1. Chapter 11: Abuse and Violence

2. Clinical Picture of Abuse and Violence
Abuse: wrongful use, maltreatment of another
Perpetrator typically someone the person knows
Victims across lifespan: spouses, partners, children, elders
Evidence of physical injuries requiring medical attention
Psychological injuries with broad range of responses

3. Characteristics of Violent Families
Family violence: spouse battering, neglect and physical, emotional or sexual abuse of children, elder abuse, marital rape
Common characteristics regardless of type of abuse (Box 11.1)
Social isolation
Abuse of power, control
Alcohol, other drug abuse
Intergenerational transmission process

4. Cultural Considerations
Domestic violence spanning families of all ages and from all ethnic, racial, religious, socioeconomic, sexual orientation backgrounds
Battered immigrant women at particular risk
Facing increased legal, social, economic barriers

5. Intimate Partner Violence
Mistreatment or misuse of one person by another in context of emotionally intimate relationship
Emotional or psychological: name calling, belittling, screaming, yelling, destroying property, threatening, refusing to speak to or ignoring victim

6. Intimate Partner Violence (cont’d)
Physical: shoving, pushing, battering, choking
Sexual: assaults during sexual relations, rape
Combination (common)
Victims: primarily women (increased rates during pregnancy)

7. Intimate Partner Violence (cont’d)
Prevalence in same-sex relationships as in heterosexual relationships; victims with fewer protections
Often perpetrated by husband against wife

8. Intimate Partner Violence (cont’d)
Clinical picture
Abuser’s view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem solving and social
Increasing violence, abuse with any signs of independence
Victim commonly dependent; viewed as unable to function without husband

9. Intimate Partner Violence (cont’d)
Cycle of abuse and violence
Violent episode → honeymoon phase → tension- building → violent episode

10. Intimate Partner Violence (cont’d)
Identification important; victims commonly not seeking direct help for problems
Screening/assessment: SAFE (Box 11.2)
Stress/safety
Afraid/abused
Friends/family
Emergency plan
Appropriate techniques (Table 11.1)

11. Question
Tell whether the following statement is true or false:
The honeymoon phase of violence often occurs before the first episode of violence.

12. Answer
False
The honeymoon phase occurs after an episode of violence in which the abuser expresses regret, and then apologizes and promises it will never happen again.

13. Intimate Partner Violence (cont’d)
Treatment and interventions
Laws related to domestic violence; arrest
Restraining order/civil orders of protection
Shelters
Individual psychotherapy/counseling, group therapy, support and self-help groups
Treatment for possible PTSD

14. Intentional injury of a child
Child Abuse
Intentional injury of a child
Physical abuse or injuries
Neglect or failure to prevent harm
Failure to provide adequate physical or emotional care or supervision
Abandonment
Sexual assault or intrusion
Overt torture or maiming

15. Clinical picture of parents
Child Abuse (cont’d)
Clinical picture of parents
Minimal parenting knowledge, skills
Emotionally immature, needy, incapable of meeting own needs
View children as property
Cycle of family violence: adults raising children in same way they were raised (adults as victims of abuse frequently abuse their own children)

16. Identification important (Box 11.3) Report suspected child abuse
Child Abuse (cont’d)
Identification important (Box 11.3)
Report suspected child abuse
Treatment and intervention
Child safety, well-being a priority
Psychiatric evaluation/possible long-term therapy/play therapy (for very young child)
Family therapy if reuniting feasible
Psychiatric or substance abuse for parents
Foster care (short- or long-term)

17. Maltreatment of older adults
Elder Abuse
Maltreatment of older adults
Physical, sexual, psychological abuse or neglect
Self-neglect
Financial exploitation
Denial of adequate medical treatment
60% perpetrators spouses, 20% adult children, 20% others

18. Elder Abuse (cont’d)
People who abuse elders almost always in caretaker role or elders depend on them in some way
Elders often reluctant to report abuse due to fear of alternative (nursing home)
Clinical picture: variable depending on type of abuse

19. Assessment (potential indicators, Box 11.4) Treatment and intervention
Elder Abuse (cont’d)
Assessment (potential indicators, Box 11.4)
Treatment and intervention
Caregiver stress relief
Additional resources
Possible removal of elder or caregiver

20. Question
Tell whether the following statement is true or false:
Adults who were abused as children are more likely to abuse their own children.

21. Answer
True
The tendency for adults to raise children in the same way they were raised perpetrates the cycle of family violence. Adults who were victims of abuse as children frequently abuse their own children.

22. Rape and Sexual Assault
Crime of violence, humiliation of victim expressed through sexual means
Perpetration of act of sexual intercourse with female against her will and without consent
Whether will is overcome by force, fear of force, drugs, or intoxicants

23. Rape and Sexual Assault (cont’d)
Also considered rape if woman incapable of exercising rational judgment because of mental deficiency or when younger than age of consent
Only slight penetration of vulva needed (full erection/ejaculation not necessary)

24. Rape and Sexual Assault (cont’d)
Strangers (approximately 50% of rapes), acquaintances, married people, people of same sex
Date rape (acquaintance rape)
Highly underreported crime
Most commonly occurring in woman’s neighborhood, often inside or near home

25. Rape and Sexual Assault (cont’d)
Most rapes premeditated
Male rape significantly underreported

26. Rape and Sexual Assault (cont’d)
Four categories of male rapists
Sexual sadists (aroused by victims’ pain)
Exploitive predators (impulsive use of victims for own gratification)
Inadequate men (belief that no woman would voluntarily have sexual relations with them; obsessed with fantasies about sex)
Men for whom rape is displaced expression of anger, rage

27. Rape and Sexual Assault (cont’d)
Feminist theory: women historically objects for aggression
Severe physical, psychological trauma
Medical problems

28. Rape and Sexual Assault (cont’d)
Severe physical, psychological trauma
Psychological problems
Fear, helplessness, shock, disbelief, guilt, humiliation, embarrassment
Avoidance of places or circumstances of rape; loss of previously pleasurable activities
Depression, anxiety, PTSD, sexual dysfunction, insomnia, impaired memory, suicidal thoughts
Myths, misunderstandings (Box 11.5)

29. Rape and Sexual Assault (cont’d)
Assessment:
Physical examination; preservation of evidence (rape kit/rape protocol)
Description of what happened
Treatment and intervention
Immediate support
Education (Box 11.6)
Prophylactic treatment of STIs, pregnancy
Therapy to restore victim’s sense of control

30. Community Violence
School violence (homicides, suicides, theft, violent crimes)
Bullying
Hazing
Effects on children, young adults
Violence on larger scale (i.e., terrorism)
Early intervention, treatment for victims

31. Question
Which of the following statements about rape is most accurate?
It is a highly reported crime.
Most rapes are premeditated.
Rape requires ejaculation.
Provocative dress invites rape.

32. Most rapes are premeditated.
Answer
Most rapes are premeditated.
Rape, an underreported crime, requires only slight penetration of the vulva. Full erection or ejaculation are not necessary. Provocative dress leading to rape is a myth.

33. Psychiatric Disorders Related to Abuse and Violence
Posttraumatic stress disorder (PTSD)
Dissociative disorders

34. Three clusters of symptoms
PTSD
Disturbing behavior due to exposure to traumatic event (natural disaster, combat, assault) at least 3 months after trauma occurred
Three clusters of symptoms
Reliving event
Avoiding reminders of event
Being on guard or experiencing hyperarousal

35. PTSD (cont’d)
Occurrence at any age
Severity, duration of trauma and proximity of person to event as most important factors

36. Dissociative Disorders
Dissociation: subconscious defense mechanism used to protect emotional self from recognizing full impact of some horrific or traumatic event by allowing mind to forget or remove itself from painful situation or memory
Occurrence both during and after event
Easier with repeated use

37. Dissociative Disorders (cont’d)
Dissociative disorders: disruption in usually integrated functions of consciousness, memory, identity, environmental perception
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder ([DID] formerly multiple personality disorder)
Depersonalization disorder

38. PTSD and Dissociative Disorders
Treatment and intervention
Community-based group or individual therapy
Cognitive behavioral therapy
Pharmacologic treatment
Paroxetine, sertraline for PTSD
Symptomatic treatment for dissociative disorders (anti-anxiety agents, antidepressants)

39. The Nursing Process: Assessment
History of trauma or abuse
General appearance, motor behavior
Hyperalertness, anxiety, agitation
Mood, affect
Wide-ranging emotions from passivity to anger
Thought processes, content
Nightmare, flashbacks, destructive thoughts or impulses

40. The Nursing Process: Assessment (cont’d)
Sensorium, intellectual processes
Disorientation [during flashbacks], memory gaps
Judgment, insight
Impaired decision-making, problem-solving abilities
Self-concept
Low self-esteem

41. The Nursing Process: Assessment (cont’d)
Roles, relationships
Problems with relationships, work, authority figures
Physiologic considerations
Difficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication

42. Question
Tell whether the following statement is true or false:
For the diagnosis of PTSD, the symptoms occur usually within 1 month of the trauma.

43. Answer
False
For the diagnosis of PTSD, the symptoms occur at least 3 months after the trauma.
A diagnosis of acute stress disorder is appropriate when the symptoms appear within the first month after the trauma and do not persist for more than 4 weeks.

44. The Nursing Process: Data Analysis
Common nursing diagnoses
Risk for self-mutilation
Ineffective coping
Posttrauma response
Chronic low self-esteem
Powerlessness

45. The Nursing Process: Outcome Identification
The client will
Be physically safe
Distinguish between self-harm ideas and taking action on those ideas
Learn healthy ways to deal with stress
Express emotions nondestructively
Establish social support network in community

46. The Nursing Process: Intervention
Promoting client’s safety
Helping client cope with stress, emotions using grounding techniques
Helping promote client’s self-esteem
Establishing social support

47. The Nursing Process: Evaluation
Outcomes possibly taking years to achieve
Protection of self
Ability to manage stress, emotions
Ability to function in daily life

48. Self-Awareness Issues
Becoming comfortable asking all women about abuse (SAFE questions)
Listening to accounts of abuse from clients, families
Recognizing client’s strengths, not just problems
Working with perpetrators of abuse; dealing with own feelings about abuse, violence