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Title: DOMESTIC VIOLENCE, ABUSE AND TRAUMA


1
DOMESTIC VIOLENCE, ABUSE AND TRAUMA
  • MODULE 9
  • RNSG 2213

2
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).

3
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.

4
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

5
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

6
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)

7
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

8
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.

9
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

10
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

11
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

12
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

13
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.

14
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

15
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.

16
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

17
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

18
CHILD SEXUAL ABUSE TERMINOLOGY
  • Incest- sexual relations with a close family
    member
  • Pedophilia-sexual attraction to children

19
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

20
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

21
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

22
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

23
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

24
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

25
Power and Control are central to the cycle of
violence
26
Effects on Victim of Domestic Violence/Partner
Abuse
  • Learned helplessness
  • Isolation and resignation
  • Believes she is responsible for the abuse
  • Believes things will improve

27
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

28
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

29
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.

30
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

31
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

32
Test Yourself
  • Review of your answers

33
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.

?
?
34
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

?
35
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.

?
36
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

?
37
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.

?
38
STRESS DISORDERS AND DISSOCIATIVE
DISORDERS
39
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

40
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

41
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

42
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

43
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)

44
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

45
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)

46
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

47
Neurobiology of PTSD, contd
  • Response to fear conditioning and sensitization
  • Release of endogenous opiates ? emotional
    numbing, dissociation or repression of memories

48
PTSD Complications and Associated Problems
  • Substance abuse
  • Severe depression
  • Suicidal behavior
  • Social and interpersonal problems
  • Occupational, legal problems
  • Homelessness
  • Physical problems

49
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.

50
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

51
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

52
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
53
PTSD Other Interventions
  • Group therapy, self-help groups
  • Veterans services
  • Substance abuse/addiction tx.
  • Assist with legal, occupational and physical
    health issues, etc.

54
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

55
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

56
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

57
Dissociative Disorders as represented by film
industry
58
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?)
59
DID
  • Long-term goal integration of feelings and
    memories about past trauma and thereby integrate
    all personalities

60
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?

61
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.
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