A Medical School Educational Intervention to Prevent and Reduce Blaming and Minimizing Trauma Patients

A MEDICAL SCHOOL EDUCATIONAL INTERVENTION TO PREVENT AND REDUCE BLAMING AND MINIMIZING TRAUMA PATIENTS

A Plan B Research Project SUBMITTED TO THE FACULTY OF UNIVERSITY OF MINNESOTA DULUTH

Natalie Maria Alexandra Slaughter

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS

Catherine M. Reich, PhD, Advisor Sarah Beehler, PhD, Committee Member Rick LaCaille, PhD, Committee Member

August 2018

Acknowledgments I would like to acknowledge everyone who assisted in this project including: Allison

Fairchild, Kalley Waller, Mariah Madden, Emily Bates, Samantha Woller, Morgan Butler-Fluth, Taylor Schultz, Yimei Li, Erik Dahl, Riley Berg, Katie Axford, Ryan Harden MD, Chantal Rozmus DO, Casey Lenderman DO, Charles Sweat MD, Jason

Parvis DO, Michaela Simmons DO. I would also like acknowledge my supportive cohort: Eden Broberg, Josephine Abate, Amy Maslowski, and Brooke Collins. I am deeply grateful to Catherine Reich PhD, who guided me through this process with patience and care. This project could not have taken place without the UMD Multimedia Department, especially Chris Lor, Cole Madson and Mary Olson-Reed. Thank you to Ryan Richardson for his performance as a voice actor. Furthermore, I greatly appreciate Sarah Beehler PhD, Rick LaCaille PhD, Erin Ayala PhD, Scott Carlson PhD, Eric Hessler PhD,

Lara LaCaille PhD, and Paula Pedersen PhD for all they have taught me. I must express my gratitude and appreciation for the mother who taught me the importance of self-love and compassion, RuPaul. Finally, thank you to those who have given me support and care throughout this process: Joseph Slaughter, Bryce Ehrman, David Baldes MD, and Jay Knuths MD.

Abstract

As medical providers care for trauma survivors, some reactions can exacerbate their patient’s suffering, yet many providers feel unprepared to respond in more helpful ways. The aim of this study was to develop and test an educational intervention to reduce unhelpful attitudes such as victim blaming. Fifty-one medical students were randomly assigned to either view an intervention video regarding potentially inappropriate reactions or an intervention control video consisting of general trauma information. Participants who viewed the intervention video were statistically significantly less likely to blame a trauma-vignette victim than the control participants with a medium effect size (d = 0.66), but this did not seem to generalize to other relevant attitudes. Limitations including small sample size and trauma and population specific rather than inclusive measures. Future research might expand to include behavioral measures and target additional areas for improvement in the medical care of trauma survivors.

ii Table of Contents

List of Tables ...... iv

List of Figures ...... v

Introduction ...... 1

Method…...... 22

Results…...... 34

Discussion ...... 37

References ...... 44

Appendices ...... 69

iii List of Tables Table Page

i. Sample Demographic Information ...... 61

ii. Zero Order Correlations, Means, and Standard Deviations for Outcome Variables...... 62

iii. Comparison of Variables Across Conditions ...... 63

iv. Relationship Between Participant Characteristics and Effectiveness of Intervention ...... 64

iv List of Figures Figure Page

i. Theorized Relationship Between Dependent Variables Following Literature Review...... 66

ii. Flow Chart Indicating Process in Which Participants Were Recruited, Randomized, and Data Analyzed ...... 67

iii. Venn Diagram Depicting Unique and Shared Features of the Intervention and Control Conditions ...... 68

v Chapter 1 Introduction Interpersonal violence can have a negative impact on both the physical (Resnick, Acierno & Kilpatrick, 1997; Ruxana & Leena, 2013) and emotional health of survivors (Barter & Stanley, 2016; Maercker & Heckler, 2016). Interpersonal trauma survivors access the healthcare system at higher rates than individuals who have not witnessed or experienced trauma (Resnick, Acierno & Kilpatrick, 1997; Ruxana & Leena, 2013) but report dissatisfaction with how their healthcare providers respond after they disclose the trauma (Bassuk et al., 2001; Yam, 2000). In fact, survivors perceive the reactions of their physicians as significantly more negative than the physicians themselves endorse (Campbell, 2005) and many practicing physicians report not feeling prepared to care for patients who have been victims of interpersonal violence (Amin, Buranosky & Chang,

2017; Green et al., 2011; Parsons, Zaccaro, Wells & Stovall, 1995). This skill deficit may be due to the fact that medical schools and residencies do not typically include psychological trauma as a part of their required curriculum (Hamberger & Patel, 2004;

Koschorke, Tilzey & Welch, 2006). This is particularly concerning, given the potential risk for harm for the patient if the physician reacts negatively to the trauma disclosure; negative social reactions are associated with a myriad of negative mental health outcomes

(DePrince, Welton-Mitchell & Srinivas, 2014; Littleton, 2010; Ullman & Fillipas, 2001; Orchowski, Untied, and Gidycz, 2013; Ullman & Peter-Hagene, 2014; Ullman & Peter- Hagene, 2016). The aim of the current research was to develop an educational intervention for medical students regarding common pitfalls (i.e., victim blaming and minimization) and to test the effectiveness of this intervention in changing negative attitudes and beliefs about interpersonal trauma survivors.

1 Health Consequences of Trauma Witnessing or experiencing interpersonal violence is a risk factor for numerous physical disorders beyond any initial trauma-related injuries (Resnick, Acierno & Kilpatrick, 1997; Ruxana & Leena, 2013). For example, survivors of interpersonal violence have increased risk for developing a number of medical conditions, potentially due to the increased activation of the hypothalamic-pituitary-adrenal axis, leading to increased cortisol production which subsequently suppresses the immune system (Resnick, Acierno & Kilpatrick, 1997). Additionally, survivors of interpersonal trauma have increased rates of gastrointestinal dysfunction (Knapp, 2011), sexual dysfunction (Ruxana & Leena, 2013; Weaver, 2009), cardiopulmonary symptoms, such as shortness of breath (Ruxana & Leena, 2013), and are more likely to engage in risky sexual behaviors post-sexual assault leading to an increase of sexually transmitted diseases (Puja et al., 2010; Weaver, 2009). Aside from increased risk of physical conditions, survivors of interpersonal violence also have increased risk for psychological conditions. For example, rape and intimate partner violence (IPV) is associated with higher risk for developing specific psychological symptomatology such as posttraumatic stress disorder (PTSD; Barter & Stanley, 2016; Maercker & Heckler, 2016), major depressive disorder (Maercker &

Heckler, 2016), borderline personality disorder (Weaver, 2009), eating disorders (Barter & Stanley, 2016), suicidality (Barter & Stanley, 2016), and substance misuse (McCauley et al., 2009; Øverup et al., 2015, Ullman & Sigurvinsdottir, 2015). Survivors of sexual violence in particular also have lower self-esteem (Perilloux, Duntley & Buss, 2011) as compared with victims of non-sexual trauma and even lower self-esteem than individuals who have not experienced a traumatic event (Kucharska, 2016). A degraded sense of self and lower self-esteem are often experienced by survivors of IPV as well (Matheson et al.,

2015).

2 Making Sense of the Trauma One factor that seems to be related to the negative outcomes following interpersonal trauma is self-blame. Self-blame is defined as attributing fault to oneself in some way as a reaction to victimization (Libow & Doty, 1979). Self-blame has been shown to be correlated with psychological distress (Breitenbecher, 2006), depressive symptoms

(Fraizer, 2000), and risk for revictimization (Mokma, Eshelman & Messman-Moore, 2016). As self-blame is associated with such negative outcomes, it leads one to question what purpose it serves. One theory on why survivors might blame themselves is because of just world beliefs (JWB). JWB is the notion that the world is a fair place in which bad things tend to happen to bad people and good things tend to happen to good people (Lerner, 1980). Therefore, if something bad happens to someone, they must have in some way deserved it. It has been theorized that belief in a just world can be an adaptive response to hearing bad news about events in the world because the person can reassure themselves that they are a good person and, therefore, safe (Furham, 2003). For example, it has been theorized that if a woman is thinking about sexual violence, a high belief in a just world is evoked to aid her in achieving a sense of control over her own possibility for victimization (Furham, 2003). In this way, JWB provides a buffer to a harsh and uncaring world and in day-to-day contexts can be associated with decreased stress (Furnham, 2003). In the context of experiencing trauma, however, the survivor faces a dilemma. If he or she continues to hold to this long held pre-existing JWB that bad things happen to bad people, the survivor is forced to either conclude that the trauma occurred because he or she is bad in some way or to question the reality of the event. This process of blaming oneself in the aftermath of a trauma is so common and distressing that is now recognized as a symptom of Posttraumatic Stress Disorder (PTSD) according to Diagnostic and

Statistical Manual 5 (American Psychiatric Association, 2013).

3 JWB is not only relevant in considering the survivor’s processing of the event, the individuals the survivor discloses the trauma to also experience this internal struggle

(Podolski,Williams & Harber, 2015). Unfortunately, another way this may manifest in others is through victim-blaming. For example, a study looking specifically at the relationship between JWB and rape myth acceptance found a positive correlation between applying JWB to others and blaming rape victims (Hayes, Lorenz & Bell, 2013). Explanations for victim blaming are not limited to JWB. According to Schwartz and Leggett (1999) victim blaming involves using parts of the victim’s behavior to put responsibility on them for the incident. This corresponds well to Alicke and Eisenberg’s (2000) conceptualization of blame as being a determination of fault through spontaneous evaluations of situations in a manner that ascribes the most blame to the person or persons whose behavior confirms the event or who produces the most negative affect.

Individuals have a tendency to blame those who evoke negative emotions; which can create a vicious cycle in which negative affective reactions made by the victim actually fuel victim blaming (Alicke & Eisenberg, 2000). Hindsight bias and the availability heuristic also play a role in victim blaming (Janoff-Culman, Timko, & Carli, 1985). In this sense, victim blaming can be seen as a form of “Monday morning quarterbacking,” as people are able to use information not available at the time of the event to determine responsibility. This is further compounded by the fundamental attribution error, or that people are more likely to ascribe events to personal dispositions and less likely to consider environmental causes (Gilbert, Malone, & Steinberg, 1995). In addition, there is evidence that if the concept of choice is brought to individuals’ attention they are more likely to blame victims, and have decreased empathy for disadvantaged peoples (Savani, Stephens & Markus, 2011). Blame is a social process that begins with a private judgement and may function to control other people’s behavior (Malle, Guglielmo, &

Monroe, 2014). So, in the event of something extreme, such as rape, typical social rules

4 and guidelines have been broken and someone must have behaved in an inappropriate way, and therefore needs to be blamed (Alicke & Eisenberg, 2000). In a more general sense, on can understand that if expectations are different from reality, it is common for individuals make assumptions which are often incorrect regarding the people involved (Gilbert, Malone, & Steinberg, 1995).

However, the most influential of the theories that explains victim blaming is likely the JWB. This theory fits particularly well for the purposes of this study due to its targeted focus on internal processes and lack of accusatory nature toward the blamer.

According to JWB theories, some individuals believe that the world is an inherently fair place, they want to maintain that view and will use various techniques to maintain their worldview (Montada & Lerner, 1998; Reichle et al., 1998; Van des Bos & Maas, 2009). One such technique is to blame the victim and rationalize that they deserve their fate because of their “own faulty actions, or omissions, or a bad character” (Reichle et al., 1998). This has been shown in a variety of situations such as refugees (e.g., Khera, Harvey, & Callan, 2014), AIDS sufferers (e.g., Connors & Heaven, 1990), and rape survivors (e.g., Grubb & Turner, 2012). Aside from its relevance across multiple domains a physician may encounter, JWB might be an appropriate way to target victim blaming among physicians because it can be observed both in the provider’s own internal reactions to a patient and also the survivor’s own internal reactions to the trauma (Jackson, Witte, Petretic-Jackson, 2001). Being able to observe and understand the source of survivor’s JWB in tandem with one’s own internal reactions may make it easier for medical students to feel empathy for the survivor and avoid colluding with survivor self- blame. It should be noted that JWB and rape myths are related. As outlined in Figure 1,

JWB and rape myths both exist within the context of dominant schemas about interpersonal violence in Western culture, also referred to as rape culture (Hayes, Lorenz

5 & Bell, 2013). JWB expresses a global belief about how the world works, often in an attempt to cope with dysregulated emotions (Furnham, 2003). Rape myths can serve a similar function, as contemplating differences from the victim can reduce the anxiety surrounding one’s own vulnerability for victimization (Hayes, Lorenz & Bell, 2013). There is additional overlap due to some attitudes (e.g. the victim holding some responsibility for their perpetrator’s actions) being seen in both rape myths and JWB (Hayes, Lorenz & Bell, 2013). JWB may therefore fuel justification of acceptance of rape myths (Vonderhaar & Carmody, 2014).

Another way in which survivors of trauma experience JWB from others is through minimization. If a person who is high in JWB is presented with evidence of injustice, they may use minimization (Bègue & Muller, 2006; Maes, 1998 Smith, 1985; Reichle et al., 1998). If confronted with an “innocent victim,” one can minimize or deny the trauma to maintain their belief in a just world (Lerner, 1988). For example, people with a strong belief in just world underestimate the amount of discrimination present (Lipkus & Siegler, 1993). In the case of sexual trauma, minimization may manifest as denying an act is rape by labeling the event sex, therefore turning it into a positive or neutral act and removing any reason to feel traumatized. One can think of denial and minimization as running along a continuum from complete denial of reality to admission of the traumatic event (Scott & Straus, 2007). Importantly, this denial or minimization can occur across multiple sources including both the survivor and perpetrator (Bograd,1988; Macdonald et al., 2016) as well as outsiders such as providers (Evert, 2005). Unfortunately, these internal JWB are sometimes communicated to the trauma survivor and such attitudes are related to a number of different negative impacts on the survivor. For example, survivors who are blamed experience increased negative cognitions (Bonnan-White et al., 2015) as well as increased self-blame cognitions

(Hassija & Gray, 2012; Relyea & Ullman, 2013). This connection between being blamed

6 by others and self-blame among survivors suggests that the blame may be internalized by survivors; which again is problematic due to the psychological distress associated with self-blame cognitions (Decou et al., 2017; Hassija & Gray, 2012; Reich et al., 2015; Ullman & Najdowski, 2010) and decreased self-esteem (Reich et al., 2015). In fact, the first response to a survivor’s disclosure is thought to serve as a blueprint for how they conceptualize their trauma (Bonnan-White et al., 2015). An example of creating this blueprint, is if a survivor is reassured that they are not responsible for the assault, they may think back to the positive response and have more evidence to combat self-blaming cognitions. On the other hand, if a trauma survivor feels distressed by the reaction of an individual they went to for support they often feel less willing to seek out help in the future (Campbell, 2005). Of note, being blamed by others for the trauma is perceived by survivors as hindering their recovery (Campbell et al., 2001), and may be related to increased social withdrawal (Relyea & Ullman, 2013), poorer coping skills (Orchowski, Untied, & Gidycz, 2013), and lower sexual assertiveness (Relyea & Ullman, 2013). Survivors who are blamed may be at increased risk for a number of negative psychological (Decou et al., 2017) and social (Relyea & Ullman, 2013) outcomes, potentially due to increased self-blaming cognitions. Likewise, survivors of sexual assault report minimizing responses to disclosure as unhelpful and distressing (Lanthier, Du Mont, Mason, 2016). A potential explanation for this distress is that survivors took minimizing reactions as evidence that the support provider did not care about them or their trauma (Ahrens et al., 2009). Additionally, rape victim advocates also note that minimizing the trauma by not believing the survivor can be revictimizing (Maier, 2008).

Social Reactions by Medical Staff. Negative social reactions may be amplified from formal systems, such as healthcare staff (Campbell, 2008). There are a few explanations to why negative social reactions such as victim blaming are particularly

7 concerning in a healthcare setting, aside from very nature of such statements being asserted by a trusted authority. Physicians who held victim blaming attitudes about patients who are survivors of interpersonal violence were less likely to offer resources such as referrals to mental health services (Jackson, Witte & Petretic-Jackson, 2001, Nayak, 1999). In addition, how the provider thinks about the abuse may impact how the survivor makes sense of the trauma. It has been suggested that victim blaming as an initial response to trauma disclosure serves as a blueprint for the survivor to blame themselves (Bonnan-White et al., 2015). This is particularly relevant in a healthcare setting as survivors are more likely to receive negative reactions from medical professionals than from informal helpers such as family or friends (Ahrens et al., 2007; Starzynski et al., 2005), which may be particularly true for African-American women (Maier, 2008). It should be noted that unhelpful or blaming responses to help-seeking patients is not limited to instances of interpersonal trauma, as medical communication commonly places some aspect of responsibility on the patient, i.e. communicating “She blew her IV” rather than “This patient needs their IV replaced” and assigning value to engaging in behaviors that may increase one’s risk for preventable illnesses (Marantz, 1990). In examining attitudes of physicians on treating intimate partner violence, this also appears, with one study finding 55% of doctors believed that their patient’s personalities lead to them being abused (Garimella, Plichta, Houseman & Garzon, 2000). Interpersonal trauma survivors report dissatisfaction with how disclosure of abuse is responded to in emergency rooms (Yam, 2000) and specifically report feeling disrespected, unaccepted, (McNutt, 2000), lacking empathy (Bassuk et al., 2001), and overall poor communication with primary healthcare providers (McNutt, 2000). They also report experiencing and feeling distressed over medical staff’s rudeness (Bassuk et al., 2001), blaming (Campbell, 2005; Orchowski, Untied, and Gidycz, 2013), asking about previous sexual history with the perpetrator (Campbell, 2005), and coldness (e.g.,

8 given medication only; Sturza & Campbell, 2005). Within the literature, these negative reactions have been referred to as a "second rape" (Campbell, 2008). It should be noted that a survivor’s perception of a provider being unhelpful may be counter to the provider’s appraisal of the situation. This was shown in a study of 81 rape survivors receiving emergency care of whom a majority rated their physicians’ reactions as unhelpful; and reported feeling bad about themselves, guilty, and disappointed (Campbell, 2005). In contrast, many of their physicians did not report perceiving the survivors’ negative emotional state or reticence to seek help in the future (Campbell,

2005). It is perhaps not surprising then that interpersonal violence survivors often report low trust for providers (Bassuk et al., 2001) and fear disclosing to their healthcare providers (Kelly, 2006). Negative social reactions from such formal supports are associated with greater survivor feelings of powerlessness, shame, and guilt (Campbell, 2005; Campbell, 2008). Less than half of the rape survivors reported their attempt at medical assistance being healing, in comparison to 70% of those who sought help through mental health professionals, 75% through rape crisis centers, and 85% through religious communities (Campbell et al., 2001). Predictably, survivors who indicated their experience with medical staff as harmful exhibited higher psychological and physical health distress

(Campbell et al., 2001). Survivors who receive negative reactions from formal support providers also frequently report feelings of powerless and being demeaned (Martsolf et al., 2010). In addition, these negative reactions are also associated with reluctance to disclose trauma history in the future (Ahrens, 2006), and social withdrawal (Relyea &

Ullman, 2013) and internalized self-blame (Hassija & Gray, 2012; Ullman & Najdowski, 2011). Though there is currently not enough literature to link negative social reactions from formal support providers with specific medical outcomes, it should be noted that reacting to patients in an empathic manner is a key component of patient-centered care,

9 which has been linked to patient satisfaction and compliance (Kim, Kaplowitz, & Johnston, 2004).

Directionality. One might question whether negative social reactions (such as blaming or unsupportive reactions) generally proceed negative psychosocial consequences or follow them. Notably, Ullman and Peter-Hagene (2016) conducted a longitudinal study and found that survivors who reported experiencing negative social reactions to disclosing the trauma later had higher rates of PTSD symptom severity relative to survivors who were not blamed or treated negatively, even three years post- victimization.

Changing Attitudes Given the evidence that negative reactions such as victim blaming or minimizing are harmful, an important goal may, therefore, be to stop such messages from being communicated. To do so, health care providers must first recognize negative internal reactions and beliefs. However, solely presenting new information is not always sufficient in changing deeply held beliefs and attitudes (Ambrose et al., 2010; Peter &

Koch, 2016, Zestcott; Blair & Stone, 2016). There are numerous barriers that are faced in attempting to debunk myths, one of which is the backfire effect (Peter & Koch, 2016). The backfire effect, or boomerang effect, is the process by which some fact-checking attempts paradoxically re-inforce the false belief due the increased salience of the information as well as decreased likelihood of remembering contextual details (Peter & Koch, 2016). One way to potentially combat this backfire that happens with deeply held beliefs is via the use of bridging, a strategy in which the learner is encouraged to relate the concept to something they already know or believe (Ambrose et al., 2010). Much has been written on the techniques for changing beliefs and attitudes. One area that has gained recent attention is attempts to recognize and change implicit biases.

Implicit bias is defined as an individual having a discriminatory thought, feeling, or

10 action on the basis of an unconscious stereotype or attitude about a group of people (Greenwalk & Krieger, 2006). Notably, this type of bias has received attention in the medical field in part due to the potential for contributing to health disparities in marginalized groups (Zestcott, Blair & Stone, 2016). Current interventions on implicit bias training for healthcare providers have been effective on changing beliefs and attitudes, but there is a great need for more studies, particularly those examining if these new beliefs and attitudes sustain in the months and years post-intervention and how this relates directly to patient care (Zestcott, Blair & Stone, 2016). It appears that simple exposure to individuals medical students may have implicit biases towards is not always effective in changing these beliefs, and can instead reinforce negative stereotypes (Hernandez, Haidet, Gill & Teal, 2013). Rather, medical students may be more likely to critically examine their biases and change their beliefs as they reflect on the material while considering their own personal experiences (Hernandez, Haidet, Gill & Teal, 2013). Furthermore, a narrative review of implicit bias interventions aimed at health care providers suggests that training is most effective if the participants are not only made aware of the issue and the potential effects on patients, but also if active learning strategies are used to practice addressing the issue (Zestcott, Blair & Stone, 2016). Active learning has gained support in academia and differs from traditional didactic approaches in promoting thoughtful student engagement with the material, rather than expecting student to be a passive receiver of information (Prince, 2004). Some active learning activities that were associated with changing beliefs and attitudes included: self- reflection, in examining one’s thoughts, perspective-taking, such as considering the positions of another person, and using strategies to address automatic cognitions, like those found in cognitive therapies (Hernandez, Haidet, Gill & Teal, 2013; Zestcott, Blair

& Stone, 2016).

11 Further knowledge on attitude/belief change was gained through norm activation theory. Norm activation theory emphasizes personal norms which may compel the individual to feel a sense of moral duty, awareness of the consequences of not acting on the moral impulse, and finally how much responsibility the person places on themselves for the negative consequences of not acting (De Groot & Steg, 2009). It stands to reason that the majority of medical students care about their patients and may be motivated to change if it corresponds with that personal value. It would, therefore, make sense that if medical students were reminded of their belief and ethical obligation of nonmaleficence they may be less likely to engage in victim blaming attitudes. The field of Cognitive Therapy targets cognitive distortions by helping the client consider alternative perspectives. For example, Cognitive Processing Therapy (CPT), a leading empirically supported treatment for PTSD, includes as a primary component the process of systematically examining and challenging self-blame cognitions related to the trauma (Resick, Monson & Chard, 2016). Cognitive therapies work to change negative core beliefs about oneself, the world, and others by helping clients first recognize negative automatic thoughts, question those thoughts, and deliberately formulate a new self-message (O’Donohue & Fisher, 2009). Notably, the CPT manual includes explicitly educating clients about JWB as part of the self-blame challenging process (Resick,

Monson & Chard, 2016). It may be a reasonable assumption that if this process is successful for helping survivors challenge their own self-blame, it may be helpful for victim blaming too. A population one might assume has strong motivation to maintain their victim-blaming cognitions is criminal offenders, and Cognitive Behavioral Therapy has even been used to effectively reduce and change criminal thought patterns including victim blaming (Lipsey, Landenberger & Wilson, 2007).

In examining studies outside academic medicine, there is also a dearth of information regarding what is the best way to stop or prevent victim blaming among

12 professionals who are likely to come into contact with the survivor, but there is some literature examining reduction of victim blaming, rape myth acceptance, and JWB across different populations. A brief, peer-lead intervention focused on male responsibility successfully reduced high schoolers endorsement of rape tolerant attitudes such as victim blaming (Smith & Welchans, 2000). One such study looked at undergraduate students taking a semester long victimology course and found they endorsed less victim blaming attitudes than students in a more generalized criminology course (Fox & Cook, 2011). Another intervention was able to reduce victim blaming attitudes by having law enforcement officers complete a four-week long training that extensively covered the dynamics of sexual abuse and used active learning activities such as role plays (Darkwinkel, Powell & Tidmarsh, 2013). In a review on teaching police to not victim blame rape survivors, it was reported that individuals who already hold less unhelpful stereotypic beliefs surrounding sexual violence find education more helpful (Campbell, 1995). Emergency Department nurses who received a brief, interactive educational intervention which focused on reducing myths and encouraging to validate and not blame survivors of intimate partner violence, reported later thinking about the training and using validating statements while working with abuse survivors (Nelms, 1999). Notably, a movement for trauma-informed care training has emerged; however, this movement often takes a broad approach educating providers about the physical and psychological consequences of trauma, emphasizes on trigger sensitivity and supportive responses and referrals, as well as general client-centered care principles (Machtinger et al., 2015). These trainings typically emphasize positive reactions but did not directly target reducing negative reactions such as victim blaming or minimization. In fact, it appears no prior study seems to have had the targeted training objective of learning about

JWB in an effort to avoid blaming or minimizing trauma survivors among healthcare providers.

13 Finally, it is important to consider recommendations and lessons learned from previous attempts to change medical students’ knowledge, attitudes, and beliefs regarding interpersonal trauma. For example, it is recommended that in creating medical educational programing surrounding sexual and intimate partner violence that care is taken to inform students of the sensitive nature of the topics, to validate any emotions that may come up for participants as well as to reinforce the seriousness of the subject matter (Dickstein, 1997; Kennedy & Scriver, 2016). It was also noted that misconceptions regarding sensitive topics such as rape and child abuse are quite common, and, therefore, may be important to debunk prevalent myths (Kennedy & Scriver, 2016). It was also advised to allow space for medical students to reflect on their feelings, as well as underlining the importance of knowing this information for future patients (Kennedy & Scriver, 2016; Warshaw, 1997).

Individual Physician Factors Previous research found a number of factors that may influence attitudes and beliefs regarding trauma disclosures. These factors generally fall into three categories: empathy, exposure to trauma, and gender. Specialties may also play a role. Physicians with high empathy take into account his or her patient’s perspectives, desires, and difficulties (Hojat et al., 2001). Physician empathy has been an increasingly researched topic, likely due to the positive association between physician empathy and patient satisfaction and compliance (Kim, Kaplowitz & Johnston, 2004). Physician empathy has been shown to be positively correlated with other factors including: exposure and interest towards courses in the humanities both during and before entrance into medical school (Hojat et al., 2000; Graham et al., 2016) and fewer years of medical education (Hojat et al., 2004). There also has been theorized to be a relationship with being a nontraditional student and having greater empathy (Jauhar, 2008). Importantly, empathy has been shown to have an inverse relationship with victim blaming (Deitz, Littman, & Bentley, 1984).

14 Previous exposure to trauma also may impact how an individual responds to a trauma survivor. Personal experience with severe violence may actually hinder one’s ability to engage with patients who are victims of intimate partner violence (Ambuel et al., 2003). However, medical students with previous exposure to violence also are more likely to want physicians to be educated on these topics and to advocate for survivors

(Cullinane, Alpert & Freund 1997). Knowing a survivor of interpersonal violence in particular may help a medical student to decide to not victim blame (Nayak, 1999). It also appears that gender is an important factor in considering the reactions and impacts of sexual and intimate partner violence. In a study looking at male and female medical student’s reactions to male and female rape survivors it was found that male medical students viewed rape survivors in a more negative manner their female counterparts (Anderson & Quinn, 2008). This may continue into medical practice, with male physicians holding more negative attitudes, such as victim blaming, towards victims of intimate partner violence (Garimella, Plichta, Houseman & Garzon, 2000). Additionally, a meta-analysis found that males endorse significantly more rape myths than females, which may contribute to the prevalence of negative beliefs about rape survivors (Suarez & Gadalla, 2010). Finally, specialty area of medical practice may be a relevant factor in how physicians view and react to trauma survivors seeking help. Previous research on practicing physicians found that psychiatrists felt they had adequate resources to help victims of intimate partner violence and obstetric-gynecologists endorsed less victim blaming than other specialties which the primary investigator theorized may translate to interest in these areas (Garimella, Plichta, Houseman & Garzon, 2000).

Medical Professionals and Trauma Education Taking into account the practical difficulties and strategies associated with changing beliefs and myths as well as the relevant factors that may influence how individuals react

15 to such information; how might one use this knowledge to educate medical professionals about trauma? First, it is important to consider the unique barriers that medical students and physicians face while attempting to communicate effectively with interpersonal trauma survivors. A contributing factor may be that many physicians and medical students feel unprepared and under-educated on the emotional and medical needs of interpersonal trauma survivors (Amin, Buranosky & Chang, 2017, Green et al., 2011, Parsons, Zaccaro, Wells & Stovall, 1995). This view is shared by experts at a recent summit on medical sexual education in North America, which recommended sexual abuse and intimate partner violence be integrated into the curriculum (Coleman et al., 2013). Medical students also report feeling worried about the negative emotional impact of speaking with trauma survivors, particularly if those students had ever been a victim of violence themselves (Ambuel et al., 2003). There are also concerns about being negatively impacted via learning the traumatic experiences of their patients (Kumajai, Jackson & Razack, 2017). Other physician barriers to providing positive social reactions for intimate partner violence include: fear of offending patients, perceived lack of relevance of intimate partner violence to clinical practice, lack of time, and perception that the patient may be lying (Hamberger & Patel, 2004). Even though many medical students and physicians reportedly want education on how to treat trauma survivors (Amin, Buranosky & Chang, 2017; Green et al., 2011), such education has not been implemented in the current medical education pedagogy. The first two years North American medical training typically begins with two years of primarily in classroom training after completing a bachelor’s degree. During this period, one study found that only 54% of medical schools surveyed had any educational training on rape/sexual violence and 75% on intimate partner violence in these preclinical years

(Steinauer et al., 2009). Following the preclinical years, American medical schools require two years of clinical rotations. Many medical educators have assumed that issues

16 such as rape and domestic violence would be covered in emergency medicine rotations (Koschorke, Tilzey & Welch, 2006). However, this is unlikely, as out of a sample of 120 medical students who had completed their emergency rotations, none of them had experienced treating a sexual assault victim in an emergency context (Best, Dansky & Kilpartrick, 1992). Looking at the first four years of medical education as a whole, a recent UK study found that 13 out of 21 medical schools did not teach about sexual assault at all, and out of the 8 schools which taught on sexual assault, only 6 covered psychosocial factors (Koschorke, Tilzey & Welch, 2006). The actual type of education that medical students are receiving appears to be variable; Hamberger and Patel (2004) noted a wide variety of the amount of coverage abuse and trauma received in medical schools, with some providing a breadth of coverage, and others producing physicians without a working definition of domestic violence. It is not surprising then that between

42% and 62% of contemporary North American medical students reported feeling inadequately trained in issues surrounding sexuality (Wittenberg & Gerber, 2009). Unfortunately, this lack of information appears to extend past the medical school years and into medical practice. In a study looking at practicing physicians, out of 821 doctors: 38.9% had no education on domestic abuse, 48.9% agreed or strongly agreed they felt inadequate dealing with domestic abuse due to lack of training, and 71% said they did not screen for domestic abuse due to lack of education or training (Parsons et al., 1995). The education also does not appear to be present in the form of continuing education for medical professionals, with 80% of publicly accessible emergency departments in Virginia surveyed reporting that they do not offer regular training on sexual violence to their medical staff (Plichta et al., 2006). Though, there have been attempts to teach medical students, residents, and physicians about trauma, there is not a uniform curriculum. For example, some inventions relating to treatment of the patient who is a survivor of interpersonal violence

17 focus on general education and beliefs and attitudes surrounding IPV (Hamberger et al., 2007; Harris et al., 2002), self-care and prevention of vicarious trauma, as well as reinforcing that that the survivor is likely doing the best they can under extreme circumstances (Green et al., 2016), and reducing rape myth acceptance and increased screening (Kennedy et al., 2013; Milone et al., 2010).

Though a few recent studies have attempted to test the effectiveness of education about trauma for medical students (Kennedy, 2013; Milone et al., 2014), these attempts have had a number of limitations. The previous studies were lecture-based interventions provided to medical students who received measures before and after relating to attitudes and beliefs about sexual violence and willingness to screen (Kennedy, 2013; Milone et al., 2014). In both studies, there was no control group which means it is not possible to know whether the observed improvement was due to other factors such as students learning more about issues of interpersonal trauma through outside research or personal experience (Kennedy, 2013; Milone et al., 2014). Though Milone et al (2014) compared individuals who received the intervention and those who did not, the lack of random assignment left it ambiguous whether the medical students who volunteered to attend a lecture on sexual assault response may have had more interest or experience in helping sexual assault survivors. One study with randomized controlled groups was found, which focused on an online continuing education course on intimate partner violence for practicing physicians; which successfully reduced victim blaming (Harris et al., 2002). The intervention assessed was a two week long self-directed online course, in which participants were asked to complete post measures three weeks after completion (Harris et al., 2002).

The Current Study Therefore, the aim of the current study was to develop and test a brief intervention to decrease medical students internal blaming and minimizing attitudes toward trauma

18 survivors. Medical students at University of Minnesota Duluth campus were randomly assigned to receive specialized education on negative social reactions to trauma or general trauma education control. The control video was designed to mirror a typical medical education lecture. These students completed measures on attitudes and beliefs before and after the intervention. The following hypotheses were indicated:

Hypothesis 1. Considering previous literature (Milone et al., 2014; Nayak, 1999; Hayes, Lorenz & Bell, 2013), it was hypothesized that students who receive the experimental intervention would show a decrease in negative attitudes, such as victim blaming, minimizing, rape myths, and JWB, relative to students who receive a typical lecture about trauma. Hypothesis 1a. Due to the primary focus on preventing victim blaming and minimization during the experimental video students who receive this intervention would show the greatest decreases in these negative attitudes. Medical students may also show the greatest gains in this area as a result of their focus on explicit instructions to best assist patients.

Hypothesis 1b. It was expected that students who receive the experimental intervention would experience a moderate reduction in rape myth acceptance, as many of the unhelpful responses discussed in the intervention video are rape myths, but are not explicitly described as such. Also, as shown in Figure 1, acceptance of rape myth beliefs can be thought of as a downstream effect of JWB surrounding sexual violence becoming salient. Hypothesis 1c. It was expected that students who receive the experimental intervention would experience a small reduction in endorsement of JWB. Though JWB are discussed at some length in the intervention video, they are a more stable construct and have been referred to as a trait (Furnham, 2003). It should also be noted that JWB were primarily discussed in the intervention as a way individuals make sense of sexual

19 violence, but JWB is a way in which individuals view the world in a broader sense. Therefore, it may be likely that participants may change how they apply JWB to sexual violence survivors, but not generalize to other situations. Therefore, changes in this variable over the course of a brief intervention were expected to be modest.

Hypothesis 2. It is predicted that Time 2 differences observed between the intervention and control group for the dependent variables would remain even after controlling for their respective Time 1 scores, for the variables which had both Time 1 and Time 2 measures (i.e., JWB and rape myth). Time 1 measures were, therefore, considered potential covariates.

Hypothesis 3. It was expected that the intervention group would show greater decrease in all dependent variables (i.e., victim blaming, minimizing, rape myths, and JWB) than the control group even after controlling for socially desirable reporting. Social desirability was, therefore, considered a potential covariate.

Hypothesis 4. Based on previous research (Deitz, Littman & Bentley, 1984), one would predict that medical students with high empathy would be less likely to blame victims. Physician empathy was, therefore, considered as a potential moderator of intervention effects. Similarly, empathy-related characteristics from the literature such as exposure to humanities (Graham et al., 2016), less years in medical school (Hojat et al.,

2004), and nontraditional student status (Jauhar, 2008) were also examined for potential moderating effects with the expectation that they may correspond to less victim blaming as well. It should also be noted that alternatively, medical students low or lacking in empathy may have more to gain from the intervention whereas high empathy medical students may already have sufficient competence in the targeted learning objectives.

Hypothesis 5.. Previous literature has indicated that individuals who have a personal relationship with an individual who has experienced interpersonal violence may victim blame less (Nayak, 1999). However, another study indicated that healthcare providers

20 who have personally experienced trauma may face additional obstacles while attempting to provide care (Ambuel et al., 2003). Due to a lack of consensus on the impact, this was considered an exploratory hypothesis and this variable was examined as a potential moderator of intervention effects.

Hypothesis 6. Previous literature has shown that practicing obstetric-gynecologists endorse less victim blaming of trauma survivors (Garimella, Plichta, Houseman & Garzon, 2000), therefore the primary investigator included interest as a potential moderator.

Hypothesis 7. Given past education research with medical students (Milone et al., 2014), the intervention was expected to be more effective for female medical students, relative to their male counterparts and gender was examined as a potential moderator of intervention effects.

Hypothesis 8. Society and perpetrator were included as items for participants to attribute blame to after considering sexual violence, however there was a dearth of research to indicate definitive patterns for either variable. Therefore the primary investigator included these as exploratory hypotheses.

Method

Participants As shown in Figure 2, 120 medical students were contacted during the recruitment process. A total of 56 participants completed the study, out of these individuals, five were excluded in statistical analysis due to incorrectly answering the manipulation check. The final participant sample (N = 51) were recruited via email from the first (N = 20) and second (N = 31) year medical school cohorts at the University of Minnesota Duluth campus in January 2018. The sample consisted of 27 (52.9%) female students and the mean age of participants was 24.8 (SD = 2.45). Demographic information on the sample is presented in Table 1. As can be seen, most participants reported European heritage, identified as traditional students, had an undergraduate major or minor in the humanities, and about half were exposed to sexual trauma. Participants were also surveyed on what medical specialties they were most interested in pursuing and were allowed to select as many options as they wanted. The most common specialties selected were all primary care: family medicine, followed by internal medicine, and obstetrics and gynecology. Participants received a $30 Amazon gift card incentive at the completion of the study.

Procedure All procedures were approved by the IRB and approval from the medical school was also attained prior to data collection. Medical students at the University of Minnesota Duluth campus were recruited via an email which outlined the benefits and potential risks of participation. Participation was voluntary and informed consent was obtained at the beginning of the study (see Appendix A). All participants completed a set of online questionnaires using via Qualtrics which included informed consent, questionnaires regarding trauma-related attitudes, beliefs, and basic demographics. Participants were then randomly assigned via Qualtrics receive the experimental or educational control

22 condition, which consisted of separate 12-minute educational videos about psychological trauma. The experimental group received information on the types of negative social reactions common in medical practice. The information provided in the experimental group focused on victim blaming and minimizing, the negative health outcomes that have been linked to such reactions, and strategies to avoid verbalizing these reactions to patients. The comparison condition did not receive any information surrounding negative social reactions and instead received general information about trauma. Following the videos, all participants were asked to complete a manipulation check to assess for attention, then the same set of questionnaires pertaining to trauma-related beliefs and attitudes. They were also asked to complete measures on victim blaming and minimizing.

Educational training videos Development. The intervention and control videos were developed using the following stages: literature review, consulting individuals with relevant medical and educational expertise, script and storyboard development, and editing. It should be noted, as depicted in Figure 3, care was taken to reduce any differences between the intervention and control group besides the independent variable to facilitate internal validity. First, effective learning strategies for educating medical students were considered. Following literature review, intervention materials attempted to validate that thinking about interpersonal trauma may bring up unpleasant emotions and reassure the viewer that having a victim blaming thought does not mean they are bad person or do not care for their patients (e.g., Kennedy & Scriver, 2016; Warshaw, 1997). In continuing with recommendations, the video also debunked myths that medical students are likely to hold

(Kennedy & Scriver, 2016) as well as incorporating the bridging strategy to avoid backfire effects from myth debunking (Ambrose et al., 2010). Active learning activities noted as effective in pedagogy were used such as self-reflection, self-testing, and

23 perspective-taking (Ambrose et al., 2010; Kennedy & Scriver, 2016, Zestcott, Blair & Stone, 2016).

Strategies from relevant literatures were also adopted with regard to changing beliefs, attitudes, and actions. Drawing from Cognitive Behavioral Therapy, the educational intervention included a thought challenging technique in which individuals are taught to identify and challenge automatic thoughts for medical students to use to reduce and replace victim blaming or minimizing thoughts (Lipsey, Landenberger & Wilson, 2007; Zestcott, Blair & Stone, 2016). Following the three tenants of Norm

Activation Theory, the intervention video also included thinking about their personal beliefs (i.e., medical student identity and ethics), sense of personal responsibility (i.e., role as expert), and consequences of behaving in a victim blaming manner (e.g., negative emotional reaction from the patient; De Groot & Steg, 2009).

For the control video, previous educational programming for medical students on psychological trauma were considered (Foster, Hines, Johnson & Davidson, 2013). From this, it was decided to include information about the neurobiological impacts of mental illnesses commonly associated with psychological trauma as well as the importance of screening and common treatments for related conditions (Foster, Hines, Johnson & Davidson, 2013). A lecture previously presented to University of Minnesota Duluth campus medical students on the impacts of psychological trauma was also examined in preparation of the development of the control video (Lewis, 2015). This lecture led the primary investigator to include references to multiple scientific studies, including the Adverse Childhood Experiences study (Lewis, 2015).

Advice was also sought from multiple outside sources during the development and production of this intervention. The multimedia department at the University of

Minnesota Duluth provided assistance to maximize participant engagement. It was suggested that the intervention be kept as brief as possible (preferably about six minutes)

24 and have the duration of each image also be brief (preferably no more than 30 seconds) and these recommendations were followed as often as possible. An animation style was decided on to create a video that is engaging and nonthreatening as well as remaining informative. Contributions to this intervention were also made by Dr. Ryan Harden, University of Minnesota, Duluth Campus Medical School Family Medicine professor, who reviewed and made suggestions on drafts of the scripts for the intervention video. Specifically, Dr. Harden assisted in ensuring the medical accuracy of the information. He helped ensure that the level of rigor was appropriate for an intervention aimed at medical students. He also helped clarify what students would already have been exposed to in other classes in order to maintain student engagement by focusing on new information. Furthermore, he helped reduce any reactivity or defensiveness on the part of medical students by noting words and phrases medical students might find pejorative and offering alternative language which was adopted. Suggestions were also utilized from four current medical students at universities other than the University of Minnesota and one practicing physician who have a personal relationship with the primary investigator. For the intervention video, these professionals highlighted aspects of the intervention that medical students may react negatively to, such as overly broad assertions, medical inaccuracies, and feeling shamed or confused. For the control video, these students also helped trim information that was perceived as overly basic or repetitive. Feedback was also incorporated from graduate and undergraduate research assistants, many of whom had familiarity with the study topic due to assisting with the literature search and contributed to similar interpersonal violence research work. This feedback was used to clarify concepts in an attempt to reduce confusion, devise appropriate visuals for concepts, optimize pace, and promote engagement.

Intervention. The educational intervention video begins with an explanation of what psychological trauma is and how it can negatively impact patients. As the video

25 precedes it explains that some reactions to trauma disclosure can be harmful to the patient, and then acknowledges that viewer likely wants to remain helpful by invoking the Hippocratic Oath. Information was then provided about patients seeking help for trauma-related needs: such as their potential fears of negative social reactions, negative impacts of such reactions, and what is particularly helpful or unhelpful about social reactions from formal support providers. The viewer was invited to think about their own identities as medical students with associated obligations. Care was also taken to normalize the experience of discomfort surrounding emotional topics. An example of a physician providing an unhelpful response to a help-seeking patient was then given. This behavior was explained through the lens of JWB in a non-judgmental manner, paying particular attention to the reactions of victim blaming and minimizing. A strategy for combating just world responses to patients was provided in the form of a Cognitive

Behavioral technique for combating automatic thoughts, and an example of this was shown. Viewers were also encouraged to take into consideration how their tone of voice may be perceived by patients. Finally, several active learning exercises were used, including: reflection on their own thoughts and feelings after a presentation with trauma survivors telling their stories, and practice exercises for both identifying and not verbalizing unhelpful thoughts. A final summary was then provided which touched upon unhelpful reactions and how to combat them.

Control. Just as with the intervention video, the control video begins with the definition of psychological trauma. The relevance to medical practice is established by explaining how trauma can impact physical health. This is reinforced by providing multiple scientific studies related to trauma and health, including the Adverse Childhood Experiences study (Felitti et al., 1998). The underlying stress response that gets engaged as an individual experiences trauma is discussed, as well mental disorders associated with a disruption in this response. Posttraumatic Stress Disorder (PTSD) is then described

26 using the DSM-5 criteria, as well as it’s correlated neurobiological variations. A screening device appropriate for primary care is also presented. Major Depressive

Disorder (MDD) is also discussed as a mental disorder commonly associated with psychological trauma. Viewers were presented with a helpful mnemonic for diagnosing MDD as well as current literature on the impact of MDD on the brain. As with PTSD, viewers were presented with a screening tool for MDD. Other mental health conditions commonly related to trauma were discussed such as anxiety and substance abuse. Interventions for trauma-related mental disorders were discussed, as well as information on appropriate referrals. As with the intervention video, active learning techniques were used, including practice questions related to the literature presented. Finally, a brief summary was included that reinforced the importance of psychological trauma to medical practice and the necessity for screening.

Measures Participant characteristics. Participant characteristics were measured including: year in school, gender, race/ethnicity, whether they consider themselves a “nontraditional” medical student meaning he or she took time off between their bachelor’s degree and matriculating in medical school, undergraduate coursework in the liberal arts/humanities, whether they had been exposed to sexual trauma, and the specialties they are most interested in pursuing (see Appendix B).

Manipulation Check. Participants were assessed for sufficient attention to the video by answering a multiple-choice question requiring them to select a key objective for the condition they viewed. The correct answer for the intervention group was “Define just world fallacies and learn strategies for just world fallacy prevention” and “Define Post-Traumatic Stress Disorder and learn strategies for screening” for the control group.

The full manipulation check is included in Appendix C and the delineation of participants who answered incorrectly is shown in Figure 2.

27 Attitudes. Both global and specific attitudes were measured. Though victim- blaming can pertain to any type of trauma, there is some evidence that negative attitudes may be stronger for sexual assaults relative to other traumas (Best, Dansky & Kilpatrick, 1992), as such specific attitude measures pertained to interpersonal trauma. Victim-blaming. Victim blaming attitudes were assessed by having participants respond to a brief vignette developed for the intervention of a rape survivor coming into the Emergency Department (see Appendix D). This vignette was created to provide multiple subtle cues that have been linked to increased participant blaming of victims without explicitly blaming the survivor; such as going to a party or walking home with a man, as well as not being emotionally expressive (Ask & Landstrom, 2010; Best, Dansky & Kilpatrick, 1992). It also mirrors common behaviors of survivors such as confiding in a friend or informal support provider first (Ahrens et al., 2007), not going to the police

(Patterson, Greeson & Campbell, 2009) as well as having the perpetrator being known to the survivor, which accounts for between 80 to 90% of rapes (Cowan, 2000). The survivor in the vignette was selected to be female because medical students have endorsed more blaming statements about female victims of sexual assault than other victim types in past research (Best, Dansky & Kilpatrick, 1992). Participants were asked to rate how much they found the perpetrator, survivor, and/or society responsible for the rape presented in the vignette on a scale from 0 to 100, providing three separate scores. Minimization. The Minimization Scale was developed for a domestic violence study by examining previous literature as well as common statements noted by clinicians working with this population (Henning, Jones & Holdford, 2005) (see Appendix E). The scale required minor adjustments (i.e. changing “The police should not have gotten involved in this because it was just a simple family argument” to “The police should not have gotten involved in this because it was just a simple misunderstanding”). Participants respond to five statements regarding the provided vignette such as “This situation got

28 blown way out of proportion.” The participants in this study responded on a 5-point Likert scale ranging from (1) strongly agree to (5) strongly disagree (Henning, Jones &

Holdford, 2005). Scoring is completed by summing items, with higher scores indicating more minimization. The internal consistency of this scale was good, Cronbach’s α = .91, for this sample.

Just world belief. The Global Belief in a Just World (Lipkus, 1991) is a 7-item self- report measure of the degree to which the respondent views the world as an inherently just and fair place in which good things happen to good people whereas bad things happen to bad people (Stromwall, Alfredsson & Landstrom, 2012) (see Appendix F). Participants rate how much they agree with statements such as “I basically feel that the world is a fair place” on a Likert scale ranging from (1) not at all to (7) extremely. Scoring is completed by summing items, with higher scores indicating more endorsement of JWB and a range of possible scores from seven to 49 (Lipkus, 1991). The Global Belief in a Just World has good internal consistency (α = 0.79 to 0.82; Furnham, 2003). The reliability of this measure was good for this sample, Cronbach’s α = .84.

Rape myth acceptance. The Acceptance of Modern Myths About Sexual Aggression (AMMSA; Gerger et al., 2013) scale is a 30-item scale (see Appendix G). Participants rate how much they agree with statements such as “When it comes to sexual contacts, women expect men to take the lead.” on a scale ranging from (1) completely disagree to (7) completely agree; (Gerger et al., 2013). The AMMSA is scored by adding up the item responses with higher scores indicating higher endorsement of rape myths yielding a range of possible total scores of 30 to 210 (Gerger et al., 2013). The reliability of this measure was good for this sample, Cronbach’s α = .90. Empathy. The Jefferson Scale of Physician Empathy (JSE; Hojat et al., 2001) is a

20-item self-report measure of the extent to which physicians attempt to empathize with their patients (see Appendix H). Participants rate how much they agree with statements

29 such as, “A physician who is able to view things from another person’s perspective can render better care” on a Likert scale ranging from (1) not at all to (7) extremely. Scores are calculated by reverse coding half of the items then summing them, with higher total scores being indicative of increased empathy for patients yielding a range of possible scores of 20 to 140 (Hojat et al., 2001). The JSE shows convergent validity with an existing Empathic Concern measure and items related to warmth were correlated with the NEO-PI-R as expected (Hojat et al., 2001) and has good internal consistency (α = 0.75 to 0.84; Hojat & LaNoue, 2014). The reliability of this measure was good for this sample,

Cronbach’s α = .85. In a large, longitudinal study of US medical students the mean empathy score was 114.3 with a standard deviation of 10.4 (Hojat & Gonnella, 2015). This continuous measure was coded based off of normative data for male and female medical students using cut offs in an attempt to account for known gender differences.

Cut-offs for high scores have been tentatively suggested by the study authors as  127 for male medical students are  129 for female medical students and  100 for male medical students and  95 for female medical students (Hojat & Gonnella, 2015). The mean empathy score for the current sample was 120.4 (SD = 11.03) for male medical students and 127.6 (SD = 9.21) for female medical students. Trauma exposure. The Life Events Checklist for DSM 5 (LEC-5; Gray, Litz, Hsu &

Lombardo, 2004) is a 17-item self-report measure which requires participants to endorse different types of traumatic events they may or may not have experienced over their lifetime (see Appendix I). It also one of the most commonly used screening measures for traumatic experiences. Participants rate items such as “Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)” by selecting from the following options on a 5-point nominal scale: “Happened to me, Witnessed it, Learned about it, Part of my job, Not sure, or Doesn’t Apply” (Gray, Litz, Hsu & Lombardo, 2004). For the purpose of analyses exposure to sexual trauma was operationalized by a score of one being

30 assigned to participants endorsing they had either experienced or witnessed sexual assault or an unwanted or uncomfortable sexual experience. Those who did not indicate experiencing or witnessing such events received a score of zero. Social desirability. Marlowe–Crowne Social Desirability Scale (MCSDS; Crown & Marlowe, 1960) is a 33-item self-report measure of how much the participant attempts to present themselves in the most positive light (Leiter & Beretvas, 2005) (see Appendix J). It is described as deserving to be retained as the “gold-standard” for this construct (Lambert, Arbuckle, Spencer, Holden & Ronald, 2016). When scoring, some items are reverse coded. Items are summed and higher scores indicate a greater likelihood of presenting oneself in an overly positive light yielding a possible range of zero to 33. Scores equal to or above 20 suggest that the respondents are answering in a way that presents themselves in an overly positive light. The reliability of this measure was good for this sample, Cronbach’s α = .80. The mean for the current sample was 16.3 with a standard deviation of 5.40, which indicates that, on average, respondents in this sample were likely not attempting to present themselves in an overly positive fashion.

Planned Statistical Analysis Analysis 1. Hypothesis 1a through 1c predicted a significant decrease for the intervention relative to the control groups for the following dependent variables: JWB, minimizing, rape myths, and victim blaming. This was examined using a series of independent samples t-tests. Given that the relationship between intervention exposure and attitudes was hypothesized to vary in strength depending on the type of attitude measures, each t-test represented a test of a unique hypothesis. Therefore, a p-value of .05 was retained for interpreting statistical significance.

Analysis 2. Hypothesis two predicted that the differences between the intervention and control group for the dependent variables (JWB and rape myths) would remain even after controlling for their respective time one scores. This was done using

31 separate analysis of covariances (ANCOVAs). These measures were selected because they had time one measures available whereas the other dependent measures could only be measured at post as participants were given a novel sexual trauma vignette.

Analysis 3. Hypothesis three predicted that differences between the intervention and control group for the dependent variables (JWB, rape myths, minimizing, victim blaming) would remain even after controlling for socially desirable responding. This analysis plan then called for the use of ANCOVA.

Analysis 4. Hypothesis four predicted the intervention may be more effective for individuals who exhibit high empathy and/or related-characteristics. Given that previous research has found gender differences for the physician empathy, cutoff scores for each gender were used. High versus low empathy for males and females, was explored as a potential moderator of intervention effects using a two-way ANOVA that examined the interaction between condition and empathy. Similarly, empathy-related characteristics such as year in school, exposure to humanities, and nontraditional status were examined as potential moderators via a series of two-way ANOVAs examining the interaction term.

Analysis 5. Hypothesis five predicted that exposure to sexual trauma would influence how participants may respond to the invention, and was explored using a two- way ANOVA. There were conflicting results in previous literature has indicating that individuals who have personal experience with interpersonal violence may victim blame less (Nayak, 1999) as well facing potential difficulties in attempting to provide care (Ambuel et al., 2003).

Analysis 6. Hypothesis six predicted that interest in obstetric-gynecology would correspond to less victim blaming among participants, and was explored using a two-way ANOVA.

32 Analysis 7. Hypothesis seven predicted that the intervention would be more effective for female participants than their male counterparts. This was examined via a two-way ANOVA.

Analysis 8. Hypothesis eight predicted that there may be differences between groups in considering society and perpetrator blame, and was explored using a two-way

ANOVA.

33 Chapter 3 Results

Preliminary Analyses All statistical analysis was performed using SPSS. All variables were examined for normal distribution and outliers. Victim blame was positively skewed whereas perpetrator blame was negatively skewed and both were transformed using the Arcsine transformation for percentage data (Cohen, Cohen, West, & Aiken, 2003). Basic descriptive statistics and simple correlations were examined (see Table 2). The variables examined were primarily correlated as expected. As predicted, the time one variables were highly correlated with their respective time two results victim blaming and perpetrator blaming were strongly negatively associated. There was also a positive association between perpetrator blame and rape myth acceptance and a negative association between victim blame and rape myth acceptance. Time one variables were highly correlated with their respective time two results and victim blaming and perpetrator blaming were strongly negatively associated. There was also a positive association between perpetrator blame and rape myth acceptance and a negative association between victim blame and rape myth acceptance. There was a strong positive relationship between rape myths and JWB.

Minimization scale. Initial investigation of minimization scale revealed that this measure was negatively skewed and not well correlated with variables known in the literature to be related such as blaming or endorsement of myths of sexual aggression even after attempts to correct the abnormal distribution via transformation. This might have been because the Likert scale for this measure was in the reverse direction relative to the remainder of the questionnaires with lower numbers indicating greater minimization. In fact, some participants noted this switch in the feedback (see Appendix

K). An examination of participant level responses revealed participants were using

34 extreme ends of the scale, but not in a consistent manner with similar items of other measures. Given the resulting ambiguous validity of this measure, the minimization scale was excluded from statistical analysis.

Covariates. Planned analyses included an examination of intervention effectiveness for attitudes after controlling for variations in time one levels using ANCOVA. Though neither time one differences in rape myth acceptance nor JWB were statistically significantly different between the experimental groups (see Table 3), adjusting for within-participant variation would provide a more powerful statistical test of intervention effects. Preliminary tests for the assumptions of ANCOVA with the time one rape myth acceptance and JWB indicated acceptable reliability (see section above), linear relationships with their respective time two scores (see Table 2), and homogeneity of regression slopes, F(1, 47) = 0.26 p =.6.

Main Analyses Intervention-control group differences for attitudes following the educational video were examined first using independent-samples t-tests. A main effect was found for victim blaming such that the intervention group blamed the vignette survivor less than the control group (see Table 4). There were no statistically significantly differences between the groups for perpetrator blame, society blame, or the post-intervention measures for

JWB and endorsement of rape myths. As can be seen, a medium time 2 effect size was found for victim blaming between the intervention and control groups, as well as small- medium effect sizes for perpetrator blame, rape myths, and JWB. Group differences for post-intervention attitudes were also analyzed adjusting for time one scores via analysis of covariance (ANCOVA). These analyses reveal no statistically significant difference for intervention versus control for JWB, F(1,48) = 2.57, p = .1 d = 0.32, nor rape myth acceptance F(1,48) = 0.40, p = .5 d = 0.39.

35 Secondary Analyses The intervention effect was examined to test whether results might vary depending on any participant characteristics as evidenced by an interaction effect via two-way ANOVA. Participant characteristics—year in medical school, gender, nontraditional student status, sexual trauma exposure, undergraduate humanities majors or minors, and physician empathy did not statistically significant interact with group condition for any of the post-intervention attitude scores (see Table 5). In addition, no statistically significant interaction effects were observed for participant characteristics and group condition for time two JWB and rape myth acceptance after also controlling for time one scores respectively, all interactions ps > .05. With one potential exception, empathy did not moderate the intervention effect for time two attitudes (see Table 5). There was a statistically significant interaction for empathy and group condition for final JWBs, such that the intervention appeared to be especially effective for those below the “high empathy” cutoff. However, it should be noted that the Levene’s test for equality of error variances was statistically significant for this analysis, suggesting this assumption may have been violated, p = .04. In such circumstances, the recommended course of action is to utilize a more conservative p- value such as .01. Notably, also, after examining the two-way ANCOVA which adjusted for time one scores, this interaction was no longer statistically significant, p = .7.

Participant Feedback Feedback was also solicited from participants. The feedback provided generally fell into two categories: encouragement for the project and suggestions regarding measures.

Some participants noted the value of the intervention for medical and broader education. Recommendations were also made regarding the measures used, including the heteronormative assumptions made and confusion regarding a few items.

36 Chapter 4 Discussion This study examined the effectiveness of a brief educational intervention for the purpose of teaching medical students about helpful and unhelpful reactions to interpersonal trauma survivors seeking help. The intervention may have successfully prevented participants from victim blaming a hypothetical female sexual assault survivor seeking medical attention. Examining the means between the control and intervention group, the intervention group blamed the survivor less than 1%, in comparison to the control which blamed the victim greater than 5% on average. This is particularly significant because it indicates a greater number of intervention participants understood the survivor is never to blame, which is further evidenced by the differences in standard deviations indicating a greater range of responses among control participants. However, statistically significant differences were not observed between the intervention and control groups for perpetrator blame, society blame, rape myth acceptance, or JWB. It should also be noted that the effectiveness of the intervention did not appear to vary based on hypothesized participant characteristics, such as sex, empathy and empathy- related characteristics, and interests. However, there were limits to the statistical analysis of characteristics due to the limited sample size and low power.

The potential effectiveness of the intervention for victim blaming could primarily be explained by the focus on this during the intervention. The intervention video harkens to the potential harm of victim blaming on multiple occasions and it is framed as a particularly egregious reaction to a person seeking help. This is a particularly promising finding due to the conceivable harm imbued by victim blaming a patient (Bonnan-White et al., 2015, Campbell et al., 2001). This also encourages further research aimed at improving medical care for survivors of psychological trauma.

37 Though an effect may have been found for victim blaming, there was no statistically significant differences between the other measured variables. Notably, the means between the two groups resulting in the predicted direction for perpetrator blame, rape myth acceptance, and JWB, albeit not at a statistically significant level. A post hoc power analysis of a two-tailed independent samples t-test with a medium effect size (Cohen’s d

= 0.5) with an alpha level of .05 indicated a 42% chance of finding an effect. Therefore, it is possible a larger sample size would have illuminated other potential effects. In addition, it remains possible that the timing of the intervention may have also played a role in the results. Participants were asked to complete post measures immediately after watching the videos. Potentially, this could not have given participants enough allotted time to reflect and absorb the content. Participants may have gathered the explicit advice to not victim blame survivors from the intervention, but may need more time to sustain the underlying message of the unhelpful nature of JWB or wrestle with the backfire effect. Perhaps if participants had more time after the video they may have considered how many of the schemas they have surrounding sexual violence may be inaccurate. In addition to the pacing of the intervention, the stability of the constructs measured may have contributed to the results. It is possible to conceptualize JWB as a relatively consistent personality trait (Furnham, 2003), which is therefore unlikely to be altered by a 12-minute educational video. One’s beliefs about the inherent fairness of the world may simply be too stable to be significantly shifted by a brief intervention. Rape myths may also be considered relatively stable, like a schema that helps individuals explain sexual violence (Sussenbach, Eyssel & Bohner, 2013). This could also explain the lack of statistically significant change in rape myths between the intervention and control groups.

38 Aside from the stability of rape myths, it should also be noted that though some rape myths were addressed it was not a major focus of the intervention. Perhaps if more time and attention had been spent on this aspect, a difference may have been observed. The victim blaming specific outcome may also reflect something unique about the medical student population. As previously mentioned, Norm Activation Theory was foundational to the development of this project. A key aspect of Norm Activation Theory is that individuals behave in a prosocial manner if they feel it is within their realm of control. Perhaps as participants completed the measures after the video they were cognizant that they may be unable to control the beliefs and attitudes of themselves and others, but they can control how much they attribute blame to the survivor. This may be in relation to medical education’s focus on equipping physicians with the tools to continually solve the same manageable problems, (i.e. identify the correct symptoms in order to determine the ‘pattern’ that is the illness across multiple patients) using a set of mostly unchanging rules (Maudsley & Strivens, 2008). Once a medical student determines the pattern and the rules it abides by, they have succeeded, and perhaps feel less urgency or desire to spend additional cognitive energy on internal beliefs. The manner in which participants approached the intervention may also have influenced the results. It may be reasonable that an effect was found solely for victim blaming because that was the most explicit advice provided in the intervention. Due to the immense amount of knowledge that medical students are expected to retain, they may attempt to focus on the main, practical action-oriented points of the information they are provided, knowing that the more detailed information can always be referenced at a later date. This approach was shown in the feedback provided by current medical students during the development phase, multiple who suggested emphasizing ways in which medical students can approach trauma survivors to promote healing.

39 The potential historical effect of the #metoo movement should also be noted. This intervention took place approximately three months after the hashtag spread virally across the internet, increasing the public conversation surrounding sexual violence (Johnson & Hawbaker, 2018). It is impossible to know the effect the movement may or may not have had on the study. The heightened attention may have generated increased interest in the intervention, and provided a way for participants to engage with the social movement in a way that was relevant to their lives. However, this may have also resulted in more floor and ceiling effects due to participants being more knowledgeable of the potential negative impacts surrounding interpersonal violence; for example, the rape myth acceptance scale yielded a mean of less than two out of a possible seven. As with any scientific endeavor, there were limitations to the study. As mentioned previously, the sample size was relatively small. Furthermore, there is no available data on individuals who chose not to participate and it is possible those who decided to complete the study had significant differences from those who did not. It is possible that those who chose to participate in the study have more interest and empathy towards trauma survivors than those who did not, and may be more likely to respond to programming aimed at helping these individuals (Campbell, 1995). Perhaps students who are apathetic or uninterested self-selected themselves out by not volunteering, and their inclusion could have impacted results. Another limitation was the lack of an appropriate minimization measure. It was originally conceptualized that victim blaming and minimizing were two negative social reactions providers should avoid in assisting interpersonal trauma survivors and this intervention would address both. However, the minimization measure chosen demonstrated poor reliability and validity. Furthermore, investigators are unable to determine if the intervention had any impact how medical students engage with patients. Additionally, because of the immediate administration of

40 the final questionnaires, one cannot know if the participants would retain the decreased victim-blaming attitudes over time.

There are also concerns regarding generalizability to academic medicine more broadly. The racial demographics of the sample were markedly different from the national averages of medical student matriculates, showing a greater than average number of European-American and Native-American students and lesser than average number of Asian-American, Black or African-American, and Hispanic/Latinx students (AAMC, 2017). In addition, the University of Minnesota Medical School Duluth Campus also has a unique focus on primary care and rural health (UMN, 2014) which was evidenced by frequencies of specialties participants reported being interested in. This is not a universal trait among medical schools, as many have different missions that may vary from scientific research to serving particular demographic groups or regions to producing specialists. It remains possible that this intervention was uniquely helpful for medical students interested in primary care and rural medicine, and results would have been different at another institution with a different focus.

Another important limitation is the heteronormative nature of the measures, which was mentioned in the feedback provided by participants. This was unfortunately unavoidable due to the majority of literature surrounding intimate partner and sexual violence, and subsequently the availability of psychometrically sound measures, revolves around male perpetrators and female victims. The rape myth scale especially may have been overly gendered and difficult to understand due to the phrasing of items as noted in participant feedback.

It should also be noted that the brief nature of the intervention as well as the timing of responses are a limitation. It is possible that a longer and more intensive intervention such (e.g., Harris et al., 2002) may have yielded more robust results.

41 Future directions might address some of the limitations mentioned here as well as whether or not the intervention impacts minimization using a more appropriate measure.

Additionally, minimization and victim blaming are not the only reactions that survivors find unhelpful. Failing to provide adequate information is also a significant barrier that survivors face, with only 20% of women who had undergone an emergency room exam immediately following their rape being told the potential health consequences associated of sexual assault (Campbell & Bybee, 1997). Furthermore, less than half of female rape survivors received information about the risk of pregnancy, the emergency contraception pill, or information on STIs and HIV (Campbell et al., 2001). This is particularly notable because nearly one-third of women who seek medical attention report their experience with medical providers to be hurtful, with those who do not receive information on pregnancy or STIs being more likely to rate their experience as harmful (Campbell et al.,

2001). An additional avenue for research could focus on ensuring that survivors’ medical needs are addressed. Future research might also include additional follow-ups as well as more time taken during the intervention to reflect on the material using their own personal experiences. Using techniques such as small group discussions, more self-reflection questions, and writing down one’s feelings may encourage this reflection. It may also make sense to increase the directive nature of the video and include more explicit instructions for providers. In conclusion, victim blaming was lower for medical students who received the intervention video as compared to the control. This is particularly important as victim blaming a trauma survivor seeking medical attention is not only perceived as unhelpful (Campbell, 2005), but may also contribute to cognitions that are common among those with post-traumatic stress disorder (Bonnan-White, Hetzel-Riggin, Diamond-Welch and

Tollini, 2015) and contribute to the survivor feeling less likely to seek help from others in

42 the future (Campbell, 2005). This is especially promising given one of the strongest predictors of whether a survivor will develop psychological problems following a trauma is social support (Beeble et al., 2009; Chivers-Wilson, 2006; Rusch, et al., 2015) which may buffer against the stress of a traumatic event (Coker et al., 2002; Ullman, 1999). Therefore, victim blaming reactions from formal support providers could be conceptualized as a double blow, that not only has the potential to harm the patient immediately, but also to create obstacles for the recovery process in the future. By providing survivors with more supportive medical care instead, it is possible medical professionals can help prevent trauma-related distress. Therefore, this study contributes to satisfying recommendations (Coleman et al., 2013; Kennedy & Scriver, 2016) imparted by medical educators on the creation of effective programs aimed at improving service for patients suffering from violence.

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60 Table 1

Sample Demographic Information

Characteristic Overall Sample N(%) Experimental Control 2

Year in School 1.92

First 20 (39.2) 7(29.2) 13 (48.1)

Second 31 (60.8) 17(70.8) 14 (51.9) Race/Ethnicity 0.24

White/European 48 (94.6) 23(95.8) 25 (92.6)

Native-American or Alaska 4 (7.8) 3(12.5) 1 (3.7)

NativeAsian- American 1 (2.0) 0(0.0) 1 (3.7) Student Status 0.79

Non-traditional 16 (31.4) 9(37.5) 7 (25.9)

Traditional 35 (68.6) 15(62.5) 20 (74.1) Humanities 0.59

Undergraduate major/minor 29 (56.9) 15(62.5) 14 (51.9)

No undergraduate 22 (43.1) 9(37.5) 13 (48.1)

Sexualmajor/minor Trauma Exposure 0.017

Experienced/witnessed 26 (51.0) 12(50) 14 (51.9)

No experience 25 (49.0) 12(50) 13 (48.1) Specialties of Interest -

Primary care 78(152.9 ) 33(137.5) 45 (166.7)

Trauma-related specialties 23(45.1 ) 10(41.7) 13 (48.1)

Surgical specialties 18(35.3 ) 11(45.8) 11 (40.7)

Other specialties 48(94.1) 20(83.3) 28 (103.7)

Note Primary Care = obstetric/gynecology, family and internal medicine. Trauma-related specialties = obstetric/gynecology and psychiatry. Surgical specialties = plastic, neurological, vascular, thoracic, orthopaedic, and general. Other specialties = pediatrics, emergency medicine, anesthesia, dermatology, preventative medicine, neurology, radiology, otolaryngology, urology. Specialties of interest were not mutually exclusive categories

61 Table 2

Zero Order Correlations, Means, and Standard Deviations for Outcome Variables

Variable 1. 2. 3. 4. 5. 6. M SD

1. Perpetratora 96.51 8.28

2. Victima -.82* 3.02 8.17 3. Society -.11 -.03 35.49 27.62 4. Just World Pre -.02 .01 -.03 18.55 5.88

5. Just World Post -.15 .18 -.14 .83* 16.10 6.98 6. Rape Myth Pre -.25 .31* -.16 .52* .63* 1.69 0.42 7. Rape Myth Post -.31* .37* -.20 .48* .61* .94* 1.55 0.46

Note. N = 51. Blame based on percent attributed to perpetrator, victim, and survivor regarding a vignette. JWB was measured using The Global Belief in a Just World scale, with higher scores indicating stronger beliefs. Rape myths were measured using the Acceptance of Modern Myths About Sexual Aggression (AMMSA) scale, with higher scores indicating stronger endorsement of myths. aArcsine transformations were used for statistical analysis, however, for ease of interpretation, raw percentage means are presented here. *p < .05

62 Table 3. Comparison of Variables Across Conditions

Time 1 Time 2

M(SD) M(SD) Measure Intervention Control t d Intervention Control t d

Physician Empathy 126.42 (11.92) 122.26 (11.92) 1.44 0.35 - - - -

Social Desirability 15.58(8.67) (5.86) 17.26 (5.27) 1.08 0.30 - - - - Just World Belief 18.29 (4.97) 18.78 (6.66) 0.29 0.08 14.92 (6.06) 17.15 (7.66) 1.16 0.32 PreRape Myth 1.61 (0.40) 1.76 (0.44) 1.26 0.35 1.46 (0.39) 1.64 (0.51) 1.40 0.39 Perpetrator Blamea - - - - 98.55 (3.27) 94.63 (10.65) 1.65 0.49 Victim Blamea - - - - 0.69 (1.80) 5.40 (10.71) 2.35* 0.60 Society Blame - - - - 33.58 (27.0) 37.17 (28.56) 0.46 0.13

Note. N=51. Empathy = Jefferson Scale of Physician Empathy, Social Desirability = Marlowe–Crowne Social Desirability Scale, JWB = The Global Belief in a Just World scale, Rape myths =Acceptance of Modern Myths About Sexual Aggression scale, and blame = the percentage blame for a sexual assault survivor vignette. Higher scores indicate greater endorsement of the construct. aFor ease of interpretation, raw means and SD are provided for Perpetrator and Victim Blame though analyses utilized arcsine transformation.

*p < .05

Table 4. Relationship Between Participant Characteristics and Effectiveness of Intervention Interaction F p Just World Post Year 2.84 .1 Sex 0.44 .5 Non-traditional 0.44 .5 Humanities 1.29 .3 Sexual Trauma Exposure 0.97 .3 Empathy 5.71 .02 Rape Myth Post Year 3.16 .08 Sex 3.15 .08 Non-traditional 0.08 .8 Humanities 2.68 .1 Sexual Trauma Exposure 0.06 .8 Empathy 1.66 .2 Victim Blame Year 2.06 .2 Sex 0.00 .9 Non-traditional 0.00 .9 Humanities 0.17 .7 Sexual Trauma Exposure 0.48 .5 Empathy 0.82 .4 Perpetrator Blame Year 0.47 .5 Sex 0.34 .6 Non-traditional 0.10 .8

64 Humanities 0.39 .5 Sexual Trauma Exposure 0.25 .6 Empathy 1.37 .2 Society Blame Year 0.18 .7 Sex 0.10 .8 Non-traditional 0.01 .9 Humanities 0.20 .7 Sexual Trauma Exposure 1.48 .2 Empathy 1.37 .2

Note. Non-traditional students reportedly took time between earning their bachelor’s degree and matriculating into medical school. Humanities were operationalized by whether or not the participant had an undergraduate major or minor in the humanities and/or liberal arts. Participants were considered to have been exposed to sexual trauma if they had witnessed or were a survivor of sexual assault or an uncomfortable sexual situation. Physician empathy was measured using the Jefferson Scale of Physician Empathy (JSE), with higher scorers valuing empathy more.

Rape Culture

Just World Beliefs

Attributions of

Minimization Blame:

of Trauma  Victim

 Perpetrator

Stress Reduction

Sense of Control and

Safety

Rape Myth Acceptance

Figure 1 Theorized Relationship Between Dependent Variables Following Literature Review

Recruitment Recruited Students (n=120)

Excluded (n=64)  Declined to participate (n=0)

Randomized (n=56)

Allocation

Allocated to experimental intervention (n=29) Allocated to control group (n=27)   Received allocated intervention (n=27) Recei ved allocated intervention (n=29)  Did not receive allocated intervention (n=0)  Did not receive allocated intervention (n=0)

Analysis

Analysed (n=24) Analysed (n=27)  Excl uded from analysis due to incorrectly  Excluded from analysis (n=0) answering manipulation check (n=5)

Figure 2 Flow Chart Indicating Process in Which Participants Were Recruited, Randomized, and Data Analyzed

67 Intervention Control

• Definition & • Describe JWB and how they can be impact of verbalized trauma • List common mental disorders and symptoms associated with trauma • Incorporated

• Describe impact of verbalized JWB on current studies survivors • Neurobiological impacts of trauma

• Animation style and • Use cognitive strategies to identify and • Importance of screening voice-over change attitudes and beliefs • 12 minutes • Helpful resources to reference in the care of trauma survivors • Examine the role of medical ethics in the • Active treatment of trauma survivors learning exercises

Figure 3 Venn Diagram Depicting Unique and Shared Features of the Intervention and Control Conditions

Appendix A Consent Form Title of Research Study: An Educational Intervention for Medical Students Working with Trauma Patients

Researcher: Natalie Slaughter; Dr. Catherine Reich, advisor

Supported By: research is supported by the University of Minnesota, and internal funding grant from the UMD Psychology Department.

Why am I being asked to take part in this research study?

We are asking you to take part in this research study because you are a University of

Minnesota – Duluth Campus Medical School student

What should I know about a research study? ● Someone will explain this research study to you. ● Whether or not you take part is up to you. ● You can choose not to take part. ● You can agree to take part and later change your mind. ● Your decision will not be held against you. ● You can ask all the questions you want before you decide.

Who can I talk to?

For questions about research appointments, the research study, research results, or other concerns, call the study team at:

Researcher Name: Natalie Slaughter Advisor: Catherine Reich

Phone Number: (218) 726-8639 Phone Number: 218 7267420 Email Address: [email protected] Email Address: [email protected]

69 This research has been reviewed and approved by an Institutional Review Board (IRB) within the Human Research Protections Program (HRPP). To share feedback privately with the HRPP about your research experience, call the Research Participants’ Advocate Line at 612-625-1650 or go to www.irb.umn.edu/report.html. You are encouraged to contact the HRPP if:

● Your questions, concerns, or complaints are not being answered by the research team. ● You cannot reach the research team. ● You want to talk to someone besides the research team. ● You have questions about your rights as a research participant. ● You want to get information or provide input about this research.

Why is this research being done?

Educational interventions about psychological trauma aimed at medical students is an under-researched area. This current study tests provides two different educational interventions to evaluate and will evaluate the effectiveness of the trainings. This line of research could improve care for trauma survivors.

How long will the research last? • 10-15 minutes for the following online questionnaires • 12-minute educational video • 5-10 minutes post-test online questionnaire

How many people will be studied?

We expect approximately 120 medical students at University of Minnesota – Duluth Campus Medical school.

What happens if I say “Yes, I want to be in this research”? • You will first complete online questionnaires that follow this page. • Participants will be randomly assigned into one of two educational groups. • Everyone will watch an approximately 12-minute educational video about caring for psychological trauma patients. • After the video, you will again complete a brief set of online questionnaires. • To thank you for your participation, you will receive a $30 gift card to

70 Amazon.com after completion of the study.

What happens if I do not want to be in this research?

All aspects of this study are voluntary. You can leave the study at any time and it will not be held against you.

Is there any way being in this study could be bad for me?

As this study involves teaching about psychological trauma and completing questionnaires about sensitive information (such as past historical events, attitudes, and beliefs) you may be exposed to information about violence which some may find uncomfortable or triggering.

Will being in this study help me in any way?

We cannot promise any benefits to you or others from your taking part in this research.

However, possible benefits might include: • Greater understanding of a common patient issue • Potentially improve care of your future patients who are interpersonal trauma survivors • At the completion of this study, participants will receive a $30 Amazon.com gift card

What happens to the information collected for the research? Results in the form of presentations or publications will be a summary of participant data and will not be identifiable for any one particular student. Your individual responses and performance will not be shared with you professor nor will it have any bearing on your grade in any of your courses. Efforts will be made to limit the use and disclosure of your personal information to people who have a need to review this information. We cannot promise complete secrecy. Organizations that may inspect and copy your information include the IRB and other representatives of this institution.

Will I have a chance to provide feedback after the study is over? After the study, you will be invited to voluntarily share your thoughts about your participation in this study via an online survey. You may also contact at any time the study team (see contact information above) or the Human Research Protection Program

71 (HRPP). See the “Who Can I Talk To?” section of this form for study team and HRPP contact information. Statement of Consent I have read the above information. I have asked questions and have received answers. I consent to participate in the study.

Yes, I agree to participate in this study.

No, I do not agree to participate in this study.

72 Appendix B Demographic Questions

Appendix C Manipulation Check

Which of the following is an objective for today’s educational programming? A. What legal considerations need to be taken into account when treating an interpersonal trauma survivor?

B. Define just world fallacies and learn strategies for just world fallacy prevention. C. What pharmacological options are available for the interpersonal trauma survivor?

D. Define Post-Traumatic Stress Disorder and learn strategies for screening

75 Appendix D Vignette

Please read and consider the following case vignette:

An attractive 20-year-old white female presents to the emergency department stating she was made to have sexual relations with a man within the last 24 hours. She does not appear to be in acute emotional distress, as she sits quietly and looks out of the window waiting to be seen. She is neatly dressed in what appears to be fresh clothing. Her hair is neatly combed. Rate of speech for this patient is slow, but in a logical sequence. She reports that she and a man she met, a 19-year old political science major, were drinking and dancing together at a party. She states that he walked her to her apartment and came inside. She stated that she did not want to have sex with him but he forced himself on her. She confided in a friend, who encouraged her to seek medical care. She also went to the police, and an investigation is ongoing.

77 Appendix E Minimization Scale

78 Appendix F Global Belief in Just World

Appendix G Rape Myths

Appendix H Physician Empathy

Appendix I Trauma Exposure

Appendix J Social Desirability

Appendix K

Participant Feedback

Enthusiasm/encouragement for project

• You should show this video to our class, or we should have some sort of training on sexual assault. I'm sure there are both men and women in our class who engage in victim-blaming. I don't know anyone specifically, but statistically it is likely.

There should also be coursework related to this in 7th grade classrooms across the country. We want people to know before they get to the ages where society starts victimizing them that they have rights.

• most other healthcare workers working with trauma survivors should see this!

• This was very informational. Thank you. Feedback on measures

• The survey seemed geared towards heterosexual relationships and so it was hard to relate to some of the questions/prompts.

• There was a double negative in one of the survey questions which was confusing. "Women like to play coy. This does not mean that they do not want to have sex."

or something like that. I had a tough time interpreting that question.

• I think something to consider is keeping the question response format similar. I almost put "Strongly Agree" for all of my last questions because the format had changed. Consistency in format might lead to less error.

• There were a couple of questions that were hard to interpret. One had to to with women playing coy. The other I cannot remember at this tim