Care of Survivors of Abuse and Violence



Care of Survivors of Abuse and Violence


Nancy Fishwick, Barbara Parker and Jacquelyn C. Campbell




Learning Objectives



1. Define family violence, its possible causes, and characteristics of violent families.


2. Describe behaviors and values of nurses related to survivors of family violence.


3. Examine short-term and long-term effects of family violence on the physical and mental health of affected individuals.


4. Discuss primary, secondary, and tertiary prevention nursing actions related to family violence.


5. Analyze nursing assessment and intervention in abuse and violence among specific populations.


6. Evaluate issues and nursing care related to survivors of sexual assault.



Nurses encounter survivors of abuse and violence in all settings. The violence sometimes is openly discussed and recognized as a reason for the current health care visit, such as when a survivor of sexual assault is treated in an emergency room. Often, however, violence is disclosed only after a trusting nurse-patient relationship is formed.


Although there are various forms of violence, such as gang behavior and drug-related violence, the types most often described by patients are family violence and nonfamily rape and sexual assault. Because the dynamics of these two forms of violence are different, they are covered in separate sections of this chapter. Rape and sexual assault also can be forms of family violence. Attention is given to populations that are particularly at risk for abuse: children, intimate partners, and the elderly.


The words used to describe people who have experienced violence are important. Traditionally, the word victim has been used. In this chapter, the word survivor is used to emphasize that the person who has experienced abuse has many strengths and coping strategies that can be incorporated into the plan of care.



Critical Reasoning


Do you agree with the use of the word survivor instead of victim in this chapter? What do you think of when you hear the words victim and survivor?



Dimensions of Family Violence


Family violence is a range of harmful behaviors that occur among family and other household members. It includes physical and emotional abuse of children, child neglect, abuse between adult intimate partners, marital rape, and elder abuse. Regardless of the type of abuse occurring within a family, all members, including the extended family, are affected. Family violence, although often unnoted, is at the core of many family disturbances.


Violence may be a family secret and often continues through generations. Some believe that the family is the training ground for violence and ask why the social group that is supposed to provide love and support is also the most violent group to which most people belong. Behaviors that would be unacceptable among strangers, co-workers, or friends are often tolerated within families.


Violence and abuse are caused by an interaction of personality, demographic, biological, situational, and sociocultural factors. Many of the unique characteristics of the family as a social group—time spent together, emotional involvement, privacy, and in-depth knowledge of each other—can lead to intimacy and violence. A family may be loving and supportive as well as abusive.


The United States has a high level of violence overall compared with other Western nations. Social norms are sometimes used to justify violence to maintain the family system. For example, a husband’s use of violence may be considered legitimate if the wife is having an extramarital affair. Many men believe they have a patriarchal right to expect and enforce obedience from all family members, and they view their abusive behaviors as normal or justified.


Historical attitudes toward women, children, and the elderly; economic discrimination; the unreliable response of the criminal justice system; and the belief that women and children are property are social factors that promote violence. Changing norms about family privacy and the role of governmental intervention in family matters have also influenced the definition and recognition of family violence.



Critical Reasoning


Why do you think more violence occurs in U.S. society than in other Western nations? What societal factors influence the use of violence?



Characteristics of Violent Families


Factors common to violent families include multigenerational transmission, social isolation, the use and abuse of power, and the effect of alcohol and drug abuse.



Multigenerational Transmission


Multigenerational transmission means that family violence is often perpetuated through generations by a cycle of violence. Figure 38-1 shows the multigenerational transmission of family violence. Social learning theory related to violence suggests that a child learns this behavior pattern in a family setting by having an abusive parent as a role model.


image
FIG 38-1 Genogram demonstrates the multigenerational transmission of family violence.

Violence and victimization are behaviors learned through childhood experience. The child learns both the means and the approval of violence. Children who witness violence between adults in the household or who experience abuse from a parental figure learn specific aggressive behaviors and come to believe that violence is a legitimate way to solve problems. When frustrated or angry as an adult, the person relies on this learned behavior and responds with violence.


Experiencing abuse as a child does not necessarily determine an adult’s later behaviors. Many people who were abused as children are able to avoid violence within their intimate relationships and with their own children. The younger the child at the onset of abuse, the longer the duration and the more severe the nature of the abuse; multiple life adversities may set the stage for being abusive as a parent. A study with adult survivors of childhood sexual abuse found that many survivors felt they “passed on the family legacy” to their children, whereas other survivors made conscientious attempts to reject their family legacy and to create a new legacy for the well-being of their children (Martsolf and Draucker, 2008).




Use and Abuse of Power


Another common factor within the various forms of family violence is the use and abuse of power. In almost all forms of family violence, the abuser has some form of power or control over those whom they abuse. For example, with the sexual abuse of children, the abuser is usually older than the victim and is in an authority position over the child.


Power issues appear to be a central factor in intimate partner abuse and violence. In marriage, abusers may justify the use of violence for trivial events, such as not having a meal ready or not keeping the children quiet. However, the controlling behaviors and violence often are related to one spouse’s need for total domination of the other spouse. For example, wife abuse often begins or escalates when the woman behaves more independently by working or attending school. Box 38-1 describes five forms of abuse within intimate relationships that reflect domestic struggles for power and control.



BOX 38-1   FORMS OF ABUSE IN INTIMATE PARTNER RELATIONSHIPS


Definition


Domestic violence is a pattern of abusive behavior in any relationship used by one partner to gain or maintain power and control over another. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound.







From U.S. Department of Justice: Domestic violence, updated May 2011. Accessed November 2011 at www.ovw.usdoj.gov/domviolence.htm.



Alcohol and Drug Abuse


Survivors of violence often report substance abuse by the abuser. However, people who abuse alcohol or drugs are not consistently violent, and people who are violent are not always intoxicated. Instead, the person may use alcohol or drug intoxication as a socially acceptable explanation for the violent behavior. Family and friends may attribute the conduct to the effects of alcohol or drugs, which to some extent may decrease the degree of blame. The use of alcohol or drugs also may increase violent behavior by reducing fear or inhibitions and decreasing sensitivity to the impact of the behavior.


Research on aggressiveness and illicit drugs indicates that marijuana and heroin use are not correlated with violence. In contrast, crack cocaine, amphetamines, mescaline, angel dust (phencyclidine, or PCP), and steroids have been associated with increased violence in general. The current use of date-rape drugs, such as flunitrazepam (Rohypnol) and ecstasy (3,4-methylenedioxymethamphetamine), clearly places people, primarily young women, in danger of sexual exploitation and physical harm.



Nursing Attitudes Toward Survivors of Violence


Nursing care of survivors of violence can be challenging. The attitudes nurses bring to these situations shape their responses. Studies of health care professionals’ attitudes indicate that myths about family violence are accepted even though there is sympathy toward the survivor. Table 38-1 describes common myths and facts about survivors of abuse.



TABLE 38-1


BEYOND THE MYTHS: RECOGNIZING ABUSE SURVIVORS































MYTH FACT
Family violence is most common among families living in poverty. Family violence occurs at all levels of society without regard to age, race, culture, status, education, or religion. It may be less evident among the affluent because they can afford private physicians, attorneys, counselors, and shelters. People with less money must turn to public agencies for help.
Violence rarely occurs between dating partners. Estimates vary, but violence does occur in a large percentage of dating relationships.
Abused spouses can end the violence by divorcing their abuser. About 75% of all spousal attacks occur between people who are separated or divorced. In many cases, the separation process brings on an increased level of harassment and violence.
The abused partner can learn to stop doing things that provoke the violence. In a battering relationship, the abuser needs no provocation to become violent. Violence is the abuser’s pattern of behavior, and the abused partner cannot learn how to control it. Even so, many abused partners blame themselves for the abuse, feeling guilty—even responsible—for doing or saying something that seems to trigger the abuser’s behavior.
Alcohol, stress, and mental illness are major causes of physical and verbal abuse. Abusive people and even those who are abused often use those conditions to excuse or minimize the abuse; but abuse is a learned behavior, not an uncontrollable reaction. People are abusive because they have acquired the belief that violence and aggression are acceptable and effective responses to real or imagined threats. Fortunately, because violence is a learned behavior, abusers can benefit from counseling and professional help to alter their behavior; but dealing only with the perceived problem (e.g., alcohol, stress, mental illness) will not change the abusive tendencies.
Violence occurs only between heterosexual partners. Gay and lesbian partners experience violence for varied reasons, similar to heterosexual partners.
Being pregnant protects a woman from battering. Battering often begins or escalates during pregnancy. According to one theory, the abuser who already has low self-esteem views his wife as his property. He resents the intrusion of the fetus and the extra attention his wife gets from friends, family, and health care providers.
Abused women accept the abuse by concealing it, not reporting it, or failing to seek help. Many women, when they do try to disclose their situation, are met with denial or disbelief. This only discourages them from persevering.

Although most nurses do not blame survivors for what has happened to them, they can be less tolerant of certain behaviors. For example, nurses are more likely to blame a rape survivor if the woman had gone out late at night, had not locked her car doors, or did not resist the assault “enough.” They have difficulty understanding abused children who want to return to abusive parents and battered women who do not leave their abusers.


Survivors often find the health care system to be unhelpful and even traumatizing when they go for help. Health care providers who use a paternalistic helping model rather than a model of empowerment will be frustrated by survivors who do follow the prescribed advice. Table 38-2 compares the characteristics of the paternalistic and the empowerment models. The empowerment model is more helpful to the survivor and is more professionally satisfying for the nurse.




Creating Positive Attitudes


The first step in providing effective nursing care is exploring your own attitudes toward survivors of abuse and violence. Self-directed learning and formal continuing education on family violence should focus on recognizing and changing beliefs and feelings, as well as learning facts about violence. Professional education materials from agencies such as Futures Without Violence (formerly the Family Violence Prevention Fund: www.futureswithoutviolence.org/section/our_work/health [accessed November 2011]) and the Centers for Disease Control and Prevention (www.cdc.gov/ViolencePrevention [accessed November 2011]); volunteer experiences with community-based rape crisis centers, domestic violence programs, or child protection programs; and attention to public education campaigns are constructive ways to increase understanding of and degree of comfort in addressing the experiences and responses of survivors.



Critical Reasoning


Many television shows and movies explore the issues of family abuse and violence. Do you think they have helped change attitudes or reinforced fears and stereotypes?



Health Effects of Family Abuse and Violence


A growing body of knowledge provides nurses with an understanding of the short- and long-term effects of family abuse and violence on the physical, behavioral, and mental health of individuals (Sato-DiLorenzo and Sharps, 2007; Straus et al, 2009; McGuinness, 2010; Okuda et al, 2011). For example, a study of the cumulative effects of adverse childhood experiences (ACEs) indicates a link between childhood adversity and the development of risky behaviors and chronic health problems in adulthood.


The ACE study correlated adults’ childhood experiences of abuse, neglect, and various household problems such as witnessing domestic violence, having a family member with mental illness or substance abuse, or having a family member incarcerated, with later health behaviors such as early initiation of cigarette smoking, early initiation of sexual activity, or illicit drug use. It found that a significant number of adults with one or more adverse childhood events went on to develop alcoholism, depression, suicidality, unplanned pregnancies, sexually transmitted infections, liver disease, chronic obstructive pulmonary disease, and heart disease. The greater the number of types of adverse experiences in childhood, the higher the risk for adult health problems (Waite et al, 2010; Centers for Disease Control and Prevention, 2011). This work highlights the need for nurses to include assessment of adverse childhood experiences during intake of children, adolescents, and adults in mental health and substance abuse care settings.



Physical Health Effects


A characteristic pattern of injuries, especially to the head, neck, face, throat, trunk, and sexual organs, may be seen when physical assault, forced restraint, or sexual abuse has been perpetrated. Physical injuries can be present at multiple sites and in various stages of healing. Although rarely mentioned by the abused individual, sexual assault often accompanies physical abuse.


Survivors of family violence often experience a range of physical symptoms not obviously related to their injuries, such as headaches, menstrual problems, chronic pain, and digestive and sleeping disturbances. Symptoms such as headaches and other forms of chronic pain may be the result of repeated blows to the head or other parts of the body. The stress experienced from past or ongoing family violence may negatively affect the immune system, putting the individual at risk for a variety of health problems. Maternal exposure to domestic violence is associated with significantly increased risk for low birth weight and preterm birth (Shah and Shah, 2010).



Psychological Effects


An emotionally abusive family environment, the experience of physical and sexual abuse, and witnessing maternal battering can have a negative impact on a person’s mental health immediately or as delayed reactions (Warshaw et al, 2009; Yanos et al, 2010). Nurses often are involved in the recovery process of adults who, years after the traumatic events, are dealing with the effects of childhood sexual abuse.


Common psychological responses include the cognitive responses of self-blame and poor problem solving and the emotional responses of depression, anxiety, and lowered self-esteem (Al-Modallal et al, 2008). In children, trauma as a result of maltreatment can even result in psychotic symptoms (Arseneault at el, 2011).


Many adults who witnessed family violence in their childhood, who personally experienced childhood abuse, or who survived abuse in adult intimate relationships can display remarkable adaptability in the wake of such trauma. Resilience, a pattern of successful coping despite challenging or threatening circumstances, can buffer a person from serious psychological effects. Access to social support and having a sense of control over the recovery process also contribute to favorable outcomes after abuse or assault (Paranjape and Kaslow, 2010).


Depression and low self-esteem are common among women in abusive relationships, adult survivors of childhood sexual abuse, abused children, and survivors of other forms of violence. Problems with self-concept are described in Chapter 17, depression is discussed in Chapter 18, and resilience is explained in Chapter 12.



Behavioral Health Effects


Many attempts have been made to understand the behavior of survivors of family violence, especially their continued involvement with an abuser. This has been especially damaging in addressing the question of why a battered woman remains in the relationship. It is assumed that she should leave rather than stay, but a woman is in the most danger of being stalked and killed by her partner when she leaves the abuser. Constraints that make it difficult to leave include concern for her children, cultural sanctions, perceived stigma, strong emotional attachment to her partner, and lack of money, social support, and other resources.


Although most women eventually leave a relationship that is continuously violent, there is often a pattern of leaving and returning many times before making a final break. Rather than being a sign of weakness, this can be seen as a normal process that is influenced by the quality of social support and assistance to the woman and the abuser’s behavior. Leaving and returning are purposeful and meant to pressure the abuser into meaningful change, test external and internal resources, or evaluate how the children react without their father.



Critical Reasoning


Discuss the issue of women remaining in abusive relationships. What factors keep them in these relationships? How do health professionals usually respond to a woman who has remained in an abusive relationship? What approach would help her?



Preventive Nursing Interventions


All nurses have important roles to play in the prevention of family violence. They do this through educating the public, identifying risk factors, and detecting the actual occurrence of family violence to assure timely intervention and prevent future recurrence (Humphreys and Campbell, 2011).



Primary Prevention


Changing society’s acceptance of violence and abuse is an important first step in prevention. Effective primary prevention includes eliminating cultural norms and values that accept and glamorize violence. This can begin by limiting the amount of violence permitted on television and in other media. The prevalence of violence on television, in movies, and in advertising plays a role in creating a social climate that says violence is exciting and appropriate. The average child watches television 20 hours per week. It has been estimated that U.S. children observe 18,000 killings before they graduate from high school. Violent content in children’s video and computer games and on the Internet also is of great concern.


A related area of primary prevention is the elimination of pornography, especially violent pornography, which has been associated with sexual violence. Concerned parents and law enforcement also are challenged by the ease of sexual predators’ access to vulnerable children and adolescents through the Internet and continued exploitation of children through child pornography websites.


Primary prevention of abuse includes strengthening individuals, families, and communities so they can cope more effectively with stress and resolve conflict nonviolently. By working collaboratively with school nurses, community health nurses, social services, law enforcement, and other community stakeholders, nurses can help develop and implement educational programs in a variety of arenas, such as schools, workplaces, and senior citizen centers. Programs can focus on healthy growth and development across the life span, healthy intimate relationships, preparation for parenting, ways to discipline children nonviolently, safe storage of firearms in the home, and raising awareness of the ways in which people can become controlled, manipulated, and potentially exploited by others.


Nurses can be involved in teaching family life and sex education courses in elementary and middle schools. Child sexual abuse can be prevented or detected when children are taught about inappropriate sexual contact and what they should do if it occurs. Middle school students need information about how to develop mutually respectful relationships in which jealousy is not viewed as a sign of love and domination of one partner over the other is not tolerated.


Family violence prevention also includes anticipatory guidance while working with families. For example, respite care is needed for families with chronically ill or incapacitated members, including the elderly and children. Planning in advance for relief from responsibility will prevent strained relationships and potential violence or abuse.


Families need to anticipate the difficult developmental stages of children. Parents need to know that infants are not intentionally frustrating to parents, that toddlers’ obstinacy is necessary for independence in later childhood, and that bed wetting signals the need for increased positive attention, not punishment.


A society must develop programs and policies that support families and reduce stresses and inequities. This includes adequate and appropriate day care for children and incapacitated elders, equity in salary and wages to make women less financially dependent, public education that ensures an adequate foundation for full employment of all, and sufficient financing of prevention and treatment programs.



Critical Reasoning


Go to a store, and search for the most popular video and computer games. Evaluate them for level of violence, sexual roles, and issues related to power and control.



Secondary Prevention


Secondary prevention efforts involve identification of families at risk for abuse, neglect, or exploitation, as well as early detection of those who are being abused or who are beginning to become violent. Systematic assessment for abuse through specific questions in the health history and through careful observations of physical health and behavior are recommended in all health care settings (Svavarsdottir and Orlygsdottir, 2008; O’Campo et al, 2011).


Studies conducted in emergency departments, prenatal care settings, primary care settings, and in mental health care and substance abuse settings indicate that individuals are likely to disclose abuse when a concerned health care professional asks questions that invite disclosure. Several protocols are available for routine assessment for potential child abuse, abuse of intimate partners, and for abuse of elder adults. These resources are available for free download on the Futures without Violence website (www.futureswithoutviolence.org [accessed November 2011]).


Box 38-2 lists indicators of actual or potential abuse that should be included in a nursing assessment. Availability and storage of firearms or other deadly weapons in the home need to be addressed because easy access has played a role in intentional injuries to family members and in communities and schools. Early indicators of families at risk include violence in the family of origin of either partner, communication problems, and excessive family stress, such as an unplanned pregnancy, unemployment, or inadequate family resources.



BOX 38-2   INDICATORS OF ACTUAL OR POTENTIAL ABUSE


Nursing History




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