Trauma and Betrayal — Complex Combination
By Scott Janssen, MSW, LCSW
Social Work Today
Vol. 19 No. 3 P. 20

Betrayal can often fan the fire of posttraumatic stress, but social workers can grow their understanding of this fusion and respond more effectively and compassionately.

James was causing his medical team frustration. Distrustful and suspicious, he was prone to shooting down suggestions as if by reflex and interrogating staff about their motives whenever they tried to get information out of him. He was constantly scanning his environment for perceived threats and could fly into fits of rage at the drop of a hat. Above all, he hated big institutions such as the hospital where he was receiving care.

This pattern of distrust had caused problems throughout his life. He’d had trouble in relationships and holding down jobs. It had undermined his willingness to follow medical recommendations, and that’s what had landed him in the hospital after nearly going into a diabetic coma.

Patients such as James often get labeled as oppositional or noncompliant. Many are described as having poor coping skills or deficits in self-awareness and social functioning. Some are even diagnosed with psychiatric issues such as delusions, paranoia, or personality dysfunction.

Knowing James was a combat veteran, his medical team recognized possible indications of PTSD—hypervigilance, hyperreactivity, irritability, and negative mood and cognition. Awareness about the signs and symptoms of PTSD is critical for social workers in medical settings since medical care can unearth painful memories and undermine coping in ways that intensify preexisting posttraumatic stress or cause delayed-onset PTSD.

For patients with PTSD, medical environments can present stressors that can cause intense emotions, defensive behaviors, involuntary physiological responses, and strong reactions like the ones James was having. In patients with no military history, medical staff may not even consider the possibility of posttraumatic stress despite the fact that traumatizing events in the general population are widespread and occur throughout the lifespan.

James was lucky his team understood the possible origins of his reactivity and distrust. What made his situation more complex, however, and the symptoms more intense, was that his PTSD was coupled with the experience of having been betrayed on a fundamental level by people and systems he had trusted.

It is difficult to estimate how frequently PTSD and betrayal interpenetrate, but it appears to be common. Though they may overlay in any patient, there are populations that appear to be at elevated risk for this combination. These include veterans, survivors of sexual assault and other kinds of interpersonal violence, and patients whose PTSD stems from trauma related to medical care.

Origins
Betrayal originates in action, or a failure of action, by individuals, groups, or institutions that causes harm to those who have given their trust. The effects of betrayal can share features with PTSD, making it difficult at times to differentiate between them. These may include anger, anxiety, distrust, dissociation, negative beliefs about others or the self, insomnia, and even physical health complaints (Rachman, 2010; Goldsmith, Freyd, & DePrince, 2012). Surviving a potentially traumatic event in which there is a corresponding betrayal can elevate one’s risk of developing symptoms of PTSD, especially when the betrayal causes intense emotional and psychological pain, severs important relationships, or undermines safety—marital infidelity resulting in divorce, for example (DePrince, 2001; Brown & Freyd, 2008).

Psychological trauma and the wound of betrayal often originate from the same events—the patient traumatized by growing up subjected to chronic negligence and verbal abuse by those who should have protected rather than harmed, for example, or the nursing home resident having symptoms of PTSD after breaking a hip in a fall that he blames on staff who repeatedly failed to answer his call bell before he decided to try to stand without assistance.

Special Populations
Veterans have been identified as a population in which there may be a higher-than-average association of PTSD and betrayal (Shay, 1994; Jordan, Eisen, Bolton, Nash, & Litz, 2017). In James’ case, the betrayal was multifocal. He’d been drafted—forced to leave behind the life he was building and sacrifice a future he might have had—to fight a war in Vietnam that he saw as unnecessary. He’d been put in morally injurious situations by decision-makers who remained far from the fighting. He’d seen friends killed by American firepower, others whose lives had been “wasted” taking a hill or hamlet that was quickly abandoned as having no strategic significance. When he returned home he felt stigmatized and betrayed by cultural animosity toward veterans of that war. Years later, he mustered the nerve to go to the VA seeking help for his drinking and “got the run-around.”

Illustrating how deeply betrayal can cut, in a conversation with his social worker, James later made clear that being betrayed was actually more traumatic for him than combat. “I could have dealt with the war and all that happened if I thought the people who sent us there did it as a last resort and if some good came out of it. But they lied to us. They all lied. Try seeing your buddies kill and be killed so some politician can get votes or a general can get another star. See if you ever look at people the same after that. I don’t trust you, but don’t take it personally. I trust nobody.”

Another group in which PTSD and betrayal often combine is those who have survived sexual assault. This is especially true when it occurs in childhood and when it is prolonged, repeated, and inescapable (Freyd, 1996; Freyd, DePrince, & Gleaves, 2007; Smith & Freyd, 2013).

According to the Centers for Disease Control and Prevention (2018) approximately one-third of women and one-sixth of men in the United States will experience sexual assault in the course of a lifetime. For survivors of sexual violence, medical environments can feel dehumanizing, shatter protective boundaries, and undermine coping strategies. The need for invasive interventions such as surgery and certain kinds of medication administration such as suppositories can register as threatening for someone who has survived rape. So can a loss of privacy, being touched or assisted with personal care, or being seen naked. People standing over a patient’s bed, threats associated with gender, loss of mobility, diminished alertness, or disease symptoms can activate intense reactions including fear, rage, dissociation, or collapse.

Many are reluctant to disclose a history of sexual assault. Painful memories may be laced with shame, stigma, or an awareness that trusting the wrong person with such information can be like rubbing salt in a wound. As such, psychological trauma and memories of betrayal, though operative beneath the surface, may go unspoken. The patient who was sexually assaulted by a spouse may harbor a burning sense of betrayal at having her trust violated and her vulnerability exploited, triggering anger or fear when a nursing assistant arrives to give her a bath. The patient who as a child was raped by a neighbor and who was betrayed by a parent who denied her reports may not trust her medical team to keep her safe or take her seriously. Another patient may have experienced sexual assault as a betrayal of the idea of human goodness and respect that has left him distrustful and afraid of professional staff responsible for conducting physical examinations.

Sometimes betrayal occurs in the aftermath of sexual assault. If law enforcement personnel are callous or accusatory or appear unconcerned, the sting of betrayal may long burn. If staff at the hospital act without compassion as they subject a survivor to the invasive gathering of criminal evidence in the wake of an assault, a patient may carry the humiliation and betrayal of having been treated coldly during a time in which they critically needed kindness and support.

If sexual violence occurs within a system that fails to prevent it or attempts to cover it up, or that blames or marginalizes the victim—an academic, religious, or military institution, for example, concerned about its public image—betrayal and psychological trauma can fuse in ways that make them all but inextricable. Unfortunately, such betrayal in the wake of sexual assault is common and has been described by some as a “second rape” (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001).

Health Care
Social workers in health care also need to be aware of the intersection of PTSD related to medical care and the ways patients may feel betrayed by their medical teams. There is ample research attesting to the increased prevalence of PTSD and its symptoms as a result of medical care. This includes patients who have undergone surgery, dialysis, childbirth, or treatment for cancer and cardiac conditions, as well as those who have needed emergency and intensive care (Hall & Hall, 2016).

If a patient experiences adverse physical or psychological effects stemming from medical treatment, they may feel betrayed by individuals or institutions perceived as being responsible for those effects. If these events are seen as being the result of medical error, incompetence, financial exploitation, or decisions a patient made under duress, the possibility of perceived betrayal exists. For example, an advanced cancer patient who has to abandon chemotherapy after an adverse reaction and who later learns that the doctor’s optimism about the likelihood of remission was overblown may show signs of posttraumatic stress and also feel betrayed, lied to, or financially exploited.

In an article on institutional betrayal in health care organizations, Smith (2017) found that two-thirds of patients receiving medical care reported some degree of feeling betrayed by those organizations. Indications of betrayal included events such as being given an inaccurate diagnosis or improper medication, being subject to unnecessary tests or procedures, or having been given inaccurate information about insurance coverage.

Although there are specific groups in which this combination of PTSD and betrayal may be more common, it’s important to keep in mind that it can occur in any patient who presents with posttraumatic stress. For example, the patient who shows up in the emergency department with signs of a panic attack who is traumatized by the suicide of a partner and secretly feels betrayed and abandoned as he struggles with grief and the challenge of raising young children alone. Or the paramedic with posttraumatic stress related to being injured helping victims of a fire who arrives for a medical appointment after learning that the building that burned down had been repeatedly cited for fire code violations that the landlord ignored and a county official failed to enforce.

Social Workers
Social workers are also at risk. According to research by Bride (2007), “social workers engaged in direct practice are highly likely to be secondarily exposed to traumatic events through their work” and to experience symptoms of posttraumatic stress including meeting the diagnostic criteria for PTSD. When practicing in settings in which agencies or institutions fail to protect them or their clients, social workers may feel betrayed by those institutions or their supervisors. For example, the social worker who is traumatized by the cumulative exposure to abused children who works in an agency she perceives as being unresponsive to the needs of these children or inadequate in efforts to protect them. A medical social worker serving a patient left disabled and in chronic pain after an unsuccessful back surgery may experience moral distress and symptoms of posttraumatic stress. If she is pressured by her supervisor to conceal information from that patient or to falsely document events to protect a hospital concerned about a lawsuit, a sense of betrayal may ensue.

Social workers sensitive to underlying PTSD in their clients often assess for comorbidities such as depression, anxiety, and substance use. Depending on a client’s history, they may also assess for issues such as shame, suicidal ideation, or complicated bereavement. Rarely though do social workers consider the potential impact of betrayal. When both are present, they may fuel each other in ways that undermine trust, safety, communication, and a patient’s willingness to follow plans of care and seek help in a timely manner.

Patients with PTSD and betrayal-related distress may have insufficient social support and be more likely to experience uncontrolled disease-related symptoms such as physical pain. If patients feel threatened by the possibility of death, they may experience an intensification of trauma and/or betrayal reminders associated with life review or environmental, somatic, and situational triggers (Feldman & Periyakoil, 2006; Ganzel, 2018).

Moreover, the psychological impact of combined PTSD and betrayal may manifest as cynicism, sarcasm, bitterness, conflict with authority figures, or anxiety in medical contexts that feel dehumanizing. Some patients may shut down, withdraw, or avoid medical care altogether.

Patients who have PTSD and who have been betrayed in ways that have caused psychological harm often experience intense emotions and strong responses that appear disproportionate to the situation. In fact, the combination may intensify these reactions and make potential triggers more numerous. Anger or rage, for example, may be a sign of PTSD, but the National Center for PTSD points out that research shows that, in survivors of psychological trauma, “anger can be especially common if you have been betrayed by others.”

Growing Your Awareness
Although betrayal in the aftermath of a potentially traumatic event can increase the likelihood of PTSD, the good news is that positive support can reduce it (Charuvastra & Cloitre, 2008). When a social worker arrives after a surgery in which unforeseen complications have left a patient intubated and restrained, or when a rape crisis or police social worker arrives after a sexual assault, they are in positions to provide essential care that may mitigate the risks of PTSD and of a patient walking away with a persistent sense of betrayal.

Whether or not a trauma survivor chooses to share or process narratives and memories of betrayal, it is important for social workers to be aware of the potential implications. For patients overwhelmed by life-altering medical conditions and the loss of protective routines and boundaries that often go along with health care treatment, the dual wounds of betrayal and posttraumatic stress can cause what appear to be irrationally strong behavioral and emotional responses. It can create barriers to trust and communication as well as conflict with professional staff that can threaten to undermine a patient’s well-being, effective treatment, and support.

Professional staff may find such patterns frustrating and be tempted to label patients as problematic rather than understanding the interior pain driving such patterns. Social workers who are aware of the indications of PTSD and its connection with betrayal will be better prepared to respond effectively and compassionately.

— Scott Janssen, MSW, LCSW, is a hospice social worker in Durham, NC, and member of the National Hospice and Palliative Care Organization’s trauma informed care work group.

References
Bride, B. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63-70.

Brown, L., & Freyd, J. (2008, Winter). PTSD criterion and betrayal trauma: A modest proposal for a new look at what constitutes danger to self. Trauma Psychology Newsletter, 11-15.

Campbell, R., Wasco, S., Ahrens, C., Sefl, T., & Barnes, H. (2001). Preventing the “second rape”: Rape survivors’ experiences with community service providers. Journal of Interpersonal Violence, 16(12), 1239-1259.

Centers for Disease Control and Prevention. (2018). National intimate partner and sexual violence survey: 2015 data brief — updated release. Retrieved from https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf.

Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59(1), 301-328.

DePrince, A. P. (2001). Trauma and posttraumatic responses: An examination of fear and betrayal (Doctoral dissertation, University of Oregon, 2001) Dissertation Abstracts International, 62(6-B), 2953.

Feldman, D., & Periyakoil, V. (2006). Posttraumatic stress disorder at the end of life. Journal of Palliative Medicine, 9, 213-218.

Freyd, J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press.

Freyd, J., DePrince, A., & Gleaves, D. (2007). The state of betrayal trauma theory: Reply to McNally — conceptual issues and future directions. Memory, 15, 295–311.

Ganzel, B. (2018). Trauma-informed hospice and palliative care. The Gerontologist, 58(3), 409-419.

Goldsmith, R., Freyd, J., & DePrince, A. (2012). Betrayal trauma: Associations with psychological and physical symptoms in young adults. Journal of Interpersonal Violence, 27 (3), 547-567.

Hall, M., & Hall, S. (2016). Managing the psychological impact of medical trauma. New York: Springer.

Jordan, A., Eisen, E., Bolton, E., Nash, W., & Litz, B. (2017). Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychological Trauma, 9(6), 627-634.

Rachman, S. (2010). Betrayal: A psychological analysis. Behavior Research and Therapy, 48(4), 304-1.1

Shay, J. (1994). Achilles in America: Combat trauma and the undoing of character. New York: Scribner.

Smith, C. (2017). First, do no harm: Institutional betrayal and trust in health care organizations. Journal of Multidisciplinary Healthcare, 10, 133-144.

Smith, C., & Freyd, J. (2013). Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress, 26(1), 119-124.