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Learn More. Psychotherapy is effective for a myriad of mental health symptoms, with the clinical situation dictating the most applicable method. For episodes of severe stress including acute depression and anxiety, supportive mechanisms crisis interventions and shoring up existing coping skills and strategies may be the best fit. During periods of relatively milder symptomatology a psychodynamic approach may be utilized with the same patient focusing on self-reflection and a more in-depth exploration. This article focuses on the use of psychotherapy with women working in the sex industry, whether indoor such as strip clubs and cabarets or outdoor such as prostitution and escort services.

These women frequently experience violence in various forms, and most report multiple traumatic experiences, both during their developmental years and while working in the industry. A composite case is included that illustrates some of the supportive and psychodynamic psychotherapy techniques that can be applied when treating these individuals.

Women involved in the adult sex industry e. Important statistics about the sex industry 124.

Currently, more women are employed in the sex industry than in any other point in time. Relative to the general population, women in the sex industry experience higher rates of substance abuse, sexually transmitted diseases, domestic violence, depression, violent assault, rape and posttraumatic stress disorder.

There has been little research on violence against women in the sex industry until recently.

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Many in society have assumed that women who work in the industry do so willingly and somehow are shielded from sexual and physical harm or that their participation is fully volitional. Raphael and Shapiro 2 found that the high prevalence of violence against women included both the indoor and outdoor sex industries. The perpetrators most commonly were identified as customers, pimps, managers, and intimate partners. More than half of the exotic dancers reported that they had been threatened with a weapon.

Violence occurred in all venues of the sex industry, but severity and frequency and type of violence varied depending on indoor versus outdoor venues. The women working in the outdoor setting reported higher prevalence of generalized physical violence; however, the indoor setting was associated with more sexual violence and threats involving weapons.

Raphael and Shapiro 2 also reviewed more than 25 research studies quantifying the level of violence in street prostitution. Eighty-two percent of the respondents reported physical violence and 68 percent reported rape. A staggering 68 percent of these prostitutes also met criteria for PTSD.

Similarly, Walls 3 reported those who engaged in survival sex a consequence of poverty and minimal opportunity for improvement carried a far greater risk of developing depression, were more often psychiatrically hospitalized, and 4. Holsopple 4 studied exotic dancers. One-hundred percent of the dancers reported that they had been physically assaulted during work-related activities at least once.

The prevalence or assaults ranged from 3 to 15 times during the time of employment in the sex industry, with a mean occurrence of eight incidents.

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Forty-four percent of the women interviewed in that study reported that they had been verbally threatened, with a range of 3 to threats for those who reported threats. These findings were substantiated by Maticka-Tyndale et al 5 who found similar. A greater prevalence of physical assaults and unwanted sexual contact occurred in indoor settings e. The outdoor workers reported being slapped, punched, and kicked in contrast to the indoor workers who reported attempted rape more frequently. Wesley 8 found that dancers accepted as commonplace these physical violations of their bodies. Complicating the problem of documenting the prevalence of violence against sex workers is their reluctance to disclose it for fear of incriminating themselves or making themselves targets of additional verbal, physical, and sexual abuse.

Navigating the secrecy of working in the sex industry coupled with societal stigmatization also often in social isolation, further complicating reporting, mental health, and subsequent treatment options. M was a divorced year-old woman who was a former exotic dancer and escort. She resided in a homeless shelter and only had temporary employment.

M had been seen by a different psychiatrist at the clinic the year and followed through in therapy with biweekly to monthly appointments during that time. When scheduling the current appointment, she was surprised to learn her initial psychiatrist had left the clinic and she would need to reinitiate treatment with a new psychiatrist. Staff turnover in mental health clinics is inevitable, and this must be clearly explained to the patient. A clear line of communication is essential as this may represent an inconsequential shift for staff, but an irreparable loss for the vulnerable patient.

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This is of special importance to the individual who has endured repeated betrayals and rejections to prevent this from being interpreted as yet another episode of abandonment. M arrived early for the reevaluation; her worn-looking apparel consisted of a faded gray zip-down sweatshirt, torn jeans, and old tennis shoes. Her hygiene was mediocre. She seemed to carry a bit of shame in her appearance; this was unspoken, but it was clear self-confidence was lacking.

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Old scars were visible on her face and arms, each one depicting a harrowing tale. The deep ridges and multiple creases in her skin revealed a deteriorated woman appearing much older than her chronological age. Her speech was spontaneous and intentional and there was no interruption in eye contact. Overall, her mood was euthymic and affect was full range and easily accessible. M became dramatically blunted in affect when she recounted the horrific trauma of her past in a mechanical way. She readily opened the session depicting interpersonal discord and her current psychosocial stressors, including being unemployed, financially strapped, and in an unstable living environment.

At first, the conversation flowed seamlessly without much break. Upon the first major pause, there fell a silence, leaving her visibly apprehensive.

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And how am I supposed to feed my children? The psychiatrist reinitiated the conversation after a pause and offered words of encouragement to proceed. Moments of silence during the psychotherapy hour can communicate important psychodynamic information as well as serve to foster the therapeutic relationship. It is an opportunity for the patient to convey emotional and relational messages of need and meaning.

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The psychiatrist could use silence to provide safety, understanding, and containment. R was a year-old single woman working as an escort at a location just off the main road of a popular tourist resort. She presented to the mental health clinic after she was allegedly sexually assaulted at work in a commonly frequented motel two weeks prior. She reported the onset of acute anxiety and fearfulness after her most recent attack, and these feelings re-emerged as she described the attack to the psychiatrist.

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She quickly transitioned into the events of her youth. Notably detached from her graphic depictions, she described her earlier experiences. She began to chronologically relate incidents starting at the age of five when she was first sexually violated. She was aware that her mother had used alcohol and street drugs while pregnant and that this caused her to have learning disabilities and developmental delay.

As a toddler, she would have at most a single meal daily and frequently was locked in a dark closet. She was placed in multiple foster and group homes. Being the youngest of three siblings, she told a story of manipulation, negligence, public humiliation, and betrayal. By the age of 15, Ms. This allowed easy access to some money and afforded her a sense of importance and desirability. The allure of instant acceptance and adoration was captivating and kept her immersed in the sex business for several years.

Unfortunately, she sustained attacks both physical and sexual in nature, plus ruthless disparagement and humiliation by the intoxicated patrons. Eventually, she acquired employment in retail and attempted to exit the profession. After being cut, beaten, robbed, gang raped and sodomized, tied up, and left to bleed to death, she again tried to dissolve all ties to the industry and sought help.

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After her second visit with the psychiatrist a malestaff noticed her transformation, which involved an overly enthusiastic demeanor and enhanced appearance jewelry and makeup plus more stylish and seductive attire when presenting for appointments.

I was just getting used to Dr. You make the decisions about what we discuss. It is important for members of the treatment team to communicate their observations to the treating psychiatrist and that staff on the team, including the doctor, not be changed abruptly without notice.

The psychiatrist should discuss with the staff possible behavioral changes that may occur, and endorse the importance of understanding how transference, countertransference, and concern about professional boundaries can affect such complicated situations.

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In this case, when the psychiatrist was changed, the patient did not return for a long time. Patient: Yeah, I called off work and took the bus to get here because I know I did much better while I was in treatment. New Doctor: I wonder how the termination with the doctor might have affected your feelings about returning?

Transference is the process of the patient unconsciously attributing aspects of important past relationships, especially those of early caregivers, onto the psychiatrist.

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Dismissal or complete avoidance of the possibility of erotic transference issues especially with this population would be a therapeutic misstep; rather, transference should be confronted and worked through. For example, although sex workers are over-represented among female murder victims, 9 sex workers often are viewed culturally as voluntarily bringing on the increased risk for violence themselves or are somehow impervious to such risk.

The patient may not keep herself safe because she does not know how to do so or does not think she has value.

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