College Students' Trust, Betrayal, and Needs During and After Their Worst Nonassault-Related Healthcare Experiences Differ Based on Sexual Violence Exposure.

The BITTEN theoretical framework conceptually links patient's past healthcare betrayal and trauma experiences with their current and future healthcare interactions. BITTEN was used to examine whether healthcare experiences, behaviors, and needs differ between those with and without a history of sexual violence exposure. College students at two public universities in the southeastern United States (n = 1,381; 59.5% White, 61.0% women) completed measures about their self-selected worst or most frightening but nonassault-related healthcare experience. Multivariate general linear and mediation models were used to test theory-derived hypotheses. Participants exposed to sexual violence reported greater healthcare institutional betrayal, lower trust, and greater need for tangible aid and trauma-informed care during their worst nonassault-related healthcare experience. They also reported greater current healthcare avoidance alongside increased utilization of more physical and mental healthcare appointments, even after accounting for gender and race differences. These results suggest that, with minimal information about past sexual violence exposure, healthcare providers could be better poised to predict and address vulnerable patients' healthcare needs.

How Healthcare Providers Reconcile Bad Things Happening to Good Patients: The Role of Just World Beliefs in Attitudes toward Trauma-Informed Care.

Despite prevalent trauma exposure among patients seeking health care, as well as widespread frameworks for enacting trauma-informed care, the uptake of trauma-informed practices such as trauma screening and referral among health-care providers remains relatively low. The current study sought to assess the roles of health-care providers' personal histories of adverse childhood experiences (ACEs) and personal beliefs in the just-world hypothesis in understanding their attitudes toward trauma-informed care. Advanced practice graduate nursing students (N = 180; M age = 34.6 years) completed a self-reported survey assessing their personal history of ACEs, global belief in a just world, and attitudes related to trauma-informed care. Results indicated the relation between providers' ACEs and attitudes toward trauma-informed care was fully mediated by their beliefs in a just world, such that providers reporting higher ACEs scores also report greater endorsement of attitudes consistent with trauma-informed care due to less belief in a just world. Implications for both health-care providers' themselves and cultural shifts necessary for provision of trauma-informed health care are discussed.

Bitten by the System that Cared for them: Towards a Trauma-Informed Understanding of Patients' Healthcare Engagement.

The BITTEN theoretical framework of trauma-informed healthcare proposes that each patient presents to a healthcare encounter with a baseline level of historical institutional Betrayal and trauma exposure that interacts with their Indicator for healthcare engagement to potentially Trigger trauma symptoms, impacting patients' Trust in healthcare providers and shaping their current and future Expectations of and Needs for healthcare. The current study sought to test and extend components of the BITTEN theoretical framework to better understand the link between trauma exposure (childhood trauma and institutional betrayal) and healthcare engagement. Results largely supported the propositions of the BITTEN theoretical framework: childhood trauma was directly related to healthcare avoidance behaviors. The relation between childhood trauma and healthcare avoidance was partially mediated by patients' reduced trust in healthcare providers. Further, the relation between childhood trauma and reduced trust in healthcare providers was potentiated by experiences of institutional betrayal. Interpreting patients' interactions with healthcare providers and the healthcare system as a whole in light of their interpersonal and institutional trauma histories is needed to more fully embody trauma-informed healthcare. The BITTEN theoretical framework of trauma-informed healthcare appears to be a viable foundation for developing a trauma-informed understanding of patients' healthcare engagement.

The "3 Es" of trauma-informed care in a federally qualified health center: Traumatic Event- and Experience-related predictors of physical and mental health Effects among female patients.

Federally Qualified Health Centers (FQHCs) are a fast-growing source of healthcare for women with intersectional identities, or those most frequently exposed to and negatively impacted by interpersonal trauma. According to the "3 E" conceptualization of trauma, certain Event- and Experience-related characteristics of a trauma predict victims' physical and mental health Effects. The "3 Es" have yet to be studied in female FQHC patients. The current study examined the prevalence of interpersonal trauma and interrelationships among traumatic Event-related factors (e.g., cumulative trauma by victim-perpetrator relationship), Experience-related factors (e.g., betrayal, resilience), and Effects (e.g., somatic symptoms, posttraumatic stress (PTS), anxiety/depression, mistrust, reduced sense of safety) among 138 predominantly Black (89.1%) women receiving care at an FQHC in the southeastern U.S. Roughly 65% of participants (n = 86) endorsed exposure to at least one type of interpersonal trauma. More cumulative trauma was significantly correlated with more somatic, PTS, and anxious/depressive symptoms, and a reduced sense of safety. Experiences of betrayal and/or resilience were better predictors of PTS and anxious/depressive symptoms and lack of safety than Event-related factors. Findings support the need for the implementation of trauma-informed care within community-based health centers. Healthcare providers should consider women's subjective experience of trauma when screening for exposure and providing trauma-sensitive care.

Conservation of resources and suicide proneness after oilrig disaster.

The current study applied the Conservation of Resources (COR) disaster theory to explain suicide proneness after the Deepwater Horizon oilrig explosion. We had 213 residents in affected areas with complete measures of resource stability, distress, and coping 18 months after the disaster. Overall, 10% expressed clinically elevated suicide proneness. The COR model had excellent fit that accounted for 41% of inter-individual differences in suicide proneness. Aligned with theory, residents lacking resources who experienced distress and coped by avoidance were more suicide-prone. Fostering resource stability and constructive coping after catastrophe may help reduce suicide proneness and prevent suicide in disaster-impacted citizens.

The Prevalence and Mental and Physical Health Correlates of Posttraumatic Stress Disorder Symptoms in Vulnerable and Underresourced Primary Care Patients Referred to a Behavioral Health Provider.

CONTEXT: The prevalence of trauma exposure among vulnerable, impoverished patients seeking primary care services is considerable. However, assessment of trauma-related symptoms is rare, even among behavioral health patients receiving primary care services within integrated health care centers. OBJECTIVE: To determine the prevalence of clinically noteworthy trauma-related symptoms and their associations with other co-occurring mental and physical symptoms as well as self-reported resiliency. PARTICIPANTS: Primary care patients (n = 120) referred to behavioral health services (76.7% black/African American; 70.8% female). SETTING: Federally qualified health center. MAIN OUTCOME MEASURES: Abbreviated Posttraumatic Stress Disorder Checklist-Civilian, 2-item version; Patient Health Questionnaire (PHQ)-15: physical health symptoms; PHQ-9: depression symptoms; Generalized Anxiety Disorder Scale, 7-item; Connor-Davidson Resilience Scale, 2-items. RESULTS: Seventy-three percent (n = 88) of provider-referred behavioral health patients screened positive for potential posttraumatic stress disorder. Patients most likely to meet criteria for posttraumatic stress disorder reported significantly higher levels of stress, depression, anxiety, and suicide ideation as well as more severe headaches, chest pains, dizziness, and poorer health care. CONCLUSIONS: Results support the need for a trauma-informed integrated approach to health care within primary care settings, particularly those serving vulnerable populations. Integrated health care services foster an environment in which patient access to and satisfaction with services is maximized while overall well-being is enhanced. Adding resiliency-enhancing strategies to patients' integrated health care treatment plans might also be health-promoting. PTSD symptoms can be assessed as part of routine integrated practice via a 2-item screener. Information obtained from trauma screening provides the health care team with useful contextual information about patients' physical and behavioral health symptoms.

The Importance of Multidisciplinary Trauma-Informed Training in Addressing Campus-Based Sexual Violence.

ABSTRACT: This study investigates the impact of a professional development training series among a multidisciplinary team (MDT) during establishment of a trauma-informed sexual assault response and prevention program at a midsized university in the southeastern United States. MDT members included forensic nurses, advocates, counselors, law enforcement officers, and relevant faculty and staff. After completion of a baseline survey assessing attitudes toward trauma-informed care and perceptions of the team climate within the MDT, team members engaged in a trauma-informed care (TIC) professional development training series consisting of (a) 4-hour-long didactic lectures with incorporated group discussion and (2) one 2-hour in-situ simulation-based training exercise. MDT members subsequently completed 3-month and long-term follow-up surveys to assess the immediate and enduring impacts of the training series.The TIC training series significantly increased MDT members' perceptions of participative safety, task orientation, and support for innovation within the group at the 3-month assessment. No long-term differences were found, likely because of a small sample size and low statistical power.Intensive TIC MDT professional development at the beginning of a campus-wide sexual assault prevention and response initiative enhances psychological safety within the group, evidenced by increased perceptions of participative safety and support for innovation, and builds team cohesiveness around a shared set of tasks. Within the present MDT, the professional development training series also appeared to facilitate adoption of a shared set of values for accomplishing the team's goal of preventing and responding to sexual assault on campus. Recommendations for MDTs with similar goals are discussed.

Rape Myth Acceptance and Other Barriers to Formally Reporting Sexual Assault Among College Students With and Without Sexual Assault Histories.

Low rates of reporting sexual assault to law enforcement have been attributed to a culture of rape myth acceptance. Yet, rape myth acceptance rates and specific barriers to reporting have not been examined by sexual assault and reporting histories. This study compared the rape myth acceptance levels of reporting survivors, non-reporting survivors, and individuals without sexual assault histories. The sample consisted of 579 undergraduate students (68.0% White, 72.5% women) at a public university in the southeastern U.S. Differences in non-reporting survivors' experienced barriers to reporting and the perceived barriers of those without sexual assault histories were also examined. Results indicate differences in rape myth endorsement by sexual assault and reporting status, with the highest rape myth adherence rates endorsed by individuals without a sexual assault history and the lowest endorsed by reporting survivors. While non-reporting survivors and those without sexual assault histories shared two of the top three barriers to reporting (i.e., wanted to avoid thinking or talking about it, did not want family or friends to find out), non-reporting survivors were more likely to endorse personal reasons for not reporting, and those without sexual assault histories were more likely to endorse concerns about the law enforcement response to rape. Several barrier factors were identified among non-reporting survivors (i.e., fear of law enforcement involvement, personal reasons, ambiguity of the event, responsibility) and among individuals without sexual assault histories (i.e., risks outweigh benefits, victim blaming, ambiguity). Although both survivors and individuals without sexual assault histories acknowledge the personal, social, and legal risks of reporting a sexual assault to law enforcement, survivors' experienced barriers differed in nuanced ways from the presumed barriers of individuals without sexual assault histories. Findings may enhance sexual assault prevention trainings and awareness campaigns by targeting both rape myth beliefs and specific barriers to reporting of those with and without sexual assault histories.

An innovative behavioral health care curriculum: The integrated advanced practice addictions nursing subspecialty.

INTRODUCTION: There is a significant shortage of behavioral health providers trained in caring for patients with problematic substance use, particularly within integrated care settings. METHOD: An innovative addictions nursing subspecialty curriculum was designed by interdisciplinary faculty from psychiatric nursing, family nursing, counseling, and social work and informed by integrated care, addictions, and telehealth competencies. The subspecialty included prevention, treatment, and recovery approaches to care and encouraged enrollment of students from various health-related disciplines to enhance the students' experiences of integrated care for substance use treatment prior to completion of the program. RESULTS: Subspecialty courses increased the number of advanced practice nurses in the behavioral health care workforce with enhanced knowledge of integrated telehealth substance use treatment. DISCUSSION: Implementation of similar innovative curricula across health disciplines may significantly improve the care delivered to patients with problematic substance use in traditional medical settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

They've been BITTEN: reports of institutional and provider betrayal and links with Ehlers-Danlos Syndrome patients' current symptoms, unmet needs and healthcare expectations.

Introduction: Patients with rare and/or care-intensive conditions, such as Ehlers-Danlos Syndrome (EDS), can pose challenges to their healthcare providers (HCPs). The current study used the BITTEN framework1 to code EDS patients' open-ended written responses to a needs survey to determine their self-reported prevalence of healthcare institutional betrayal and its link with their expressed symptoms, provider perceptions, unmet needs, and on-going healthcare-related expectations. Methods: Patients with EDS (n = 234) were recruited via a rare disease electronic mailing list and snowball sampling. A total of one-hundred and six respondents (45.3%) endorsed having unmet healthcare-related needs; of these, 104 (99%) completed an open-ended prompt about these needs. Responses were coded for components of BITTEN, a framework designed to link patients' past, current, and future healthcare-related experiences in a trauma informed manner. Results: Many respondents with ongoing needs endorsed experiencing past institutional and provider betrayal (43%; n = 45), current mental health symptoms (91.4%; n = 95), negative expectations for future healthcare (40.4%; n = 62), and a lack of trust in their healthcare provider (22.1%; n = 23). There were no significant differences in post-traumatic stress disorder (PTSD)/anxiety, depression/sadness, or isolative symptoms between respondents coded for institutional betrayal (n = 45) compared with those not (n = 59). However, EDS respondents reporting institutional betrayal were significantly more likely to self-report anger and irritability symptoms, a lack of trust in their HCPs, and more negative expectations for future healthcare than those not reporting institutional betrayal. Discussion/conclusions: The frequent spontaneous reporting of past healthcare betrayals among patients with EDS implies the need for trauma-informed care and provider education. Given that experiences of institutional betrayal are associated with increased anger and irritability, as well as with negative expectations for future healthcare interactions, efforts to repair healthcare provider and system-wide relationship ruptures might have positive healthcare consequences. Plain language summary: Reports of Institutional and Provider Betrayal and Links with Ehlers-Danlos Syndrome Patients' Current Symptoms, Unmet Needs and Future Healthcare Expectations What is EDS? Ehlers-Danlos Syndrome (EDS) refers to a group of rare genetic connective tissue disorders that are primarily characterized by skin hyperelasticity, joint hypermobility, and tissue fragility. Connective tissue is largely responsible for the structural integrity of our bodies, and there are several EDS subtypes which each describe a specific connective tissue problem. In addition, there is significant overlap between EDS types and other kinds of connective tissue disorders. As a result, recognizing, diagnosing, and treating EDS is often challenging. What is Institutional betrayal? Institutional Betrayal here refers to a harmful action (i.e. commission) or lack of action (i.e. omission) on the part of a healthcare institution, individual provider/healthcare team, or insurance company. When a patient trusts that the healthcare system will act in their best interest, and trust is violated, institutional betrayal occurs. What is BITTEN? BITTEN is an acronym for Betrayal, Indicator, Trauma symptoms, Trust, Expectations, and Needs. It is a framework meant to capture previous problematic healthcare-related experiences in EDS patients, then to consider how those experiences influence a patient's current symptoms, provider trust, future expectations in healthcare encounters, and on-going needs. Why was this done? EDS, like many rare diseases, is hard to recognize and manage. We aim to:Give voice to EDS patients and their common unmet needs and healthcare-related expectations.Highlight how healthcare providers can apply BITTEN to improve care practices in rare disease patient encounters. What did we do? Using a newly articulated applied model of healthcare, BITTEN, we analyzed the open-ended responses of EDS patients describing their unmet emotional and mental health needs. What did we find? Nearly half of EDS patients who indicated they had unmet needs reported experiencing institutional betrayal.EDS patients who reported institutional betrayal also expressed anger, a lack of trust in healthcare providers, negative expectations for future healthcare, and more unmet needs more frequently than EDS patients who did not report institutional betrayal. What does this mean? The EDS patients in this sample were not directly asked if they had experienced institutional betrayal, so the exact prevalence is not known. Furthermore, responses were obtained voluntarily via the internet, so caution should be taken when generalizing these findings.However, results indicate that too many patients with EDS have experienced healthcare betrayals; these experiences are associated with current anger and negative expectations for future healthcare interactions.The prevalence of past negative healthcare experiences, along with current unmet needs and future negative healthcare expectations in EDS patients who have experienced institutional betrayal, highlights the need for healthcare providers to tend to these experiences, mend patient-provider barriers, and provide higher quality healthcare.

Recognizing the hurt: Prevalence and correlates of elevated PTSD symptoms among adolescents receiving mental/behavioral health services in primary care.

Youth are commonly exposed to potentially traumatic events (PTEs). Following exposure, approximately 25% develop persistent mental and behavioral health (M/BH) symptoms, yet many go untreated or are misdiagnosed and suffer adverse outcomes. Primary care is an ideal setting for detection of trauma-related symptoms. The current article uses archival data to (1) examine the prevalence of posttraumatic stress symptoms that are unlikely, possible, and likely to meet diagnostic criteria for posttraumatic stress disorder (PTSD) and the M/BH and physical health concerns that co-occur with PTSD symptoms among adolescents (n = 133, mean age = 15.1 years, 67% female, 60% White) referred for brief, integrated M/BH services within primary care and (2) identify the prevalence of referred adolescents with elevated symptoms of PTSD that would not be identified for services by traditional depression screening. M/BH providers assessed referred patients for PTSD, M/BH, and physical health symptoms as a routine part of services. Fifty-eight percent screened positive for PTSD (PTSD-possible or PTSD-likely range). The subset of adolescents in the PTSD-likely range (29%) reported significantly greater stress, depression, anxiety, anger, and externalizing symptoms than those categorized as PTSD-possible or PTSD-unlikely. Adolescents in the PTSD-possible or PTSD-unlikely ranges did not differ on any M/BH variables; PTSD groups' physical health did not differ. Of note, 15% of adolescents reporting symptoms likely to meet PTSD criteria did not report elevated depressive symptoms and would have been overlooked by depression screening alone. Given the prevalence of PTEs among M/BH patients, trauma-informed care is necessary for quality patient care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Once BITTEN, Twice Shy: An Applied Trauma-Informed Healthcare Model.

Nurses need a pragmatic theory to understand and respond to the impact of vulnerable patients' previous healthcare experiences, as these are likely to influence response and adherence to treatment plans. The authors of this paper present the new BITTEN (Betrayal history by health-related institutions, Indicator for healthcare engagement, Traumas related to healthcare, Trust in healthcare providers, patient Expectations and Needs) Model of Trauma-Informed Healthcare. BITTEN identifies patients' current healthcare expectations and needs as a function of their previous betrayal by healthcare systems, which operates in conjunction with their current health indicators to potentially trigger trauma symptoms and impact trust in healthcare providers.

ACTively Integrating Suicide Risk Assessment Into Primary Care Settings.

Adequate evaluation and response to suicide risk require (i) awareness of need, (ii) comfort gathering key information, and (iii) ongoing training. A survey administered at 2 urban primary care settings in the process of implementing integrated care measured awareness, comfort, and training related to suicide risk assessment among 31 primary care providers (PCPs). Greater PCP comfort asking patients about psychological trauma was associated with more frequent engagement in safety planning with suicidal patients. Findings highlight the need for trauma-informed primary care while showcasing the importance of enhancing PCP training to support their expanded role within the integrated health team.