18, Sep, 2017

Marti MacGibbon is Keynote Speaker at NAMI and NSRC Recovery Month Event

Professional Speaker Marti MacGibbonMarti MacGibbon delivered the opening keynote speech at the North Sound Recovery Coalition’s inaugural National Recovery Month Event in Mt. Vernon, Washington. Five counties in the North Puget Sound area, north of Seattle, participated. The event was sponsored by National Alliance on Mental Illness, North Sound Behavioral Health, and others.

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25, Aug, 2017

Humorous Motivational Speaker Marti MacGibbon keynotes Women’s Recovery Conference in Flint, MI

Marti with Meeting Planners

Marti MacGibbon with Event Planner and SAMHSA award winner Athena Haddon

Marti MacGibbon is a nationally known humorous inspirational speaker and an internationally known author. She is an expert on trauma resolution and addiction. Her personal story of overcoming adversity is compelling and inspiring, and she shares strategies for resilience, healing, and empowerment. Marti delivered the keynote speech entitled, “Gratitude, Celebration, and the Power of Second Chances” to a capacity audience of women — both service providers and consumers. The event took place at the University of Michigan at Flint, Riverfront Plaza West. After her talk, Marti signed copies of her two nationally award-winning memoirs, Never Give in to Fear: Laughing All the Way Up from Rock Bottom and Fierce, Funny, and Female: A Journey Through Middle America, the Texas Oil Field, and Standup Comedy. The Indiana Addictions Issues Coalition has honored Marti with the Lifetime Addiction Recovery Advocate Award, for her significant work in reducing the stigma surrounding addiction, mental illness, human trafficking, homelessness, and domestic violence.

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20, Jul, 2017

Marti MacGibbon Encourages Community Leaders to Face Addiction, Develop Solutions

Nationally renowned speaker and author Marti MacGibbon spoke to law enforcement, mental health specialists, community leaders and concerned citizens in Evansville, IN at the Old National Bank Auditorium. Both the event and Marti’s presentation focused on bringing the community together to address the nationwide epidemic of opioid and other drug addiction. Ms. MacGibbon is an award-winning recovery advocate and an expert on trauma resolution and addiction. The event was sponsored by Holly’s House and Ruth’s House. Marti’s talk included both clinical and experiential insights. Her down-to-earth style and ability to add light humor to any presentation makes Marti MacGibbon a popular speaker on such topics as overcoming adversity, mental health awareness, and addiction recovery.

Inspirational Speaker Marti MacGibbon

Ruth’s House Presents:
Gratitude, Celebration & the Power of Second Chances!

Guest Speaker: Marti MacGibbon, CADC-II, ACRPS
Old National Auditorium
101 Main Street
Thursday July 20th
10:00 am – 12:00 pm

Marti MacGibbon, CADC-II, ACRPS, is a nationally renowned humorous speaker and nationally award-winning author. She holds five professional certifications in addiction treatment. Marti delivers a high-energy, often humorous presentation that includes both experiential and clinical insights into the recovery process, and provides tools to reduce stress, build resiliency, avoid burnout, and celebrate progress while facing adversity. She has recovered from and triumphed over nightmare experiences such as being trafficked to Tokyo and held prisoner by Japanese organized crime, homelessness, domestic violence, severe PTSD and hardcore drug addiction.

Facing the Opioid Crisis; Addiction, Recovery & Resilience
You will learn:

  • How courage, kindness, and resilience can be built, and can benefit personal, professional,
    community, and business relationships while facing addiction
  • Insights into the connection between trauma, addiction, and stress, and insights into addiction
    recovery and trauma resolution
  • How shame and fear fuel addiction, but gratitude and celebration fuel recovery
  • Why recovery empowers, strengthens, and improves lives, families, and communities —
    and how it is possible!
  • Navy Seals use specific strategies to build and maintain resiliency in the face of adversity and
    challenges — these strategies are also key to addiction recovery
  • Facts about addiction and recovery
  • Myths and misconceptions about addiction (substance use disorder) and recovery, and myths
    and misconceptions about relapse and relapse prevention.
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12, Jul, 2017

Marti MacGibbon is Keynote Speaker at MAHEC Women’s Recovery Conference in NC

Marti Macgibbon Humorous SpeakerHumorous inspirational speaker Marti MacGibbon delivered the keynote speech at the Keys to Sustaining Recovery Conference in Asheville, North Carolina. The conference is designed for substance abuse, mental health, psychology, criminal justice, human services and other healthcare professionals. It was held at Mountain Area Health Education Center (MAHEC) Mary C. Nesbitt Biltmore Campus on May 3rd, 4th and 5th of 2017. Marti is author of two nationally award-winning memoirs, Never Give in to Fear: Laughing All the Way Up from Rock Bottom and Fierce, Funny, and Female: A Journey Through Middle America, the Texas Oil Field, and Standup Comedy. Ms. MacGibbon is a nationally renowned speaker, internationally known author, and expert on trauma resolution and addiction. Her personal story of triumph over adolescent sexual assault/abuse, addiction, mental illness, human trafficking, domestic violence and homelessness is inspiring, and she’s gifted in that she can tell her story with humor. She has been interviewed in Investors Business Daily and Entrepreneur, and articles she wrote have appeared in the AMA Journal of Ethics, and over 100 corporate and trade magazines.

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11, Jul, 2017

Marti MacGibbon is Keynote Speaker at Geminus Corporation Conference in Indiana

Marti MacGibbon Author and Professional Speaker Professional Speaker Marti MacGibbonThis year’s Geminus Community Partners Conference in Merrillville, Indiana focused on secondary trauma. Marti MacGibbon delivered the opening keynote speech to an audience that included judges, community leaders, and professionals in a variety of fields: juvenile justice, child protective services, social work, behavioral health, addiction treatment, marriage and family therapy, legal and judicial, and healthcare. Marti’s powerful personal comeback story, clinical expertise, and skill as a humorist all contribute to a dynamic, informative, and inspiring presentation that is also entertaining. Marti also signed copies of her two nationally award-winning memoirs, Fierce, Funny, and Female and Never Give in to Fear.

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9, Jul, 2017

Marti MacGibbon is Keynote Speaker at Women in Criminal Justice Conference in Texas

Inspirational Speaker Marti MacGibbonMarti MacGibbon delivered the closing keynote speech at the Women in Criminal Justice Conference in Galveston, Texas. She followed the keynote with a workshop on stress management, stress reduction and emotional resiliency. The conference, held at the San Luis Resort, featured educational presentations from experts in the criminal justice field. Criminal justice professionals include probation officers, parole officers, correctional officers, legal experts, healthcare in correctional settings, and law enforcement. Marti is both a clinical and experiential expert on trauma resolution and addiction. Her powerful personal story of overcoming adversity, combined with her skill and talent as a humorist, make her presentations both fun and informative. Her message empowers, uplifts, and entertains audiences.

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2, Jun, 2017

Press Release: 11th Annual National Indie Excellence® Awards Announced

Local Author receives national recognition from the 11th Annual National Indie Excellence® Awards!

NIEA Finalist AwardLos Angeles: — The 11th Annual National Indie Excellence® Awards recognized Fierce, Funny, and Female in the category of Womens’ Health as a winner in this year’s competition. This title also received recognition in the category of Humor in this year’s competition.

This prestigious National award is open to all English language books in print from small, medium, university, self and independent publishers.

The National Indie Excellence® Awards exists to help establish independent publishing as a strong and proud facet of the publishing industry. Recognizing authors that put their heart and soul into their work, the NIEA is a champion of self-publishers and the small, independent presses that go the extra mile to produce books of excellence in every aspect. Established in 2007, the NIEA competition is judged by experts from all aspects of the book industry, including publishers, writers, editors, book cover designers and professional copywriters.

Winners and finalists are determined based on “overall excellence of presentation – a synergy of form and content.” Fierce, Funny, and Female is a memoir of resilience in the face of adversity and challenges. In her raw, vivid, and unabashed style, author Marti MacGibbon delivers a sometimes heartbreaking, often hilarious, always engaging account of her passage through trauma, betrayal, and loss in adolescence and young adulthood to discover her inner badass self. As one of the first women to work as a laborer in the Texas oil field, she set off explosives and staked oil wells before realizing her childhood dream of becoming a successful standup comic. Marti introduces readers to a wide range of characters in her life: from sleazy authority figures, wannabe Sixties musicians and crazed Corn Belt cult leaders, to Texas oil billionaires and wildcatters, to wild-eyed redneck coworkers who robbed banks on their lunch hour—in the company truck. The book includes scenes with iconic comedians, Hollywood entertainment industry moguls, and a legendary bluesman, and offers insights into resiliency, courage, and self-empowerment.

“We are proud to announce the winners & finalists whose books truly embody the excellence that this award was created to celebrate, and we salute you all for your fine work.” –Ellen Reid, Founder NIEA

For more information please visit: www.indieexcellence.com

19, Apr, 2017

Marti MacGibbon, Keynote Speaker at Chillicothe Ross Chamber of Commerce Annual Dinner

Humorous inspirational speaker Marti MacGibbon spoke to over 350 business leaders in Chillicothe, Ohio at the city’s annual Chamber of Commerce dinner held at the Shoemaker Center on Ohio University Chillicothe campus. The theme of the event was Progress, Pride, and Perseverance, and focused on resiliency and overcoming challenges. The audience responded with a standing ovation. Chillicothe, Ohio is a thriving, closely-knit community, home to the ancient sacred Hopewell earthworks, also known as America’s Stonehenge. The community’s businesses and leaders are role models, since their energy, innovation, and unity help to build local economy while confronting issues that affect all their citizens.The Chillicothe Gazette’s Chris Balusik covered the event, and he’s a terrific writer.

Read More Online: Chillicothe Gazette

18, Apr, 2017

Foreword Reviews Article

Billboard image. (See a blank space here? Turn on images or scroll down.)

If laughter is the best medicine, then Marti MacGibbon has not only healed herself, but has healed others. Through traumas including drug abuse, eating disorders, and sexual exploitation, and into her recovery, MacGibbon has learned that the ability to laugh at herself and to make others laugh can be a lifeline. In her new memoir, Fierce, Funny, and Female, MacGibbon “celebrates her resilience and her willingness to keep laughing,” according to Foreword Reviews’ Claire Foster. In the interview below, MacGibbon tells how she achieved this.

Fierce, Funny, and Female

You’d think that the trauma you’ve been through in your life would have muted your sense of humor. Instead, it seems to have enhanced it. How did you achieve that?

Throughout my life, my sense of humor has served me well: as a means of communication, a coping mechanism, and a way of affirming and preserving my sense of self. I gravitate toward funny people, so that helps. When your friends make you laugh, or you make them laugh, it’s a celebration of life. I embrace humor that is never mean-spirited. My husband, Chris Fitzhugh, is one of the funniest people I’ve ever known; we’ve laughed together each and every day for decades.

I’ve lived through some very traumatic things. The addiction and trauma developed and escalated along the way; trauma, shame and fear fuel addiction. Then I discovered that life is brimming with second chances, and I took a chance—on healing and resilience.

Since my first day in recovery, I’ve celebrated humor and laughter, gratitude, love, and courage. Life is challenging, sometimes terrifying, but beauty, hope, and strength can be found every step of the way. When I reflect on the most difficult parts of my life today, that’s what I see. Look back, learn, and whenever possible, laugh—that’s my motto. Stand-up comedy taught me powerful lessons about life, and how to meet challenges and overcome them. I describe some of those lessons, and stories about how I learned them, in both Fierce, Funny, and Female and Never Give in to Fear.

When you sit down to write a memoir, what comes first: the anecdotes, the stories … or an overall vision of what you want to say?

As both author and keynote speaker, the stories come first, and I use stories to carry the message. The way I see it, our lives are made up of stories: things we experienced and remember today, and the stories we tell ourselves that influence our concept of self, and outlook on life. If you tell yourself good stories with positive outcome, your attitude tends to be more optimistic as you confront obstacles and difficulties. And you have the power to look back on past painful experiences, along with real or perceived failures—and see the courage and strength in your actions, the grace in situations, the lessons learned.

When you recognize that you are sum of all your experiences, and make a conscious decision to love and accept yourself, you reach a place of empowerment in knowing that you are stronger, braver, funnier, smarter, not in spite of the things you’ve lived through, but because of them. In both Never Give in to Fear and Fierce, Funny, and Female, my voice as a writer proceeds from that place of empowerment. Trauma therapy, cognitive reframing, and mindfulness meditation helped me to get there, and I engage those tools to stay grounded and empowered today.

Never Give in to Fear

When was your “rock bottom?” When, or how, did you make the decision to end the cycle of addiction?

I spent years of my life at “rock bottom.” There was no single low point. But my recovery began with one powerful moment of clarity, a flame ignited by the recognition of hope and of unconditional love. I described that defining moment in Never Give in to Fear, and if I include it in this interview it may be a spoiler for those who have not yet read my books. I count one specific date as the turning point, because in that moment I found the strength to carry out a plan of action toward recovery. But many moments led toward that ultimate place of healing and empowerment.

Speaking as an addiction specialist, I want to remind readers that addiction is a disease, it’s not a series of bad decisions, or a failure to make a decision to end the cycle; it is not a moral weakness. The idea that an addict must hit rock bottom in order to recover has been disproven many times over. Addiction specialists and interventionists work to “raise the bottom” so that individuals can recover earlier in the disease process and not have to go through what I went through.

In Fierce, Funny, and Female, you are very honest and down-to-earth, and you describe experiences that are traumatic, hilarious, and even terrifying. You don’t try to pass yourself off as a victim or hero. Is it difficult to write in that style?

I like to describe what happened and leave it up to reader to make conclusions if they are so inclined. When I started doing standup in the 1980s, Jay Leno told me, “Never underestimate your audience.” He gave me, along with other beginning comics, a lot of valuable advice. Some of those stories are included in Fierce, Funny, and Female. I took a page from Leno’s playbook when I wrote Never Give in to Fear, and again when I wroteFierce, Funny, and Female. I would not describe the process as difficult, but I would say it feels pretty scary sometimes. If I begin to listen to the fear, worrying about what people will think of me, fear of judgment, etc., then I remind myself I may be either underestimating my audience, or underestimating myself. And then the fear is replaced by courage and a desire to create something that offers depth, humor, inspiration, entertainment, satisfaction and more for the reader.

What are you working on next?

I’ve been putting together an inspirational book that includes strategies for stress management, motivation, increasing creativity, and having fun. And I am beginning to work on a third memoir that uses stories and anecdotes all the beauty and power of healing I’ve experienced since I turned my life around. Within the past few weeks, it struck me that these two books may merge. Why not? It might be a fun read.

Fierce, Funny, and Female and Never Give in to Fear

Fierce, Funny, and Female: A Journey through Middle America, the Texas Oil Field, and Standup Comedy

Book CoverMarti MacGibbon
Stay Strong Publishing
Softcover $15.95 (424pp)

The subject matter in itself is daunting, even frightening, but MacGibbon’s courage and comedy make Fierce, Funny, and Female a winner.

Being funny is a survival skill. Marti MacGibbon’s incredible memoir Fierce, Funny, and Female is not only a survivor’s tale but an inspirational story of overcoming the unthinkable, again and again.

Through drug abuse and eating disorders, through sexual trauma and the murky waters of sobriety, MacGibbon relates how she found a way to smile again. An inspirational speaker and mental health professional, she has clearly made peace with her personal story.

Fierce, Funny, and Female has an accessible, friendly tone that sometimes stands in sharp contrast to the extremely dark, tragic subject material. These memories have clearly been shared more than once, and the chapters read like well-worn territory. This is MacGibbon’s story, and she’s sticking to it.

Rather than depict herself as a victim in every scene—which would be logical, considering what she’s been through—MacGibbon represents herself as a survivor. With the value of hindsight, sobriety, and a hell of a lot of therapy, her narrative self puts the pieces together to make sense of her wild and crazy life.

“I realize now that I was attempting to control the trauma not only with drug seeking, but with anorexia, that this is fairly common behavior for a teen with post-traumatic stress, but then I only knew I was running, as fast as I could, to keep ahead of some unknown, inexorable destruction,” MacGibbon writes.

The point isn’t to portray herself as a hero or even to score sympathy points: it’s to show that recovery is possible, no matter what your circumstances are.

Although being kidnapped, or forcibly injected with psychiatric drugs, aren’t everyday experiences, MacGibbon is very relatable and, yes, even funny while discussing such incidents. Her sense of humor, she shows, became a shield from an early age to “fight off all the other stuff,” including the guns, LSD, mental wards, hippies, and gangsters that pepper her pages.

What MacGibbon remembers—and doesn’t—may lead to flinching. She’s comfortable with her material and spares no one, even herself, from a gimlet-eyed inventory.

Above all, MacGibbon celebrates her resilience and her willingness to keep laughing. She goes in swinging, and from the first vivid scene, it’s clear that she is a natural comedian and a wonderful storyteller. As she tackles her difficult adolescence and young adulthood, she seems to ask, “What else ya got?”

The subject matter in itself is daunting, even frightening, but MacGibbon, like the best magician, assures her audience that there’s nothing up her sleeve. Her courage and comedy make Fierce, Funny, and Female a winner.

Read Online: http://eepurl.com/cJVK6n

28, Mar, 2017

Marti MacGibbon co-authors article published in AMA Journal of Ethics. Topic: Human Trafficking, Mental Illness, and Addiction

Marti MacGibbon, CADC-II, ACRPS, co-authored this article that was published in the AMA Journal of Ethics in January 2017. January is National Slavery and Human Trafficking Awareness Month.
Download Article

AMA Journal of Ethics, January 2017 23
AMA Journal of Ethics®
January 2017, Volume 19, Number 1: 23-34
Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing
Commentary by Hanni Stoklosa, MD, MPH, Marti MacGibbon, CADC-II, ACRPS, and Joseph Stoklosa, MD
This article reviews an emergency department-based clinical vignette of a trafficked patient with co-occurring pregnancy-related, mental health, and substance use disorder issues. The authors, including a survivor of human trafficking, draw on their backgrounds in addiction care, human trafficking, emergency medicine, and psychiatry to review the literature on relevant general health and mental health consequences of trafficking and propose an approach to the clinical complexities this case presents. In their discussion, the authors explicate the deleterious role of implicit bias and diagnostic overshadowing in trafficked patients with co-occurring addiction and mental illness. Finally, the authors propose a trauma-informed, multidisciplinary response to potentially trafficked patients.
Dr. Shah, an emergency department (ED) resident in New York City, entered the room of a young pregnant patient who was bleeding and visibly frightened. The patient, who only spoke Spanish, was accompanied by her brother, who translated. He explained that the patient suffered from schizophrenia and had been refusing her medications for the last couple of weeks. He added that she’d had a few episodes of aggressive behavior, directed at others and herself. While the patient’s brother was talking, Dr. Shah noticed a few bruises and puncture marks with associated ecchymosis (subcutaneous bleeding similar to a bruise) on the patient’s arm. The brother saw that Dr. Shah had noticed these marks and explained that the patient sells herself for drugs.
Dr. Shah began to suspect that the patient’s brother might not be trustworthy, so she requested a certified clinical interpreter. Through the interpreter, the patient conveyed that she was miscarrying and asserted that she does not have schizophrenia, although she admitted feeling depressed sometimes. The patient’s tone became increasingly desperate and she explained, through the interpreter, that the man claiming to be her brother was holding her captive. She stated she was brought to the US as his fiancée, and, upon arrival, he confiscated her passport, forced her to have sex with him, and introduced her to drugs.
At this point, the man explained that his sister had long had delusions of persecution. He also disclosed that she had required temporary restraints the day before after threatening family members while she was high. He suggested that perhaps this episode had fueled the current delusion.
Dr. Shah had recently read about a case in which a 14-year-old girl had been to the emergency department for treatment and had told the staff she was being sex trafficked. The man accompanying the girl had also claimed she had schizophrenia. The clinicians believed the man and discharged the girl to his care; he was later found to be trafficking girls into commercial sex. The girl was not rescued until police found her bound in a closet during a drug raid weeks later.
Dr. Shah wondered what to do.
The clinical scenario described above might seem far-fetched or extreme. However, Dr. Shah’s dilemma mirrors many human trafficking clinical encounters in which patients present with medical, mental health, and substance use disorder needs. The health needs of this patient might very well suggest that she is being trafficked and should not be dismissed merely because the “brother” has identified the patient as having a mental illness or substance use disorder. This paper will discuss the implications of the patient’s presenting symptoms, the role of implicit bias and diagnostic overshadowing in trafficked patients with co-occurring addiction and mental illness, and the importance of providing trauma-informed care to patients who could be trafficking victims.
The article authors define human trafficking according to United States law. Federal law defines “severe forms of trafficking in persons” as:
(A) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or
(B) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery [1].
Note that trafficking does not necessarily involve movement and does not necessarily involve physical captivity. Vulnerable people are lured and trapped via myriad means AMA Journal of Ethics, January 2017 25
including economic abuse, psychological coercion, threats against family, drug addiction, physical abuse, and sexual abuse [2]. Vulnerability to trafficking exists on societal, community, and individual levels, and might be a result of society’s demand for cheap goods, disruption of a community through humanitarian crisis, or childhood sexual abuse [3].
The authors also specifically use the term “survivor” to refer to those who currently are or previously have been trafficked. “Survivor” is used rather than “victim,” as it is an empowering term that has been embraced by anti-trafficking organizations [4-6] to capture the strength it takes to face extensive trauma.

Health Implications of Being Trafficked
Physical consequences of being trafficked include a range of health problems resulting from occupational, trauma, and living condition-related risk exposures [7].
Pregnancy complications. One category of medical sequelae of being trafficked is pregnancy-related complications. Pregnancy resulting from sexual assault during labor or sex trafficking can be used as a means to coerce a trafficked female, keeping her emotionally bound to her trafficker and further reliant on the trafficker to meet her own and her child’s needs [8]. In a survey of sex trafficking survivors in the United States, 71.2 percent of 66 respondents reported at least one unwanted pregnancy during the period of their exploitation, and 21.2 percent reported five or more pregnancies [9]. The same survey found that 55.2 percent of the 67 female survivors reported at least one abortion, and 29.9 percent reported multiple abortions, with half of those who had had an abortion indicating that they were forced to have at least one of the abortions [9]. Similarly, 54.7 percent of 64 respondents reported at least one miscarriage and 29.7 percent had more than one miscarriage. In addition to enduring abortions and miscarriages with little, if any, clinical attention, trafficking survivors might not have adequate access to prenatal health care and can suffer from pregnancy-complicating sexually transmitted infections, such as HIV [8, 10]. Not surprisingly, a study from the United Kingdom showed that the health professional group most likely to encounter trafficked persons is maternity services professionals [11]. And a US-based study of trafficked persons found that approximately one quarter of labor and sex trafficked persons reported that they saw obstetricians during their period of exploitation [12]. So, the patient in this case presenting as pregnant and miscarrying should be regarded as a warning sign for Dr. Shah and as an opportunity for her to intervene.
Addiction. The patient in this scenario has physical stigmata of intravenous drug use in the form of track marks. Addiction has a complex relationship with human trafficking: it can exacerbate a trafficked person’s vulnerability, be part of a captor’s means of coercing a captive person to submit, be part of a captor’s means of incentivizing a captive person to remain captive, and be used by the captive person as a mechanism of coping with the www.26 amajournalofethics.org
physical and mental traumas of being trafficked [9, 13]. The first explanation appears to be the most common, although research is limited. For example, an anti-trafficking service provider in Maine found that 66 percent of its clients reported that substance use led to their being trafficked while only 4.5 percent reported that it arose after their being trafficked [13]. A broader survey of US survivors of sex trafficking found that 84.3 percent used substances during their trafficking exploitation. Alcohol, marijuana, and cocaine were each used by more than 50 percent of respondents and nearly a quarter (22.3 percent) used heroin [9].
Opioids in particular are an effective coercion tool for traffickers because they numb both emotional and physical pain; clinicians have noted clear links between the current US opioid epidemic and trafficking [14]. Some traffickers recruit directly from substance use disorder treatment facilities [15]. Moreover, high rates of opioid-overdose death underscore the potentially lethal consequences of an opioid addiction for trafficked persons [16].Therefore, as in this case, opioid addiction in and of itself may be a red flag for clinicians to screen for trafficking.
The power of addiction in trafficking has been recognized by the criminal justice system as well. In 2014, a man in Florida was convicted of sex trafficking based on his use of drug addiction to coerce his victims [17]. One of the survivors he exploited was quoted as saying, “He made me believe that he cared and that he loved me and he was going help get me off the streets.… Instead he got me addicted…. [The drugs] were all bought illegally for the purpose of addicting me and controlling me” [17]. Given the well-documented nature of addiction’s links to trafficking, in our case example, even if the “brother” is telling the truth about the patient’s substance use problem, it should be yet another component of a physician’s index of suspicion that the patient is trafficked.
Mental health. The “brother” in this scenario claims that the patient is suffering from delusions, possibly as a result of schizophrenia or her drug use. While labeling the patient delusional could be a ploy to undermine her agency and negate the veracity of her claims, clinicians should be aware that mental illness can be an indicator that a patient is being trafficked and should raise a clinician’s index of suspicion that she’s being exploited. Studies have shown that people with a known major mental illness like schizophrenia are more likely to be victimized physically than those without mental illness [18]. Moreover, intense, complex trauma—such as could develop in a person who is trafficked—is strongly associated with a patient’s development of psychosis, including schizophrenia [19, 20]. Not surprisingly, 15 percent of trafficked persons in contact with mental health services in South London between 2006 and 2012 met criteria for schizophrenia and related disorders in the International Statistical Classification of Diseases and Related Health Problems [21]. Trafficked persons with psychotic disorders and experiences of violence prior to being trafficked are likely to require more therapeutic support than patients with nonpsychotic disorders or those suffering from psychological distress [22]. Research AMA Journal of Ethics, January 2017 27
conducted in many countries demonstrates that, in addition to psychosis, survivors of labor and sex trafficking experience high rates of depression, anxiety, and posttraumatic stress disorder (PTSD), self-harm, and attempted suicide [23-25].

Responding to a Potentially Trafficked Person with Mental Illness and Addiction
Trauma-informed approach to care. Any patient encounter involves obtaining and analyzing subjective and objective data with varying degrees of uncertainty and using this information to formulate a care plan. However, in cases of potential human trafficking, like this one, the stakes are particularly high, underlining the need for a protocol, and a multidisciplinary approach that is survivor-centered, culturally relevant, evidence-based, gender-sensitive, and trauma-informed [26]. A summary of recommendations for how to approach potentially trafficked patients, compiled from survivors and international experts, is outlined in the table below. Protocols for identifying, assessing, and caring for trafficked persons can also be found on the HEAL Trafficking website [27]; these models can be adapted to particular practice settings, as exemplified by the National Human Trafficking Resource Center’s “Framework for a Human Trafficking Protocol in Healthcare Settings” [28]. Health care professionals should familiarize themselves with state-specific mandatory reporting requirements. The overarching goal of the clinical encounter is not rescue but rather improving health and safety. It is important to respect all patients’ assessment of their situation and risks to their safety. The core components of the general approach to a potentially trafficked patient include meeting basic needs, building trust and rapport, being conscious of language, remaining sensitive to power dynamics, and avoiding retraumatization [29, 30]. The patient should be interviewed alone, with an interpreter as needed.

Table 1. Expert and survivor-informed tenets: caring for a trafficked person [29, 30]
General approach

  • Do no harm.
  • Remember that the goal is not rescue, but improving health and safety.
  • Prioritize the safety of trafficked persons, yourself, and other staff.
  • Provide respectful, equitable, non-discriminatory care.
  • Approach interactions with the victim or survivor with respect and kindness.
  • Be empathetic, but not sympathetic, or appearing to pity.
  • Recognize that the victim is a human being that has been abused, exploited, and traumatized far beyond what most people can imagine.
  • Be aware of nonverbal communication: do not show shock or disgust.
  • Be nonjudgmental.
  • Know the basics of the patient’s cultural and religious background in www.28 amajournalofethics.org
  • order to understand his/ her worldview and to avoid potential offenses.
  • Use same-sex staff when possible.
  • Provide a private, warm, quiet, and comfortable place for the interview and exam.


  • Interview the patient alone.
  • Adequately select and prepare interpreters and co-workers.
  • Sit, don’t stand or hover. Take your time, don’t multitask; avoid writing while the patient is talking.
  • Avoid asking the same question more than once, which may cause frustration or distrust on the part of the patient.
  • Communicate effectively with other members of the care team to avoid repeated interviews with the victim, which may result in retraumatization.
  • Listen to and respect each patient’s assessment of their situation and risks to their safety.

Physical exam

  • Allow the patient to lead or set the pace of the exam.
  • Provide assurance that he/she is in control of the exam.
  • Ask permission each time you touch the patient.
  • Explain exactly what you are going to do.
  • If it is going to hurt, say it is going to hurt.
  • Be gentle, but don’t “sugar coat.”


  • Collaborate with multidisciplinary health care team to formulate plan; include patient advocate and social worker where possible.
  • Provide information in a way that is understood.
  • Obtain informed consent before sharing information about patients or beginning procedures to diagnose, treat, or make referrals.
  • Be prepared with referral information and contact details for trusted individuals and organizations that can provide support.
  • Never promise more than you can deliver.
  • Ensure the confidentiality and privacy of trafficked persons and their families.
  • Respect the rights, choices, and dignity of each person by encouraging independent decision making.
  • Include the patient in conversations about him/her when present.

AMA Journal of Ethics, January 2017 29
In particular, it is critical to approach all patients with a trauma-informed care perspective [26], which prioritizes a safe environment for the clinical encounter, helping the patient to regain a sense of agency and autonomy during the clinical encounter. Victims of interpersonal violence, including violence stemming from human trafficking, can experience sexual, physical, verbal, or psychological assault on a daily or even hourly basis. Any or all of these ongoing traumas, combined with social stigma, can result in the exploited person feeling less than, or other than, human. In the experience of one of the authors (MM), those who live with the stigma and pain of a diagnosis and experience mental illness and/or addiction can also have feelings of extreme social degradation. A trauma-informed approach to care enables clinicians to recognize that many patients have experienced abuse in their past, that many routine aspects of providing health care—such as asking a patient to undress or performing a gynecological exam—might be unintentionally retraumatizing, and that structural and personnel level changes might be needed. When a health care professional interacts with a potentially trafficked patient in a nonjudgmental manner and treats that patient with human dignity by asking permission before examining patients and reassuring them that they are in control of the exam, these actions alone can be interventions. Trauma-informed care is an approach that entire health systems should adopt for all patients. Training all staff, including receptionists and security staff on trauma-informed principles; not requiring patients to tell their clinical story multiple times during a clinical visit; and providing multidisciplinary, team-based care for survivors of interpersonal violence are all possible systems-level changes that may improve care for trafficking survivors [31].
Mental illness and addiction. An especially challenging component of this clinical vignette is the possibility that the trafficking exploitation reported by the young woman could be a delusion rather than reality. Mental health clinicians have expressed that it is often difficult to obtain histories from trafficking survivors [32]. To further obfuscate the clinical picture, patients with psychoses who have been sexually abused or bullied can have hallucinations in which the actual content or the themes of content is similar to that of their trauma, making it difficult to separate the two [33].
In approaching patients with co-occurring addiction and mental illness, clinicians must be particularly aware of their own biases and potential “diagnostic overshadowing” [34]. Diagnostic overshadowing refers to a well-described clinically and ethically problematic phenomenon in which clinicians ignore patients’ general health concerns because of that patient’s mental illness [35-38]. At the core of diagnostic overshadowing is a clinical reasoning error; that is, some clinicians unconsciously tend to express negative bias when diagnosing patients who have co-occurring mental health and general health problems, such that legitimate general health problems are misattributed as originating from a patient’s mental illness [36]. For example, a clinician might assume the patient www.30 amajournalofethics.org
with schizophrenia complaining of chest pain is just “crazy” or anxious, rather than accounting for a higher risk for heart disease among those with schizophrenia [36, 39].
Clinicians should be particularly vigilant to avoid diagnostic overshadowing, given that persons with chronic mental illness are not only at increased risk for all forms of interpersonal violence [18], but also more likely to suffer subsequent ill general health and to disclose the violence exclusively to health professionals [34, 40]. It is important to maintain a high index of suspicion for true interpersonal violence or exploitation, thoughtfully evaluating each concern expressed by a patient, knowing that even delusions can have kernels of truth and important places in a patient’s story of what she or he has experienced. Also, just because a patient has a known delusion, clinicians should not assume that the patient’s other concerns are not valid or do not deserve their attention.


Because each interaction with a potentially trafficked person is complex and critical, health systems should have trauma-informed interpersonal violence protocols in place that involve a multidisciplinary response team and respond to the critical needs of trafficking survivors. Dr. Shah should be mindful of the sway of implicit bias and diagnostic overshadowing, applying core principles in response to trafficking coupled with the use of a multidisciplinary team in her encounter with this woman and her “brother.” A response team should include social workers, emergency clinicians, behavioral health professionals, substance use disorder specialists, and obstetrics and gynecology colleagues [29, 41, 42].

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Hanni Stoklosa, MD, MPH, is the executive director of HEAL Trafficking and an emergency physician at Brigham and Women’s Hospital in Boston, with appointments at Harvard Medical School, the Harvard T.H. Chan School of Public Health, and the Harvard Humanitarian Initiative. She is a researcher, advocate, and speaker focusing on the public health of trafficking survivors in the US and internationally. She has advised the US Department of Health and Human Services, US Department of Labor, and National Academy of Medicine on issues of human trafficking and testified as an expert witness multiple times before the US Congress.

Marti MacGibbon, CADC-II, ACRPS, is an inspirational speaker and author and an expert on trauma resolution and addiction. She uses her personal story to raise awareness of, and strip away stigma from, human trafficking, domestic violence, addiction, PTSD, and homelessness. As a human trafficking survivor leader and advocate, Ms. MacGibbon has lobbied and shared her expertise at the White House, US Department of State, and California State Legislature.

Joseph Stoklosa, MD, is an instructor in psychiatry at Harvard Medical School in Boston. He is also the assistant program director for the MGH/McLean Adult Psychiatry Residency Training Program and the clinical director of McLean Hospital’s Psychotic Disorders Division.

Related in the AMA Journal of Ethics
Addiction, 12-Step Programs, and Evidentiary Standards for Ethically and Clinically Sound Treatment Recommendations: What Should Clinicians Do?, June 2016
Caring for the Trafficked Patient: Ethical Challenges and Recommendations for Health Care Professionals, January 2017
Diagnosing and Treating Schizophrenia, January 2009
Long-Term Opioid Treatment, May 2013
Managing Care of an Intrapartum Patient with Agitation and Psychosis: Ethical and Legal Implications, March 2016
Who is in Your Waiting Room? Health Care Professionals as Culturally Responsive and Trauma-Informed First Responders to Human Trafficking, January 2017

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
Copyright 2017 American Medical Association. All rights reserved.
ISSN 2376-6980

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