Brian Marx | Boston University (original) (raw)

Papers by Brian Marx

JAMA psychiatry, Jan 17, 2018

Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat p... more Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT). To determine if WET is noninferior to CPT in patients with PTSD. In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis. Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that includes written accounts was delivered ind...

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International Journal of Business Continuity and Risk Management, 2019

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Psychiatric Services, 2015

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Psychological Trauma: Theory, Research, Practice, and Policy, 2011

This study explored relations among childhood physical abuse, internalized homophobia, experienti... more This study explored relations among childhood physical abuse, internalized homophobia, experiential avoidance, and current psychological symptoms in a community sample of 122 adult lesbians and 115 adult gay men. Childhood physical abuse predicted depression and posttraumatic stress disorder (PTSD) symptoms. Furthermore, for gay men, internalized homophobia completely mediated the relation between childhood physical abuse and depression symptoms and partially mediated

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Current Treatment Options in Psychiatry, 2015

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Neuropsychology, Jan 20, 2015

Although loss of consciousness associated with moderate or severe traumatic brain injury (TBI) is... more Although loss of consciousness associated with moderate or severe traumatic brain injury (TBI) is thought to interfere with encoding of the TBI event, little is known about the effects of mild TBI (mTBI), which typically involves only transient disruption in consciousness. Blast-exposed Afghanistan and Iraq War veterans were asked to recall the blast event. Participants were stratified based on whether the blast was associated with probable mTBI (n = 50) or not (n = 25). Narratives were scored for organizational structure (i.e., coherence) using the Narrative Coherence Coding Scheme (Reese et al., 2011) and episodic recollection using the Autobiographical Interview Coding Procedures (Levine et al., 2002). The mTBI group produced narratives that were less coherent but contained more episodic details than those of the no-TBI group. These results suggest that mTBI interferes with the organizational quality of memory in a manner that is independent of episodic detail generation. (PsycIN...

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Military Medicine, 2015

To examine military, demographic, and psychosocial predictors of military retention following ope... more To examine military, demographic, and psychosocial predictors of military retention following operational deployment. Military status 12 months following return from Iraq deployment was assessed via service records in 740 regular active duty Army Soldiers. Potential predictors of military retention were derived from prospectively administered in-person interviews and questionnaires conducted within 3 months following return from Iraq. At 12 months following return from deployment, 18.1% (n = 134) of the sample had separated from military service. Cox proportional hazards analyses, adjusting for demographic, military, and psychosocial predictors, identified several factors that were independently associated with military attrition: less than (vs. equal to or more than) 6 years military experience (hazards ratio [HR], 3.98; 95% CI, 2.12-7.45); unmarried (vs. married) status (HR, 1.51; 95% CI, 1.06-2.16); and lower (vs. higher) levels of self-reported unit support during deployment (HR, 2.22; 95% CI, 1.42-3.47). Service members early in their career may be especially prone to military attrition. With regard to military retention, our findings suggest that it may be particularly important to develop initiatives that target organizational cohesion and support.

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2014 IEEE International Conference on Acoustics, Speech and Signal Processing (ICASSP), 2014

ABSTRACT Psychological health disorders pose a growing threat to society. Disorders such as Depre... more ABSTRACT Psychological health disorders pose a growing threat to society. Disorders such as Depression, Post-Traumatic Stress Disorder (PTSD), and mild Traumatic Brain Injury (mTBI), are often under-diagnosed and under-treated. Crisis hotlines are often the last resort for people who, from the lack of proper treatment, are considering suicide or intend to harm themselves or others. This paper describes a system that automatically analyzes online crisis hotline chats to (1) extract fine-grained distress indicators that map to Diagnostic and Statistical Manual of Mental Disorders (DSM) IV codes, and to (2) perform triage classification based on the severity of distress. For distress detection, we present several approaches which leverage annotator rationales and dialogue structure to improve classification performance, demonstrating significant gains over a state-of-the-art approach from literature. For triage classification, we demonstrate early detection capability for the most severe triage code. We evaluate our work on a large corpus of chats from the U.S. Department of Veterans Affairs' online Crisis Hotline.

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Clinical psychological science : a journal of the Association for Psychological Science, 2015

The eleventh edition of the International Classification of Diseases (ICD-11) is under developmen... more The eleventh edition of the International Classification of Diseases (ICD-11) is under development and current proposals include major changes to trauma-related psychiatric diagnoses, including a heavily restricted definition of posttraumatic stress disorder (PTSD) and the addition of complex PTSD (CPTSD). We aimed to test the postulates of CPTSD in samples of 2695 community participants and 323 trauma-exposed military veterans. CPTSD prevalence estimates were 0.6% and 13% in the community and veteran samples, respectively; one-quarter to one-half of those with PTSD met criteria for CPTSD. There were no differences in trauma exposure across diagnoses. A factor mixture model with two latent dimensional variables and four latent classes provided the best fit in both samples: classes differed by their level of symptom severity but did not differ as a function of the proposed PTSD versus CPTSD diagnoses. These findings should raise concerns about the distinctions between CPTSD and PTSD ...

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Post-Traumatic Stress Disorder, 2009

... on the time elapsed since the trauma or if the trauma occurred in childhood or as an ... size... more ... on the time elapsed since the trauma or if the trauma occurred in childhood or as an ... size did vary according to whether the prior trauma resulted from an accident, combat, or noncombat ... Together, these studies suggest that prior trauma and life adversity may sensi-tize people to ...

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Clinical psychological science : a journal of the Association for Psychological Science, 2013

We examined the extent to which cognitive emotion-regulation (ER) strategies moderated posttrauma... more We examined the extent to which cognitive emotion-regulation (ER) strategies moderated posttraumatic stress disorder (PTSD) treatment outcome among 40 motor vehicle accident survivors. Participants were randomly assigned to either a brief written exposure therapy (WET) condition or a waitlist condition and were assessed pre- and posttreatment and at a 3-month follow-up. Positive-reappraisal and putting-into-perspective strategies at baseline interacted with condition to predict symptom change over time. Both strategies predicted greater reductions in PTSD in the waitlist group, suggesting facilitation of natural recovery. However, positive reappraisal was associated with smaller reductions in PTSD in the WET group, suggesting that this strategy may interfere with treatment. Treatment also reduced use of the maladaptive ER strategy of rumination. These results provide evidence that putting-into-perspective and positive-reappraisal strategies are beneficial in the absence of treatment...

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Journal of consulting and clinical psychology, 2014

Administrative planning and policy decisions frequently rely on diagnostic data extracted from la... more Administrative planning and policy decisions frequently rely on diagnostic data extracted from large electronic databases. However, the accuracy of this diagnostic information is uncertain. The present study examined the degree to which various diagnoses of posttraumatic stress disorder (PTSD) within Department of Veterans Affairs (VA) electronic databases were concordant with PTSD diagnostic status determined by standardized diagnostic interview. We interviewed 1,649 veterans of the Iraq and Afghanistan wars using the PTSD Module of the Structured Clinical Interview for DSM-IV (SCID). Participants also completed other interview-based and self-report measures of psychopathology and provided consent to access their electronic medical records (EMRs). Concordance between database diagnosis and SCID diagnosis was 72.3% for current PTSD and 79.4% for lifetime PTSD. We observed associations between concordance status and combat exposure, PTSD symptom presentation, comorbid anxiety and dep...

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Psychological services, 2014

The Veterans Health Administration (VHA) has promoted the use of telehealth technologies to deliv... more The Veterans Health Administration (VHA) has promoted the use of telehealth technologies to deliver mental health care to veterans with limited access to services on account of geographic and other barriers. The use of technology to deliver interventions to veterans with posttraumatic stress disorder (PTSD) has been a particular focus within VHA. Much less attention has been paid to the use of telehealth technologies to diagnose veterans with PTSD for both treatment and/or disability compensation purposes, in spite of the need for such services. The literature evaluating the use of video teleconferencing methods in the assessment of PTSD is limited; to our knowledge, only 1 previous study has been published. The current study evaluated the psychometric characteristics of the Clinician Administered PTSD Scale (CAPS) administered by video teleconferencing with a larger and more diverse sample of veterans. The CAPS raters had high interrater reliability and there were strong correlatio...

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Handbook of Clinical Psychology Competencies, 2010

ABSTRACT Behavioral assessment, as opposed to traditional assessment, emphasizes the antecedents ... more ABSTRACT Behavioral assessment, as opposed to traditional assessment, emphasizes the antecedents and consequences of behavior. The primary goal of behavioral assessment is to operationalize behavioral excesses and deficits, such that the situations or events that precipitate the event and the responses to the event are reframed as causes and reinforcers of problem behaviors. The information obtained via behavioral assessment can be used to create interventions that aim to alter those problem behaviors through the use of the environment. Although behavioral assessment was initially concerned with strictly observable behaviors, the domain has expanded to include beliefs, attitudes, and emotional states. Interest in behavioral assessment with children specifically has increased dramatically since Ollendick and Hersen (1984) published the first text devoted to this topic. The use of behavioral assessment with children poses new challenges to clinicians who are accustomed to working with adult clients. This chapter intends to explain and provide specific examples of various behavioral assessment techniques that can be implemented with children, while emphasizing the unique challenges that present when working with such clients. The first half of this chapter is devoted to basic behavioral assessment competencies (e.g., behavioral interviewing, direct observation) that all clinicians who work with children should be familiar with and comfortable using. The second half of this chapter focuses on advanced behavioral assessment techniques (e.g., peer sociometry, psychophysiological assessment) that are likely to require additional, specialized training. It is our hope that this chapter will help clinicians who encounter child populations in their practice by refreshing their knowledge of basic behavioral assessment competencies and introducing more advanced behavioral assessment techniques that can be implemented with children.

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Journal of anxiety disorders, 2014

Research suggests that military unit support and community postdeployment social support are asso... more Research suggests that military unit support and community postdeployment social support are associated with fewer PTSD symptoms following military deployment. This study extended prior research by examining the associations among predeployment unit support and PTSD symptoms before Iraq deployment as well as unit support, PTSD symptoms, and postdeployment social support after deployment among 835 U.S. Army and 173 National Guard soldiers. Multiple regression analyses indicated that predeployment unit support was not significantly associated with postdeployment PTSD severity in either group of soldiers, whereas higher unit support during deployment was significantly associated with lower postdeployment PTSD severity among active duty soldiers only. Among both groups, higher levels of postdeployment social support were associated with lower levels of postdeployment PTSD symptom severity. These findings suggest that postdeployment social support is a particularly strong buffer against ...

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Journal of Traumatic Stress, 1996

Vietnam combat veterans with current posttraumatic stress disorder (PTSD), with other Axis-I diso... more Vietnam combat veterans with current posttraumatic stress disorder (PTSD), with other Axis-I disorders, or with no Axis-I disorders completed a series of tasks designed to elucidate the psychophysiological parameters of information-processing in PTSD. These tasks included a modified Stroop procedure (MSP), a standard Stroop procedure, a recognition memory task, and a threat rating task. Physiological responses were recorded throughout the

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Journal of traumatic stress, 2014

Tonic immobility (TI) is an involuntary freezing response that can occur during a traumatic event... more Tonic immobility (TI) is an involuntary freezing response that can occur during a traumatic event. TI has been identified as a risk factor for posttraumatic stress disorder (PTSD), although the mechanism for this relationship remains unclear. This study evaluated a particular possible mechanism for the relationship between TI and PTSD symptoms: posttraumatic guilt. To examine this possibility, we assessed 63 female trauma survivors for TI, posttraumatic guilt, and PTSD symptom severity. As expected, the role of guilt in the association between TI and PTSD symptom severity was consistent with mediation (B = 0.35; p < .05). Thus, guilt may be an important mechanism by which trauma survivors who experience TI later develop PTSD symptoms. We discuss the clinical implications, including the importance of educating those who experienced TI during their trauma about the involuntary nature of this experience.

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JAMA psychiatry, Jan 17, 2018

Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat p... more Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT). To determine if WET is noninferior to CPT in patients with PTSD. In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis. Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that includes written accounts was delivered ind...

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International Journal of Business Continuity and Risk Management, 2019

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Psychiatric Services, 2015

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Psychological Trauma: Theory, Research, Practice, and Policy, 2011

This study explored relations among childhood physical abuse, internalized homophobia, experienti... more This study explored relations among childhood physical abuse, internalized homophobia, experiential avoidance, and current psychological symptoms in a community sample of 122 adult lesbians and 115 adult gay men. Childhood physical abuse predicted depression and posttraumatic stress disorder (PTSD) symptoms. Furthermore, for gay men, internalized homophobia completely mediated the relation between childhood physical abuse and depression symptoms and partially mediated

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Current Treatment Options in Psychiatry, 2015

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Neuropsychology, Jan 20, 2015

Although loss of consciousness associated with moderate or severe traumatic brain injury (TBI) is... more Although loss of consciousness associated with moderate or severe traumatic brain injury (TBI) is thought to interfere with encoding of the TBI event, little is known about the effects of mild TBI (mTBI), which typically involves only transient disruption in consciousness. Blast-exposed Afghanistan and Iraq War veterans were asked to recall the blast event. Participants were stratified based on whether the blast was associated with probable mTBI (n = 50) or not (n = 25). Narratives were scored for organizational structure (i.e., coherence) using the Narrative Coherence Coding Scheme (Reese et al., 2011) and episodic recollection using the Autobiographical Interview Coding Procedures (Levine et al., 2002). The mTBI group produced narratives that were less coherent but contained more episodic details than those of the no-TBI group. These results suggest that mTBI interferes with the organizational quality of memory in a manner that is independent of episodic detail generation. (PsycIN...

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Military Medicine, 2015

To examine military, demographic, and psychosocial predictors of military retention following ope... more To examine military, demographic, and psychosocial predictors of military retention following operational deployment. Military status 12 months following return from Iraq deployment was assessed via service records in 740 regular active duty Army Soldiers. Potential predictors of military retention were derived from prospectively administered in-person interviews and questionnaires conducted within 3 months following return from Iraq. At 12 months following return from deployment, 18.1% (n = 134) of the sample had separated from military service. Cox proportional hazards analyses, adjusting for demographic, military, and psychosocial predictors, identified several factors that were independently associated with military attrition: less than (vs. equal to or more than) 6 years military experience (hazards ratio [HR], 3.98; 95% CI, 2.12-7.45); unmarried (vs. married) status (HR, 1.51; 95% CI, 1.06-2.16); and lower (vs. higher) levels of self-reported unit support during deployment (HR, 2.22; 95% CI, 1.42-3.47). Service members early in their career may be especially prone to military attrition. With regard to military retention, our findings suggest that it may be particularly important to develop initiatives that target organizational cohesion and support.

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2014 IEEE International Conference on Acoustics, Speech and Signal Processing (ICASSP), 2014

ABSTRACT Psychological health disorders pose a growing threat to society. Disorders such as Depre... more ABSTRACT Psychological health disorders pose a growing threat to society. Disorders such as Depression, Post-Traumatic Stress Disorder (PTSD), and mild Traumatic Brain Injury (mTBI), are often under-diagnosed and under-treated. Crisis hotlines are often the last resort for people who, from the lack of proper treatment, are considering suicide or intend to harm themselves or others. This paper describes a system that automatically analyzes online crisis hotline chats to (1) extract fine-grained distress indicators that map to Diagnostic and Statistical Manual of Mental Disorders (DSM) IV codes, and to (2) perform triage classification based on the severity of distress. For distress detection, we present several approaches which leverage annotator rationales and dialogue structure to improve classification performance, demonstrating significant gains over a state-of-the-art approach from literature. For triage classification, we demonstrate early detection capability for the most severe triage code. We evaluate our work on a large corpus of chats from the U.S. Department of Veterans Affairs&#39; online Crisis Hotline.

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Clinical psychological science : a journal of the Association for Psychological Science, 2015

The eleventh edition of the International Classification of Diseases (ICD-11) is under developmen... more The eleventh edition of the International Classification of Diseases (ICD-11) is under development and current proposals include major changes to trauma-related psychiatric diagnoses, including a heavily restricted definition of posttraumatic stress disorder (PTSD) and the addition of complex PTSD (CPTSD). We aimed to test the postulates of CPTSD in samples of 2695 community participants and 323 trauma-exposed military veterans. CPTSD prevalence estimates were 0.6% and 13% in the community and veteran samples, respectively; one-quarter to one-half of those with PTSD met criteria for CPTSD. There were no differences in trauma exposure across diagnoses. A factor mixture model with two latent dimensional variables and four latent classes provided the best fit in both samples: classes differed by their level of symptom severity but did not differ as a function of the proposed PTSD versus CPTSD diagnoses. These findings should raise concerns about the distinctions between CPTSD and PTSD ...

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Post-Traumatic Stress Disorder, 2009

... on the time elapsed since the trauma or if the trauma occurred in childhood or as an ... size... more ... on the time elapsed since the trauma or if the trauma occurred in childhood or as an ... size did vary according to whether the prior trauma resulted from an accident, combat, or noncombat ... Together, these studies suggest that prior trauma and life adversity may sensi-tize people to ...

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Clinical psychological science : a journal of the Association for Psychological Science, 2013

We examined the extent to which cognitive emotion-regulation (ER) strategies moderated posttrauma... more We examined the extent to which cognitive emotion-regulation (ER) strategies moderated posttraumatic stress disorder (PTSD) treatment outcome among 40 motor vehicle accident survivors. Participants were randomly assigned to either a brief written exposure therapy (WET) condition or a waitlist condition and were assessed pre- and posttreatment and at a 3-month follow-up. Positive-reappraisal and putting-into-perspective strategies at baseline interacted with condition to predict symptom change over time. Both strategies predicted greater reductions in PTSD in the waitlist group, suggesting facilitation of natural recovery. However, positive reappraisal was associated with smaller reductions in PTSD in the WET group, suggesting that this strategy may interfere with treatment. Treatment also reduced use of the maladaptive ER strategy of rumination. These results provide evidence that putting-into-perspective and positive-reappraisal strategies are beneficial in the absence of treatment...

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Journal of consulting and clinical psychology, 2014

Administrative planning and policy decisions frequently rely on diagnostic data extracted from la... more Administrative planning and policy decisions frequently rely on diagnostic data extracted from large electronic databases. However, the accuracy of this diagnostic information is uncertain. The present study examined the degree to which various diagnoses of posttraumatic stress disorder (PTSD) within Department of Veterans Affairs (VA) electronic databases were concordant with PTSD diagnostic status determined by standardized diagnostic interview. We interviewed 1,649 veterans of the Iraq and Afghanistan wars using the PTSD Module of the Structured Clinical Interview for DSM-IV (SCID). Participants also completed other interview-based and self-report measures of psychopathology and provided consent to access their electronic medical records (EMRs). Concordance between database diagnosis and SCID diagnosis was 72.3% for current PTSD and 79.4% for lifetime PTSD. We observed associations between concordance status and combat exposure, PTSD symptom presentation, comorbid anxiety and dep...

Bookmarks Related papers MentionsView impact

Psychological services, 2014

The Veterans Health Administration (VHA) has promoted the use of telehealth technologies to deliv... more The Veterans Health Administration (VHA) has promoted the use of telehealth technologies to deliver mental health care to veterans with limited access to services on account of geographic and other barriers. The use of technology to deliver interventions to veterans with posttraumatic stress disorder (PTSD) has been a particular focus within VHA. Much less attention has been paid to the use of telehealth technologies to diagnose veterans with PTSD for both treatment and/or disability compensation purposes, in spite of the need for such services. The literature evaluating the use of video teleconferencing methods in the assessment of PTSD is limited; to our knowledge, only 1 previous study has been published. The current study evaluated the psychometric characteristics of the Clinician Administered PTSD Scale (CAPS) administered by video teleconferencing with a larger and more diverse sample of veterans. The CAPS raters had high interrater reliability and there were strong correlatio...

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Handbook of Clinical Psychology Competencies, 2010

ABSTRACT Behavioral assessment, as opposed to traditional assessment, emphasizes the antecedents ... more ABSTRACT Behavioral assessment, as opposed to traditional assessment, emphasizes the antecedents and consequences of behavior. The primary goal of behavioral assessment is to operationalize behavioral excesses and deficits, such that the situations or events that precipitate the event and the responses to the event are reframed as causes and reinforcers of problem behaviors. The information obtained via behavioral assessment can be used to create interventions that aim to alter those problem behaviors through the use of the environment. Although behavioral assessment was initially concerned with strictly observable behaviors, the domain has expanded to include beliefs, attitudes, and emotional states. Interest in behavioral assessment with children specifically has increased dramatically since Ollendick and Hersen (1984) published the first text devoted to this topic. The use of behavioral assessment with children poses new challenges to clinicians who are accustomed to working with adult clients. This chapter intends to explain and provide specific examples of various behavioral assessment techniques that can be implemented with children, while emphasizing the unique challenges that present when working with such clients. The first half of this chapter is devoted to basic behavioral assessment competencies (e.g., behavioral interviewing, direct observation) that all clinicians who work with children should be familiar with and comfortable using. The second half of this chapter focuses on advanced behavioral assessment techniques (e.g., peer sociometry, psychophysiological assessment) that are likely to require additional, specialized training. It is our hope that this chapter will help clinicians who encounter child populations in their practice by refreshing their knowledge of basic behavioral assessment competencies and introducing more advanced behavioral assessment techniques that can be implemented with children.

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Journal of anxiety disorders, 2014

Research suggests that military unit support and community postdeployment social support are asso... more Research suggests that military unit support and community postdeployment social support are associated with fewer PTSD symptoms following military deployment. This study extended prior research by examining the associations among predeployment unit support and PTSD symptoms before Iraq deployment as well as unit support, PTSD symptoms, and postdeployment social support after deployment among 835 U.S. Army and 173 National Guard soldiers. Multiple regression analyses indicated that predeployment unit support was not significantly associated with postdeployment PTSD severity in either group of soldiers, whereas higher unit support during deployment was significantly associated with lower postdeployment PTSD severity among active duty soldiers only. Among both groups, higher levels of postdeployment social support were associated with lower levels of postdeployment PTSD symptom severity. These findings suggest that postdeployment social support is a particularly strong buffer against ...

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Journal of Traumatic Stress, 1996

Vietnam combat veterans with current posttraumatic stress disorder (PTSD), with other Axis-I diso... more Vietnam combat veterans with current posttraumatic stress disorder (PTSD), with other Axis-I disorders, or with no Axis-I disorders completed a series of tasks designed to elucidate the psychophysiological parameters of information-processing in PTSD. These tasks included a modified Stroop procedure (MSP), a standard Stroop procedure, a recognition memory task, and a threat rating task. Physiological responses were recorded throughout the

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Journal of traumatic stress, 2014

Tonic immobility (TI) is an involuntary freezing response that can occur during a traumatic event... more Tonic immobility (TI) is an involuntary freezing response that can occur during a traumatic event. TI has been identified as a risk factor for posttraumatic stress disorder (PTSD), although the mechanism for this relationship remains unclear. This study evaluated a particular possible mechanism for the relationship between TI and PTSD symptoms: posttraumatic guilt. To examine this possibility, we assessed 63 female trauma survivors for TI, posttraumatic guilt, and PTSD symptom severity. As expected, the role of guilt in the association between TI and PTSD symptom severity was consistent with mediation (B = 0.35; p < .05). Thus, guilt may be an important mechanism by which trauma survivors who experience TI later develop PTSD symptoms. We discuss the clinical implications, including the importance of educating those who experienced TI during their trauma about the involuntary nature of this experience.

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