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Perceptions of Institutional Betrayal Predict Suicidal Self-Directed
Violence Among Veterans Exposed to Military Sexual Trauma
Lindsey L. Monteith,
1,2
Nazanin H. Bahraini,
1,2
Bridget B. Matarazzo,
1,2
Kelly A. Soberay,
1
and Carly Parnitzke Smith
3
1
Rocky Mountain Mental Illness Research, Education and Clinical Center
2
University of Colorado Anschutz Medical Campus
3
University of Oregon
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 ap-
pear to be highly relevant to MST and its sequelae. These findings underscore the importance of
Veterans’ perceptions of the milit ary institution’s efforts to prevent and respond to MST to individual
recovery from sexual trauma. Additional research regarding the association between institutional be-
trayal and health-related outcomes is needed.
C
2016 Wiley Periodicals, Inc. J. Clin. Psychol. 0:1–13,
2016.
Keywords: military sexual trauma; institutional betrayal; suicidal ideation; suicide attempt; posttraumatic
stress; depression; Veterans
Military sexual trauma (MST) is defined in the Department of Veterans Affairs (VA) as “psy-
chological trauma . . . result(ing) from a physical assault of a sexual nature, battery of a sexual
nature, or sexual harassment which occurred while the Veteran was serving on active duty or
active duty for training” (38 USC §1720D, 2011). The Veterans Health Administration (VHA)
implemented standardized screening for MST in Fiscal Year 2002. Since then, VHA providers
have screened approximately 4.8 million Veterans for MST; 24.3% of women and 1.3% of men
have screened positive (VA, 2014). Consequently, VA has identified MST as a priority focus
area for research (Yano et al., 2006). Reports of sexual harassment and assault among active
duty service members have also raised public awareness of MST, prompting research aimed at
understanding its effect.
We would like to thank Lacey Brown for assisting with screening, enrollment, and data entry, Emma
Genco for database management, and the Rocky Mountain MIRECC Recruitment Core for assisting with
participant recruitment.
This material is based upon work supported in part by the Department of Veterans Affairs and the Rocky
Mountain MIRECC. The views expressed are those of the authors and do not necessarily represent the
views of the Department of Veterans Affairs or the United States Government.
Please address correspondence to: Lindsey L. Monteith, Rocky Mountain MIRECC, 1055 Clermont St.,
Denver, CO 80220. E-mail: Lindsey.Monteith@va.gov
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 0(0), 1–13 (2016)
C
2016 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22292
2 Journal of Clinical Psychology, XXXX 2016
MST is associated with significantly increased risk for suicidal self-directed violence, defined
as “behavior that is self-directed and deliberately results in injury or the potential for injury
to oneself” (Centers for Disease Control and Prevention, 2011, p. 21). Veterans who screen
positive for MST are more likely to have a history of suicide attempt, relative to Veterans
without MST (Kimerling, Gima, Street, Smith, & Frayne, 2007; Klingensmith, Tsai, Mota,
Southwick, & Pietrzak, 2014; Pavao et al., 2013). Further, multiple studies suggest that MST
is also associated with suicidal ideation (Gradus, Street, Suvak, & Resick, 2013; Klingensmith
et al., 2014; Monteith, Menefee, Forster, Wanner, & Bahraini, 2015).
In addition, exposure to MST is associated with a multitude of mental health problems (c.f.
Allard, Nunnink, Gregory, Klest, & Platt, 2011; Sur
´
ıs & Lind, 2008), including posttraumatic
stress disorder (PTSD) and depression (Kimerling et al., 2007; Klingensmith et al., 2014). For
example, a history of military sexual assault is associated with a ninefold increase in PTSD
diagnosis, relative to no sexual assault history (adjusted odds ratio [AOR] = 9.27; Sur
´
ıs, Lind,
Kashner, Borman, & Petty, 2004). Moreover, this association remains significant when adjusting
for childhood and adulthood sexual assault (AOR = 3.87).
Other studies have also found that the association between MST and adverse psychiatric
outcomes remains significant when controlling for other types of interpersonal violence (e.g.,
childhood abuse, civilian sexual trauma) and combat (Kang, Dalager, Mahan, & Ishii, 2005;
Luterek, Bittinger, & Simpson, 2011; Monteith et al., 2015). MST is also associated with more
severe physical health outcomes and lower quality of life than civilian s exual trauma (Sur
´
ıs, Lind,
Kashner, & Borman, 2007). These findings suggest that the effects of MST are independent of
other types of trauma. Considering the broad range of negative sequelae associated with MST,
studies are needed to identify processes that influence these outcomes.
The vast majority of research examining factors that affect posttraumatic outcomes have
focused on individual-level factors; few studies have examined the role of macro-level factors,
such as the cultural or institutional response to sexual trauma, in posttraumatic outcomes. One
potential explanation for the deleterious effect of MST concerns the institutional response to the
trauma (Campbell, Dworkin, & Cabral, 2009). Drawing from betrayal trauma theory (Freyd,
1996), researchers have speculated that sexual trauma occurring in an institution that “betrays
its members’ trust” (p.120) may be particularly harmful (Smith & Freyd, 2013). This concept,
referred to as institutional betrayal, includes failure of an institution to prevent or respond
supportively to wrongdoings committed by individuals within the context of the institution
(Smith & Freyd, 2013, 2014).
Smith and Freyd (2013) postulated that institutional betrayal may be particularly injurious
for MST survivors not only because the trauma occurs in the context of a military institution,
but also because the survivor must continue to function within the institution, relies on it for
safety, and may highly identify with it. Additionally, the foundation of military service is built
upon trust, which is essential to unit cohesion, mission readiness, and survival (Department of
the Army, 2012). Those expectations of trust are violated with MST, which typically occurs at
military installations, where service members work and reside (Department of Defense [DoD],
2013). The most common perpetrators of MST are military coworkers, individuals within one’s
chain of command, other higher ranking military personnel, and other military personnel
(DoD, 2013). Consequently, service members often must continue working and living alongside
the perpetrator(s) after sexual harassment or assault occur (Sur
´
ıs & Lind, 2008). This may be
exacerbated while deployed to a combat zone (Dutra et al., 2011), where it may be particularly
difficult to evade the perpetrator(s) (Bell & Reardon, 2011).
The potential significance of perceptions of institutional betrayal to MST is further under-
scored when considering research on barriers to reporting MST. Many service members express
reluctance to report sexual assault, particularly if the perpetrator was of higher rank or was
in their chain of command, secondary to fear of reprisal and concerns that leaders would pro-
tect the accused (DoD, 2013). Many service members do not report sexual assault to military
authorities because of fear of retaliation or ostracism (DoD, 2013). Service members also re-
port concerns about the consequences of reporting MST on unit cohesion, individual safety,
and one’s military career (e.g., opportunities for promotion, security clearance; Bell & Rear-
don, 2011; DoD, 2013; Sur
´
ıs & Lind, 2008). Moreover, approximately 34% to 56% of service
MST and Perceptions of Institutional Betrayal 3
members who experience MST consider leaving the service (DoD, 2013); however, doing so
may entail detrimental legal and career consequences, including disciplinary action and loss of
benefits.
To our knowledge, no studies have examined perceptions of institutional betrayal among
service members or Veterans with a history of MST. Only one study, conducted with college stu-
dent women with a history of sexual assault, has examined the association between institutional
betrayal and psychiatric symptoms (Smith & Freyd, 2013). Institutional betrayal was associated
with trauma-related anxiety, sexual difficulties, and dissociation (Smith & Freyd, 2013). Ex-
amining the association between institutional betrayal and psychiatric outcomes among MST
survivors could yield valuable information regarding how perceptions of the military institu-
tional response to MST influences individuals’ emotional health.
Given the lack of knowledge regarding institutional betrayal among MST survivors, our first
aim was to examine the frequency of perceptions of institutional betrayal among Veterans with
MST. Considering the high rates of psychiatric symptoms and suicidal self-directed violence
associated with MST, our second aim was to examine whether perceptions of institutional
betrayal were associated with PTSD symptoms, depressive symptoms, and suicidal ideation
and attempt after MST. We hypothesized that perceived institutional betrayal would positively
predict PTSD symptoms, depressive symptoms, and post-MST suicidal ideation and attempt.
Method
Participants
Participants were recruited for a mixed-methods study
1
aimed at examining the effect of MST
and identifying processes by which MST relates to suicidal self-directed violence. The sample
size was determined a priori at n = 50 to allow for a sufficient number of men and women
to conduct separate qualitative analyses by gender. We screened 227 Veterans, 60 (26.4%) of
whom were eligible to participate. Of those, 50 (83.3%) consented to participate. One Vet-
eran discontinued participation early, resulting in a final sample of 49 Veterans (31 women,
18 men).
Procedures
Our target population was Veterans aged 18 to 65 with a history of MST (as defined by VA;
38 USC §1720D, 2011). Veterans were informed about the study through announcements and
flyers at community events and in VA healthcare settings. Veterans who had previously partic-
ipated in research at the local VA medical center and who agreed to be contacted for future
research were also invited to participate in a brief telephone screen to deter mine study eligibility.
The screening process entailed review of VA medical records and answering a series of brief
questions regarding MST history and psychiatric conditions.
The standard VHA MST screening questions were used to assess history of MST: (a) “While
you were in the military, did you receive any uninvited and unwanted s exual attention, such as
touching, cornering, pressure for sexual favors, or inappropriate verbal remarks?”; (b) “While
you were in the military, did anyone ever use force or the threat of force to have sexual contact
with you against your will?” (Department of Veteran Affairs, 2010, p. 1).
The first question assesses military sexual harassment and the second question assesses mil-
itary sexual assault. Veterans who answered “yes” to either question are considered to have a
positive screen for MST, which was required for inclusion in the present study. Veterans deemed
to be at imminent suicide risk, with severe cognitive impairment, or exhibiting severe psychiatric
symptoms (e.g., active psychosis, current mania) were excluded. Those who were eligible met
with study personnel for informed consent at a local VA facility. Participants provided demo-
graphics and completed a qualitative interview, followed by self-report and interview measures.
1
Qualitative results will be reported separately.
4 Journal of Clinical Psychology, XXXX 2016
At the conclusion of the study visit, participants were compensated $50 for participating and
were provided with information regarding VA MST resources. The Colorado Multiple Institu-
tional Review Board and the local VA Research and Development Committee approved this
research.
Measures
Institutional Betrayal Questionnaire, Version 2 (IBQ.2).
The IBQ.2 (Smith, 2014) was
developed to assess institutional betrayal associated with sexual assault. The present study used
the IBQ.2, with instructions modified to assess perceptions of institutional betrayal regarding
MST (C. Smith, personal communication, April 22, 2014). In filling out the questionnaire,
respondents were instructed to recall “larger military institutions” they belonged to, including
“the military in general or an entire branch of the Armed Forces ...[or]asmallersystem,suchas
a military academy, military base, or specific unit.” The first twelve IBQ.2 items assess perceptions
of institutional betrayal. Participants indicated their perception of whether a military institution
played a role in the MST by engaging in each behavior (e.g., “covering up the experience”).
Responses are scored as 1 (yes)or0(no) and are summed to produce a total institutional
betrayal score ranging from 0 to 12.
Respondents also indicated how much they identified with the institution prior to MST
(item 13), indicate whether t hey are still part of the institution (item 14), and briefly describe
the institution (item 15). Because the IBQ.2 is intended to be administered in relation to a
specific trauma, we administered it after an interview focused on MST. Although psychometric
evaluation of the IBQ.2 is forthcoming (Smith & Freyd, 2015), data support the use of an earlier
version of the IBQ and suggest that institutional betrayal constitutes a unidimensional construct
(Smith & Freyd, 2013). The IBQ.2 demonstrated high internal reliability (α = .90) in our sample.
PTSD Checklist for DSM-5 (PCL-5). The PCL-5 (Weathers, Litz et al., 2013) items
correspond to the symptom criteria for PTSD in the Diagnostic and Statistical Manual of Mental
Disorders Fifth Edition (DSM-5; American Psychiatric Association, 2013). The PCL-5 includes
20 items rated on a 5-point scale (ranging from 0 to 4). Responses are summed to produce a
total score of current PTSD symptom severity. Participants in the present study completed the
generic version of the PCL-5, indicating the extent to which they have been bothered by each
symptom in the past month “in response to a very stressful experience.” This is in contrast to
alternate PCL-5 formats, which instruct participants to identify their “worst” trauma and rate
symptoms accordingly. Because the generic version of the PCL-5 was used, it is possible that
the PTSD symptoms reported were unrelated to MST. Initial research suggests that the PCL-5
has acceptable reliability and validity among military personnel (Hoge, Riviere, Wilk, Herrell,
& Weathers, 2014). In our sample, the PCL-5 had high internal reliability (α = .96).
Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 (Kroenke, Spitzer, & Williams,
2001) includes nine items rated on a 4-point scale (ranging from 0 to 3). Items correspond to
the symptom criteria for major depression in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000). Individuals
rate the frequency with which each symptom has bothered them in the past 2 weeks. Responses
are summed to produce a score of depressive symptom severity. The PHQ-9 has demonstrated
strong reliability and validity (Kroenke et al., 2001; Kroenke, Spitzer, Williams, & L
¨
owe, 2010)
and had high internal reliability in our sample (α = .92).
Self-Injurious Thoughts and Behaviors Interview (SITBI). The SITBI (Nock, Holm-
berg, Photos, & Michel, 2007) is a structured interview that assesses a broad range of self-
injurious behaviors and thoughts. We used the SITBI to assess suicidal ideation and suicide
attempts that occurred after MST. A licensed psychologist or a master’s-level licensed profes-
sional counselor administered the SITBI. Participants who endorsed a lifetime history of suicidal
ideation or attempt were asked when they most recently had thoughts of killing themselves and
when they most recently attempted suicide. To determine whether this occurred after MST,
MST and Perceptions of Institutional Betrayal 5
participants were then asked: “Was this before or after you experienced MST?” Participants
who reported that their most recent suicidal ideation or suicide attempt occurred after MST
were respectively coded as having post-MST suicidal ideation or post-MST suicide attempt.
The SITBI has demonstrated high inter-rater reliability and good concurrent validity with other
measures of suicidal self-directed violence (Nock et al., 2007).
Analysis Plan
All analyses were conducted in IBM SPSS (version 22). Given the directional nature of our
hypotheses, analyses assumed a one-tailed test of hypothesis, with a significance level established
aprioriatp < .05. To describe the sample, means and standard deviations were computed
for continuous variables and n and percentages for categorical variables. Missing data were
minimal. Item-level missing data included one PHQ-9 item, which was addressed with single
mean imputation. One participant discontinued the study prematurely and did not provide any
PCL-5 data, yielding complete PCL-5 data for 48 (of 49) participants. Given the minimal amount
of missing data (0.97%), results are reported for the full sample of N = 49, with the exception of
PCL-5 results (n = 48).
To describe the frequency of different perceptions of institutional betrayal, we calculated n and
percentages. Linear regression was used to test hypotheses with continuous dependent variables,
with the total institutional betrayal score entered as the predictor variable and PTSD symptoms
and depressive symptoms separately entered as the dependent variables. For hypotheses with
dichotomous dependent variables, binary logistic regressions were conducted, with institutional
betrayal included as the predictor variable and post-MST suicidal ideation and attempt entered
separately as the d ependent variables. Because military sexual harassment may not necessarily
meet DSM-5 criteria for trauma, the regression analyses were repeated with the subsample
of Veterans who reported experiencing military sexual assault (excluding those who reported
experiencing military sexual harassment only).
Because this was a small pilot study, no confounders were identified a priori. To further assess
the need to include confounders, correlations were calculated between the measures of interest
with demographic and military variables (i.e., age, gender, race, ethnicity, branch, service era,
military service duration, and time since military discharge). Because none of these significantly
associated with both the independent and dependent variables, no confounders were included
in the regressions.
Results
Sample Characteristics and Descriptives
Participant characteristics are presented in Table 1. Our sample was middle-aged and racially
diverse. Most participants served in the Army post-Vietnam or in the recent conflicts in Iraq
and Afghanistan. Regarding the specific type of MST, 98.0% (n = 48) of participants reported
experiencing sexual harassment; 71.4% (n = 35) reported experiencing sexual assault. Table 2
presents descriptives and bivariate correlations for the measures of interest.
Participants reported high levels of perceived institutional betrayal (mean = 8.18, standard
deviation [SD] = 3.77; median = 10; range = 0 to 12). Most reported identifying with a military
institution before MST, with 49.0% (n = 24) indicating “very much” and 24.5% “a good deal”
(n = 12). Few reported identifying with a military institution “very little”(n = 8; 16.3%) or “not
at all”(n = 5; 10.2%) before MST. As expected, most participants reported that they were no
longer a part of the institution (n = 43; 87.8%). When asked to describe the institution involved,
most participants named a military branch ( n = 22; 44.9%). Others named the military in general
(n = 7; 14.3%), a specific unit or company (n = 7; 14.3%), a military post/base (n = 6; 12.2%),
or another military institution (e.g., division, brigade, battalion; n = 7; 14.3%).
Characterizing Perceptions of Institutional Betrayal Among Veterans With MST
Nearly all participants (n = 47; 95.9%) reported experiencing at least one indicator o f perceived
institutional betrayal associated with MST. When queried about their specific perceptions of
6 Journal of Clinical Psychology, XXXX 2016
Table 1
Demographic and Military Characteristics (N = 49)
Characteristic n (%) or mean (SD)
Age 46.82 (13.39)
Gender
Men 18 (36.7%)
Women 31 (63.3%)
Race
Caucasian 26 (53.1%)
African American 14 (28.6%)
Multiracial 7 (14.3%)
Native American 2 (4.1%)
Ethnicity
Hispanic 9 (18.4%)
Not Hispanic 40 (81.6%)
Branch
a
Army 36 (73.5%)
Air Force 6 (12.2%)
Navy 7 (14.3%)
Marines 3 (6.1%)
Coast Guard 1 (2.0%)
National Guard 1 (2.0%)
Service era
a
Post-Vietnam 25 (51.0%)
OEF/OIF/OND 21 (42.9%)
Vietnam 10 (20.4%)
Desert Storm 9 (18.4%)
Years of military service 7.10 (6.53)
Years since military discharge 18.98 (15.15)
Note. SD = standard deviation; OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom;
OND = Operation New Dawn.
a
Totals exceed 100% due to some participants endorsing more than one response.
Table 2
Descriptives and Correlations
Variable Mean SD n %12345
1. Institutional betrayal (IBQ.2) 8.18 3.77 – –
2. PTSD symptoms (PCL-5) 33.88 21.17 – – .31
*
3. Depressive symptoms (PHQ-9) 9.35 6.95 – – .34
*
.81
***
4. Post-MST suicidal ideation (SITBI) – – 32 66.7% .21 .29
*
.35
*
5. Post-MST suicide attempt (SITBI) – – 17 35.4% .39
**
.25 .19 .44
**
Note. SD = standard deviation; IBQ.2 = Institutional Betrayal Questionnaire, Version 2; PTSD = post-
traumatic stress disorder; PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire-9;
MST = military sexual trauma; SITBI = Self-Injurious Thoughts and Behaviors Interview.
*p < .05.
**
p < .01.
***
p < .001.
institutional betrayal (Table 3), participants most commonly reported the perception that a
military institution played a role in MST by creating an environment in which MST seemed
more likely to occur and normal or common, and in which they no longer felt like a valued
member of the institution. Participants also commonly reported perceiving that a military
institution made it difficult to report MST and did not take proactive steps to prevent such
events.
MST and Perceptions of Institutional Betrayal 7
Table 3
Perceptions of Institutional Betrayal Among Veterans with Military Sexual Trauma (N = 49)
Item n %
1. Not taking proactive steps to prevent this type of experience? 38 77.6%
2. Creating an environment in which this type of experience seemed common or normal? 39 79.6%
3. Creating an environment in which this experience seemed more likely to occur? 42 85.7%
4. Making it difficult to report the experience? 39 79.6%
5. Responding inadequately to the experience, if reported? 33 67.3%
6. Mishandling your case, if disciplinary action was requested? 25 51.0%
7. Covering up the experience? 30 61.2%
8. Denying your experience in some way? 33 67.3%
9. Punishing you in some way for reporting the experience (e.g., loss of privileges or status)? 24 49.0%
10. Suggesting your experience might affect the reputation of the institution? 29 59.2%
11. Creating an environment where you no longer felt like a valued member of the institution? 36 73.5%
12. Creating an environment where continued membership was difficult for you? 33 67.3%
Table 4
Do Perceptions of Institutional Betrayal Predict Psychiatric Symptoms?
Variable Model BSE(B)95% CI β
PTSD symptoms F(1, 46) = 4.85
*
1.73
*
0.79 [0.15, 3.32] .31
Depressive symptoms F(1, 47) = 6.08
*
0.62
**
2.53 [0.12, 1.13] .34
Note. SE = standard error; CI = confidence interval; PTSD = posttraumatic stress disorder.
*p < .05.
**
p < .01.
Table 5
Do Perceptions of Institutional Betrayal Predict Post-MST Suicidal Self-Directed Violence?
Variable Model BSE(B)OR95% CI
Suicidal ideation χ
2
(1) = 2.06 0.12 0.82 1.12 [0.96, 1.32]
Suicide attempt χ
2
(1) = 8.44
**
0.29
**
0.12 1.34 [1.06, 1.69]
Note. MST = military sexual trauma; OR = odds ratio; CI = confidence interval.
**p < .01.
Examining whether Perceptions of Institutional Betrayal Are Associated With
Psychiatric Symptoms and Post-MST Suicidal Self-Directed Violence
Table 4 reports results examining the association between perceptions of institutional betrayal
with symptoms of PTSD and depression. Perceived institutional betrayal was significantly asso-
ciated with PTSD symptoms (p = .017), accounting for 7.6% of the variance in PCL-5 scores.
Institutional betrayal was also significantly associated with depressive symptoms (p = .009),
explaining 9.6% of the variance in PHQ-9 scores.
Table 5 reports results concerning the association between perceptions of institutional betrayal
with post-MST suicidal ideation and attempt. Institutional betrayal was not associated with
post-MST suicidal ideation (p = .078). However, perceived institutional betrayal was associated
with significantly increased odds of attempting suicide after MST (p = .008), explaining 22.2% of
the variance in post-MST suicide attempt. As levels of institutional betrayal increased, Veterans
were more likely to have attempted suicide after MST.
Next, we conducted a post hoc analysis to examine whether these results extended to the
subsample of Veterans exposed to military sexual assault (n = 35), excluding those who solely
8 Journal of Clinical Psychology, XXXX 2016
experienced military sexual harassment. Among Veterans exposed to military sexual assault,
perceptions of institutional betrayal were significantly associated with depressive symptoms,
F(1, 33) = 5.96, B = 0.70, standard error [SE] = 0.29, p = .02, and increased odds of attempting
suicide after MST, χ
2
(1) = 9.24, B = 0.37, SE = 0.15, odds ratio [OR] = 1.44 [95% confidence
interval [CI] [1.07, 1.95], p = .016. Similar to our results with the full sample of Veterans with
MST, perceptions of institutional betrayal were not associated with post-MST suicidal ideation,
χ
2
(1) = 2.01, B = 0.14, SE = 0.10, OR = 1.15 [95% CI [0.95, 1.41], p = .16. However, when
examining the subsample of Veterans with a history of military sexual assault, the association
between institutional betrayal and PTSD symptoms only approached significance, F(1, 32) =
3.50, B = 1.73, SE = 0.92, p = .07.
Discussion
Although research has established that MST is associated with PTSD, depressive symptoms,
and suicidal self-directed violence (Kimerling et al., 2007; Klingensmith et al., 2014; Pavao
et al., 2013), few studies have examined factors that predict these outcomes in MST survivors.
Additionally, the majority of studies that have done so have focused on individual-level factors,
such as preexisting trauma history. Less attention has focused on how macro-level factors, such
as societal and cultural reactions to sexual victimization, affect individual response to trauma
(Campbell et al., 2009). Examining the influence of both individual-level and macro-level factors
on posttraumatic outcomes is critical to obtaining a comprehensive understanding of the myriad
of ways in which individuals may be affected by MST.
In our sample of military Veterans, perceptions of institutional betrayal were associated with
increased odds of attempting suicide after MST. In contrast, the association between perceived
institutional betrayal and post-MST suicidal ideation only approached significance. Our finding
regarding the association between perceived institutional betrayal and post-MST suicide attempt
is noteworthy because it suggests that perceptions of the military institution’s role in preventing
and responding adequately to sexual trauma is relevant to subsequent risk for suicide attempt.
Because this is the first study to examine the association between perceptions of institutional
betrayal with suicidal self-directed violence, future studies examining these associations are
essential.
Perceptions of institutional betrayal were also associated with symptoms of PTSD and de-
pression among the full sample of Veterans with MST (i.e., those who experienced military
sexual harassment and/or assault). Because MST experiences of sexual harassment may not
necessarily meet DSM-5 criteria regarding trauma exposure, we re-ran these analyses with the
subsample of Veterans exposed to military sexual assault; when doing so, the association be-
tween institutional betrayal and PTSD symptoms only approached significance. This may have
been due to the smaller sample size that resulted from excluding those without a history of
military s exual assault; alternately, it may indicate that perceptions of institutional betrayal are
not associated with PTSD symptoms among survivors of military sexual assault. Disentan-
gling whether institutional betrayal is differentially associated with PTSD based on the type
of MST experienced (i.e., sexual harassment versus sexual assault) will be important for future
research.
Our findings highlight the need to identify potential mechanisms by which perceived insti-
tutional betrayal associates with post-MST suicide attempt, depressive symptoms, and PTSD
symptoms. One potential explanation concerns the role of social support. Our sample gen-
erally reported no longer being part of the military institution after experiences of perceived
institutional betrayal. It may be that individuals who feel betrayed by the military institu-
tion subsequent to MST disengage from the military and consequently lose an important
source of social support that places them at heightened risk for suicidal self-directed vio-
lence, depressive symptoms, and PTSD symptoms (Smith & Freyd, 2014). Research suggests
that social support is protective against these outcomes (Han et al., 2014; Pietrzak et al., 2010)
and military support, in particular, buffers the association between exposure to service-related
stressors and PTSD (Smith et al., 2013). On the other hand, feeling like one does not be-
long (i.e., thwarted belongingness; Joiner, 2005) is associated with depression and suicidal
MST and Perceptions of Institutional Betrayal 9
self-directed violence (Silva, Ribeiro, & Joiner, 2015; You, Van Orden, & Conner, 2011), un-
derscoring the possibility that feeling ostracized or betrayed may lead to adverse posttraumatic
sequelae.
The results of our study offer the first evidence suggesting that perceived institutional betrayal
is a salient issue among Veterans exposed to MST. Veterans reported many different ways in
which they perceived institutional betrayal to have occurred. Moreover, the levels of perceived
institutional betrayal reported by Veterans in our sample (mean = 8.18, SD = 3.77) far ex-
ceeded those obtained previously with college student sexual assault survivors (mean = 0.72,
SD = 1.05; Smith & Freyd, 2013). One potential explanation for this concerns the context in
which the MST occurred–during military service. When enlisting, service members are required
to take an oath to defend their country. Carrying out these duties often entails risks to one’s
mortality and well-being. The foundation of that is trust, of both one’s fellow service members
and the military institution. Yet MST, which typically occurs within a military institution and
at the hands of other military personnel (DoD, 2013), transgresses those expectations. The dis-
ruption to those expectations may be exacerbated when individuals strongly identify with an
institution, as participants reported doing prior to MST.
If replicated, these findings emphasize the importance of repairing individuals’ perceptions
of the military institution’s role in preventing and responding supportively to MST (Reinhardt,
Smith, & Freyd, 2015). Although most interventions aimed at reducing posttraumatic sequelae
focus on the individual, our findings suggest several potential ways in which military institu-
tions may help to lessen the effect of MST. First, continued institutional efforts to prevent
MST–and to increase service members’ awareness of these prevention efforts–are essential. Vet-
erans frequently endorsed items suggesting perceptions of institutional betrayal in the form
of a military institution not preventing MST and creating an environment in which such ex-
periences seemed more likely to occur. This is consistent with qualitative findings in which
service women reported that military culture (e.g., sexism, rank) contributed to MST (Burns,
Grindlay, Holt, Manski, & Grossman, 2014). In addition, the institutional response after MST
appears to be important because many Veterans indicated that they encountered difficulty re-
porting such experiences and no longer felt like a valued member of the military institution
after MST.
The DoD has implemented significant efforts to prevent and respond adequately to military
sexual assault and harassment. In 2005, the DoD developed the Sexual Assault Prevention and
Response (SAPR) Program, which includes several initiatives aimed at preventing sexual assault,
such as training service members, reviewing military policy, and improving command culture
(DoD, 2014). The SAPR Program also aims to improve the military response after sexual assault.
This encompasses several different strategies, including initiatives to investigate sexual assault
allegations, accountability programs, advocacy and victim assistance programs, and assessment
programs to evaluate these initiatives (DoD, 2014).
Additionally, the DoD implemented a restricted reporting option for reporting sexual assault,
which allows military personnel to “confidentially access medical care and advocacy services
without initiating an official investigation” (DoD, 2014, p. 110). As such, it will be important
to continue to examine perceptions of institutional betrayal as service members become more
aware of DoD efforts to prevent and respond to MST.
Clinical Implications
Our findings suggest that one consideration for clinicians working with MST survivors is to assess
their clients’ perceptions of the institutional response to MST. Additionally, although screening
for PTSD, depression, and suicide risk are critical components of care for MST survivors (c.f.
Kimerling et al., 2007), our findings underscore the necessity of assessing for these outcomes
among MST survivors who report high levels of perceived institutional betrayal. Because some
Veterans may consider the VA to be an extension of the military, clinicians are encouraged to
explore the effects of institutional betrayal on treatment engagement and the working alliance.
10 Journal of Clinical Psychology, XXXX 2016
Limitations
Some limitations of the present study should be acknowledged. First, this was a pilot study based
on a small sample, which necessitates further examination in a larger sample. The small sample
size was adequate for conducting an initial examination of institutional betrayal, but precluded
us from stratifying analyses by gender. Notably, gender was not associated with perceptions
of institutional betrayal (p = .72) or any of our outcomes (p’s ranging from .17–.83); however,
stratifying analyses by gender will be important for future research in this area because men
and women may experience different sequelae after MST. Doing so would further knowledge
regarding whether gender differences exist in the prevalence and correlates of institutional
betrayal.
In addition, our cross-sectional design limits determining the causal association between
institutional betrayal and posttraumatic outcomes. It is possible that Veterans who are depressed,
suicidal, or experiencing symptoms of PTSD are more likely to perceive that a military institution
played a role in failing to prevent or respond appropriately to MST. Relatedly, we examined
individuals’ perceptions of institutional behavior; thus, higher levels of institutional betrayal
reflect respondents’ subjective experiences of whether a military institution was involved in
MST, rather than reflecting an objective examination of the military institution’s response
per se.
Another limitation concerns our use of the generic version of the PCL-5 instead of the version
that asks participants to indicate the worst trauma they have experienced and assesses whether
individuals meet criteria for exposure to a traumatic event. Thus, we cannot determine whether
the PTSD symptoms endorsed were due to MST or an alternate event, nor can we ascertain
whether participants’ experiences of military sexual harassment met DSM-5 criteria regarding
trauma exposure.
Additionally, because the PCL-5 assesses PTSD symptoms, rather than diagnosis, we are
precluded from determining whether perceptions of institutional betrayal are associated with
PTSD diagnosis; a structured clinical interview, such as the Clinician-Administered PTSD Scale
for DSM-5 (Weathers, Blake et al., 2013), would address this limitation. Similarly, the PHQ-9 can
be used to screen for depression or to assess depressive symptom severity but cannot be used to
diagnose depression. Lastly, more research is needed to establish the psychometric performance
of the IBQ.2.
Future Research
Our findings highlight several important avenues for future research. First, subsequent studies
should examine whether the associations between perceived institutional betrayal with psychi-
atric symptoms and suicidal s elf-directed violence remain significant when adjusting for the
severity of sexual trauma exposure (c.f. Smith & Freyd, 2013). Second, because our sample
comprised military Veterans, participants reported no longer being involved with the military
institution associated with the perceived institutional betrayal. Nonetheless, examining the effect
of perceptions of institutional betrayal on psychiatric outcomes among active duty personnel
would inform future research and could potentially elucidate reasons for attrition from military
service.
Third, Veterans in our sample displayed a range of responses regarding the specific military
institutions involved in the institutional betrayal. Subsequent research should examine whether
MST sequelae differ based on whether individuals identify the perpetrating institution as more
global (e.g., military in general or an entire military branch) or specific (e.g., military unit,
post, or brigade). Last, an important next step for subsequent research in this area will be
to examine whether perceptions of institutional betrayal are unique to MST or whether they
also occur for other types of trauma (e.g., combat-related trauma, injuries incurred in the
battlefield). Continuing to elucidate how perceptions of institutional betrayal relate to health-
related outcomes will be valuable for understanding how the DoD and VA can help to mitigate
these outcomes after MST.
MST and Perceptions of Institutional Betrayal 11
Conclusions
Perceptions of institutional betrayal are relevant to understanding military Veterans’ experi-
ences with MST and recovery after trauma exposure. Moreover, perceived institutional betrayal
is associated with a range of adverse outcomes, including increased odds of attempting suicide
after MST and depressive and PTSD symptoms. Veterans reported various ways in which they
felt betrayed by a military institution after MST; for example, they felt the military institution
failed to prevent the sexual trauma from occurring, that it was difficult to report the experience,
and that they no longer felt like a valued member of the military institution after military sexual
harassment or assault. These findings underscore the necessity of implementing different strate-
gies to help Veterans and service members feel more supported in the prevention and aftermath
of MST.
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