ABUSE and

VIOLENCE
BY: BUENAF
E, DREXLER JU
STINE
0 The most alarming statistics relate to violence in the
home and abuse, or the wrongful use and
maltreatment of another person. Statistics show that
most abuse is perpetrated by someone known to the
victim. Victims of abuse are found across the life span.
They can be a spouse or partner, a child, or an elderly
parent.
 Victims of violent behavior
0 Child
0 Spouse
0 Elderly
 CHILD ABUSE
0 or maltreatment generally is defined as the
intentional injury of a child.
0 It can include physical abuse or injuries, neglect or
failure to prevent harm, failure to provide adequate
physical or emotional care or supervision,
abandonment, sexual assault or intrusion, and overt
torture or maiming (Biernet, 2000).
 TYPES OF CHILD ABUSE:
0 PHYSICAL ABUSE
-results from unreasonably severe corporal punishment or
unjustifiable punishment such as hitting an infant for crying
or soiling his or her diapers.

-Intentional deliberate assaults on children include burning, biting,

cutting, poking, twisting limbs, or scalding with hot water.

-The victim often has evidence of old injuries (e.g., scars,

untreated fractures, multiple bruises of various ages)
that the history given by parents or caregivers does
not explain adequately.
0 SEXUAL ABUSE
-abuse involves sexual acts performed by an adult on a child younger than 18
years.

-Examples include 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.

-Sexual abuse may consist of a single incident or multiple episodes over a

protracted period.

-A second type of sexual abuse involves exploitation, such as making, promoting,

or selling pornography involving minors, and coercion of minors to participate in
obscene acts.
0 NEGLECT
-is malicious or ignorant withholding of physical, emotional, or
educational necessities for the child’s well-being.

-Child abuse by neglect is the most prevalent type of

maltreatment and includes refusal to seek health care or delay
doing so; abandonment; inadequate supervision; reckless
disregard for the child’s safety; punitive, exploitive, or abusive
emotional treatment; spousal abuse in the child’s presence;
giving the child permission to be truant; or failing to
enroll child in school.
0 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;
and emotional deprivation or withholding of affection,
nurturing, and normal experiences that engender acceptance, love,
security, and self-worth. Emotional
abuse often accompanies other types of abuse (e.g.,
physical or sexual abuse).

-Exposure to parental alcoholism, drug use, or prostitution, and the

neglect that results also fall within this category.
WARNING SIGNS OF ABUSED/
NEGLECTED CHILDREN
0 Serious injury, such as fractures, burns, or lacerations with no reported history of
trauma
0 Delay in seeking treatment for a significant injury
0 Child or parent gives a history inconsistent with
severity of injury, such as a baby with countercoup injuries to the brain (shaken
baby syndrome) that the parents claim happened when the infant rolled off the sofa
0 Inconsistencies or changes in the child’s history during the evaluation by either the
child or the adult
0 Unusual injuries for the child’s age and level of development, such as a fractured
femur on a 2 month old or a dislocated shoulder in a 2 year old
0 High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears
or bruising of rectum or vagina
0 Evidence of old injuries not reported, such as scars, fractures not treated, multiple
bruises that parent/caregiver cannot explain adequately
KNOW THE SIGNS. STOP IT
NOW.
Treatment and Intervention
0 Ensure the child’s safety and well-being (Biernet,
2000). This may involve removing the child from the
home, which also can be traumatic. Given the high risk
for psychological problems, a thorough psychiatric
evaluation also is indicated. A relationship of trust
between the therapist and child is crucial to help the
child deal with the trauma of abuse. Depending on the
severity and duration of abuse and the child’s
response, therapy may be indicated over a significant
period.
SPOUSE OR PARTNER ABUSE
0 abuse is the mistreatment or misuse of one person by
another in the context of an intimate relationship. The
abuse can be emotional or psychological, physical,
sexual, or a combination (which is common).
0 Emotional or psychological abuse includes name-
calling, belittling, screaming, yelling, destroying
property, and making threats as well as subtler forms
such as refusing to speak to or ignoring the victim.

0 Physical abuse ranges from shoving and pushing to

severe battering and choking and may involving broken
limbs and ribs, internal bleeding, brain damage, even
homicide. Sexual abuse includes assaults during sexual
relations such as biting nipples, pulling hair, slapping
and hitting, as well as rape (discussed later).
 Clinical Picture
0 Because abuse often is perpetrated by a husband against a wife,
that example is used in this section. These same patterns are
consistent, however, between partners who are not married,
same-sex partners, and wives who abuse their husbands.

0 An abusive husband often believes his wife belongs to him (like

property) and becomes increasingly violent and abusive if she
shows any sign of independence such as getting a job or
threatening to leave. Typically the abuser has strong feelings of
inadequacy and low self-esteem as well as poor problem-
solving and social skills.
0 By bullying and physically punishing the family, the
abuser often experiences a sense of power and
control, a feeling that eludes him outside the home.
Therefore the violent behavior often is rewarding and
boosts his self-esteem.
Cycle of abuse and violence
0 The cycle of violence or abuse is another reason often cited
for why women have difficulty leaving an abusive
relationship.
0 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 flowers).
This period of contrition or remorse sometimes is called the
honeymoon period.
0 After this honeymoon period, the tension-building phase
begins; there may be argu ments, stony silence, or complaints
from the husband. The tension ends in another violent
episode after which the abuser once again feels regret and
remorse and promises to change. This cycle continually
repeats itself.
 DOS AND DON’TS OF WORKING WITH VICTIMS OF PARTNER ABUSE
0 DON’TS
0 Don’t disclose client communications
without the client’s consent.
0 Don’t preach, moralize, or imply that you
doubt the client.
0 Don’t minimize the impact of violence.
0 Don’t express outrage with the
perpetrator.
0 Don’t imply that the client is responsible
for the abuse.
0 Don’t recommend couples’ counseling.
0 Don’t direct the client to leave the
relationship.
0 Don’t take charge and do everything for
the client.
0 DO’S
0 Do ensure and maintain the client’s
confidentiality.
0 Do listen, affirm, and say “I am sorry you
have been hurt.”
0 Do express: “I’m concerned for your safety.”
0 Do tell the victim: “You have a right to be safe
and respected.”
0 Do say: “The abuse is not your fault.”
0 Do recommend a support group or
individual counseling.
0 Do identify community resources and
encourage the client to develop a safety
plan.
0 Offer to help the client contact a shelter, the
police, or other resources.
 ELDERLY ABUSE
0 is the maltreatment of older adults by family
members or caretakers. It may include physical and
sexual abuse, psychological abuse, neglect, self-
neglect, financial exploitation, and denial of adequate
medical treatment.

0 Abuse is more likely when the elder has multiple,

chronic mental and physical health problems and
when he or she is dependent on others for food,
medical care, and various activities of daily living.
0 Persons who abuse elders almost always are in a
caretaking position or the elder depends on them in
some way.
0 Elders are often reluctant to report abuse, even when
they can, because the abuse usually involves family
members whom the elder wishes to protect. Victims
also often fear losing their support and being moved
to an institution.
 CLINICAL PICTURE
0 The victim may have bruises or fractures; may lack
needed eyeglasses or hearing aids; may be denied
food, fluids, or medications; or may be restrained in a
bed or chair. The abuser may use the victim’s financial
resources for his or her own pleasure, while the elder
cannot afford food or medications. Abusers may
withhold medical care itself from an elder with acute
or chronic illness. Self-neglect involves the elder’s
failure to provide for himself or herself.
 POSSIBLE INDICATORS OF
ELDER ABUSE:
0 PHYSICAL ABUSE INDICATORS
• Frequent, unexplained injuries accompanied by a habit
of seeking medical assistance from various locations
• Reluctance to seek medical treatment for injuries, or
denial of their existence
• Disorientation or grogginess indicating misuse of
medications
• Fear or edginess in the presence of family member or
caregiver
0 PSYCHOLOGICAL OR EMOTIONAL ABUSE INDICATORS
• Helplessness
• Hesitance to talk openly
• Anger or agitation
• Withdrawal or depression

0 FINANCIAL ABUSE INDICATORS

• Unusual or inappropriate activity in bank accounts
• Signatures on checks that differ from the elder’s
• Recent changes in will or power of attorney when elder is not capable
of making those decisions
• Missing valuable belongings that are not just misplaced
• Lack of television, clothes, or personal items that are easily affordable
• Unusual concern by the caregiver over the expense of the elder’s
treatment when it is not the caregiver’s money being spent
0 NEGLECT INDICATORS
• Dirt, fecal or urine smell, or other health hazards in the elder’s living
environment
• Rashes, sores, or lice on the elder
• Elder has an untreated medical condition or is malnourished or
dehydrated not related to a known illness
• Inadequate clothing

0 INDICATORS OF SELF-NEGLECT
• Inability to manage personal finances, such as hoarding, squandering, or
giving away money while not paying bills
• Inability to manage activities of daily living such as personal care,
shopping, housework
• Wandering, refusing needed medical attention, isolation, substance use
• Failure to keep needed medical appointments
• Confusion, memory loss, unresponsiveness
• Lack of toilet facilities, living quarters infested with animals or vermin
0 WARNING INDICATORS FROM CAREGIVER
• Elder is not given opportunity to speak for self, to have
visitors, or to see anyone without the presence of the
caregiver
• Attitudes of indifference or anger toward the elder
• Blaming the elder for his or her illness or limitations
• Defensiveness
• Conflicting accounts of elder’s abilities, problems, and so
forth
• Previous history of abuse or problems with alcohol or
drugs
Treatment and Intervention
0 Elder abuse may develop gradually as the burden of
caregiving exceeds the caretaker’s physical or
emotional resources. Relieving the caregiver’s stress
and providing additional resources may help to
correct the abusive situation and leave the caregiving
relationship intact. In other cases, the neglect or
abuse is intentional and designed to provide personal
gain to the caregiver such as access to the victim’s
financial resources. In these situations, removal of the
elder or caregiver is necessary.
TORTURE AND RITUAL ABUSE
0 Ritual abuse-torture (RAT) is the abuse and torture of
children and captive adults within violent organizing
family/group systems and gatherings and is a form of
non-State torture (NST).
0 Ritualisms influence people’s beliefs, values, thoughts,
perceptions, attitudes, and motivations, shaping their
behaviors. Ritualisms impact on a person’s way of fitting
into families or groups—work, play, church, and
friendship networks. Ritualisms shape positional power
in relationships i.e., leaders over followers, men over
women, parents over children.
0 Ritualisms helps shape perpetrator-victim relationships.
Perpetrators assert domination over victims,
overwhelming them with drugs and reality distortions
using costumes, chants, darkness, terror, torture, and
horrification pain; using omnipotent themes and roles,
programming victims to fit into their victim role.
Acts of Torture reported by Victims
PHYSICAL TORTURE:

0 Burnt with cigarettes, lit candles and hot light bulbs.

0 Beaten on the soles of the feet.
0 Tied down hung by limbs.
0 Caged. 
0 Guns used as in Russian roulette. 
0 Made unconscious by choking, suffocating with a
plastic bag, or face submerged under water. 
0 Forced to lie naked in the snow. 
0 Electric shocked.
SEXUALIZED TORTURE
0 A gun placed in one’s mouth, vagina, or anus and
hearing the clicking sound when the trigger is pulled.
0 Violent family/group rapes. 
0 Raped with objects – weapons, knife, broom handle, tree
branches, and kitchen items.
0 Forced to consume or be smeared with animal/human
waste - vaginal fluid, sperm, blood, urine, and feces;
forced into pornography, trafficked/snuff movies. 
0 Bestiality. 
0 Forced pregnancy/abortions.
MIND-SPIRIT TORTURE

0 Humiliation. 
0 Degradation.
0 Objectified. 
0 Treated like an animal. 
0 Trained to commit suicide so they never tell.
0 Drugged. 
0 Forced to participate in cruelty/killing of pets and
witness the torture of others.
RAPE AND SEXUAL ASSAULT
0 Rape is a crime of violence and humiliation of the victim
expressed through sexual means. Rape is the perpetration
of an act of sexual intercourse with a female against her
will and without her consent, whether her will is
overcome by force, fear of force, drugs, or intoxicants.
0 It is also considered rape if the woman is incapable of
exercising rational judgment because of mental deficiency
or when she is below the age of consent (which varies
among states from 14 to 18 years) (van der Kolk, 2000).
Recent research has categorized
male rapists into
four categories:
0 Sexual sadists who are aroused by the pain of their
victims
0 Exploitive predators who impulsively use their
victims as objects for gratification
0 Inadequate men who believe that no woman would
voluntarily have sexual relations with them and are
obsessed with fantasies about sex
0 Men for whom rape is a displaced expression of
anger and rage (van der Kolk, 2000)
0 The physical and psychological trauma that rape
victims suffer is severe. Related medical problems can
include acute injury, sexually transmitted diseases,
pregnancy, and lingering medical complaints.
 ASSESSMENT
0 To preserve possible evidence, the physical examination should
occur before the woman has showered, brushed her teeth,
douched, changed her clothes, or had anything to drink. This may
not be possible, because the woman may have done some of these
things before seeking care. If there is no report of oral sex, then
rinsing the mouth or drinking fluids can be permitted immediately.
0 To assess the woman’s physical status, the nurse asks the victim to
describe what happened. If the woman cannot do so, the nurse may
ask needed questions gently and with care. Rape kits and rape
protocols are available in most emergency room settings and
provide the equipment and instructions needed to collect physical
evidence. The physician is primarily responsible for this step of the
examination.
 WARNING SIGNS OF
RELATIONSHIP VIOLENCE
• Emotionally abuses you (insults, makes belittling comments, acts sulky or
angry when you initiate an idea or activity)
• Tells you with whom you may be friends or how you should dress, or tries to
control other elements of your life
• Talks negatively about women in general
• Gets jealous for no reason
• Drinks heavily, uses drugs, or tries to get you drunk
• Acts in an intimidating way by invading your personal space such as standing
too close or touching you when you don’t want him to
• Cannot handle sexual or emotional frustration without becoming angry
• Does not view you as an equal: sees himself as smarter or socially superior
• Guards his masculinity by acting tough
• Is angry or threatening to the point that you have changed your life or
yourself so you won’t anger him
Treatment and Intervention
0 Victims of rape fare best when they receive immediate
support and can express fear and rage to family
members, nurses, physicians, and law enforcement
officials who believe them. Education about rape and
the needs of victims is an ongoing requirement for
health care professionals, law enforcement officers,
and the general public.
 Points to Consider When Working
With Clients Who Have Been
Abused or Traumatized

0 These clients have many strengths they may not realize. The
nurse can help them move from being victims to being survivors.
0 Nurses should ask all women about abuse. Some will be offended
and angry, but it is more important not to miss the opportunity
of helping the woman who replies, “Yes. Can you help me?”
0 The nurse should help the client to focus on the present rather
than dwelling on horrific things in the past.
0 Usually a nurse works best with either the survivors of abuse or
the abusers themselves. Most find it too difficult emotionally to
work with both groups.
0 THANK YOU 