DOMESTIC VIOLENCE, ABUSE AND TRAUMA

1. DOMESTIC VIOLENCE, ABUSE AND TRAUMA MODULE 8 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. 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.

4. 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 incrisis

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. COMMUNICATION: CRITICAL THINKING Helpful or Unhelpful? • “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.”

16. RAPE  SEXUAL ASSAULTNURSE-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

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 ABUSETERMINOLOGY • 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 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

21. NURSE-CLIENT RELATIONSHIP, CONT’D • 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. 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

23. 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

24. Powerand control are central to the cycle of violence

25. EFFECTS ON VICTIM OF DOMESTIC VIOLENCE/PARTNER ABUSE • Learned helplessness • Isolation and resignation • Believes she is responsible for the abuse • Believes things will improve

26. ☼ 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

27. 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

28. 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

29. 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

30. POST TRAUMATIC STRESS DISORDER AND DISSOCIATIVE DISORDERS

31. 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

32. Post Traumatic Stress Disorder (PTSD) • Symptoms appear one month or more after event • Stress disorders involve dissociative experiences

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

34. 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

35. 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

36. 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

37. 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

38. PTSD:Complications • Abuse of substances • Paranoia • Severe depression • Suicidal behavior • “Addiction to trauma”

39. PTSD: Nurse-Client Relationship • 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

40. 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

41. PTSD: Other Interventions • Group therapy, self-help groups • Veteran’s services • Substance abuse/addiction tx.

42. 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

43. 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

44. 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

45. 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?)

46. DID • Long-term goal: integration of feelings and memories about past trauma and thereby integrate all personalities

47. 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?