Transcript domestic violence, abuse and trauma

DOMESTIC VIOLENCE,
ABUSE AND TRAUMA
MODULE 8
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).
OVERVIEW
• Recovery☼ 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
(Compare with Selye’s General Adaptation Theory
also, the victim’s 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
STAGES OF RECOVERY, CONT’D
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
STAGES OF RECOVERY, CONT’D
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)
OVERVIEW, CONT’D
• 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
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
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
OVERVIEW: NURSE-CLIENT
COMMUNICATION
• Helpful Responses
– Acknowledge client’s 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
OVERVIEW: NURSE-CLIENT
COMMUNICATION
• Unhelpful Responses
– May imply the nurse doesn’t believe
client
– Reinforce guilt by implying blame or
responsibility
– Show lack of acceptance when client
regresses or displays maladaptive
coping
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.
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
ASSSESSMENT:
CRITICAL 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
COMMUNICATION:
CRITICAL THINKING
Helpful or Unhelpful?
1.
2.
3.
4.
5.
“Why did you take off your top if you didn’t 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 can’t start the
assessment process.”
“Yes he is your boyfriend, but that does not mean he
didn’t hurt you.”
“You took a shower, so now we do not have any
physical evidence.”
RAPE  SEXUAL ASSAULT
NURSE-CLIENT RELATIONSHIP
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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 AND NURSING
IMPLICATIONS
• Treatment: long-term counseling with trust
and self-acceptance as goals
• Nurse-client relationship:
– matter of fact discussion of abuse
– 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
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 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
Power and control are central to the cycle of violence
EFFECTS ON VICTIM OF
DOMESTIC VIOLENCE/PARTNER
ABUSE
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Learned helplessness
Isolation and resignation
Believes she is responsible for the abuse
Believes things will improve
☼ RECOVERY AND THE NURSECLIENT 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
NURSE-CLIENT RELATIONSHIP,
CONT’D
• 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
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
POST TRAUMATIC
STRESS DISORDER AND
DISSOCIATIVE
DISORDERS
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
Post Traumatic Stress
Disorder (PTSD)
• Symptoms appear one month or more
after event
• Stress disorders involve dissociative
experiences
Dissociation
• Dissociative Symptoms:
– Splitting off of feelings, thoughts, memories
from conscious awareness
– Defense mechanism: may protect person
from unbearably painful experiences or
emotional conflicts
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
PTSD, cont’d
• Signs, symptoms:
- Detachment, social withdrawal, avoidance
- Blunting or numbing of emotions
        
- Re-experiencing the trauma
- outbursts of anxiety, rage
- panic-like episodes
- Intrusive memories
PTSD Symptoms, CONT’D
– Intrusive memories, cont’d
• flashbacks (re-experiencing the event)
• nightmares, illusions and/or hallucinations
• triggers may or may not resemble original
event
        
– Symptoms of hyperarousal
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
PTSD: Complications
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Abuse of substances
Paranoia
Severe depression
Suicidal behavior
“Addiction to trauma”
PTSD: Nurse-Client Relationship
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Individualized approach
Provide safety and security
Client’s story will be upsetting
Long Term Goals:
– safely evaluate and make sense of the
event(s)
– (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
PTSD: Other Interventions
• Group therapy, self-help groups
• Veteran’s services
• Substance abuse/addiction tx.
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
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
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
• 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?