Asylum seekers

Asylum seekers are displaced individuals seeking international protection, often because of trauma or persecution experienced in their home country. Not all asylum seekers are victims of modern slavery: estimates suggest that just under 20% report such experiences (Clark Reference Clark, Fox and Gillam2022). The identification of modern slavery is important to ensure that victims seeking asylum receive the additional support and treatment they require for the purpose of recovery, but also to ensure that their needs as survivors of this crime are taken into account by the Home Office when determining their asylum claim. These factors will also be of importance to the First-tier Tribunal (Immigration and Asylum Chamber) should judicial review of a Home Office refusal to grant asylum be required. A detailed account of issues affecting asylum seekers can be found in my article on psychiatric evidence in immigration and asylum cases (Galappathie Reference Galappathie2024).

Human trafficking

Human trafficking has no borders and can occur entirely in the UK or involve international travel. Recruitment is the initial part of the trafficking process and it includes a range of practices to gain initial control over the victim. These may include the false promise of a well-paid job in another country, followed by transportation of the victim by plane or clandestinely by lorry or boat and the subsequent containment of the individual by use of threats or force. In some cases, the victim may describe being duped into what they thought was a romantic relationship, travelling with their ‘presumed partner’ to another country but then being beaten and exploited on arrival. Victims of trafficking may be subjected to carefully orchestrated grooming and psychological conditioning, which is used by their traffickers to create invisible chains that prevent them from leaving while being trafficked. The grooming may start with kind attention, praise and gifts, which are then followed by requests for favours and finally threats or use of violence to maintain control. The victim may be threatened with physical harm or fatal injury to themselves or their family and loved ones. The trafficker may simply need to threaten to kill the individual’s parents in their home country to gain control. Victims may be coerced into believing they have to work to pay off ever-increasing debts, leading to ‘debt bondage’. Important documentation such as their passport may be taken from them. Individuals trafficked to the UK who lack leave to remain, such as asylum seekers, may be told there is no help or support available for them as they are in the country illegally.

Slavery

Slavery includes a wide range of exploitative practices, with many victims experiencing multiple forms of exploitation. These include forced labour, which typically involves being made to work long hours with few breaks on an unpaid basis or with limited pay in a variety of work environments, such as construction, factory work, farming or nail bars. Victims may be forced to live in a house with other victims in poor conditions, being transported each day to sites where they are made to work. Domestic servitude involves staying in a family home, where the victim is prevented from leaving or has their freedom restricted, while being exploited into domestic labour, typically housework or childcare. Sexual exploitation includes all forms of sexual abuse, such as being raped and forced to work as a prostitute. Criminal exploitation occurs when the victim is forced or coerced into carrying out criminal acts, notably ‘county lines’ drug offences or cannabis cultivation. Vulnerable individuals may also be made to carry out benefit fraud, with their trafficker keeping the illegally obtained funds.

First responders

The duty of first responders is to recognise indicators of modern slavery, identify potential victims, gather information, complete the required referral and provide ongoing follow-up, including requesting reconsideration of a negative decision when appropriate.

It is notable that although a variety of statutory and non-statutory first responder organisations are included in the accepted list (Box 1), ranging from police forces to charities such as Barnardo’s, the list of organisations for England, Wales and Scotland does not include National Health Service (NHS) trusts and health boards. In contrast, health and social care trusts are listed as accepted first responders in Northen Ireland. It might be argued that clinicians in mental health organisations, the victim’s general practitioner (GP) or their legal representative may have greater knowledge of the individual’s plight, physical and mental condition and circumstances, placing them in a better position both to identify the need for referral and to enable a more effective referral.

Where a clinician is not on the first responder list

In regions where healthcare organisations cannot act as first responders, psychiatrists should think carefully whether a first responder organisation should be contacted to refer their patient to the NRM. Careful thought is required, given the need to maintain the patient’s trust, consider issues related to confidentiality, and, ideally, obtain their consent for referral. However, priority must be placed on the safety and welfare of a vulnerable patient who must be safeguarded. It will therefore be helpful to explain to the patient that referral to the NRM by a first responder will be beneficial, as it may gain them recognition as a victim of modern slavery and enable them to receive the additional support and treatment they require.

Appeals

I suggest that in relation to appeals following a negative NRM decision, it is more likely that the victim’s legal representative, if they have one, will request reconsideration of the decision, rather than the police force or Home Office, especially if the lawyer is in possession of new evidence that supports the finding that their client may be a victim of modern slavery, such as the diagnosis of PTSD in a psychiatric report.

Disclosure

Victims may experience high levels of shame, guilt and avoidance and may not feel able to disclose their history of trauma or their mental health symptoms. It takes time for a victim to trust and confide their full experience and symptoms to their lawyers or to a psychiatrist, which helps explain why a diagnosis of PTSD is often made late in the course of a victim’s recovery, often after a negative decision is made following their initial referral to the NRM. The diagnosis of mental disorder then becomes a strong indicator of modern slavery, warranting reconsideration of the initial decision.

For clinicians who suspect the presence of modern slavery, advice on how to manage difficulties in obtaining disclosure can be found in the Trauma-Informed Code of Conduct (Witkin Reference Witkin and Robjant2022) or the handbook on national referral mechanisms published by the Organization for Security and Co-operation in Europe (2022). Practical suggestions include prioritising safety, following local safeguarding procedures and addressing any urgent or emergency needs. Clinicians may find that remaining interested and curious about the person’s experience, asking questions sensitively and making the person feel there is plenty of time for a detailed consultation will be helpful. Attempts should be made to carefully explain the NRM process and obtain informed consent for referral. Discussion should also take place about referral to appropriate organisations, such as the police, support charities or the Modern Slavery Helpline. Follow-up appointments should be made to provide ongoing support and monitor progress.

Reasonable grounds decisions and interim support

Once a referral or notification has been made by a first responder, the relevant competent authority will endeavour to make a reasonable grounds decision within 5 working days. In 2024, the average time from referral to a reasonable grounds decision was 9 days. Although the data indicate that timely decisions are typical, in some cases several months will elapse before a decision is reached. In 2024, 20 090 reasonable grounds decisions were made, with 53% being positive (Home Office 2025a). A positive reasonable grounds decision enables the victim to receive specialist support for at least 30 days during what is termed their recovery period (Home Office 2026a) while a final decision is made.

Article 12 of the Council of Europe Convention on Action against Trafficking in Human Beings requires authorities to ensure that victims of trafficking are identified and their immediate needs are met, including accommodation, medical treatment and psychological therapy. The need to allow victims to remain in the country for the purpose of recovery is also recognised on humanitarian grounds. The EU directive on trafficking (Directive 2011/36/EU) outlines further protective measures, including the prevention of prosecution if the victim was forced into criminal acts as a result of their trafficking and focuses on the needs of victims, including the appointing of guardians to ensure that the needs of child victims are protected. Following Brexit, both of these laws are no longer directly applicable in the UK, but they are still effectively implemented through the Modern Slavery Act 2015. Specialist support in the UK includes the provision of accommodation, which may be in the form of placement in a safe house if protection from re-trafficking is required. Allocation of a support worker and practical support, such as access to childcare and emotional support, including funding for third-party counselling services, may also be provided. Currently, an additional £26.88 per week (the so-called ‘Recovery Rate’) may be awarded to assist with costs associated with recovery, including access to leisure, well-being classes, transport and communication (Home Office 2026a).

In England and Wales one avenue of support for victims of modern slavery is the Salvation Army or its specialist subcontractors under the Modern Slavery Victim Care Contract (MSVCC). People working in these organisations invariably have experience and expertise in supporting such individuals. Placement in a safe house enables 24 h support by specially trained staff and protects the victim from being re-trafficked.

Conclusive grounds decisions and recovery needs assessments

The competent authority will aim to make a conclusive grounds decision within 45 days, although delays, potentially of up to several years, can occur. In 2024, the average time from referral to a conclusive grounds decision was 637 days. In 2024, 17 304 conclusive grounds decisions were made, 56% being positive (Home Office 2025a). The most common reason for a negative decision, accounting for 76%, was that the referral had insufficient information to meet the standard of proof required. This indicates that psychiatric assessment reports could be a valuable source of information that should be submitted. A further 12% were found not to meet the NRM’s definition of modern slavery, with only 11% being found to lack credibility. A positive conclusive grounds decision enables formal recognition as a victim of modern slavery.

A positive conclusive grounds decision should trigger a recovery needs assessment (RNA) (Home Office 2025b). This enables support workers to consider whether the victim has recovered from their experience or has unmet needs related to it. The assessment’s recommendation decisions are then made by the Single Competent Authority. A positive conclusive grounds decision, although helpful for the individual in terms of recognition of their experience, can potentially lead to the termination of the support that was being provided during the recovery period, given that MSVCC support is provided only for recovery needs directly related to their modern slavery experience. A 45-day period of ‘move-on’ support is provided while alternative arrangements are made for the victim.

A positive conclusive grounds decision for an asylum seeker does not automatically confer leave to remain as a refugee on the basis of their asylum application. Instead, it requires the Home Office to consider whether to grant temporary permission to stay (‘leave to remain as a victim of human trafficking or slavery’, known as VTS leave), to enable the victim to continue their recovery, before being returned to their home country (Home Office 2026a). VTS leave can also be granted to enable the victim to assist authorities, such as the police with trafficking investigations, or to allow the victim to complete a claim in the civil courts for compensation related to their modern slavery experience. The grant of VTS leave for a finite, often short, period of time, such as 24 months, can be problematic, given that as the expiry of the leave approaches, this may trigger a deterioration in the victim’s mental health, as they may start to fear being returned to their home country.

The number of individuals granted VTS leave is not widely reported, but appears to be low: a freedom of information request revealed that only 36 people were granted it between February and July 2023 (Detention Taskforce 2024). The low numbers raise concern about the vulnerability victims face while remaining in the UK without a stable immigration status. Despite surviving their modern slavery experience, they are left fearing removal from the UK and detention pending removal, and at risk of homelessness, destitution and a lack of support and treatment because of their lack of status: these are all factors that will increase their risk of being abused, exploited and re-trafficked (Mullan-Feroze Reference Mullan-Feroze and Dorling2025).

Trauma-informed care

The type, nature and duration of therapy should follow the principles of trauma-informed care (Witkin Reference Witkin and Robjant2022), tailored to each individual’s unique needs. The optimum treatment for complex PTSD is yet to be fully determined, but initial suggestions indicate that a holistic approach is required, including addressing housing, support requirements, access to healthcare and reduction in post-trafficking stress (Evans Reference Evans, Sadhwani and Singh2022). Victims of modern slavery require a safe and supportive environment to enable them to feel contained and secure in order to take part in and benefit from psychological therapy. In many cases, this will require having a stable immigration status so they do not fear being returned to the country from which they were trafficked, where they might fear that their traffickers could harm or re-traffic them, especially if debts are still owed or grievances are held because they escaped from their traffickers.

A sense of safety has been identified as a requirement for psychological therapies to be effective, regardless of the patient population: safety in the context of therapy helps ensure continued survival, supports restoration and enables positive risk-taking and psychological integration (Podolan Reference Podolan and Gelo2023), which are all highly relevant to recovery from the sustained multiple traumas associated with modern slavery.

Durable recovery requires symptom improvement as well as functional improvement to enable reintegration into society, which can be measured by the ability to form and maintain networks of support, take part in education and obtain employment. However, even after achieving recovery, survivors of modern slavery are likely to have a continuing propensity for relapse if stressed, especially if that stress is reminiscent of their past traumas. They also remain vulnerable to re-trafficking and should this occur, a severe and prolonged relapse is likely (Oram Reference Oram, Khondoker and Abas2015).

In terms of housing, survivors may benefit from having self-contained accommodation or their own room in a shared house. Hotel accommodation is rarely appropriate, as individuals may feel unsafe, threatened and reminded of their trafficking experience. Having their own room gives survivors a safe place they can call their own, where they can quietly reflect on their experiences as part of the process of taking part in therapy and gradually recovering. Having their own room will also avoid the distress of being disturbed by the broken sleep and nightmares of other traumatised residents and will ensure they do not feel guilty about disrupting the sleep of others because of their own nightmares.

Individuals may benefit from being housed in large cities such as London, Birmingham or Manchester, given that these locations are more likely to have specialised support and therapy services, such as the Helen Bamber Foundation or Freedom from Torture, making in-person access to support and therapy more feasible. In addition, large cities are more likely to have established communities of individuals from the same background as the victim, enabling better social support.

The ability to take part in education and paid employment will also help in recovery (Jannesari Reference Jannesari, Damara and Witkin2024).

Public Order Disqualification (POD) powers

Under the Nationalities and Borders Act 2022, the Home Office may apply a Public Order Disqualification (POD) notice, which controversially enables the relevant authorities to withdraw support and protection given to victims of modern slavery if they are considered to be a threat to public order. In practice, a trafficked individual who is convicted of a criminal offence, such as cultivation of cannabis, can be stripped of treatment and support, despite being granted a positive reasonable or conclusive grounds decision by the competent authority. This is despite recognition in the form of a positive conclusive grounds decision that the conviction was in the context of likely coercion.

A POD notice can lead to difficulty meeting the mental health and recovery needs of the individual, which still remain, despite the threat to public order. A POD also provides grounds for the Home Office to deny VTS leave, making the victim more vulnerable to being returned to their country of origin if their asylum application is refused.

Wider effects of modern slavery on its victims

Modern slavery has many adverse impacts on victims. In addition to the mental health problems outlined above, victims often have problems with authority figures, given that their power and control often reminds victims of their traffickers. Victims may lack trust in state processes, given that these processes did not prevent their exploitation (Stanley Reference Stanley, Oram and Jakobowitz2016). High levels of physical symptoms, such as urinary problems, trauma-related fistula, headaches, musculoskeletal pain and injuries, have also been reported (Oram Reference Oram, Ostrovschi and Gorceag2012; Klabbers Reference Klabbers, Hughes and Dank2023). Where sexual exploitation has occurred, higher levels of sexually transmitted diseases have been found (Beyrer Reference Beyrer and Stachowiak2003; Silverman Reference Silverman, Decker and Gupta2007). Victims may have endured adverse experiences with the police while subjected to modern slavery, such as being arrested during a police raid on the premises where they were forced to work, making them distrustful of police officers (Klabbers Reference Klabbers, Hughes and Dank2023).

Psychiatrists should be aware of such adverse impacts of modern slavery on its victims and that negative decisions by the competent authority, refusal of VTS leave by the Home Office or withdrawal of support and protection as a result of a POD notice may have further adverse effects on a victim’s already fragile mental health.