Betrayal Trauma, Mindfulness, and Emotional Dysregulation

Featured Article

Traumatology | 2025, Vol. 31, No. 2, p. 212-226

Article Title

Betrayal Trauma, Mindfulness, and Emotional Dysregulation: Associations With Moral Injury and Posttraumatic Stress Disorder

Authors

Mahsa Mojallal; Department of Psychology, University of South Dakota

Raluca M. Simons; Department of Psychology, University of South Dakota

Jeffrey S. Simons; Department of Psychology, University of South Dakota

Surabhi Swaminath; Department of Psychology, University of South Dakota

Abstract

This study tested a structural equation model of associations between betrayal and nonbetrayal trauma, mindfulness, emotional dysregulation, shame, moral injury, and posttraumatic stress disorder symptoms (PTSS) in a sample of college students (N= 680).We hypothesized significant associations between betrayal trauma and PTSS and moral injury, mediated by facets of emotional dysregulation and shame and moderated by mindfulness. Betrayal trauma was associated with PTSS directly and indirectly, via the following facets of emotional dysregulation: lack of emotional clarity, limited access to strategies, and difficulty in impulse control. Betrayal trauma was also associated with moral injury directly, and indirectly via limited access to strategies. Mindfulness was associated with PTSS directly, and indirectly via four facets of emotional dysregulation and moral injury. Mindfulness was also indirectly associated with PTSS via shame and moral injury, and limited access to strategies and moral injury. Mindfulness was also associated with moral injury directly and indirectly via shame and limited access to strategies. Mindfulness did not moderate the associations between betrayal trauma and facets of emotional dysregulation. The indirect effect of betrayal trauma on moral injury via shame was not significant over and above other variables. The findings extend the existing literature and support the hypotheses on the indirect effects of betrayal trauma and mindfulness on moral injury and PTSD via facets of emotional dysregulation and shame. However, it did not support the moderating effect of mindfulness on the associations between betrayal trauma and emotional dysregulation.

Keywords

Betrayal trauma, emotional dysregulation, mindfulness, posttraumatic stress disorder, moral injury

Summary of Research

“According to the betrayal trauma theory, traumas perpetrated by a trusted person or whom the victim depends upon for survival (e.g., primary caregiver or intimate partner) can cause more severe psychological outcomes compared to traumas perpetrated by strangers or nonbetrayal traumas, such as car accidents. Indeed, traumas higher in betrayal have been associated with more severe PTSD symptoms. However, there are also some null findings where betrayal trauma did not predict PTSD symptoms significantly more than low-betrayal traumas (LBTs) or nonbetrayal traumas. These mixed findings signal the necessity to further investigate the associations between betrayal trauma and PTSD and determine underlying risk and resiliency mechanisms linking betrayal trauma to PTSD” (p. 212).

“Emotional dysregulation may be one mechanism that could explain the association between betrayal trauma and PTSD. Due to their specific characteristics, high-betrayal traumas (HBTs), such as childhood abuse or interpersonal violence, can interfere with one’s ability to use adaptive emotion regulation techniques. Difficulties in emotion regulation can in turn increase the risk of developing and maintaining psychological outcomes, including PTSD. However, very few studies have investigated the role of specific emotional dysregulation factors as risk mechanisms between betrayal trauma and PTSD symptoms… Another construct that has been constantly associated with emotion regulation is mindfulness. Mindfulness has been linked to better and more effective emotion regulation strategies and lower PTSD symptoms. Mindfulness is a purposeful awareness of the present moment with a nonjudgmental and nonreactive attitude. Mindfulness can protect individuals from the negative consequences of trauma by shifting their attention from ruminative thoughts to the present moment and enhancing more effective and flexible ways of responding to situational requirements” (p. 212-213).

“In addition to PTSD, moral injury is another potential, but understudied outcome associated with betrayal trauma. Moral injury is a trauma-related syndrome that is characterized by intense feelings of guilt, shame, and spiritual crisis that develop following the perceived violation of deeply held moral principles by oneself or trusted others. Initially, moral injury was considered a subcategory of PTSD, but further research showed that though some features of moral injury may overlap with PTSD, they are two distinct constructs. Specifically, while PTSD is a fear-based response to a life threat, moral injury is a shame-based syndrome resulting from moral transgression that may or may not involve a life threat and involves avoidance of moral pain” (p. 213).

“...the proposed moderated mediation latent model aimed to (a) examine the distinct mediation model of trauma types and mindfulness with PTSD and moral injury via emotion regulation difficulties and shame, and (b) examine the interaction between betrayal trauma and mindfulness in predicting PTSD symptoms. Innovatively, we included both PTSD and moral injury in the same model to help uncover each construct’s similarities and potentially unique predictors… The data were collected from 720 undergraduate college students through a university research participation pool. Participants were recruited from a Midwestern university through online flyers and class announcements. Students 18–30 years old were eligible to participate” (p. 213-214). The following measures were used: The Brief Betrayal Trauma Survey, TheMindful Attention Awareness Scale, The Difficulties in Emotion Regulation Scale Short Form (DERS-SF), The Guilt and Shame Proneness Scale (GASP), PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5th ed. (PCL-5), and The Moral Injury Scale for Youth (MISY).

“This study had two aims. First, we tested the distinctive mediation model of trauma types, namely betrayal and nonbetrayal trauma, and mindfulness with PTSD symptoms and moral injury via facets of emotional dysregulation and shame. Second, we tested the moderating role of mindfulness on the associations between betrayal trauma and facets of emotional dysregulation. The results demonstrated that betrayal trauma was indirectly associated with PTSD via several facets of emotional dysregulation and moral injury. Furthermore, mindfulness was indirectly associated with PTSD via several facets of emotional dysregulation, shame, and moral injury. However, the results did not support the moderating effect of mindfulness on the associations between betrayal trauma and emotional dysregulation” (p. 217-218).

Translating Research into Practice

“Current findings have important clinical implications. First, these results may assist clinicians in distinguishing between the different mental health outcomes of betrayal and nonbetrayal traumas. The findings show that compared to nonbetrayal traumas, traumas involving a sense of betrayal are associated with difficulties in emotion regulation, more severe PTSD symptoms, and potential moral injury. It is recommended that clinicians pay close attention to traumas of betraying nature. Second, these findings may assist clinicians in targeting the most relevant underlying processes (e.g., lack of emotional clarity, limited access to emotion regulation strategies, difficulty in impulse control, and mindfulness) when working with survivors of HBTs. Third, our findings highlighted the direct and indirect associations between mindfulness and PTSD symptoms and facets of emotional dysregulation. These findings can encourage clinicians to consider increasing mindfulness as a therapeutic goal when working with survivors of HBTs and clients who experience symptoms related to PTSD and emotional dysregulation. Furthermore, identifying the distinct pathways from trauma to moral injury and PTSD highlights the importance of moral injury as one of the less-known consequences of trauma exposure. Finally, the results of this study shed light on the role of shame as an underlying mechanism that explains the protective effects of mindfulness on developing moral injury and PTSD. This finding may encourage clinicians to target decreasing shame as a treatment goal when working with clients who exhibit symptoms related to moral injury and tailor their services based on the clinical characteristics and needs of these clients” (p. 222).

Other Interesting Tidbits for Researchers and Clinicians

“There are several limitations to this study. First, the lack of diversity in the sample’s age and race, and the fact that the sample is comprised of college students, may limit the generalizability of this study. Second, additional risk factors common among individuals with a history of betrayal trauma, such as lack of learning opportunities and substance use, may contribute to poor emotion regulation abilities. Third, this study assessed dispositional mindfulness as a stable trait over time. However, recent literature has emphasized mindfulness’s dynamic and context-based nature. Therefore, conceptualizing mindfulness as a stable trait may reduce our ability to detect its nuanced effects on other psychological processes. Fourth, this study used self-report to measure constructs such as lack of awareness. It is possible that individuals high in such traits have less insight into their internal experiences, precisely their avoidance or lack of awareness. This lack of insight can interfere with our ability to measure these constructs and their influence on mental health. Finally, given the cross-sectional design of this study, causal relationships cannot be determined. Although it is expected that the trait mindfulness affects constructs such as emotional dysregulation, shame, or PTSD that are more state-based, it is likely that PTSD-related symptoms or states resulting from trauma exposure impact one’s mindfulness status” (p. 222).