THE ASSOCIATION OF MILITARY SEXUAL TRAUMA SEVERITY WITH RISKY AND SUICIDAL BEHAVIORS: RISK FACTORS FOR PREMATURE MORTALITY EXAMINED THROUGH AN INTERPERSON AL THEORY by KELLY A. SOBERAY B.A., University of Dayton, 2005 M.A., University of Denver, 2010 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Masters of Arts Psychology Program 2018
ii This thesis for the Master of Arts degree by Kelly A. Soberay has been approved for the Psychology Program by Elizabeth Allen, Chair Krista Ranby Lindsey Monteith
iii Date: December 1 5, 2018 Soberay, Kelly A (MA, Psychology Program) The Association of Military Sexual Trauma Severity with Risky and Suicidal Behaviors: Risk Factors for Premature Mortality Examined through an Interpersonal Theory Thesis directed by As sociate Professor Elizabeth Allen ABSTRACT Risky and suicidal behaviors are global health concerns as well as of great interest in mil itary popul ations . The current study examined the a ssociation s between military sexual trauma (MST) severity , risk taking, an d suicide risk among veterans . The interpersonal psychological theory (IPT) of suicidal behavior provided a model by which to understand the p otential association s of MST severity with risky and suicidal behaviors . Specifically, interrelationships among higher levels of MST severity, shame, and IPT constructs (perceived burdensomeness, thwarted belongingness, and acquired capability) were expect ed to predict a greater risk for premature mortality (risky and suicidal behaviors). T hese associations were examine d in a sample of 59 v eterans , with a history of MST. Forty six percent of this survivor sample endorsed suicidal ideation and ten percent re ported at least one suicide attempt, within the past year. Relationships among the variables were explored with bivariate correlations, two way and three way interactions, exploratory factor analysis, and within a structural equation model. Results indicat e d that MST severity , via shame, wa s indirectly associated with higher levels of total perceived burdensomeness and thwarted belongingness, risky behaviors , and post MST suicidal ideation . T he significance of greater levels of shame for MST increased risk for risky and suicidal outcom es and how it relates to perceived burdensomeness and thwarted belongingness are discussed . This study adds to the current
iv research , with the results suggesting clinicians target shame and interpersona l difficulties in their efforts to improve v term health outcomes following exposure to MST . The form and content of this abstract are approved. I recommend its publication. Approved: Elizabeth Allen
v TABLE OF CONTENTS CHAPTER I. INTRODUCTION Military Sexual Trauma and Associated Sequelae Considerations in Military Re II. METHODS 7 Sexual Harassment Scale Domain Specific Risk Taking Scale Health and Safety Subscale The Alcohol Use Disorders Identification Test 19 The Dr ug Use Disorders Identification Self Injurious Thoughts and Behaviors Interview Short Form ...21 21 Interpersonal Needs Q uestionnaire .21 Acquired Capability for Suicide Scale Fearlessness About . 22
vi Trauma Related Shame Inventory III. RESULTS Model Fit: An Examination of MST Severi ty, Shame, Perceived Burdensomeness, and Thwarted Belongingness, on Risky Behaviors and Suicide Risk Outcomes..29 IV. DISCUSSION .....32 Fut REFERENCES
vii LIST OF TABLES TABLE 1. Descriptives and Correlation s 2. Interaction of perceived burdensomeness and thwarted belongingness predicting suicidal ideation; 3 way interaction of perceived burdensomeness, thwarted belongingness, and acquired capability predicting suicide attempt and non suicidal self 3. Interaction of total perceived burdensomeness and thwarted belongingness (total INQ) and acquired capability predicting risky behaviors and suicide risk outcomes..47 4. Summary of Exploratory Factor Analysis results for premature mort
viii LIST OF FIGURES FIGURE 1. Conceptual model (based on IPT) of MST severity predictin g risk for premature mortality .. 49 2. Standardized results of MST severity predicting increased shame and its association with Tota 3. Standardized results of MST severity predicting increased shame and its association with Total INQ on risky behaviors and suicide risk outcomes
1 CHAPTER I INTRODUCTION The Association of M ilitary Sexual Trauma Severity with Risky and Suicidal Behaviors: Risk Factors for Premature Mortality Examined through an Interpersonal Theory V eterans are at a higher risk for a number of mental and physical health problems , compared t o the general popu lation ( e.g., Drescher, Rosen, Burling, & Foy, 2003; Kasprow & Rosenheck, 2000). For example, veter ans are at an increased likelihood of : substance use ( Johnson et al., 2013 ), posttraumatic stress disorder ( Johnson et al., 2013) , traumatic brain injury ( Ba hraini et al., 2014 ) , and suicidal thoughts and attempts ( RAND, 2011; Kemp & Bossarte, 2012; Rudd, Goulding, & Bryan, 2011) . In addition, veterans are at greater risk for liver disease ( Weiner, Richmond, Conigliaro, & Wiebe, 2011) , lung cancer and circulat ory diseases (Bedard & DeschÃªnes, 2006 ) , chronic pain (Olenick, Flowers, & Diaz, 2015) and disabilities from exposure to Agent Orange ( Erdtmann, 2015 ; Olenick, Flowers, & Diaz, 2015 ) . These findings are particularly concerning given that i ncreased mental a nd physical health problems significantly predict premature mortality ( Calitz, Pollack, Millard, & Yach, 2015 ; Vreeland, 2007 ). n population is of great national concern . U mature mortality risk require s further exploration into t he unique experiences which they endure. Research has begun to investigate the risk for premature mortali ty . In an examination of cause of death among mal e Vietnam veterans who sought PTSD treatment , Drescher and colleagues (2003) found that 62.4% of all deaths were accounted for by possibly preventable behavioral causes, including accidents (29.4%), chronic substance abuse (14.7%), and intentional death by suicide, homicide, or police (13.8%). In
2 addition, Weiner and colleagues (2011) conducted a respective cohort study comparing the mortality rates of veterans receiving inpatient treatment following a suicide attempt during 1993 1998 at a Veterans Affairs (VA) medical facility, to the general U.S. adult population. The authors found that the cumulative mortality risk in the veterans was th ree times greater than expected within the U.S. civilian cohort matched on age and sex. Weiner and colleagues (2011) sug gest that veterans are a unique community, compared to civilians, and prevention efforts shou ld not only target suicide risk, but also major chronic diseases and unintentional injuries. Ri sky and suicidal behaviors (e.g., non suicidal self injury, non fata l suicide attempts) are concerning health outcomes fo r veterans , especially because they are risk factors for premature mortality . Complicating the research is t he paradox of . The rigorous physical and mental examinations give n upon e ntering the military would suggest that military personnel should be generally healthier than their civilian counterparts upon beginning their service , which has been found to be true ( Seltzer & Jablon, 1974; Bollinger et al., 2015; Weiner, Richmon d, Conigliaro, & Wiebe, 2011) . However, Waller and McGuire ( 2011) described that there was an excess of death by suicide and motor vehicle accidents that negated the expec ted healthy soldier effect for a prolonged life expectancy compared to civilian count erparts. Similarly, Bollinger and colleagues (2015) reported no support for the expected lower mortality from the healthy soldier effect among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Both studies suggest that post deployment risky behaviors , such as risky driving, premature mortality and requires further examination . In addition, the unique influences
3 contributing to risky and suicidal behav iors for veterans have not been completely understood and addressed. Thus, it is important to recognize specific factors that increase risk for premature mortality among veteran populations. Military sexual trauma (MST) is a distinct military experience th at is hypothesized, for this study, to be associated with risky and suicidal behaviors. Military Sexual Trauma and Associated Sequelae In 2002, the U.S. Department of Veterans Affairs (VA) instituted a national screening program i n which all veterans enrolled in VA health care are assessed for MST. The standard Veteran Health Administration ( VHA) MST screening includes two questions that determine if a veteran experienced sexual harassment and/or sexual assault while in the military ( Depart ment of Veteran Affairs, 2010 ) . The VA identified MST as a priority for research after results demonstrated that approximately 1 in 4 women and 1 in 100 men screen positive for MST (VA, 2015 b ; Yano et al., 2006). Although the rate of MST for women is significantly higher than men, the numbers of MST survivors by gender are similar due to the significantly greater percentage of men who have serv ed in the military . In addition, t hese estimates only account for veterans seeking service s at a VA who wer e willing to disclose MST when screen ed by a VA health care provider . S upporting the VA reports regarding men , but n ot limited to VA help seeking veterans , are data from the longitudinal Millennium Cohort Study . In this study, Millegan and colleagues (2016) found that among 37,711 service men, one percent reported r ecent sexual harassment and 0.2 percent reported recent sexual assault. In terms of rates for women, e arlier research found that as many as 63 percent of service women re ported sexual harassment and 43 percent experienced attempted rape during their military service (Fontana & Rosenheck, 1998) , which
4 are even higher rates than found by more recent research. This could be indicative of the high number of false negatives reported with standardized scre enings, which may be in part influenced by the sensitive nature of the questions and the stigma associated with MST. Accurate knowledge of the rates and prevalen ce of MST uncovers the number of veterans at heightened risk for mental and physical health pro blems . On average, MST is associat ed with lower levels of mental and physical health for both men and women (e.g., Klingensmith et al., 2014; Millegan et al., 2016; SurÃs & Lind, 2008) . However, there may be differences in the specif ic types or intensity of such problems after MST for men compared to women. For example, Kimerling and colleagues (2007) found gender differences among male and female MST survivors in physical and mental health sequelae despite similar characteristics in age, race/ethnicity, and marital status . Of the physical and mental health conditions evaluated , MST was most strongly associated with PTSD in both men and women . However, a lcohol use and anxiety disorders, including PTSD, were significantly more common am ong female survivors of MST compared to male survivors of MST . In contrast, m en who reported MST had a higher prevalence of adjustment disorders, bipolar disorders, and schizophrenia or other psychotic disorders compared to women who reported MST . Dissocia tive, eating, and depressive disorders were similarly prevalent in both men and women survivors of MST (Kimerling et al., 2007). In addition to differences examined among men and women MST survivors, s tudies have found that the association between MST and negative health issues , such as posttraumatic stress disorder (PTSD), depression, and suicidal ideation and attempt, remain significant after controlling for other types of abuse (e.g., childho od abuse ; Suris et al., 2007) and combat (Kang, Dalager, Mahan, & Ishii, 2005; Luterek, Bittinger,
5 & Simpson, 2011; Monteith et al., 2015). These findings suggest that MST is an important correlate of adverse mental and physical health , including risk for premature mortality. Given the extensive mental and physical h ealth correlates of MST, it is perhaps not surprising that it is also as sociated with suicidal thoughts and behaviors. Indeed, MST is significantly associated with increased risk for self is self directed and deliberately results in injury or the potential f 2013 , p. 21). V eterans who screen positive for MST are more likely to have a history of suicid al ideation and attempts, relative to those who screen negative ( e.g., Bryan, Bryan, & Clemans, 201 4 ; Kimerling et al. , 20 16 ; Monteith, Menefee, Forster, Wanner, & Bahraini, 2015; Pavao et al., 2013). Kimerling and colleagues (2016) described that male and female veterans who screened positive for MST we re significantly more likely to die by suicide compared to veterans who did not report MST. This effect remained significant even after adjusting for age, rural residence, medical morbidity, and mental health diagnoses, although the effect size was not as large. Furthermore, MST was associa ted with recent suicidal ideation after adjusting for exposure to combat in a recent study of OEF/OIF/OND veterans (Monteith et al., 2015). Understanding the associations between MST and suicidal behaviors may have a direct link to prev ention efforts regar ding premature mortality in veterans. F or example, offering additional points of intervention for MST survivors while still e ngaged in the Armed Forces may mitigate an increased risk for engaging in risky and suicidal behaviors for these individuals. Simil arly, continued efforts to identify and support veteran survivors of MST is warranted, for those enrolled and not enrolled in the VA. To determine the factors that are associated with increased risk for premature mortality, the context and culture in which it occurs must be considered. Generally,
6 a ctive duty military servicemembers , Reserve and National Guard, and veterans may be at an elevated risk for suicide due to unique stressors experienced compared to civilian populations (Pease, Bil lera, & Gerard, 2015; Morin, 2011). Military culture includes distinct values, traditions, hierarchies , and codes of conduct that greatly differ from civilian culture, in addition to the possible distress of deployment, exposure to combat and killing, and military related physical and psychological injuries (Coll, Wiess, & Yarvis, 2011; Pease, Billera, & Gerard, 2015; Denneson et al. 2015). Military traditions, hierarchies, and code of conduct may also create an environment which inhibits reporting of MST , with several studies stating that survivors are encouraged to keep quiet (Monteith et al., 2018a; Pavao et al., 2013). According to the Department of Defense (2011), approximately 80 to 90 percent of military sexual assaults are unreported while in the ser vice . If the individual does not disclose, he or she is left to manage with the long term effects silently and likely continues to work alongside the perpetrator. If an individual does report MST, reports are also often ignored or retaliated against (Burge ss, Slattery, & Herlihy, 2013) , which further encourages survivors to keep silent . Additional research is needed on the association of MST with risk factors for premature mortality , and potential mediators such as thwarted belongingness, perceived burden so meness , shame, and acquired capability to engage in lethal self harm . The reasons these constructs were chosen is further described below . Active Duty Military and Veteran Risky Behaviors Before exploring such mediators, it is important to fully understand the range of behaviors considered to be risk factors for premature mortality. While research has begun to explore the relationship between MST and suicide, little is known about the association between MST and risky behaviors specifically . However, m ilita ry suicide research includes several
7 studies on specific types of risky behavio rs , taking ( e.g., Sheppard and Earleywine, 2013; Thomsen et al., 2011; Rosen et al., 2008 ). Operationalizing risky behavior i s difficult given the wide range of behaviors identified as risky and the diverse definitions for each of those. According to Strom and colleagues (2012), risky behavior is defined as purposeful engagement in behavior that may result in a negative conseque nce or loss. E ngagement in the following types of risky behaviors will be explored for the purpose of this study : risky driving, unsafe sexual behavior, substance use , and non suicidal self injury . Risky driving is rampant within military populations. Ris ky driving includes racing cars, riding a motorcycle without a helmet, drinking and driving, driving aggressively , and carrying a firearm in the vehicle while driving . Research varies widely with reports that 14.8 to 77.8% of servicemembers and veterans re port engaging in risky driving (Kuhn et al., 2010 ; Strom et al., 2012 ; Sayer et al., 2010; Fear et al., 2008 ; Sheppard & Earleywine, 2013 ; Borders , McAndrew, Quigley, & Chandler, 2012 ). An examination of National Guard members found that the prevalence of risky driving was significantly greater in soldiers with a history of mental health problems, deployment to a combat area, deployment related traumatic events, and combat stress (Hoggatt et al., 2015). Given the high rates of vehicular accidents and deaths in veteran and active duty populations, risk y increase d risk for premature mortality. The likelihood of engaging in one type of risky behavior is also associated with a greater likelihood to enga ge in another, including that of risky sexual behavior. Risky sexual behavior is positively associated with sexual trauma history in both military and civilian populations (Johnson & Johnson, 2013; Lang et al., 2003). Risky sexual behaviors
8 are described a s increasing the likelihood for contracting or transmitting disease or the occurrence of an unwanted pregnancy. These behaviors include unprot ected sex , promiscuity, and unreliable methods of birth control . Borders and colleagues (2012) found that in a sam ple of mostly male recently returned veterans , 20% had unsafe sex within the past month alone. In addition, research supports that increased risky sexual behavior often occurs concurrently with substance use (Wray et al., 2015). Among female veterans, a li fetime history of sexual assault is associated with higher levels of substance use and risky sexual behaviors (Lang et al., 2003). In fact, s ubstance u se is y et another risky behavior that is found consistently higher within military samples compared to ci vilian counterparts (Hoerster et al., 2012) . Between 2004 and 2006, surveys by the Substance Abuse and Mental Health Services Administration (SAMSHA) reported that 7.1% of veterans met criteria for a substance abuse disorder in the past year (SAMSHA, 2014) . Risky substance use is generally associated with premature mortality, and this has been explicitly examined use and increased risk for suicide (Chapman & Wu, 2014) and medical disease (Possemato, Wade, Anderson, & Ouimette, 2010 ). In addition, w omen engaging in risky substance use were reported to be at higher risk for premature mortality than men (Lindbald et al., 2016) . Thus, greater risk for premature m ortality in veterans may be partially attri butable to engaging in more risky behaviors. As noted above, there are significant overall c onnections between substance use and risky sexual behavior in veterans . Another established link is between substance use and aggressive behaviors (Dowd, 1998) . Re latedly, veterans engage in self aggressive behavior or self directed violence more than civilians. Researchers fail to agree on whether self injurious behaviors such as non suicidal self injury (NSSI; e.g., cutting, pulling hair, picking at scabs) and sui cide
9 attempts should be included in the study of risky behaviors. The literature support s a distinction between NSSI as a unique risky behavior in a study comparing individuals with NSSI history to injury (e.g., abusive relationships, substance abuse, or other risky behaviors), and a control group (Germain & Hooley, 2012). The NSSI group was more self critical, scored higher on suicide proneness, and reported more suicide attempts than injury and control groups. In studies of NSSI in military and veteran samples, NSSI was positively associated with PTSD symptoms (James, Strom, & Leskela, 2014), greater trauma exposure, more combat support deployments, being female, and suicide ideation, attempt s, and planning (Bryan & Bryan, 2014). T hus, t he literature supports that veterans engage in an increased rate of risky behaviors, such as risky driving, unsafe sexual behaviors, substance use, and non suicidal self injury , compared to their civilian coun terparts. However, f ew studies have considered multiple types of risk y behavior in their research. There is also a gap in the literature on the specific types of r isk taking behaviors among MST survivors. Identifying and appropriately attending to the spec ific types of risky behaviors that MST survivors engage in has important implications for preventing premature death , including suicide and accidents . In addition, u nderstanding risky and suicidal behaviors of MST survivors within a theo retical model wi ll provide a basis for prevention and intervention recommendations regarding reducing the risk for premature mortality . The Interpersonal Psychological Theory of Suicidal Behavior In both military and civilian cultures, t he interpersonal ps ychological theory (IPT) of suicidal behavior (Joiner, 2007 ) offers a model by which to understand predictors of suicide . This theory focuses on three distinct constru cts: thwarted belongingness, perceived
10 burdensomeness , and acquired capability for suicid e. Thwarted belongingness refers to when the . Perceived burdensomeness comprises two dimensions of interpersonal functioning beliefs that the self is so flawed as to be a liability to others, and affectively laden cognitions of self hatred. Together, thwarted belongingness and perceived burdensomeness are theorized to lead to a desire for death (Joiner, 2007 ; Van Orden et al., 2010 ) . The third construct is acquired capability for lethal self harm, or suicide. Acquired capability for suicide is comprised of both increased physical pain tolerance and reduced fear toward death . It is theorized that this occurs through habituation and exposure to physically painful and/or fear in ducing experiences (Joiner, 2007 ). Through repeated expo sure, an individual can habituate to the physically painful and fearful aspects of self harm, making it more possible for him or her to engage in increasingly painful, physically damaging, and lethal forms of self harm. The IPT posits that i ndividuals wit h high levels of thwarted belongingness and perceived burdensomeness are at risk for suicidal ideation. However, it is those who also have increased acquired capability who are at an increased risk for lethal (or near lethal) suicide attempts. Essentially, the acquired capability facilitates suicidal action in the context of the desire to die or from suicidal ideation arising from thwarted belongingness and perceived burdensomeness. The constructs of the IPT ha ve received support in studies of civilian, act ive duty, and veteran populations (Bryan, Clemans, & Hernandez, 2012; Bryan, Morrow, Anestis, & Joiner, 2010; Brenner et al., 2008; Monteith et al., 2013). IPT has also been recently examined in a sample of 92 female veterans with a history of MST (Monteit h, Bahraini, & Menefee, 2017 ). The authors reported significant association s for perceived burdensomeness and fearlessness toward death with suicidal ideation in the past week and highlighted the importance of continued research of the IPT model with MST s urvivors .
11 In addition, the IPT constructs have been associated with not only suicidal behaviors, but also different types of risky behaviors such as substance use and risky sexual behaviors ( Woerner, Kopetz, Lechner, & Lejuez, 2016 ). I n a series of studie s examining induced thwarted belongingness, results included higher levels of aggressive behaviors (Twenge, Baumeister, Tice, & Stucke, 2001), reduced prosocial behaviors (Twenge, Baumeister, DeWa ll, Ciarocco, & Bartels, 2007), greater unhealthy life choic es, and accident proneness (Twenge, Catanese, & Baumeister, 2002). Similarly, perceived burden someness on the family was significant in predicting self injurious behaviors among patients with alcohol and drug abuse ( Al Sharqi, Sherra, Al Habeeb, & Qureshi, 2012). Interpersonal difficulties, specifically t hwarted belongingness and perceived burd ensomeness , are proposed to be dynamic factors and when these states are prolonged , their relationship to suicidal ideation is theorized to be strengthened (Van Orden et al., 2010). As previously described, MST is strongly associated with a history of suicidal ideation. Therefore, for the current study it was hypothesize d that MST severity will predict higher levels of thwarted belonging and perceived burdensomeness , p ossibly mediated by shame . Shame is of particular interest as it is significantly associated with s exual trauma (DeCou et al., 2017 ) and suicidal ideation in a military population (Bryan, Ray Sannerud, Morrow, & Etienne, 2013; Bryan, Morrow, Etienne, & Ray Sannerud, 2013 ), and is a common theme in suicide notes (Foster, 2003). Furthermore, in recent qualitative studies of male MST survivors, shame was often expressed by survivors who also experienced suicidal ideation (Monteith et al.,
12 2018a; Monteith et al ., 2018b). In the current study, it is hypothesized that shame will mediate the association between MST severity and perceived burdensomeness. Painful and provocative events , such as childhood maltreatment, repetitive physical and sex ual abuse history, combat exposure, and previous suicide attempts have been theorized to increase the risk for lethal and near lethal suicidal behaviors , as such physically painful and frightening experience s theoretically increase acquired capability for suicide ( Joiner, 2007 ). In a qualitative study of veterans recently returning from deployment, Brenner and colleagues (2008) coded themes that support ed the salience of painful and provocative events potentially linked to acquired capability for suicide am ong veterans , finding that these are often painful experiences related to military training and experience. I n the current study, i t is expected that MST severity , which may indicate greater levels of painful and frightening experiences, will be associated with higher levels of acquired capability for suicide. In turn, acquired capability for suicide is also hypothesized to interact with thwarted belongingness and perceived burdensomeness, with higher levels of all three in combination predicting an increas ed likelihood for risky and suicidal behaviors . Considerations in Military Research In addition to the hypothesized links delineated above, it is also important to consider the interplay of gender and military experience variables which may also shape the associations of MST with the variables of interest in this study (VA, 2015a). G ender and combat exposure have been shown to be impor tant in regard to clinical implications for MST, s uicide, and risky
13 behavior research. M ilitary women are more likely to be sexually assaulted by a fellow service member than to be killed in combat ( Kamarck, 2015 ) , which further demonstrates the significantly increased risk women are at for MST . In addition, male and female risk taking is exhibited differently. For example, men are more likely to engage in risky health / safety behaviors compared to women (Rolison, Hanoch, Wood, & Liu, 2013). Lastly, engagement in suicidal behaviors and risk for death by suicide differs by gender. B oth veterans and individuals who die by suicide a re more likely to be male (Kemp & Bossarte, 2012) . Male veteran MST survivors are also more likely to report suicidal ideation as compared to female veteran MST survivors (Monteith et al., 2016). However, f emale veterans are six times more likely to die by suicide than their civilian counterparts ( Hoffmire, Kemp, & Bossarte, 2015 ). These findings are C ombat exposure has also been of interest to research in the recent wars, wit h a number of studies on risky behaviors focused on combat exposure (Thomsen et al., 2011; Sheppard & Earleywine, 2013 ; Killgore et al., 2008 ). In support of the recent conflicts, 65% of OIF soldiers and 46% of OEF soldiers reported engaging in combat (Hog e et al., 200 4 ). In suicide research, the evidence has varied regarding the impact of combat on risk for suicide and requires further exploration on the experiences the individual had while in combat and beyond exposure ( LeardMann et al., 2013; Reger et al ., 2015; Bryan et al. , 2015 ; Bryan et al., 2010 ). Due to the possible influence of gender and combat on the outcomes evaluated in this study, the relationships between the study variables and g ender and combat exposure are important to explore . H ypotheses for the C urrent S tudy The current study has five hypotheses .
14 H1: G reater MST severity w ill predict higher levels of shame, perceived burdensomeness, thwarted belongingness, acquired capability for suicide , suicidal ideation, and risky and suicidal behavi ors . In terms of risky and suicidal behaviors, greater MST severity will specifically predict a higher likelihood of engaging in post MST risky health and safety behaviors, risky drug and alcohol use, non suicidal s elf injury (NSSI), and suicide attempts. H2: A two way interaction of perceived burdensomeness and thwarted belong ingness w ill predict a history of post MST suicidal ideation. Specifically, the posited positive relationship between perceived burdensomeness and suicidal ideation will be stronger a t high levels of thwarted belongingness compared to low levels of thwarted belongingness. H3 : A three way interaction of perceived burdensomeness, thwarted belongingness, and acquired capability for suicide will predict a history of post MST suicide attemp ts, non suicidal self injury, risky health and safety behaviors, and risky drug and alcohol use. Specifically, high levels of perceived burdensomeness, thwarted belongingness, and acquired capability in combination will predict a greater likelihood for ris ky and suicidal behaviors. H4 : Higher levels of risky health an d safety behaviors , alcohol use , and drug use, and endorsement of po st MST NSSI an d post MST suicide attempt will predict a one factor latent variable, risk for premature mortality. H5: The ass ociation between MST severity and perceived burdensomeness will be at least partially mediated by shame. The preceding hypotheses are seen as building toward a larger model which is based on the conceptual framework for this study (e.g., IPT). Figure 1 pre sents the conceptual pathways guided by the literature reviewed above in which: (a) MST severity directly predict s greater levels of shame, perceived burdensomeness, thwarted belongingness, and acquired capability , (b)
15 a two way interaction of perceived bu rdensomeness and thwarted belongingness predict ing a history of post MST suicidal ideation , (c) a three way inter action of the IPT constructs predict ing post MST suicide attempts and engagement in risky behaviors , (d) MST severity and perceived burdensomen ess at least partially mediated by shame, and ( e ) perceived burdensomeness, thwarted belonging, and acquired capability each predict ing a latent factor representing behavioral risk factors for premature mortality (i.e., risky and suicidal behaviors). H ypo theses 1 5 are conceptualized as a sequence of tests which may or may not ultimately support this model. Therefore, the actual model to be tested in this study will b e planned based on the results obtained as the basic analyses of H ypotheses 1 5 are compl eted. Furthermore, the best fitting model will depend on iterative tests of measurem ent and structural indices. That is, the model presented in Figure 1 is largely conceptual and theoretical, whereas the actual model(s) to be ultimately tested will be empi rically informed by the preceding analyses. As the analyses proceed, the conceptual model of Figure 1 will continue to operate as an orienting framework as much as possible, although specific paths and/or latent constructs may evolve. Given the relevance of combat exposure and gender to a number of constr ucts in the current study, the association of these variables with other study constructs will also be explored.
16 CHAPTER II METHODS Participants and Procedures Veterans aged 18 to 89 with a history of M ST (as defined by VA; 38 USC Â§1720D, U.S. Government, 2014 ) who were eligible to receive Veteran Health Administration (VHA) care were recruited and eligible to enroll . Recruitment procedures consisted of posting flyers at community events and in VA settin gs and contacting veterans who provided their information to the lab with an interest to be recruited for future research . The flyers ranged in wording and images to attract male and female participants. Eligibility was determined utilizing a brief telepho ne screen, including the VHA MST screening questions. The standard VHA MST screening questi ons to assess history of MST asked were did you receive any uninvited and unwanted sexual attention, such as touching, cornerin g, military, did anyone ever use force or the threat of force to have sexual contact with you against a rtment of Veteran Affairs, 2010 , p. 1). Permiss ion was requested to review the presence of psychiatric disorders. A positive MST screen within the VA medical record was not an inclusion criterion on account of the likelihood for f alse negatives . Veterans who answered affirmative to either MST question during the telephone screen described above were considered positive for MST. Exclusion criteria included imminent risk for suicide, severe psychiatric symptoms (e.g., active psychosi s), or severe cognitive impairment. This w as determined by a review of each medical record and clinical judgment by the team during the screening process . The local VA
17 Research and Development (R&D) Committee and Colorado Multiple Institutional R eview Board (COMIRB) approved the research protocol. Upon completion of participation , participants were compensated and provided information on VA MST services. A total of 59 veteran participants were included in this study, with 31 (52.5%) reporting an affiliation to the Army, 16 (27.1%) Air Force, 13 (22.0%) Navy, 3 (5.1%) Marines, and 2 (3.4%) Reserves. The percentages equate to more than one hundred percent, as participants were able to indicate service with more than one branch. The sample was predom inately cisgender female (55.9%), with 37.3% reporting as cisgender male, 5.1% transgender, and 1.7% intersex. The participants ranged in age from 22 to 73 (M=50.05; SD=12.54). The racial distribution was 66.1% White/Caucasian, 15.3% Black/African American , 5.1% Native American/Native serving during the following military eras: 1.7% Post Korean War, 20.3% Vietnam War, 61% Post Vietnam War (Peacetime), 39% Desert Storm, and 18 (30.5%) Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn. In addition, 54.2% reported a history of deployment, with 22% having been in combat. Measures Demographics The veterans complete d a brief demographic questionnaire tha t assessed age, sex, race, and ethnicity. Military specific demographic information include d branch(es) of service, service
18 MS T Severity Sexual Harassment Scale (SHS ) The SHS is Section K Deployment Risk and Resiliency Inventory 2 (DRRI 2), I tems 9 16 (Vogt et al., 2013 ) . The DRRI 2 was created within the VA National Center for PTSD. Research utilizing the DRRI 2 is limited in MST research. The SHS assesses exposure to unwanted verbal conduct of a sexual nature or unwanted sexual contact while in the military. The perpetrator may be other unit members, commanding officers, or civilians encountered during deploymen t (Vogt et al., 2013). The eight items are rated on a Li , with a total score ranging from 8 to 32. Higher scores represent greater MST severity . A sample item from the SH remarks directed at m e, either publicly or privately . The original DRRI 2 measure is specific to . However, f or this study, a n amended version w as included that m easured the same eight W hile you were in the military. This modification was made recent deployment. The SHS was found to be highl y reliable with this sample ( =.88). Risky and Suicidal Behaviors Engagement in r isky and suicidal behaviors was measured by four self report assessments . Domain Specific Risk Taking Scale Health and Safety Subscale (DOSPERT HS) The DOSPERT is a 30 item self report questionnaire assessing the likelihood of engaging in risk taking in five content domains: financial decisions, health/safety, recreational, ethical, and social (Blais & Weber, 2006). For the purpose of this study only the Health/Safety
19 subsca le was included. This subscale is comprised of six items from the following risk taking behaviors supported in the literature review: risky driving, risky sexual behaviors, risky substance use in a social setting, and a disregard for personal safety. The D OSPERT instructs participants to rate the likelihood that they would engage in specific risky activities using a 7 point Likert rating scale ranging from 1 ( Extremely Unlikely ) to 7 ( Extremely Likely ), with summed scores ranging from 6 to 42 for the He alth/Safety subscale. Higher scores represent an increased likelihood of engaging in health/safety risky behaviors. An example item from the DOSPERT or behavior if you w s & Weber, 2006). Test retest reliability for the Health/Safety subscale has been estimated at 0.75 , and the subscale has shown concurrent validity with behavioral risky assessments ( such as counts of alcohol and drug use; Blais & Weber, 2006 ) . In the current sample, t he DOSPERT HS was reliable with an alpha coefficient of .85. The Alcohol Use Disorders Identification Test Consumption (AUDIT C) The AUDIT C is a brief three item scre ening for risky drinking and possible alcohol abuse (Bush et al., 1998). This measure was initially developed as a screening tool for problematic drinking in male VA primary care patients. H owever, it has since been validated in non VA primary care setting s and the US general population ( Bradley et al., 1998; Daeppen, Yersin, Landry, PÃ©coud, & Decrey, 2000). The AUDIT C is scored on a scale of 0 to 12 ; summed for the purpose of this study. The higher the score on the AUDIT C, the more likely the s drinking is affecting his or her safety. The three items assess how often the individual drinks alcohol, how many standard drinks are consumed on a typical day, and how often he or she is having six or more drinks in one occasion (binge drinking). T he pa rticipants
20 were prompted to answer the questions as they are relevant to him or her within the last 12 months or year. The reliability and validity of t he AUDIT C were supported by comparing the AUDIT C with the AUDIT within a health questionnaire (H AUDIT ) and the AUDIT used as a single scale (S AUDIT) in 332 non VA primary care patients (Daeppen, Yersin, Landry, PÃ©coud, & Decrey, 2000). In the current sample, t he AUDIT C was reliable with an alpha coefficient of .85. The Drug Use Disorders Identification Test (DUDIT) The DUDIT is a validated 11 item self report measure t hat assesses drug use (Ber man et al., 2005 ) . The measure includes a list of commonly abused drugs, such as sedatives, hypnotics, analgesics, and prescription medications , and notes not to consider alcohol when answering the questions . The DUDIT offers a scaled response for each item on behavioral frequency to provide a more comprehensive description of use compared to a dichotomous yes/no option found in many other drug use instruments. An example question item is . The responses were scored from 0 to 4, with summed scores ranging from 0 to 44 and higher scores indicating greater drug use. Similar to the AUDIT C, the participants were prompted to answer the questions as they are relevant to him or her within the last 12 months or year. The DUDIT has been found to be psychometrically valid with high convergent validity ( r = .85) and reliability ( = .94) when compared with the Drug Abuse Screening Test (DAST 10; Voluse et al., 2012). In addition, the DUDIT had sensitivity and specificity scores of .90 and .85, when using the cut off score of 8. In the current sample, t he DUDIT wa s highly reliable ( =.93).
21 Self Injurious Thoughts and Behaviors Interview Short Form (SITBI Short Form ) The SITBI Short Form is a structured interview that measures a broad range of suicidal thoughts a nd behaviors with 72 items , including NSSI (N ock et al., 2007 ) . The SITBI was administered by a licensed psychologist or a masters level licensed professional counselor. For the purpose of this study, questions were added to assess if the NSSI, suicidal ideation , and suicide attempts occurred prior to or following MST. Participa nts endorsi ng a lifetime history of NSSI, suicidal ideation , or attempt were asked follow up questions of how recently they had these thoughts or behaviors. Participants who MST NSSI, post MST suicidal ideation, or post MST suicide attempt within the past year were coded as 1, whereas participants who denied these occurrences within the past year were coded as 0. The SITBI has demonstrated high inter rater reliability and sound concurrent validity with other measure s of self injurious thoughts and behaviors ( Nock et al., 2007 ). Interpersonal Psychological Theory of Suicidal Behavior Interpersonal Needs Questionnaire 12 (INQ 12) The INQ 12 (Van Orden et al., 2008) is a 12 i tem measure designed to quantify particip dis connected from others (i.e. thwarted belongingness) and feel like a burden on people in their lives (i.e., perceived burdensomeness). Five items measure thwarted belongingness and seven items meas ure perceived burdensomeness. An example item capturing recent experiences of belongingness is: ; Van Orden et al., 2008 ). A sample item indicating level of recent perceived burdensomeness is:
22 Participants indicate the magnitude each item is true for him or her using a 7 point Likert scale (1: Not at all true for me; 7: Very true for me) . Summed scores for thwarted belongingness , perceived burdensomeness, and total INQ were included in this study. Higher scores reflect greater thwarted belongingness, perceived burdensomeness, and the composite of these two constructs (total INQ). Research on the INQ 12 has demonstrated high const ruct validity and int ernal reliability for the subscales scores (Freedenthal et al., 2011; Van Orden et al., 2008; Davidson, Wingate, Rasmussen, & Slish, 2009; Hill & Pettit, 2012; Lamis & Lester, 2012). The total INQ 12 score was highly reliable in this s ample ( =.94), as were the thwarted belongingness ( =.91) and perceived burdensomeness subscales ( =.94). Acquired Capability for Suicide Scale Fearlessness About Death (ACSS FAD) The ACSS FAD is a 7 item self r eport measure of fearlessness about death and the likelihood to engage in potentially lethal self harmful behaviors (Ribe iro et al., 2014 ) . Each item is rated on a 5 a higher total score indicating greater fearless ness about engaging in self harm behaviors and death. An item from the ACSS (Ribeiro et al., 2014) . There is not a specified time period which the participant is directed for answering the extent he or she feels a fearlessness toward death. Findings suggest the ACSS FAD demonstrates high reliability and validity (Ribeiro et al., 2014), including within a military population (Anestis, Khazem, Mohn, & Green, 2015). In the current sample, t he reliabi lity of the ACSS FAD was .80.
23 Trauma Related Shame Inventory (TR SI 24 ) The TRSI 24 (Ã˜ktedalen, et al., 2014) is a 24 item measure of trauma related shame. The assessment measures the different shame reactions that people sometimes feel or think about the mselves after experiencing trauma. The participants are prompted in the directions to answer 24 is: et al., 2014). Trauma related shame is measured on a 4 . total scores indicate higher levels of experienced trauma related shame. Initial evidence support s construct validity, with further examination of construct validity and reliability recommended for this relatively new measure (Ã˜ktedalen, et al., 2014). The TRSI was found to be highly reliable with this sample ( =.98). Data Analytic Plan To describe the sample, m eans and standar d deviations will be evaluated. For hypothesis one, a series of bivariate analyses will be conducted wherein higher levels of shame, perceived burdensomeness, thwarted belongingness, acquired capabili ty, suicidal ideation, and risky behaviors and suicidal behaviors are expected to be associated with greater MST severity . For the second hypothesis, a two way interaction between perceived burdensomeness and thwarted belongingness will be tested with a regression , which includes the interaction of PB and TB. If the interaction term is significant, TB will be tested as the moderator to determine if the posited positive relationship between perceived burdensomeness and suicidal ideation will be stronger at high levels of thwarted belongingness compared to low l evels of thwarted belongingness.
24 For the third hypothesis, a 3 way interaction of the IPT constructs (perceived burdensomeness, thwarted belongingness, and acquired capability for suicide) o n r isky and suicidal behaviors will be assessed with a series of m ultiple linear and logistic regressions . The fourth hypothesis will be tested through an exploratory factor analysis (EFA) . A latent variable of risk for premature mortality is expected to be comprised of three observable variables of risky beh aviors ( sum med scores of the following measures: DOSPERT, AUDIT C, DUDIT ), and two observable variable s of suicidal behaviors ( history of post MST suicide attempt within the past year and post MST NSSI within the past year ) . Per Baron and Kenny (1986), t he fifth hyp othesis will be explored by a series of multiple regressions to determine if MST severity and perceived burdensomeness is at least partially mediated by shame. As described earlier, the results of these analyses and the conceptual framework presented in Figure 1 will be used to develop a structural equation model ing (SEM) to evaluate overall pathways. This model will be tested with MPlus statistical software (Version 7.31; Muthen & Muthen, 2014). A SEM analysis will be conducted to obtain the direct and i ndirect effects of all variables. The estimated model parameters determined by the results of hypotheses 1 5 will be utilized to predict the correlations or covariances between measured variables . The pred icted correlations or covariances will then be comp ared to observed correlations or covariances to determine overall model fit. SEM also has advantages in examining latent variables and complex relationships between variables in a single model that are corrected for measurement error (Geiser et al. , 2013). A SEM power analysis recommends a minimum sample size of 200 to detect an effect for the number of potential variables within this model (per Figure
25 1) . This study is under powered with a sample of 59 veterans . A full information maximum likelihood estimat ion will be used to analyze the model. The following indices for goodness of fit will be calculated: Chi Square Test, Root Mean Square Error of Approximation (RMSEA), the Comparative Fit Index (CFI), and Standardized Root Mean Square Residual (SRMR; Hoope r, Coughlan, & Mullen, 2008; Hu & Bentler, 1999). The RMSEA will help determine how well the developed a priori model fits the data and what is the most parsimonious model, in part due to its sensitivity to the number of parameters in the model (Hooper et al., 2008). The CFI is a commonly used fit indices, performing well even with a small sample size. Conventional criteria recommend an acceptable fit at the following values: chi square >.05, a RMSEA < 0.08, and a CFI >0.90, SRMR < .07 . Whereas a chi square >.05, RMSEA < 0.05, CFI >0.95, SRMR <.08 indicate a good fit (Hooper et al., 2008; Hu & Bentler, 1999).
26 CHAPTER III RESULTS Variable Descriptives and Correlations Table 1 presents descriptives , means of the summed scores, and correlati ons for the variab les examined . Exploring some specific responses on the MST, suicide risk, and risky behavior measures yielded important indicators for this sample. Over half of the veterans in the ically forced me to Over 4 5 % of the participants ( n =27) reported a history of post MST suicidal ideation within the past year. Furthermore, approximately 10.2% ( n= 6) reported at least one post MST suicide attempt and 11. 9% ( n =7) reported a history of post MST non suicidal self injury (NSSI) . In addition, over 20% of the participants reported being somewhat to extremely likely to drink heavily at a social function and drive in a car without a seat belt. Over 30% of the sam ple endorsed a likelihood to engage in unprotected sex, ride a motorcycle without a helmet, and walk home alone in an unsafe area, if they found themselves in that situation. The first hypothesis was not supported , as MST severity was only significant ly re lated to shame ( r =.30, p <.05) , but no other outcome variable . Given these results, the hypotheses were adapted to consider the indirect effects of MST severity via shame not only on p erceived burdensomeness, but on several other variables . The association s between shame and other study variables are found in Table 1 . Specifically, s hame was significantly associated with perceived burdensomeness ( r =.72, p r = .46, p total INQ score (perceived burdensomeness and thwarted belongingness; r =.67, p behaviors ( r =.34, p r =.35, p , and post MST suicidal ideation
27 ( r pb =.44, p . Due to the small number of participants who identified as transgender and intersex, gender includes only the male and female participants in these analyses. Shame was not significantly associated with acquired capability for suicide, ri sky alcohol use, post MST suicide attempt , post MST NSSI , gender, or combat exposure . To inform the other hypotheses , including developing the best fitting model , all bivariate correlations were considered. Total INQ score was similarly significantly asso ciated with risky health and safety behaviors ( r =.31, p r =.56, p MST suicid al ideation ( r pb =.44, p health and safety behaviors had a significant relationship to both risky drug use ( r =.69, p r =.40, p however, risky drug and alcohol use were not correlated ( r =.16, p >.05). Furthermore, post MST suicidal ideation was associated with post MST suicide attempt ( r =.37, p MST NSSI within the past year ( r =.29, p MST suicide attempt and post MST NSSI were not significantly associated ( r =.05, p > .05 ). Gender (relative to male or female) and combat exposure widely varied in their relationships to the other items. Having identified as male was significantly related to perceived burdensom eness ( r pb = . 31 , p <. 05 ), risky health and safety behaviors ( r pb = . 47 , p < .0 0 1), and risky drug use ( r pb = .37 , p <.0 1 ). Surprisingly, reporting no combat exposure was significantly associated with perceived burdensomeness ( r pb = .24, p <.05) and risky drug use ( r pb = .22, p <.05). C ombat exposure was not significantly related to other measures within this sample. Int erpersonal Psychological Theory Interactions on Suicidal Outcomes The two and three way interactions of the interpersonal psychological theory of suicidal behavior constructs (perceived burdensomeness, thwarted belongingness, and acquired cap abili ty for suicide) on suicide risk outcomes (post MST suicidal ideation , suicide attempt , and NSSI ) are
28 presented i n Table 2 . A multiple linear regression was conducted to explore Hypothesis 2 , an expected two way interaction of perceived burdensomeness and thwarted belongingness . There was not a significant two way interaction effect for perceived burdensomeness and thwarted belongingness on post MST suicid al ideation in the past year . However, the overall model was significant ( F (3, 55) = 8.170, p <. 001). Regarding Hypothesis 3 , there was not a three way interaction effect of perceived burdensomeness, thwarted belongingness , and acquired capability in the prediction of post MST suicide attempt or NSSI . T he overall model was not statistically significant for post MST suicide attempt (F (3, 51) = .503 , p =.828 ) or post MST NSSI ( F (7, 51 ) = .299, p = .951 ), within the past year . As a result of these finding s, the interaction of acquired capability for suicide and Total INQ score w as examined as a predictor of a range of risky behaviors and su icide risk outcomes as shown in Table 3 . The purpose of this was to simplify the interaction term (i.e., by combining perceived burdensomeness and thwarted belonging into one construct of Total INQ) and to explore if acquired capability for suicide moderates the association between INQ and multiple aspects of risky and suicidal behavior s . However, r esults revealed no sign ificant interaction effects, indicating that a cquired capability for suicide does not moderate the association between Total INQ sc ore and any of the risky behavio rs and suicide risk outcomes. Due to these findings, acquired capability for suicide was remo ved from further analyses. Exploratory Factor Analysis of Risk for Premature Mortality To test the fourth hypothesis , a principal axis factoring (PAF) analysis examined if risky health and safety behaviors, risky drug use, risky alcohol use, post MST suic idal ideation, post MST suicide attempt, and post MST NSSI loaded onto on e factor, risk for premature mortality.
29 An oblimin rotation was utilized to allow factors to be correlated. The exploratory factor analysis (EFA) result ed in four factors (Table 4 ). I nitial eigenvalues indicated that the first two factors explained 35.7% and 20.9% of the variance, respectively. T he third and fourth factor s had eigen values at and just under one and 16.9% and 14.0% of the variance. Furthermore, there were some significan t cross loadings . Considering the EFA did not support one latent factor , the four factor solution was not completely clean, the four factor solution did not result in a larg e reduction of variables (from six to four ), and the association between the six ri sk variables and other variables in the current study differed per risk variable, the six risky behavior and suic ide risk outcomes were retrained separately in the evolving SEM model . Model Fit: An Examination of MST Severity, Shame, Perceived Burdensomene ss and Thwarted Belongingness, on Risky Behaviors and Suicide Risk Outcomes In an effort to bu ild the best fitting model, results from the bivariate correlations, interactions, and potential factors were considered as previously described. In addition, d ue to a non significant relationship between MST severity and perceived burdensomeness, Hypothesis 5 (shame will at least partially mediate the association between MST severity and perceived burdensomeness) was not supported . T he models tested were revised t o examine the indirect effect of M ST severity on Total INQ score via shame . Total INQ was then posited as a direct predictor of the six risky behavior s (health and safety, drug use, alcohol use) and suicide risk outcomes (post MST suicidal ideation, NSSI, and suicide attempts ; see Figure 3) . However, the best fitting model, which has only the three risky behaviors as outcomes , is presented in Figure 2. The process of testing and comparing these two models is described below. T he t wo m odels (Figures 2 and 3) produced adequate fit statistics . The best fitting, parsimonious model to describe the associations between these variables is detailed in Figure 2
30 and included 15 parameters . The model h ad adequate fit: x 2 ( 7 ) = 12.90 ( p > .05), RMSEA = 0 .120 (90% CI: 0.0 0 0 0. 221 ), CFI = 0.9 40 , and SRMR = 0.0 76 . The res ults revealed that shame explained 44.9% of the total variance ( R 2 = .449, p <.001) , in predicting total INQ (perceived burdensomeness and thwarted belongingness) . Due the small sample size, the CFI is inform ative about the fit and promising for examining this model with a larger sample. Due to the use of categorical suicide risk outcome variables (yes/no) , model fit is not available as described above when including the six risky behavior and suicide risk va riables . However, model fit can be determined by comparing the Akaike Information Criteria (AIC) and Bayesian Information Criteria (BIC) . The best fitting model remains the one including only risky behaviors as outcomes (Figure 2 ). Th e larger model , with 2 4 parameters that included risky behaviors and s uicide risk outcomes (Figure 3 ) , has a larger AIC and BIC . However, the larger model is useful in providing logistic regression odds ratio (OR) results for the suicide risk outcomes. Total INQ scores were ass ociated with a n increased risk for post MST suicidal ideation within the past year ( OR 1. 06 , p <.001 ) . Total INQ was not significantly associated with higher odds of post MST suicide attempt (OR 1.0 2 , p >.05 ) and post MST NSSI (OR 1.0 2 , p >.05), within the past year. The significant finding for post MST suicidal ideation , even with the relatively low odds ratio , is informative given the generally low base rate of suicide risk outcomes. When gender and combat exposure were added to the analyses, to further e xplore their relationship with variables in the model , the model retained an adequate fit. H owever, the overall patterns of associations among variables are better explained as represented in Figure 2 .
31 CHAPTER IV DISCUSSION The current study findings ar e consistent with prior research, in that military sexual trauma (MST) severity wa s associate d with sham e 2013, SurÃs & Lind, 2008) . However, this study broadens the literature by further demonstrating the sign ificant association between shame and interpersonal difficulties , specifically thwarted belongingness a nd perceived burdensomeness, which in turn is associated with increased likelihood for risky behaviors ( drug use and health/safety behavio rs) and suicidal ideation . Of note, although MST severity was not directly associated with increased suicidal ideation or attempts, 46% of this survivor sample as a whole reported suicidal ideation in the past year and 10% reported at least one suicide att empt in the past year. These findings support the literature that MST survivors are at an increased risk for suicidal ideation and attempt, compared to veterans without history of MST (e.g., Bryan, Bryan, & Clemans, 201 4 ; Kimerling et al., 2016 ; Monteith et al., 2015 ). Furthermore, MST suicidal ideation and attempt within the past year is startling when compared to a recent national survey that found in a sample of 10,406 veterans only 5.0% reported suicidal ideation an d 1.0% reported attempted suicide within the past 12 months (Blosnich, Brenner, & Bossarte, 2016). The current In addition, over 20% of the survivors within this sample reported a likelihood to engage in risky health and safety behaviors (e.g., excessive drinking, unprotected sex, risky driving, walking alone at night). Although MST severity was not significantly associated with the risk outcomes of this study, prevalence of these among the p articipants suggests that additional
32 attention is warranted for potentially contributing factors such as, shame and interpersonal MST Se verity and S hame S hame has been previously linked to MST (e.g., Johnson, 2012; Monteith et al., 2018a; Monteith et al., 2018b). For this sample, shame was associated MST and with several additional negative sequelae . This is also consistent with findings that shame has serious implications on an nctioning. Shame has been described as a stable, uncontrollable psychological state that perpetuates a negative self evaluation or self hatred and leaves an individual feeling inferior and vulnerable (Bryan et al., 2013 ; Van Orden et al., 2010 ). T hemes ass ociated with shame include deeply demo ralizing events that exacerbate feelings of b etrayal and heightened sensitivity to anger and mistrust of others (Gamliel & Levi Belz , 2016) , which likely contribute elves and interpersonal difficulties . Furthermore, MST survivors are often retraumatized , in ways that may increase shame , even after single events of harassment or assault , from their experiences of blame, misdiagnosis, and questioning of culpability (Nor thcut & Kienow, 2014) . Shame and Interpersonal Difficulties T his study found that veteran MST survivors who endorsed higher levels of shame were more likely to experience greater total perceived burden someness and thwarted belongingness. Intense feelings of shame in MST survivors can be debilitating, with other studies similarly reporting trouble connecting with others and social isolation ( Bell, Turchick, & Karpenko, 2014; Luterek et al., 2011; Mondragon et al., 2015 ) and per ceived burden (Katz et al., 2012 ). The strong association of shame to self hate found in other research is
33 one e xplanation for why MST survivor s experience increased rates of perceived burden an d thwarted belonging from others . Furthermore, t he c ontext in which MST occurs is important to consider in regard to shame and interpersonal difficulties . MST transpires within a complex environment, where stereotypical masculine and paternalistic expectations are reinforced, such as the importance of leade rship, intolerance of mistakes, expected emotional control and self sufficiency, and loyalty to the institution and those within the institution (Bell, Turchik, & Karpenko, 2014; Northcut & Kienow, 2014). Although this environment aligns with the goals of military readiness, it may also unintentionally contribute to the retraumatization of MST survivors . Their trauma and shame may be compounded by efforts to preserve the high standards of the military and maintain the status quo. Furthermore, rape myths (e. g., men canno t be raped, MST is not important enough to report, fears about sexuality ; Monteith et al. , 2018a; Monteith et al., 2018b; Murdoch et al., 2007 ) likely perpetuate feelings of perceived burden and thwarted belonging to the military and others in general . In addition, survivors of MST often continue to work and live with perpetrator(s), as well as friends of the perpetrator(s) and may rely on their perpetrator(s) for career a dvancement (Katz et al., 2007). The se interpersonal stressors may influen ce experiences of thwarted belongingness and perceived burden someness for the survivor with in his/her unit and continue to manifest postdischarge . Research on institutional betrayal experienced by MST survivors supports findings that higher l evels of shame and interp ersonal difficulties are associated with increased engagement in post MST risky behaviors and suicidal ideation. Expe riences of MST within a unit or by superiors are likely to lead to significant emotional distress and betrayal fro m the institution (unit, leadership, branch, military) that exist to keep peo ple safe ( Mondragon et al.,
34 2015; Monteith et al., 2016; Smith & Freyd, 2013). Negative experiences from reporting MST relate to perceptions of institutional betrayal (Monteith, B ahraini, Matarazzo, Soberay, & Smith, directed violence through feelings of thwarted belongingness (Monteith, Bahraini, & Menefee, 2017). The identity of MST survivors can then subvert from individual needs to loyalty of the unit, branch of service, and country identity to one of shamefulness and isolation (Northcut & Kienow, 2014). The expectations for servicemembers to continue to be at peak performance post MS T may contribute to feelings of shame, thwarted belongingness , and perceived burdensomeness as MST survivors struggle to manage the physical, emotional, behavioral, and interpersonal effects of the trauma. Previous research has found that s hame can inhibit disclosure of trauma related experiences and entrap survivors in negative ruminations that invite self criticism and punish ment, which increases the likelihood of not connecting with significant others, family, friends, and providers (Gaudet et al., 2016; Forbes, Creamer, Hawthorne, Allen, & McHugh, 2003). Factors like social withdrawal and low social support are often precursors for risky and suicidal behaviors. Subsequent negative outcomes may perpetuate experiences of shame and increase engagement in ri sky behaviors and suicidal thoughts. Therefore, i t is not surprising that MST survivors experience the compounded effect of shame, perceived burdensomeness, and thwarted belongingness (Monteith, Bahraini, & Menefee, 2017) , as well as an increased likelihoo d for risky behaviors and suicidal ideation . Shame, Interpersonal Difficulties, Risky Behaviors, and Suicide Risk The literature suggest s that shame is a risk factor for r isk taking behaviors ( Stuewig & Tangney, 2007 ) and suicide (Dutra, Callahan, Forman, Mendelsohn, & Herman, 2008; Bryan,
35 Morrow, Etienne, & Ray Sannerud, 2013) , although few studies have examined the mechanisms which may also contribute to the increased risk for premature mortality among these individuals. Service members and veterans who s truggle with feelings of shame and interpersonal difficulties are also likely to experience additional barriers in coping effectively (Gaudet, Sowers, Nugent, & Boriskin, 2016). This study support s that individuals who experience shame and interpersonal d ifficulties are more likely to report an increase in self sabotaging behaviors (e.g., risky health and safety behaviors and substance use) and suicidal ideation . The effects of MST may be exacerbated through what Northcut and Kienow (2014) examined as the trauma trifecta: loss of professional an d personal identity, the occurrence of self harm behaviors in an effort to gain control of the body , and the traumatization that can transpire due to the distinct culture in which MST occurs , especially should the in dividual report the incidence and try to seek help . In an effort to gain control of their body, MST survivors may resort to risky behaviors . To the degree that Veterans engage in risky health and safety behaviors such as risky driving, substance use, and w alking alone in a n unsafe neighborhood, this may represent some level of general disregard for personal safety and perhaps even a type of passive suicidal ideation suicidal ideation through reported ideation and risk taki ng behaviors emphasize the need to cultivate an environment in which they are believed, supported, and that there are interventions which will help survivors manage negative thoughts and feelings effectively. In addition, s hame, perceived burdensomeness , a nd thwarted belongingness are important factors to account for in understanding chronic suicide risk (Monteith, Bahraini, & Menefee, 2017) . By recognizing the precursors of risky behaviors and suicide risk, appropriate avenues for prevention and interventi on can be instituted.
36 Future Directions: Clinical Care Due to the large numbers of service members that return with a history of MST and the current number of veterans who are MST survivors, clinicians should expect to see MST survivors in practice and will need the appropriate skills to work with this population (Valente & Wight, 2007; Williams & Bernstein, 2011). The experience as a civ ilian, to a service member, to a veteran, uniquely contributes to how vete rans view themselves and relate to others around them (Northcut & Kienow, 2014). Conceptualizing MST as a violation of trust that occurs within the context of close relationships may help clinicians u nderstand why MST survivors experience higher levels of shame, and, as the findings of this study suggest , that the degree to which they experience shame then increases the likelihood of interpersonal difficulties , risky behaviors, and suicid al ideation. Furthermore, given the high levels of reported suicidal ideation in this sample, clinicians should be prep ared to assess, monitor, and intervene on suicidal ideation when working with MST survivors. Factors to target within clinical care may include shame and interpersonal difficulties. The significant associations found in this study , specifically bet ween sha me and interpersonal difficulties ( total perceived burdensomeness and thwarted belongingness) , suggest that group interventions may be particularly helpful for veterans with a history of MST . Group ssen e xperiences of shame, by provi di ng an opportunity to connect with other survivors. There are several existing programs (Hoyt, Rielage, & Williams, 2012) that benefit MST survivors that would also be important for civilian providers to offer . Because the tra uma occurred within a military context, civilian mental health facilities could support veterans by offering individual and group services for MST survivors who are not comfortable within a military related setting such as the VA.
37 Hoyt, Rielage, and Willi ams (2012) described a treatment program for male MST survivors that integrated elements of evidence based treatment such as dialectical behavior therapy, safety seeking, and cognitive processing therapy. These interventions focused on increasing coping sk ills (e.g., interpersonal effectiveness) and emotional regulation (e.g., managing shame) prior to trauma focused therapy. Several therapeutic techniques, including t raditional cognitive behavior therapy and mind/body interventions, have been found to be su ccessful in decreasing shame in survivors of sexual trauma (Northcut & Kienow, 2014) that most veteran and civilian clinicians are trained to incorporate in their p ractice. Continued education for veteran and civilian providers on the prevalence and negati ve sequelae linked to MST will likely improve appropriate screening of and access to care for MST survivors. The tools that target factors associated with risky and suicidal outcomes, such as shame and interpersonal difficulties, exist. However, for MST su rvivors to receive appropriate care, improve coping strategies , and reduce risk for premature mortality, known barriers to accessing care must be overcome first . Future Directions: Access ing Care Despite mandatory screening and eligibility to receive free treatment for MST survivors at VAs, research has found that OEF/OIF male MST survivors are less likely to use outpatient mental health s ervices than OEF/OIF female MST survivors (Turchik, Pavao, Hyun, Mark, & Kimerling, 2012). In addition, Turchik and col leagues (2011) found no other gender differences in mental health utilization, only in MST related care. This provides further ins ight on the negative effects of shame and perceived burden that male MST survivors report in this study and previous findings . T he male survivors in this study may be at an increased risk for perceived burdensomeness and risky drug use and health and safety behaviors in part due to this lack of
38 help seeking and shame . Although resources and evidence based treatment exi s t, there may be a lack of knowledge and barriers to engage in these services . According to previous research, f emale veterans also experience stigma related to MST, such as distrust in providers and being seen as weak, that may interfere with help seeking (Holland, Rabelo, & Cortina, 2016; Koo & Maguen, 2014) . Although i n this study ma le and female survivors were significantly different in reported levels of sham e experienced, shame should be addressed in both female and male resources and treatment. Give n the different barriers in help seeking reported by male and female MST survivors in prior studies, it is important that informational dissemination attends to these differences (Turchick, Rafie, Rosen, & Kimerling, 2014) . M ale survivors, who see sexual a ssault as a may benefit from receiving information that addresses shame and its association with interpersonal difficulties and risky behaviors . Similarly, female MST survivors would benefit from targeted information that addresses the shame and interpersonal difficulties that are specific to female survivors, for example coping with the masculine and paternalistic environment in which MST occurs . Other health research (e.g., breast cancer; Thomas, 2010) found that there needs to be a marked difference in not only changing the gender in which the materials target, but also adjust the symptoms and treatment implications as needed. Although Turchick and colleagues (2014) reported that the gender targeted brochures were acceptable and expected to facilitate treatment, the lack of uptake emphasizes the complexity in relation to shame experienced and possible perceived need of care (e.g., perceived burdensomeness) to access care. These discrepancies further suggest that survivors may benefit from ci vilian providers offering MST related resources and treatment .
39 Future Directions: Screening and Assessment Prior r esearch supports that there is a need to educated civilian clinicians on military culture and experience to provide unique and appropriate s ervices to the veteran population , which includes military sexual trauma ( Coll, Weiss, & Yarvis, 2011 ) . Incorporating standard intake questions related to military service and experience would support efforts to recognize and treat military specific trauma . Furth ermore, clinical providers of MST survivors should re evaluate a pre existing diagnosis of bipolar disorder and borderline personality disorder (Northcut & Kienow, 2014) . MST survivors have been misdiagnosed as having long standing pathology to skew the credibility of survivors when reporting MST . M isdiagnosis may perpetuate feelings of sha me and perceived burden postdischarge . Survivors may also not challenge these misdiagnoses as they may increasingly feel as if they can not trust their own judgment (Northcut & Kienow, 2014). There is strong research support for clinicians to use theoretically driven and empirically informed risk assessments ( e.g., Gamliel & Levi Belz, 2016 ; Rogers , 2003 ). However, the c urrent research is limited on th e use of the I PT constructs and shame within clinical settings. In a study of 388 mental health professionals, the interpersonal theory of suicidal behavior constructs (e.g., thwarted belongingness and perceived burdensomeness) was significantly associated with therapis ssment for suicidal ideation and attempts and general resiliency ( Gamliel & Levi Belz, 2016 ). This suggests that clinicians recognize the importance of these factors on suicide risk; however, there does not appear to be a consistent manner in which these interpersonal difficulties are considered in combination or discretely. Efforts to explicitly inclu de perceived burdensomeness, thwarted belongingness , and shame within risk assessments is warranted. Furthermore, providing clinicians knowledge about empirically supported ways of
40 he potential to prevent premature mortality . Future Directions: Research Continued research that examines the extent in which MST severity is associated with eory of suicidal behavior (IPT) is supported by this and other studies . The field would benefit from understand ing the full extent that factors of the IPT a re linked to risky behaviors, suicidal thoughts, and suicidal behaviors as it relates to premature mortality, specific to veterans with and without a history of MST. F uture research should include a comprehensive methodology that captures the engagement in risky behaviors including but not limited to risky driving, recreation, substance use, social behaviors, sexual behaviors, and ethical and financial behaviors. The field is currently limited in its examination of several specific types of risky behaviors in active duty military and veterans, specifically those with a history of MST. This study and other research support the alarming rate at which veterans report engaging in risky behaviors (e.g., Sheppard & Earleywine, 2013; Borders et al., 2012; Lang et a l., 2003) and suicidal thoughts and behaviors ( e.g., Kimerling et al., 2016 ; Monteith, Menefee, Forster, Wanner, & Bahraini, 2015). Furthermore, t here are limited studies on the potentially cyclical nature of shame and risky and suicidal behaviors. A dditio nal research on the process which shame, the IPT constructs, and risky and suicidal outcomes prolong the cycle of negative experiences for MST survivors would also inform barriers to help seeking and opportunities for prevention and intervention. An e xamin ation of perceived burden related to perceived need for care, which may deter veterans from help seeking, would also provide additional knowledge and inform efforts to engage MST survivors in care.
41 In addition, continued efforts to explore the acceptabil ity and effectiveness of MST groups through c ivilian practice is warranted . Civilians providers have the opportunity to reach more M ST survivors who experience shame and want to avoid military institutions in seeking help. Efforts to expand the kn owledge o f and decrease shame, perceived burdensomeness, and other behaviors related to MST care, would improve the mental and physical health outcomes for MST survivors. Limitations The following limitations should be considered when interpreting the results . Thi s study is underpowered to adequately examine the relationships among several variables. With a small sample size, it is often difficult to find significant relationships and therefore, increases the likelihood for type II error. Although relationships wer e found in bivariate correlations and within a larger model that builds on the indirect relationship of MST severity via shame to thwarted belongingness and perceived burdensomeness, potentially there exists a more meaningful and precise model. A study wit h a larger sample size could appropriately examine if a latent variable of premature mortality exists and if the inclusion of acquired capability for suicide provides a better understanding of MST survivors risk for premature mortality. In addition, t he d esign and procedures limit generalizability given the use of a convenience sample with no control group. The results of this research may not generalize to MST survivor vet erans outside of the Denver VA Medical Center and Colorado Springs Community Based O utpatient Clinics ( CBOC ) , and to veterans seeking care outside of the VA. Furthermore, i t is likely that veterans engage in riskier behaviors than tho se of the general population. T herefore, including a civilian control group would determine how risky beh aviors vary by population and sexual trauma history, military related or otherwise. Generalizability also
42 may be limited due to the distri bution among branches within the veteran sample (Department of Veterans Affairs, 2018) . Sailors and Marines were under represented, whereas Soldiers and Airmen were slightly overrepresented. The measures within the study also had varying reporting time intervals (e.g., risky behaviors and su icide risk within the past year associated with recent feelings of perceived burde nsomeness and thwarted belongingness). T here were efforts to control for this . For example, suicide risk within the past year was specifically chosen from the SITBI to match the prompts for the AUDIT and DUDIT. Furthermore, p erceived mental hea lth stigma m ay negatively influence thoughts and behaviors (Hoge et al., 2004). Although research supports that self report measures have been shown to be well suite d for suicide research ( Fri e d man & Asni s, 1989; Kaplan et al., 1994), I acknowledge the potential for rep orting bias , especially with a veteran population . T o my knowledge few, if any, studies have examined shame, risky behaviors, suicide risk, perceived burdensomeness, thwarted be longingness, and acquired capability among is limited. Therefore, this study has the potential to inform future research that will improve prevention, interventi on, and assessments ef forts for MST survivors and veterans in general. Conclusions MST is a significant trauma that precedes negative mental health outcomes . The findings of th e current study found that MST survivors endorsed suicidal ideation at a high rate (46%). In addition, the results indicated that MST severity, via shame, was indirectly associated with risky behaviors, and post MST suicidal ideation . Furtherm ore , greater total thwarted
43 belongingness and perceived burdensomeness, constructs within the interpersonal theor y of suicidal behavior, were significantly associated with post MST drug use, risky health and safety behaviors, and suicidal ideation. Althoug h this study has limitations, it contributes to the current literature and suggests areas of intervention to decrease risk for premature mortality among MST survivors. Treatment of MST survivors should be flexible in not only addressing symptom reduction o f shame , but also increase interpersonal and social functioning. This study begins to examine the gaps in the literature on the association of shame on risky and suicidal outcomes, specifically as it relates to the constructs of the interpersonal theory o f suicidal behavior (IPT) theoretical model can better inform leadership and clinici based treatment. The results of this study point to the need to co nsider shame, perceived burdensomeness, and thwarted belongingness as salient variables associated with risky behaviors and suicidal ideation , among MST survivors . There is a need to inform prevent ion and intervention strategies to use specifically in mili tary and civilian setting s that address MST and associated negative outcomes. By educating providers and leadership on MST and assessing it and the constructs of shame and IPT in practice, it will illuminate opportunities to intervene and impro ve MST survi vors .
1 Table 1 Descriptives and Correlations Variable Range Mean SD n (%) 1 2 3 4 5 6 7 8 9 10 11 12 13 1. MST Severity (SHS) 8 32 18.20 6.45 2. Shame (TRSI) 0 72 29.03 23.77 .30* 3. INQ Total (INQ 12) 12 79 36.42 18.77 .06 .67*** 4. Thwarted Belonging (INQ 12) 5 35 16.58 8.88 .04 .46*** .88*** 5. Perceived Burden (INQ 12) 7 48 19.85 11.80 .12 .72*** .93* ** .64*** 6. Acquired Capability (ACSS FAD) 0 28 18.19 7.21 .06 .03 .04 .04 .09 7. Risky Health/ Safety (DOSPERT HS) 6 42 17.36 10.19 .19 .34** .31** .08 .43*** .03 8. Drug Use (DUDIT) 0 42 6.51 10.62 .10 .35** .56** .16 .45* ** .07 .69*** 9. Alcohol Use (AUDIT C) 0 11 2.00 2.87 .11 .25 .21 .02 .32* .08 .40*** .16 10. SI Past Year (SITBI) 27 (45.8) .14 .44*** .44*** .25 .53*** .01 .20 .20 .24 11. SA Past Year (SITBI) 6 (10.2) .02 .07 .10 .06 .11 .13 .02 .23 .04 .37* * 12. NSSI Past Year (SITBI) 7 (11.9) .02 .15 .11 .11 .09 .00 .08 .09 .18 .29* .05 13. Gender* 55 .18 .23 .23 .08 .31* .20 .47*** .37** .02 .15 .20 .07 14. Combat 13 (22.0) .06 .17 .21 .13 .24* .07 .21 .22* .06 .15 .04 .07 . 08
1 Note. SD = standard deviation; SHS = Sexual Harassment Scale; TRSI = Trauma Related Shame Inventory; INQ 12 = Interpersonal Needs Questionnaire 12; ACSS FAD = Acquired Capability for Suicide Scale Fearlessness About Death; DOSPERT HS = Domain Specific Risk Taking Scale Health and Safety Subscale ; DUDIT = The Drug Use Disorders Identification Test ; AUDIT C = Alcohol Use Disorders Identification Test Consumption; SI = Suicidal Ideation; SA = Suicide Attempt; NSSI = Non Suicidal Self Injury; SIT BI = Self Injurious Thoughts and Behaviors Interview. Gender* Three participants identified as transgender and one participant identified as intersex. Due to the small number of participants in these categories, gender includes only 55 (22 male and 33 fema le) participants. * p <.05 , **p p
1 Table 2 Interaction of perceived burdensomeness and thwarted belongingness predicting suicidal ideation. 3 way interaction of perceived burdensomeness, thwarted belongingness, and acquired capability predicting suicide attempt and no n suicidal self injury . Post MST Suicidal Ideation b SE t P Perceived Burden .017 .013 1.276 .207 Thwarted Belonging .021 .014 1.474 .146 Burden*Belonging .001 .001 .885 .380 Post MST Suicide Attempt b SE t P Perceived Burden .03 1 .029 1.091 .280 Thwarted Belonging .30 .034 .882 .382 ACSS FAD .022 .022 .991 .327 Burden*Belonging .001 .001 1.047 .300 Burden*ACSS FAD .002 .001 1.226 .226 Belonging*ACSS FAD .001 .001 .883 .382 Burden*Belonging*ACSS FAD 6.939 .000 1 .061 .294 Post MST NSSI b SE t P Perceived Burden .027 .031 .856 .396 Thwarted Belonging .010 .037 .282 .779 ACSS FAD .008 .024 .341 .734 Burden*Belonging .001 .002 .857 .395 Burden*ACSS FAD .001 .002 .717 .476 Belonging*ACS FAD .0 00 .002 .249 .804 Burden*Belonging*ACS FAD 5.22 .000 .737 .464 Note. ACSS = Acquired Capability for Suicide Scale Fearlessness About Death
47 Table 3 Interaction of total perceived burdensomeness and thwarted belongingness (total INQ) and acquired capability predicting risky behaviors and suicide risk outcomes. Post MST Suicidal Ideation B SE t P Total INQ .006 .009 .695 .490 ACSS FAD .010 .017 .550 .584 Total INQ*ACSS FAD .000 .000 .727 .470 Post MST Suicide Attempt B SE t P T otal INQ .003 .006 .443 .659 ACSS FAD .003 .012 .222 .825 Total INQ*ACSS FAD .000 .000 .785 .436 Post MST Non Suicidal Self Injury b SE t P Total INQ .005 .006 .779 .439 ACSS FAD .006 .013 .459 .648 Total INQ*ACSS FAD .000 .000 .515 .608 Risky Health & Safety Behaviors b SE t P Total INQ .187 .185 1.011 .316 ACSS FAD .011 .377 .029 .977 Total INQ*ACSS FAD .001 .010 .111 .912 Risky Drug Use b SE t P Total INQ .056 .188 .300 .765 ACSS FAD .158 .383 .413 .681 Total INQ*ACSS FAD .008 .010 .845 .402 Risky Alcohol Use b SE t P Total INQ .099 .052 1.881 .065 ACSS FAD .100 .107 .936 .354 Total INQ*ACSS FAD .004 .003 1.383 .172 Note. Total INQ = Interpersonal Needs Questionnaire 12 Total; ACSS = Acquired Capability for Suicide Scale Fearlessness About Death
48 Table 4 Summary of Exploratory Factor Analysis results for premature m ortality Factor Loadings Item Risky Health and Drug Use Post MST SI and SA Risky Health and Alcohol Use Post MS T Suicidal Behaviors DOSPERT HS .881 .023 .636 .118 DUDIT .866 .309 .239 .162 AUDIT C .257 .049 .630 .162 Post MST SI .194 .588 .374 .568 Post MST SA .156 .685 .015 .128 Post MST NSSI .081 .126 .143 .539 Note. Factor loadings over .50 appear in bol d
49 Figure 1 Conceptual model (based on IPT) of MST severity predictin g risk for premature mortality in which (a) MST severity directly predict ing greater levels of shame, perceived burdensomeness, thwarted belongingness, and acquired capability, (b) a two way interaction of perceived burdensomeness and thwarted belongingness predicting a history of post MST suicidal ideation, (c) a three way interaction of the IPT constructs predicting post MST suicide attempts and engagement in risky behaviors, (d) MST se verity and perceived burdensomeness at least partially mediated by shame, and (e) perceived burdensomeness, thwarted belonging, and acquired capability each predict ing a latent factor representing behavioral risk factors for premature mortality (i.e., risk y and suicidal behaviors). Shame MST Severity Thwarted Belonging Premature Mortality Perceived Burden Acquired Capability Post MST Suicidal Ideation Post MST NSSI Post MST Suicide Attempts Risky Alcohol Use Risky Drug Use Risky Health & Safety
1 Figure 2 Shame MST Severity Risky Health & Safety Behaviors Total PB & TB (Total INQ) Risky Drug Use Risky Alcohol Use .652* ** .097 .365*** .295* .670 * ** .310** .355** .209 * p <.05 , **p p S t a n d a r d i z e d r e s u l t s o f M S T s e v e r i t y p r e d i c t i n g i n c r e a s e d s h a m e a n d i t s a s s o c i a t i o n w i t h T o t a l I N Q o n r i s k y b e h a v io r s .
51 Figure 3 Post MST SI Post MST SA Post MST NSSI Shame MST Severity Risky Health & Safety Behaviors Total PB & TB (INQ) Risky Drug Use Risky Alcohol Use .295* .670*** .310** .355** .209 .482*** .165 .175 .652*** .097 .365*** * p <.05 , **p p S tandardized results of MST severity predicting increased sh ame and its association with Total INQ on risky behaviors and suicide risk outcomes.
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