelter worker,

Have you had experiences where recreational materials have been used to harm?

If not, can you think of any recreational materials that could be used to harm?

One means of reducing the possibility of the misuse of recreational materials is to closely monitor all recreational activities in the shelter. It is good for shelter workers or other staff members to become part of the play as this helps to develop trust with clients as well as allows the staff to offer guidance and to notice risks. It is also important to set clear ground rules for all recreational activities. Encourage creativity in clients when possible.

Dear Shelter worker,

The choice of recreational activity will depend on availability of resources and also on the health of the VOT. Please create a detailed plan for a play activity for both an individual client and a group of clients. Make sure that shelter staff including case managers, are involved in the activity. For more options of recreational possibilities, look at the list of over 80 self-care activities to reduce burnout among shelter staff in session 11 of this document. The frequency and intensity of the recreational activities will depend on the health of the women.

It is recommended to schedule activities mid-morning (10:30 am), afternoon (3:30 pm) and before bed in order to induce sleep. The case manager, in consultation with the clients and other shelter staff members, must determine all scheduling.

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Session 9: Basic Skills Training

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Dear Shelter worker,

Accommodation, medication, and counseling are needed to rehabilitate VOT but successful reintegration requires strong empowerment and capacity building work for clients. Empowerment trainings can be split into two categories: Life skills training and Business/financial education.

Session Objectives After completing this session, trainees will be able to: • Provide relevant life and entrepreneurial skills to VOT • Know the requirements for effective communication • Describe the steps to be followed in decision making as a life skill • Identify the characteristics of an entrepreneur • Guide VOT to develop skills in starting and improving their businesses • Know key strategies/techniques for successful job placement • Sort out the challenges and obstacles in economic empowerment of VOT • Discuss the topical issues related to financial education for VOT

9.1. Life Skills Training Life skills have become a vital component of trainings for various vulnerable groups. Life skills training for returnees contribute to a successful, healthy and peaceful reintegration. The specific components in life skills are: Communication, decision-making, problem solving and critical thinking.

A. Relationship and Communication Skills

Dear Shelter worker,

At the end of this session you will be able to: 1. Identify the four basic components of communication.

2. Use the requirements for effective communication.

3. Understand the requirements related to better communication with VOT.

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Communication is the exchange of message and meaning between two or more people. The forms of exchange include: When one thinks within himself/herself Exchange of ideas among two or more people Exchange of ideas within a group Exchange of ideas among two or more groups In any communication, there are five components namely: participants, message, channels of communication, barriers to communication, and feedback.

The means of communication may be oral, nonverbal, visual or audio-visual.

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Below is a model of communication

Model of Communication Process SENDER DECODES MESSAGE

Channel

RECEIVER DECODES MESSAGE

Noise (Return message decoded)

Feedback Loop

(Return message decoded)

Channel

Effective communication requires doing the following: • Choosing appropriate words • Understanding messages - being brief and clear • Using non-verbal communication • Giving constructive feedback • Asking about what is not understand • Telling the truth • Removing barriers • Having eye contact • Putting oneself in the shoes of the speaker – showing empathy • Listening more than speaking and waiting for a turn to speak • Appreciating others’ ideas, respecting others’ ideas and not focusing on criticism • Understanding the speakers’ emotions • Not crossing the speaker’s boundary Communicating effectively with VOT requires: • Gaining the trust of trafficking victims as a first step to helping • Showing that we are there to help them • Informing that our priority is their safety • Informing that we are there to give them medical care when needed • Indicating that we can find them a safe place to stay • Informing them that they have the right to live without being abused • Telling them that we are there to help them learn to be self-sufficient and independent • We are there to help them get assistance

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B.

Decision Making Skills

• • • • •

Take time to think critically before deciding Question the importance of the decision Examine ideas from different angles Think about the process and outcome for alternative decisions Once the decision has been made, implement it properly

Decision-making means choosing one option among many possibilities. Life is full of decisions.

Some decisions are routine like choosing what food to eat while others are so critical that they may affect our entire lives; marital decisions, career decisions, migration decisions, investment decisions and decisions regarding education. We may be happy about some of our decisions but disappointed in others. Some decisions may change the course of our lives for better or for worse.

So, we need to make informed decisions.

Benefits of informed decision-making are: • To be successful in life • Enhance our confidence enabling us to know our beginning, our process and our end • To reduce errors • To accomplish things in the required time, place and situation • To identify solutions or alternatives to our problems

Effective decision-making requires the following principles • Knowing one’s strengths and weaknesses - Shelter workers should help VOT to identify strengths and weaknesses • Knowing one’s limits (capability) - For example, in business decision-making, shelter workers can support VOT to identify their financial, skill and educational limits.

• Knowing our environment - opportunities, challenges and change alternatives • Identifying our emotions and realities - For example, VOT may dream of being rich within a short period of time. Shelter workers can help VOT stay grounded and make realistic decisions.

• Not making decisions when we are stressed out Steps in decision making • Knowing the objective • Thinking and rethinking about the issue • Collecting evidence • Deeply thinking about alternative solutions • Examining the strengths and weaknesses of each alternative • Choosing one of the alternatives • Implementing the decision • Evaluating the decision-making process

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Post-Session Questions

Dear Shelter worker, Do you think you are meant to decide for a client? What do you think will affect the decisions of trafficking survivors? Can you give an example of a very important decision that you made in your life? Was it an informed decision? Are you happy about your decision or do you regret it? Can you provide an example of one informed and one immature decision that a client made that affected her life for better or worse?

Dear Shelter worker, Other relevant life skills worth teaching to VOT: critical thinking skills, problem solving, managing emotions, assertiveness and resisting peer pressure.

9.2. Business Skills Planning Dear Shelter worker, Life skills help VOT to be socially and psychologically functional but at the end of the day, their greatest concerns are finding a job and earning money. Having a vision, using time effectively, saving resources, making investments, entrepreneurship, having skills to do a job, being responsible, starting and improving a business are all crucial skills for VOT. Dear Shelter worker, The objectives to be achieved by participating in business skills training are: • To gain entrepreneurial skills • To learn how to develop a concrete business idea and plan • To learn how to establish, grow and manage a business • To learn business strategies and to manage competition • To gain more knowledge about running a business

9.2.1. Entrepreneurship

Entrepreneurship has three characteristics: innovation, business skills and risk-taking. Teaching entrepreneurship to trafficking returnees will help them to gain confidence and understand the business environment in which they hope to operate (Skripak, 2016). Entrepreneurship is the capacity and willingness to offer a new product, apply a new technique or technology, open a new market, or develop a new form of organization for producing or enhancing a product.

An entrepreneur typically combines resources to produce goods or services to make a profit.

Entrepreneurs work under a certain degree of uncertainty and must be willing to take risks. The process of generating and identifying the most appropriate idea for starting one’s business has five key components: 1. Assess one’s skills, experiences and personal characteristics as an entrepreneur 2. Understand what makes a successful business idea

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3.

4.

5.

Identify many potential business ideas Analyze these business ideas Select the most suitable business idea

Characteristics of an Entrepreneur 1. Skillful 2. Creative personality 3. Pioneer of economic development 4. Creator of wealth 5. Risk-taker 6. Innovator 7. Plan-maker 8. Dynamic leader 9. Self-confident and ambitious 10. Adventurer A person’s entrepreneurial endeavors might be influenced by the following factors: His or her educational level, presence of legal support, availability of infrastructure, presence of institutional support, one’s financial capacity, one’s communication skills, availability and capacity to use proper information and communication technology, adjustment to rapid changes, support from stakeholders, and trends of globalization.

9.2.2. Starting and Improving Ones Business (SIYB)

SIYB emerged from the ‘look after your firm’ training package developed in the 1970s by the Swedish Employment Federation for SMEs. Then, in 1977, Sida funded ILO to customize this material to reflect the needs and situations of entrepreneurs in developing countries. Until 2006, over 150,000 entrepreneurs, 3,500 trainers and 400 organizations in 96 different countries from Asia, Africa, Eastern Europe and the Middle East, benefited from this project (ILO, 2014). SIYB is now an ILO trademark or flagship material. SIYB has four components namely: GYBI (generate your business idea), SYB (start your business), IYB (improve your business) and EYB (expand your business). SIYB was designed mainly for disadvantaged groups like women, people with disabilities and migrants. SIYB is available both as a training and self-help tool. The main purpose of SIYB training is to enable potential entrepreneurs to start their small businesses and, for existing entrepreneurs to develop and strengthen their basic management skills for better performance and profitability.

SIYB Objectives 1.

2.

3.

4.

5.

Define entrepreneur and describe the three characteristics of entrepreneurial activity.

Identify five potential advantages to starting your own business.

Define a small business and explain the importance of small businesses to the economy.

Explain why small businesses tend to foster innovation more effectively than large ones.

Describe the goods-producing and service-producing sectors of an economy.

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6.

7.

8.

Explain what it takes to start a business and evaluate the advantages and disadvantages of starting a business from scratch, buying an existing business, or obtaining a franchise.

Explain why some businesses fail.

Identify sources of small business assistance from the Small Business Administration.

The SIYB program is a system of inter-related training packages and support materials for smallscale entrepreneurs to start and grow their businesses. It is structured into four separate training packages that cater to (potential) businesses at different stages of maturity: 1. Generate Your Business Idea (GYB) is a training program which is customized for people who would like to start a business and it helps them to select the most feasible business idea.

2. Start Your Business (SYB) is for potential entrepreneurs who want to start a small business.

The program is a combination of training and practical support that helps participants to assess their readiness to start a business, prepare a business plan and take the necessary steps to get a business started.

3. Improve Your Business (IYB) introduces already practicing entrepreneurs to good principles of business management. Its 6 modules (Marketing, Costing, Buying & Stock Control, Record Keeping, Planning and People & Productivity) can be taught individually or as a full course.

4. Expand Your Business (EYB) gives growth-oriented SMEs practical tools for business growth and assistance through training and non-training interventions focusing on business strategy.

The Golden Rules in SIYB Implementation are: aiming for impact, responding to demand, keeping up technical quality, reaching scale through SIYB’s multiplier effect, strengthening financial viability, adapting & responding to needs, monitoring & measuring results, promoting, and finally, planning for sustainability. Evidence shows that 70-95% of GYB clients develop a feasible business idea after they finish the training. SIYB trainings enhance self-reliance, as well as foster social and economic reintegration.

Some of the strengths of the SIYB training manuals are: its modular approach which allows partner-agencies to adapt the training program to target groups, its simplicity to understand, its practical content, its step-by-step approach to learning, its action-oriented and highly participatory approach, and its monitoring and evaluation system which is helpful for everyone at all levels including entrepreneurs, trainers and master trainers (SIYB Bulletin, 2011).

One concern in using SIYB is that it assumes that people in the program have potential entrepreneurial qualities but it is difficult to expect everyone to be an entrepreneur. Some of the trainees used SIYB and found it to have a ripple effect on family members who also became interested in starting a business.

Methods of Delivery in SIYB Games - Simulations of business models with potential risks and consequences Role-playing Case stories Exercises and activities Peer counseling Graphs Video links -Videos of the best SIYB trainings can be downloaded and used.

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Some methods relevant for SIYB training and their benefits are described below: a. b. c. d. e.

Case studies: are used to show and practice decision-making, problem solving, and understanding ways of doing things.

Critical incidents: are used to explore the existing ways of seeing things and testing experiential knowledge. Are entrepreneurs born or made? Do you agree with this?

Anecdotes: are used to link theory with practice through telling stories or giving examples Drawings: are used to stimulate creative expression, build confidence as to how a person sees things and to show feelings and emotions.

Quizzes: are used to test the existing knowledge of participants and provide a basis for discussion.

Dear Shelter worker,

SIYB manuals are available on ILOs website if GSA decides to actually give the training but it seems better to refer clients to other relevant organizations for such training.

What makes a good business idea?

A good business idea is based on: • Products or services that customers want • Products or services you can sell at a price most customers can afford, and which will give you a profit • Products or services that have little negative impact on your family and community’s environment • Knowledge and skills you have or can get • Resources and money you can invest

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All good businesses begin with a good idea that has been well thought out. Below is the SIYB model.

SIYB SMALL ENTERPRISE MANAGEMENT TRAINING SOLUTION

PROGRESS

EXPAND

EYB

CONSOLIDATE

IYB SYB

START

TIME PREPARE

GYB

Fig 3 adopted from ILO SIYB document

The five key issues to go through in the process of generating and identifying the most appropriate business idea for starting your business are: • Assessing your skills, experiences and personal characteristics as an entrepreneur • Understanding what makes a successful business idea • Identifying many potential business ideas • Analyzing these business ideas • Selecting the most suitable business idea Small Business Administration suggests assessing your strengths & weaknesses asking relevant questions:

ᴥ ᴥ

Am I a self-starter? You’ll need to develop and follow through on your ideas.

ᴥ ᴥ

How good am I at making decisions, especially under pressure?

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How well do I get along with different personalities? Strong working relationships with a variety of people are crucial.

Do I have the necessary physical and emotional stamina? You should expect to work 12 hours a day for 6 or 7 days a week.

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How well do I plan and organize? Poor planning is the culprit in most business failures.

How will my business affect my family? Family members need to know what to expect: long hours and, at least initially, a more modest standard of living.

Strategies and Techniques for Successful Micro Business Development • Provide professional business training • Undertake professional market appraisal • Conduct feasibility assessments • Provide small business grants and loans • Provide vocational training where requisite skills are not pre-existing • Subsidize during initial start-up phase of the business • Provide legal advice and assistance in setting up a micro business • Combine social support and micro business development skills • Provide on-going support and counseling while starting up and running the business • Monitor using a multi-disciplinary team • Provide an “emergency fund”

9.3. Employment Opportunities Dear Shelter worker, Every client is not likely to be an entrepreneur. Some clients may not develop the entrepreneurial spirit even after business training. You will need to think about job placement for your clients who do not wish to start their own businesses. Clients will need to be prepared. Below are some strategies you may use to support your clients as they are placed in jobs.

Strategies and Techniques for Successful Job Placement • Assessment of labor market and realistic job opportunities • Skills development and vocational training • Job counseling and work readiness programs • Increased involvement of state employment agencies in job placement • Employment mediation • Sensitization of employers about trafficking victims • Apprenticeships and on-the-job training • Use of affirmative action employment policies • Options for work in the state/public sector • Strategic partnerships with organizations focused on vocational training and job placement • Database of vacancies for vulnerable persons Challenges and Obstacles in Economic Empowerment of Survivors Things to focus on: • Finding job opportunities given the client’s lack of experience in a competitive job market

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• • • • • • • • • • • • •

Stress, anxiety, trauma Insufficient level of education or professional skills to find a “good job” Lack of confidence in one’s own capacity Unrealistic expectations about work and salary Inadequate or unavailable vocational training opportunities Vocational training that does not align with market realities Unsuitable employment options Labor-intensive process to find and follow job placements Issues in job retention Limited number of “good jobs” Stigmatization and discrimination Preconceptions and biases of employers Practical barriers, such as childcare and transportation

9.3.1. Proper Use of Resources and Financial Education

Dear Shelter worker,

If a trafficking survivor is to benefit from doing business and being employed, it is important that she uses her resources wisely, is financially educated and is capable of making good financial decisions. Resources may include money, property, time, skills, health and relationships. Principles for proper use of resources include: 1. Proper identification of resources (wealth) 2. Knowing for what purpose, when and how to use resources 3. Using a proper plan to reduce unwise use of resources 4. Using tacit resources (skills, relationships) properly 5. Giving attention to one’s health The client must identify useful resources, know how to properly use these resources and understand the challenges or barriers to using these resources. There is an Amharic saying “kemogn ber mofer yiqoretal” which means, ‘in the very doorstep of an unwise person, others will collect an important item which he has not noticed’.

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Suggestion Dear Shelter worker, For more details on specific training, you can use the TVET modules on caregiving, domestic work and household service. As it may be difficult for GSA to provide trainings, it is perhaps better to refer or link clients with organizations already giving the training. At this juncture, ask clients if they prefer to work in a private, family or group business. Also, share success stories about former clients who were rehabilitated by GSA and who have done very well in business. Finally, if a client is not interested in starting a business and prefers finding a job, you may connect them to local GOs or NGOs who offer employment particularly to vulnerable groups.

If available resources are used properly, a trafficking survivor can expect: • • • • • • •

To lead a happy, healthy, and bankrupt free life To accomplish what she wants to accomplish To solve her problems using her own capacity To reduce threats in her life To avoid unwanted decisions like re-migrating To withstand undesirable influences from others To enhance her acceptance by others

Financial Education Financial literacy is the ability to make informed decisions and to take effective actions regarding the current and future use and manage¬ment of money. It includes the ability to under¬stand financial choices, plan for the future, spend wisely, and manage the challenges associated with life events. Financial education will provide trafficking survivors with the tools, products and skills to make the most of their income. Financial education means proper training concerning earning, spending responsibly, saving, budgeting, staying within the budget, making a household budget, remitting, investing, good and bad debt, the dangers of being in debt and default & asset accumulation. The ‘Budget Smart Financial Education for Migrant Workers and Their Families’ Training Manual from ILO (ILO, 2011) added training involving financial goal setting (How do we finance our goals? How much does it cost to reach the goal?), family decision making, managing money, risk management, spending decisions, equity or debt financing, financial negotiations, pathways to earning money (wage-employment or self-employment?), skills and work choices.

Financial education promotes empowerment, positive attitudes towards saving, more prudent spending and borrowing as well as better record keeping. The impact of providing financial training goes beyond the survivors and in the end, benefits their whole families and communities as well.

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Financial education for trafficking survivors has the following direct and indirect benefits: 1.

2.

3.

4.

5.

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Deeper understanding of risks and benefits of financial services such as credit Higher household savings levels Protection against unfair, discriminatory practices such as predatory lending Management skills in finance so that informed financial decisions are possible Better budget planning, increased savings and more thoughtful spending and borrowing

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How is it delivered?

• Through training sessions using a participatory approach, through techniques such as roleplaying, case studies, brainstorming, and small group discussions. GSA can refer survivors to other organizations such as Women In Self-Employment (WISE) for training.

• The separate and detailed training curriculum can be prepared and delivered through individual sessions or in classroom trainings.

Budget Smart - Financial Education Training for trafficking survivors and their families may focus on the following topical issues • Financial goal-setting and family decision-making • Budgeting and staying within the budget - including a family household budget • Managing your money

Planning ahead • Savings - plans, decisions, comparing saving services and spending decisions • Equity or debt financing and dangers of over-indebtedness and default • Risk management • Financial negotiations • Pathways to earning money: Skills, work choices, wage-employment and self-employment

Dear Shelter worker,

Financial skills trainings can be provided either within the shelter or outside of the shelter. Setting financial goals, saving and investment decisions encourage the whole family to be involved. Below is a hypothetical case for you to read. Make suggestions about counseling and training related to financial education.

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A young Ethiopian woman who was working in Saudi Arabia did not know how to remit money back to her family in Ethiopia. She decided to trust her earnings to her neighbor, a young man who promised to send the money to Ethiopia. The young man took the money from her every month but only remitted half of it and kept the other half for himself. The young woman was unaware that the man was stealing her money. Her family in Ethiopia used all the money that she sent for their daily needs. Her family saved nothing for her. When she returned to Ethiopia after finishing her two-year contract, she learnt that no money had been saved for her. She got mad at her family and left home.

She began to live with her friend whom she knew before migration. The young woman was disappointed and she soon spent the little remaining money she had brought from Saudi Arabia. Eventually, she was left with no means of survival so she began to have casual sex with multiple men in exchange for money. After some time, she decided that her only course of action was to go back to the Middle East to work. During the process of reintegration, she had a medical check-up where she learnt that she was HIV positive.

She became confused. Her physical and mental health deteriorated to the point where she was referred to your organization. a. For counseling, what are the issues of concern? b. Outline the procedures of support for this young woman.

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Session 10: Supervision, Monitoring and Follow-Up

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Pre-session Questions

Dear Shelter worker, What is supervision to you? Whom do we supervise? Why do we supervise? Have you taken a course or training on supervision before?

If so, what are the types of supervision? How can we use data from supervision? How does supervision contribute to create a healthy workplace culture?

Objectives of the Session Dear Shelter worker, The general objective of this session is to help you to be competent in supporting employees at GSA. Shelter staff must be capable, well trained, be able to follow instructions and want to remain in their jobs. The specific objectives are to enable you to: 1. Motivate employees to be productive and understand shelter clients’ needs.

2. Conduct effective supervision of the shelter’s staff and clients.

3. Deliver effective feedback to frontline staff.

4. Create a positive workplace culture where there is open communication, tolerance, and dignity.

5. Examine the different supervisory styles.

10.1. Concept and Role of Supervision Dear Shelter worker, Providing shelter to victims of trafficking, is a little like constructing a building. Supervision is the cornerstone, a key piece that holds up the structure. To do their job right, frontline employees need a secure foundation. The supervisor must provide that foundation of understanding and knowledge about acceptable work practices and behavior. The supervisor must provide the guidance, support, and feedback that help the employees to do their best. Employees need to understand what is expected of them, and it is the supervisor’s responsibility to communicate this information in a way that can be best understood.

Supervisors provide frontline staff with ongoing support in two main areas: 1. Performance: Assist staff to review their performance, troubleshoot challenges identified in their work, and provide feedback as to how they can improve their response to these challenges. This area sometimes includes giving advice. By doing so, supervisors help to maintain high standards of service within the shelter. Supervisors provide structure and support to staff members in such areas as: a. Address and reduce stress, anxiety, re-traumatization and vicarious trauma among clients b. Process and debrief following a crisis or traumatic event

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c. Create an atmosphere of problem-solving and learning d. Build and maintain morale e. Provide constructive ways to approach difficult situations with service recipients f. Facilitate regular feedback, and a structure for ongoing communication and collaboration 2. Growth: Assist staff in their professional growth. Help them identify growth opportunities whether it is a job opportunity with higher wages and more responsibility within the organization or, an educational opportunity within the larger social-service arena. Helping an employee to grow, involves helping them to better learn their job so that they can excel at it and also, helping them to recognize barriers to professional growth with accompanying possible solutions. One of the most difficult supervisory roles is to help a staff member to identify a challenging area within their work and to develop an action plan to deal with the challenge.

A related vital role of the supervisor is to help all staff understand the concept of supervision, its purpose, and how it will ‘look’ in the workplace. This is accomplished by explaining the purpose of supervision, providing supervision for employees over a period of time and by creating an environment where neither the supervisor nor the staff is afraid of the concept of supervision.

10.2. Creating a Productive Workplace Culture An ‘agency culture’ refers to the group of values, norms, and shared experience that help to govern employee and sometimes client behavior. A positive, productive workplace culture results in employees who: • Want to perform at peak efficiency • Understand and apply the values of the agency effectively • Want to work to improve their skills • Recognize personal growth opportunities and accept change-oriented feedback • Suggest ways to improve upon their own work, as well as shelter policies and procedures Dear Shelter worker, How do you know if your shelter has established a positive workplace culture? The following questions can help you decide.

1. Do employees show up on time?

2. Have most employees used all their sick time?

3. Do employees seem to enjoy staff meetings?

4. Do your employees reject what you say? Do they let you be an effective supervisor?

5. Do your employees enjoy their jobs or are they there only because they need a paycheck?

6. Is your interaction with employees enjoyable for you? Does humor play a role in your interactions with employees? Do you laugh with co-workers or subordinates?

7. How do you feel about the work you do?

8. How do you feel about your supervisors? Do you feel supported and encouraged?

9. Do you feel hopeful about your work, your possibilities, and the possibilities for your staff?

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Answering these questions should provide a guide to determine whether your supervision is effective, your employees are motivated, and your workplace is one that demonstrates a positive agency culture. At a workplace with a positive culture, people take on tasks and duties because they want to and not just because they are paid. Workers are motivated to do their jobs by three things; money, the work, and the relationships they have with others in the workplace. In a positive workplace, employee turnover, theft, hostile behavior and employee non-compliance are reduced because employees feel that their goals are allied with the agency’s goals. In shelters, usually the salaries are not very high and yet, the work can be difficult, demanding, and challenging. The constant fight for resources wears down both clients and staff. Therefore, it is even more essential that staff members gain a great deal of satisfaction from relationships with their coworkers and the feeling that they are helping others. It is the supervisor’s responsibility to make sure that this happens, even though it is difficult as everyone values each slice of the pie: money, work and relationships, differently. A worker who depends on salary for job satisfaction is going to have a hard time working in a shelter. This worker will be hard to motivate and may soon quit. On the other hand, a worker who gets a lot of satisfaction from the actual work and enjoys good relationships with coworkers may be more satisfied and more prepared to accept a relatively low salary. Developing a positive workplace culture, especially in the absence of high salary possibilities, is vital. Good supervision makes a difference.

10.3. Standard Supervisory Tasks There are two essential tasks at the heart of supervision. The first task involves meetings with individual workers where you give advice, examine challenges and set goals. The second task is the performance evaluation and review. Let’s look at these two elements.

A. Meetings with individual staff members The frequency of these meetings will vary depending upon the situation but it is recommended to have these meetings at least once a week. At this meeting, both parties should bring an agenda that lists issues that both parties wish to discuss. An agenda can be constructed during the meeting itself, but it is recommended to use a standardized format each week that can be built on or modified as needed.

B. Written performance review and evaluation This provides feedback to the employee about their performance, knowledge, skills, and attitude.

A review document that evaluates a staff member’s performance should list clearly and honestly the employee’s accomplishments, the challenges they have faced, and their continuing areas of growth. A review document should be shared with the supervisee before it is finalized to give them an opportunity to contribute remarks. The review should be discussed with the worker.

Supervisory Meeting Blueprint (Standard Supervisory Agenda) A weekly meeting agenda may be flexible but should include four items: 1. Check-In - Ask how the staff member has been feeling about their work this week or since your last meeting. Check-Ins help to normalize the interaction with the supervisor and are reassuring. A useful check-in question - How has it been going since we last met?

2. Hotspots- These are burning issues that need to be discussed. What are work challenges that you’ve faced in the past week or since our last meeting? How have staff members handled,

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or attempted to handle these challenges? Challenges include: Relations with other staff and relations with clients. Staff members will need advice about how to handle ‘hotspots’.

3. Troubleshooting and giving advice - This is the problem-solving section of the meeting. Most successful supervisors find a balance between giving advice, which may allow an employee to talk through a problem and generate their own solution, and outright telling the employee what they must do.

4. Feedback – The supervisor discusses and evaluates an employee’s present and past performance.

Supervisory Decision Making Supervisors often have trouble deciding. Some decisions are complex and require the supervisor to decide between competing needs. For example, should an employee who is making mistakes be allowed to continue with a task but with corrective supervision and closer observation, or should the task and responsibilities be taken away? The decision to provide closer, more hands-on supervision and to check for mistakes, means more demands on a supervisor’s time.

Any supervisory decision must be evaluated in terms of: • Program needs: Does this decision reflect the values of the mission statement and goals of the program?

• Staff needs: Does this decision reflect the needs of the staff?

• Client needs: Does this decision reflect the needs of the shelter clients?

Any decision weighted towards only one of the above stated three needs is a lopsided decision.

If you find yourself making skewed decisions that don’t reflect the needs of any one of the three groups that you should support, it is a good idea to evaluate the reasons behind the lopsided decisions. Not all decisions can meet all three needs equally, but when they do, they have a much better chance of being achieved.

10.4. Styles of Supervision There are two styles of supervision, the autocratic and the participatory. Each supervisor must choose which model works best for them as well as their agency, staff, and clients.

Autocratic Supervision Style Autocratic means that the supervisor makes all or most of the decisions and then announces them to the others. There is little opportunity for input from others. In this style, the supervisor has a great need for control and is unwilling to take risks or allow others to take risks. Autocratic supervisors will enforce decisions according to established standards and their own view.

Permission to bypass norms must be approved. This type of supervisor is focused on the final product, is highly task oriented and uses primarily punitive action to maintain discipline. An autocratic supervisor does not feel the need to listen to employees or engage them in discussions.

Participatory Supervision Style Participatory means the supervisor consults others before deciding. The work is viewed as a partnership. At times, the decision may be a group decision. A participatory supervisor delegates

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well and takes reasonable risks. This type of supervisor employs standards as guidelines but trusts employees to take risks in unusual situations and adjust policy accordingly, without necessarily asking for approval first. Both relationships and the decision-making process are important. This supervisor will use positive reinforcement such as motivation, incentives, and rewards, to maintain discipline. She encourages discussion and may spend more time listening to others. Though it may take more time to get staff’s input on important matters, in the long run, participatory supervision makes for better relationships in the workplace, which is key in retaining employees.

There is a lot of literature for supervisors, ranging from the inspirational work of popular managers, to technical and educational training material for supervisors. The system of care you serve in is continuously changing. Keeping up, remaining interested, alert, and learning will make you a good supervisor and help your employees become supervisors in their own right.

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Post Session Questions

Dear Shelter worker, Which style of supervision do you prefer (as supervisor or supervisee)? Why? In the past, which style has your supervisor most often used? If the style of supervision you and most other people prefer is participatory, why is it that most people have autocratic supervision experiences?

10.5. Monitoring and Follow-up Monitoring entails checking on trafficking victims in order to ensure that reintegration is going well and to assist them if there is a need. Monitoring and tracking of clients is important.

• If the client is with family, check to make sure that the family provides support to prevent re-trafficking.

• For clients who are living independently, check to make sure that they are well and safe.

• Provide emotional support, training opportunities and employment where appropriate.

• Seek community feedback.

• Listen to the client’s experiences and plans and identify difficulties.

• Assess progress, problems encountered and encourage necessary adjustments.

Documenting, Reflecting and Sharing It is vital to document, reflect and share in order to learn from our successes and failures. Other shelters can also learn from our experiences. If shelter workers fail to document, reflect and share, it may be due to time and resource constraints. Shelter workers are extremely busy involved in the direct support of individuals and rarely have the time, space or resources to document and review their practices. Shelter workers may not actually know what to document. Shelter workers may presume that others possess the same level of knowledge and consequently, they may not always know what information would be of most use and interest to others. Shelter workers may simply not be motivated to reflect, document and share. The benefits of documenting may not be clear to shelter workers. Service providers are often preoccupied with direct work, donor reporting and grant writing and although reflection can help improve future work and documentation can minimize duplication, shelter workers are rarely given incentives to document work. Fear may stop shelter workers from documenting work properly. Organizations do not always feel comfortable sharing their learning, especially their mistakes and the things that went wrong. It is human nature to be reluctant to admit a mistake, and this may be even more pronounced within the NGO environment, a sector that traditionally relies on success stories to attract funds.

Finally, competition may be a reason why shelter workers don’t document their work. Despite the progress made in terms of cooperation, some NGOs still do not always wish to share their learning with others. This may be partly due to the funding environment surrounding NGOs in which, there is a lot of competition with each other when it comes to applying for grants for the same pools of money. It may also be due to rivalry over recognition.

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Final Check Before a client leaves the shelter, ask the following questions: How satisfied are you with the services you have received from the programs at GSA? Rate your satisfaction - very satisfied=5, satisfied=4, undecided=3, somewhat satisfied=2, dissatisfied=1.

Put a tick mark as



on the level that fits your choice.

5

S.N Service

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

4

3

2

1

Accommodation - food, shelter, clothes, bed, closet, and hygienic products Security and safety - quiet, clean and secure environment Medical assistance - diagnosis, medical visits, treatment, and proper medication Psychosocial counseling - quality of the individual and group counseling you received Effectiveness of counseling – to reduce emotional difficulties, stabilize sleep, improve self-esteem, improve family connections and relations Treatment by staff – with dignity and respect Family mediation Support for legal assistance Social and recreational activities – activities available in and out of shelter, indoor and outdoor games Socio-cultural activities outside shelter - visits to church, museum Life skills training – decision-making, problem solving, communication Facilitating educational opportunity - formal, informal Business skills - entrepreneurship, financial literacy, business management Income generation activities for self-employment - arrangement for professional courses such as hair styling, cleaning, food preparation, embroidery, tailoring Employment facilitation or support for self-employment Information on existing services in community Assistance and support for the children of VOT Monitoring and follow-up

Briefly describe areas with which you were satisfied --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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Briefly describe areas of dissatisfaction and give examples ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Dear Shelter worker

Record the addresses of VOT who have been rehabilitated by GSA and check on your clients through phone conversations and field visits. Create an alumni database for both staff and clients and include videotaped success stories.

Documentation, especially of successful reintegration, helps to develop institutional memory and serves to develop the organization.

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Session 11: Self-Care For Staff

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Session Objectives Dear Shelter worker, After completing this session, you will be able to: • Define burnout and compassion fatigue • Identify the signs and symptoms of burnout and compassion fatigue • Apply techniques which are helpful for promoting self-care and reducing burnout Staff members who take care of themselves are better able to provide good service to clients.

Working with VOT or clients who have experienced tremendous challenges and traumatic events, can take a toll on the helping professional. When staff members are able to recognize signs of work-related stress or ‘burnout’, they can take steps to reduce that stress and maintain good customer service.

11.1. Burnout

Burnout refers to emotional exhaustion resulting from built-up stress. People who work in human service professions can experience burnout due to the emotionally demanding aspect of their work. In 1995, a psychologist named Charles Figley coined a phrase that referred to a type of burnout he discovered among helping professionals. He called it “compassion fatigue”. Most of his work was with people who gave emotional support to disaster and trauma victims, which is very much like shelter work. He discovered that compassion fatigue, like burnout, resulted from the professional’s desire to help and their repeated exposure to other people’s traumatic events.

If you think you are immune to burnout or compassion fatigue, think again. The key to avoiding burnout is to accept that it could happen to you.

Signs and symptoms of burnout and compassion fatigue • Emotional - Fear, sadness, depression, mood swings, feeling empty, overly sensitive, or angry • Physical – Great incidence of illness, headache, muscle ache, stomach problems, fatigue, increased heart rate, sweating • Mental - Difficulty concentrating, decreased self-esteem, lack of concern or indifference, disorientation, forgetfulness, intrusive thoughts or dreams • Behavioral - Impatience, irritability, appetite changes, substance use, sleep disturbance, given to more frequent accidents • Spiritual - Questioning meaning of life, loss of purpose, lack of self-satisfaction, hopelessness, anger at God, loss of faith • Personal Relations - Isolation, decreased intimacy, mistrust, overprotection, anger and blame towards family and friends, intolerance, loneliness, increased conflicts • Work Performance - Negativity, feeling unappreciated, detachment, loss of commitment, staff conflicts, increased absenteeism, and irritability with co-workers and clients

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Not surprisingly, the person experiencing these symptoms may not be the first to recognize them.

Often family and friends notice early warning signs. Listen to those around you when they express worry about changes they notice if your behavior. Burnout and compassion fatigue affect, not only you, but also those who love and support you. Symptoms come on slowly over time.

Dear Care Taker,

Your own wellbeing is as important as the wellbeing of the clients you serve? Self-care is vital. Which of the above emotional, physical, mental, behavioral, spiritual, personal and work performance problems have you experienced? What do you often do to try to alleviate emotional exhaustion?

11.2. Burnout Self-Exam Dear Shelter worker, Here is a burnout self-exam. It helps you determine the level of burnout you may be experiencing.

It is a good tool to use particularly when you begin to recognize symptoms of stress. Take it now and check your score.

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Are you Burning Out? Review your life over the last six months, both at work and away from work. Read each of the following items and rate how often the symptom is true for you.

1 = Rarely 2 = Sometimes true 3 = Often true 4 = Frequently true 5 = Usually true 1. I feel tired even when I’ve had enough sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

2. I often feel dissatisfied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .

3. I feel sad for no apparent reason . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . ..

4. I am forgetful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. I am irritable and snap at people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. I am withdrawn and keep to myself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. I have trouble sleeping. I wake up frequently during the night or too early . . . . . . . . . .

8. I get sick a lot. I’ve used most or all of my sick time . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. My attitude about work is, “why bother” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. I get into conflicts with others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. My job performance is not its best . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12. I use alcohol or drugs to feel better . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13. Communicating with others is a strain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14. I can’t concentrate like I once could. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15. I am easily bored . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16. I work hard but accomplish little . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17. I feel frustrated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18. I don’t like going to work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19. I find social activities draining. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20. Sex is not worth the effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Scoring: —— 20-40= You are doing well.

41-60= You are Okay—if you take preventative action.

61-80= You are a candidate for burnout 81-100 =You are burning out.

11.3. Practicing Self-Care to Reduce Burnout The best way to deal with stress is to detect the symptoms early. Practicing self-care techniques helps you a lot. Here are important self-care practices that help to prevent burnout and compassion fatigue, and act as remedies for staff members suffering from the stress of shelter work.

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Recognize your feelings - Accepting that you are affected by the difficult nature of your work does not make you weak. It shows that you recognize your feelings as a normal process of working with clients who present difficult and extraordinary issues every day.

Talk about your feelings - Sharing your experience with others lifts some of the burden of carrying these feelings alone. Take time to share what is going on with coworkers. This lets you realize that you may not be alone in your feelings. It reduces isolation and increases your connection to others.

Take time for yourself - When stress feels unmanageable, consider taking time off to rest.

Make sure that if you take time off, you use that time for activities that you enjoy.

Stay connected to your social support- Family, friends, coworkers, religious and social groups can be valuable in helping you cope.

Rest, eat well, and exercise - Stress can knock you off your feet. There can be a temptation to crawl into bed and stay there. Sleep is important, but so are exercise and a good diet. For many, exercise is the number one way to prevent burnout as it increases energy levels and helps to reduce anxiety. Even a daily, short walk done for enjoyment can be effective.

Set time aside each day for relaxation - You may do this for 15-30 minutes.

Avoid alcohol and drugs - The use of substances may make you feel better in the short term, but not in the long-term.

Seek supervision - Let your supervisor know when you are experiencing greater stress than usual. Together, you can create a plan for reducing burnout. This may include temporarily taking on some different, less stressful responsibilities or maybe, you can arrange for some changes in your schedule to break up your work routine.

Seek additional support - Consider obtaining the services of an outside facilitator to assist in the staff’s debriefing after any critical incident at the shelter. Critical incidents may include violent outbursts, suicide or death of a client. Religious leaders, community leaders, police and others can help.

Several possibilities in caring for yourself Practicing self-care to reduce stress leaves will leave you physically and emotionally fit. Look at this list to find and participate in one or more pleasurable activities to help reduce your stress and anxiety. Enjoy your time!!!

• Soaking in the bathtub • Getting out of debt • Collecting & organizing your coins, shells, stamps, etc.

• Thinking about your future when you finish school • Jogging, walking, or exercising • Buying a household gadget • Playing a musical instrument • Thinking about past trips

• Think about becoming active in the community • Spending an evening with good friends • Relaxing • Going to a movie in the middle of the week • Listening to music • Lying in the sun • Laughing • Listening to others

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• Reading magazines or newspapers • Meeting new people • Saving money • Eating good food • Repairing something broken • Gardening and taking care of your plants • Going to a party • Playing a sport • Singing in the shower • Arranging flowers • Working to help others • Thinking “I’m a person who copes.”

• Cooking • Watching boxing or wrestling • Buying clothes • Sewing or knitting • Going to the beauty parlor • Enjoying morning coffee and newspaper • Thinking “I have a lot more going for me than most people.”

• Daydreaming • Teaching someone a skill • Doing something new • Being with friends • Writing a diary or journal entry • Taking children places • Going on a picnic • Thinking “I did that pretty well” after doing something • Having lunch with a friend • Playing cards • Having a political discussion • Talking on the phone • Lighting candles • Thinking about your good qualities

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• Planning a day’s activities • Remembering beautiful scenery • Working on your car or bicycle • Having coffee in a sidewalk café • Remembering words & deeds of loving people • Drawing and painting a picture • Thinking about what you’d like to buy • Riding a motorcycle or bicycle • Going to church or praying with others • Thinking “I’m an OK person.”

• Having an aquarium • Thinking about boyfriend/girlfriend/partner • Doing arts and crafts • Writing an article, poem, or story • Going out to dinner • Sightseeing • Watching children play • Going to a concert, show, or play • Watching TV • Taking photographs • Playing with animals • Reading fiction • Being alone • Cleaning • Dancing • Meditating • Thinking about a happy moment in childhood • Solving puzzles • Shooting pool • Reflecting on how you’ve improved • Going to a museum • Saying, “I love you.”

Dear Shelter worker, 1.

2.

Which of the above tactics work best for you? Choose at least three and elaborate.

What favorite activities can you add to this list based on your experience or the experience of others?

Post Training Questions Dear Shelter worker, Please evaluate this curriculum.

1. Was the curriculum material informative? Elaborate and give examples.

2. Was the content of this curriculum material comprehensive?

3. Was the curriculum material accompanied by sufficient examples and cases?

4. Has the curriculum material provided adequate practice exercises?

5. What are your suggestions on how to improve this curriculum material?

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