Implementing Shared Decision Making with Child Trafficking Survivors

12 June 2019
Research Innovation

Samantha Sahl  | Initiative Coordinator, Orleans Parish Juvenile Court

The United Nations Convention on the Rights of the Child calls for every child to have the right to self-determination, dignity, respect, non-interference, and the right to make informed decisions. In a recent article published in the Journal of the American Academy of Child and Adolescent Psychiatry, “Using Shared Decision Making to Empower Commercially Sexually Exploited Youth”, Chris Knoepke and I argue that these rights are rarely afforded to sexually exploited children due to the well-meaning, yet paternalistic notion that youth are incapable of making smart decisions for themselves. We propose a novel approach to engaging and empowering youth victimized by human trafficking by adapting and applying the medical model of Shared Decision Making (SDM) to increase youth voice and participation in treatment and placement planning decisions.

This research into improving youth voice and inclusion in service planning was prompted by a forensic interview in which a youth recounted her experience in foster care. She described the feeling of being “just a paycheck” to several of her foster parents and the traumatic experience of being moved around with no notice or preparation after “failing” at placement after placement. She asked the interviewer: “If they [child welfare] place me in homes with strangers who don’t care about me, why is it such a big deal if I leave with a stranger who tells me that he does care?”

Despite best efforts by foster care workers and parents, youth may feel a lack of love and connection, as well as a loss of autonomy and control, especially when compared to the idealized relationships and lifestyles promised by exploiters. Traffickers are often able to identify and even meet the needs of youth better than the service systems that they are involved with. While the loss of actual agency and control is central to the trauma of human trafficking, traffickers simultaneously create a perception of adult-like autonomy, control, choice and independence for youth that is in sharp contrast to the often paternalistic and prescriptive treatment of well-meaning child welfare and juvenile justice service systems.

The concept of youth voice and inclusion is not new to the juvenile justice or child welfare system, but models for how to effectively engage youth in a meaningful or measurable way are lacking. Furthermore, attempts to engage youth voice are often undermined by the paternalistic assumption that youth, especially after experiencing trauma, lack the ability and maturity to make smart decisions for themselves. While this assumption is seated in the science of adolescent frontal lobe development, it leads to the harmful outcome of youth being denied agency and left out of the decision-making process altogether.

Failure to engage trafficked youth in a meaningful way leads them to be frustrated, distrustful of service and healthcare providers, and less likely to follow through with treatment and placement decisions that they did not take part in. This exclusion further serves to push youth back to a trafficker who is creating the perception of agency and independence.

To address this disconnect while maintaining youth safety and well-being, we propose adapting and applying the medical model of Shared Decision Making (SDM) to include youth voice in service planning and give youth back some degree of autonomy and control over their lives. SDM is defined as “a transactional/interpersonal model of communication in which health care providers and patients work collaboratively to select treatment and care that include patients’ health experiences and preferences.” It is an approach that makes youth active participants in the decisions that affect their lives. Decision-making power is not handed over to youth—rather, when multiple safe options exist, SDM is an approach for teaching youth how to voice their goals, values and preferences around the decision, while collaborating with professionals in making a safe decision.

This approach is consistent with employing a “victim-centred” response, as SDM shifts children from being viewed as beneficiaries to being understood as individuals with rights and needs. SDM has proven successful in improving the therapeutic alliance between the provider and patient, and is supported by the Substance Abuse and Mental Health Services Administration for being “consistent with recovery-based transformation and the foundation values of choice, self-determination, and empowerment”. Furthermore, and most relevant to working with youth who have experienced complex trauma such as human trafficking, SDM helps confer agency, or the capacity of individuals to act independently and make their own free choices.

While many providers do attempt to include youth in decision-making conversations, SDM clinical trials found that simply having a conversation around options was not sufficient in creating a sense of agency in patients or leading to better clinical outcomes. In the medical field, use of SDM decision aids, or concrete and tested tools used to facilitate a shared decision-making interaction, were found to improve patient-provider communication and lead to greater follow-through with decisions made. Some providers may already be practicing in ways which promote youth involvement, but the structure of SDM may ensure that all of the victim-centric elements of care are done routinely.

These tools can be adapted to support a number of decisions specifically related to the care for youth victimized by human trafficking. These include placement decisions (not only where and with whom, but how to feel safe and connected at a determined placement), mental health and psychiatric treatment decisions, healthcare related decisions, tattoo removal, involvement in prosecution (whether or not to participate and under what circumstances), decisions about story sharing, and numerous other situations in which youth can regain power and control over their lives. Even in situations when there may be only one safe option, such as the availability of only one safe placement option available, SDM still provides a process and tools for engaging youth in the conversation around this decision, and in identifying smaller choices they are able to make in order to regain a sense of independence and control over their lives.

Juvenile justice, child welfare and other service systems risk perpetuating the traumatic loss of control endemic to human trafficking situations if youth are not presented with choices or meaningfully engaged in decision-making conversations. SDM processes and tools can provide an evidence-supported approach for not only engaging youth voice, but in promoting self-determination and empowerment, leading to overall satisfaction and well-being for youth.

For more information about Shared Decision Making for Commercially Trafficked Children, download HEAL’s factsheet here.

Samantha Sahl, LMSW is a Doctoral Candidate at the University of Southern California School of Social Work and is the RISE (Respect, Invest in, Support, and Empower) Initiative Coordinator at Orleans Parish Juvenile Court.

This article has been prepared by Samantha Sahl as a contributor to Delta 8.7. As provided for in the Terms and Conditions of Use of Delta 8.7, the opinions expressed in this article are those of the author and do not necessarily reflect those of UNU or its partners.

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