Title
Self-harm in trafficked adults accessing secondary mental health services in England
Disclosures and acknowledgments
This report is independent research commissioned and funded by the Department of Health Policy Research Programme (Optimising Identification, Referral and Care of Trafficked People within the National Health Service [NHS]; 115/0006). The views expressed in this publication are those of the authors and not necessarily those of the Department of Health. The funder had no role in the design or conduct of the study, collection, management, analysisor interpretation of the data or writing of the report. The study was supported by the Clinical Records Interactive Search (CRIS) system funded and developed by the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London and a joint infrastructure grant from Guy’s and St Thomas’ Charity and the Maudsley Charity.The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication.
RB is supported by a McKenzie Postdoctoral Fellowship from The University of Melbourne, Australia (0038703). SO, LMH, and CZ received support from the Department of Health Policy Research Programme (115/0006). LMHis also supported by an NIHR Research Professorship (NIHR-RP-R3-12-011) and by the NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre-Mental Health. RD is supported by a Clinician Scientist Fellowship from the Health Foundation, working with the Academy of Medical Sciences.SK is supported by an Australian National Health and Medical Research Council Senior Research Fellowship (APP1078168).
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ABSTRACT
Objective:This study estimated the prevalence, correlates and mental health service responses to self-harm among trafficked adults accessing secondary mental health services in England.
Methods: A clinical recordsdatabase was searched to identify trafficked adultswho accessed secondary mental health services in South London from 2006-2012. A matched cohort of non-trafficked patients was selected. Data were extracted on self-harm, socio-demographic, clinical and service use characteristics. Logistic regression models compared trafficked and non-trafficked patients.
Results: 96 trafficked adults were identified; 31 (32%) had self-harmed prior to care and 21 (22%) self-harmed during care. After self-harming, trafficked patients were more likely than non-trafficked patients to be admitted as a psychiatric inpatient(AOR 2.81; 95%CI: 1.12–6.50)and compulsorily detained(AOR 28.75, 95%CI: 3.12–264.72),but less likely to attend an emergency department (AOR 0.47, 95%CI: 0.23–0.95).
Conclusions: Self-harm is prevalentamong trafficked adults accessing secondary mental health services;mental health professionals therefore need to be aware that some patients may be victims of trafficking and aim to optimise the service response by avoiding compulsory detention where possible.
Human trafficking is the recruitment of people - through means such as the use of deception, threat or coercion - for the purposes of exploitation (1). It is a crime thought to affect all countries of the world and is frequently characterised by psychological, physicalor sexual abuse (2). Adult survivorsof trafficking often suffer from complex trauma,post-traumatic stress disorder, depression and/or anxiety (3-5), and experiencedissociation, despair and a range of adverse somatic symptoms. They are also at heightened risk of substance abuse and other self-destructive and risk-taking behaviours(5). Yet, empirical research examining self-harm in trafficked adults is lacking.Recently, Kiss et al.(6) reported a high prevalence of past month suicide attempts among trafficked adults (5%) and children (5%) in contact with post-trafficking services in Cambodia, Thailand and Vietnam, and of past month self-harm among trafficked children in the same region (6). However,to date there have been no published studies examining self-harm among trafficked adults or among a sample of trafficked people in contact with mental health services. This is a notable gap in the literature becausethe link between trafficking and self-destructive behaviours - and the strong association between self-harm and subsequent suicide(7)- may place this population at considerably heightened risk of early mortality.
Using data from a historical cohort study, the aims of this study were to (a) estimate the prevalence and correlates of self-harm among trafficked adults accessing secondary mental health services in London, UK (b) examine emergency and mental health service responses to self-harm among trafficked adults, and (c) compare emergency and mental health service responses to self-harm in patients who had and had not been trafficked.
METHODS
Study design
Data were collected as part of a historical cohort study of trafficked and matched non-trafficked patients in contact with secondary mental health services at South London and Maudsley National Health Service Foundation Trust (SLaM) between 1stJanuary 2006 and 31stJuly 2012.
Procedure
Data were obtained from the CaseRecords Interactive Search (CRIS) system, which allows the searching and retrieval of pseudo-anonymised full patient records(8).Cases were SLaM patients whose care team had recorded concerns that they may have been trafficked.Terms used to search CRIS records included: “victim of trafficking”, “sex trafficking”, “trafficked”, “traffiked”, “trafiked”, “sex traffickers”, “human trafficking”, “forced prostitution”, “child trafficking”, “people trafficking”, “forced labour”, “trafficking”, “sexual slavery”and “Poppy Project” (an organisation in the UK providing support, advocacy and accommodation to trafficked women).
Eligibility was assessed by reviewing patients' clinical notes and correspondence between the healthcare team and other professionals involved in the patients' care. These records were screened against the study inclusion criteria usingthe United Nations definition of human trafficking(i.e. the recruitment or movement of people, by means such as force, fraud, coercion, deception, and abuse of vulnerability, for the purposes of exploitation) and included both international and internal trafficking(9). One researcher assessed eligibility (i.e. documented concerns that the patient may have been trafficked as per the UN definition of human trafficking) and a second researcher (SO) independently assessed the first ten records and an additional random 10% of records. Full details of the methodology and cohort characteristics are provided elsewhere(4).
Amatched cohort of non-trafficked adult patients was produced using computer-generated random selection from all potential controls that met matching criteria.Up to four controls per case were selected. Cases and controls were matched for gender, age, [+/- 2 years], primary diagnosis, psychiatric inpatient admission at first contact, and year of most recent service contact.
Data were extracted on socio-demographic, clinical, and service use characteristics (described in full elsewhere(4)). The following terms were used to search electronic health records for references to self-harm: “self-harm”, “self harm”, “DSH”, “suicid*”, “overdos*”, “electrocut*”, “hang*”, “ligature*”, “burn*”, “lacerat*” and “cut”. Data were extracted by SO on self-harm prior to and during contact with SLaM services, and on emergency department attendancesand psychiatric inpatient admission(voluntary and/or compulsory)following self-harm.
Data analysis
Logistic regression models were fitted to compare prevalence of, and service responses to, self-harm by trafficked and non-trafficked patients, using a random intercept for the match identifier to allow for possible correlation between matched individuals. Models comparing trafficked and non-trafficked patients’ self-harm while accessing SLaM care included as an a priori confounder the duration of time in contact with SLaM services (calculated by subtracting date of first referral from date of final discharge, excluding any periods between referrals, with an upper date limit of January 24th 2013). Models comparing trafficked and non-trafficked patients’ emergency department attendance and psychiatric admission after self-harm includedhistory of self-harm (i.e. self-harm prior to contact with SLaM) and the duration oftime in contact with SLaM services. As<10% of data were missing for all variables included in logistic regression models; complete case analysis wasused. Ethics approval was granted by an independent Research Ethics Committee (Oxfordshire C, reference 08/H0606/71). An Oversight Committee reviews all applications to use CRIS and gave approval for this study (11/025).
RESULTS
Most trafficked patients were female (78; 81%), aged in their twenties (mean: 26.7 years, SD: 6.8; 47.9% aged 18-25), had been trafficked for the purpose of sexual exploitation (56; 58%) and had escaped the trafficking situation (94;98%).Data on type of exploitation were missing for 22 (23%) patients. Trafficked patientsoriginated from 33 different countries, with Nigeria (17;18%), China (9;9%) and Uganda (7;7%) jointly accounting for more than one third of all patients. The most prevalent diagnoses were affective disorders (33; 34%),PTSD / severe stress / adjustment disorder (27; 28%) and schizophrenia and related disorders (14; 15%).
Self-harm
Almost one thirdof trafficked patients(31; 32%) reported a history of self-harm prior to receiving care from SLaM. More than one fifth(21; 22%) self-harmed whilst under the care of SLaM, of whom 13 (62%) had a recorded history of self-harm. Of those who self-harmed whilst under SLaM care, 12 (57%) were admitted as a psychiatric inpatient following the episode of self-harm and six (29%) were admitted compulsorily under the Mental Health Act. Ten patients who self-harmed (48%) had a diagnosis of an affective disorder and five (24%) had a diagnosis of PTSD, severe stress or adjustment disorder. Self-poisoning (42%), attempted hanging (29%) and cutting (24%) were the most frequently reported methods of self-harm.
INSERT TABLE 1 HERE
The recorded prevalence of history of self-harm did not differ significantly between trafficked and non-trafficked adults (32.3% vs. 33.5%; OR 1.01, 95%CI: 0.59–1.71). Similarly, the recorded prevalence of self-harmwhilst under the care of SLaM services - adjusted for self-harm prior to contact with SLaM and the duration of time in receipt of SLaM care - did not differ significantly between trafficked and non-trafficked adults (21.9% vs. 31.7%; AOR 0.74, 95%CI 0.41–1.34). However, trafficked adults were more likely than non-trafficked adults to be admitted as a psychiatricinpatient after self-harm (12.5% vs. 6.6%; AOR 2.81; 95%CI: 1.12–6.50) and to becompulsory admitted as a psychiatric inpatient after self-harm(6.3% vs. 0.4%; AOR 28.75, 95%CI: 3.12–264.72).Trafficked adults weresignificantly less likely to have attendedan emergency department after self-harming (26.8% vs. 12.5%; AOR 0.47, 95%CI: 0.23–0.95).
DISCUSSION
Theprevalenceof recorded self-harm among trafficked adults receiving secondary mental health care from SLaM was high, although no higher than among a matched sample of non-trafficked adult patients. However,trafficked and non-trafficked patientswho self-harmed experienced different mental health service responses. Trafficked patients were more likely to be admitted as psychiatric inpatients - and to be compulsorily admitted - following an episode of self-harm. This is an important finding ascompulsory admission may be particularly distressing for trafficked people who may have, during the course of their exploitation, experienced restrictions on their movementsandcontrols on their daily routines.By contrast, trafficked patients were less likely than non-trafficked patients to attend an emergency department following self-harm. This may be a function of the nature and severity of the self-harm episodes, but may also reflect a limitedknowledge of the UK health system, experiences of care in their home countries (especially regarding the cost of care),or other factors not yet understood. Further research is needed to identify risk and protective factors for self-harm, and immediate precipitants of self-harm that may be particularto trafficked adults, and to investigate appropriate mental health service responses.
Ross et al. (10) recently reported that, although up to one in seven mental health professionals in the UK may have had contact with a person they knew or suspected had been trafficked, 81% of those surveyed reported that they had received insufficient training to assist trafficked people. It is imperative that mental health professionals understand the issues surrounding human trafficking and are equipped adequately to identify and respond to trafficked people. An enhanced understanding of trafficking may contribute to the implementation of a wider range of treatment options following self-harm.
Strengths and Limitations
These are the first published data on self-harm among trafficked adults and among a clinical sample of trafficked people internationally. The rich self-harm data and selection of a highly matched sample allowed us to make detailed comparisons across a range of outcomes of interest, including service responses to self-harm. Our study also had some limitations.First, most of our participants were female and, as self-harm is more common in females(11), our findings may not be generalizable to male trafficking survivors. Second, we were unable to examine the reasons participants engaged in self-harm.Research with this cohort has shown that after escaping exploitation, many trafficked patients continued to experience physical and sexual violence and legal, financial, and social stressors, including ongoing or failed asylum claims and a lack of stable accommodation(4, 12). Such stressors were perceived by mental health professionals to negatively impact trafficked people’s mental health(12)and,as self-harm is associated with stress in the absence of more constructive coping strategies (13), it is possible that many of these anxiety-inducing structural factors may contribute to further self-harm.
Conclusions
The findings of this study demonstrate that self-harm is commonamong trafficked adults accessing secondary mental health services in England. Mental health professionals need to address human trafficking as a serious health risk because, like other forms of violence, it is associated with considerable psychological and physical harm, including self-harm.Given the extreme nature and severe consequences of trafficking, mental health professionals have a crucial role to play in supporting survivors,including through the assessment and prevention of self-harm and suicide, andensuring sensitive and humane responses to self-harm.
References
1.UN. Optional Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention Against Transnational Organized Crime, G.A. Res. 55/25(2000). United Nations. 2000.
2.Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS medicine. 2012;9(5):615.
3.Abas M, Ostrovschi NV, Prince M, Gorceag VI, Trigub C, Oram S. Risk factors for mental disorders in women survivors of human trafficking: a historical cohort study. BMC Psychiatry. 2013;13(1):204.
4.Oram S, Khondoker M, Abas M, Broadbent M, Howard L. Characteristics of trafficked adults and children with severe mental illness: a historical cohort study. Lancet Psychiatry. 2015;(in press).
5.Courtois CA. Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, Training. 2008;41(4):412-25.
6.Kiss L, Yun K, Pocock, N., Zimmerman C. Exploitation, violence and suicide risk among child survivors of human trafficking in the Greater Mekong subregion. JAMA Pediatrics. 2015; in press.
7.Hawton K, Zahl D, Weatherall R. Suicide following deliberate self harm: long term follow up of patients who presented to a general hospital. British Journal of Psychiatry. 2003;182:537-42.
8.Stewart R, Soremekun M, Perera G, Broadbent M, Callard F, Denis M, et al. The South London and Maudsley NHS foundation trust biomedical research centre (SLAM BRC) case register: development and descriptive data. BMC Psychiatry. 2009;9(1):51.
9.UN. Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime. United Nations General Assesmbly. 2002.
10.Ross C, Dimitrova S, Howard LM, Dewey M, Zimmerman C, Oram S. Human trafficking and health: a cross-sectional survey of NHS professionals’ contact with victims of human trafficking. BMJ Open. 2015;5(8):e008682.
11.Skegg K. Self-harm. Lancet. 2005;366:1471-83.
12.Domoney J, Howard L, Abas M, Broadbent M, Oram S. Mental health service responses to human trafficking: a qualitative study of professionals' experiences of providing care. BMC Psychiatry. 2015; (in press).
13.Sinclair J, Green J. Understanding resolution of deliberate self harm: qualitative interview study of patients' experiences. British Medical Journal. 2005;330(7500):1112.
Table 1. Clinical electronic health records data relating to self-harm in 96 trafficked adults accessing secondary mental health services in London, UK.
Self-harm variable / Trafficked adults (N=96)N (%)
History of self-harm prior to receiving care from SLaM / 31 / 32.3
Self-harm whilst under care of SLaM / 21 / 21.9
Of those who self-harmed whilst under care of SLaM (N=21):
First contact with SLaM related to self-harm / 5 / 23.8
Number of self-harm events whilst under care of SLAM (if >0); (M, SD) / 2.3 / 3.8
Attended A&E after self-harm / 12 / 57.1
Admitted as inpatient after self-harm / 12 / 57.1
Number of admissions following self-harm (M, SD) / 1.3 / 0.8
Admitted under MHA following self-harm / 6 / 28.6
Diagnosis of patients who self-harmed whilst under care of SLaM1 (N=21):
Affective disorder(s) / 10 / 47.6
PTSD / severe stress / adjustment disorder / 5 / 23.8
Other / 6 / 28.6
Type of self-harm whilst under care of SLaM1 (N=21):
Poisoning / 9 / 42.9
Hanging / 6 / 28.6
Cutting / burning / 5 / 23.8
Other2 / 4 / 19.0
M = mean; SD = standard deviation
1 Not mutually exclusive
2 Running/jumping into traffic, attempted drowning, undisclosed method
1 | Self-harm in trafficked adults accessing secondary mental health services
November, 2015