Survivors of Abuse

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					Survivors of Abuse
                  Issues of Abuse

   The Prominent feature in all forms of
    abuse is power.
   Most abusers are fearful of losing control.
   Abuse escalates during pregnancy.
   There is a CYCLE OF VIOLENCE.
   Cycle does not apply to sexual abuse.
        Helpful responses to Abuse

   Ask if abuse is occurring
   Identifies described behavior as abuse
   Acknowledges the seriousness of abuse
   Being directive in exploring resources
     informing about shelters, other resources
     support groups

   Active listening
    Unhelpful responses to Abuse

   Displays of anger toward abused
   Blaming victim
   Giving advise
   Ignoring abuse
   Aligning with the abuser
   Refusing to help the person until they
    leave the abuser
                  Other Issues
   Family violence is accompanied by
   Hostage Syndrome
       Victims always blame themselves
       Feel unworthy of help
       fear they will not be believed
   Most common form of abuse is sibling
             Family violence

   Elder Abuse
   Parent abuse by violent adolescents
   Two Types of Violence in Couples
   Expressive Violence and Instrumental
     Instrumental and Expressive
   Expressive violence is           Instrumental violence
    mutual combat                     is unequal conflict
   Goal is to express
                                     Goal is CONTROL
    emotions/and hurt
   Role of victim and
    perpetrator are not fixed        Role of victim and
   Partners share                    perpetrator is fixed
    responsibility for violence      Victim is ALWAYS
                                      trying to please and
             Treatment issues
   Couple counseling is inappropriate for
    Instrumental violence
   Victim must be safe/ Arrest policies very
    important/Danger is real
   Groups very important modality
   Progress is made when victim starts defining her
   Assess for alcohol and drug use
   LONG term goal: Change self concept from
    victim to survivor status
                   Child Abuse

     1.   May have been abused as a child
     2.   Lack of knowledge of normal development
     3.   Lack of parenting skills; no role models
     4.   Socially isolated, stress, low self esteem
     5.   Lack of trust in the system
     6.   Abuse of alcohol and drugs
      Characteristics of the Child

   Position of child, sex of child
   Product of difficult labor and delivery
   Physically ill, hyperactive, sleeplessness
   Temperament of child performing tasks

   Chronic stress, divorce, financial stress
   Instability; absence of support system
   Socioeconomic level may influence
   Paternalistic culture: Rule of thumb
       Spare the rod, spoil the child
        Assessment: nursing care

   Physical evidence of abuse
   Conflicting stories about the “accident”
     Child with concussion fell out of bed.
     6 month old turned on hot water
     Concern about a cold when burns are present
     excessive delay in seeking treatment
     parent absent when you try to question
             Assessment Cont:

   Inappropriate response of the child
     Little or no response to pain
     Excessive fear of being touched
     Excessive or lack of separation anxiety
     Indiscriminate friendliness to strangers

   Previous reports of abuse
   Repeated visits to the ER for injuries
              Legal Aspects
   When must we report abuse
   Who must report. Professionals are held to
    a higher standard
   It is not enough to just report abuse to
    the Health Care Provider (MD or FNP) and
    hope for the best
   School nurses observe abuse and must
                     When to Report
   A Child or Elder; Abuse Neglect or Exploitation
   Adults: it is up to the individual to report
       Toll Free Hotline 1-877-786-7263
            (1-877-STOP ANE)
            Local telephone: (512) 424-6716
       Facsimile (512) 424-6700
       Email
       Address           4900 North Lamar, 5th floor
                          Austin Texas 78751
Characteristics of the family
     Maslow's hierarchy of needs

   Security
   Self Value
   Strokes (Recognition)
   Stimulation
   Structure
   Self actualization
                The Healthy Family
   Each member works on                 Each person can get their
    basic tension of:                     needs met.
       How can I maintain a             Each spouse can function
        sense of self and remain in       without the other
        this family.
                                         Open and flexible;
   Problems, but the family              members have other
    owns them                             relationships in the
   Like an orchestra                     community
       everyone is playing their            An open system vs. a
        own instrument but are                closed system
       playing the same tune
   Open System
           The Unhealthy Family
   The basic unit is:
       immature and needy
       low self-esteem
       not in the relationship by choice
       enmeshment
   A closed system
       Dependent on each other to get needs met
       Communication is triangulated
Triangles in Communication
                Mother talks to child
                 about problems with
                Child tries to support
                 mother and meet her
                Child also tries to support
                 father and meet his
                Mother needs to talk to
                 Father and not the child
      The Dysfunctional Family:

   Appears insecure; hides strength
   Submissive, humble
   Hates decisions
   Individual blames self
   Other centered
   I understand this is just a front
   I will just try harder
   Insecure, angry and shamed
         Dysfunctional Family:

   Self-centered
   Insensitive and proud of it
   Intrusive and intimidating
   Insecure, angry and shamed
   Appears secure, hides fear
   Grandiose, power dominance
   Who do I trust: me
   Who is at fault: them
   Deny weakness
   Emotional and physical space between you and
    another person
   Where you stop and the next person begins
   A Limit that others are not allowed to cross
    because of the negative impact
   Allows for appropriate closeness in the
   Boundary within a family:
       If a bathroom or bedroom door is shut
       Knock and wait
                Healthy Boundaries

   The right and need for the individual to:
       To explore
          Interests
          Hobbies

          Outlets

       Make their own mistakes
   Bring back to the family:
            My unique personality to enrich our lives
           Healthy Boundaries
   Enmeshment
   Dissociation
   Excessive Detachment
              Incest Family Dynamics
   Multigenerational and Multifaceted
   Mother
        Parentified in family of origin
        Low self-esteem
   Father
        Immature and dependent
        Needs mothering
        Self-centered
   Relationship
        She “mothers” him
         Children place stress on the relationship
             Less time to take care of the father
             Needs are left unmet
             Incest Family Dynamics
   Mother becomes overwhelmed
       Increases if family
            Has increased stress
                  Several children
                  Financial problems
                  Chronic illness
   A child becomes parentified
       helps mother in caretaker role
       helps to meet father’s needs
            Father feels neglected by mother
            Looks to child for affection
            Incest occurs gradually as child begins to take on the
             mother’s roles
       Family places the child’s needs last
   Confusion created by the perpetrator
       Child believes it is their fault
       Father coerces child to keep secret
       Father perceives child as sexual peer
       Closed system
            Isolated family
            Must keep the secret

   Mother and child relationship
       Mother denies sexual abuse is happening
       Ambivalence
            Love for the mother
            Anger about the lack of protection from abuse
        Survivors of Childhood Sexual
   Adult perpetrator is most often known and trusted
       Fathers, brothers, camp councilors, coaches, religious leaders
       Most often male perpetrator
       92% of females: male perpetrator
       38% of males: female perpetrator
       Average length of time of when an adult begins to perpetrate children
        and they get caught is 9 years
   Abuse most often begins before the age of 7
   Childhood sexual abuse
       15% to 30% of girls
       4% to 16% of boys
            More difficulty reporting
            Fear of being labeled gay or weak (male perpetrator)
            They are supposed to like it (female perpetrator)
   Incest (p.488)
       Sexual victimization of a child or adolescent
       Perpetrator does not seek occupations for access to victims
       Relationships by
            Blood or Marriage
       Perpetrator looks to the child for
            Gratification
            Fulfillment
            Power and control
            Child may feel special
       Distorted thinking
            Teaching the child about sexuality
            Giving the child pleasure
   Pedophilia (p.487)
       Primary sexual attraction is to children
       The victim is younger than 13
       Pedophile
            16 years or older
            5 years older than victim
       Expressed towards either same-sex or opposite-sex children
       Pedophile
            May need to feel power over the victim
            Provides more control than relationships with adults
            Attracted to children
                  Less than 13 years old
                  Lack of secondary sex characteristics
                   Sexual Abuse

   All Survivors are not the same
       Effect of sexual abuse varies with factors
   Differs from physical abuse
       not cyclical

   Neglect can play a powerful role
                     Effects of Abuse

   Can contribute to:
       Depression
       Personality problems
       Achievement
            Grades and achievement drop
            Super-achiever; often care takers
   May marry abusive spouses
       Use alcohol and drugs
       Develop mental illness
   Problems with trust
                    DSM IV DX

   Anxiety Disorders
   Major Depression
   Post Traumatic Stress Disorder and Acute
    Stress Disorder
       (reviewed in the crisis module)
   Dissociative Identity Disorder
    Dissociative Identity Disorder
   Presence of 2 or more distinct personalities
       At least 2 of these personalities take control of the
        person’s behavior
       Very difficult to diagnose
       Response to severe abuse in CHILDHOOD
   In order to be multiple, must be able to
   The greater the severity of dissociative
    symptoms, the smaller the left hippocampus is.
        Dissociative Phenomena

   All of us dissociate
     Dissociation is the defensive device by which
      people split off from conscious awareness
      different aspects of experience
     Aspects are: cognitive, affective, behavioral
      and somatic
     Ever been bored and “left class”
     Sexual Assault Nurse Examiner

   This Registered Nurse is educated to be able to:
       Provide comprehensive care to sexual assault
       Demonstrate competency in conducting a forensic
        exam to include evaluation for evidence collection
       Have the expertise to provide effective courtroom
       Show Compassion and sensitivity to survivors of
        sexual assault
         Unhelpful Responses

   Displays of anger toward abused
   Giving advise
   Ignoring abuse
   Aligning with the abuser
        The Therapeutic Relationship:
             Helpful Responses
   Ask if abuse is occurring
   Identifies described behavior as abuse
   Acknowledges the seriousness of abuse
   Acknowledge feelings
       Seeing you hurt upsets me
   Being directive in exploring resources
       informing about shelters, other resources
       support groups
   Active listening
                                  The Milieu
   Provide a safe environment
        Clients can be comforted by the locked environment
   Inpatient Psychiatric Units
        Consistency
             Response to the client’s behavior is always the same
             Communicate the staff are here to keep you safe
             Be careful with the use of touch
                   Misunderstood
                   Abreaction
                        Recall of a repressed traumatic experience
                        Client re-experiences the abuse

        Client will test to see if the Nurse will remain therapeutic or become
             Remain nonjudgmental
             Objective
             Non-threatening
         Therapy for the Survivor

   Group therapy
       Rape Support Groups
       Incest Survivor Support Groups
       Survivors of Childhood Sexual Abuse
        Sexual Abuse and Children

   Memories change over time
       “I should have stopped it”
       “Bad Girl”
   “Fix” the memory
   Talk about it
   Allow the Survivor to talk