2Clinical Picture of Abuse and Violence Abuse: wrongful use, maltreatment of anotherPerpetrator typically someone the person knowsVictims across lifespan: spouses, partners, children, eldersEvidence of physical injuries requiring medical attentionPsychological injuries with broad range of responses
3Characteristics of Violent Families Family violence: spouse battering, neglect and physical, emotional or sexual abuse of children, elder abuse, marital rapeCommon characteristics regardless of type of abuse (Box 11.1)Social isolationAbuse of power, controlAlcohol, other drug abuseIntergenerational transmission process
4Cultural Considerations Domestic violence spanning families of all ages and from all ethnic, racial, religious, socioeconomic, sexual orientation backgroundsBattered immigrant women at particular riskFacing increased legal, social, economic barriers
5Intimate Partner Violence Mistreatment or misuse of one person by another in context of emotionally intimate relationshipEmotional or psychological: name calling, belittling, screaming, yelling, destroying property, threatening, refusing to speak to or ignoring victim
6Intimate Partner Violence (cont’d) Physical: shoving, pushing, battering, chokingSexual: assaults during sexual relations, rapeCombination (common)Victims: primarily women (increased rates during pregnancy)
7Intimate Partner Violence (cont’d) Prevalence in same-sex relationships as in heterosexual relationships; victims with fewer protectionsOften perpetrated by husband against wife
8Intimate Partner Violence (cont’d) Clinical pictureAbuser’s view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem solving and socialIncreasing violence, abuse with any signs of independenceVictim commonly dependent; viewed as unable to function without husband
9Intimate Partner Violence (cont’d) Cycle of abuse and violenceViolent episode → honeymoon phase → tension- building → violent episode
10Intimate Partner Violence (cont’d) Identification important; victims commonly not seeking direct help for problemsScreening/assessment: SAFE (Box 11.2)Stress/safetyAfraid/abusedFriends/familyEmergency planAppropriate techniques (Table 11.1)
11QuestionTell whether the following statement is true or false:The honeymoon phase of violence often occurs before the first episode of violence.
12AnswerFalseThe honeymoon phase occurs after an episode of violence in which the abuser expresses regret, and then apologizes and promises it will never happen again.
13Intimate Partner Violence (cont’d) Treatment and interventionsLaws related to domestic violence; arrestRestraining order/civil orders of protectionSheltersIndividual psychotherapy/counseling, group therapy, support and self-help groupsTreatment for possible PTSD
14Intentional injury of a child Child AbuseIntentional injury of a childPhysical abuse or injuriesNeglect or failure to prevent harmFailure to provide adequate physical or emotional care or supervisionAbandonmentSexual assault or intrusionOvert torture or maiming
15Clinical picture of parents Child Abuse (cont’d)Clinical picture of parentsMinimal parenting knowledge, skillsEmotionally immature, needy, incapable of meeting own needsView children as propertyCycle of family violence: adults raising children in same way they were raised (adults as victims of abuse frequently abuse their own children)
16Identification important (Box 11.3) Report suspected child abuse Child Abuse (cont’d)Identification important (Box 11.3)Report suspected child abuseTreatment and interventionChild safety, well-being a priorityPsychiatric evaluation/possible long-term therapy/play therapy (for very young child)Family therapy if reuniting feasiblePsychiatric or substance abuse for parentsFoster care (short- or long-term)
17Maltreatment of older adults Elder AbuseMaltreatment of older adultsPhysical, sexual, psychological abuse or neglectSelf-neglectFinancial exploitationDenial of adequate medical treatment60% perpetrators spouses, 20% adult children, 20% others
18Elder Abuse (cont’d)People who abuse elders almost always in caretaker role or elders depend on them in some wayElders often reluctant to report abuse due to fear of alternative (nursing home)Clinical picture: variable depending on type of abuse
19Assessment (potential indicators, Box 11.4) Treatment and intervention Elder Abuse (cont’d)Assessment (potential indicators, Box 11.4)Treatment and interventionCaregiver stress reliefAdditional resourcesPossible removal of elder or caregiver
20QuestionTell whether the following statement is true or false:Adults who were abused as children are more likely to abuse their own children.
21AnswerTrueThe 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.
22Rape and Sexual Assault Crime of violence, humiliation of victim expressed through sexual meansPerpetration of act of sexual intercourse with female against her will and without consentWhether will is overcome by force, fear of force, drugs, or intoxicants
23Rape 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 consentOnly slight penetration of vulva needed (full erection/ejaculation not necessary)
24Rape and Sexual Assault (cont’d) Strangers (approximately 50% of rapes), acquaintances, married people, people of same sexDate rape (acquaintance rape)Highly underreported crimeMost commonly occurring in woman’s neighborhood, often inside or near home
25Rape and Sexual Assault (cont’d) Most rapes premeditatedMale rape significantly underreported
26Rape and Sexual Assault (cont’d) Four categories of male rapistsSexual 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
27Rape and Sexual Assault (cont’d) Feminist theory: women historically objects for aggressionSevere physical, psychological traumaMedical problems
28Rape and Sexual Assault (cont’d) Severe physical, psychological traumaPsychological problemsFear, helplessness, shock, disbelief, guilt, humiliation, embarrassmentAvoidance of places or circumstances of rape; loss of previously pleasurable activitiesDepression, anxiety, PTSD, sexual dysfunction, insomnia, impaired memory, suicidal thoughtsMyths, misunderstandings (Box 11.5)
29Rape and Sexual Assault (cont’d) Assessment:Physical examination; preservation of evidence (rape kit/rape protocol)Description of what happenedTreatment and interventionImmediate supportEducation (Box 11.6)Prophylactic treatment of STIs, pregnancyTherapy to restore victim’s sense of control
30Community ViolenceSchool violence (homicides, suicides, theft, violent crimes)BullyingHazingEffects on children, young adultsViolence on larger scale (i.e., terrorism)Early intervention, treatment for victims
31QuestionWhich 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.
32Most rapes are premeditated. AnswerMost 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.
33Psychiatric Disorders Related to Abuse and Violence Posttraumatic stress disorder (PTSD)Dissociative disorders
34Three clusters of symptoms PTSDDisturbing behavior due to exposure to traumatic event (natural disaster, combat, assault) at least 3 months after trauma occurredThree clusters of symptomsReliving eventAvoiding reminders of eventBeing on guard or experiencing hyperarousal
35PTSD (cont’d)Occurrence at any ageSeverity, duration of trauma and proximity of person to event as most important factors
36Dissociative 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 memoryOccurrence both during and after eventEasier with repeated use
37Dissociative Disorders (cont’d) Dissociative disorders: disruption in usually integrated functions of consciousness, memory, identity, environmental perceptionDissociative amnesiaDissociative fugueDissociative identity disorder ([DID] formerly multiple personality disorder)Depersonalization disorder
38PTSD and Dissociative Disorders Treatment and interventionCommunity-based group or individual therapyCognitive behavioral therapyPharmacologic treatmentParoxetine, sertraline for PTSDSymptomatic treatment for dissociative disorders (anti-anxiety agents, antidepressants)
39The Nursing Process: Assessment History of trauma or abuseGeneral appearance, motor behaviorHyperalertness, anxiety, agitationMood, affectWide-ranging emotions from passivity to angerThought processes, contentNightmare, flashbacks, destructive thoughts or impulses
41The Nursing Process: Assessment (cont’d) Roles, relationshipsProblems with relationships, work, authority figuresPhysiologic considerationsDifficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication
42QuestionTell whether the following statement is true or false:For the diagnosis of PTSD, the symptoms occur usually within 1 month of the trauma.
43AnswerFalseFor 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.
44The Nursing Process: Data Analysis Common nursing diagnosesRisk for self-mutilationIneffective copingPosttrauma responseChronic low self-esteemPowerlessness
45The Nursing Process: Outcome Identification The client willBe physically safeDistinguish between self-harm ideas and taking action on those ideasLearn healthy ways to deal with stressExpress emotions nondestructivelyEstablish social support network in community
46The Nursing Process: Intervention Promoting client’s safetyHelping client cope with stress, emotions using grounding techniquesHelping promote client’s self-esteemEstablishing social support
47The Nursing Process: Evaluation Outcomes possibly taking years to achieveProtection of selfAbility to manage stress, emotionsAbility to function in daily life
48Self-Awareness Issues Becoming comfortable asking all women about abuse (SAFE questions)Listening to accounts of abuse from clients, familiesRecognizing client’s strengths, not just problemsWorking with perpetrators of abuse; dealing with own feelings about abuse, violence