CHAPTER 6

ABUSE AND VIOLENCE

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain the
following Intended Learning Outcomes:
 Discuss the characteristics, risk factors and family dynamics of abusive and
violent behaviour
 Examine incidence and trends in domestic violence
 Apply the nursing process in the care of clients experiencing abuse and
violence
 Evaluate own responses, feelings and attitude about abusive and violent
behavior
 Prepare your books and notebooks. Highlight concepts that need to be reinforced. Jot
down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of this
chapter is also provided along with other resources to facilitate better understanding of
the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Child abuse
 Violence
 Rape
 Elder abuse
 Cycle of violence
 Family volence

 Abuse: wrongful use and maltreatment of

another person
 Victims of abuse can have physical injuries
as well as psychological responses
needing medical attention
 Domestic violence remains undisclosed for
months or even years because victims
fear their abusers
 Victims often contain their anger and
resentment
 Survivors: often feel guilt and shame
o Children: miss school
o They feel degraded, humiliated
and dehumanized.
o Self-esteem is low and they view themselves as unlovable
o They find it hard to trust others
o They are likely erratic, intense and perceived as unpredictable
 CHARACTERISTICS OF VIOLENT FAMILIES

 Family violence encompasses spouse battering; neglect and physical, emotional, or

sexual abuse of children; elder abuse; and marital rape
 Social isolation: families keep it to themselves
 Abuse of power and control: abuser exerts physical, economic and social control over
the victims
 Alcohol and other drug abuse: an abusive person is likely to use alcohol or other
drugs; ALCOHOL is also cited as a factor in acquaintance or date rape
 Intergenerational Transmission Process: means that patterns of violence are
perpetuated from one generation to the next through role modeling and social
learning; family violence is a learned pattern of behavior

INTIMATE PARTNER VIOLENCE

o Mistreatment of misuse of one person by another in the context of an
emotionally intimate relationship
o Psychological abuse (emotional abuse): name-calling, belittling, screaming,
yelling, destroying property and making threats
o Physical abuse: shoving and pushing to severe battering and choking and
may involve broken limbs, bleeding and even death
o Battering during pregnancy leads to miscarriage and other maternal and fetal
conditions
o Violence also occurs in same-sex relationship. Sodomy (anal intercourse)
is considered as a crime in USA

CYCLE OF ABUSE AND VIOLENCE

- A typical pattern exists; usually the initial episode of
battering or violence is followed by a period of the abuser
expressing regret, apologizing, and promising it will never
happen again. He professes his love for his wife and may
even engage in romantic behavior (e.g., buying gifts and periodViolent Behavior
of remorse or contrition
Tension building
flowers). This period of contrition or remorse sometimes is
called the honeymoon period.
- After this honeymoon period, the tension-building phase
begins (arguments, silence); it ends with another violent
episode
- The honeymoon period may last weeks or even months,
however the violent episodes continue to arise and may even worsen
- Remember: The cycle does not apply to all. Some may experience only one or two of the
cycle
- Assessment is critical when it comes to abuse. Most women do not seek direct help
- Nurses may ask the following questions to assess the safety of the victim:
o Do you feel safe in the relationship?
o Are you concerned for your safety?
o Are family or friends concerned for your safety?
o if you feel threatened or unsafe, do you have someone to call?
o Do you have a safe place to go if you need to?

Below are things that you need to remember when working with victims:
 DON’T DO
Don’t disclose client communications without Do ensure and maintain the client’s
the client’s consent. confidentiality.
Don’t preach, moralize, or imply that you Do listen, affirm, and say “I am sorry you
doubt the client. have been hurt.”
Don’t minimize the impact of violence. Do express: “I’m concerned for your safety.”
Don’t express outrage with the perpetrator. Do tell the victim: “You have a right to be
Don’t imply that the client is responsible for safe and respected.”
the abuse. Do say: “The abuse is not your fault.”
Don’t recommend couples’ counseling. Do recommend a support group or individual
Don’t direct the client to leave the counseling.
relationship. Don’t take charge and do Do identify community resources and
everything for the client encourage the client to develop a safety
plan. Offer to help the client contact a
shelter, the police, or other resources

CHILD ABUSE
- Maltreatment; unintentional injury of a child; can include physical abuse or injuries,
neglect or failure to prevent harm, failure to provide adequate physical or emotional
care, abandonment, sexual abuse
-
- LI: Research on the recent statistics for child abuse a.)national b) regional c. )
local

- Types of child abuse:

o Physical abuse: often result from unreasonably severe corporal punishment or
unjustifiable punishment
o Sexual abuse involves sexual acts performed by an adult on a child younger
than 18 years (incest, rape, and sodomy performed directly by the person or
with an object; oral-genital contact; and acts of molestation such as rubbing,
fondling, or exposing the adult’s genitals)
o Neglect is malicious or ignorant withholding of physical, emotional, or
educational necessities for the child’s well-being
o Psychological abuse (emotional abuse) includes verbal assaults, such as
blaming, screaming, name-calling, and using sarcasm; constant family discord
characterized by fighting, yelling, and chaos
- Parents (abusers): often have minimal parenting knowledge and skills.
o they do not understand their children’s needs; they get mad because they are
emotionally (not being able to meet their own needs) or financially
unequipped
o
o
o lack of education and poverty contribute also to child abuse but can also
happen to families who have successful careers and are financially stable

Warning Signs of Abused Children

- Serious injury, such as fractures, burns (usually have identiafiable shape or may
have “stocking and glove” distribution, or lacerations with no reported history of
trauma
- Delay in seeking treatment for a significant injury
- Child or parent gives a history inconsistent with severity of injury, such as a baby
with contrecoup injuries to the brain (shaken baby syndrome) that the parents
claim happened when the infant rolled off the sofa
- Inconsistencies or changes in the child’s history during the evaluation by either the
Treatment:
- Ensure safety and well-being of the child
- Establish trust and rapport with the patient
- Play therapy: to help the child with communication
o Therapist establishes a friendly relationship
o Accepts the child as he is
o Creates a permissive relationship; child has freedom of expression
o Validates (acknowledge and reflect) child’s feelings
o Responsibility for decisions and change is left mostly to the child
o Child directs the therapeutic process; therapist follows
o Therapeutic interaction is not rushed
o Limits are set only when necessary for child’s outcomes
- Arrange for social services (whether the child will be returned home)
- Family therapy
- Parents: rehabilitation/ manage substance abuse
- Foster care maybe necessary

ELDER ABUSE
- is the maltreatment of older adults by family members or
caretakers.
- Physical, sexual, psychological, neglect, self-neglect, financial
exploitation, denial of medical treatment
- Statistics: 1 out of 10 elders aged 65 and above are injured
and exploited
- Most abused: WOMEN
- Abusers: living with the patient
- Assessment: may have bruises; lack of needed medical
treatment; restrained; self-neglect involves the elder’s failure to provide for himself
 Possible indicators of elder abuse:
- PHYSICAL ABUSE INDICATORS
o Frequent, unexplained injuries accompanied by a habit of seeking medical
assistance from various locations
o Reluctance to seek medical treatment for injuries, or denial of their existence
o Disorientation or grogginess indicating misuse of medications
o Fear or edginess in the presence of family member or caregiver
- PSYCHOLOGICAL OR EMOTIONAL ABUSE INDICATORS
o Helplessness
o Hesitance to talk openly
o Anger or agitation
o Withdrawal or depression
- FINANCIAL ABUSE INDICATORS
o Unusual or inappropriate activity in bank accounts
o Signatures on checks that differ from the elder’s
o Recent changes in will or power of attorney when elder is not capable of
making those decisions
o Missing valuable belongings that are not just misplaced
o Lack of television, clothes, or personal items that are easily affordable
o Unusual concern by the caregiver over the expense of the elder’s treatment
when it is not the caregiver’s money being spent
- NEGLECT INDICATORS
o Dirt, fecal or urine smell, or other health hazards in the elder’s living
environment
o Rashes, sores, or lice on the elder
o Elder has an untreated medical condition or is malnourished or dehydrated
not related to a known illness
o Inadequate clothing
- INDICATORS OF SELF-NEGLECT
o Inability to manage personal finances, such as hoarding, squandering, or
giving away money while not paying bills
o Inability to manage activities of daily living such as personal care, shopping,
housework
o Wandering, refusing needed medical attention, isolation, substance use
o Failure to keep needed medical appointments
o Confusion, memory loss, unresponsiveness
o Lack of toilet facilities, living quarters infested with animals or vermin
- WARNING INDICATORS FROM CAREGIVER
o Elder is not given opportunity to speak for self, to have visitors, or to see
anyone without the presence of the caregiver
o Attitudes of indifference or anger toward the elder
o Blaming the elder for his or her illness or limitations
o Defensiveness
o Conflicting accounts of elder’s abilities, problems, and so forth
o Previous history of abuse or problems with alcohol or drugs
- Treatment:
o Abuse may develop gradually as the burden exceeds the caretaker’s physical
or emotional resources
o Relieve the caregiver’s stress; provide additional resources
o Discuss concerns related to suspected abuse or neglect
 Include in the treatment plan and enlist their active support and
participation
o Involve professionals from other disciplines (to assist in the evaluation)
o Continued contact with a trusted family physician

RAPE AND SEXUAL ASSAULT

- Rape: Perpetration of an act of sexual intercourse with a person against his or her
will and without her consent
- It is a crime of violence and humiliation
- It is considered rape if the victim is incapable of exercising rational judgment
because od mental deficiency or because he/she is a minor
- Only requires a SLIGHT penetration of vulva or rectum; SODOMY; victim maybe
battered or injured
- Can occur between strangers, acquaintances, married persons, same sex
- Date rape (acquaintance rape) – may occur on the first date, a ride home, or
when two people have known each other for some time; more prevalent around or
on college campuses; increases with consumption of alcohol
- it is a highly unreported crime
- unreported cases: due to victim’s feelings of shame and guilt; fear of further injury
- victims: any age (15 months to 82 years old)
- Highest incidence: Women (16-24 years old)
 - Male rape is also significantly unreported; occurs between gay partners or strangers;
prevalent in prisons

DYNAMICS OF RAPE
- Men who commit rape:
30 years and above
(50%), 21 to 29 years
old (25%); Race (57%
are white); alcohol
involvement (34%)
- Women are in frequently
life-threatening situations
so their motivation is to
SURVIVE or STAY ALIVE
- Degree of submission is
higher when the
perpetrator is armed
- RESULT: physical and
psychological trauma is SEVERE!
- Victims especially women tend to less likely care for themselves which make them
more vulnerable to medical conditions (depression, malnutrition etc); they
experience fear, helplessness, shock and disbelief, guilt, humiliation

Interventions:
- Provide immediate support and encourage verbalization of feelings
- Educate family about the warning signs of violence and the needs of victims
- Allow the victim to proceed at his/her own pace
- Allow the victim to have control of herself
o Allow victim to make decisions
o Secure consent before gathering evidences
- Give prophylactic treatment for STI
- Facilitate HIV testing
- For pregnancy: Prophylaxis includes ethinyl estradiol and norgestrel
- Encourage patient to join support groups
- Arrange for further counseling (provides emotional support)
- Facilitate supportive therapy: gaining control, promoting independence, relieving
feelings of helplessness, regaining trust, dealing with feelings of guilt and shame
- Initiate group therapy
- **it takes 1 year or more for rape survivors to regain previous levels of functioning

Profile of an ABUSER WARNING SIGNS OF CHILD ABUSE

Social Isolation Child or parent giving a history
Low Self-esteem inconsistent with the severity of injury
Abused as a child High incidence of UTI, swollen or
bruised rectum and genitalia
Poor impulse control
Injuries not usual for the child’s age
Poor coping skills and level of development
Extreme jealousy Lacerations, scars, multiple bruises on
Drug or alcohol abuse various stages of healing
Delay in seeking treatment for a
significant injury
Teacher’s Insight:
Nurses must be open when dealing with victims and abusers. Often, they become reluctant
to ask questions because of their personal beliefs and misconceptions about abuse. Clients
with these case are sensitive and have low self-esteem. Nurses must be able to facilitate
positive self-concept among these patients. We should facilitate acceptance to promote
healing.

ACTIVITY!
 Movie analysis
1. Watch the documentary in the link provided and answer the following guide
questions:
a. What did you feel while watching the video?
b. What do you think are the reasons why victims choose to stay silent?
c. What are your thoughts about “stigma”?
d. What was the worst thing that you have heard about rape victims?
e. What are possible ways that you can do to help these victims?

Video link: https://youtu.be/Mg0Iq55FOVE

 Things to ponder:
2. Is spanking a child an acceptable form of discipline? Why or why not? State
circumstances to justify your answer

3. What factors should the nurse consider when dealing with abusers? What about
when dealing with victims?
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