Transcript domestic violence, abuse and trauma

DOMESTIC VIOLENCE,
ABUSE AND TRAUMA
MODULE 9
RNSG 2213
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).
STAGES OF RECOVERY FROM
TRAUMA
(Compare with Selye’s General Adaptation Theory
also, the victim’s experience in Cycle of Violence
--Keltner, p. 624)
Successful Readjustment after a traumatic event
depends on:
1) duration and severity of trauma
2) victim’s resources (emotional, physical,
financial, legal etc.)
3) nature of help available immediately after the
traumatic event.
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 impact—initially calm and rational)
• Alterations in sleep, appetite
STAGES OF RECOVERY, CONT’D
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
STAGES OF RECOVERY, CONT’D
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)
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
STAGES OF RECOVERY
Test Yourself
1) Which client(s) is (are) in the Recoil/
Adaptation phase? Choose all that apply.
A. “This can’t have happened to me.”
B. “Why didn’t I recognize that he was stalking
me?”
C. “If I just keep busy, I can put it out of my mind
for a while.”
D. “I’m able to drive again, but I’m still tense when
I go through that intersection.”
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
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
OVERVIEW: NURSE-CLIENT
COMMUNICATION
• Helpful Responses
– Acknowledge client’s 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
OVERVIEW: NURSE-CLIENT
COMMUNICATION
• Unhelpful Responses
– May imply the nurse doesn’t 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
RAPE  SEXUAL ASSAULT
• Def: Forced sexual contact; rape—bodily
penetration. Rape not sexually
motivated—power and control.
• Underreported esp. if elderly or disabled
• Even if reported, authorities may not
consider it rape.
ASSSESSMENT:
Test 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
COMMUNICATION:
Test Yourself
3) Choose all the helpful responses:
A. “I’m wondering why you took off your top if you didn’t
want to have sex.”
B. “I can see you are very upset, but I have to go over this
information sheet or we can’t start the assessment
process.”
C. “You love him, but that does not mean he didn’t hurt
you.”
D. “You took a shower, so we do not have any physical
evidence.”
E. (3 months later): “Dwelling on it won’t help now. It’s time
to get on with your life.”
RAPE  SEXUAL ASSAULT
NURSE-CLIENT RELATIONSHIP
•
•
•
•
Collect evidence
Medical attention
S.A.N.E. or Crisis specialist
Legal advocacy and victim’s assistance
referrals
• Follow-up important
• Support group for survivors
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
CHILD SEXUAL ABUSE
TERMINOLOGY
• Incest- sexual relations with a close family
member
• Pedophilia-sexual attraction to children
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
☼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 client’s negative emotions;
remind client she/he is not to blame and
could not consent
– offer hope
Nurse-Client Relationship, cont’d
– develop plan for safety and selfmaintenance
– provide outlets for negative emotions:
e.g. writing, physical activity
– counsel on potential risks, benefits of
confronting abuser
CHILD SEXUAL ABUSE
Test Yourself
4) An adult client was just admitted to the inpatient unit for
A.
B.
C.
D.
severe depression after her partner left her. She has a
history of childhood sexual abuse. Adult relationships
are unstable, and the client’s 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
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
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
Power and Control are central to the cycle of violence
Effects on Victim of Domestic
Violence/Partner Abuse
•
•
•
•
Learned helplessness
Isolation and resignation
Believes she is responsible for the abuse
Believes things will improve
☼ 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
cont’d
Nurse-Client Relationship, cont’d
• 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
DOMESTIC VIOLENCE
Test Yourself
5) A client, who has been battered for years by the partner,
A.
B.
C.
D.
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 nurse’s best approach while the
client is an inpatient?
Encourage the client to attend assertiveness training
classes.
Give the client a list of community resources and shelters.
Discuss an escape plan with the client.
Schedule a discharge-oriented family meeting with the
partner.
Recovery, cont’d
• 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
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
Test Yourself
Review of your answers
STAGES OF RECOVERY
Test Yourself
1) Which client(s) is (are) in the Recoil/
Adaptation phase? Choose all that apply.


A. “This can’t have happened to me.”
B. “Why didn’t I recognize that he was stalking
me?”
C. “If I just keep busy, I can put it out of my mind
for a while.”
D. “I’m able to drive again, but I’m still tense
when I go through that intersection.”
ASSSESSMENT:
Test 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
COMMUNICATION:
Test Yourself
3) Choose all the helpful responses:

A. “I’m wondering why you took off your top if you didn’t
want to have sex.”
B. “I can see you are very upset, but I have to go over
this information sheet or we can’t start the assessment
process.”
C. “You love him, but that does not mean he didn’t hurt
you.”
D. “You took a shower, so we do not have any physical
evidence.”
E. (3 months later): “Dwelling on it won’t help now. It’s
time to get on with your life.”
CHILD SEXUAL ABUSE
Test Yourself
4)
A.

B.
C.
D.
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 client’s 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
DOMESTIC VIOLENCE
Test Yourself
5) A client, who has been battered for years by the partner,
A.

B.
C.
D.
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 nurse’s best approach while
the client is an inpatient?
Encourage the client to attend assertiveness training
classes.
Give the client a list of community resources and shelters.
Discuss an escape plan with the client.
Schedule a discharge-oriented family meeting with the
partner.
STRESS DISORDERS
AND DISSOCIATIVE
DISORDERS
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
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
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
PTSD, cont’d
• 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
PTSD Symptoms, CONT’D
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)
PTSD cont’d
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
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)
Neurobiology of PTSD, cont’d
• Increased dopaminergic and
norephinephrine activity create increased
ANS hyperarousal responses
• Overactivation of Hypothalamic-PituitaryAdrenal (HPA) Axis with down-regulation
of CRH and other stress-activating
hormones
Neurobiology of PTSD, cont’d
Response to fear conditioning and
sensitization:
Release of endogenous opiates 
emotional numbing, dissociation or
repression of memories
PTSD: Complications and
Associated Problems
•
•
•
•
•
•
•
Substance abuse
Severe depression
Suicidal behavior
Social and interpersonal problems
Occupational, legal problems
Homelessness
Physical problems
PTSD: Two Cases
• A 42 year old divorced
• A 33 year-old veteran of
female comes in for treatment
Iraq is hospitalized for
of sleep deprivation. She has
depression with suicidal
been having nightmares and
thoughts. He reports a 5fleeting memories of being
year history of alcohol
abused as a child for several
abuse, is often violent
months. These started
when under the influence.
around the time she began a
He says, “when I am drunk
new high stress job in the
financial world with a critical
I let out my ‘war demons.’
boss. She questions the
Most of the time I keep to
reality of her memories, but
myself and I don’t even talk
says she often feels
to my wife. I’m scaring
extremely tense, anxious and
myself and I know it’s
fearful of falling asleep and
hurting my kids.”
being alone at night.
PTSD: Nurse-Client Relationship
• Non-judgmental and accepting
– Client’s story may be upsetting
• Assist to express negative emotions
• Provide safety and security: r/f suicide, selfinjury 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
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
“Match the Med.” exercise
3
5
2
1
4
a. Ruminations of guilt
about having survived
b. Flashbacks of dead
persons
c. Palpitations during
panic episodes
d. Generalized anxiety
feelings 24/7
e. Stays up all night long to
check locks on the
house
1.
2.
3.
4.
5.
buspirone (BuSpar)
propranolol (Inderal)
paroxetine (Paxil)
clomipramine (Anafranil)
aripiprazole (Abilify)
PTSD: Other Interventions
•
•
•
•
Group therapy, self-help groups
Veteran’s services
Substance abuse/addiction tx.
Assist with legal, occupational and
physical health issues, etc.
DISSOCIATIVE DISORDERS
Disorders involving persistent
episodes of dissociation
which disturbs person’s
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
Dissociation Terminology
• Derealization: sense of unreality or that
the world has changed in some way
• Depersonalization: experience of
detachment or not being in one’s body
(Person remains alert & Ox3)
• Dissociative Amnesia: loss of memory or
of personal information after a traumatic
event
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
Dissociative Disorders
as represented by film industry
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?)
DID
• Long-term goal: integration of feelings
and memories about past trauma and
thereby integrate all personalities
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?
SUGGESTIONS FOR ANSWERS:
CRITICAL THINKING
1. 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)
2. Most common: Antianxiety agents. (Remember
that anxiety precipitates or exacerbates
dissociative symptoms.) Antidepressantsdepression is a common result of this disorder.