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Family Violence and Abuse – Helping Victims and Survivors
Domestic abuse and violence refers to physically and emotionally harmful behaviors that occur between family and household members. These include child abuse, child neglect, intimate partner abuse and violence, marital rape and elder abuse. It could be a learned behavior that can be unlearned through therapy. The perpetrators try to isolate the family in order to keep it secret and avoid sanctions. They usually have some power and control over other family members. They can rationalize violence by using drugs. Use of cocaine, PCP, amphetamines, etc. may increase violent behavior.
Forms of abuse
Physical abuse includes hitting, kicking, pushing, stabbing, shooting, kicking, and withholding medication, wheelchairs, food, and fluids. Sexual abuse includes coercion, marital rape and denial of sex. Psychological abuse includes threats, harassment and blackmail. Emotional abuse includes name-calling, insults and ridicule. Economic abuse includes complete control over finances, accumulation of accounts, prohibition from school or work.
The reality of violence
Domestic violence occurs at all levels of society. Divorce or divorce may not end the violence. A bully should not be provoked. Some survivors wrongly blame themselves. Treat violence, but also alcohol, drugs, stress and mental health problems if any. Violence also occurs between homosexuals and lesbians. Abused women are discouraged from disclosing by threats, fear, denial and disbelief expressed by ‘trustees’.
The paternalistic model assumes that the clinician has more knowledge than the patient; that the survivor is responsible for ending the violence; that the clinician should provide advice and compassion; and view the patient as a victim. Whereas, the empowerment model, which is better, assumes that the clinician should mutually share knowledge with the patient, plan strategies with the patient, respect the patient’s competence, experience and strengths, and see the patient as a survivor.
Survivors’ response to violence
Physical signs of abuse include multiple injuries in various stages of healing (head, neck, face, throat, genitals), headache, insomnia, and stress. A behavioral sign is that the person does not leave the abuser or leaves and returns before making a final break. Psychological signs include delayed reaction, depression, lowered self-esteem, attributions, e.g. self-blame, impaired school or work performance and behavior, poor concentration, and poor problem solving.
Why does the individual not leave the abuser?
Abused people do not leave the abuser for a variety of reasons, which include fear of being stalked and killed (which is a real fear), strong emotional attachment to the abuser, determination to end the abuse, sanctions present in the couple’s culture, fear of stigma, lack of means of living far away from the abuser and considering what will happen to her children if she leaves. She may leave and come back, thinking, “Maybe he will change.”
Child abuse and neglect
In every state, child abuse and neglect must be reported. Types of abuse include child sexual abuse, physical child abuse, emotional child abuse, and child neglect. A child who witnesses domestic violence may also suffer abuse.
Sexual abuse of children
It is the involvement of children in sexual activities that they do not fully understand and to which they do not or cannot freely give their consent. This violates the child’s trust in the adult who is supposed to protect him. Threatening the child, pet, and others silences the child. This results in confusion, shame and helplessness. Its effect can last a lifetime and affect mental health. It can be kept as a family secret.
Visible signs of sexual abuse
Noticeable signs of child sexual abuse include physical aggression, excessive masturbation, social withdrawal, low self-esteem, impaired school performance, sleep disturbance, sexually transmitted diseases, bleeding, pain, itching, UTI, pregnancy, bruising, swelling, redness, fractures, burns, and messy appearance.
Violence at school
School violence is usually caused by child drug use, child access to weapons, antisocial and impulsive behaviors, family dysfunction, community irresponsibility, interpersonal disputes, and bullying and harassment by peers.
Most abductions are done by the parent. 70% are fathers, 25% are mothers. Parents who are likely to abduct include those who have threatened or attempted to abduct in the past, suspect abuse by the other parent, may be paranoid, may intend to use it as revenge, punishment, trophy, or parents who strongly believe the child will be raised in his or her home country.
Assessment and intervention of child abuse
Do your research and be aware of your attitude towards victims of abuse so you don’t get judged. Do a thorough history and physical assessment. Enjoy a private, quiet environment without interruption. Be honest about the purpose of the interview. Notify the victim of the pending physical evaluation. Use a calm and supportive approach. If possible, interview the child separately first before interviewing the parent or guardian together. Pay attention to the child’s affect (appearance) and behavior, the mother’s understanding of the problem, discrepancies in their stories, and the parents’ emotional reactions. Document your assessment fully. Report suspected abuse to CPS. Coordinate services such as further assessment, psychological testing, individual psychotherapy, family psychotherapy, and group psychotherapy.
Intimate partner violence (IPV)
IPV is a pattern of coercive and assaultive behavior between intimate and dating partners. Abuse by female partners is the most common form of IPV. Female violence is more common in self-defense. Many IPVs end in murder or murder-suicide. Leaving or attempting to kill the victim increases the risk of murder. There is a higher risk of gun homicides, a history of suicidal thoughts or attempts, being beaten during pregnancy, sexual abuse, substance use, extreme jealousy, and controlling behavior (“if I can’t have you, no one can”). Few women kill their abusers if there is no intervention. Assessment of IPV should be part of a mental health assessment. Ask partners about their history of conflict, pushing and shoving, and relationship quality. Notice the hesitation, side-eye, and discomfort. Be supportive, let the victim know they are not alone. Describe and map the extent of the injuries. Assess attribution, e.g. self-blame. Assess for depression, PTSD and anxiety. If the patient is an abuser, assess the potential for further violence. Consult legal counsel for “Duty to Warn”. Courts have made it mandatory for abusers (which happen to be mostly men) to be treated. Treatment includes confronting the abuse, affirming that the abuser is responsible, behavior therapy, anger management, changing attitudes toward women, couples counseling, and cognitive behavioral therapy (CBT). Empower women, using laws, community resources, support groups and safe shelters. Set goals together with the victim. Consider and choose between the options together. Help mobilize natural, social and professional support.
Rape and sexual assault
It affects men, women and children, especially women and children. Sexual assault is a forced act of sexual contact without consent. It is usually done to humiliate, defile or dominate the victim. Rape is a crime, but most of it is not reported. Survivors of marital rape do not seek care because of shame and humiliation. Careful assessment and examination is required. In caring for the victim, listen, be non-judgmental and provide emotional support. Document your observation and assessment fully. Help gather evidence if the patient decides to litigate. In the acute phase, assess for fear, disorganization, shock, and restlessness. In the second phase, assess whether there are flashbacks, phobias of places and people, and sexual difficulties. Encourage the victim to talk about feelings. Explore options e.g. change of telephone number. Explore available community services and support groups. Refer to physical treatment and psychotherapy. Plan a follow-up phone call in a few days.
About 5 million elderly people are abused in the US every year. Spouse abuse overlaps with elder abuse. Abused people do not come forward for fear of being left in a nursing home or isolated. Signs include bruises on the hands, wrists, ankles, facial lacerations, vaginal lacerations, fractures, malnutrition, poor hygiene, dehydration, shaking and moving around in the presence of the abuser. Help and care include reporting suspected abuse to Adult Protective Services (APS), counseling, psychotherapy, substance abuse, and treatment for the abuser, if needed.
Reference: Stuart, GW & Laraia, MT (2005). Principles and practice of psychiatric nursing (8th ed.). St. Louis, MO: Elsevier Mosby.
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