Chpt 17-Mental Health Care for Survivor of Violence

Special Concerns for Victims of Sexual Assault

ASSESSMENT FOCUS The history and physical examination of the survivor of sexual assault differ significantly from other assessment routines because the evidence obtained may be used in prosecuting the perpetrator. Therefore, the purpose is twofold: To assess the patient for injuries To collect evidence for forensic evaluation and proceedings Usually, someone with appropriate training, such as a nurse practitioner who has taken special courses, examines a victim of rape or sexual assault. Generalist nurses may be involved in treating the injuries that result from the assault, including genital trauma (e.g., vaginal and anal lacerations, and extragenital trauma (e.g., injury to the mouth, throat, wrists, arms, breasts, thighs). KEY INTERVENTIONS Nursing intervention to prevent short- or long-term psychopathology after sexual assault is crucial. Psychological trauma after rape and sexual assault includes immediate anxiety and distress and the development of PTSD, depression, panic, and substance abuse. Key interventions include: Early treatment because initial levels of distress are strongly related to later levels of posttraumatic stress disorder, panic, and anxiety. Supportive, caring, and nonjudgmental nursing interventions during the forensic rape examination are also crucial. This examination often increases survivors' immediate distress because they must recount the assault in detail and submit to an invasive pelvic or anal examination. Anxiety-reducing education, counseling, and emotional support, particularly in regard to unwanted pregnancies and sexually transmitted infections, including HIV. All survivors should be tested for these possibilities. Treatment may include terminating a pregnancy; administering medications to treat gonorrhea, chlamydia, trichomoniasis, and syphilis; and administering medications that may decrease the likelihood of contracting HIV infection. Interventions that are helpful for survivors of domestic violence; these also apply to survivors of sexual assault.

Imbalance in Relationship Power

Another body of literature suggests that IPV is a manifestation of gender-based imbalances in relationship power. Usually, this perspective explains IPV as violence against women by their male romantic partners related to issues of gender, inequality, power and privilege, patriarchy, and the subordination of women Patriarchal systems exist and are supported at the macro level (e.g., government, bureaucracies, religion) and at the micro level (e.g., families), and both levels have gender inequities. Within a patriarchal society, men often hold traditional gender role beliefs. For example, whereas men are heads of households and provide for their families, women are homemakers and mothers. When these beliefs are challenged, such as when a woman enters the workforce and earns more than her partner, men may feel threatened and respond with violence. Historically, women and children had few or no rights in most cultures, and in many countries today, women's rights remain limited Women and children were considered part of the household over which the male held absolute power and violence was accepted as a permissible way to exercise authority. Even after popular opinion changed and so-called "wife-beating" became formally illegal in all states in the United States by 1920, IPV was treated differently than other crimes and viewed as a private matter that rarely resulted in arrest or prosecution until the latter part of the 20th century. Until recently, men in the United States were able to use physical violence with relative impunity within the context of intimate relationships. Cycle of Violence Many, but not all, cases of IPV reflect a recognized cycle of violence. The cycle consists of three recurring phases that often increase in frequency and severity.

Screening for Violence and Abuse

Because of the prevalence of IPV, the U.S. Preventive Services Task Force recommends universal screening for all women of child-bearing age. However, actual rates of screening in most settings are low. Most survivors do not report violence to health care workers without specifically being asked about it. Survivors may be reluctant to report abuse because of shame, embarrassment, fear of not being believed, or fear of retaliation. Survivors who depend on the abuser for care or financial support may be concerned about consequences of disclosure. If the suspected abuser is present, it is important to speak to the survivor alone. Asking specific abuse screening questions substantially increases the detection of abuse. For that reason, nurses must develop a repertoire of age-appropriate, culturally sensitive abuse-related questions. Avoid using terms such as "abuse" and "rape," because those labels may not be consistent with an individual's perception of his or her experience

Violence

Besides injuries and death, survivors suffer multiple conditions directly caused by IPV or the chronic stress associated with it. Anxiety disorders, depression, posttraumatic stress disorder (PTSD), and substance use disorders are all associated with family violence. Examples of health problems associated with IPV include asthma, gastrointestinal conditions, cardiovascular problems, bladder infections, migraines, joint pain, gynecological disorders, and sexually transmitted diseases (STDs) Strangulation and blows to the head can cause traumatic brain injuries that have lasting effects on cognition and functioning. Risk Factors for Intimate Partner Violence IPV occurs across all demographics and socioeconomic levels. Younger women, women who are divorced or separated, and Native American and Alaska Native women are at highest risk Although women are disproportionately affected, men can also be victims of IPV. Nonheterosexual couples experience IPV at rates similar to heterosexual couples, but victims often receive less support as a result of social stigma associated with nontraditional relationships. Within any type of relationship, frequent conflicts, jealousy, and possessiveness are associated with an increased risk of violence. Individual characteristics such as low self-esteem, emotional insecurity, depression, antisocial or borderline personality traits, or a history of violence increase the likelihood of perpetration of violence. There is a strong association of substance use, especially alcohol abuse, with family violence. The presence of firearms in the home increases the risk of lethal violence. Personal stressors such as low income and unemployment, and external stressors such as natural disasters or economic crises, may challenge individual and family coping, resulting in violence. In unstable families, violence sometimes begins or escalates when a pregnancy occurs. Abuse during pregnancy is a significant risk factor for several fetal and maternal complications, including miscarriages, low birth weight, low maternal weight gain, infections, and anemia. Pregnancy is a window of opportunity for health care providers to screen women for IPV and refer them to the appropriate services

Child abuse and Neglect

Child abuse includes acts of commission and acts of omission. Acts of commission are intentional harmful behaviors directed toward a child and include physical, sexual, and psychological abuse. Child neglect is an act of omission, which occurs when a child's basic physical, emotional, educational, and health care needs are not met. Failure to protect a child from harm, inadequate supervision, or exposure to violence are other forms of neglect Children who are younger than 4 years of age, who are products of unwanted pregnancies, or who have developmental or physical disabilities are at highest risk of abuse Young parents who lack social support, resources, and knowledge of normal childhood development are at increased risk of abusing their children. Multiple stressors, emotional or substance abuse problems, and the use of harsh punishment are additional parental risk factors. Children who are abused or neglected may develop physical, emotional, and behavioral problems Their cognitive development may be impaired and they may exhibit academic difficulties. Abuse leads to problems getting along with or trusting others. Survivors of child abuse are at increased risk for depression, anxiety, low self-esteem, and substance abuse. Adverse experiences in childhood have a negative impact on health and well-being throughout life. A child who is emotionally or psychologically abused does not have visible injuries to alert others. Nevertheless, psychological abuse severely affects a child's self-esteem and often leaves permanent emotional scars. For many survivors of childhood abuse, emotional abuse is worse than physical abuse. Psychological abuse frequently co-occurs with other types of abuse and can take various forms. Children often believe the abuse is their fault. Sexual abuse occurs to children of all ages and is frequently perpetrated by someone the child knows and trusts. To maintain their silence, children may be threatened or told that they will not be believed if they disclose the abuse. No child is psychologically prepared to cope with repeated sexual stimulation. A victim of prolonged sexual abuse will develop low self-esteem, a feeling of worthlessness, and a distorted view of sex. The child may become withdrawn, distrustful, or suicidal. Other characteristics of children who have been sexually abused include an unusual interest or avoidance of sexually related content, nightmares, seductiveness, refusal to go to school, conduct problems, secretiveness, and unusual aggressiveness

EBP Nursing for Violence

Conducting a Safety Assessment First Once physiologic stability is established, the nurse should determine whether the survivor is in danger for his or her life, either from homicide or suicide, and, if children are in the home, whether they are in danger. Trauma may trigger suicidal ideation or exacerbate pre-existing mental health conditions that place the survivor at risk. Suicide precautions should be initiated if indicated. Children who are present during abusive episodes are at risk for emotional and developmental harm even if they are not direct recipients of abuse. Exposing a child to violence carries legal consequences in many states The Danger Assessment Screen is a useful tool for assessing the risk that IPV will end in homicide This assessment may help survivors recognize the serious nature of the violence they routinely experience.

Psychosocial Interventions

Coping With Anxiety Anxiety management is a crucial intervention for all survivors. A high comorbidity exists involving trauma, PTSD, and anxiety disorders. During treatment, survivors experience situations and memories that provoke intense anxiety and must know how to soothe themselves when they experience painful feelings. Moreover, most survivors struggle with control issues, especially involving their bodies. Anxiety management skills offer one way to maintain some control over their bodies and choices Finding Strength and Hope Providing hope and a sense of control is fundamental for survivors of trauma. Help survivors find hope by assisting them to identify specific strengths and aspects of their lives that are under their control. This type of intervention may empower survivors to find options other than remaining in an abusive relationship. Interventions that focus on empowerment encourage and create opportunities for survivors to make decisions about their lives, thereby restoring a sense of autonomy and competence lost in the abusive environment

Psychoeducation:Abuse

Cycle of violence Access to shelters Legal services Government benefits Support network Symptoms of anxiety, dissociation, and PTSD Safety or escape plan Relaxation Adequate nutrition and exercise Sleep hygiene HIV testing and counseling

Physical Health Assessment

Documentation of abuse or suspected abuse includes a complete history and physical examination. Note vital signs, sleep and appetite disturbances, exaggerated startle responses, flashbacks, and nightmares that may suggest PTSD or depression. Assess for injuries in need of immediate attention. Documentation should include a detailed history of how injuries occurred and a careful description of the injuries. A body map may be used to indicate location, size, and type of injuries. The nurse's documentation may become evidence if there are legal consequences related to the violence, even if the survivor declines to file a report at the time of the incident. Victims of violence experience mild to severe physical consequences. Mild injuries may include bruises and abrasions of the head, neck, face, trunk, and limbs. People who are chronically abused may have multiple bruises in various stages of healing. Severe injuries include multiple traumas, major fractures, major lacerations, and internal injuries (including chest and abdominal injuries and subdural hematomas). Loss of vision and hearing can result from blows to the head. Physical or sexual violence may result in head injuries that can produce changes in cognition, affect, motivation, and behavior. Survivors of sexual abuse may have vaginal and perineal trauma. Anorectal injuries may also be present, including disruption of anal sphincters, retained foreign bodies, and mucosal lacerations. Examination for sexual abuse, acute or chronic events, may require referral to a trained registered nurse in sexual assault, known as a SANE (sexual assault nurse examiner) Healthy child development and deviations that may be related to abuse or neglect are critical components of the nursing assessment of children. Assessing developmental milestones, school history, and relationships with siblings and friends is important. Intracranial hemorrhage in an infant in the absence of an obvious cause, such as a motor vehicle accident, may suggest shaken baby syndrome. Infants do not begin to move or ambulate on their own prior to the age of 6 months, when they begin to crawl; therefore, any bruises on an infant before the age of 6 months is cause for suspicion. Any discrepancies between the history and physical examination and implausible explanations for injuries and other symptoms should be an alert to the possibility of abuse Children and adolescents who wear clothing that covers parts of the body in a manner inconsistent with the season may be hiding bruises, abrasions, or burns caused by cigarettes or boiling water. Other circumstances that should heighten the suspicion of childhood abuse include multiple fractures or types of fractures (such as spiral fractures) that would only occur in an abusive situation. Other injuries such as bite marks or injuries to the genitals or anus always require further investigation. For reference when assessing older adults, become familiar with normal aging and signs and symptoms of common illnesses to distinguish those conditions from abuse. Observe for signs of malnutrition or inattention to activities of daily living (ADLs). As with children, bruises, lacerations, and other injuries are suspicious if they are inconsistent with a description of how they occurred. Some older adults are unable to communicate effectively because of dementia or other cognitive impairment. Evidence that excessive medications or physical restraints are being used to control an older adult's behavior should be investigated.

Establishing Therapeutic Relationship

Establishing a trusting nurse-patient relationship is one of the most important steps in caring for any person experiencing violence. When interviewing, to establish rapport and put the survivor at ease, start with the least sensitive areas and progress to more sensitive topics Survivors are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Important considerations in establishing open communication are ensuring confidentiality and providing a quiet, private place in which to interact. A supportive, empathetic approach is most effective. The nurse must continually monitor personal reactions to prevent negative feelings from influencing the nurse-patient relationship in a way that could retraumatize the survivor. Nurses must make clear during the assessment their responsibility for mandated reporting.

Evaluation and Treatment

Evaluation and outcome criteria depend on the setting for interventions. For instance, if a survivor is encountered in the emergency department, successful outcomes might be that injuries are appropriately managed and the patient's immediate safety is ensured. For long-term care, outcome criteria and evaluation might center on ending abusive relationships. Examples of other outcome criteria that would indicate successful nursing interventions are recognizing that one is not to blame for the violence, demonstrating knowledge of strengths and coping skills, and reestablishing social networks. Evaluation of nursing care for abused children depends on attaining goals mutually set with the parents or guardians. An end to all violence is the optimal outcome criterion; however, attainment of smaller goals indicates progress toward that end. Outcomes such as increased problem-solving and communication skills within the family, increased self-esteem in both children and parents, and increased use of nonphysical forms of discipline may all indicate progress toward the total elimination of child abuse. Follow-up efforts are important in evaluating the outcomes of elder abuse. The optimal outcome is to end all abuse and keep the older adult in his or her own living environment, if appropriate. Although the abuse may have been resolved temporarily, it may flare up again. Ongoing support for the caregiver and assistance with caregiving tasks may be necessary if the older adult is to remain at home. Nursing home or assisted living may be the only desirable option if the burden is too great for the family and the likelihood of ongoing abuse or neglect is high. Another important outcome of nursing intervention with survivors is appropriate treatment of any disorder resulting from abuse (e.g., acute stress disorder, PTSD, anxiety disorders, dissociative identity disorder, major depression, substance abuse). Follow-up nursing assessments should monitor symptom reduction or exacerbation, adherence to any medication regimen, and side effects of medication. The ultimate outcome is to end violence and enable the survivor to return to a more productive, safe, and nurturing life without being continually haunted by memories of the abuse. Nurses must become accustomed to measuring gains in small steps when working with survivors. Making any changes in significant relationships has serious consequences and can be done only when the adult survivor is ready. It is easy to become angry or discouraged with survivors, so it is important not to communicate such feelings. Discussing such feelings with other staff provides a way of dealing with them appropriately. In such discussions with supervisors or other staff, it is imperative to protect the survivor's confidentiality by discussing feelings around issues, not particular individuals, in order to ensure that survivors cannot be identified.

Psychosocial Assessment

Guilt and Shame A history of abuse is often associated with guilt and shame. Survivors are ashamed of being manipulated and violated and for having put themselves in such a situation. Abusive partners tell the survivors that the abuse is their fault and many victims believe them. Feelings of humiliation and shame prevent survivors from seeking medical care and other forms of support and reporting abuse to authorities. The experience of being battered is so degrading and humiliating that survivors are often afraid to disclose it to anyone. Many fear that they will not be taken seriously or will be blamed for inciting the abuse or for staying with their abusers. Keeping their circumstances secret and maintaining a front of normality places enormous tension and pressure on survivors. Problems with Intimacy Abused children, especially those who have experienced child sexual abuse, experience intrusion, abandonment, devaluation, or pain in the relationship with the abuser instead of the closeness and nurturing that are normal for intimate relationships Consequently, intimacy is associated with shame and fear rather than warmth and caring and with concerns about dominance and submission rather than mutuality. Shame in turn is associated with being submissive, feeling devalued, and the desire to retaliate against a person who is seen as the source of humiliation. In adulthood, unresolved feelings of shame as well as symptoms of PTSD or depression may disrupt the development of intimacy and lead to relationships characterized with dissatisfaction and poor relationship quality Conversely, some survivors of child abuse and child sexual abuse may engage in risky sexual behavior such as early sexual activity (before age 15 years), promiscuity, and prostitution. These behaviors place survivors at risk for developing sexually transmitted diseases and HIV. Survivors who engage in this type of behavior may have learned that sexual activity is a means for securing affection, intimacy, or material rewards such as money or drugs. Revictimization Many survivors who experienced childhood trauma are revictimized later in life. Numerous factors are related to revictimization, including symptoms of PTSD, dissociation, boundary issues, and role reversal with both mothers and fathers Excessive use of alcohol and other drugs by survivors makes them more vulnerable and less able to defend themselves. Survivors with substance use problems are more likely to enter a relationship with someone who also uses, placing them at risk for substance-related violence People with abuse histories frequently have difficulty with boundaries. During childhood abuse, they experienced frequent boundary violations and associate those violations with intimate relationships. Role reversal in childhood in which a child takes care of one or both parents may lead to difficulty with boundaries and may be associated with intrusiveness, boundary dissolution with a partner, and risk of IPV in adulthood Social Networks An evaluation of social networks provides additional clues of psychological abuse and controlling behavior. Having supportive family or friends is crucial in short-term planning for developing a safety plan and is also important to long-term recovery. A survivor cannot leave an abusive situation with nowhere to go. Supportive family and friends may be willing to provide shelter and safety, as well as emotional support.

Psychosocial Assessment

Fear Living with an abusive partner, parent, or caregiver means living with constant fear and uncertainty. Because victims never know what might precipitate an incident of violence, they are constantly hypervigilant and fearful. The back-and-forth nature of the relationship, that is, alternating between love and violence, is confusing, so the survivor may try to do everything possible to please the abuser in an effort to prevent another violent episode. Low Self-Esteem Being the victim of abuse is devastating to healthy self-esteem, or feelings of self-acceptance, self-worth, self-love, and self-nurturing. Emotional abuse may be particularly devastating. Victims are criticized, rejected, devaluated, and ignored. Feeling stupid was a recurring theme in a qualitative study of women who had left abusive relationships. Women consistently labeled themselves stupid for not recognizing abusive behaviors, allowing their partners to abuse them, and staying in an abusive relationship Low self-esteem has been linked to physical and mental health problems, and problems with relationships, which may affect survivors' ability to achieve financial independence.

Safety Issues and Mandatory Reporting

Health care providers, including nurses, are mandated reporters. This means that they must report known or suspected abuse in specific circumstances. Some states require reporting of injuries sustained as a result of abuse. Mandatory reporting for IPV is controversial because it may act as a barrier to disclosure, especially in cases in which the victim fears that the abuser will retaliate All states require reporting of known or suspected abuse involving children and vulnerable adults. It is important for nurses to be familiar with the laws of the state in which they practice and with the policies of their organization. Removing children and older adults from their families or caregivers may be necessary to ensure their immediate safety. In most settings, nurses do not have to make this decision alone; rather, they involve other professionals to assist with assessment and alternate placement if the current living situation of an abused or neglected child or older adult cannot be made safe. When an older adult's decision making is not impaired (competence is the legal term), he or she must be allowed an appropriate degree of autonomy in deciding how to manage the problem even if he or she chooses to remain in the abusive situationretaliate

Types

IPV is a significant public health problem in the United States, and across the globe. Behaviors that constitute IPV include physical, sexual, and psychological (emotional) abuse or a combination of these perpetrated by a current or former spouse, significant other, or dating partner. The prevalence of IPV can only be estimated, because much abuse goes unreported. The most recent data available suggest that during their lifetimes, 1 in 4 women and nearly 1 in 10 men experience adverse psychological or physical consequences related to physical or sexual violence perpetrated by an intimate partner Intimate partner violence involves physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner. IPV occurs on a continuum from psychological abuse to lethal violence. Physical Abuse Physical abuse involves any act of aggression with or without use of an object or weapon that results in injury, pain, or impairment to another. Examples include striking, kicking, shoving, choking, burning. Frequently, this behavior becomes a pattern that increases in severity over time. Physical abuse not only causes immediate injuries but contributes to health problems that may persist long after the abuse ends. Although anyone can be a victim of physical abuse, women are far more likely than men to be seriously injured or killed by an intimate partner. Psychological abuse (also referred to as emotional abuse) involves threats, intimidation, or violence used as a means of asserting dominance and causing fear. Psychological abuse includes behaviors such as criticizing, insulting, humiliating, or ridiculing someone in private or in public. Abusers may destroy property, threaten or harm pets, control or monitor spending and daily activities, or isolate a person from family and friends. Gaslighting is a form of psychological abuse in which the victim is made to question his or her own judgment and perceptions. Perpetrators downplay the consequences of their behavior, deny abusive intent, or argue that actions are somehow justified. They often blame the victim for provoking or otherwise causing the abuse, leaving the victim with feelings of guilt or responsibility. About one third of adults report experiencing psychological abuse by an intimate partner during their lifetime Whereas physical violence may be episodic, psychological abuse is frequently more unrelenting. Over time, psychological abuse is devastating to an individual's self-esteem and self-confidence and can lead to psychiatric and physical disorders resulting from chronic stress Teen partner abuse Teens and adults are often not aware of the frequency with which teen dating violence occurs. In a recent national survey of adolescents in the United States, 12% of girls and 7% of boys reported being struck or physically hurt on purpose by a boyfriend or girlfriend in the 12 months prior to the survey. Conflict or relationship problems with parents and peers may be predictors of teen partner abuse. Teens who experience violence in intimate relationships are more likely to develop problems such as depression, substance abuse, eating disorders, and thoughts of suicide. School performance may suffer.

Factors Influencing Leaving Vs Staying in Violent Relationship

Many women do not report abuse, fearing retaliation against themselves or their children. Often, they continue to hold strong feelings for their partners despite the abuse. When medical care is required, women may attribute their injuries to other causes; health care providers may be reluctant to inquire about abuse. Provision of assistance to women who are involved in violent intimate relationships can pose unique problems in that seeking support can be dangerous to the women if their activities are discovered by the abusive partner. Therefore, the challenge for health care providers is twofold—ensuring that support is both available and safely accessible, whether or not it is accepted at a given time. Even though it might be difficult to understand why a person would remain in an abusive relationship, it is critical to remain nonjudgmental and to realize that there are valid reasons for deciding to remain in a potentially harmful environment. Leaving an abusive relationship is a process that can be quite complex. Many women leave and return several times as they learn new coping skills and build support networks before ending the relationship permanently. When abuse is intermittent, and strong emotional and psychological ties to the abusive partner remain, victims continue to hope that the behavior will change. Women who lack job skills, financial resources, and support systems may stay because of economic dependence on their partner. Some are concerned about losing custody of their children if they are unable to provide for them independently. Fear is another important factor in deciding whether to leave or to stay in a violent relationship. Some women stay because of threats not only against themselves but against other family members or pets. Women recognize the valid concern that leaving may not stop the violence. If victims attempt to leave or actually do leave the relationship, perpetrators often escalate their violence, stalk their partners, and may even kill them, which makes leaving the time of greatest risk in an abusive relationship

Abuse of OA

Older adults and adults who have mental or physical disabilities are vulnerable to abuse. Elderly individuals may be victims of physical, psychological, or sexual abuse. The most common type of elder abuse is financial abuse, in which older adults may be manipulated by family or caregivers to give up control of their money and are vulnerable to scams and fraud perpetrated by outsiders. Elder abuse is increasingly recognized as a serious problem in the United States and other countries. As the population continues to age, it is likely that the problem will worsen. The actual prevalence of elder abuse is uncertain, as most abuse is unreported, and relatively little research has focused on this population. The violence usually occurs at the hands of a caregiver or a person the older adult trusts, but is also a significant problem in nursing homes and assisted living facilities. Individuals who are isolated, have poor support systems, or have mental or physical impairments that foster dependency on others are more vulnerable to harm. Older people may be reluctant to report maltreatment by those they love or on whom they depend, or cognitive deficits may prevent them from being able to articulate their situation. In addition to the obvious physical problems (e.g., injuries, pressure sores, malnutrition) that can result from abuse or neglect, older adults can experience worsening of existing medical conditions and emotional problems such as depression, anxiety, and fearfulness Costs of medical care related to abuse and neglect are estimated to be well over $5 billion annually; losses to elderly individuals associated with financial exploitation are similarly alarming . High-risk factors for those who are more likely to abuse older adults include using drugs or alcohol, high levels of stress, lack of social support, high emotional or financial dependence on the older adult, lack of training in taking care of older adults, and depression. Caring for a dependent older adult can be overwhelming. It is important for the nurse to listen to and assess both older adults and their caregivers to help prevent abuse and neglect in this population.

Safety Planning

One of the most important interventions when caring for individuals who are in an ongoing abusive relationship is to help survivors develop a safety plan. The first step in developing such a plan is helping the survivor recognize the signs of danger. Changes in tone of voice, substance use, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before battering begins. The next step is to devise the escape. For families at risk for violence, this may involve mapping the house for an escape route. The IPV survivor needs to have a bag packed and hidden but readily accessible that includes what is needed to get away. Important things to pack are clothes, a set of car and house keys, bank account numbers, birth certificate, insurance policies and numbers, marriage license, valuable jewelry, important telephone numbers, and money. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place. A safety plan for a child or dependent elder might include safe places to hide and important telephone numbers, including 911 and those of the police and fire departments and other family members and friends.

Psychoeducation

Other nursing interventions include teaching self-protection skills, healthy relationship skills, and healthy sexuality. This teaching may be especially important for children who have no role models for healthy relationships. Children also need to know what constitutes controlling and abusive behavior and how to get help for abuse. Survivors also need information about resources, such as shelters for battered women, legal services, government benefits, and support networks. Before giving the survivor any written material, first discuss the possibility that if the perpetrator were to find the information in the survivor's possession, he or she might use it as an excuse for further battering. Family Interventions Family interventions in cases of child abuse focus on behavioral approaches to improve parenting skills. A behavioral approach has multiple components. Child management skills help parents manage maladaptive behaviors and reward appropriate behaviors. Parenting skills teach parents how to be more effective and nurturing with their children. Leisure skills training is important to reduce stress in the household and promote healthy family time. Household organization training is another way to reduce stress by teaching effective ways to manage the multiple tasks that families have to perform. Such tasks include meal planning, cooking, shopping, keeping health care providers' appointments (e.g., dental care, health visits, counseling), and planning family activities Anger control and stress management skills are important parts of behavioral programs for families. Anger control programs teach parents to identify events that increase anger and stress and to replace anger-producing thoughts with more appropriate ones. Parents learn self-control skills to reduce the expression of uncontrolled anger. Stress-reduction techniques include relaxation techniques and methods for coping with stressful interactions with their children. Community Involvement Nurses may be involved in interventions to reduce violence at the community level. Many abusive caregivers, parents, and guardians as well as battered partners, older adults, and children are socially isolated. Developing support networks may help reduce stress and therefore reduce abuse. Community contacts vary for each abuser and survivor but might include crisis hot lines, support groups, and education classes. Nurses may also make home visits. Home visits provide support to families and provide them with knowledge about stress and management. Abuse of any kind creates a volatile situation, so nurses may be putting themselves or the survivor in danger if they do make home visits. Carefully assess this possibility before proceeding. If necessary, arrange a safe place to meet the survivor instead.

History and Physical Findings Suggesting Abuse

PRESENTING PROBLEM Vague information about cause of problem Delay between occurrence of injury and seeking of treatment Inappropriate reactions of significant other or family Denial or minimizing of seriousness of injury Discrepancy between history and physical examination findings FAMILY HISTORY Past family violence Physical punishment of children Children who are fearful of parent(s) Father or mother (or both) who demands unquestioning obedience Alcohol or drug abuse Violence outside the home Unemployment or underemployment Financial difficulties or poverty Use of older adult's finances for other family members Finances rigidly controlled by one member HEALTH AND PSYCHIATRIC HISTORY Fractures at various stages of healing Spontaneous abortions Injuries during pregnancy Multiple visits to the emergency department Elimination disturbances (e.g., constipation, diarrhea) Multiple somatic complaints Eating disorders Substance abuse Depression Posttraumatic stress disorder Self-mutilation Suicide attempts Feelings of helplessness or hopelessness Low self-esteem Chronic fatigue Apathy Sleep disturbances (e.g., hypersomnia, hyposomnia) Psychiatric hospitalizations PERSONAL AND SOCIAL HISTORY Feelings of powerlessness Feelings of being trapped Lack of trust Traditional values about home, partner, and children's behavior Major decisions in family controlled by one person Few social supports (isolated from family, friends) Little activity outside the home Unwanted or unplanned pregnancy Dependency on caregivers Extreme jealousy by partner Difficulties at school or work Short attention span Running away Promiscuity Child who has knowledge of sexual matters beyond that appropriate for age Sexualized play with self, peers, dolls, toys Masturbation Excessive fears and clinging in children Verbal aggression Themes of violence in artwork and school work Distorted body image History of chronic physical or psychological disability Inability to perform activities of daily living Delayed language development PHYSICAL EXAMINATION FINDINGS General Appearance Fearful, anxious, hyperactive, hypoactive Watching partner, parent, or caregiver for approval of answers to your questions Poor grooming or inappropriate dress Malnourishment Signs of stress or fatigue Flinching when approached or touched Inappropriate or anxious nonverbal behavior Wearing clothing inappropriate to the season or occasion to cover body parts Vital Statistics Elevated pulse or blood pressure Other signs of autonomic arousal (e.g., exaggerated startle response, excessive sweating) Underweight or overweight Skin Bruises, welts, edema, or scars Burns (cigarette, immersion, friction from ropes, pattern like an electric iron or stove) Subdural hematoma Missing hair Poor skin integrity: dehydration, decubitus ulcers, untreated wounds, urine burns, or excoriation Eyes Orbital swelling Conjunctival hemorrhage Retinal hemorrhage Black eyes No glasses to accommodate poor eyesight Ears Hearing loss No prosthetic device to accommodate poor hearing Mouth Bruising Lacerations Missing or broken teeth Untreated dental problems Abdomen Abdominal injuries during pregnancy Intra-abdominal injuries Genitourinary System or Rectum Bruising, lacerations, bleeding, edema, tenderness Untreated infections Musculoskeletal System Recent fractures or old fractures in various stages of healing Dislocations Limited range of motion in extremities Contractures Neurologic System Difficulty with speech or swallowing Hyperactive reflexes Developmental delays Areas of numbness Tremors Mental Status Anxiety, fear Depression Suicidal ideation Difficulty concentrating Memory loss Medications Medications that are not indicated by physical condition Overdose of drugs or medications (prescribed or over the counter) Medications not taken as prescribed Communication Patterns and Relations Verbal hostility, arguments Negative nonverbal communication, lack of visible affection One person answers questions and looks to other person for approval Extreme dependency on family members

Treatment for abuser

Participants in programs that treat abusers are usually present only because the court has mandated the treatment. Programs are often outpatient groups that meet weekly for an extended period of time, often 36 to 48 weeks. Some programs advocate longer programs, believing that chronic offenders require from 1 to 5 years of treatment to change abusive behavior. States vary on requiring that treatment programs for abusers contact partners. Interventions must be culturally sensitive. Many factors can affect violence against others, including socioeconomic status, racial or ethnic identity, country of origin, and sexual orientation; those differences must be addressed. When applicable, intervention programs may require abusers to undergo substance abuse treatment concurrently, so patients are required to remain sober and to submit to random drug testing.

Physical Interventions

Physical Health Interventions Treatment of trauma symptoms may include cleaning and dressing burns or other wounds and assisting with setting and casting broken bones. Malnourished and dehydrated children and older adults may require nursing interventions such as intravenous therapy or nutritional supplements that alleviate the alteration in nutrition and fluid and electrolyte imbalances. Victims of sexual assault require additional considerations Individuals who are experiencing IPV need their basic needs met (e.g., safety, housing, food, child care) before their psychological traumas can be addressed. Promoting Healthy Daily Activity Teaching sleep hygiene (i.e., practices conducive to healthy sleep patterns) and promoting exercise, leisure time, and nutrition will help battered survivors regain a healthy physical state and self-care activities. Taking care of themselves may be difficult for survivors who have spent years trying to separate themselves from their bodies (dissociate) to survive years of abuse. Techniques such as going to bed and arising at consistent times, avoiding naps and caffeine, and scheduling periods for relaxation just before retiring may be useful in promoting sleep Aerobic exercise is a useful technique for relieving anxiety and depression and promoting sleep Managing Care of Patients With Mental Health or Substance Abuse Issues Survivors of abuse and sexual assault, and those in abusive relationships, may experience depression, anxiety, and posttraumatic stress. These disorders interfere with cognitive processes—including judgment, decision making, and problem solving—and impede healing even after the survivor is in a safe environment. Trauma-informed cognitive-behavioral therapy and interpersonal therapy specifically targeting psychological consequences of IPV are the most effective treatments for survivors. Refer the survivor to a qualified mental health provider for treatment. Survivors who have a substance use disorder need referral to a treatment center for such disorders. The treatment center should have programs that address the special needs of survivors. Alcohol- and drug-dependent survivors frequently stop treatment and return to previous dysfunctional use patterns if their violence-related problems are not addressed appropriately. Survivors who are impaired by substances are at high risk for HIV infection and other infectious diseases. If survivors do not know their HIV status, they should be encouraged to get tested.

Psychosocial Interventions

Several issues must be addressed for survivors including guilt, shame, and stigmatization. These issues can be approached in several ways. Assisting survivors to verbalize their experience in an accepting nonjudgmental atmosphere is the first step. Directly challenging attributions of self-blame for the abuse and feelings of being dirty and different is another. Helping survivors to identify their strengths and validating thoughts and feelings may help to increase their self-esteem. Working With Children Children may need to learn a "violence vocabulary" that allows them to talk about their abuse and assign responsibility for abusive behavior. Children also need to learn that violence is not okay, and it is not their fault. Allowing children to discuss their abuse in the safety of a supportive, caring relationship may alleviate anxiety and fear. Respond to children's disclosures with sensitivity, belief, and a calm demeanor. Avoid pressuring children to talk or share details if they are uncomfortable. Reenacting the abuse through play is another technique that may be helpful in assisting children to express and work through their anxiety and fear. Play therapy uses dolls, human or animal figures, video games, or puppets to work through anxiety or fears. Other techniques include reading stories about recovery from abusive experiences (literal or metaphoric), using art or music to express feelings, and psychodrama. In addition, teaching strategies to manage fear and anxiety, such as relaxation techniques, coping skills, and imagery, may give the child an added sense of mastering his or her fear Managing Anger Anger and rage are part of the healing process for survivors. Expression of intense anger is uncomfortable for many nurses. However, anger expression should be expected from the survivor, so it is necessary to develop comfortable ways to respond. Moreover, an important nursing intervention is teaching and modeling anger expression appropriately. Inappropriate expressions of anger might drive supportive people away. Anger management techniques include appropriately recognizing and labeling anger and expressing it assertively rather than aggressively or passive-aggressively. Assertive ways of expressing anger include owning the feeling by using "I feel" statements and avoiding blaming others. Teaching anger management and conflict resolution may be especially important for children who have seen nothing but violence to resolve problems.

Rape and Sexual Assault

Sexual assault includes any form of nonconsenting sexual activity, ranging from fondling to penetration. Rape and Sexual Assault Sexual assault is any type of sexual activity inflicted on a nonconsenting person or on someone who is unable to consent because of age, mental status, or impairment. Rape, the most severe form of sexual assault, refers to forced vaginal, oral, or anal penetration or attempted penetration by the offender, including use of a foreign object. Perpetrators use physical force, coercion, or threats to gain control over their victims. Rape is a crime of violence and domination, with sexuality used as a weapon. Most sexual assaults are perpetrated by someone known to the victim. Children are most likely to be sexually abused by family members or others close to them, as are elderly and disabled adults. Adolescents and young adults are especially vulnerable to drug-facilitated assault by acquaintances, which involves the use of "date-rape" drugs, often combined with alcohol, to make a victim incapable of resistance. It is common for sexual assault to occur in conjunction with IPV, as an additional means of intimidation and humiliation. Nonconsensual sex within a marriage was exempt from rape laws until the 1970s, and it was not until 1993 that all states had removed that exemption Stalking is a pattern of repeated unwanted contact, attention, and harassment that often increases in frequency. Stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress. Stalking may include such behaviors as following someone, showing up at the person's home or workplace, vandalizing property, using technology to track or harass someone, or sending unwanted gifts. One in 6 women and 1 in 19 men experience stalking at some point in their lifetime. Stalking can be prolonged and takes a tremendous toll on victims' health and functioning.

Psychosocial Assessment

Social Isolation Many perpetrators isolate their family from all social contacts, including other relatives. Some survivors isolate themselves because they are ashamed of the abuse or fear nonsupportive responses. Nurses can assess restrictions on freedom that may suggest abuse and control by asking such questions as: "Are you free to go where you want?" "Is staying home your choice?" and "Is there anything you would like to do that you cannot?" Economic and Emotional Dependency Women who have young children and depend on the perpetrator financially may believe that they cannot leave the abusive relationship. Those who are emotionally dependent on the perpetrator may experience an intense grief reaction that further complicates their leaving. Older adults and children often depend on the abuser and cannot leave the abusive situation without workable alternatives.

Interventions

The goals of all nursing interventions in cases of violence are to prevent injury, stop the violence, ensure the survivor's safety, and restore health. As appropriate concerning age and ability, nursing interventions should empower survivors to act on their own behalf. This must be done in a collaborative partnership. Nurses must be willing to offer support and information and not impose their own values on survivors by encouraging them to leave abusive relationships. Strong psychological and economic bonds tie many survivors to their perpetrators. Moreover, adult survivors who are capable of making decisions are the experts about their situations. They are the best judges to determine the appropriate time to leave a relationship. Intervention strategies for older adults depend on whether the individual accepts or refuses assistance and whether he or she can make decisions. If the person refuses treatment, it is important to remain nonjudgmental and provide information about available services and emergency contact information. If the older adult appears incapable of making decisions, then guardianship, foster care, or nursing home placement may be needed. The nurse should initiate a referral to a case manager or other who can facilitate further intervention.

Key points

The most common type of abuse results from domestic violence. IPV is a significant public health problem; it includes physical violence, sexual violence, stalking, and psychological aggression. IPV crosses all ethnic, racial, and socioeconomic lines. Women are more likely to be injured or killed by current or former intimate partners than by any other perpetrators. Stalking is repeated unwanted contact, attention, and harassment that increase in frequency. Child maltreatment includes child abuse (i.e., overt actions that cause harm, potential or threat of harm) and child neglect (i.e., failure to provide needs or to protect from harm or potential harm). Elders may also be physically, emotionally, and sexually abused or neglected. The most common type of elder abuse is economic. Among the many theories that have been proposed to explain violence are neurologic problems, psychopathology, alcohol and other drug abuse, intergenerational transmission of violence, and economic and community factors. A well-documented cycle of violence consists of three phases of increasing frequency and severity. Nurses need to be familiar with signs and symptoms of abuse and to be vigilant when assessing patients. Nurses need to be nonjudgmental when caring for a victim of abuse. Many reasons a person could cause a person to remain in an abusive situation. Nursing interventions include physical health interventions and psychosocial interventions that focus on helping victims identify their strengths and validating thoughts and feelings.

Theories of Violence

The neurobiologic and psychological factors that contribute to anger and poor impulse control are relevant to the use of aggression in the home. However, the ability of many abusers to refrain from angry outbursts and violence in public settings suggests that their behavior toward family members is not solely attributable to poor self-control. The risk factors discussed in previous sections increase the likelihood of violence occurring but do not cause it. Many people share the same risks but do not engage in violence. Individual characteristics likely intersect with risk factors to produce behavior that is learned and reinforced in families, communities, and society. Social Learning Theory (Intergenerational Transmission of Violence) Being a victim of childhood abuse is one of the strongest predictors of violence as an adult. Violent families create an atmosphere of tension, fear, intimidation, and confusion about intimate relationships. Children in violent homes learn that violent behavior is an approved and legitimate way to solve problems and to cope with difficulty. Social learning or intergenerational transmission of violence theory posits that children who witness or experience violence in their homes are more likely to perpetuate violent behavior within their own families. Experiencing harsh physical discipline increases the risk of perpetrating family violence as an adult. This learned behavior is reinforced when violence as a means of control or punishment is sanctioned within social systems or when there are inadequate social or legal constraints to discourage such behaviors Economics Disadvantage, Community Disorganization and Attitude Supportive of Violence Neighborhoods that are more socially cohesive are more intolerant of deviant behavior. The presence of concentrated economic disadvantage (i.e., neighborhoods with the lowest incomes, high unemployment, and institutional disinvestment), racial or ethnic heterogeneity, and community instability is associated with community disorganization and weak social control, which leads to increased levels of crime and IPV. Within these disadvantaged communities, institutions that normally foster social control, such as churches, schools, and other community organizations, lose their ability to exercise social control over the community. Community disorganization, crime, and weak social control also foster individual acceptance of violence, which in turn is associated with increased rates of IPV, child abuse, and elder abuse

Violence

Violence in the form of abuse of intimate partners, children, and elders is a national health problem. This type of violence permanently changes the survivor's reality and meaning of life. It wounds deeply, endangering core beliefs about the self, others, and the world. It can damage or destroy the survivor's self-esteem. Nurses encounter survivors of violence and abuse in all health care settings. For this reason, being knowledgeable about abuse risk factors, indicators, causes, assessment techniques, and effective nursing interventions is a must. This chapter presents evidence that can shape contemporary nursing practice in caring for persons and families who survive violence and abuse. The most common type of abuse occurs as a result of domestic (family) violence; that is, the perpetrator is or formerly was a loved and trusted partner or family member. When this kind of violence occurs, the world and home are no longer safe in the eyes of the survivor. This chapter includes a discussion of intimate partner violence (IPV), child abuse and neglect, and elder abuse with emphasis on IPV.

Danger Assessment

When survivors are disclosing abuse, they need privacy and time to tell their story. The nurse should listen attentively without offering unsolicited advice or making judgmental remarks about the possible abuse or the perpetrator. Use validating messages to convey that the survivor is believed and that the nurse is concerned for his or her safety and well-being Survivors of IPV may deny the abuse, make excuses for the perpetrator's behavior, or attribute an injury to an unlikely cause. Avoid pressuring or confronting them, but carefully document a description of the survivor's account of how the injury happened, using the survivor's own words. After assessment is completed in a health care agency and abuse is evident, the nurse should offer the adult survivor use of the telephone. This may be the only time that the survivor can make calls in private to family, who might offer support, or to the police, lawyers, or shelters. Scheduling future appointments may provide the survivor with a legitimate reason to leave the perpetrator and continue to explore options.