Survivors of AbuseSurvivors of Abuse

Issues of AbuseIssues of Abuse

The Prominent feature in all forms of The Prominent feature in all forms of abuse is power.abuse is power.

Most abusers are fearful of losing Most abusers are fearful of losing control.control.

Abuse escalates during pregnancy.Abuse escalates during pregnancy. There is a CYCLE OF VIOLENCE.There is a CYCLE OF VIOLENCE. Cycle does not apply to sexual abuse.Cycle does not apply to sexual abuse.

Helpful responses to AbuseHelpful responses to Abuse

Ask if abuse is occurringAsk if abuse is occurring Identifies described behavior as abuseIdentifies described behavior as abuse Acknowledges the seriousness of abuseAcknowledges the seriousness of abuse Being directive in exploring resourcesBeing directive in exploring resources

informing about shelters, other resources informing about shelters, other resources support groupssupport groups

Active listeningActive listening

Unhelpful responses to Unhelpful responses to AbuseAbuse

Displays of anger toward abusedDisplays of anger toward abused Blaming victimBlaming victim Giving adviseGiving advise Ignoring abuseIgnoring abuse Aligning with the abuserAligning with the abuser Refusing to help the person until Refusing to help the person until

they leave the abuserthey leave the abuser

Other IssuesOther Issues

Family violence is accompanied by Family violence is accompanied by brainwashingbrainwashing

Hostage SyndromeHostage Syndrome Victims always blame themselvesVictims always blame themselves Feel unworthy of helpFeel unworthy of help fear they will not be believedfear they will not be believed

Family violenceFamily violence

Elder AbuseElder Abuse Parent abuse by violent adolescentsParent abuse by violent adolescents LOW COST TO PERPETRATORSLOW COST TO PERPETRATORS Two Types of Violence in CouplesTwo Types of Violence in Couples Expressive Violence and Instrumental Expressive Violence and Instrumental

ViolenceViolence

Instrumental and Expressive Instrumental and Expressive violenceviolence

Expressive violence is Expressive violence is mutual combatmutual combat

Goal is to express Goal is to express emotions/and hurtemotions/and hurt

Role of victim and Role of victim and perpetrator are not perpetrator are not fixedfixed

Partners share Partners share responsibility for responsibility for violence violence

Instrumental Instrumental violence is unequal violence is unequal conflictconflict

Goal is CONTROL Goal is CONTROL anotheranother

Role of victim and Role of victim and perpetrator is fixedperpetrator is fixed

Victim is ALWAYS Victim is ALWAYS trying to please and trying to please and placate placate

Treatment issuesTreatment issues

Couple counseling is inappropriate for Couple counseling is inappropriate for Instrumental violenceInstrumental violence

Victim must be safe/ Arrest policies very Victim must be safe/ Arrest policies very important/Danger is real important/Danger is real

Groups very important modalityGroups very important modality Progress is made when victim starts Progress is made when victim starts

defining her strengths defining her strengths Assess for alcohol and drug use Assess for alcohol and drug use LONG term goal: Change self concept from LONG term goal: Change self concept from

victim to survivor statusvictim to survivor status

Child AbuseChild Abuse

DEFINITIONDEFINITION CHARACTERISTICS OF PARENTSCHARACTERISTICS OF PARENTS

1. May have been abused as a child1. May have been abused as a child 2. Lack of knowledge of normal 2. Lack of knowledge of normal

developmentdevelopment 3. Lack of parenting skills; no role models3. Lack of parenting skills; no role models 4. Socially isolated, stress, low self esteem 4. Socially isolated, stress, low self esteem 5. Lack of trust in the system5. Lack of trust in the system 6. Abuse of alcohol and drugs6. Abuse of alcohol and drugs

Characteristics of the ChildCharacteristics of the Child

Position of child, sex of childPosition of child, sex of child Product of difficult labor and deliveryProduct of difficult labor and delivery Physically ill, hyperactive, Physically ill, hyperactive,

sleeplessnesssleeplessness Temperament of child performing Temperament of child performing

tasks tasks

EnvironmentEnvironment

Chronic stress, divorce, financial Chronic stress, divorce, financial stressstress

Instability; absence of support Instability; absence of support systemsystem

Socioeconomic level may influenceSocioeconomic level may influence Paternalistic culture: Rule of thumbPaternalistic culture: Rule of thumb

Spare the rod, spoil the childSpare the rod, spoil the child

Assessment: nursing careAssessment: nursing care

Physical evidence of abusePhysical evidence of abuse Conflicting stories about the “accident”Conflicting stories about the “accident”

Child with concussion fell out of bed.Child with concussion fell out of bed. 6 month old turned on hot water 6 month old turned on hot water Concern about a cold when burns are Concern about a cold when burns are

presentpresent excessive delay in seeking treatmentexcessive delay in seeking treatment parent absent when you try to question parent absent when you try to question

Assessment Cont:Assessment Cont:

Inappropriate response of the childInappropriate response of the child Little or no response to painLittle or no response to pain Excessive fear of being touchedExcessive fear of being touched Excessive or lack of separation anxietyExcessive or lack of separation anxiety Indiscriminate friendliness to strangersIndiscriminate friendliness to strangers

Previous reports of abusePrevious reports of abuse Repeated visits to the ER for injuriesRepeated visits to the ER for injuries

Legal AspectsLegal Aspects

When must we report abuseWhen must we report abuse Who must report. Professionals are Who must report. Professionals are

held to a higher standardheld to a higher standard It is not enough to just report abuse It is not enough to just report abuse

to the Health Care Provider (MD or to the Health Care Provider (MD or FNP) and hope for the bestFNP) and hope for the best

School nurses observe abuse and School nurses observe abuse and must reportmust report

When to ReportWhen to Report

A Child or Elder; Abuse Neglect or ExploitationA Child or Elder; Abuse Neglect or Exploitation Adults: it is up to the individual to reportAdults: it is up to the individual to report

Toll Free Hotline 1-877-786-7263 Toll Free Hotline 1-877-786-7263 (1-877-STOP ABUSE)(1-877-STOP ABUSE) Local telephone: (512) 424-6716Local telephone: (512) 424-6716

Facsimile (512) 424-6700Facsimile (512) 424-6700 Email abuseneglect@tjpc.state.tx.usEmail abuseneglect@tjpc.state.tx.us AddressAddress 4900 North Lamar, 54900 North Lamar, 5thth floor floor

Austin Texas 78751Austin Texas 78751Reporting Abuse of ChildrenReporting Abuse of Childrenhttp:www.dfps.state.tx.us/training/reportin/default.asp http:www.dfps.state.tx.us/training/reportin/default.asp 1-800-252-54001-800-252-5400

Characteristics of the Characteristics of the family family

Maslow's hierarchy of needsMaslow's hierarchy of needs

SecuritySecurity Self ValueSelf Value Strokes (Recognition)Strokes (Recognition) StimulationStimulation StructureStructure Self actualizationSelf actualization

The Healthy FamilyThe Healthy Family

Each member works on Each member works on basic tension of:basic tension of: How can I maintain a How can I maintain a

sense of self and remain in sense of self and remain in this familythis family. .

Problems, but the family Problems, but the family owns themowns them

Like an orchestraLike an orchestra everyone is playing their everyone is playing their

own instrument but are own instrument but are playing the same tuneplaying the same tune

Open SystemOpen System

Each person can get Each person can get their needs met.their needs met.

Each spouse can Each spouse can function without the function without the otherother

Open and flexible; Open and flexible; members have other members have other relationships in the relationships in the community community An open system vs. a An open system vs. a

closed systemclosed system

The Unhealthy FamilyThe Unhealthy Family

The basic unit is:The basic unit is: immature and needyimmature and needy low self-esteemlow self-esteem not in the relationship by choicenot in the relationship by choice enmeshmentenmeshment

A closed systemA closed system Dependent on each other to get needs Dependent on each other to get needs

metmet Communication is triangulatedCommunication is triangulated

Triangles in CommunicationTriangles in Communication

Mother talks to child Mother talks to child about problems with about problems with FatherFather

Child tries to support Child tries to support mother and meet her mother and meet her needsneeds

Child also tries to Child also tries to support father and support father and meet his needsmeet his needs

Mother needs to talk Mother needs to talk to Father and not the to Father and not the childchild

BoundariesBoundaries

Emotional and physical space between you Emotional and physical space between you and another personand another person

Where you stop and the next person Where you stop and the next person beginsbegins

A Limit that others are not allowed to cross A Limit that others are not allowed to cross because of the negative impactbecause of the negative impact

Allows for appropriate closeness in the Allows for appropriate closeness in the relationshiprelationship

Boundary within a family:Boundary within a family: If a bathroom or bedroom door is shutIf a bathroom or bedroom door is shut Knock and waitKnock and wait

Healthy BoundariesHealthy Boundaries

The right and need for the individual The right and need for the individual to:to: To exploreTo explore

Interests Interests HobbiesHobbies OutletsOutlets

Make their own mistakesMake their own mistakes Bring back to the family:Bring back to the family:

My unique personality to enrich our livesMy unique personality to enrich our lives

Healthy BoundariesHealthy BoundariesPreventPrevent

EnmeshmentEnmeshment DissociationDissociation Excessive DetachmentExcessive Detachment

Incest Incest

Confusion created by the perpetratorConfusion created by the perpetrator Child believes it is their faultChild believes it is their fault Adult relative coerces child to keep secretAdult relative coerces child to keep secret Adult relative perceives child as sexual peerAdult relative perceives child as sexual peer Family systemFamily system

Isolated familyIsolated family Must keep the secretMust keep the secret

Mother and child relationshipMother and child relationship Mother denies sexual abuse is happeningMother denies sexual abuse is happening AmbivalenceAmbivalence

Love for the motherLove for the mother Anger about the lack of protection from abuseAnger about the lack of protection from abuse

Survivors of Childhood Sexual Survivors of Childhood Sexual AbuseAbuse

Adult perpetrator is most often known and trustedAdult perpetrator is most often known and trusted Fathers, brothers, camp councilors, coaches, religious leadersFathers, brothers, camp councilors, coaches, religious leaders Most often male perpetratorMost often male perpetrator 92% of females: male perpetrator92% of females: male perpetrator 38% of males: female perpetrator38% of males: female perpetrator Average length of time of when an adult begins to perpetrate Average length of time of when an adult begins to perpetrate

children and they get caught is 9 yearschildren and they get caught is 9 years Abuse most often begins before the age of 7Abuse most often begins before the age of 7 Childhood sexual abuseChildhood sexual abuse

15% to 30% of girls 15% to 30% of girls 4% to 16% of boys4% to 16% of boys

More difficulty reportingMore difficulty reporting Fear of being labeled gay or weak (male perpetrator)Fear of being labeled gay or weak (male perpetrator) They are supposed to like it (female perpetrator)They are supposed to like it (female perpetrator)

IncestIncest

Incest (p.357)Incest (p.357) Sexual victimization of a child or adolescentSexual victimization of a child or adolescent Perpetrator does not seek occupations for access to Perpetrator does not seek occupations for access to

victimsvictims Relationships by Relationships by

Blood or MarriageBlood or Marriage Perpetrator looks to the child forPerpetrator looks to the child for

GratificationGratification FulfillmentFulfillment Power and controlPower and control Child may feel specialChild may feel special

Distorted thinkingDistorted thinking Teaching the child about sexualityTeaching the child about sexuality Giving the child pleasure Giving the child pleasure

PedophiliaPedophilia

Pedophilia (p.356)Pedophilia (p.356) Primary sexual attraction is to childrenPrimary sexual attraction is to children The victim is younger than 13The victim is younger than 13 Pedophile Pedophile

16 years or older16 years or older 5 years older than victim5 years older than victim

Expressed towards either same-sex or opposite-sex Expressed towards either same-sex or opposite-sex childrenchildren

PedophilePedophile May need to feel power over the victimMay need to feel power over the victim Provides more control than relationships with adultsProvides more control than relationships with adults Attracted to children Attracted to children

Less than 13 years oldLess than 13 years old Lack of secondary sex characteristicsLack of secondary sex characteristics

Sexual Abuse Sexual Abuse

All Survivors are not the sameAll Survivors are not the same Effect of sexual abuse varies with Effect of sexual abuse varies with

factorsfactors Differs from physical abuseDiffers from physical abuse

not cyclicalnot cyclical

Neglect can play a powerful roleNeglect can play a powerful role

Effects of AbuseEffects of Abuse

Can contribute to: Can contribute to: Depression Depression Personality problemsPersonality problems AchievementAchievement

Grades and achievement dropGrades and achievement drop Super-achiever; often care takersSuper-achiever; often care takers

May marry abusive spousesMay marry abusive spouses Use alcohol and drugsUse alcohol and drugs Develop mental illnessDevelop mental illness

Problems with trustProblems with trust

DSM IV DXDSM IV DX

Anxiety DisordersAnxiety Disorders Major DepressionMajor Depression Post Traumatic Stress Disorder and Post Traumatic Stress Disorder and

Acute Stress Disorder Acute Stress Disorder (reviewed in the crisis module)(reviewed in the crisis module)

Dissociative Identity DisorderDissociative Identity Disorder

Dissociative Identity Dissociative Identity DisorderDisorder

Presence of 2 or more distinct personalitiesPresence of 2 or more distinct personalities At least 2 of these personalities take control of At least 2 of these personalities take control of

the person’s behavior the person’s behavior Very difficult to diagnoseVery difficult to diagnose Response to severe abuse in CHILDHOODResponse to severe abuse in CHILDHOOD

In order to be multiple, must be able to In order to be multiple, must be able to dissociate.dissociate.

The greater the severity of dissociative The greater the severity of dissociative symptoms, the smaller the left symptoms, the smaller the left hippocampus is.hippocampus is.

Dissociative PhenomenaDissociative Phenomena

All of us dissociateAll of us dissociate Dissociation is the defensive device by Dissociation is the defensive device by

which people split off from conscious which people split off from conscious awareness different aspects of awareness different aspects of experienceexperience

Aspects are: cognitive, affective, Aspects are: cognitive, affective, behavioral and somaticbehavioral and somatic

Ever been bored and “left class”Ever been bored and “left class”

S.A.N.E.S.A.N.E.Sexual Assault Nurse ExaminerSexual Assault Nurse Examiner

This Registered Nurse is educated to be able to:This Registered Nurse is educated to be able to: Provide comprehensive care to sexual assault Provide comprehensive care to sexual assault

survivorssurvivors Demonstrate competency in conducting a forensic Demonstrate competency in conducting a forensic

exam to include evaluation for evidence collectionexam to include evaluation for evidence collection Have the expertise to provide effective courtroom Have the expertise to provide effective courtroom

testimonytestimony Show Compassion and sensitivity to survivors of Show Compassion and sensitivity to survivors of

sexual assaultsexual assault http://www.oag.state.tx.us/victims/sapcs.shtmlhttp://www.oag.state.tx.us/victims/sapcs.shtml

Unhelpful ResponsesUnhelpful Responses

Displays of anger toward abusedDisplays of anger toward abused Giving adviseGiving advise Ignoring abuseIgnoring abuse Aligning with the abuserAligning with the abuser

The Therapeutic Relationship: The Therapeutic Relationship: Helpful ResponsesHelpful Responses

Ask if abuse is occurringAsk if abuse is occurring Identifies described behavior as abuseIdentifies described behavior as abuse Acknowledges the seriousness of abuseAcknowledges the seriousness of abuse Acknowledge feelingsAcknowledge feelings

Seeing you hurt upsets meSeeing you hurt upsets me Being directive in exploring resourcesBeing directive in exploring resources

informing about shelters, other resources informing about shelters, other resources support groupssupport groups

Active listeningActive listening

The MilieuThe Milieu

Provide a safe environmentProvide a safe environment Clients can be comforted by the locked environmentClients can be comforted by the locked environment

Inpatient Psychiatric UnitsInpatient Psychiatric Units ConsistencyConsistency

Response to the client’s behavior is always the sameResponse to the client’s behavior is always the same Communicate the staff are here to keep you safeCommunicate the staff are here to keep you safe Be careful with the use of touchBe careful with the use of touch

MisunderstoodMisunderstood Abreaction Abreaction

Recall of a repressed traumatic experienceRecall of a repressed traumatic experience Client re-experiences the abuseClient re-experiences the abuse

Client will test to see if the Nurse will remain therapeutic or Client will test to see if the Nurse will remain therapeutic or become abusivebecome abusive

Remain nonjudgmentalRemain nonjudgmental ObjectiveObjective Non-threateningNon-threatening

Therapy for the SurvivorTherapy for the Survivor

Group therapyGroup therapy Rape Support GroupsRape Support Groups Incest Survivor Support GroupsIncest Survivor Support Groups Survivors of Childhood Sexual AbuseSurvivors of Childhood Sexual Abuse

Sexual Abuse and ChildrenSexual Abuse and Children

Memories change over timeMemories change over time ““I should have stopped it”I should have stopped it” ““Bad Girl”Bad Girl”

““Fix” the memoryFix” the memory Talk about it Talk about it Allow the Survivor to talkAllow the Survivor to talk