|Year : 2022 | Volume
| Issue : 2 | Page : 100-106
Betrayal trauma, dissociative experiences, and posttrauma cognitions among women in a state shelter home
Chaitra Nagaraj Kumble, LN Suman
Department of Clinical Psychology, NIMHANS, Bengaluru, Karnataka, India
|Date of Submission||03-Jul-2022|
|Date of Decision||15-Jul-2022|
|Date of Acceptance||25-Jul-2022|
|Date of Web Publication||16-Dec-2022|
Ms. Chaitra Nagaraj Kumble
Department of Clinical Psychology, NIMHANS, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Context: There is a long history of interpersonal trauma in women, and the risk factors and mental health consequences have been well studied. Betrayal trauma (BT) theory by Freyd talks about the specific kind of trauma perpetrated by someone close to the victim, which may lead to increased dissociative responses. Recent research extends the theory to explain the role of posttrauma appraisals playing a mediating role in the development of psychopathological responses.
Aim: The aim of this study was to explore trauma history, BT, and dissociative experiences among women in a Government Reception Centre.
Setting: The sample included 30 women from the Reception Centre, Bangalore.
Subjects and Methods: Data were obtained using a Sociodemographic Data Sheet, Brief BT Survey (revised), the Dissociative Experiences Scale, Posttrauma Cognitions Inventory and a visual analog scale for assessing psychological distress.
Statistical Analysis Used: Descriptive statistics and nonparametric inferential statistics were used for quantitative analysis.
Results: All the women in the sample had experienced BT directly or as witnesses. There was no significant difference in dissociation between high- and low-BT groups. The presence of negative cognitions toward oneself was associated with increased dissociative experiences. Negative cognitions toward self and depersonalization experiences were higher in the group with severe physical trauma than the group without.
Conclusion: The article highlights the high prevalence of betrayal trauma, and risk for trauma-related psychopathology and revictimization that go unassessed in government shelter homes, while reiterating the need for a trauma-informed care approach to intervention.
Keywords: Abuse, betrayal trauma theory, betrayal trauma, dissociation, psychological trauma, reception center, shelter home, trauma appraisals, women
|How to cite this article:|
Kumble CN, Suman L N. Betrayal trauma, dissociative experiences, and posttrauma cognitions among women in a state shelter home. Telangana J Psychiatry 2022;8:100-6
|How to cite this URL:|
Kumble CN, Suman L N. Betrayal trauma, dissociative experiences, and posttrauma cognitions among women in a state shelter home. Telangana J Psychiatry [serial online] 2022 [cited 2023 Jun 5];8:100-6. Available from: https://tjpipstsb.org/text.asp?2022/8/2/100/363971
| Introduction|| |
History of trauma experience, in childhood or adulthood, is linked to various psychological disorders such as posttraumatic stress disorder (PTSD) and dissociative disorders, depression and anxiety disorders, substance use disorders, and schizophrenia. Betrayal trauma (BT) refers to interpersonal trauma experiences where the perpetrator of the act is an individual who is trusted and needed by the victim. The betrayal trauma theory (BTT) suggests that BT experiences lead to memory distortions that may range from unawareness of the entire traumatic event, to different degrees of loss of awareness of the betrayal, and inadequate processing of the event. Studies have shown that there is a link between trauma experiences involving high betrayal and the occurrence of dissociative experiences later in life. Studies on trauma and PTSD have shown that the person's feelings and behaviors during the trauma event, as well as their appraisal of the trauma event play crucial roles in the development of psychopathology., Negative trauma-related cognitions about oneself have the strongest relationship with concurrent PTSD symptom severity,, and severe negative trauma-related cognitions may be associated with poorer outcome in therapy.
Interpersonal trauma experiences, especially in the form of intimate partner violence, are more prevalent among women globally, compared to men. Similarly in India, crimes against women and children prevail in various forms such as rape, domestic violence, sexual harassment, and trafficking of women and children for bonded or other kinds of forced labor and sex trafficking. Poverty and lack of social support are associated with higher incidence of violence and abuse against women and higher revictimization risks. Untreated mental illness and sex trafficking are some of the other risks for interpersonal trauma, along with homelessness, which is both a vulnerability and a consequence related to trauma. Studies on women in shelter homes show evidence of disproportionately high rates of trauma experiences and mental illness compared to the community population.
Studies in India have found that interpersonal violence (mainly physical and emotional abuse), betrayal by a partner, and the lack of social support are some of the main reasons for being placed in shelter homes., Poverty, low levels of education, and lack of access to resources for care are some of the other vulnerabilities. A study in a rehabilitation home for women found similar vulnerabilities for homelessness, in addition to becoming orphaned at a young age, lack of support from and interpersonal conflicts with extended family.
The government Reception Centre is a short-term shelter for vulnerable women, who are in need of shelter and care. The shelter-homes cater to their basic needs, medical care, protection, and make an attempt to rehabilitate them. However, the shelters are seldom sufficiently equipped to provide the required quality of care due to the lack of human resource, lack of awareness among the staff, and the overwhelming number of residents. Consequently, the psychosocial needs of these women are often ignored, impairing their recovery., A better understanding about the circumstances and experiences of these women is required for the development of treatment or rehabilitation plans that are best suited for their needs.
This study aims to examine the experiences of betrayal trauma, dissociative experiences, posttrauma cognitions, and levels of distress among the women in a Reception Centre in Bengaluru.
| Subjects and Methods|| |
The sample consisted of 30 women, placed in the government Reception Centre in Bengaluru, Karnataka, who are 18 years or older with a working knowledge of English, Kannada or Hindi. Women with intellectual disability or psychotic disorders were excluded from this study.
- Sociodemographic Data Sheet was developed by the investigator. It was used to obtain details of the participants such as age, educational qualification, marital status, and employment history
- Brief Betrayal Trauma Survey revised (BBTS-R) developed by Goldberg and Freyd (2003) was used to assess trauma history and details regarding the trauma experience. It has 14 items specifying events that involve sexual, physical, and emotional mistreatment by someone close (high betrayal), mistreatment by someone not so close (low betrayal), and noninterpersonal trauma events (no betrayal). Participants report whether it occurred before they turned 18 or after. The response category for each item is “never,” “1 or 2 times” and “more than that.” It has additional questions pertaining to the gender of and relationship with the perpetrator, and provisions for description of the event. Indices of test–retest reliability for the BBTS-R were 83% for childhood events and 75% for adulthood events on an average. It has been used in various studies on trauma and trauma-related variables, and has been found to have significantly high content validity
- Dissociative Experiences Scale (DES) developed by Carlson and Putnam in 1993 was used to assess dissociative experiences. The 28-item scale, measures the percentage of time a particular dissociative symptom is experienced. The items cover dissociative experiences in the suggested subscales which are depersonalization and derealization, amnesia, and absorption. Items range from normal dissociative experiences such as “spacing out” during a conversation with someone, to more unusual experiences such as not recognizing oneself in the mirror. The DES has been found to have good overall psychometric properties in a number of studies. The DES score test–retest reliability was between 0.78 and 0.96. The scale has been widely used both as a screening and diagnostic tool in clinical practice, and in research studies
- Posttrauma cognitions inventory (PTCI) developed by Foa et al. was used to assess post trauma cognitions. It is a 33-item scale, rated on a Likert-type scale ranging from 1 (totally disagree) to 7 (totally agree) measuring appraisals of trauma and its sequelae, related to the development and persistence of PTSD. The scale has three subscales, namely, negative cognitions about the self, negative cognitions about the world, and self-blame. PTCI has significantly high test–retest reliability for a 3-week interval; α ranged between 0.80 and 0.86 for the three subscales. It has significantly high convergent validity. The PTCI subscales and total score have significantly high correlations with PTSD severity, depression, and general anxiety. PTCI also has high sensitivity of 0.78 and specificity of 0.93 for indicating the absence or presence of posttraumatic stress disorder
- A visual analog scale (VAS) was used to measure psychological distress in the participants. A VAS is usually a horizontal line, 100 mm long, representing an attitude or characteristic that ranges across a continuum. It is anchored by word descriptors at each end that measure extremes of a feeling or a characteristic. In this study, the VAS measured psychological distress that ranged from “currently not distressed” to “currently very distressed.” The participant marks the point that they feel represents their perception of their current level of distress.
Setting of the study
The Reception Centre is a custodial center with strict security and monitoring, managed by the Women and Child Welfare Department. It acts as a temporary shelter for women from highly vulnerable situations who join voluntarily, or in most cases, are committed by the court under the Immoral Traffic (prevention) Act when there is a threat to their life, physical or mental health, or they are at risk of being abused or trafficked. It houses 30–50 women, at any point of time, in large dormitories. They are actively involved in taking care of certain chores and responsibilities assigned to them, such as cooking, cleaning, and washing clothes following a preset schedule. After approximately 2 months, they are to be placed in longer stay shelters/NGOs, providing occupational training and rehabilitation, or left in the care of supportive family members if located. Often, they require permanent placements as they are either abandoned by their family members or the perpetrators include close family members. If there is an ongoing legal case against them, they may be transferred to another facility based on court orders.
This article is based on a larger study that included quantitative and qualitative data. The present article reports the results from the quantitative data. Ethical clearance was obtained for the study from NIMHANS. Written permission was obtained from the Department of Women and Child Development to obtain data from the Reception Centre. The superintendent and the caretaker in-charge of the Reception Centre were consulted and suitable participants meeting the inclusion and exclusion criteria were approached. The participants were contacted individually and the study was explained in detail. Those who were willing to participate in the study were asked to give written informed consent, or oral consent in the presence of a witness (who vouched in writing) in case of participants who were not formally educated. Privacy and confidentiality were ensured, and assessments were carried out in individual sessions. The duration for the assessment and interview session ranged between 90 and 120 min per participant, and was completed in a single session. The sessions were paused any time for the participants who requested it. After the assessments, participants were debriefed and offered a brief supportive intervention of a single session of 30–45 min.
Descriptive statistics were used to describe the sociodemographic details of the sample. Nonparametric tests were used for analysis as the sample was not normally distributed. Spearman's rank correlation (rho) was used to measure the interrelationships between the variables. Subgroup analysis using Kruskal–Wallis H-test and Mann–Whitney U-test was performed based on significant groups that arose from the sociodemographic profile and severity of betrayal trauma.
| Results|| |
The age of participants ranged from 18 years to 43 years, and the mean age of the sample was 25.87 years (standard deviation [SD] = 7.52). Sociodemographic details of the participants such as age, education, employment, income, and marital status are shown in [Table 1].
Under the employment category, some examples of unskilled jobs held by participants include daily wage labor, domestic help, shop attendant or helper, and street performer. Semi-skilled jobs include employment in a garment factory, a textile factory, or weaving factory. The job of a school teacher was an example under the skilled jobs category. The mean monthly income of the sample was Rs. 5270, and a majority of the participants were from a lower socioeconomic background. Some of the participants had been forced to work as bonded laborers and were not given any income (illustrated as “nil”), apart from being provided with basic needs such as food and shelter, though inadequately.
All the participants had experienced BT, either in their childhood or adulthood. The participants had multiple experiences of similar trauma experiences, very often inflicted by the same perpetrator. The level of BT experienced by the participants during childhood and adulthood is illustrated in [Table 2].
Examples of high-BT events are witnessing someone who is very close (such as a parent, brother or sister, caretaker, or intimate partner) being killed, or being severely injured by another person; witnessing someone who is very close deliberately attack another family member severely, being deliberately attacked severely by someone very close, being forced to have some form of sexual contact, such as touching or penetration, by someone who is very close (such as a parent or lover), or being emotionally or psychologically mistreated over a significant period by someone who is very close (such as a parent or lover). Examples of low BT experiences are events such as trauma events involving a perpetrator who is not very close, or is unknown to the participant, or trauma events of a noninterpersonal nature. The nature of the trauma experiences of the participants is shown in [Table 3].
The DES and PTCI scores obtained by the sample are shown in [Table 4].
|Table 4: Distribution of Dissociative Experiences Scale and posttrauma cognitions inventory in the sample|
Click here to view
One participant scored above the cut-off on DES cut-off (total score of 30), indicating that she has a high likelihood of having PTSD or dissociative disorder. Some examples of dissociative experiences reported on DES are being absorbed while watching a movie or TV, and losing awareness of what is happening around them; or sitting and staring into space, not thinking of anything, and losing track of time; and not being able to remember whether they have just thought about doing something or actually done it. On PTCI, the common negative cognitions reported by participants were in the form of “feeling that one is incapable or inadequate;” “feeling that if they had not behaved in a particular way, the event would not have happened;” “feeling that nobody can be trusted;” or “feeling that nobody can be relied upon.”
On the VAS, the participants obtained a mean of 4.5, with an SD of 3.1, indicating that a majority of the sample was experiencing a moderate level of distress at the time of the study. Fourteen participants scored above the mean, and 16 scored below the mean. The scores ranged from 0, indicating no distress, to 10, indicating a high level of distress.
The results of the correlation analysis between the PTCI and the DES are shown in [Table 5].
|Table 5: Intercorrelations between Dissociative Experiences Scale, posttrauma cognitions inventory and Visual Analog Scale|
Click here to view
DES, PTCI, and VAS scores between significant groups that emerged based on high, low, and no BT were compared using Kruskal–Wallis Test. There was no significant difference in DES and PTCI total scores, their subscale scores, and VAS scores among the three groups. DES, PTCI, and VAS scores between groups having experienced BT in the form of severe physical violence and other kinds of BT were compared using Mann–Whitney U-test. There was no significant difference between the DES and PTCI total scores, or the VAS scores between the two groups. The results of Mann–Whitney U-test comparing groups based on BT experience in the form of severe physical abuse and no severe physical abuse experience are shown in [Table 6].
|Table 6: Mann-Whitney U-test results for Dissociative Experiences Scale and posttrauma cognitions inventory for groups based on severe physical abuse|
Click here to view
| Discussion|| |
A majority of the sample in the present study hailed from a lower socioeconomic status, and was poorly educated. The high prevalence of trauma events in this sample could indicate a vulnerability of women from such a background for trauma experiences and victimization. A meta-analysis of previous studies on violence against women found similar factors linked to the vulnerability of women to violence and victimization, and an increased risk for homelessness. Studies in women's shelter homes in India,,, have found similar sociodemographic factors to being placed in shelter homes; including domestic violence, which often leads to separation or divorce. Poverty, low levels of education, unemployment, and domestic violence, and consequent separation contribute to increased vulnerability to victimization and risk of homelessness as they limit the women's scope for independent living.
All the participants had experienced BT, with a majority having experienced high BT events in the form of severe physical or emotional abuse, and in a few cases, sexual abuse by close family members. Betrayal blindness was observed in the form of unawareness of the betrayal element involved in the event or normalizing the experiences while narrating it. Further, betrayal blindness was observed for trauma experiences at all ages, but was more prevalent for those during childhood, suggesting that as age progresses, coping through betrayal blindness may also reduce, as indicated by the BTT theory. The theory also implies that unawareness, a dissociative process, leads to the development of relationship schemas during childhood that normalizes abuse, furthering the risk of revictimization. In the present study, it was similarly noted that many of the participants experienced multiple instances of abuse, either by the same or different perpetrators, demonstrating that the chances of revictimization are very high. They had previously made few efforts to escape the relationship even when there was a threat to their life.
However, contrary to the BTT and existing literature suggesting that high BT experiences predict memory disturbances or dissociative experiences,, only one participant scored above the cut-off on DES. On comparing groups based on high and low BT, no significant difference was found on scores of DES, indicating that high BT did not lead to the increased probability of dissociative experiences in the sample. One probable reason for this is that women in such shelter homes are most likely to represent a subset of the BT victims who have become aware of the betrayal element involved, and made a choice to leave the care of the perpetrator. Further, victims who faced abandonment by the spouse or parent have no reason to be blind to the betrayal element to cope, negating the need for memory distortions described in the BTT.
The results also indicate a highly significant positive correlation between posttraumatic cognition, and all forms of dissociation, consistent with prior studies which indicate that negative posttrauma appraisal is associated with psychopathology development, in the form of dissociation or PTSD., NCS subscale of PTCI was seen to be highly correlated with DES scores and level of distress, indicating that specifically, having more negative cognitions about oneself is associated with higher distress, and dissociative experiences, and is consistent with the findings of previous studies. Negative cognitions toward oneself, and depersonalization/derealization experiences (or the tendency to lose awareness of oneself) were higher among those who had experienced high BT in the form of severe physical abuse, which could suggest a higher risk of psychopathology in this group. This difference can be explained by the fact that severe physical violence was one of the most severe forms of BT, very often involving a threat to life, or long-lasting injuries and/or disability in the victims, as compared to other forms of BT.
| Conclusions and implications|| |
This is one of the first studies to explore BT among women in a shelter home such as a Reception Centre in India. The participants had all experienced some form of BT, either as children or as adults, and there is a risk of psychopathology, especially in the group that has experienced BT in the form of severe physical abuse. A high risk of revictimization is also present. The findings illustrate the importance of routine screening for trauma and trauma-related disorders in shelter homes. The study can inform professionals working with individuals with trauma experiences, or at shelter homes for developing an effective trauma-informed care approach to intervention. It highlights the urgent need for such interventions which is not the routine practice in shelter homes.
The study can be replicated on a larger sample in the government Reception Centre, and in other shelter homes. Longitudinal studies on this population may provide a better understanding of trauma and victimization, and help reduce the risk of revictimization in this group of vulnerable women.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sar V. Epidemiology of dissociative disorders: An overview. Epidemiol Res Int 2011;2011:404538.
Seng JS, D'Andrea W, Ford JD. Complex mental health sequelae of psychological trauma among women in prenatal care. Psychol Trauma 2014;6:41-9.
Gatov E, Koziel N, Kurdyak P, Saunders NR, Chiu M, Lebenbaum M, et al.
Epidemiology of interpersonal trauma among women and men psychiatric inpatients: A population-based study. Can J Psychiatry 2020;65:124-35.
Freyd JJ. Betrayal trauma: Traumatic amnesia as an adaptive response to childhood abuse. Ethics Behav 1994;4:307-29.
Sivers H, Scooler J, Freyd JJ. Recovered memories. In: Encyclopaedia of the Human Brain. Vol. 4. California, USA: Elsevier Science; 2002.
Gómez JM, Kaehler LA, Freyd JJ. Are hallucinations related to betrayal trauma exposure? A three-study exploration. Psychol Trauma 2014;6:675.
Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 2000;38:319-45.
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M. Cognitive therapy for post-traumatic stress disorder: Development and evaluation. Behav Res Ther 2005;43:413-31.
Moser JS, Hajcak G, Simons RF, Foa EB. Posttraumatic stress disorder symptoms in trauma-exposed college students: The role of trauma-related cognitions, gender, and negative affect. J Anxiety Disord 2007;21:1039-49.
Lancaster SL, Rodriguez BF, Weston R. Path analytic examination of a cognitive model of PTSD. Behav Res Ther 2011;49:194-201.
Moser JS, Cahill SP, Foa EB. Evidence for poorer outcome in patients with severe negative trauma-related cognitions receiving prolonged exposure plus cognitive restructuring: Implications for treatment matching in posttraumatic stress disorder. J Nerv Ment Dis 2010;198:72-5.
Klest B. Childhood trauma, poverty, and adult victimization. Psychol Trauma 2012;4:245-51.
Oram S, Khalifeh H, Howard LM. Violence against women and mental health. Lancet Psychiatry 2017;4:159-70.
Hopper EK, Bassuk EL, Olivet J. Shelter from the storm: Trauma-informed care in homelessness services settings. Open Health Serv Policy J 2010;3:80-100.
Sekar K. Psychosocial Care for Women in Shelter Homes: A Training Manual. UNODC and NIMHANS Report; 2011.
Sowmya HS, Suman LN. Pathways to homelessness, psychological distress and perceived social support among married women in a shelter: Implications for trauma informed care. Indian J Clin Psychol 2013;40:109-15.
Suman LN, Shesha BV. Loss, trauma and suicidal ideation among women living in a shelter home. Indian J Clin Psychol 2013;40:34-40.
Goldberg LR, Freyd JJ. Self-reports of potentially traumatic experiences in an adult community sample: Gender differences and test-retest stabilities of the items in a brief betrayal-trauma survey. J Trauma Dissociation 2006;7:39-63.
Carlson EB, Putnam FW. An Update on the Dissociative Experiences Scale. Dissociation: Progress in the Dissociative Disorders; March, 1993.
Dubester KA, Braun BG. Psychometric properties of the Dissociative Experiences Scale. J Nerv Ment Dis 1995;183:231-5.
Foa EB, Ehlers A, Clark DM, Tolin DF, Orsillo SM. The posttraumatic cognitions inventory (PTCI): Development and validation. Psychol Assess 1999;11:303.
Lesage FX, Berjot S, Deschamps F. Clinical stress assessment using a visual analogue scale. Occup Med (Lond) 2012;62:600-5.
MOWCD & UNODC. India Country Report to Prevent and Combat Trafficking and Commercial Sexual Exploitation of Children and Women; 2008.
Kaehler LA, Freyd JJ. Betrayal trauma and borderline personality characteristics: Gender differences. Psychol Trauma 2012;4:379.
Gagnon KL, DePrince AP. Head injury screening and intimate partner violence: A brief report. J Trauma Dissociation 2017;18:635-44.
Karpel MG, Jerram MW. Levels of dissociation and nonsuicidal self-injury: A quartile risk model. J Trauma Dissociation 2015;16:303-21.
Briere J, Scott C, Weathers F. Peritraumatic and persistent dissociation in the presumed etiology of PTSD. Am J Psychiatry 2005;162:2295-301.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]