The Role of Race, Social Support, Empowerment, and Posttraumatic Cognitions in Survivors of Intimate Partner Violence Symptoms of Posttraumatic Stress Disorder

Abstract

Black women experience more frequent and severe intimate partner violence (IPV), but there are mixed findings on their posttraumatic stress disorder (PTSD) symptom severity. This may be explained by cultural-salient factors which are associated with fewer posttraumatic cognitions. We hypothesized an indirect effect of race on PTSD symptoms via social support, empowerment, and posttraumatic cognitions, serially. Path analysis revealed Black women reported increased social support, which was associated with higher levels of empowerment, which was associated with lower levels of posttraumatic cognitions. Decreased posttraumatic cognitions were associated with less severe PTSD symptoms. Results increase understanding of culturally-salient factors that may impact PTSD symptoms in Black women.

Intimate partner violence (IPV) is a pervasive societal issue that can have lasting adverse mental health effects. IPV is disproportionately experienced by women, with one in three women reporting IPV victimization in their lifetime (Smith et al., 2018). Posttraumatic stress disorder (PTSD) is the most prevalent mental health outcome for women who have experienced IPV (Spencer et al., 2019). Among women who have experienced IPV, rates of PTSD diagnosis have been estimated as high as 75% (Johnson et al., 2008). Additionally, there is much evidence to suggest that women residing in IPV shelters are likely to have experienced more severe IPV and injury than women who have experienced IPV who do not reside in shelters (Galano et al., 2013; Jones et al., 2001; Saunders, 1994). Further, women who are experiencing severe IPV may view shelter as a final recourse due to the absence of safe alternative housing resources. Women who experience more severe IPV are suffering an acute crisis that may include physical injury and emotional distress, and shelters provide emergency assistance for physical safety as well as emotional support for women who lack alternative resources (Saunders, 1994). Moreover, women residing in shelters are likely to experience more severe IPV-related PTSD (Bosch & Ferrer, 2003; Jonker et al., 2012; McFarlane et al., 2015).

Experiencing a traumatic event such as IPV can also negatively impact women’s thoughts and beliefs about themselves, others, and the world around them (Jaffe et al., 2019). These trauma-related cognitions have an important role in how women emotionally respond to trauma (Foa et al., 1999). Additionally, critical posttraumatic cognitions of the self (i.e., self-blame) and the world (i.e., belief that the world is a dangerous place) impact the development and maintenance of PTSD through inducing a continual sense of danger and threat (Ehlers & Clark, 2000; Foa & Rothbaum, 1998). Further, negative posttraumatic cognitions of the self and world predict PTSD symptom severity (Whiteman et al., 2020), and discriminate between individuals with PTSD and without (Dunmore et al., 1997; Ehring et al., 2008; Foa et al., 1999). The current study used the Clinician-Administered PTSD Scale to define PTSD symptom severity as the intensity and frequency of PTSD symptoms in the past month.

IPV and Race

A growing body of literature suggests that race may be another important factor in understanding the link between IPV and PTSD (Koo et al., 2014). Black women consistently report more frequent and more severe IPV than their White counterparts (Breiding et al., 2014; Wright et al., 2010). However, the research on the rates of PTSD for Black women has been mixed. Some research finds that Black women are more likely to have PTSD symptoms, across trauma types, relative to their White counterparts (Erving et al., 2019; Seng et al., 2009). Still, when looking at PTSD specific to IPV, some research finds no difference between Black and White women in PTSD symptom severity (Kramer et al., 2015). Additional research on IPV-specific PTSD finds that Black women report fewer PTSD symptoms relative to White women (Wright et al., 2010). These findings contrast the well-documented health disparities between Black and White individuals such as higher death rate of Black Americans for physical health concerns, less and poorer quality of mental health care for Black Americans, and greater exposure to social negative determinants of health like discrimination for Black Americans (Kramer et al., 2015). Research findings suggest that there is a “Black-White mental health paradox” (p. 1), which is the discrepancy that although Black Americans experience more material hardship, general stress, and physical health problems, Black Americans have a lower prevalence of psychological disorders compared to White Americans (Erving et al., 2019). As such, Black women are significantly less likely than their White counterparts to meet criteria for a wide range of psychological disorders (Erving et al., 2019; Kramer et al., 2015).

There are several potential explanations for this. For example, assessment tools that are often normed on White participants may not be measurement invariant, and thus, may not equivalently capture Black individuals’ experiences of distress (Tran, 1997). Meta-analysis revealed that many studies comparing PTSD and IPV across racial groups did not have an adequate sample size of populations of color, did not use appropriate statistical analysis, or confounded race with other social determinants of health (Stockman et al., 2015). Alternatively, Black women may have internalized cultural messages of the Strong Black Woman stereotype, that Black women be resilient during struggles and responsible for taking care of others (Beauboeuf-Lafontant, 2007). Due to the internalization of this stereotype, they may endorse less psychological distress which may explain the finding that Black women are less likely to meet the criteria for psychological disorders compared to White women (Abrams et al., 2014; Wright et al., 2010). Finally, it is also possible that there are true group differences attributable to protective factors that are culturally-salient. Different from culturally specific factors (e.g., factors unique to a population), culturally-salient factors refer to factors that are relevant to a community but not unique to that population (López & Ho, 2013). Cultural salience allows for an exploration of how relevant factors explain the occurrence, meaning, and alleviation of distress and how these factors can be manifested differently across settings and populations (López & Ho, 2013). For example, social support is widely considered a culturally-salient protective factor for Black women (Spates et al., 2019). In this article, we focus on culturally-salient factors that may be protective for Black women and explain the mixed findings.

To date, much of the research that conceptualizes IPV and treatments for IPV-related disorders are theoretically grounded from the experiences of White women (De Coster & Heimer, 2021). Theoretical conceptualizations of IPV that attend to race include structural oppression, culture, intimate relationships, the daily experience of racism, and racial stereotypes that justify such experiences (De Coster & Heimer, 2021). For example, the stereotype of the Strong Black Woman is particularly relevant to understanding Black women’s experience with IPV (De Coster & Heimer, 2021). Historically, the presumption of Black women’s resilience has created the stereotype of compulsory strength (Beauboeuf-Lafontant, 2007). Beauboeuf-Lafontant (2007) discussed strength as a hegemonic social construct that exists to silence psychological distress for Black women. Additionally, the stereotype of strength has been found to normalize IPV, influence decisions to leave IPV situations, and affect help-seeking for Black women (Banks-Wallace & Parks, 2004; Flicker et al., 2011; Gillum, 2008; Johnson & Zlotnick, 2007). However, Black women may also perceive their strength as helping them achieve their goals, gain independence, and give them character (Beauboeuf-Lafontant, 2007). Additionally, Black women have also been conceptualized as having resiliency to the stressors that they experience due to coping strategies such as utilizing faith or spirituality, social support, political action, covert or overt forms of resistance, redefining Black womanhood, and cultural shifting (Spates et al., 2019). Thus, empowerment (e.g., enabling women to access skills, such as the ones listed above) and resources to cope more effectively could be a culturally-salient protective factor against the development of IPV-related PTSD among Black women (Wright et al., 2010).

IPV and Empowerment

Historically, empowerment theory defined empowerment as a process that oppressed groups must go through to gain power and control over their situations, with the goal of creating political and social change (Kasturirangan, 2008). This definition is less applicable to women experiencing IPV-related PTSD who are residing in shelters, as feeling a sense of control may be more difficult with psychopathology and acute threats to their safety. Worell and Remer (2003) suggested a model of empowerment that utilizes feminist theory along with four principles for developing an empowerment-based intervention for women: (a) attention to the diversity of women’s personal and social identities; (b) a consciousness-raising approach; (c) an egalitarian relationship between client and therapist; and (d) a woman-valuing and self-validating process. Overall, this model specifically addresses the need for an empowerment-based intervention for women that focuses on their personal identity and how society shapes and affects their identities (Johnson et al., 2005; Worell & Remer, 2003).

Based on this model, Johnson et al. (2005) defined empowerment as “enabling women to access skills and resources to cope more effectively with current as well as future stress and trauma” (p. 109) and developed a measure of empowerment, the Personal Progress Scale—Revised (PPS-R), that includes dimensions (e.g., personal strength, resource access, awareness of discrimination) that account for personal, contextual, and multicultural differences among women. With a sample of predominantly White women who experienced IPV, Johnson and colleagues found that empowered women had increased resiliency to stress and trauma with subsequently fewer symptoms of psychological distress. Building on this initial research, Wright et al. (2010) explored how differences in empowerment among White and Black women affect IPV-related PTSD. Results of the study found an indirect effect of race on IPV-related PTSD and depression via empowerment, indicating that Black women endorse more empowerment than their White counterparts, which may explain Black women’s greater levels of resiliency when experiencing IPV. Overall, these findings demonstrate the importance of empowerment in the treatment of IPV. Specifically, empowerment-based references in IPV interventions such as emphasizing choice, individual goals, and self-efficacy have been associated with reduced PTSD symptom severity (Johnson et al., 2020). Additional literature (Cattaneo & Goodman, 2015; Kasturirangan, 2008; Perez, Johnson, & Wright, 2012) suggests that agencies and programs that aim to utilize empowerment as a goal in IPV-related treatment, should have women set their own goals and access resources that work towards their goals, to be protective against IPV-related PTSD. However, there has been criticism of empowerment approaches to IPV because clients may see themselves as primarily responsible for change, rather than the community and broader advocacy movements (Aiken & Goldwasser, 2010). Women may interpret a lack of ability to make choices, set individual goals, and a lack of self-efficacy as a continued failure on their part to change their situation, which may impact their level of distress. Clinicians should be cautious of this potential misinterpretation of empowerment strategies and emphasize identifying aspects of their situation under their control when working with women who experience IPV.

Likewise, Samuels-Dennis et al. (2013) explored the mediating effects of empowerment, interpersonal conflict, and social support among a racially diverse sample of single mothers who experienced IPV and IPV-related PTSD symptoms. Results indicated an indirect effect of empowerment on IPV-related PTSD symptom severity via social support. Further, the study found that childhood abuse and IPV increased women’s experiences with interpersonal conflict, which decreased empowerment, then decreased social support, and ultimately increased PTSD severity. This finding underlines the importance of another construct that has been found to be a protective resource against PTSD symptom severity for individuals who experience trauma that is associated with empowerment among women: social support.

IPV and Social Support

Social support has consistently been found to be an important protective resource against PTSD for individuals who experience trauma. A moderate negative relationship between social support and PTSD symptom severity has consistently been found in the literature (Samuels-Dennis et al., 2013). Schumm et al. (2006) explored social support as a protective factor when predicting PTSD for women who experienced IPV. Results indicated that women with greater social support systems were 56% less likely to have PTSD symptoms than women who had lower social support. Further, Coker et al. (2002) explored social support as a protective factor for IPV-related PTSD among women with previous IPV experiences. The study found that women who experienced emotional support from family, friends, and non-abusive partners had a 20% to 40% decreased risk of PTSD.

Social support has been conceptualized as being a culturally-salient protective factor among Black women to assist them in coping with adversity (Bronder et al., 2014; Davis, 2019; Spates et al., 2019). Further, among Black women, those who reported high social support also reported greater well-being and better mental health (Talwar et al., 2017). Research consistently shows that social support is a method of help-seeking used more often than mental health treatment among Black women (Nelson et al., 2020). Likewise, Short et al., (2000) conducted a qualitative study exploring protective factors among Black and White women with recent IPV. Substantial racial differences were found as Black women tended to identify social support as one of their primary forms of help-seeking, and White women did not. Since then, findings that Black women rely on social support have been consistently reproduced in the literature (Spates et al., 2019). Moreover, research has shown that Black women utilize social support to cope with other forms of trauma such as racial oppression (Jones et al., 2021). Social support has been found quantitatively to be a help-seeking behavior that is more likely to be utilized among Black women compared to White women (Johnson et al., 2016). Additionally, a greater emphasis on interdependence, family networks, and collective responsibility may be cultural values that are more salient to the Black community (Johnson & Carter, 2020). Indeed, research shows that collective support is an adaptive cultural resource for Black women (Davis & Afifi, 2019). These findings suggest that social support may be a culturally-salient protective factor against IPV-related PTSD symptoms among Black women.

Moreover, the aforementioned study conducted by Samuels-Dennis et al. (2013) found that empowerment and social support had links to each other in predicting IPV-related PTSD symptom severity. These findings suggest that more research is needed on these constructs for women who experience IPV and IPV-related PTSD. It may be that increased social support among Black women may increase empowerment, which may impact PTSD symptom severity. These factors have also been linked to negative posttraumatic cognitions, which is related to the development and maintenance of PTSD symptoms (Robinaugh et al., 2011).

Social Support, Empowerment, Posttraumatic Cognitions, and PTSD

Just as social support can be a protective factor against PTSD, lack of social support is also considered one of the greatest risk factors for PTSD amongst many different types of traumas (Southwick et al., 2005). Much of the research has focused on social support’s links to the development and maintenance of PTSD, but less is known about the mechanism by which social support impacts the development and maintenance of PTSD (Vogt et al., 2007). Understanding the process by which social support impacts PTSD is imperative to developing future treatments for PTSD (Kraemer et al., 2001). Theoretically, the literature has suggested that greater social support may lead to lower rates of PTSD by hindering the development and continuance of negative posttraumatic cognitions (Ehlers & Clark, 2000; Guay et al., 2006; Joseph et al., 1997), but this has not been tested.

It may be that empowerment also plays a role in the development of posttraumatic cognitions; however, no research to the authors’ knowledge has specifically investigated the impact of empowerment on posttraumatic cognitions. Given empowerment’s links to social support and PTSD, it is possible that empowerment also impacts the development and maintenance of PTSD. Empowerment, most recently defined as “a meaningful shift in the experience of power attained through interaction in the social world” (Cattaneo & Goodman, 2015, p. 84) is conceptualized as the capacity to access necessary internal and external skills and resources for coping, as well as to have personal control over one’s development and daily decision-making (Johnson et al., 2005; Samuels-Dennis et al., 2013). One such resource is perceived social support. Black women who have more social support may have increased empowerment, and thus, may have fewer negative cognitions about themselves and the world.

Extant research on racial differences in posttraumatic cognitions is scarce and inconsistent (Koo et al., 2014; Williams et al., 2012), wherein some results indicate racial differences and others do not. There is no research to date that explores the indirect effect of race on IPV-related PTSD symptom severity through social support, empowerment, and posttraumatic cognitions for women who experience IPV. Existing research does support the link between social support and empowerment and the link between social support and posttraumatic cognitions. However, there is a lack of research on empowerment’s link to posttraumatic cognitions. Understanding culturally-salient protective factors for Black women and their effects on posttraumatic cognitions is essential to learning about the impact, development, and maintenance of Black women’s PTSD symptoms. Filling this gap in the literature allows future researchers and clinicians to develop better treatments and interventions to help Black women who experience IPV-related PTSD. The present study aimed to increase understanding of culturally-salient protective factors as they related to post-traumatic cognitions and IPV-related PTSD symptom severity. Specifically, we hypothesized that there would be racial differences on three of the primary variables (H1). We expected IPV severity (H1a), social support (H1b), and empowerment (H1c) would be higher for Black women. Additionally, the present study hypothesized an indirect effect of race on IPV-related PTSD symptom severity via social support, empowerment, and posttraumatic cognitions, serially (H2). The present study also had two exploratory aims. First, we examined potential racial differences in posttraumatic cognitions and PTSD symptom severity (Exploratory Aim 1). Second, we explored other potential indirect effects given the dearth of research in this area (Exploratory Aim 2). This approach is consistent with Hayes’s (2013) recommendation for testing parallel models of multiple mediations. Understanding how these factors influence PTSD symptom severity can assist in the development and delivery of treatments for IPV-related PTSD for women who experience IPV.

Methods

Participants

Participants were a sub-sample of women from the baseline assessment of a larger longitudinal study on the treatment of PTSD in shelter women. The current study includes women who completed the baseline assessment regardless of treatment or non-treatment condition. The initial sample was comprised of 273 participants. Participants who did not self-identify as either Black or White were omitted (n = 27). An additional 24 participants were removed because they had not completed at least 80% of each of the primary measures, a threshold employed to avoid biasing scale reliability (Downey & King, 1998). In the final sample (N = 222), half of the women (50%) identified their racial/ethnic background as White, while the other half (50%) identified as Black/African-American. Participants’ ages ranged from 19 to 59 (M = 35.12, SD = 9.23) and, on average, participants had been at the shelter for 17.5 days at the time of assessment (SD = 20.07). Additional demographic information is provided in Table 1.

Table 1.

Demographic Characteristics (N = 222).

	N White Women	Percentage White Women	N Black Women	Percentage Black Women
Ethnicity
Non-Latina	106	95.50%	107	96.40%
Latina	5	4.50%	4	3.60%
Relationship status
Single, never married	40	36%	79	71.20%
Married	14	12.60%	8	7.20%
Separated	25	22.50%	8	7.20%
Divorced	31	27.90%	13	11.70%
Widowed	1	0.90%	3	2.70%
Children
Yes	103	92.80%	98	88.30%
No	8	7.20%	13	11.70%
Sexual orientation
Straight	102	91.90%	104	93.70%
Lesbian	1	0.90%	0	0
Bisexual	8	7.20%	7	6.30%
Educational degree
<7 years completed	0	0	1	0.90%
Completed junior high	4	3.60%	6	5.40%
Some high school	20	18%	34	30.60%
Graduated high school	37	33.30%	29	26.10%
Some college	41	36.90%	36	32.40%
Graduated college	9	8.10%	5	4.50%
Household income
Under $10,000	99	89.20%	102	91.90%
$10,000–$15,000	7	6.30%	6	5.40%
$10,000–$19,999	1	0.90%	1	0.90%
$20,000–$24,999	2	1.80%	1	0.90%
Above $25,000	2	1.80%	1	0.90%

Procedures

The senior author obtained Institutional Review Board approval before study initiation. Participants were women recruited from six domestic violence shelters in five counties. All participants received the standard shelter services including a therapeutic milieu environment, case management, and educational groups. Eligibility criteria included identifying as a woman, residing in a participating shelter, being 18 years or older, and experiencing violence from an intimate/romantic partner within the past month of entering the shelter. Graduate-level psychology students conducted study recruitment and assessment under the supervision of the senior author. Participants learned about the study through in-person meetings at the shelter, the distribution of study flyers with the lab contact information, and from shelter staff. Graduate assistants screened participants in person and via telephone to determine their eligibility. Participants who were eligible and gave their informed consent completed self-report surveys via computer and diagnostic interview in the shelter. Participants were reimbursed $40 for their time.

Measures

IPV.

The Severity of Violence Against Women Scales (SVAW; Marshall, 1992) was used to assess self-reported IPV victimization over the past 30 days. Respondents endorse the frequency of different types of violence on a scale ranging from 1 (“no report of the act”) to 5 (“four or more occurrences”). Example items include acts of symbolic violence (“threw, smashed, or broke an object”), physical violence (“choked her”), and sexual violence (“made her have sexual intercourse against her will”). The SVAW is a frequently used measure with good reliability and validity (e.g., Graham-Bermann & Miller-Graff, 2015). The SVAW total score (sum of all items from all subscales) was used as a covariate in the current study. Cronbach’s alpha in the current study was .97.

Satisfaction with social support.

The Social Support Questionnaire-Short Form (SSQ6; Sarason et al., 1987) measures a respondent’s perception of their social network and their satisfaction with the support available to them. The SSQ6 has two dimensions: satisfaction with support and perceived number of individuals from whom to receive support. Respondents indicate, on a Likert-type scale, their satisfaction with the support available to them from 1 (“very dissatisfied”) to 6 (“very satisfied”). Only the satisfaction subscale was used in the current study. The SSQ6 has been used across various populations, from grieving parents to individuals with psychosis, and is considered a valid, reliable measure of social support (e.g., Gayer-Anderson & Morgan, 2013). The satisfaction scale was used in the current study, with a Cronbach’s alpha of .90.

Empowerment.

The Personal Progress Scale-Revised (PPS-R; Johnson et al., 2005) measures women’s empowerment. Based on the model of empowerment proposed by Worell and Remer (2003), the PPS-R assesses seven dimensions of empowerment: perceptions of power and competence, self-nurturance and resource access, interpersonal assertiveness, awareness of cultural discrimination, expression of anger and confrontation, autonomy, and personal strength and social activism (Johnson et al., 2005). Example items are: “I am aware of my own strengths as a woman,” and “It is important to me to be financially independent.” Items are rated from one (“almost never”) to seven (“almost always”). In the current study, Cronbach’s alpha was .85.

Posttraumatic cognitions.

The 33-item Posttraumatic Cognition Inventory (PTCI) was used to assess thoughts and beliefs about the world, subsequent to experiencing trauma (Foa et al., 1999). Participants denote their agreement with items on a Likert-type scale from one (“totally disagree”) to seven (“totally agree”). Example items include: “I will not be able to control my emotions, and something terrible will happen,” and “My life has been destroyed by the trauma.” The PTCI has evidence of good reliability and validity (Foa et al., 1999).

Cronbach’s alpha in the current study was .96.

PTSD symptoms.

The CAPS (Blake et al., 1995) was used to assess PTSD symptom severity in the past month. In contrast to other measures used in the current study, the CAPS is a structured interview. Items correspond to the DSM-symptom clusters from DSM-IV-TR. Participants rate their symptom frequency from 0 (“never”) to 4 (“daily or almost every day”) and their symptom severity from 0 (“no problem with symptom”) to 4 (“extreme, incapacitating”; National Center for PTSD, 2000). Frequency and severity items were summed to create a total score for PTSD symptom severity. Weathers et al. (2001) provides a classification of total CAPS scores including, asymptomatic/few symptoms (0–19), mild/subthreshold PTSD (20–39), moderate PTSD/threshold (40–59), severe PTSD (60–79), and extreme PTSD symptoms (≥80). The CAPS is considered the “gold standard” instrument to assess PTSD, with excellent reliability and validity (Weathers et al., 2001). In the current study, the CAPS had good internal consistency, evidenced by a Cronbach’s alpha of .94. To assess inter-rater reliability, 20 randomly selected CAPs were scored by a second rater, yielding a kappa of 1.0.

Results

Available item analysis was utilized to address missing data in the final sample of 222 participants (Parent, 2013). See Table 2 for descriptive statistics and zero-order correlations.

Table 2.

Descriptive Statistics and Correlations Among Variables

Variable	1	2	3	4	5	M (SD)	Possible Range	Observed Range
1. IPV severity	–					35.99 (23.65)	0–138	0–88
2. Social support	−.04	–				4.94 (1.39)	1–6	1–6
3. Empowerment	−.08	.31 ***	–			130.47 (25.78)	28–196	54–194
4. Posttraumatic cognitions	.08	−.28***	−.59***	–		108.87 (41.95)	36–252	33–228
5. PTSD symptoms	.36***	−.30***	−.33***	.56***	–	68.16 (25.36)	0–136	2–121

^***p < .001.

Examining Differences by Race

To test for potential racial differences among the variables, a one-way MANOVA was conducted. The results demonstrated a significant multivariate effect of race on the set of dependent variables, F(6, 211) = 2.02, p = .015, Wilk’s Λ = .94, ${\eta }_p^2=.06$ and, thus, univariate main effects were interpreted. Consistent with Hypothesis 1, Black women reported significantly higher levels of social support (H1b) and empowerment (H1c) than their White counterparts (see Table 3). Contrary to Hypothesis 1, there were no differences by race on IPV severity (H1a) or PTSD symptom severity (Exploratory Aim 1). Additionally, there were no racial differences for posttraumatic cognitions (Exploratory Aim 1).

Table 3.

Means, Standard Deviations, and MANOVA for Differences by Race on Variables.

	White (n = 111) M (SD)	Black (n = 111) M (SD)	Between Subjects
			F (1, 220)	P	${\eta }_p^2$
IPV severity	34.64 (22.76)	37.34 (24.53)	.72	.396	.03
Social support	4.69 (1.53)	5.20 (1.20)	7.58**	.006	.03
Empowerment	125.79 (27.10)	135.16, (23.58)	7.56**	.006	.03
Posttraumatic cognitions	111.59 (42.88)	106.14 (41.02)	.94	.334	.004
PTSD symptoms	70.24 (25.59)	66.07 (25.22)	1.50	.223	.01

Note. There was a statistically significant difference between White and Black women on the combined dependent variables.

^**p < .01.

Examining Indirect Effects of Race on PTSD

To examine potential indirect effects of race on PTSD symptoms (H2), path analysis with 10,000 bootstrap samples was conducted using Model 6 of PROCESS for SPSS (Hayes, 2013), controlling for IPV severity and length of shelter stay at time of assessment. As hypothesized, there was a significant indirect effect of race on PTSD symptoms via social support, empowerment, and posttraumatic cognitions, serially (see Table 4). Specifically, Black women reported higher levels of social support, higher levels of social support were associated with higher levels of empowerment, higher levels of empowerment were associated with lower levels of posttraumatic cognitions, and lower levels of posttraumatic cognitions were associated with lower levels of PTSD symptoms (see Figure 1). Additionally, two other indirect effects were significant (Exploratory Aim 2). There was an indirect effect of race on PTSD symptoms via empowerment and posttraumatic cognitions, serially, as well as an indirect effect of race on PTSD symptoms through social support alone (see Table 4, Figure 1).

Table 4.

Indirect Effects of Race on PTSD Symptoms.

Indirect Paths	Indirect Effect	95% Confidence Interval
Race → Social support → PTSD symptoms	−1.57*	[−3.06, −.35]
Race → Empowerment → PTSD symptoms	−.16	[−1.44, 1.10]
Race → Posttraumatic cognitions → PTSD symptoms	.98	[−.99, 3.37]
Race → Social support → Empowerment → PTSD symptoms	−.06	[−.53, .38]
Race → Social support → Posttraumatic cognitions → PTSD symptoms	−.38	[−1.06, .01]
Race → Empowerment → Posttraumatic cognitions → PTSD symptoms	−1.42*	[−3.09, −.12]
Race → Social support → Empowerment → Posttraumatic cognitions → PTSD symptoms	-.54*	[−1.1, −.13]

Note. Race was dichotomized (1 = White, 2 = Black). IPV severity and length of shelter stay at time of assessment included as a covariates. The indirect effect in bold was hypothesized and the remainder were exploratory.

^*p < .05.

Figure 1.

Relationships among variables in the proposed model of controlling for IPV severity and length of shelter stay at time of assessment.*p < .05. **p < .01. ***p < .001.

Discussion

Consistent with the prior research on empowerment (Samuels-Dennis et al., 2013; Wright et al., 2010) and social support (Johnson et al., 2016; Spates et al., 2019), the present study found racial differences in social support and empowerment, in that Black women had higher rates on both variables compared to White women. In addition to replicating these results, this study is the first to explore the indirect effects of race on IPV-related PTSD symptom severity through social support, empowerment, and posttraumatic cognitions among IPV survivors. Results revealed that Black women reported higher levels of social support, which was associated with higher levels of empowerment, which in turn was associated with lower levels of posttraumatic cognitions. These results suggest that mixed findings in Black women’s report of IPV-related PTSD symptoms may be related to culturally-salient factors for Black women such as social support and empowerment. These culturally-salient factors are thus important in understanding Black women’s experiences of IPV and IPV-related PTSD.

Inconsistent with some previous research (Black, 2011; Breiding et al., 2014; Wright et al., 2010), there were no racial differences found for IPV severity. Additionally, though the previous research on racial differences of PTSD has been mixed (Erving et al., 2019; Kramer et al., 2015; Seng et al., 2009), the present study found no differences for Black and White women for PTSD symptom severity. This may be surprising given that overall Black women are likely exposed to more traumatic events (e.g., discrimination and health disparities, among others) than their White counterparts (Kramer et al., 2015). However, most literature assessing PTSD prevalence in Black women focuses on general trauma, which likely accounts for their increased exposure to racial trauma and oppression (Roberts et al., 2011). Whereas, in samples where all participants are trauma-exposed, such as in this study, racial differences in PTSD symptom severity may disappear. Future research, particularly meta-analysis, to compare rates between samples that are IPV specific and samples that include general trauma, is needed.

Moreover, there may be additional race-related risk factors that the present study did not assess. A potential risk factor that may account for the lack of difference in PTSD symptom severity for Black and White women is the experience of racial discrimination for Black women. The research on racial discrimination has consistently found a negative impact on the mental health of Black individuals, such as depression and anxiety (Pascoe & Smart Richman, 2009; Williams & Mohammed, 2009). Recent research has also found a relationship between racial discrimination and PTSD in Black individuals (Brooks Holliday et al., 2020; Carter & Forsyth, 2010; Kirkinis et al., 2021; Sibrava et al., 2019). In a longitudinal study (Sibrava et al., 2019) exploring the impact of racial discrimination over five years on PTSD diagnosis with a sample of Black and Latinx individuals, the researchers found that frequent experiences of racial discrimination significantly predicted having a PTSD diagnosis. Though Black women in our sample had higher levels of protective factors (i.e., social support and empowerment), they may have increased PTSD severity due to their experiences with racial discrimination that may impact their PTSD symptoms. More research is needed to understand how race-related risk factors such as racial discrimination impact Black women’s experience with IPV and subsequent PTSD symptoms.

Our results also add to the literature by revealing that Black women who have more social support are more empowered, which is associated with less severe posttraumatic cognitions and ultimately less severe PTSD symptom. These results support previous research highlighting how critical it is to address empowerment in IPV interventions (Johnson et al., 2020) and research that links empowerment and social support for predicting IPV-related PTSD symptom severity (Samuels-Dennis et al., 2013). The current study adds to the existing literature in that social support and empowerment were associated with lower levels of posttraumatic cognitions and PTSD symptom severity, suggesting these factors are important for IPV survivors and are an important target of clinical intervention for Black women. This is a vital result given the historical underrepresentation of Black women in IPV research (De Coster & Heimer, 2021). Moreover, these results confirm previous research that social support may be an important culturally-salient protective factor for Black women in general (Spates et al., 2019).

Exploratory analyses revealed that there were also indirect effects of race on PTSD symptom severity, such that Black women had higher levels of empowerment, which was related to lower posttraumatic cognitions, which was related to lower levels of PTSD symptom severity (Figure 1). This is consistent with previous research on empowerment and PTSD symptom severity (Wright et al., 2010). Although results are cross-sectional, it is possible that some components of empowerment such as perceptions of power and competence, autonomy, and personal strength (Johnson et al., 2005) may directly influence negative cognitions about oneself and the world which maintain PTSD symptoms. These empowerment components may serve as evidence that disproves the negative cognitions that follow a traumatic event, subsequently aiding in trauma recovery. Empowerment components, such as awareness of discrimination and anger, may be particularly relevant to Black women who are bound by stereotypes such as the Strong Black Women which can minimize their experiences of trauma by silencing them through the belief that being strong means minimizing their adverse experiences. These empowerment components may facilitate the acknowledgement and experiencing of emotions (e.g., anger about adversity is valid and part of healing). The previous research has largely focused on social support’s links to the development and maintenance of PTSD (Vogt et al., 2007) and to the development and continuance of negative posttraumatic cognitions (Ehlers & Clark, 2000; Guay et al., 2006; Joseph et al., 1997). This study’s finding adds to the existing literature in that there has been no research to date that has explored empowerment’s link to posttraumatic cognitions and the development and maintenance of PTSD symptoms for Black women who have experienced IPV. Our results suggest that empowerment may be a culturally-salient protective factor for Black women in addition to social support.

Additionally, an indirect effect of race on PTSD was also found, with higher social support relating to less PTSD symptom severity. This result is consistent with the aforementioned literature on the relationship between social support and PTSD symptom severity for Black women (Short et al., 2000). Further, the presence of an indirect effect would suggest that the construct of social support is essential in understanding PTSD symptom severity in Black women who experience IPV. This may be due to Black women’s tendency to choose social support over other forms of help-seeking, like traditional therapy (Nelson et al., 2020). Collective support is an adaptive resource for Black people, especially Black women (Davis & Afifi, 2019). Social support may be especially beneficial for Black women given that they are often viewed as not needing support due to the Strong Black Women stereotype (Jones et al., 2021) and that experiences of oppression may deplete Black women of the psychological resources necessary to support other Black women (Davis, 2019; Davis & High, 2017). However, Black women benefit most from large social support networks and especially from the support of other Black women (Bronder et al., 2014; Davis, 2019). Thus, assessing for social support as well as methods of enhancing Black women’s social support may be an important consideration in clinical work with survivors of IPV.

One potential factor associated with social support, as well as empowerment, is social cohesion. Social cohesion is the concept of participating in one’s community through shared emotional commitment and relational connection between community members. Social cohesion has long been associated with empowerment strategies and has been found to be higher in women (Peterson et al., 2005). It is possible that social support is also rooted in a sense of shared connection and belonging, which ultimately empowers Black women. Indeed, the mechanisms by which social support may reduce distress include recognizing that the support network will provide help, the network will generate other ways of coping, or the network will reduce the impact of the stressor by providing potential solutions (Jones et al., 2021; Malcome et al., 2019). Thus, social cohesion and support protect Black women from increased distress following a stressful event (Malcome et al., 2019) through empowering them to find healthier coping strategies and solutions to their problems. Social cohesion and social support should be explored when intervening with Black women who experience IPV. Additionally, empowerment-based intervention models should continue to be utilized by mental health providers when addressing Black women’s psychological distress, including IPV-related PTSD symptoms. Such strategies include psychoeducation, providing training in coping strategies, case management, and psychological treatments that include cognitive restructuring (Johnson & Zlotnick, 2009; Johnson et al., 2020). Empowerment-based strategies may be important factors in treating Black women’s mental health, especially when they are residing in IPV shelters.

Limitations, Strengths, and Future Directions

This study evidenced multiple strengths. First, it expands scholarship on the specific mental health needs, and protective factors, of a marginalized group: women who have experienced IPV residing in domestic violence shelters. Data on PTSD symptoms were collected with the gold-standard assessment tool for PTSD, the CAPS, and empirically sound measures were used for the other respective variables. By using a racially diverse sample of both Black and White women, these timely findings also lend nuance to the “Black-White mental health paradox” (Erving et al., 2019).

Despite these strengths, study results are limited. The current study employed a convenience sample of women residing in shelters and therefore cannot be assumed to be representative of all IPV survivors. Further, this study employed a cross-sectional design so causality cannot be assumed. Additionally, revisions to the diagnostic criteria for PTSD in the updated DSM-V have occurred since data collection for this study ended, which may complicate diagnostic comparisons made over time. Thus, future research should attempt to replicate the current results among other samples of IPV survivors, utilizing a prospective longitudinal design, and assessing PTSD based on DSM-5 criteria.

Conclusion

In summary, the results of the current study demonstrate the utility of empowerment and social support for treating IPV-related PTSD as well as the importance of culturally-salient factors for Black women IPV survivors. Results demonstrate a necessity for clinicians to bolster social support networks and incorporate empowerment factors when working with Black women IPV survivors. Further research is needed to replicate findings and delineate the mechanisms by which empowerment and social support reduce PTSD related cognitions and symptoms severity for Black women.

Biographies

Taylor L. Ceroni, PhD, received her doctorate in Counseling Psychology from The University of Akron and completed her doctoral internship at the Southeast Louisiana Veterans Health Care System. She subsequently served as the Intimate Partner Violence Coordinator and interim Military Sexual Trauma Coordinator. Her research is focused on women’s experiences with intimate partner violence and subsequent posttraumatic reactions, military sexual trauma, and experiences of oppression.

Samantha C. Holmes, PhD, is an assistant professor in the Department of Psychology at the College of Staten Island, City University of New York (CUNY). Her research is focused on women’s experiences of trauma, particularly identifying protective and risk factors of mental health outcomes, developing and disseminating interventions for clients with complex clinical presentations, and expanding the conceptualization of trauma to explicitly include oppression as a potentially traumatizing event.

Nuha Alshabani, PhD, is an assistant professor of Psychiatry at Boston University Chobanian and Avedisian School of Medicine. She received her doctorate in Counseling Psychology from The University of Akron. Her research focuses on improving health equity in posttraumatic stress disorder (PTSD) treatment for marginalized groups.

Kristin E. Silver, PhD, HSP, is a clinical health psychologist at VA Northeast Ohio Healthcare System and an assistant professor of Medicine at Case Western Reserve University. She received her BA from The Ohio State University and her MA/PhD from The University of Akron. She completed her Residency and Post-Doctoral Fellowship at Durham VA Medical Center and Duke University’s Department of Neurology. She is a dedicated scientist with research interests in the areas of women’s health, sexuality, behavioral medicine, and trauma/PTSD.

Dawn M. Johnson, PhD, is professor of Psychology at the University of Akron. She received her PhD in Counseling Psychology from the University of Kentucky and completed her postdoctoral training at Brown University. Her research interest is in gender-based violence in vulnerable populations. She developed HOPE, an empowerment-based cognitive behavioral treatment targeting PTSD in residents of domestic violence shelters.