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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.