DOMESTIC VIOLENCE, ABUSE AND TRAUMA

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DOMESTIC VIOLENCE, ABUSE AND TRAUMA

• MODULE 8
• 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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OVERVIEW

• Recovery 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

• (Compare with Selyes General Adaptation Theory
  also, the victims experience in Cycle of
  Violence --Keltner, p. 624)
• Impact or Disorganization Phase
• Cognitive shock, confusion, disbelief or denial
• Intense emotions fear, horror, helplessness
• (Delayed impact--may initially be calm
  and rational, with emotional distress experienced
  at later time)
• Alterations in sleep, appetite
• Person is in crisis

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STAGES OF RECOVERY, CONTD

• Recoil or Adaptation Phase
• Temporary dependence on others
• May function, but with intermittent episodes
  of disorganization, breakdown
• Wants to talk about it and get support
• Revenge fantasies common

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STAGES OF RECOVERY, CONTD

• Reorganization Phase
• Diminishing anger and fear
• Attempts to make sense of what happened
• Re-engagement with life and activities but with
  sense that something has changed
• Regains sense of control and trust
• May take months or years
• Some symptoms may linger (e.g. disturbed sleep)
• If adaptation was not effective, then severe
  symptoms will continue (e.g. PTSD)

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OVERVIEW, CONTD

• If exposure to violence or trauma is repeated,
  recovery becomes more complicated and will be
  prolonged it may be lifelong
• Additional life stressors may delay recovery
• Trauma may be re-experienced at specific
  intervals, e.g. times of increased stress

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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
• 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

• 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
• Promote trust
• Show unconditional acceptance
• Follow legal guidelines for obtaining information
  or evidence
• Support problem-solving, when client able
• Provide information at level client can absorb

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OVERVIEW NURSE-CLIENT COMMUNICATION

• Unhelpful Responses
• May imply the nurse doesnt believe client
• Reinforce guilt by implying blame or
  responsibility
• Show lack of acceptance when client regresses or
  displays maladaptive coping

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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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RAPE ? SEXUAL ASSAULT

• Self-blame element
• Victim may destroy evidence
• Denial/Suppression common, esp. at time of event
• May have thoughts of dying
• Assoc. with many traumatic memories

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ASSSESSMENTCRITICAL THINKING

• Who is the best ED nurse to assign to
• assess a male rape victim?
• --Dawn highly efficient, organized
• --Sean former cop, knows all legal procedures
  relating to sexual assault
• --Carlos eager to help and empathetic
• --Nadine quiet, a good listener

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COMMUNICATION CRITICAL THINKING

• Helpful or Unhelpful?
• Why did you take off your top if you didnt want
  to have sex?
• Could you maybe have said something that got him
  angry?
• I can see you are very upset, but I have to go
  over this information sheet with you or we cant
  start the assessment process.
• Yes he is your boyfriend, but that does not mean
  he didnt hurt you.
• You took a shower, so now we do not have any
  physical evidence.

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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 AND NURSING IMPLICATIONS

• Treatment long-term counseling with trust and
  self-acceptance as goals
• Nurse-client relationship
• matter of fact discussion of abuse
• 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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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 Terminology

• Mutual violence a pattern of relating couple
  may be willing to change
• Non-consensual violence (sometimes called
  instrumental violence) woman 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 AND THE NURSE-CLIENT RELATIONSHIP

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

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NURSE-CLIENT RELATIONSHIP, CONTD

• Non-judgmental approach toward victim and
  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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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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POST TRAUMATIC STRESS DISORDER AND
DISSOCIATIVE DISORDERS
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POST TRAUMATIC STRESS DISORDER (PTSD)

• Distressful or disabling symptoms which develop
  after exposure to specific traumatic event, e.g.
  war, violence, catastrophic illness or injury,
  etc.
• May affect both rescuers and victims
• Acute Stress Disorder (ASD) symptoms develop
  during or immediately after event

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Post Traumatic Stress Disorder (PTSD)

• Symptoms appear one month or more after event
• Stress disorders involve dissociative experiences

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Dissociation

• Dissociative Symptoms
• Splitting off of feelings, thoughts, memories
  from conscious awareness
• Defense mechanism may protect person from
  unbearably painful experiences or emotional
  conflicts

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PTSD

• Risk factors
• Lack of balancing factors (i.e. strong coping
  skills, support system and effective crisis
  intervention at time of event)
• Pre existing psychiatric disorder, esp.
  personality disorders
• Previous exposure to trauma
• reactivation of stress response

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PTSD, contd

• Signs, symptoms
• Detachment, social withdrawal, avoidance
• Blunting or numbing of emotions
• ? ? ? ? ? ? ? ? ?
• Re-experiencing the trauma
• outbursts of anxiety, rage
• - panic-like episodes
• - Intrusive memories

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PTSD Symptoms, CONTD

• Intrusive memories, contd
• flashbacks (re-experiencing the event)
• nightmares, illusions and/or hallucinations
• triggers may or may not resemble original event
• ? ? ? ? ? ? ? ? ?
• Symptoms of hyperarousal

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Neurobiology of PTSD

• Conditioned Fear Responses (failure of
  extinction)
• Sensitization (excessive response to a
  stimulus)
• ? Hyperarousal
  (activation of brain centers which encode
  traumatic memory)
• Response to fear conditioning and sensitization
• release of endogenous opiates (emotional
  numbing) and dissociation or repression of
  memories

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PTSD Complications

• Abuse of substances
• Paranoia
• Severe depression
• Suicidal behavior
• Addiction to trauma

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PTSD Nurse-Client Relationship

• Individualized approach
• Provide safety and security
• Clients story will be upsetting
• Long Term Goals
• safely evaluate and make sense of the event(s)
• (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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PTSD Other Interventions

• Group therapy, self-help groups
• Veterans services
• Substance abuse/addiction tx.

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DISSOCIATIVE DISORDERS

• Involve alteration in consciousness in
• which dissociation is persistent and
• disturbs identity or memory
• Symptoms may occur immediately after traumatic
  event, or years later
• Risk Factors
• Extreme stress or trauma
• Pre-existing PTSD

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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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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

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