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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: Drug Alcohol Depend. 2021 Jul 27;227:108924. doi: 10.1016/j.drugalcdep.2021.108924

Associations among Betrayal Trauma, Dissociative Posttraumatic Stress Symptoms, and Substance Use among Women Involved in the Criminal Legal System in three US cities

Sofía Mildrum Chana 1, Caitlin Wolford-Clevenger 1, Alexandra Faust 1, Jordana Hemberg 2, Megha Ramaswamy 3, Karen Cropsey 1
PMCID: PMC8464486  NIHMSID: NIHMS1729138  PMID: 34333280

Abstract

BACKGROUND:

Betrayal trauma, as defined by (Freyd, 1996), refers to a subcategory of trauma characterized by a significant violation of trust surrounding interpersonal maltreatment (physical, sexual or emotional). Previous research has shown that people with betrayal trauma histories experience greater dissociative symptoms of posttraumatic stress disorder and comorbid substance use disorder symptoms. Women in the criminal legal system commonly have significant histories of betrayal trauma and related posttraumatic stress symptoms and substance use. However, no studies have specifically explored the impact of dissociative posttraumatic stress symptoms on substance use outcomes in this population. Additionally, no studies have explored whether betrayal trauma relates to nonfatal overdoses.

METHODS:

This cross-sectional survey study of N = 508 women with criminal legal system involvement examined the indirect effects of betrayal trauma history on substance use outcomes through dissociative posttraumatic stress symptoms.

RESULTS:

Multivariate analyses supported an indirect effect of betrayal trauma on substance use severity, daily substance use, and history of overdose, but not alcohol use severity, through dissociative symptoms.

CONCLUSIONS:

Women in the criminal legal system with betrayal trauma and dissociative symptoms may be at risk for substance use and related outcomes (i.e., overdose). Future work is needed to examine whether targeting such symptoms may improve substance use treatment and prevention of serious outcomes in this population.

Keywords: overdose, substance use, women, betrayal trauma, dissociative symptoms, criminal legal system

1. Introduction

Substance Use Disorders (SUD) are a highly prevalent public health concern with devastating health consequences, including increased risk of overdose, infections like HIV and Hepatitis C, and mortality (NIDA, 2020b). The Centers for Disease Control and Prevention (CDC) reported 967,615 nonfatal overdoses in 2017, and 70,630 overdose fatalities reported in 2019 (CDC Injury Center, 2021; Vivolo-Kantor, 2020). The consequences of SUD are particularly dire for women, who are more likely than men to die from overdose (NIDA, 2020a). Compared to the general population SUD rates are estimated to be four to five times higher among individuals with criminal legal (CL) system involvement (Bello et al., 2020; Grant et al., 2016; Karberg et al., 2002; Mumola, 1999). Women in the CL system are especially affected by SUDs, reporting higher rates of drug use and psychological distress than their male counterparts (DeHart et al., 2014; James & Glaze, 2006; Mooney et al., 2002; Prost et al., 2020). Despite this, research with CL populations has predominantly focused on men (Fazel & Seewald, 2012; Giarratano et al., 2020; Spitzer et al., 2006). The identification of factors linked to SUD among women in the CL system is critical to the tailoring of SUD prevention and intervention programs.

Posttraumatic stress symptoms (PTSS; e.g., negative alterations in mood and arousal, avoidance, intrusive recollections, emotional dysregulation, irritability, sleeping difficulties) may be particularly relevant in the etiology and treatment of SUD of women in the CL system, as many women frequently experience PTSS following a traumatic event and are at higher risk of subsequently developing posttraumatic stress disorder (PTSD; Bennett et al., 2018). Typically there is a clearly identifiable cause for development of PTSS, and a prompt clinical diagnosis can identify women at heightened risk and offer appropriate services (Dworkin & Schumacher, 2018; Forneris et al., 2013). In addition, there is a well-established association between PTSS and CL involvement, with some scientists suggesting that PTSS rather than solely trauma exposure puts women in the path of the CL system (Bennett et al., 2018; Donley et al., 2012). Numerous studies of community and nationally-representative samples have reported a large comorbidity of PTSD and SUD, with as many as 46.4% of individuals sharing both diagnoses (Driessen et al., 2008; Goldstein et al., 2016; Lee et al., 2019; Pietrzak et al., 2011; Roberts et al., 2015). Theories to explain this comorbidity include Khantzian’s self-medication theory (1985, 1990, 1997), which asserts that substance use serves as an attempt to mitigate PTSS, with PTSD preceding SUD, and the high risk (Chilcoat & Breslau, 1998) or the susceptibility hypotheses (Jacobsen et al., 2001; McCauley et al., 2012) which suggest SUD precedes PTSD.

The PTSD-SUD comorbidity is also evident among people with CL system involvement (Wolff et al., 2011). Physical and sexual victimization are especially prevalent for incarcerated women, leading to the development of PTSD and SUDs (Browne et al., 1999; Giarratano et al., 2020; Salina et al., 2007, 2011). Childhood physical and sexual abuse rates, as well as adult victimization rates (e.g. intimate partner violence), are elevated among women in the CL system and predict severe mental health, along with increased likelihood of committing criminal offenses (Carlson & Shafer, 2010; LeBel & Rose, 2020). About two-thirds of incarcerated women with a severe mental health diagnosis also met criteria for a SUD (James & Glaze, 2006), and a positive association has been observed between the number of traumatic events reported by women with CL involvement and the number of substances they used, as well as the severity of their psychiatric scores (Saxena et al., 2016).

Betrayal trauma theory (BTT; Freyd, 1994, 1996) describes the mental health effects of betrayal traumas (BT), defined as traumatic events characterized by the violation of trust between the perpetrator and the victim, who usually share a close relationship (Lindblom & Gray, 2010). Betrayal trauma theory might facilitate our understanding of the effects of trauma and PTSD on substance use-related outcomes among women in the CL system. In this context, childhood sexual abuse or interpersonal violence are examples of high BTs, while exposure to a natural disaster is considered a low BT. Individuals who experience high BT demonstrate greater levels of dissociative symptoms (i.e., depersonalization, derealization, memory problems, reduced awareness of one’s surroundings) compared to those experiencing low BT (Gobin & Freyd, 2017; Platt et al., 2017; Platt & Freyd, 2015). Dissociative symptoms may serve a unique adaptive role for victims of high BT, as they may be in continued contact with or dependent on their perpetrator, and dissociative symptoms allow victims to detach from the reality of abuse, thus promoting post-trauma survival (Freyd, 1996; Platt & Freyd, 2015).

Limited literature supports the notion that PTSS, particularly dissociative symptoms, may explain increased risk for SUDs and related outcomes (e.g., overdoses) among victims of high BT. Dissociative PTSS include feelings of detachment, derealization, emotional numbing, and depersonalization (Burton et al., 2018; Haagen et al., 2018). Extant research suggests BT’s (e.g., childhood sexual abuse, adult sexual assault) and PTSD are linked to SUD outcomes among individuals in a jail diversion sample (Cusack et al., 2013) and in community-based samples (Ullman et al., 2013) suggesting that PTSD serves as a mediator between BT and SUD (Epstein et al 1998, Sullivan et al 2009). BT and PTSS have also been found to be associated with substance use-related outcomes, including nonfatal substance overdoses, in cohort studies of individuals who use substances (Braitstein et al., 2003; Lake et al., 2015; Lee et al., 2019). In the most direct support of BTT, BT was associated with substance use via the indirect effects of PTSS in young adults (Delker & Freyd, 2014) and individuals in the CL system (Cusack et al., 2013). Delker and Freyd (2014) suggested two BTT-based pathways linking high BT to problematic substance use: one of self-destructiveness ideation (i.e., instead of attributing the betrayal to the perpetrator, the victim adopts a sense of agency that increases self-blame and shame, which in turn increase destructive behavior like substance use and self-harm), and one of difficulty in evaluating and discerning risk due to a history of betrayal. Also noteworthy is that high BT victims in either of these two pathways might not engage in substance use unless there are concurrent PTSS present (Delker & Freyd, 2014). When considering dissociative PTSS specifically, studies also support betrayal trauma to indirectly affect SUD through these symptoms. Studies of individuals with SUDs show that dissociative symptoms are associated with betrayal traumas and a more severe SUD clinical picture (Gidzgier et al., 2019; Mergler et al., 2017; Najavits & Walsh, 2012). What is not known, however, is whether betrayal traumas are associated with substance use outcomes via the indirect effects of PTSS among women with CL system involvement. Further, no studies have examined dissociative PTSS in this population, which BTT hypothesizes as a critical mechanism to increased mental health symptoms among victims of betrayal traumas (Freyd, 1994, 1996). Specifying potential mediators can help identify targets for treatment of comorbid PTSD and SUD outcomes among CL-involved women. As such, the current study aims to investigate whether experiences of betrayal trauma are associated with substance use outcomes (i.e., alcohol use severity, past 30-day substance use, substance use severity, and history of nonfatal overdose) via the indirect effects of dissociative PTSS.

2. Material and Methods

2.1. Participants

Participants (n = 508) were CL system-involved women enrolled in a community-based study taking place three U.S. cities (Kansas City, KS/MO; Birmingham, AL; and Oakland, CA). The mean age of the participants was 42.33 (SD = 11.71), and almost 70% reported a monthly income lower than $1,000. Participants were primarily Black (58.4%) or White (31.3%). Nearly all women in each site reported previous involvement in a city or county jail (96.8%), and 89.4% had spent time on probation in the past. Refer to Table 1 for further details.

Table 1.

Substance Use, Trauma, and Posttraumatic Stress Disorder Symptoms of overall sample and across sites

Overall (n = 508) Birmingham (n = 162) Kansas City (n = 108) Oakland
M/n SD/% M/n SD/% M/n SD/% M/n SD/%
Sociodemographic Variables
Age (M/SD) n missing =0 42.33 11.71 40.36b 11.28 38.64b 9.42 45.35 12.19
Race and ethnicity (n/%) n missing =6
 Black 293 58.4 65 41.1 39b 36.4 189 79.4
 White 157 31.3 87b 55.4 4/b 43.9 23 9.7
 American Indian/Alaskan Native 9 1.8 2 1.3 6b 5.6 1 0.4
 Asian 6 1.2 1 0.6 1 0.9 5 2.1
 Other race 14 2.8 1 0.6 4 3.7 9 3.8
 Hispanic/Latinx 23 4.6 2a 1.3 10 9.3 11 4.6
Sexuality (n/%) n missing =13
 Gay or lesbian 20 4 7 4.6 1 1.0 12 5.0
 Bisexual 63 12.7 21 13.7 21b 20.2 21 8.8
 Straight or heterosexual 396 80 119 77.8 81 77.9 196 82.4
 Other sexuality/unsure 6 3.2 6 3.9 1 1.0 9 3.8
Income (n/%) n missing =21
 Less than $1,000 monthly income 336 69.0 115a 76.7 59 59.0 162 68.4
 $1,000 - $2,000 monthly income 118 24.2 32 21.3 27 27.0 59 24.9
 More than $2,000 monthly income 33 6.8 3a 2.0 14 14.0 16 6.8
Education (n/%) n missing =6
 Less than high school 121 24.1 33 21.0 22 20.4 66 27.7
 High school graduate/GED 194 38.6 67 42.7 40 37.0 87 36.6
 More than high school education 187 37.3 57 36.3 45 41.7 85 35.7
Employment (n/%) n missing =11
 Unemployed 165 33.2 62a 40.5 35 33 68 28.6
 Disabled 147 29.6 33b 21.6 19b 17.9 95 39.9
 Full time 94 18.9 31 20.3 29b 27.4 34 14.3
 Part time 48 9.7 12 7.8 10 9.4 26 10.9
 On and off / “under the table” 21 4.2 6 3.9 6 5.7 9 3.8
 Full time student 12 2.4 3 2.0 4 3.8 5 2.1
 Stay at home 10 2.0 6b 3.9 3 2.8 1 0.4
Lifetime Adult Criminal Legal History (n/%)
 City/county jail nmissing =8 484 96.8 141a,b 91.0 107 100.0 236 99.2
 State/federal prison nmissing =8 167 33.4 48a 31.2 60b 55.6 59 24.8
 Probation nmissing = 7 448 89.4 123b 78.8 97 89.8 228 96.2
 Parole nmissing = 343 119 72.1 22 a,b 45.8 46 78.0 51 87.9
 Diversion program participation nmissing =10 248 49.8 104b 68.0 62- 57.4 82 34.6
Primary Study Variables
 AUDIT-C (M/SD) nmissng =26 5.95 3.25 5.86 3.7; 6.67b 3.14 5.70 2.90
 Past 30-day daily substance use (n/%) nmissing =11 106 21.3 19b 12.3 2 3 21.9 64 26.9
 DAST (M/SD) nmissing =117 3.18 3.22 5.41a,b 2.8. “I ĵ.97b 2.98 1.58 2.52
 Lifetime Overdose (n/%) nmissing =12 94 19 48b 29.6 21 19.8 25 10.6
 Past PTSD Diagnosis (n/%) nmissing =18 242 49.4 62a 40.5 60 57.1 120 51.7
 Sum of PTSD symptoms (M/SD) nmissing =17 6.57 4.44 6.44 4.52 6.15 4.72 6.85 4.26
 Betrayal trauma (M/SD) nmissing =20 1.65 1.53 1.99b 1.67 1.87b 1.52 1.34 1.53
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Notes: GED: Graduate Equivalency Degree; PTSD: Posttraumatic Stress Disorder; AUDIT-C: Alcohol Use Disorders Identification Test-Concise; DAST: Drug Abuse Screening Test. Lifetime Adult Criminal Legal History evaluated as 1 = any time spent, 0 = no time spent.

a

Statistically different from Kansas City

b

Statistically different from Oakland.

Missing data values are due to participants’ being allowed to decline answering certain questions.

2.2. Procedures

All study procedures were approved by the Institutional Review Board (IRB) of the University of Kansas Medical Center, with reliance agreements from two participating sites (University of Alabama at Birmingham and RTI International). The present research questions were examined using baseline data from a larger, ongoing project examining cervical cancer screening acceptability in women in the CL system in the three cities. At the time of the analysis for the present manuscript, the sample size for both the parent study and current analysis was 508, although the final sample size for the parent study is aimed to be about 600 participants. Participants in Birmingham AL were recruited from a court-ordered outpatient substance use treatment center and from a residential community corrections center following a similar methodology as described in (Cropsey et al., 2015); the participants in Kansas City MO/KS were recruited from local jails and prisons and followed-up after being released; and the participants in Oakland CA were recruited through community outreach labors and through the county probation office. In all three cities, the eligibility criteria were the same: women who were 18 years or older, with a past or current history of criminal justice involvement, willing to provide additional contacts in case the research staff was not able to get a hold of them personally.

A 288-item survey was administered to participants, and for the present study, we included measures on demographic characteristics, CL history, substance use and overdose history, betrayal traumas (operationalized as interpersonal trauma experiences during childhood and adulthood), and PTSD symptoms. Participants provided verbal informed consent at their baseline appointment before being administered the questionnaires in person at the study site, over the phone with study staff, or via text or email of a REDCap survey link. Participants were compensated a $50 gift card upon completing the questionnaires.

2.3. Measures.

2.3.1. Demographics.

The following demographic characteristics were collected: age, race/ethnicity, education, employment, income, stable housing, state of residence, insurance status, CL history variables (i.e., past year diversion program involvement, months ever spent in jail, spent time in jail in past year, ever on probation, years on probation, ever been in a state or federal prison, months spent in prison), and past diagnosis of PTSD.

2.3.2. Betrayal Trauma.

Betrayal traumas were operationalized as interpersonal traumas including childhood and adulthood exposure to interpersonal trauma, as research has shown that a majority of these traumas are perpetrated by someone known to the victim (Goldsmith et al., 2013). We created a betrayal trauma variable by summing five dichotomous items related to interpersonal trauma created and adapted from various sources. First, we asked broadly if “Before age 16, were you physically abused?” (0 = No, 1 = Yes). Next, combining content from multiple items from the Childhood Experiences of Violence Questionnaire (Walsh et al., 2008), we assessed sexual violence occurring prior to age 16 (i.e., forced touch of private parts, threatened or try to have sex, sexually forced themselves on the victim, etc.; 0 = no, 1 = yes). Finally, dichotomous, yes/no, items assessed physical assault (i.e., punched, slapped, kicked, or beat), sexual assault, and physical and psychological (i.e., insult and yell) intimate partner aggression in the past year. The content of these items approximated those used in the 2006 Behavioral Risk Factors Surveillance System violence modules. Internal consistency in the sample was adequate (α = .71).

2.3.3. Dissociative Posttraumatic Stress Disorder Symptoms.

The 6-item dissociation subscale of the Trauma Symptom Checklist-40 (Briere & Runtz, 1989; Elliott & Briere, 1992) assessed symptoms of flashbacks, “spacing out,” dizziness, memory problems, derealization, and depersonalization over the past two months. These items were dichotomized into 0 = no and 1 = yes, and later combined as one unique score. Internal consistency of this measure for the current sample was adequate (α = .78)

2.3.4. Substance Use.

Past-year alcohol use severity was assessed using the total score of the 3-item Alcohol Use Disorder Identification Test-Concise (AUDIT-C; Bush et al., 1998). This measure has demonstrated good to excellent psychometric properties in similar populations (Caviness et al., 2009). In the current sample, the Cronbach’s alpha value was good (α = .86). Participants were asked to endorse which, if any, substances (i.e., methamphetamines, stimulants, PCP, heroin, other opiates, benzodiazepines, cocaine, cannabis, and hallucinogens) they used daily or almost daily in the past 30 days. We coded these responses 0 (no) vs. 1 (yes) for daily substance use in the past month. Past year substance use severity was assessed using the total score of the Drug Abuse Screening Test-10 (DAST-10; Cocco & Carey, 1998), which also showed good internal consistency in our sample (α = .88). Finally, we also examined lifetime and past-year history of overdose (0 = no, 1 = yes).

2.4. Data Analytic Approach

We used Statistical Package for the Social Sciences (SPSS) version 25 to conduct the following analyses. We computed descriptives (means, standard deviations [SD], frequencies, and percentages) of sociodemographic and primary study variables. For descriptive purposes, we examined site differences in these variables using univariate analysis of variance and Chi-Square analyses. To identify potential confounding variables to include in the multivariate analyses, we examined sociodemographic correlates of the outcomes of interest (alcohol use severity, any daily or almost daily substance use in the past 30 days, substance use severity, and history of nonfatal overdose) using correlations, t-tests, and Chi-Square analyses. Finally, we ran the multivariate models, including covariates identified in the aforementioned analyses, to examine whether betrayal traumas are associated with substance use outcomes via the indirect effect of dissociative PTSS symptoms. We conducted these analyses by running four separate models for each substance use outcome using (Model 4) of Hayes’ (2013) PROCESS macro in SPSS, which employs bootstrapping procedures. Using 5,000 bootstrapped samples, the substance use outcome was specified as the dependent variable (Y variable), betrayal trauma as the independent variable (X variable), dissociative symptoms as the mediator (M variable), and sociodemographic/site correlates included as covariates.

3. Results

3.1. Descriptives, Site Differences, and Potential Covariates

See Table 1 for a summary of descriptives for the overall sample and each site and Table 2 for correlations among primary study variables. Table 1 also denotes site differences in sociodemographic and primary study variables. Regarding our outcome variables, Birmingham participants reported greater substance use severity than Kansas City and Oakland participants. Kansas City reported greater alcohol use severity than Oakland participants. Birmingham participants were more likely to have past overdose than Oakland participants. There were no site differences in prevalence of past 30-day substance use. These results align with nationally-representative data of substance use prevalence estimates in each city (Alabama Department of Mental Health, 2018; Substance Abuse and Mental Health Services Administration, 2012).

Table 2.

Bivariate Correlations of Betrayal Trauma, Dissociative Posttraumatic Stress Symptoms, and Substance Use Variables

1 2 3 4 5 6
1. Betrayal Trauma - - - - - -
2. Dissociative Postraumatic Stress Symptoms .35** - - - - -
3. Alcohol Use Severity .12* .02 - - - -
4. Drug Use Severity .25** 21** 17** - - -
5. Past 30-Day Drug Use .10* .18** 20** .16** - -
6. Lifetime History of Non-Fatal Overdose 23** .16** −.04 .40** .01 -
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Note:

*

p < .05

**

p < .01 (two-tailed)

Regarding other correlates of our outcome variables, univariate analyses of variance showed that White participants (M = 5.10, SD = 3.16) reported greater substance use severity than Black participants (M = 2.20, SD = 2.83; F (1,5) = 16.20, p < .001) and Hispanic/Latinx participants (M = 2.13, SD = 2.92; F (1,5) = 16.20, p = .004). White participants (36.9%) had a higher prevalence of lifetime history of overdose than Black participants (8.7%, p = .03, Cramer’s V = 0.34). These results also align with nationally-representative data evaluating racial and ethnic differences in substance use patterns (Substance Abuse and Mental Health Services Administration, 2014, 2020). There were no racial/ethnic differences in alcohol use severity or past 30-day substance use. The prevalence of substance use in the past 30 days was higher among people without stable housing (29.8%) than those with stable housing (19.2%; p = .02, Cramer’s V = 0.11). There were no differences between people with stable housing and those without in substance use severity, alcohol use severity, or history of overdose. Age was negatively associated with substance use severity (r = −.17, p = .01) and was not associated with alcohol use severity, history of overdose, and past 30-day substance use. There were no differences among income levels, sexual orientation, education, or employment in any alcohol use severity, substance use severity, or history of overdose. Finally, the proportion of the overall sample using opioids in the past 30 days was relatively small (3%). Regarding lifetime history of overdose (substance not specified), the prevalence was 19%.

3.2. Tests of Indirect Effects

3.2.1. Alcohol Use Severity.

Because of site differences in alcohol use severity (Kansas City greater alcohol use severity than Birmingham and Oakland), dummy-coded site variables were included as a covariate. The overall model fit testing the effect of betrayal trauma on dissociative PTSS was significant (R2 = .14, F(3,460) = 24.96, p < .001), showing that betrayal trauma was positively associated with dissociative PTSS (B = 1.09, t = 8.36, p < .0001). The direct effects of dissociative PTSS (B = −0.01, t = −0.23, p = .82) and betrayal trauma (B = 0.21, t = 1.94, p = .05) on alcohol use severity were not significant. Further, the overall model fit testing the indirect effect of betrayal trauma on alcohol use severity through dissociative PTSS was not significant (R2 = .13, F(4,459) = 1.88, p = .11), with the indirect effect being nonsignificant (B = −0.01, 95% CI [−0.10, 0.07]). See Figure 1.

Figure 1.

Figure 1.

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Visual Depiction of Indirect Effects of Betrayal Trauma on Substance Use Outcomes through Dissociative Posttraumatic Stress Symptoms

Note: *statistically significant; ap = .05

3.2.2. Past 30-Day Substance Use.

Because stable housing was associated with decreased likelihood of past 30-day substance use, this was included as a covariate. The overall model fit testing the effect of betrayal trauma on dissociative symptoms was significant (R2 = .15, F(2, 460) = 40.22, p < .001), showing that betrayal trauma was positively associated with dissociative PTSS (B = 0.95, t = 7.56, p < .0001), and dissociative PTSS were associated with past 30-day substance use (B = 0.09, Z = 3.07, p = .002). The direct effect of betrayal trauma on past 30-day substance use was nonsignificant (B = 0.05, Z = 0.68, p = .50). The overall model fit testing the indirect effect of betrayal trauma on past 30-day substance use through dissociative symptoms was significant (Nagelkerke R2 = .06, df = 3, p = .0003), with the indirect effect being significant (B = 0.08, 95% CI [0.03, 0.14]). See Figure 1.

3.2.3. Substance Use Severity.

Because of site differences in substance use severity (Kansas City greater substance use severity than Birmingham and Oakland), dummy-coded site variables were included as a covariate. Further, because White participants reported greater substance use severity than Black and Hispanic/Latinx participants, a dummy-coded race/ethnicity variable was included as a covariate (1 = White, 0 = Non-White). Age was also included as a covariate, given its negative correlation with substance use severity. The overall model fit testing the effect of betrayal trauma on dissociative PTSS was significant (R2 = .16, F(5,371) = 13.75, p < .001), showing that betrayal trauma was positively associated with dissociative PTSS (B = 1.10, t = 7.96, p < .0001). The direct effects of dissociative PTSS (B = 0.12, t = 3.58, p = .0004) and betrayal trauma (B = 0.39, t = 4.18, p < .0001) on substance use severity were also significant. The overall model fit testing the indirect effect of betrayal trauma on substance use severity through dissociative symptoms was significant (R2 = .41, F(6,370) = 43.58, p < .0001), with the indirect effect being significant (B = 0.13, 95% CI [0.06, 0.20]).

3.2.4. History of Nonfatal Overdose.

Because of site differences in history of nonfatal overdose (Birmingham participants were more likely to have past overdose than Oakland participants), dummy-coded site variables were included in the analysis. Further, because White participants reported greater substance use severity than Black and Hispanic/Latinx participants, a dummy-coded race/ethnicity variable was included as a covariate (1 = White, 0 = Non-White). The overall model fit testing the effect of betrayal trauma on dissociative symptoms was significant (R2 = .15, F(4, 469) = 20.51, p < .0001), showing that betrayal trauma was positively associated with dissociative PTSS (B = 1.11, t = 8.75, p < .0001) and history of non-fatal overdose (B = 0.24, Z = 2.75, p = .006). The direct effect of dissociative PTSS on history of nonfatal overdose was not significant (B = 0.06, Z = 1.96, p = .05). The overall model fit testing the indirect effect of betrayal trauma on overdose history through dissociative symptoms was significant (Nagelkerke R2 = .22, df = 5, p < .0001), with the indirect effect being significant (B = 0.07, 95% CI [0.002, 0.14]). See Figure 1.

4. Discussion

Due to the burden of betrayal traumas and SUDs among women in the CL system, it is important to identify and understand potential targets for intervention, such as dissociative PTSS, to reduce risk for SUD in this population. As such, the purpose of the present study was to use BTT (Freyd, 1994, 1996) as a theoretical guide to evaluate the indirect association of betrayal trauma with several substance use outcomes through dissociative PTSS among women involved in the CL system. The use of this sample of women in the CL system is a significant strength given the currently small body of literature available addressing substance use and various other health issues in this population. Results of this study support the mediating effect of dissociative PTSS on the association between betrayal trauma and most substance use outcomes, with the exception of alcohol use severity.

Interpersonal traumatic experiences, such as childhood sexual abuse and intimate partner violence, are characterized by a violation of trust between the perpetrator and the victim, and therefore are considered high betrayal trauma events (Freyd, 1996; Platt & Freyd, 2015). Community samples have found strong associations between experiences of interpersonal trauma and substance use (Epstein et al., 1998; Sullivan et al., 2009), and studies of CL-involved youth and adults confirm PTSS as potential mediating variables of betrayal trauma and substance use outcomes (Cusack et al., 2013; Sanders et al., 2018). Our study added to this body of literature, underlining the association between experiences of betrayal trauma and substance use outcomes via indirect effects of dissociative PTSS. More specifically, we found an indirect effect of betrayal trauma on drug use severity, nonfatal overdose, and past-30 day substance use via dissociative PTSS. However, we did not find a mediating effect of dissociative PTSS on the relation between betrayal trauma and alcohol use severity. Prior studies with CL populations have shown overall PTSS to mediate the association between betrayal traumas (e.g., sexual abuse) and alcohol use severity (Cusack et al., 2013; Sanders et al., 2018). However, these studies did not look at dissociative PTSS specifically. Another explanation for our contradictory finding is the limited variability in alcohol use (i.e., restricted range issue) and therefore limited power to be able to detect an effect. Further work is needed to clarify the potential impact of dissociative PTSS with alcohol use severity.

A notable novel outcome examined in the present study was history of nonfatal substance overdose. Ample evidence indicates a significant positive association between CL system involvement and overdose reports, especially opioid overdoses, since the forced abstinence from incarceration can reduce individuals’ tolerance (Fendrich et al., 2019; Leach & Oliver, 2011); however, research addressing the association between nonfatal overdose and betrayal trauma is limited. The current study highlights the potential mediating role of dissociative PTSS of the association between betrayal trauma and nonfatal overdose in a sample of women with CL system involvement. While these results are compelling, further empirical research is encouraged to replicate our findings.

The results presented in the current study underscore the potential for BTT to understand the close relationship between betrayal traumas and substance use outcomes among women under CL system supervision. Our study generally supports BTT, showing that dissociative PTSS may explain the association between betrayal traumas and substance use outcomes in this population. Evidence shows that improvement in the severity of PTSD symptoms can lead to improvement in severity of substance use disorder severity (Cusack et al., 2013), and future work may examine whether dissociative PTSS, in particular, may be important to target to improve SU outcomes. With these symptoms and behaviors being especially common among individuals with CL involvement, it is important to incorporate integrated clinical interventions addressing these issues, which in turn can help decrease relapse and recidivism post-release (Kubiak, 2004).

4.1. Limitations and Future Directions

The current study advances the existing literature by testing the BTT as it relates to substance use outcomes among women with a CL history. Given the present small body of literature addressing substance use and related issues in women involved in the CL system, this study presents itself as a significant novel contribution to the field. However, while the results of the present study provide interesting directions for future research, several limitations should be considered while interpreting findings. With regards to the study design, we focused on dissociative PTSS, rather than a formal diagnosis of a dissociative subtype of PTSD, which limits its comparison to research on formal diagnoses. Future studies are encouraged to incorporate structured interview assessments to accurately capture PTSD diagnoses. An additional limitation of using the dissociation subscale is the similarity between the characterization of dissociative symptoms and the experiences that an individual may feel while having consumed certain drugs. The question preceding the dissociative symptoms inquired “have you experienced each of the following in the last two months” followed by the different dissociative symptoms. Given that it was not explicitly stated that the symptoms had to be related to previously experienced trauma, it is possible that some women responded to these questions in reference to physiological experiences of substance intoxication of substances as opposed to dissociative symptoms of PTSD.

Further, we used cross-sectional data to examine our research question, which does not allow us to draw temporal conclusions about the effects found. Additionally, we did not compare substance use outcomes derived from high betrayal trauma experiences to those of low betrayal trauma. Given the continuous nature of the betrayal trauma measure used in this study, we can still conclude that the extent of betrayal trauma experienced impacts most substance use outcomes (with the exception of alcohol use severity) through dissociation; however, future research is encouraged to perform a comparison analysis to better illustrate the unique influence of dissociative symptoms on substance use. In addition, our analysis of past 30-day substance use did not differentiate between various substance use profiles (e.g., individuals using only drug versus individuals using multiple drugs; individuals using cannabis only versus individuals using methamphetamines). While the past-year substance use severity score obtained from the DAST-10 can account for some of that information, future research that expands on profiles of substance use in relation to betrayal trauma and dissociative symptoms would provide important context. Finally, future studies should also provide further insight on the demonstrated differences in substance use outcomes between the three cities and address possible policy, community, or social factors impacting these variations. The nature of the recruitment location for the participants in Birmingham, AL can serve as a possible explanation for the higher substance use prevalence observed in this city; therefore, future studies should take this into consideration ensuring variety in recruitment locations.

As previously explained, the current study used the BTT framework to study the effect of dissociative PTSS symptoms on substance use outcomes. While this is a novel study in terms of the approach followed, we encourage future research to tests other frameworks as well, in the interest of furthering our understanding of mechanisms underlying substance use in this population. For example, previous authors have explored these questions using different theoretical frameworks. For example, Joudrey et al. (2019) proposed a theoretical heuristic model (i.e. Post-Release Opioid-Related Overdose Risk Model) that supports the empirical findings of the present study. In this model, underlying factors such as incarceration are related to several “proximate determinant” outcomes (i.e., opioid use, poly-drug use, insufficient naloxone access, etc.) and biological outcomes (i.e., tolerance, overdose, and mortality) through the indirect effects of several proposed mediators that include PTSD among others. Future research is encouraged to examine other theoretical frameworks that may identify important targets for SUD treatment among women in the CL system.

Overall, the present study highlights the impact of dissociative PTSS on substance use outcomes. As such, these findings can inform and strengthen treatment approaches for betrayal trauma victims with SUD, and serve as the foundation for future studies addressing dissociative PTSS as a potential target for interventions to reduce the risk of SUD.

4.2. Conclusions

The current study highlights the mediating effect of dissociative PTSS on the association between BT and several substance use outcomes (i.e., past 30-day substance use, drug use severity, and nonfatal overdose) in a sample of women with CL system involvement. We did not find, however, an indirect effect of betrayal trauma on alcohol use severity via dissociative PTSS. Further research is needed to examine dissociative PTSS as a potential target in clinical interventions to reduce SUD risk. Incorporating targeted treatment approaches for individuals involved in the CL system could prove beneficial to decrease recidivism and substance use relapse.

Highlights.

  • Betrayal trauma is prevalent among women involved in the criminal legal system

  • Dissociative PTSS mediate the link between betrayal trauma and nonfatal overdose

  • No mediation of dissociative PTSS between betrayal trauma and alcohol use severity

  • Dissociative PTSS should be targeted in clinical interventions to reduce SUD risk

Acknowledgments

Role of Funding Source

This work was funded by grants provided by the National Institutes of Health and the National Cancer Institute (R01CA226838, Tri-City Cervical Cancer Prevention Study among Women in the Justice System), the National Institute on Alcohol Abuse and Alcoholism (K23AA028818), and the National Institute on Drug Abuse (R01DA039678). The funding sources did not have any direct role in study design, data collection and analysis, report writing, or manuscript submission.

Footnotes

Author Disclosures

Conflict of Interest

No conflict declared.

Declaration of Interests

None.

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