Madeline J. Bruce, Deborah M. Little, Melba A. Hernandez-Tejada, & Ron Acierno
July 22, 2025
Consider the following scenarios . . .
1) While deployed in the army, a woman survives a sexual assault committed by one of her own comrades. When she reported the assault, her command staff replied, "Well, are you sure this happened as you are describing? Maybe you misunderstood the situation…”
2) A teacher reports a student’s threatening behavior to school officials. The officials downplay the seriousness of the behavior, openly question the teacher’s report, and tell her, "Get back to work."
3) Event planners significantly underprepare for a concert, leaving security and medical personnel overwhelmed when a crowd crush begins. The entertainer encourages crowd aggression and continues to perform despite being alerted to distressed concert-goers.
In each of these scenarios, those impacted experienced not just a potentially traumatic event, but an institution failed to either prevent, or respond appropriately to, the event. These breaches of trust, from cover-ups to mishandled reports to protecting perpetrators, are examples of institutional betrayal (Smith & Freyd, 2014). Betraying actions have been documented across many institutions, from medicine, higher education, and whole governments. People who have experienced institutional betrayal report more posttraumatic stress disorder (PTSD) symptoms, more emotional dysregulation, and more suicidal actions. These trends raised concern within our specialty trauma clinic. We questioned whether current evidence-based treatment approaches were enough support to those with trauma after institutional betrayal.
New Research
In our quality assurance project, we identified 57 patients who presented to our clinic after institutional betrayal and compared their treatment process and outcomes to 57 clinic patients without such history. While many people found symptom relief regardless of betrayal exposure, a more detailed analysis revealed notable differences:
1) Betrayed patients were more likely to leave treatment by the third session.
2) Betrayed men and betrayed Black patients were especially at risk for early dropout.
3) Betrayed patients who stayed in treatment often needed a change in protocol to meet their goals (i.e., stopping prolonged exposure to start cognitive processing and vice versa).
4) Only 37% of betrayed patients completed treatment, compared to 53% of their non-betrayed counterparts.
Clinical Implications
These results are concerning and encourage future research to help clinicians address the unique needs of those institutionally betrayed. We noted that betrayed patients tended to leave by session three – typically when patients first attempt emotionally demanding tasks like confronting trauma reminders. These attempts can challenge one’s trust in the treatment and the provider, which may be fragile in betrayed patients. Betrayed patients experiencing a change in treatment protocol raises questions as well. It may be that the first protocol application “fell flat” if the nuances of institutional betrayal were not well incorporated into treatment. For example, in prolonged exposure, deciding what is harmful verses adept avoidance may be difficult if the patient must remain in contact with the offending institution. If so, research on the lived experience of institutional betrayal can help clinicians more artfully integrate this topic into treatment planning and therapy.
Summary
Taken together, while people who have been institutionally betrayed can see PTSD symptom relief with current treatments, they also report more challenges, are at risk of early dropout, and therefore, they may not see the same symptom relief. The overall completion rate is also comparatively low. These results underscore the need for more targeted research and adaptation in post-trauma experience and recovery.
Discussion questions
- How can mental health professionals build and maintain trust with patients who have experienced institutional betrayal?
- What aspects of institutional betrayal should clinicians be aware of/sensitive to when treatment planning?
- How might peer support or group therapy help a betrayed patient meet their treatment goals?
About the Authors
Madeline J. Bruce, PhD is an Assistant Professor at Webster University in St. Louis and a visiting scholar at the UTHealth Houston Trauma and Resilience Center.
Deborah M. Little, PhD is a Professor and the Director of Research at the UTHealth Houston, Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center.
Melba A. Hernandez-Tejada, PhD, DHA is an Associate Professor at the UTHealth Houston, Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center.
Ron Acierno, PhD is a Professor, Vice Chair for Veteran Affairs, and Executive Director at the UTHealth Houston, Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center.
References
Smith, C. P. & Freyd, J. J. (2014). Institutional betrayal. American Psychologist, 69(6), 575–587. http://doi.org/10.1037/a0037564
Read the full paper here in JOTS:
, , , & (2025). Posttraumatic stress disorder treatment outcomes for events related to institutional betrayal. Journal of Traumatic Stress, 1–8. https://doi.org/10.1002/jts.23187