UNDERSTANDING POSTTRAUMATIC STRESS DISORDER AMONG VICTIMS OF INTIMATE PARTNER VIOLENCE: THE ROLES OF PERCEIVED

Transcription

1 UNDERSTANDING POSTTRAUMATIC STRESS DISORDER AMONG VICTIMS OF INTIMATE PARTNER VIOLENCE: THE ROLES OF PERCEIVED SOCIAL SUPPORT, SELF-ESTEEM, AND SELF-BLAME Thesis Submitted to The College of Arts and Sciences of the UNIVERSITY OF DAYTON In Partial Fulfillment of the Requirements for The Degree Master of Arts in Psychology By Anne Louise Steel UNIVERSITY OF DAYTON Dayton, Ohio August, 2012

2 UNDERSTANDING POSTTRAUMATIC STRESS DISORDER AMONG VICTIMS OF INTIMATE PARTNER VIOLENCE: THE ROLES OF PERCEIVED SOCIAL SUPPORT, SELF-ESTEEM, AND SELF-BLAME Name: Steel, Anne Louise APPROVED BY: Catherine L. Zois, Ph.D. Faculty Advisor Jackson A. Goodnight, Ph.D. Committee Member Melissa L. Guadalupe, Ph.D. Committee Member Concurrence: Carolyn Roecker Phelps, Ph.D. Chair, Department of Psychology ii

3 ABSTRACT UNDERSTANDING POSTTRAUMATIC STRESS DISORDER AMONG VICTIMS OF INTIMATE PARTNER VIOLENCE: THE ROLES OF PERCEIVED SOCIAL SUPPORT, SELF-ESTEEM, AND SELF-BLAME Name: Steel, Anne Louise University of Dayton Advisor: Dr. Catherine Zois The relationship between the experience of intimate partner violence (IPV) and the development of Posttraumatic Stress Disorder (PTSD) has been well-established in the literature (Basile, Arias, Desai, & Thompson, 2004; Coker, Smith, Thompson, McKeown, Bethea, & Davis, 2002). However, researchers have called for more complex statistical models capable of identifying and analyzing the pathways potentially linking IPV and PTSD. Research indicates that IPV victims report lower levels of perceived social support than non-ipv victims (Bengtsson-Tops & Tops, 2007) and that, as a result, victims are at greater risk of developing PTSD (Ozer, Best, Lipsey, & Weiss, 2008). Drawing from the stress buffering hypothesis (Cohen & Willis, 1985), which states that social support acts as a buffer, protecting an individual from the negative effects of a stressful event, the current study analyzed the moderating role of perceived social support in the relationship between IPV and PTSD. It was hypothesized that the positive iii

4 relationship between IPV and PTSD would be stronger among individuals perceiving lower social support. It was also hypothesized that characterological self-blame and selfesteem would mediate the moderator effect of perceived social support. The hypotheses were tested by distributing questionnaires to 132 adult female participants recruited at a substance abuse treatment facility and a private university. The results indicated that IPV was positively associated with PTSD, and perceived social support negatively predicted PTSD. Further, perceived social support moderated the positive relationship between IPV and PTSD. At the extreme levels of perceived social support, the positive relationship between IPV and PTSD was stronger among individuals perceiving low levels of social support than among those perceiving high levels of social support. However, at the moderate levels of perceived social support, the positive relationship between IPV and PTSD was stronger among individuals perceiving high levels of social support than among those perceiving low levels of social support. Lastly, the results showed that selfesteem mediated the observed moderator effect of perceived social support. Possible explanations for the apparent shift in the direction of the moderation as well as the clinical implications of the findings, limitations of the current study, and directions for future research are discussed. iv

5 ACKNOWLEDGEMENTS My special thanks are in order to Dr. Catherine Zois, my advisor, who graciously dedicated her time and expertise to the directing of this thesis to its conclusion. In addition, I would like to thank Dr. Melissa Guadalupe and Dr. Jackson Goodnight for their time and valuable feedback in reviewing this text. Particular thanks are in order to Dr. Goodnight for providing his expertise and guidance in the area of statistical analysis. I would also like to thank Laura Stayton, Avery Ozimek, and Rusty Schnellinger who assisted with data collection for this study. Lastly, while I will not name the agency for privacy purposes, I would like to express my appreciation to the staff members at a local substance abuse treatment facility for their willingness to permit and facilitate data collection within their agency. v

6 TABLE OF CONTENTS ABSTRACT...iii ACKNOWLEDGEMENTS...v LIST OF TABLES...vii INTRODUCTION...1 METHOD...23 RESULTS...40 DISCUSSION...54 REFERENCES...71 APPENDICES A. DEMOGRAPHIC DATA SHEET...83 B. SOCIAL PROVISIONS SCALE...84 C. ROSENBERG SELF-ESTEEM SCALE...86 D. CONFLICT TACTICS SCALE...87 E. RELATIONSHIP DATA SHEET...90 F. BEHAVIORAL AND CHARACTEROLOGICAL SELF-BLAME SCALE...91 G. IMPACT OF EVENTS SCALE REVISED...92 H. SYMPTOM QUESTIONNAIRE...94 vi

7 LIST OF TABLES 1. Descriptive Statistics for Nominal and Ordinal Level Study Measures Independent Samples T-Test Analysis Identifying Differences in Continuous Study Variables Between Participants Recruited at Different Locations Zero-Order Correlations Between Primary Study Variables Hierarchical Multiple Regression Analysis Predicting PTSD from IPV Hierarchical Multiple Regression Analysis Predicting PTSD from Perceived Social Support Hierarchical Multiple Regression Analysis Predicting PTSD from IPV x Perceived Social Support Interaction Zero-Order Correlations Between IPV and PTSD at Varying Levels of Perceived Social Support Hierarchical Multiple Regression Analysis Predicting PTSD from Behavioral Self-Blame...53 vii

8 INTRODUCTION According to the National Centers for Disease Control and Prevention (CDC), intimate partner violence (IPV) is defined as physical violence, sexual violence, threat of physical or sexual violence, or psychological or emotional abuse when prior physical or sexual violence or threat of physical or sexual violence has occurred between intimate partners (Saltzman, Fanslow, McMahon, & Shelley, 1999/2002). The CDC defines intimate partners as current or former spouses and current or former non-marital heterosexual or homosexual dating partners, including first date acquaintances. Thus, acquaintance rape is considered a form of IPV. In 2005, a telephone survey conducted by the CDC of over 70,000 US respondents found that approximately one in four women (26.4%) and one in seven men (15.9%) reported having experienced some form of lifetime IPV victimization (Breiding, Black, & Ryan, 2008). Further, the National Violence against Women Survey conducted by the National Institute of Justice and the CDC in 2000 found that 7.7 percent of women and 0.3 percent of men reported being raped by an intimate partner during their lifetime, and approximately 201,394 women are raped annually by an intimate partner (Tjaden & Thoennes, 2000). The survey also found that 64 percent of all violence against women over the age of 18 is perpetrated by an intimate partner. Various studies have demonstrated the detrimental impact of IPV on victims mental and physical well-being. In a meta-analysis of the existing literature concerning 1

9 IPV victims mental health, Golding (1999) found that after weighting average prevalence rates across studies, rates of depression (47.6%), suicidality (17.9%), Posttraumatic Stress Disorder (PTSD; 63.8%), alcohol abuse or dependence (18.5%), and drug abuse or dependence (8.9%) among IPV victims were significantly higher than the rates among the general female population. Further, Coker and colleagues (2002) found that among women seeking medical treatment at two family practice clinics, 53.9 percent had experienced some type of IPV. Following the mental health assessment of these victims, results showed significant relationships between IPV (independent of type) and perceived mental and physical health, smoking, anxiety, depression, and suicide ideation and attempts. Sexual and physical IPV were significantly related to drug and alcohol abuse as well as PTSD symptoms; the relationship between IPV and mental health outcomes was stronger among those experiencing sexual IPV than those experiencing physical IPV. Though the differential effect of the various types of IPV on mental health outcomes is often debated in the literature, Basile and colleagues (2004) found that all types of IPV are positively associated with the development of PTSD symptoms. Further, Pico-Alfonso, Garcia-Linares, Celda-Navarro, Blasco-Ros, Echeburua, and Martinez (2006) reported that when compared to a control group, IPV victims report significantly higher rates of PTSD. Given this well-established link between IPV and PTSD (Basile et al., 2004; Coker et al., 2002; Golding, 1999; Pico-Alfonso et al., 2006), Dutton (2009) has noted the need for more complex statistical models that yield a better understanding of the different pathways potentially linking the experience of IPV and the development of PTSD. 2

10 The current study sought to identify such pathways by analyzing the moderating role of perceived social support in the relationship between IPV and PTSD. Further, the study sought to determine whether this moderation is mediated by characterological selfblame and self-esteem. In the remainder of the introduction, general findings in the area of perceived social support among IPV victims are discussed. The literature addressing the relationship between this variable and the dependent variable, PTSD, is also presented. In addition, research suggesting the potential mediating roles of characterological self-blame and self-esteem in this relationship is discussed. Lastly, after presenting specific hypotheses, a study designed to test a model in which perceived social support moderates the relationship between IPV and PTSD, and characterological selfblame and self-esteem mediate the moderator effect is described. Intimate Partner Violence and Posttraumatic Stress Disorder According to the current Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [DSM-IV-TR], 2000), PTSD is defined as the development of characteristic symptoms including re-experiencing of the traumatic event, avoidance of stimuli associated with the event and numbing of responsiveness, and symptoms of increased arousal following the experience of a traumatic event. Further, a traumatic event is defined in the DSM-IV-TR as the direct experience of or the witnessing of another individual in a situation involving actual or threatened death or serious injury or other threat to one s physical integrity. A traumatic event may also include the learning about the unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or close associate. An individual s response to such a stressor must involve intense fear, helplessness, or horror, and their 3

11 characteristic symptoms must persist for at least one month in order to receive a diagnosis of PTSD. While PTSD is one of the most frequent mental health consequences of IPV, there remain a substantial minority of female IPV victims who do not develop PTSD or other mental health problems, including the commonly co-morbid diagnosis of major depression (Dutton, 2009). This finding suggests that factors beyond the mere experience of IPV likely contribute to the consequential development of PTSD symptoms. The pathways linking IPV and PTSD are numerous, and it is important to note that while the factors analyzed in the current study are limited to those occurring after the traumatic event, factors occurring both before and during the traumatic event must also be considered. The pre- and peri-trauma factors discussed below, relating to demographics, pre-trauma mental health, history of abuse, and severity and type of trauma, are commonly identified in the research as risk factors increasing likelihood of developing PTSD symptoms following experience of IPV. Demographic risk factors and pre-trauma mental health. Prevalence rates of PTSD among IPV victims tend to be higher among female, lower socioeconomic, and ethnic minority populations. However, there is some debate in the literature as to whether racial differences are no longer significant after controlling for socioeconomic status or whether these differences remain significant due to factors such as prejudice and stigmatization (Dutton, 2009). Further, risk for the development of PTSD following IPV appears to be higher among individuals with a family history of mental illness as well as individuals with preexisting mental disorders (Dutton, 2009). 4

12 History of abuse. Other pre-trauma factors including experience of prior abuse are often analyzed in reference to the development of PTSD following experience of IPV. Research suggests that childhood abuse, particularly sexual abuse, as well as witnessing maternal domestic violence not only increase an individual s risk of experiencing IPV (Pico-Alfonso, 2005) but, as a result of increased sensitivity to later traumatic experience (Dutton, 2009), these individuals are also at higher risk of developing PTSD (Dutton, 2009; Pico-Alfonso, 2005). Further, IPV victims are also more likely to have been exposed to other forms of victimization as adults, suggesting the possibility that the development of PTSD is a result of cumulative traumatic experiences (Pico-Alfonso, 2005). A meta-analysis of PTSD risk factors among the general population (Brewin, Andrews, & Valentine, 2000) found that demographic and prior history factors including female gender, lower socioeconomic status, lower education level and intelligence, younger age, race, family and personal psychiatric history, and history of abuse, trauma, and childhood adversity were significantly correlated with PTSD. However, these factors were, in fact, very weak predictors of PTSD. Rather, Brewin, Andrews, and Valentine (2000) found that factors occurring both during and after the event (e.g., trauma severity, social support, life stress) were the strongest predictors of PTSD. Severity and type of trauma. When analyzing factors occurring during trauma, the combination of IPV severity and the presence of sexual abuse, psychological abuse, and coercion appear to determine risk for development of PTSD (Dutton, 2009). Dutton, Kaltman, Goodman, Weinfurt, and Vankos (2005) compared the prevalence rates of probable PTSD diagnosis among IPV victims experiencing differing patterns of IPV. 5

13 Results showed that 56 percent of victims experiencing a pattern of moderate physical violence, sexual abuse, psychological abuse, and stalking developed symptoms meriting a PTSD diagnosis. Further, 76 percent of those experiencing a pattern of severe physical violence, psychological abuse, and stalking, but low sexual abuse, and 88 percent of those experiencing severe physical violence, psychological abuse, stalking, and sexual abuse developed symptoms meriting PTSD diagnosis. Though the literature continues to debate whether sexual abuse, psychological abuse, or severity of physical abuse is the strongest predictor of PTSD, it is important to note evidence suggesting that all forms of IPV are correlated with the development of PTSD symptoms (Basile et al., 2004). While both pre- and peri-trauma factors play a role in the development of PTSD following experience of IPV, the current study focused on the role of post-trauma perceived social support. Because research suggests that IPV victims possess lower levels of perceived social support than non-ipv victims (Barnett, Martinez, & Keyson, 1996) and that this low post-trauma support significantly predicts development of PTSD (Kemp, Green, Hovanitz, & Rawlings, 1995; Ozer et al., 2008), the current study sought to determine whether perceived social support moderates the relationship between the experience of IPV and the development of PTSD. Thus, I will now discuss the means by which perceived social support acts a possible buffer between stress (e.g., IPV) and distress (e.g., PTSD). The Moderating Role of Perceived Social Support Much diversity exists in definitions and measures of social support. Distinctions have been made between the concepts of social embeddedness (i.e., an indicator of ties to others in one s social environment), enacted support (i.e., the actions taken by others to 6

14 provide support), and perceived social support (i.e., the cognitive appraisal of the availability and adequacy of connections to others) (Barrera, 1986). These types of social support are only loosely correlated with one another and demonstrate unique patterns of relationships with measures of both stress and distress. Perceived social support, the most frequently assessed support concept in the literature, has the most consistently demonstrated relationship with stress and distress (Barrera, 1986; Sarason, Sarason, & Gurung, 2001), including PTSD symptoms (Kemp et al., 1995; Ozer et al., 2008) and is, thus, the social support concept that was the focus of the current study. The stress buffering hypothesis is one prominent model of specifically how social support is linked to stress (including traumatic events) and distress (including PTSD symptoms). As the name implies, the stress buffering hypothesis (Cohen & Willis, 1985; Gremore, Baucom, Porter, Kirby, Atkins, & Keefe, 2011) states that social support protects an individual from the negative effects of a stressful event. The model proposes that support may act as a buffer between the stressful event and the stress reaction by allowing the individual to redefine the potential harm of the stressor and his or her ability to cope. Perceived social support may also act as a buffer between the stressor and the onset of negative outcomes by decreasing an individual s physiological response to stress (Heffner, Kiecolt-Glaser, Loving, Glaser, & Malarkey, 2004). In order to provide evidence for a buffering effect, when exposed to high levels of psychosocial stressors, symptoms should be more likely for individuals reporting low levels of perceived social support than those reporting high levels of social support. In the case of IPV victims, the prevalence of PTSD symptoms should, thus, be lower among victims perceiving higher support. Statistically, this amounts to perceived social support 7

15 serving as a moderator of the relationship between IPV and PTSD. Before summarizing the results of empirical tests of the stress buffering hypothesis specifically pertaining to IPV and PTSD, I will first discuss what is known about perceived social support among IPV victims (Coker et al., 2002; Levendosky, Bogat, Theran, Trotter, Von Eye, & Davidson, 2004). Perceived social support among IPV victims. Barnett, Martinez, and Keyson (1996) state that in response to an IPV experience, victims often undergo a stress response characterized by fear, depression, anxiety, and low self-esteem. As a result, victims experience a decrease in effective coping, thus requiring additional social support. However, IPV victims report having less social support than non-ipv victims (Barnett, Martinez, & Keyson, 1996; Bengtsson-Tops & Tops, 2007) as well as experiencing interpersonal problems affecting close relationships and reliance on others. One study found that among female IPV victims, 43 percent reported needing more social support than they currently had in the form of professional health care, family interventions, self-help groups, medical care, legal support, and unspecified support (Bengtsson-Tops & Tops, 2007). Levendosky and colleagues (2004) attempted to identify reasons for this decreased social support among the IPV victim population, including social isolation while in the abusive relationship and minimal or lack of disclosure of the abuse. Findings from this study showed a positive correlation between frequency of disclosure and degree of social network homophily (i.e., the number of network members who have also been abused). Thus, women were more likely to disclose their IPV experiences to other members within the social network who have also experienced IPV. The results of this 8

16 study also indicated that, in general, victims who more frequently disclosed their IPV experiences received higher levels of practical aid and emotional support than those disclosing these experiences less frequently. Thus, it is possible that victims of IPV may feel more comfortable discussing their experiences with those who have shared similar abuse experiences and may, therefore, receive increased support. This suggests that social network homophily could be protective. However, while disclosure may increase the overall level of support received by the victim, there may be possible negative consequences of social support derived from others who are also involved in an abusive relationship. Levendosky and colleagues (2004) found that among IPV victims, those reporting greater social network homophily received lower levels of emotional support and higher levels of criticism than those reporting lower social network homophily. Researchers (Levendosky et al., 2004) suggest that supporters who have experienced IPV may be coping with depression and may, therefore, possess an internal attribution style. As a result, these individuals maybe more likely to criticize the victim and less capable of providing positive support. Interestingly, this degree of homophily is common within social networks of IPV victims, as IPV victims, in comparison to non-ipv victims, are more likely to have supporters with a history of IPV. Further, Coker and colleagues (2002) found that among IPV victims, 31 percent had never talked to anyone about the IPV experience, 17 percent had talked once or twice about the experience, 20 percent had talked three to ten times, and 32 percent had talked about the experience on more than ten occasions. In contrast to findings by Levendosky and colleagues (2004), in the study by Coker and colleagues (2002), 82 percent of those 9

17 victims who had disclosed reported that the individual to whom they disclosed was supportive (Coker et al., 2002). However, it is unknown as to whether these supporters were also IPV victims. In addition to the finding that IPV victims tend to report lower levels of perceived social support, research also suggests that this support deficit places victims at greater risk of developing PTSD. Thus, in the next section, I will discuss research identifying low levels of perceived social support as a predictor of PTSD among IPV victims (Brewin, Andrews, & Valentine, 2000; Kemp et al., 1995; Ozer et al., 2008) as well as research analyzing perceived social support as a moderator of the relationship between IPV and mental health outcomes (Carlson, McNutt, Choi, & Rose, 2002; Coker et al., 2002; Kaslow et al., 1998; Levendosky et al., 2004). Relationship between perceived social support and PTSD and empirical research on perceived social support as a moderator. Based on the high volume of research supporting the buffering hypothesis with respect to general mental health outcomes (Cohen & Willis, 1985), it is not surprising that among the general population, lack of post-trauma social support is not only a significant predictor of PTSD following a traumatic event (Kemp et al., 1995; Ozer et al., 2008), but a meta-analysis identified it as one of the strongest predictors of PTSD (Brewin, Andrews, & Valentine, 2000). Similarly, Kemp and colleagues (1995) used a multiple regression analysis to identify predictors of PTSD among victims of physical IPV recruited from shelters, counseling centers, and the community. The findings of this study also showed that perceived social support was one of the strongest predictors of PTSD among the variables examined in this study. The results of this study also revealed that while the qualitative dimension of perceived social support (feeling close to friends) significantly predicted PTSD, the 10

18 quantitative dimension (number of contacts with friends) was not significantly related to PTSD. This is consistent with the research discussed above indicating that perceived social support, in general, tends to better predict symptoms than social embeddedness or enacted support. Expanding upon this finding, Coker and colleagues (2002) conducted a crosssectional survey of women recruited from family practice clinics to assess the relationship between IPV and mental health outcomes and determine whether abuse disclosure and support play a protective role in this relationship. The results showed that social support, measured as the individual s perception of whether she has someone to rely on for various needs, was negatively related to risk of negative mental health outcomes, including PTSD. While mere disclosure was not associated with decreased risk for such negative outcomes, the results showed that individuals receiving supportive reactions upon disclosure were at lower risk for suicide ideations and attempts. Thus, in order to protect mental health, support must be gained from disclosure; in fact, in this study, the risk of developing adverse mental health outcomes following IPV was decreased by nearly 50 percent among individuals who reported gaining this support. While research tends to provide evidence for the direct effect of perceived social support on development of PTSD symptoms among IPV victims (Babcock, Roseman, Green, & Ross, 2008; Coker et al., 2002; Kemp at al., 1995), fewer studies have investigated the role of perceived social support as a moderator of the relationship between IPV and mental health outcomes. Carlson and colleagues (2002) analyzed the moderating role of potential protective factors including social support, education, employment, self-esteem, health, and lack of economic hardship in the relationship 11

19 between lifetime abuse (including recent IPV, past IPV, and child abuse) and depression and anxiety. The combination of the protective factors showed a buffering, or moderating, effect in this relationship. While the moderating effect was significant, it is important to note that as the severity of abuse increased, the strength of the buffering effect decreased. Thus, women reporting more severe forms of IPV were less likely to benefit from the protective factors than women reporting less severe IPV. Further, social support was not analyzed as an independent moderator but rather as one of several factors included in the total protective factors variable. Further attempts to examine the moderating role of perceived social support include Kaslow and colleagues (1998), who found that perceived social support moderated the relationship between IPV and suicidal behavior among African American women. Levendosky and colleagues (2004) also found that levels of both practical aid and criticism moderated the relationship between IPV and self-esteem, with low criticism and high practical aid predicting higher self-esteem. While low criticism significantly buffered the effect of IPV on self-esteem among victims reporting low levels of violence, this effect was not significant among victims reporting high levels of violence. High practical aid, however, significantly buffered the effect of IPV on self-esteem among victims reporting both high and low levels of violence, though the effect was particularly strong among those reporting low levels of violence. Thus, previous studies have shown a relationship between perceived social support and PTSD among IPV victims (Babcock et al., 2008; Coker et al., 2002; Kemp at al., 1995) and have demonstrated the role of perceived social support as a moderator of various negative outcomes among IPV victims such as suicidal behavior and decreased 12

20 self-esteem (Kaslow et al., 1998; Levendosky et al., 2004). However, previous studies have not directly tested perceived social support as a moderator of the relationship between IPV and PTSD, specifically. In addition, analysis of factors possibly mediating this moderation, such as self-blame and self-esteem, is also needed. In the next section, I will, therefore, identify the distinctions often made in the literature between types of selfblame. I will then discuss the research providing evidence for the potential relationship between self-blame and perceived social support (Barnett, Martinez, & Keyson, 1996; Ullman, Townsend, Filipas, & Starzynski, 2007) as well as the possible link between self-blame and PTSD (Koss, Figueredo, & Prince, 2002). Self-Blame: Mediating the Moderator of Perceived Social Support Before analyzing self-blame as a potential mediator of the moderator effect of perceived social support in the relationship between experience of IPV and development of PTSD, it is necessary to note a common distinction between two types of self-blame often referenced in the sexual assault literature. Janoff-Bulman (1979) described characterological self-blame as esteem-related blame, the source of which is nonmodifiable. This type of blame may be associated with feelings of personal deservingness for the negative outcome. Behavioral self-blame, however, is control related, attributing blame to a modifiable source; behavioral self-blame may, therefore, be associated with future avoidability. For example, a rape victim engaging in behavioral self-blame may attribute her rape to having walked home alone after dark. Though much of the selfblame research has analyzed its prevalence and effect among sexual assault survivors, these concepts may also be relevant to the broader IPV victim population. 13

21 Relationship between self-blame and perceived social support. The prevalence of self-blame among IPV victims was noted by Barnett, Martinez, and Keyson (1996) who conducted a cross-sectional study comparing IPV victims participating in counseling, IPV victims not participating in counseling, and non-ipv victims on a number of variables. Of relevance to the current study, Barnett, Martinez, and Keyson (1996) found that overall, IPV victims reported higher levels of self-blame than non-ipv victims. In addition, this study found a marginally significant negative correlation between perceived social support and feelings of self-blame. Though Barnett, Martinez, and Keyson (1996) concluded that other variables likely contribute to the relationship between perceived social support and self-blame, they noted that because providing social support may enhance coping and decrease self-blame, the inclusion of a social support component in treatment programs for IPV victims would likely be beneficial. Further examining the link between social support and self-blame, Ullman and colleagues (2007) developed and tested two structural equation models to determine the relationships between assault severity, global social support, negative social reactions, avoidance coping, self-blame, traumatic experience, and PTSD among women who reported having an unwanted sexual experience prior to age fourteen. Participants (n=761) were recruited from the community to complete a mail survey. More than half of the participants identified themselves as being an ethnic minority, though the researchers specifically targeted various minority groups during recruitment. Of interest, the models showed that higher frequency of negative, assault-specific social reactions (e.g. taking control of the victim s decisions) were associated with greater self-blame. Further, lower levels of global social support, defined as one s number of confidantes, frequency of 14

22 contact with confidantes, and perception of the self as getting along with confidantes, was also associated with greater self-blame. I will now discuss the research that suggests that self-blame may be positively related to likelihood of developing negative mental health outcomes, including PTSD. Relationship between self-blame and PTSD. In understanding the relationship between self-blame and PTSD, it is again important to note the different types of selfblame (i.e., characterological and behavioral self-blame) and their differential effects on mental health outcomes. Janoff-Bulman (1992) stated that behavioral self-blame allows the victim to make control-related attributions for his or her assault. Thus, because the victim believes that by behaving differently, she or he could have avoided the assault, behavioral self-blame may serve an adaptive function. Through behavioral self-blame, the victim can reestablish a sense of control and meaningfulness. However, victims engaging in characterological self-blame attribute their assault to enduring qualities, often using the present tense to describe blame attributions (e.g. I am a careless person ). Because the victim views the blame-worthy characteristics as unchangeable, she or he is unable to regain a sense of control or overcome feelings of helplessness. Individuals engaging in characterological self-blame are also likely to engage in behavioral selfblame; Janoff-Bulman (1992), therefore, clarified that behavioral self-blame can only be an adaptive motivation in the absence of characterological self-blame. In their attempt to develop complex models to test the cognitive mediation of rape s effects on overall health, Koss, Figueredo, and Prince (2003) found support for Janoff-Bulman s theory (1992) of self-blame. Their findings showed that characterological, though not behavioral, self-blame predicted psychological distress, a 15

23 factor that strongly predicts the development of PTSD symptoms. Thus, rape victims engaging in characterological self-blame, believing that their personality or character led to the assault, were more likely to develop PTSD. Janoff-Bulman s theory was further supported by Breitenbecher (2006) who also found that following sexual victimization, only characterological self-blame was associated with negative outcomes, including psychological distress. In contradiction to Janoff-Bulman s theory, however, other studies have found that both types of self-blame (Frazier, 1990) as well as self-blame as a single entity (Branscombe, Wohl, Owen, Allison, & N'gbala, 2003) were significantly related to depression following sexual assault, a diagnosis commonly co-diagnosed with PTSD among IPV victims (Dutton, 2009). Research suggests that IPV victims may engage in self-blame following IPV experience and that this self-blame is associated with perceived social support. While studies involving victims experiencing solely sexual assault have shown a significant relationship between self-blame and negative mental health outcomes including PTSD, little research analyzing this relationship has been conducted with the overall IPV victim population. In order to better understand the moderating role of perceived social support in the relationship between experience of IPV and development of PTSD, characterological self-blame was analyzed as a mediator of the moderating effect of perceived social support in this relationship. That is, in the current study, I hypothesized that one reason perceived social support might moderate the relationship between IPV victimization and PTSD symptoms is that these individuals are less likely to engage in characterological self-blame. Individuals perceiving higher levels of social support are likely to view themselves as valued and cared about by others, and, thus, may be more 16

24 likely to see themselves in a positive light. As such, these individuals may be less likely to engage in characterological self-blame following IPV and, thus, less likely to develop PTSD. Given the similarities between characterological self-blame and low self-esteem, self-esteem was also analyzed as a mediator of the moderating effect of perceived social support in the relationship between IPV and PTSD. Self-Esteem: Mediating the Moderator of Perceived Social Support Overall, research shows that IPV victims tend to report lower levels of selfesteem than non-ipv victims (Aguilar & Nightingale, 1994; Bengtsson-Tops & Tops, 2007; Clements, Sabourin, & Spiby, 2004). Though this finding is fairly consistent throughout the literature, in a cross-sectional study, Aguilar and Nightingale (1994) found that while emotional/controlling abuse significantly predicted low self-esteem among female IPV victims, other types of abuse including physical and sexual/emotional abuse were not significant predictors of self-esteem. In order to understand the role of self-esteem as a mediator of the moderation of perceived social support in the relationship between IPV and PTSD, it is necessary to explore the potential relationships between self-esteem and perceived social support as well as self-esteem and PTSD. Relationship between self-esteem and perceived social support. In their discussion of the Stress Buffering Hypothesis, Cohen and Willis (1985) identify four support resources that function to lessen the effect of stressful events. Support resources include esteem or emotional support, informational support, social companionship, and instrumental support. Of most relevance to the current study, esteem support, information that one is valued and accepted, enhances self-esteem by allowing an individual to feel a sense of self-worth and belonging despite personal struggles or flaws. Thus, when faced 17

25 with a life stressor, the receipt of esteem support may offset the threats to self-esteem often associated with a stressor such as IPV. Though researchers have not analyzed the relationship between perceived social support and self-esteem in recent years, Mitchell and Hodson (1983) sought to determine whether IPV indirectly affects adjustment factors such as self-esteem as a result of its effect on social support. This study found that among IPV victims seeking assistance from shelters, higher frequency and greater severity of IPV was significantly related to lower self-esteem. Further, after controlling for frequency and severity of IPV, partial correlations showed a significant relationship between responses from friends and level of self-esteem, with more empathic and fewer avoidant responses associated with higher levels of self-esteem. Thus, Mitchell and Hodson (1983) concluded that the impact of IPV on adjustment factors including self-esteem may be due, in part, to the negative effect of IPV on social support. Relationship between self-esteem and PTSD. Researchers have analyzed the role of self-esteem with respect to the effect of its fluctuations on psychological wellbeing. For example, Kashdan, Uswatte, Steger, and Julian (2006) found that combat veterans diagnosed with PTSD exhibited greater fluctuations in self-esteem than combat veterans not diagnosed with PTSD. Further, among all combat veterans, self-esteem instability was significantly associated with decreased well-being. However, the current study focused on the role of overall level of self-esteem, rather than its stability, in the relationship between IPV and PTSD. Bradley, Schwartz, and Kaslow (2005) found that among low income African American IPV victims, selfesteem was significantly negatively correlated with severity of PTSD symptoms. Further, 18

26 results showed that both self-esteem and religious coping acted as mediators in the relationship between IPV and PTSD. When these factors were combined with social support in a regression model, social support was the only non-significant predictor of PTSD. Because social support was significantly related to PTSD as determined by a bivariate correlation, this finding suggests that social support may be interacting with either self-esteem or religious coping to predict PTSD. Further research is needed to better understand the role of self-esteem in the relationship between IPV and PTSD. Research provides evidence to suggest that IPV victims report lower levels of self-esteem (Aguilar & Nightingale, 1994; Bengtsson-Tops & Tops, 2007; Clements, Sabourin, & Spiby, 2004) and higher levels of PTSD (Pico- Alfonso, 2005) than non-ipv victims. The current study sought to determine whether individuals perceiving high levels of social support would be less likely to experience a decrease in self-esteem following IPV experience and would, therefore, be less likely to develop PTSD. In order to make this determination, self-esteem was tested as a mediator of the moderator of perceived social support in the relationship between IPV and PTSD. Current Study Though the link between IPV and PTSD has been well-established in the literature (Basile et al., 2004; Coker et al., 2002; Golding, 1999; Pico-Alfonso et al., 2006), Dutton (2009) has noted the need for more complex statistical models that yield a better understanding of the different pathways potentially linking the experience of IPV and the development of PTSD. The current study sought to identify such pathways by analyzing the moderating role of perceived social support in the relationship between IPV and PTSD as well as determine whether this moderation is mediated by characterological 19

27 self-blame and self-esteem. The current model draws from the stress buffering hypothesis (Cohen & Willis, 1985) which states that social support protects an individual from the negative effects of a stressful event by acting as a buffer. Thus, the relationship between IPV and PTSD should be stronger among individuals perceiving lower social support. Research indicates that overall, the level of perceived social support among IPV victims is lower than that reported by non-ipv victims (Barnett, Martinez, & Keyson, 1996; Bengtsson-Tops & Tops, 2007) and that this social support deficit places victims at greater risk of developing PTSD (Kemp et al., 1995; Ozer et al., 2008). Further, studies have shown that levels of self-blame are higher among IPV victims than non-ipv victims (Barnett, Martinez, & Keyson, 1996), and levels of self-esteem (Aguilar & Nightingale, 1994; Bengtsson-Tops & Tops, 2007; Clements, Sabourin, & Spiby, 2004) are lower among IPV victims than non-ipv victims. Lastly, researchers have found that lower levels of global social support are associated with greater self-blame (Ullman et al., 2007), while more empathic and fewer avoidant responses from friends are associated with higher self-esteem (Mitchell & Hodson, 1983). In the current model, the relationship between PTSD and the interaction of IPV and perceived social support is thought to be accounted for by the intervening roles of characterological self-blame and self-esteem. That is, it was hypothesized that perceived social support alters the strength of the relationship between IPV and PTSD due to the intervening roles of self-esteem and characterological self-blame. IPV victims reporting low levels of perceived social support would be more likely to experience a decrease in self-esteem and to engage in characterological self-blame than IPV victims reporting high levels of perceived social support; it is this decreased level of self-esteem and increased 20

28 engagement in characterological self-blame that would account for the increased likelihood of developing PTSD. The hypotheses of the current study were as follows: Hypothesis 1: A significant, positive relationship will be found between the experience of IPV during the lifetime and the prevalence of PTSD symptoms among women. Thus, female IPV victims will be more likely to present PTSD symptoms than female non-ipv victims. Hypothesis 2: A significant, negative relationship will be found between perceived social support and the prevalence of PTSD symptoms among women. Thus, individuals reporting lower levels of perceived social support will be more likely to present PTSD symptoms than individuals reporting higher levels of perceived social support. Hypothesis 3: A significant, negative relationship will be found between the experience of IPV during the lifetime and perceived social support among women. Reports of greater IPV experiences will be related to lower levels of perceived social support. Hypothesis 4: The relationship between IPV and PTSD among women will be moderated (or buffered) by perceived social support. Thus, perceived social support will alter the strength of the effect of IPV on PTSD, yielding a weaker effect of IPV on PTSD among individuals perceiving higher levels of social support. 21

29 Hypothesis 5: The moderator effect of perceived social support in the relationship between IPV and PTSD among women will be mediated by characterological self-blame and self-esteem. That is, IPV victims reporting lower levels of perceived social support will be more likely to report lower levels of self-esteem and higher levels of self-blame than non-ipv victims. As a result, the relationship between IPV and PTSD will be stronger among IPVvictims, such that IPV victims will be more likely to present PTSD symptoms than non-ipv victims. 22

30 METHOD Participants In order to analyze the relationship between IPV and PTSD, it was necessary to collect a sample including both women with and without IPV histories. To ensure that a victimization-diverse sample was attained, female adults were sampled from two separate locations in Montgomery County, Ohio. A minimum sample size of 110 participants was desired, with roughly equal numbers of participants with and without IPV histories. This number was determined by conducting a power analysis, assuming moderate statistical effect sizes and accounting for a total of five predictors (Green, 1991). A total of 132 female adults participated in the current study. Of these participants, 99 were undergraduate students currently enrolled in an introductory psychology course at a private university in the Midwestern United States. Student participants were between the ages of 18 and 22, with a mean age of (SD=.63). The sample consisted of 53.5 percent first year students, 40.4 percent second year students, and 6.1 percent third year students. In the student sample, 91.1 percent was European American, 4.0 percent was African American, 1.0 percent was Latina, 2.0 percent was Asian or Pacific Islander, and 1.0 percent was from other racial or ethnic backgrounds. When reporting gross family income, 43.4 percent of students indicated an income over 90,000 dollars, 24.2 percent indicated an income between 70,000 and 90,000 dollars, and 23

31 20.2 percent indicated an income between 50,000 and 70,000. It is important to note that only 9.1 percent of students indicated an income below 50,000 dollars. Descriptive statistics for the nominal and ordinal variables in the current study are summarized in Table 1. A second sample of 33 community participants included female adults currently receiving inpatient treatment at a substance abuse treatment facility. Community participants were between the ages of 21 and 52, with a mean age of (SD=9.84). In the community sample, 75.8 percent was European American, 21.2 percent was African American, and 3.0 percent was Latina. When reporting gross family income, 78.8 percent of community participants indicated an income less than 10,000 dollars, 9.1 percent indicated an income between 10,000 and 30,000 dollars, and 9.1 percent indicated an income between 30,000 and 50,000. Only 3.0 percent of community participants indicated an income above 70,000 dollars. Regarding highest achieved education level, the majority of community participants reported having completed a high school education (42.4%), while 36.4 percent reported having only partially completed a high school education. Further, 9.1 percent reported having an Associates-level degree, 3.0 percent reported having a Bachelors-level degree, and 3.0 percent reported having a Masters-level degree. While participating in this study, participants were asked to reflect on their most intense conflict with a current or past romantic partner. Participants were then asked to provide basic information regarding this specific conflict and relationship. In both the student and community samples, the majority of participants reflected on a conflict 24

32 Table 1 Descriptive Statistics for Nominal and Ordinal Level Study Measures University Treatment Facility Variables Frequency Percentage Frequency Percentage Ethnic Background African American 4 4% 7 21% European American 91 92% 25 76% Latino/Latina 1 1% 1 3% Asian American 2 2% 0 0% Other 1 1% 0 0% Highest School Grade Level Achieved 9 th grade 0 0% 2 6% 10 th grade 0 0% 4 12% 11 th grade 0 0% 6 18% 12 th grade 53 54% 14 42% 1 st year of college 40 40% 2 6% 2 nd year of college 6 6% 3 9% 3 rd year of college 0 0% 0 0% 4 th year of college 0 0% 2 6% College Degrees None % 28 85% Associates 0 0% 3 9% Bachelors 0 0% 1 3% Masters 0 0% 1 3% Gross Family Income (Yearly) Under 10, % 26 79% 10,000-30, % 3 9% 30,000-50, % 3 9% 50,000-70, % 0 0% 70,000-90, % 1 3% Over 90, % 0 0% Missing 3 3% 0 0% Length of time since most conflicted relationship ended Less than 2 months ago 7 7% 1 3% 2-4 months ago 7 7% 0 0% 4-6 months ago 4 4% 2 6% 6 months-1year ago 13 13% 4 12% Over 1 year ago 32 32% 20 61% Currently in this relationship 23 23% 4 12% Missing 13 13% 2 6% 25

33 Length of time since most intense relationship conflict occurred Less than 2 months ago 20 20% 0 0% 2-4 months ago 11 11% 4 12% 4-6 months ago 11 11% 0 0% 6 months-1year ago 17 17% 4 12% Over 1 year ago 32 32% 22 67% Missing 8 8% 3 9% Status of most conflicted relationship Dating (Living together) 3 3% 18 55% Dating (Not living together) 90 91% 2 6% Married 0 0% 11 33% Missing 6 6% 2 6% Gender of partner (in most conflicted relationship) Male 90 91% 29 88% Female 3 3% 3 9% Missing 6 6% 3 3% 26

34 occurring over one year ago with a male partner. Among the student sample, 90.9 percent of participants were dating but not living with the particular partner, and no participants reported being married to the partner. Among the community sample, 54.5 percent of participants were dating and living with the partner, 33.3 percent were married to the partner, and 6.1 percent were dating but not living with the partner. When asked how long ago the particular relationship ended, the majority of student participants (32.3%) and community participants (60.6%) indicated that the relationship ended over one year ago. Further, 23.2 percent of student participants and 12.1 percent of community participants indicated that they are currently in the relationship. One item on the Relationship Data Sheet was improperly answered by a number of participants. The item how long were you in this relationship? was originally designed to be answered numerically (i.e., number of months, years). However, some participants responded to the item categorically, by marking either months or years. Among the student sample, 26.3 percent indicated months and 12.1 percent indicated years. When combined with the numerical data, it can be concluded that 56.4 percent of student participants were in the relationship for less than one year, while 43.6 percent were in the relationship for greater than one year. Among the community sample, 9.1 percent indicated years. When combined with the numerical data, it can be concluded that all community participants were in the relationship for greater than one year. Measures Conflict Tactics Scale (CTS2). The Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) was administered to determine whether the participant had experienced IPV. The scale measures the extent to which the 27