DOMESTIC VIOLENCE, ABUSE AND TRAUMA

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DOMESTIC VIOLENCE, ABUSE AND TRAUMA

• MODULE 9
• RNSG 2213

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OVERVIEW OF RESPONSES TO VIOLENCE AND ABUSE

• Responses to violence, abuse, rape, trauma may
  manifest as both short term reactions and
  long term dysfunction.
• Many of these are similar, no matter what the
  form or manner of the actual traumatic event(s).

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STAGES OF RECOVERY FROM TRAUMA

• (Compare with Selyes General Adaptation Theory
  also, the victims experience in Cycle of
  Violence --Keltner, p. 624)
• Successful Readjustment after a traumatic event
  depends on
• 1) duration and severity of trauma
• 2) victims resources (emotional, physical,
  financial, legal etc.)
• 3) nature of help available immediately after
  the traumatic event.

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Stages of Recovery from Trauma

• Impact or Disorganization Phase of Traumatic
  Event
• Person is in crisis
• Lasts a few minutes to a few days
• Cognitive shock, confusion, disbelief or denial
• Intense emotions fear, horror, helplessness, or
• Detachment or dissociation (emotional numbing,
  amnesia),
• (Delayed impactinitially calm and rational)
• Alterations in sleep, appetite

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STAGES OF RECOVERY, CONTD

• Recoil or Adaptation Phase
• Lasts weeks to months
• Significant emotional distress remains
• Temporary dependence on others
• May function, but with intermittent episodes of
  breakdown
• Wants to talk about it and get support
• Revenge fantasies common

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STAGES OF RECOVERY, CONTD

• Reorganization Phase
• Months to years
• Diminishing anger and fear
• Making sense of what happened
• Re-engagement with life and activities but with
  sense that something has changed
• Regains sense of control and trust
• Some symptoms may linger (e.g. disturbed sleep)

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Complications of Successful Readjustment After
Trauma

• Ineffective adaptation (does not progress)
• If exposure to violence or trauma is repeated,
  recovery becomes more complicated and will be
  prolonged
• Additional life stressors may delay recovery
• Re-experiencing of traumatic event,
• e.g. at times of increased stress

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STAGES OF RECOVERYTest Yourself

• Which client(s) is (are) in the Recoil/
  Adaptation phase? Choose all that apply.
• This cant have happened to me.
• Why didnt I recognize that he was stalking me?
• If I just keep busy, I can put it out of my mind
  for a while.
• Im able to drive again, but Im still tense
  when I go through that intersection.

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OVERVIEW NURSE-CLIENT RELATIONSHIP

• Recovery Facilitated by immediate and
  appropriate response to the crisis by caregivers.
• Nurses often the primary contact
• If Client in Crisis
• provide safety, offer support and assess risk for
  further injury/suicide
• provide information and resources

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OVERVIEW NURSE-CLIENT RELATIONSHIP

• For Client In Recovery
• assess adaptive coping vs. maladaptive responses
  and need for continued services
• recognize that healing takes time and progress is
  not always steady

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OVERVIEW NURSE-CLIENT COMMUNICATION

• Helpful Responses
• Acknowledge clients emotions
• Show unconditional acceptance
• Follow legal guidelines for obtaining information
  or evidence
• Support problem-solving, when client able
• Provide information at level client can absorb
• Explore resources

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OVERVIEW NURSE-CLIENT COMMUNICATION

• Unhelpful Responses
• May imply the nurse doesnt believe client
• Ignore or minimize degree of abuse
• Reinforce guilt by implying blame or
  responsibility
• Refuse to help until person leaves abuser/abusive
  situation
• Show lack of acceptance when client does not make
  steady progress or displays maladaptive coping in
  recovery phase

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RAPE ? SEXUAL ASSAULT

• Def Forced sexual contact rapebodily
  penetration. Rape not sexually motivatedpower
  and control.
• Underreported esp. if elderly or disabled
• Even if reported, authorities may not consider it
  rape.

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ASSSESSMENTTest Yourself

• 2) Who is the best ED nurse to assign to
• assess a male victim of gang rape?
• A. Dawn highly efficient, organized
• B. Sean former cop, knows all legal
  procedures relating to sexual assault
• C. Carlos eager to help and empathetic
• D. Nadine quiet, a good listener

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COMMUNICATION Test Yourself

• 3) Choose all the helpful responses
• A. Im wondering why you took off your
  top if you didnt want to have sex.
• B. I can see you are very upset, but I
  have to go over this information sheet or we
  cant start the assessment process.
• C. You love him, but that does not mean
  he didnt hurt you.
• D. You took a shower, so we do not have
  any physical evidence.
• E. (3 months later) Dwelling on it wont
  help now. Its time to get on with your life.

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RAPE ? SEXUAL ASSAULT NURSE-CLIENT RELATIONSHIP

• Collect evidence
• Medical attention
• S.A.N.E. or Crisis specialist
• Legal advocacy and victims assistance referrals
• Follow-up important
• Support group for survivors

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SURVIVORS OF CHILD SEXUAL ABUSE

• Abuse may or may not involve sexual assault
• Perpetrators male, usually trusted relative
• Commonly involves repeated episodes, multiple
  perpetrators
• Coercion rather than violence
• Children cannot consent
• Frequently not reported or recognized

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CHILD SEXUAL ABUSE TERMINOLOGY

• Incest- sexual relations with a close family
  member
• Pedophilia-sexual attraction to children

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EFFECTS OF CHILD SEXUAL ABUSE

• Fundamental, profound disturbances in trust and
  autonomy
• Disturbances in mood and emotions, sleep, eating,
  impulse control, sexuality, etc. Many behavioral
  problems
• May self-mutilate or be suicidal frequently
  abuse substances
• Repression of memories until adulthood
• Untreated abuse often continues in families

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Recovery from Sexual Abuse and Nurse-Client
Relationship

• Treatment long-term counseling with trust and
  self-acceptance as goals
• Nurse-client relationship
• Supportive, but matter-of-fact approach
• acknowledge clients negative emotions remind
  client she/he is not to blame and could not
  consent
• offer hope

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Nurse-Client Relationship, contd

• develop plan for safety and self-maintenance
• provide outlets for negative emotions e.g.
  writing, physical activity
• counsel on potential risks, benefits of
  confronting abuser

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CHILD SEXUAL ABUSETest Yourself

• 4) An adult client was just admitted to the
  inpatient unit for severe depression after her
  partner left her. She has a history of childhood
  sexual abuse. Adult relationships are unstable,
  and the clients self-image is negative. She
  often lightly scratches her legs as punishment
  for feeling like a failure. The client has been
  in recovery therapy at an outpatient clinic for
  several years. What is the priority tx. goal?
• Will acknowledge relationship between depression
  and sexual abuse history
• Will not self-injure
• Will report improved mood and outlook
• Will discuss loss of partner

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DOMESTIC VIOLENCE ? PARTNER ABUSE

• High rates with low reporting up to 50 of
  women up to 35 of teen girls
• Crosses all racial, ethnic, sexual groups and
  economic classes
• Multiple episodes with escalating severity
• Abusive behavior correlates with alcohol and drug
  abuse

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Domestic Violence/Partner Abuse Terminology

• Mutual (aka Expressive) violence a pattern of
  relating couple may be willing to change
• Non-consensual violence (sometimes called
  Instrumental violence) one partner is victim
  perpetrator has little motivation to change
• Cycle of Violence repeated, characteristic
  behaviors shown by both perpetrator and victim
  which serve to perpetuate violence

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Power and Control are central to the cycle of
violence
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Effects on Victim of Domestic Violence/Partner
Abuse

• Learned helplessness
• Isolation and resignation
• Believes she is responsible for the abuse
• Believes things will improve

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Recovery from Domestic Violence and the
Nurse-Client Relationship

• Victims most likely to seek help just before or
  at the time a battering incident occurs
• Provide privacy for interview, if possible
• Assess for physical injury and degree of danger
• contd

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Nurse-Client Relationship, contd

• Non-judgmental approach toward victim and
  perpetrator
• Do not confront perpetrator
• If victim unable or unready to leave abuser,
  provide contact information
• Develop an escape or safety plan
• Even when victim finally leaves abuser,
  problems are not over

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DOMESTIC VIOLENCETest Yourself

• 5) A client, who has been battered for years by
  the partner, receives inpatient tx. after a
  suicide attempt. The client does not readily
  acknowledge the abuse problem and consistently
  states an intention to return home to remain
  with the partner whom the client states is my
  only support. What is the nurses best approach
  while the client is an inpatient?
• A. Encourage the client to attend assertiveness
  training classes.
• B. Give the client a list of community
  resources and shelters.
• C. Discuss an escape plan with the client.
• D. Schedule a discharge-oriented family meeting
  with the partner.

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Recovery, contd

• Referrals
• Housing during crisis and long term
• Legal assistance
• Job training, financial and education assistance,
  parenting classes
• Long term therapy, support and self-help groups,
  assertiveness and communication groups

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Violence and Abuse LEGAL ASPECTS

• Must report abuse to protective services agency
  child, elder or adult with disabilities
• Immunity from prosecution for person reporting
• Reporting is confidential
• Penalties for not reporting

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Test Yourself

• Review of your answers

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STAGES OF RECOVERYTest Yourself

• Which client(s) is (are) in the Recoil/
  Adaptation phase? Choose all that apply.
• This cant have happened to me.
• Why didnt I recognize that he was stalking me?
• If I just keep busy, I can put it out of my mind
  for a while.
• Im able to drive again, but Im still tense
  when I go through that intersection.

?
?
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ASSSESSMENTTest Yourself

• 2) Who is the best ED nurse to assign to
• assess a male victim of gang rape?
• A. Dawn highly efficient, organized
• B. Sean former cop, knows all legal
  procedures relating to sexual assault
• C. Carlos eager to help and empathetic
• D. Nadine quiet, a good listener

?
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COMMUNICATION Test Yourself

• 3) Choose all the helpful responses
• A. Im wondering why you took off your
  top if you didnt want to have sex.
• B. I can see you are very upset, but I
  have to go over this information sheet or we
  cant start the assessment process.
• C. You love him, but that does not mean
  he didnt hurt you.
• D. You took a shower, so we do not have
  any physical evidence.
• E. (3 months later) Dwelling on it wont
  help now. Its time to get on with your life.

?
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CHILD SEXUAL ABUSETest Yourself

• 4) An adult client was just admitted to the
  inpatient unit for severe depression after her
  partner left her. She has a history of childhood
  sexual abuse. Adult relationships are unstable,
  and the clients self-image is negative. She
  often scratches on her legs as punishment for
  feeling like a failure. The client has been in
  recovery therapy at an outpatient clinic for
  several years. What is the priority tx. goal?
• Will acknowledge relationship between depression
  and sexual abuse history
• Will not self-injure
• Will report improved mood and outlook
• Will discuss loss of partner

?
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DOMESTIC VIOLENCETest Yourself

• 5) A client, who has been battered for years by
  the partner, receives inpatient tx. after a
  suicide attempt. The client does not readily
  acknowledge the abuse problem and consistently
  states an intention to return home to remain
  with the partner whom the client states is my
  only support. What is the nurses best approach
  while the client is an inpatient?
• A. Encourage the client to attend assertiveness
  training classes.
• B. Give the client a list of community
  resources and shelters.
• C. Discuss an escape plan with the client.
• D. Schedule a discharge-oriented family meeting
  with the partner.

?
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STRESS DISORDERS AND DISSOCIATIVE
DISORDERS
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STRESS DISORDERS

• Distressful or disabling symptoms which develop
  after exposure to a specific traumatic event(s)
  e.g. war, violence, catastrophic illness or
  injury, etc.
• May affect rescuers and victims

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Stress Disorders

• Acute Stress Disorder (ASD)
• Symptoms develop during or immediately after
  the event
• Post Traumatic Stress Disorder (PTSD) Symptoms
  appear one month or more after event

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PTSD

• Risk factors
• Lack of balancing factors during
  crisis/traumatic event
• Ineffective adaptation to crisis
• Pre existing psychiatric disorder, esp.
  personality disorders
• Previous exposure to trauma
• reactivation of stress response

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PTSD, contd

• Signs, Symptoms
• 1. Re-experiencing the trauma
• Intrusive memories
• Flashbacks (re-experiencing the event)
• Nightmares, illusions and/or hallucinations
• Triggers may or may not resemble original event

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PTSD Symptoms, CONTD

• 2. Social withdrawal, avoidance
• Blunting or numbing of emotions, detachment,
  dissociation
• (What is dissociation?
  Splitting off of feelings, thoughts, memories
  from conscious awareness
• Protective defense helps person avoid anxiety
  experienced in trauma or abuse)

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PTSD contd

• 3. Intense negative emotions rage, fear, severe
  anxiety, when exposed to cues that resemble
  traumatic event
• 4. Other symptoms
• -Hyperarousal hypervigilence, tension,
  difficulty falling asleep, exaggerated startle
  response

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Neurobiology of PTSD

• Failure of Extinction of Conditioned Fear
• Responses ? activation of brain centers
  which encode traumatic memory, e.g. amygdala,
  hypothalamus, thalamus, hippocampus
• Sensitization (excessive response to a
  stimulus)

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Neurobiology of PTSD, contd

• Increased dopaminergic and norephinephrine
  activity create increased ANS hyperarousal
  responses
• Overactivation of Hypothalamic-Pituitary-Adrenal
  (HPA) Axis with down-regulation of CRH and other
  stress-activating hormones

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Neurobiology of PTSD, contd

• Response to fear conditioning and sensitization
• Release of endogenous opiates ? emotional
  numbing, dissociation or repression of memories

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PTSD Complications and Associated Problems

• Substance abuse
• Severe depression
• Suicidal behavior
• Social and interpersonal problems
• Occupational, legal problems
• Homelessness
• Physical problems

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PTSD Two Cases

• A 33 year-old veteran of Iraq is hospitalized for
  depression with suicidal thoughts. He reports a
  5- year history of alcohol abuse, is often
  violent when under the influence. He says, when
  I am drunk I let out my war demons. Most of the
  time I keep to myself and I dont even talk to my
  wife. Im scaring myself and I know its hurting
  my kids.

• A 42 year old divorced female comes in for
  treatment of sleep deprivation. She has been
  having nightmares and fleeting memories of being
  abused as a child for several months. These
  started around the time she began a new high
  stress job in the financial world with a critical
  boss. She questions the reality of her memories,
  but says she often feels extremely tense, anxious
  and fearful of falling asleep and being alone at
  night.

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PTSD Nurse-Client Relationship

• Non-judgmental and accepting
• Clients story may be upsetting
• Assist to express negative emotions
• Provide safety and security r/f suicide,
  self-injury and violence to others
• Long Term Goals
• Client safely evaluates, make sense of the
  event(s)
• Relates current situation to past trauma
• (re-)establish supportive relationships

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PTSD Psychopharmacology

• Antianxiety medications benzodiazepines
• or buspirone (BuSpar)
• clonidine or propranolol reduce ANS arousal
  symptoms
• Antidepressants for depressive sx.
• SSRIs address repetitive behaviors
• Antipsychotic agents for psychotic symptoms or
  during acute crisis

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Match the Med. exercise

• Ruminations of guilt about having survived
• Flashbacks of dead persons
• Palpitations during panic episodes
• Generalized anxiety feelings 24/7
• e. Stays up all night long to check locks on
  the house

• buspirone (BuSpar)
• propranolol (Inderal)
• paroxetine (Paxil)
• clomipramine (Anafranil)
• aripiprazole (Abilify)

3
5
2
1
4
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PTSD Other Interventions

• Group therapy, self-help groups
• Veterans services
• Substance abuse/addiction tx.
• Assist with legal, occupational and physical
  health issues, etc.

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DISSOCIATIVE DISORDERS

• Disorders involving persistent
• episodes of dissociation
• which disturbs persons
• identity or memory
• Symptoms develop during or after extreme stress
  or trauma situations Risk Factors
• A survival mechanism becomes an illness
• Pre-existing PTSD is a risk factor

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Dissociation Terminology

• Derealization sense of unreality or that the
  world has changed in some way
• Depersonalization experience of detachment or
  not being in ones body
• (Person remains alert Ox3)
• Dissociative Amnesia loss of memory or of
  personal information after a traumatic event

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Dissociative Identity Disorder (DID)

• Existence of 2 or more different, personalities
  (alters)
• Person (host) is unaware of these
• Personalities control behavior
• Possible etiology a way to cope with extreme
  anxiety resulting from trauma, abuse
• Difficult to diagnose, treat
• Hospitalized for self injury or suicidal impulses

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Dissociative Disorders as represented by film
industry
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DID Nurse-Client Relationship

• Establishing trust is challenge
• High anxiety, easily overwhelmed
• Contract for safety
• Education about disorder
• Processing feelings and memories may be
  overwhelming, even dangerous

(Note Students will rarely be assigned to these
clients in acute settings. Why not?)
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DID

• Long-term goal integration of feelings and
  memories about past trauma and thereby integrate
  all personalities

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CRITICAL THINKING

• 1. What types of groups and milieu activities
  would be most appropriate for the hospitalized
  client who has Dissociative Identity Disorder?
• 2. When would medications be necessary and what
  types might be used?

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SUGGESTIONS FOR ANSWERS CRITICAL THINKING

• Expressive arts esp. art therapy, poetry, and
  crafts, exercise/physical activity, stress
  management, leisure and social skills. Meditation
  and relaxation exercises might induce
  dissociative episodes)
• Most common Antianxiety agents. (Remember that
  anxiety precipitates or exacerbates dissociative
  symptoms.) Antidepressants-depression is a common
  result of this disorder.