Perceptions of Institutional Betrayal Predict Suicidal Self-Directed Violence Among Veterans Exposed to Military Sexual Trauma.

OBJECTIVES: We examined perceptions of institutional betrayal among Veterans exposed to military sexual trauma (MST) and whether perceptions of institutional betrayal are associated with symptoms of posttraumatic stress disorder (PTSD), depression, and suicidal ideation and attempt after MST. METHOD: A total of 49 Veterans with MST completed self-report measures and interviews in a Veterans Health Administration setting. RESULTS: Many participants reported perceptions that a military institution created an environment in which MST seemed common, likely to occur, and did not proactively prevent such experiences. Many participants expressed difficulty reporting MST and indicated that the institutional response to reporting was inadequate. Over two-thirds perceived that the institution had created an environment in which they no longer felt valued or in which continued membership was difficult. Perceptions of institutional betrayal were associated with PTSD symptoms, depressive symptoms, and increased odds of attempting suicide after MST. In contrast, perceptions of institutional betrayal were not associated with post-MST suicidal ideation. Among the subsample of Veterans exposed to military sexual assault, the association between institutional betrayal and PTSD symptoms approached significance. CONCLUSIONS: Perceptions regarding institutional betrayal appear to be highly relevant to MST and its sequelae. These findings underscore the importance of Veterans' perceptions of the military institution's efforts to prevent and respond to MST to individual recovery from sexual trauma. Additional research regarding the association between institutional betrayal and health-related outcomes is needed.

Systemic trauma.

Substantial theoretical, empirical, and clinical work examines trauma as it relates to individual victims and perpetrators. As trauma professionals, it is necessary to acknowledge facets of institutions, cultures, and communities that contribute to trauma and subsequent outcomes. Systemic trauma-contextual features of environments and institutions that give rise to trauma, maintain it, and impact posttraumatic responses-provides a framework for considering the full range of traumatic phenomena. The current issue of the Journal of Trauma & Dissociation is composed of articles that incorporate systemic approaches to trauma. This perspective extends conceptualizations of trauma to consider the influence of environments such as schools and universities, churches and other religious institutions, the military, workplace settings, hospitals, jails, and prisons; agencies and systems such as police, foster care, immigration, federal assistance, disaster management, and the media; conflicts involving war, torture, terrorism, and refugees; dynamics of racism, sexism, discrimination, bullying, and homophobia; and issues pertaining to conceptualizations, measurement, methodology, teaching, and intervention. Although it may be challenging to expand psychological and psychiatric paradigms of trauma, a systemic trauma perspective is necessary on both scientific and ethical grounds. Furthermore, a systemic trauma perspective reflects current approaches in the fields of global health, nursing, social work, and human rights. Empirical investigations and intervention science informed by this paradigm have the potential to advance scientific inquiry, lower the incidence of a broader range of traumatic experiences, and help to alleviate personal and societal suffering.

Dangerous safe havens: institutional betrayal exacerbates sexual trauma.

Research has documented the profound negative impact of betrayal within experiences of interpersonal trauma such as sexual assault (Freyd, 1994, 1996; Freyd, DePrince, & Gleaves, 2007). In the current study of college women (N = 345, 79% Caucasian; mean age = 19.69 years, SD = 2.55), we examined whether institutional failure to prevent sexual assault or respond supportively when it occurs may similarly exacerbate posttraumatic symptomatology-what we call "institutional betrayal." Almost half (47%) of the women reported at least one coercive sexual experience and another 21% reported no coercion, but at least one unwanted sexual experience (total reporting unwanted sexual experiences, N = 233). Institutional betrayal (e.g., creating an environment where these experiences seemed more likely, making it difficult to report these experiences) was reported across different unwanted sexual experiences (47% and 45% of women reporting coercion and no coercion, respectively). Those women who reported institutional betrayal surrounding their unwanted sexual experience reported increased levels of anxiety (R(2) = .10), trauma-specific sexual symptoms (R(2) = .17), dissociation (R(2) = .11), and problematic sexual functioning (R(2) = .12). These results suggest that institutions have the power to cause additional harm to assault survivors.

How Should Surgeons Balance Transplantation Innovation With Acceptance of a Trauma Survivor's Appearance?

Clinical and ethical issues involved in counseling a patient about reconstructive surgery for a traumatic and disfiguring injury require special consideration. This article proposes prioritizing 2 considerations: (1) the influence of traumatic experiences on a survivor's cognitive processes and (2) insights into a survivor's acceptance of his or her posttrauma appearance or consent to high-risk or experimental surgery, which can be gained from dialectical behavior therapy. This article argues that these priorities should be explicitly discussed by plastic surgeons counseling patients whose appearances are altered by trauma.

The impact of patient-physician alliance on trust following an adverse event.

OBJECTIVE: Adverse events in maternity care have a negative impact on the patient-physician relationship. This study assesses the effects of healthcare institutions, communication, and patient involvement on patient trust following adverse events. METHODS: Surveys were distributed online to women across the US who had given birth. Women were asked to recount their experiences during their most recent pregnancy including unexpected procedures, adverse events, support from healthcare institutions, and perceived betrayals by healthcare institutions. RESULTS: Adverse events were negatively correlated with patient trust in their physician. This study's results illustrated that patient involvement and institutional betrayal mediated patient trust following adverse events. Patients who were more involved in decision-making with their physician were found to have more trust in them following adverse events than those who did not. CONCLUSIONS: Patient-physician trust is negatively affected by adverse events, but patient-physician alliance in decision-making can decrease this impact. Therefore, physicians can work proactively to lessen the detrimental effects of adverse events on patient trust, but the patient-physician relationship is still impacted by healthcare institutions. PRACTICE IMPLICATIONS: This study demonstrates the benefits of encouraging patient alliance with their physician and supports a need for education on the use of these strategies in healthcare.

First, do no harm: institutional betrayal and trust in health care organizations.

PURPOSE: Patients' trust in health care is increasingly recognized as important to quality care, yet questions remain about what types of health care experiences erode trust. The current study assessed the prevalence and impact of institutional betrayal on patients' trust and engagement in health care. PARTICIPANTS AND METHODS: Participants who had sought health care in the US in October 2013 were recruited from an online marketplace, Amazon's Mechanical Turk. Participants (n = 707; 73% Caucasian; 56.8% female; 9.8% lesbian, gay, or bisexual; median age between 18 and 35 years) responded to survey questions about health care use, trust in health care providers and organizations, negative medical experiences, and institutional betrayal. RESULTS: Institutional betrayal was reported by two-thirds of the participants and predicted disengagement from health care (r = 0.36, p < 0.001). Mediational models (tested using bootstrapping analyses) indicated a negative, nonzero pathway between institutional betrayal and trust in health care organizations (b = -0.05, 95% confidence interval [CI] = [-0.07, -0.02]), controlling for trust in physicians and hospitalization history. These negative effects were not buffered by trust in one's own physician, but in fact patients who trusted their physician more reported lower trust in health care organizations following negative medical events (interaction b = -0.02, 95%CI = [-0.03, -0.01]). CONCLUSION: Clinical implications are discussed, concluding that institutional betrayal decreases patient trust and engagement in health care.

Institutional betrayal.

A college freshman reports a sexual assault and is met with harassment and insensitive investigative practices leading to her suicide. Former grade school students, now grown, come forward to report childhood abuse perpetrated by clergy, coaches, and teachers--first in trickles and then in waves, exposing multiple perpetrators with decades of unfettered access to victims. Members of the armed services elect to stay quiet about sexual harassment and assault during their military service or risk their careers by speaking up. A Jewish academic struggles to find a name for the systematic destruction of his people in Nazi Germany during the Holocaust. These seemingly disparate experiences have in common trusted and powerful institutions (schools, churches, military, government) acting in ways that visit harm upon those dependent on them for safety and well-being. This is institutional betrayal. The purpose of this article is to describe psychological research that examines the role of institutions in traumatic experiences and psychological distress following these experiences. We demonstrate the ways in which institutional betrayal has been left unseen by both the individuals being betrayed as well as the field of psychology and introduce means by which to identify and address this betrayal.