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. Author manuscript; available in PMC: 2016 Mar 15.
Published in final edited form as: J Aggress Maltreat Trauma. 2015 Jun 10;24(5):501–519. doi: 10.1080/10926771.2015.1029182

Childhood Maltreatment and PTSD: Spiritual Well-Being and Intimate Partner Violence as Mediators

Huaiyu Zhang 1, Delishia M Pittman 2, Dorian A Lamis 3, Nicole L Fischer 4, Tomina J Schwenke 5, Erika R Carr 6, Sanjay Shah 7, Nadine J Kaslow 8
PMCID: PMC4792129  NIHMSID: NIHMS749609  PMID: 26989343

Abstract

Childhood maltreatment places individuals, including African American women who are undereducated and economically disadvantaged, at risk for developing posttraumatic stress disorder (PTSD) symptoms. Participants were 192 African American women with a history in the prior year of both a suicide attempt and intimate partner violence (IPV) exposure. They were recruited from a public hospital that provides medical and mental health treatment to mostly low-income patients. A simple mediator model was used to examine if (1) existential well-being (sense of purpose) and/or religious well-being (relationship with God) mediated the link between childhood maltreatment and adult PTSD symptoms. Sequential multiple mediator models determined if physical and nonphysical IPV enhanced our understanding of the mediational association among the aforementioned variables. Findings suggest that existential well-being mediated the association between childhood maltreatment and adult PTSD symptoms in a simple mediator model, and existential well-being and recent nonphysical IPV served as sequential multiple mediators of this link. However, religious well-being and physical IPV were not significant mediators. Findings underscore the importance of enhancing existential well-being in the treatment of suicidal African American women with a history of childhood maltreatment and IPV.

Keywords: PTSD symptoms, existential well-being, religious well-being, African American women, spouse abuse

Childhood maltreatment is linked to various psychological problems in adulthood, particularly posttraumatic stress disorder (PTSD) symptoms (Bendall, Alvarez-Jimenez, Hulbert, McGorry, & Jackson, 2012; Farruigia et al., 2011; Ogle, Rubin, & Siegler, 2013). Among individuals with substance use and PTSD, a history of childhood maltreatment is associated with higher levels and greater duration of PTSD symptoms (Farruigia et al., 2011). Similarly, among individuals with psychotic symptoms, childhood maltreatment is correlated with higher rates of PTSD (Bendall et al., 2012). Childhood maltreatment also predicts more adverse outcomes, such as more severe PTSD symptoms, than do traumas experienced later in life (Ogle et al., 2013).

The long-term effects of childhood maltreatment on adult traumatic experience have also been explored. Compared to those without a history of childhood abuse and neglect, individuals with childhood maltreatment histories encounter a higher number of traumas and more chronic trauma exposure later in their lives (Cloitre et al., 2009). Women who experience childhood maltreatment are more likely than women who do not experience childhood maltreatment to encounter intimate partner violence (IPV) during adulthood (Patel, Bhaju, Thompson, & Kaslow, 2012). These findings often are stratified along socioeconomic and racial lines, being markedly higher for low-income women of color (Capaldi, Knoble, Shortt, & Kim, 2012). Unfortunately, women maltreated as children frequently believe they lack control over violence directed toward them or are deserving of the violence, and these beliefs may render them more vulnerable to IPV in adulthood (Patel et al., 2012).

IPV, a significant public health issue, is widespread and affects one in three women in the United States during their life time (Centers for Disease Control and Prevention, 2011). African American women are at elevated risk for IPV when they are undereducated, economically disadvantaged, urban dwelling, and impoverished (West, 2004). Self-reported incidents of IPV are higher among African American women and women from low-income backgrounds (U.S. Department of Justice, 2012). The negative psychological consequences of IPV are often long lasting and include depression, anxiety, PTSD, substance use, and suicidal ideation and attempts. All of these connections have been well documented (Beydoun, Beydoun, Kaufman, Lo, & Zonderman, 2012; Cerulli, Poleshuck, Raimondi, Veal, & Chin, 2012; Kaslow et al., 2002). For example, recent studies reveal that women exposed to IPV are at higher risk for major depressive disorder, postpartum depression, and PTSD symptoms (Becker, 2012; Beydoun et al., 2012).

Despite the negative implications of childhood maltreatment and IPV, exposure to adverse life events does not necessarily lead to PTSD symptoms (Wright, Perez, & Johnson, 2010). One study that reported greater frequency and severity of IPV in African American than European American women also found that the African American women endorsed fewer symptoms of PTSD in response to IPV (Wright et al., 2010). This leads to the speculation that cultural context might play a critical role in individuals’ capacity to cope effectively with stress. Cultural context is of importance as we work to improve our understanding of the development and maintenance of PTSD (Zayfert, 2008). More specifically, traumatic events often are embedded in a cultural context that shapes the meaning individuals derive from their experience and informs their response to the event itself. As examined in this study, spiritual well-being may represent one such culturally relevant variable in the development and maintenance of PTSD among low-income African American women. Given the centrality of spiritual well-being in the African American culture (Boyd-Franklin, 2010), it befits researchers to understand its role in coping practices within this community relative to traumatic experiences.

Spiritual well-being is characterized as a sense of meaning and life purpose and a relationship with God (Ellison, 1983). It is separated into religious and existential well-being. The former involves a commitment to a specific religious group or belief system, and the latter involves a more general system of beliefs and values. The literature supports the notion that spiritual well-being should be included among overall indicators of health and well-being, and particularly among African American individuals (Arnette, Mascaro, Santana, Davis, & Kaslow, 2007). Spiritual well-being is positively correlated with increased health benefits, greater life satisfaction, and higher quality of life among African Americans (Utsey et al., 2007). It mediates relations between coping behavior and positive health outcomes in this population (Utsey et al., 2007). Studies with different populations have found that childhood maltreatment serves as a risk factor for lower levels of existential well-being, whereas one form of childhood maltreatment, childhood sexual abuse, has been linked to lower levels of religious well-being (Feinauer, Middleton, & Hilton, 2003; Weber & Cummings, 2003). Further, a negative association has been revealed between spiritual well-being, particularly existential well-being, and levels PTSD symptoms (Nad, Marcinko, Vuksan-Æusa, Jakovljevic, & Jakovljevic, 2008). However, a paucity of research examines these connections among African Americans. Thus, the current study investigated the relations among these factors in underserved African American women with a history of IPV and suicide attempts.

To better understand the relation between childhood maltreatment and ongoing PTSD symptoms, this study aimed to ascertain if spiritual well-being and IPV mediated the link between these two variables. We proposed the following hypotheses in our sample of low-income, abused, and suicidal African American women: (1) Childhood maltreatment would be positively associated with current PTSD symptoms; (2) Childhood maltreatment would be negatively associated with religious and existential well-being; (3) Both religious and existential well-being would be negative associated with PTSD symptoms; (4) Religious and existential well-being would mediate the childhood maltreatment – PTSD symptom link; and (5) In the multiple mediation model, spiritual well-being (religious, existential) and IPV (physical, nonphysical) would sequentially mediate the childhood maltreatment – PTSD symptom link. The last hypothesis was based on the temporary sequence and speculated associations among childhood maltreatment, IPV, and PTSD symptoms, and the well-supported protective role of spiritual well-being.

Method

Participants

Participants (N = 192), who self-identified as African American, were from a large, Southern, urban, public hospital that provides health and mental health care to low-income and mostly minority patients. During recruitment and screening, which took place in emergency rooms, inpatient units, and outpatient clinics, participants reported involvement in an abusive romantic relationship and a suicide attempt in the prior year. IPV was assessed via the 5-item Universal Violence Prevention Screening protocol (UVPSP), which covers physical, sexual, and emotional IPV and has satisfactory construct validity with the study population (Dutton, Mitchell, & Haywood, 1996; Heron, Thompson, Jackson, & Kaslow, 2003). A suicide attempt was determined if the woman indicated she had attempted suicide and she endorsed at least a moderate level of intent (i.e., ≥ 8) on the 20-item Suicide Intent Scale (SIS) (Beck, Schuyler, & Herman, 1974). Other inclusion criteria included ages 18 to 64, adequate cognitive ability as measured by the Mini-Mental State Exam (Folstein, Folstein, McHugh, & Fanjiang, 2001), and no or minimal active psychotic symptoms as measured by the 10-item Nia Psychotic Screen.

Procedure

Assessments

This study was part of a large longitudinal study that had four data collection points: pre-intervention, post-intervention, 6-month and 12-month follow-ups. The study was conducted from 2000 to 2006. The current study only included data from the pre-intervention interview when both interviewers and participants were blind to the participants’ condition. Participants were compensated $20 for the pre-intervention interview.

Measures

The Demographics Questionnaire collected basic demographic information (e.g., relationship status, children, homelessness status, employment status, monthly income).

The Childhood Trauma Questionnaire – Short Form (CTQ) contains 28 self-report items and measures levels of childhood maltreatment (Bernstein & Fink, 1998). Respondents reported “experiences growing up as a child and a teenager” using a 5-point Likert scale ranging from 1 (never true) to 5 (very often true). The CTQ yields a total score and five subscale scores. The CTQ’s psychometric properties have been investigated in large clinical and community samples, and internal consistency, stability over time, and construct validity have been established (Bernstein & Fink, 1998; Bernstein et al., 2003; Scher, Stein, Asmundson, McCreary, & Forde, 2001). There is evidence for the invariance of the scale’s five-factor structure (Thombs, Lewis, Bernstein, Medrano, & Hatch, 2007). In this study, the total CTQ scale demonstrated good internal consistency (α = .90) and was used for analyses.

The Spiritual Well-Being Scale (SWBS) assessed religious and existential well-being (Ellison, 1983; Ellison & Smith, 1991). Respondents rated their agreement with 20 statements using a 6-point Likert scale from 1 (strongly agree) to 6 (strongly disagree). Psychometric studies indicated good internal consistency and convergent, discriminant, and construct validity in diverse samples, including African Americans (Arnette et al., 2007; West, 2004). For this study, Cronbach’s α was .86 and .85 for religious and existential well-being respectively.

The Index of Spouse Abuse (ISA) examines physical and nonphysical abuse (Hudson & McIntosh, 1981). This 30-item inventory is rated on a 5-point Likert scale from 1 (never) to 5 (very frequently) regarding the level of IPV. A total score is created for each of these two forms after assigning weights to individual items depending on the degree of severity. The literature has shown good internal consistency and discriminant validity for the two subscales (Campbell, Campbell, King, Parker, & Ryan, 1994; Hudson & McIntosh, 1981). In the current study, the Cronbach’s α for physical abuse and nonphysical abuse were .90 and .89 respectively.

The 17-item Davidson Trauma Scale (DTS) examines frequency and severity of PTSD symptoms (Davidson et al., 1997) described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Each item has 5-point Likert scales on frequency rating ranging from 0 (not at all) to 4 (everyday) and on severity rating ranging from 0 (not distressing at all) to 4 (extremely distressing). The total score is generated as the sum of frequency and severity ratings in all items (Mason, Lauterbach, McKibben, Lawrence, & Fauerbach, 2012). The DTS has good internal reliability and construct validity across diverse samples of trauma survivors (McDonald, Beckham, Morey, & Calhoun, 2009; McKibben, Bresnick, Wiechman Askay, & Fauerbach, 2008). The Cronbach’s α for this measure in the sample was .95.

Statistical Analyses

Analyses were conducted using SPSS 19.0. Descriptive statistics are presented, Cronbach’s α of measures were calculated to determine the scales’ internal reliability, and partial correlations demonstrated associations among variables (Leech, Barrett, & Morgan, 2011). Multiple linear regression models were applied to test the first, second, and third hypotheses (Leech et al., 2011). For the fourth and fifth hypotheses, path analyses of two simple mediation models and two multiple mediator models were performed to determine the indirect effects between the predictor (childhood maltreatment) and outcome variable (PTSD symptoms). Bootstrap estimates based on 10,000 resamples were generated for each indirect pathway using the SPSS Macro (Hayes, 2013). Bootstrapping is recommended for testing indirect effects because it does not assume normality in sampling distribution (Preacher & Hayes, 2008).

Results

Descriptive Statistics

Participants’ demographic information is shown in Table 1. Table 2 reports descriptive statistics of study-related variables and their internal reliability and partial correlations.

Table 1.

Demographic Characteristics of the Participants

Demographic Characteristics Descriptive Statistics
Age (Mean; SD) 34.9; 9.29
Relationship status (%)
   In relationship 58.2
   Not in relationship 41.8
Have children (%) 81.9
Homeless (%) 54.0
Unemployed (%) 86.7
Individual monthly income
   $0-$249 56.1
   $250-$499 15.3
   $500-$999 21.7
   >$999 6.9
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Table 2.

Demographic Statistics, Cronbach’s α, and Partial Correlations between Variables Controlling for Age, Relationship Status, Homelessness, and Monthly Income

Mean SD Cronbach’s α Partial Correlations
1 2 3 4 5 6
1. CTQ 71.4 22.1 .90 ---
2. ISAP 46.6 28.2 .90 .093 ---
3. ISANP 57.1 25.8 .89 .131 .798** ---
4. RELWB 45.8 9.70 .86 −.074 .028 .060 ---
5. EXTWB 36.9 10.1 .85 −.144* −.141* −.182** .567** ---
6. DTS 79.9 32.8 .95 .278** .219** .231** −.176* −.389** ---
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Note. CTQ stands for Childhood Trauma Questionnaire, which measures childhood trauma; ISAP stands for Index of Spouse Abuse – Physical, which measures physical IPV; ISANP stands for Index of Spouse Abuse – Nonphysical, which measures nonphysical IPV; RELWB stands for religious well-being subscale of the Spiritual Well-Being Scale, which measures religious well-being; EXTWB stands for existential well-being subscale of the Spiritual Well-Being Scale, which measures existential well-being; DTS stands for Davidson Trauma Scale, which measures PTSD symptoms.

*

p ≤ .05, two-tailed.

**

p ≤.01, two-tailed.

Childhood Maltreatment and PTSD Symptoms

Multiple regression models revealed that childhood maltreatment was significantly associated with PTSD symptoms, controlling for age, relationship status, homelessness, and monthly income, t(186) = .377, p < .001. Previous studies have suggested the use of age, relationship status, and monthly income as covariates (Boals, Hayslip, Knowles, & Banks, 2012; Ditlevsen & Elklit, 2010; Feinstein, Humphreys, Bovin, Marx, & Resick, 2011; Rennison & Planty, 2003; Williams & Mickelson, 2007). In addition, homelessness was found to significantly correlate with PTSD symptoms in this study, r(192) = .193, p <.01, and thus was also controlled. Thus, findings were consistent with the first hypothesis that higher levels of childhood maltreatment would be associated with higher levels of PTSD in adulthood.

Childhood Maltreatment and Spiritual Well-Being

Multiple regression models showed that childhood maltreatment was not associated with religious well-being, t(186) = −.963 p > .05, but was significantly associated with existential well-being, t(186) = −1.93, p = .05, controlling for covariates. Therefore, there was partial support for the second hypothesis, as higher levels of childhood maltreatment were associated with lower levels of existential well-being.

Spiritual Well-Being and PTSD Symptoms

Multiple regression models revealed that both religious well-being (t(186) = −2.46, p < .05) and existential well-being (t(186) = −5.73, p < .001) were significantly correlated with PTSD symptoms, controlling for covariates. Thus, the third hypothesis was supported, as higher levels of religious and existential well-being were associated with lower levels of PTSD symptoms in adulthood.

Religious and Existential Well-Being as Single Mediators

Two simple mediation models determined if the childhood maltreatment - adult PTSD symptom link was mediated by either or both of the two proposed mediators (as shown in Figure 1.A).

Fig. 1.

Fig. 1

Fig. 1

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Bootstrap estimates showed nonsignificant indirect effects via religious well-being, but significant indirect effects via existential well-being, 95% confidence interval [.001, .113]. Details of the simple mediation model with existential well-being as the mediator is shown in Table 3. Thus, the fourth hypothesis was partially supported by the results. More specifically, the association between childhood maltreatment and PTSD was mediated by existential well-being, but not religious well-being.

Table 3.

Regression Results for Simple Mediation with Existential Well-Being as the Mediator and Age, Relationship Status, Homelessness, and Monthly Income as Covariates

Regression results Beta t p
1. DTS regressed on CTQ (c) .267 3.77 <.001
2. EXTWB regressed on CTQ (a) −.141 −1.93 .05
3. DTS regressed on EXTWB controlling for CTQ (b) −.345 −5.36 <.001
4. DTS regressed on CTQ controlling for EXTWB (c’) .219 3.25 .001
Indirect effect (ab) Value
 SE
.049 .028
95% confidence interval of indirect effect (ab) based on

10,000 bootstrap samples		 Lower Limit
 . Upper Limit
.001 .113
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Note. In Tables 3 and 4, CTQ stands for Childhood Trauma Questionnaire, which measures childhood trauma; ISANP stands for Index of Spouse Abuse – Nonphysical, which measures nonphysical IPV; RELWB stands for religious well-being subscale of the Spiritual Well-Being Scale, which measures religious well-being; EXTWB stands for existential well-being subscale of the Spiritual Well-Being Scale, which measures existential well-being; DTS stands for Davidson Trauma Scale, which measures PTSD symptoms.

Multiple Mediation Models

The fifth hypothesis focused on multiple mediator models with mediators in sequence. The mediational effect of religious/existential well-being on the childhood maltreatment – PTSD symptom link was expected to be mediated by physical/nonphysical IPV (as shown in Figure 1.B).

Given that results of the fourth hypothesis revealed that existential, but not religious, well-being mediated the association between childhood maltreatment and PTSD symptoms, only existential well-being and physical and nonphysical IPV were examined for this hypothesis. Therefore, two multiple mediator models were tested: one with physical IPV and existential well-being as two sequential mediators, and one with nonphysical IPV and existential well-being as two sequential mediators. Both models included childhood maltreatment as the predictor, and PTSD symptoms as the outcome variable. Bootstrap estimates revealed that for the model involving physical IPV and existential well-being as the mediators all three indirect pathways were nonsignificant. In comparison, for the model involving nonphysical IPV and existential well-being as mediators, the bootstrap estimates of indirect effect of a1a3b2 (i.e., childhood maltreatment –> nonphysical IPV –> existential well-being –> PTSD symptoms) were significant, 95% confidence interval [.0002, .018]. Details of the model with nonphysical IPV and existential well-being as mediators are presented in Table 4. Thus, the fifth hypothesis was partially supported by the multiple mediator model with nonphysical IPV and existential well-being. In other words, the link between childhood maltreatment and PTSD is mediated in a sequential fashion by nonphsycial IPV and existential well-being.

Table 4.

Regression Results for the Multiple Mediator Model with Nonphysical IPV and Existential Well-Being as the Mediators and Age, Relationship Status, Homelessness, and Monthly Income as Covariates

Regression results Beta t p
1. DTS regressed on CTQ (c) .267 3.77 <.001
2. ISANP regressed on CTQ (a1) .095 1.79 .07
3. EXTWB regressed on CTQ controlling for ISANP (a2) −.121 −1.67 .10
4. EXTWB regressed on ISANP controlling for CTQ (a3) −.166 −2.28 .02
5. DTS regressed on ISANP controlling for EXTWB, CTQ (b1) .152 2.13 .03
6. DTS regressed on EXTWB controlling for ISANP, CTQ (b2) −.321 −4.93 <.001
7. DTS regressed on CTQ controlling for ISANP, EXTWB (c’) .213 3.17 .002
Indirect effects Value
 SE
   Total indirect effects (a1b1+a2b2+a1a3b2) .058 .029
   a1b1 .014 .012
   a2b2 .039 .026
   a1a3b2 .005 .004
95% confidence interval based on 10,000 bootstrap samples Lower Limit Upper
Limit
   Total indirect effects (a1b1+a2b2+a1a3b2) .008 .012
   a1b1 −.0005 .048
   a2b2 −.007 .098
   a1a3b2 .0002 .018
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Discussion

This study increases our understanding of the complex nature of the association between childhood maltreatment and PTSD symptoms in a high risk sample, namely low-income African American women. Given the intersections of the various forms of demographic (race, class) and psychosocial marginalization experienced by the women in this sample (family violence in childhood and adulthood) , it is essential that attention be paid to protective factors that might reduce their vulnerability to negative mental health outcomes, such as PTSD symptoms in adulthood. Of interest was a culturally relevant construct, namely spiritual well-being.

This study found a positive association between childhood maltreatment and PTSD symptoms, which increases our confidence in results from other studies that individuals who experience childhood maltreatment are more vulnerable to PTSD symptoms later in life (Lang et al., 2008). Moreover, the study adds to a growing body of research with urban, low-income, African American women showing that in women with a history of IPV, childhood maltreatment predicts adult PTSD symptoms (Bradley, Schwartz, & Kaslow, 2005). Further, an earlier investigation revealed that childhood maltreatment in combination with PTSD symptoms predicts suicide attempts (Thompson, Kaslow, Bradshaw, & Kingree, 2000). Taken together, childhood maltreatment has long lasting, profound psychological effects on the individual, with survivors often exhibiting increased symptoms of PTSD (Cerulli et al., 2012; Kaslow et al., 2002).

Second, no association was found between childhood maltreatment and religious well-being, but a significant association emerged between childhood maltreatment and existential well-being. Other studies have also revealed an impact of childhood maltreatment on levels of existential well-being (Feinauer et al., 2003; Weber & Cummings, 2003). However, lack of an association between childhood maltreatment and religious well-being is inconsistent with literature demonstrating that religious or spiritually-based coping play a central role in African Americans’ lives (Taylor, Chatters, & Levin, 2004) and that African American women benefit from and are satisfied with spiritually-based coping strategies (Lugo et al., 2008). The differential findings related to religious versus existential well-being raise questions about how spirituality is experienced. In a study of ethnic differences on the effects of spiritual well-being, researchers suggested that the connection between spiritual and psychological well-being is unique for African American women who live at the intersection of race, class, and gender (Douglas, Jiminez, Lin, & Frisman, 2008). Similarly, study findings likely reflect a collective and community oriented cultural value in which women strive to find meaning in ways that are personally valuable and possibly more broadly defined than religiously prescribed (Sales, Merrill, & Fivush, 2013).

Third, both religious and existential well-being correlated with PTSD symptoms. This is consistent with what was expected, as the literature describes that African American women efficiently utilize protective factors of empowerment and resilience, such as spiritual means to cope with stress and reduce psychological symptoms (Taylor et al., 2004). Further, research with other populations has supported the links between both religious and existential well-being and PTSD symptoms (Lee & Waters, 2003; Nad et al., 2008). While existential and religious well-being both correlated with PTSD symptoms in the mediational model, existential well-being had a stronger association.

Fourth, contrary to expectation, religious well-being was not found to mediate the relation between childhood maltreatment and PTSD symptoms. These results are inconsistent with prior empirical studies that have shown that religious coping and well-being protect against negative mental health outcomes following traumatic experiences (Bierman, 2006; Ellison, Musick, & Henderson, 2008). Given that the childhood maltreatment-religious well-being relation was not significant, it is not surprising that religious well-being did not mediate the association between childhood maltreatment and PTSD symptoms. However, as predicted, existential well-being did mediate the childhood maltreatment – PTSD link. This result expands our understanding of the significance of existential well-being, which in other studies has also been found to be more strongly associated with positive mental health outcomes than religious well-being in college students and African American women (Arnette et al., 2007; Taliaferro, Rienzo, Pigg, Miller, & Dodd, 2009). It is plausible that a sense of purpose and meaning in life (i.e., existential well-being) is more universally sought out regardless of one’s level of religiosity. This result is also in keeping with studies that have found that other protective factors, such as social resources, are key in understanding the childhood maltreatment-adult PTSD symptom link (Vranceanu, Hobfoll, & Johnson, 2007).

The fifth hypothesis was partially supported in that the multiple mediator model involving childhood maltreatment, nonphysical IPV, existential well-being, and PTSD symptoms was significant. This result means that in low-income African American women, nonphysical IPV and existential well-being jointly influence the association between childhood maltreatment and PTSD symptoms in adulthood. Moreover, existential well-being ameliorates the impact of childhood maltreatment and nonphysical IPV on PTSD symptoms. However, lack of support for the multiple mediator model occurred when childhood maltreatment, physical IPV, existential well-being, and PTSD symptoms were considered. This shows that the sequential mediators, physical IPV and existential well-being, do not predict PTSD symptoms in women maltreated as children. Whereas nonphysical IPV is characterized by non-violent abuse, such as verbal and emotional abuse and over-controlling behavior, physical IPV is more centered on the abuse that takes a physical form and is likely to cause injuries in the survivors. Although both forms of IPV may adversely impact women, nonphysical IPV may have more detrimental influence than physical IPV on one’s psychological well-being due to its higher frequency and greater terrorizing effects (Johnson & Leone, 2005).

Although our findings contribute to the extant literature by investigating factors that may contribute to PTSD in low income, abused African American women, there are a number of ways in which future research could be enhanced. The fact that our participants were low-income, suicidal, minority individuals, half of whom were homeless, has restricted the applicability of the findings. Future research that replicates our findings in other ethnic/racial and social class samples would allow for cross-validation of the current results and indicate the extent to which the results were generalizable. Future studies should utilize various collection strategies with African American women, such as interviews in addition to self-report measures, to minimize response bias associated with social desirability (Davis, Couper, Janz, Caldwell, & Resnicow, 2010). This would be important for assessing both childhood maltreatment and PTSD. To reduce recall bias and underreporting associated with the retrospective reports of childhood maltreatment (Hardt & Rutter, 2004), researchers should collect information from childhood to adulthood. Additional constructs should be examined as potential mediators of the childhood maltreatment-PTSD link, such as adaptive coping, family and social support, and stress (Vranceanu et al., 2007). Longitudinal designs should be employed to gain a greater appreciation of the bidirectionality of effects and the causal nature of the associations. Finally, the cultural relevance of this work could be enhanced. For example, given data that African American female suicide attempters report higher levels of IPV than African American as compared to non-African American interviewers, race of the interviewer should be considered in future analyses (Samples et al., 2014). Moreover, other culturally salient mediators could be examined such as racial identity, religious involvement, and religious coping.

Despite these limitations, study results have several clinical implications. Most treatments related to individuals experiencing childhood maltreatment who develop symptoms of PTSD have been developed and evaluated for children. Best known among these treatments is trauma-focused cognitive behavioral therapy (TF-CBT) (Cohen, Deblinger, Mannarino, & Steer, 2004). It is only in recent years that randomized controlled trials have been conducted with adults with PTSD symptoms who were maltreated as children. There is promising support for this population for cognitive processing therapy (CPT) (Chard, 2005), and Skills Training in Affect and Interpersonal Regulation (STAIR), which focuses on developing emotion management and interpersonal skills and subsequently using a modified version of prolonged imaginal exposure therapy (Cloitre, Cohen, Koenen, & Han, 2002; Cloitre et al., 2010). Similarly, a small literature demonstrates the effectiveness of interventions for treating PTSD symptoms in women with a history of IPV (Dutton, Bermudez, Matas, Majid, & Myers, 2013; Graham-Bermann & Miller, 2013). However, no treatment outcome studies were designed specifically for women with PTSD symptoms who had a history of childhood maltreatment and IPV, despite the high co-occurrence of these forms of family violence (Cloitre et al., 2009). In addition, the applicability of these interventions for low-income African American women remains an empirical question.

Our study results confirm that culturally informed interventions for this population should focus on spirituality as an effective coping and survival technique for dealing with interpersonal and societal adversity (Boyd-Franklin, 2010). Most beneficial would be prioritizing enhancing existential well-being. Clinicians should encourage patients to strive for meaning in their lives to bolster their coping and reduce risk for negative outcomes. To enhance a sense of purpose in trauma-impacted individuals, a humanistic-existential approach is desirable. It emphasizes people’s freedom in making life choices and helps them work toward their values and derive meaning for personal growth (Tan & Wong, 2012). Empirical evidence has shown promise with this approach (Henoch, Danielson, Strang, Browall, & Melin-Johansson, 2013). With evidence from this study, it would be helpful to examine the efficacy and effectiveness of integrating this humanistic-existential framework with more standard cognitive-behavioral interventions in a population of African Americans impacted by multiple forms of trauma.

Acknowledgments

This research was supported by grants from the Centers for Disease Control and Prevention National Center for Injury Prevention and Control (R49 CCR421767-01, Group interventions with suicidal African American women) and the National Institute of Mental Health (1R01MH078002-01A2, Group interviews for abused, suicidal Black women) awarded to the last author.

Biographies

Huaiyu Zhang, PhD, is an Assistant Professor in the Psychiatry Department at Indiana University. She received her PhD in Clinical Psychology from Emory University. Her current research interests focus on resilience factors among individuals experiencing life adversities.

Delishia M. Pittman, PhD, is an Assistant Professor in the Department of Counseling and Human Development at The George Washington University. She received her PhD in Counseling Psychology from the University of Georgia. Her current research interests focus on social, psychological, and cultural determinants of racial/ethnic disparities in health behaviors and health outcomes in African Americans.

Dorian A. Lamis, PhD, is an Assistant Professor in the Department of Psychiatry at Emory School of Medicine. His research focuses on mood disorders, substance use, and suicidal behaviors in a variety of populations including adolescents, young adults (e.g., college students), and African Americans.

Nicole L. Fischer, PhD is a Staff Psychologist and Adjunct Professor at Marymount University in Arlington, VA. She received her PhD in Counseling Psychology from Virginia Commonwealth University. Her current research interests focus on trauma and substance abuse among African American women.

Tomina Schwenke, PhD, is a Forensic Evaluator for the Department of Behavioral Health and Developmental Disabilities. She received her Counseling Psychology doctorate from Georgia State University and Masters in Counseling and Deafness Rehabilitation from New York University. Her current research interests focus on trauma, deafness, burnout and resilience.

Erika Carr, PhD, is an Assistant Professor in the Department of Psychiatry at Yale University School of Medicine. She received her doctoral degree from the University of Tennessee and completed her internship at Emory University School of Medicine. Her current research interests focus on trauma, sexual objectification of women, serious mental illness, and recovery-oriented care.

Sanjay Shah, JD, PhD, is a Forensic Psychologist at Georgia Regional Hospital at Atlanta. He received his PhD from Drexel University. His current research interests focus mainly on forensic mental health assessment.

Nadine J. Kaslow, PhD, ABPP, is Professor and Vice Chair in the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine and Chief Psychologist at Grady Health System. Her research interests include culturally competent assessment and treatment of suicidal persons, the link between family violence and suicide, depression and post-traumatic stress disorder, and psychology education and training.

Footnotes

None of the authors have conflicts of interest to report.

Contributor Information

Huaiyu Zhang, Department of Psychiatry, Indiana University.

Delishia M. Pittman, Department of Psychology, George Washington University

Dorian A. Lamis, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine

Nicole L. Fischer, Department of Psychology, Marymount University

Tomina J. Schwenke, Georgia Department of Behavioral Health and Department of Disabilities

Erika R. Carr, Department of Psychiatry, Yale University

Sanjay Shah, Georgia Regional Hospital at Atlanta.

Nadine J. Kaslow, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine

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