Domestic Violence

1 INTRODUCTION Violence is a leading worldwide public health problem (WHO, 1996). Violence also is an inescapable public health problem, with an estimated 1.9 million women and 3.2 million men being physically assaulted each year (Tjaden & Toennes, 2000b). Prevalence of some types of violence varies based on race or ethnicity, with some minority women and men reporting more frequent and more violent victimization. The family is generally regarded as a basic social institution that must be cherished, preserved and protected. The Family Code of the Philippines declares that no custom, practice or agreement destructive of the family shall be recognized or given effect. The premise, of course, is that the family is a haven where spouses and children expect to get protection and security, a safe place of nurturing and growth. It is certainly the last place where one should get physically, sexually, economically and emotionally abused. But the principle that the family is all important as upheld in the Family Code has been misused and distorted to justify an endemic Filipino culture or tradition of keeping the family intact at all cost, purportedly for the sake of children. A restrictive culture maintains that whatever occurs in marriage – even if it takes on a violent, criminal nature – is a private matter between husbands and wife. It is culture that tolerates violence against children and considers it within a parent’s right to enforce discipline; a culture of silence that is justified by another misused value – honor. The shame of the family outweighs the abuse and violence being committed against its member, who, studies show, is most likely a woman or a defenseless and innocent child. It is understandable that since domestic violence occurs in the confines of homes, it remains largely hidden and unrecognized as a problem. Only in 1985 did the United Nations make its first resolution on the problem, calling in member states to undertake research and formulate strategies to combat violence in the home. Findings from Breaking the Silence: The Realities of Family Violence in the Philippines and Recommendations for Change by Women in Development-Interagency Committee Fourth County Programme for Children, U.P. Center for Women’s Studies Foundation, Inc. reveal that a total of 1,000 documented cases of family violence obtained from files of both government and non-government organizations – including shelters and transition houses, a government hospital’s pioneering child protection unit, and private clinics – covering the period from 1994 to the first quarter of 1996 was analyzed. The study found many forms and dimensions of family violence. Collaboration among health care professionals is recognized as the most effective way of responding to the needs of survivors of violence. Nurses and other health care providers must guard against insensitivity when working with survivors of violence. Making health care system responsive and relevant to the needs of the client, assisting them to develop greater independence and make accessible to them all the available health services to help them resolve their problems. The basic requisite for a health advocate is time and commitment and the willingness to take the risk in the process of advocacy.

2 VIOLENCE & ABUSE Definition of Terms: Assaulter – men who abuse and control women through threats, physical, psychological, verbal and sexual aggression. Perpetrator - A person who inflicts abuse or injury on another Child abuse – the act of deliberately inflicting or causing to inflict physical injuries upon a child or unreasonably depriving him/her of basic needs for survival such as food, shelter or a combination of both to a degree that if not immediately, could seriously impair the child’s growth and development or result in permanent incapacity or death. Includes any act which debases, degrades or demeans the intrinsic worth and dignity of a child as a human being (Guerrero) Elder Abuse – is the maltreatment of older adults by family members or caretakers. It may include physical and sexual abuse, psychological abuse, neglect, financial exploitation and denial of adequate medical treatment. Economic Abuse – denial or withdrawal of financial support, prohibiting the wife from handling money; forbidding her to work outside the home or controlling a woman’s own earnings. - having total control over conjugal financial resources; using household money for drinking, gambling or drugs. Domestic violence - physical, sexual or emotional and psychological abuse of men or women, may they be related by blood or affinity or may not be related by blood or affinity but lived in the same domicile or constitute a household. Family violence - a specific form of violence, may it physical, sexual or emotional and psychological abuse of men or women, where the perpetrator and the victim are related to each other and may or may not live in the same household. Physical Violence – may be a single manual act or a series of different acts or a combination of assaults with use of weapons. Psychological or Emotional Violence – involves threat or intimidation or verbal abuse; verbal or gestured threats to kill or harm physically.  Nagging, use of degrading words or insulting words  Public humiliation, accusation of infidelity  Prolonged silence after arguments, withdrawal of affection  Openly siding with relatives against sudden abandonment  Forcing to bear children or forcing her to have abortion Sexual Abuse – could be demanding sex regardless of the partner’s condition, forcing her to perform sexual acts that are hurtful or unacceptable to her  forcing her to watch pornographic videos and other materials  having sex with another woman in the marital bedroom  forcing the wife and mistress to sleep with him in the same bedroom Social Abuse – encompasses the many actions that a batterer can use to influence or to limit his wife’s contact with society (isolation and public humiliation) Violence – an action, policy or attitude that causes bodily or mental injury and debases or dehumanizes a person. Intimate Partner Violence: Physical, sexual, or emotional and psychological abuse of men or women occurring in past or current intimate relationships, cohabiting or not, and including dating relationship Neglect - The failure to provide for the individual’s basic needs for subsistence, including food, housing, clothing, education, medical care, and emotional care. At its most extreme, neglect results in death, especially in the older adults and in very young children. A. TYPES OF ABUSE I. Physical abuse – involves the intentional use of physical force against another person. It encompasses child/sibling/spouse/elderly/homosexual abuse and battered child syndrome. Characteristics 1. Behavioral – pattern of behavior usually develops, the first incident maybe precipitated by frustration or stress. If the pattern is to be avoided, the victim must

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3 immediately refuse to accept the violence. If the victim submits to the violence or physical force, without the stimulus of frustration or stress, it becomes a way of relating to one another and the pattern becomes difficult to change. Intrafamily violence is typically cyclic. 1.1. Acts of violence within the family range from slight slaps to severe beatings to homicide. 1.2. Women do more hitting, kicking and throwing of objects when involved in violent conflict with men. Men are likely to push, shove, slap, beat up and even use weapons ( e.g. knives, guns ) against their wives/girlfriends 1.3. Perpetrators lack impulse control and their behavior is immature and selfserving. 1.4. Abused children often try to please the abusing parent and may become overly compliant to all adults. They avoid peers and withdraw from outside contact. When he grows up as an adolescent, he will act out with aggressive behavior 2. Affective 2.1. Physically abusive people are often described as extremely jealous and possessive Some have strong dependency needs and fear the loss of intimate relationships Closely related to the dependency need is the feeling of inadequacy. Abusers use violence in an attempt to prove to themselves and others that they are superior and in control. Victims maybe immobilized by a variety of affective responses to the abuse. A study showed that 25% of the victims feel guilty, 50% felt helpless and 75% experienced feelings of depression. Fear helps to keep a woman in an abusive relationship. 3. Cognitive 3.1. Many abusive people set perfectionist standards for themselves and members of their families. They convey a sense of rigidity and have an obsession with discipline and control. Some are self-righteous, believing it is their right to use physical force to get others to comply with their wishes. Many parents who abuse their children suffered emotional deprivation when they themselves were children. As a result, they may have unrealistic expectations of their own children. Victims of abuse often develop low self-esteem. Some victims believe they are helpless to change the pattern of domination or to leave the relationship. Some rationalize that the behavior was due to alcohol or stress. 4. Physiologic 4.1. Abuse children maybe retarded in the areas of growth and development. 4.2. In victims of all ages, any combination of the following : Bruised or swollen eyes, hemorrhage into the eyes or petechiae around the eyes Bald patches where hair has been pulled out or subdural hematomas from blows to the head Bruises, burns, scars of past injuries on the skin, genitals and rectal areas Fracture or evidence of precious fractures, particularly of the face, arms and ribs Dislocated joints especially in the shoulder when the victim is grabbed or pulled by the arm Intra-abdominal injuries especially in pregnant women Numbness from old injuries and hyperactive reflexes due to neurologic damage 5. Sociocultural 5.1. The experience of violence in the family of origin teaches that the use of physical force is appropriate

2.2. 2.3. 2.4. 2.5.

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4 5.2. Abused children grow to become another abuser or another adult victim 5.3. The violent family is often socially isolated. 5.4. Violent families have experienced significant life stressors before the onset of physical abuse II. Sexual Abuse – inappropriate sexual behavior, instigated by an adult family member or surrogate family member, whose purpose is sexual arousal of a child or adult, exhibitionism, peeping and explicit sexual talk to touching, caressing, masturbation and intercourse. - abusive sexual contact, completed, attempted, against the will of the other, or in circumstances in which the other is unable to understand, refuse or communicate unwillingness to engage in the sexual activity. A. Characteristics 1. Behavioral 1.1. Adult perpetrators believe in extreme parental restrictiveness and domination. 1.2. Children victims exhibit regressive behavior, most common of which is bedwetting. Sleep disturbances are common, some are clinging, others isolate themselves. 1.3. Children victims may act out sexually with other children and adults. 1.4. Adolescent victims may run away from home to escape 1.5. Long-term behavioral effects include indiscriminate sexual activity/dysfunctions, sleeping problems, chemical abuse, social isolation and suicide. 2. Affective 2.1. Perpetrators often feel weak, afraid and inadequate. They are unable to distinguish between sexual and non-sexual affection for children. 2.2. Incest victims experience many fears : loss of parental love, being blamed or thrown out of the house, physical abuse 2.3. Extremely prevalent is the feeling of powerlessness 2.4. Long term effects – are fear of sex and distrust and fear of men. They suffer from chronic anxiety attacks or demonstrate borderline personality disorder symptoms. Anger maybe the only emotion they experience and express. 3. Cognitive 3.1. Dissociation is the victim’s major defense mechanism. 3.2. Children molested during the night experience nightmares. 3.3. Adult survivors have total amnesia for episodes of incest. 3.4. Self-blame and self-hatred contribute to low self-esteem in adult survivors. 4. Physiologic 4.1. Irritated or swollen genitals or rectal issue in children or presence of sexually- transmitted disease 4.2. Some become pregnant 5. Sociocultural 5.1. It is difficult for a child for a child to protest any type of abusive treatment in highly structured, authoritarian family system. 5.2 Chronic stress in the family can contribute to abuse. III. Emotional or psychological abuse - usually verbal abuse designed to control another through use of intimidation, degradation or fear. - It refers to acts or behaviors or omissions by primary caregivers that result in or increase the risk of serious behavioral, cognitive, emotional, and mental disorders. This definition includes, but is not limited to psychological, verbal and mental injury. IV. Neglect - The failure to provide for the individual’s basic needs for subsistence, including food, housing, clothing, education, medical care, and emotional care. At its most extreme, neglect results in death, especially in the older adults and in very young children. Types of Neglect:

5 1. Failure to protect – ingestion of poison, accidents and disregard for the child’s safety. Lack of appropriate supervision. 2. Physical neglect – failure to provide food, clothing, and shelter. Failure to provide adequate healthy diet, and hygiene. 3. Medical neglect – failure to provide for the medical needs of the child, including failure to seek timely intervention or failure to comply with prescribed medical treatment. 4. Emotional neglect or non organic failure to thrive – failure to provide nurturing and psychological support. B. FAMILY CHARACTERISTICS VULNERABLE TO DOMESTIC VIOLENCE 1. Alcohol Abuse – the habitual alcohol intake leading to drunkenness - the perpetrator is more prone to uncontrolled violent outbursts - alcoholism is used as an excuse for an abusive behavior, therefore it is dangerous because treatment will be toward alcoholism and not the behavior. Thus victims of the abuse still continue to suffer. 2. Cultural Stereotypes - the use of physical force as contributing to the attainment of the family structure - the husband as the head of the family, the disciplinarian, the one in authority, assertive and aggressive (macho image) - the use of spanking as a culturally accepted behavior (legitimizes domestic violence) 3. Jekyll and Hyde personality - both husband and wife has low self-esteem; Man: uses violence as manifested in an explosive temperament accompanied by physical blows and other forms of abuse, ex. Isolation Woman: blames one’s self as deserving the violence secondary to one’s failure to meet the husband’s expectations; has low self-esteem and low self image. 4. Family at or below the poverty level – violence is five times greater compared to other strata due to poor cooping from lack of financial resources well as related stress. 5. Pregnancy – creates an increase stress in the family and provokes attack of battering. 6. A childhood history of witnessing/ being a victim of violence - both have low self-esteem attributed to their childhood history (spanking as a way of instilling discipline). 7. Ineffective family functioning – ineffective coping to stress (hostility and displacement) 8. Family with elderly members – being frail and weak 9. Homosexual unions C. PSYCHODYNAMICS 1. Biologic Theories 1.1. People possess a natural fighting to preserve the species 1.2. The neurophysiologic theory proposes that the limbic system and then neurotransmitters are implicated. 1.3. Substance abuse especially alcohol is often implicated. 2. Interpersonal Theories – suggest that violence has its roots in the individual personalities of the abusers. Aggression is seen as a basic drive within the personality and violence is the result of the inability to control the impulsive expression of anger and hostility. 2.1. Rejection of the child and failure of bonding between parents and child. 2.2. Abusers are often obsessive-compulsive, jealous, suspicious, paranoids or sadistic 3. Social Learning Theory – proposes that violence is a learned behavior rather than an instinctive one. It is believed that stimulation of the neurophysiologic mechanisms for violence is under cognitive control. Both the abuser and the victim learn their roles during childhood. 4. Sociologic Theory – the social environment can place additional stress on the family. Violence tends to occur in multiproblem families that have experienced a prolonged series significant stressors ( e.g. unemployment, economic crises ) Family Systems Theory – violence does not occur in isolation but results from the interrelationships between people, events and behavior.

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6 6. Feminist Theory – the patriarchal organization gives dictatorial authority over women and children. Women are viewed as childlike, passive, unreasonable & overly emotional individuals who need to be dominated and controlled. Theories that describe the causative factors for abusive behavior toward spouses and elderly parents: 1. The abuser is deprived of nurturing and mothering as a child. 2. The abuser may have a history of antisocial behavior. 3. Specific behaviors learned during various developmental stages become part of person’s interactions with spouse and family. Inadequate family functioning contributes to neglect and child psychopathology (Moss, Lynch, Hardie & Baron, 2002). 4. Poor socio-economic conditions resulting in increased stress, anxiety, or frustrations may precipitate abusive behavior within the family unit. 5. Poor communication skills may result in the use of verbal or physical abuse. 6. Abusive behavior may increased after the death of a significant family member, the loos of job, geographic move, the onset of physical or mental illness, developmental change, or a family change such as pregnancy or the birth of a child. 7. Violent acts generate positive feedback.

WHEEL OF POWER AND CONTROL

ISOLATION
Controlling what she does, who she sees & talks to or where she goes

EMOTIONAL ABUSE
Putting her down or making her feel bad about herself; calling her names, making her think she is crazy., playing mind games.

INTIMIDATION
Putting her in fear by using looks, actions, gestures, or loud voice, smashing things, destroying her property

ECONOMIC ABUSE
Trying to keep her from getting or keeping a job, making her ask for money, giving her an allowance, taking her

money

USING MALE PRIVILEGE
Treating her like a servant; making all the “big” decisions, acting like the “master of the castle”

POWER AND CONTROL

SEXUAL ABUSE
Making her engage in sexual acts against her will, physically attacking the sexual parts of her body, treating her like a sex object

THREATS
Making and/or carrying out threats to hurt her emotionally, threatening to take the children, commit suicide or report her to the welfare agency

USING CHILDREN
Making her feel guilty about the children; using the children to give messages, visitation as a way to harass her

7 THE DESIRE FOR CONTROL AND POWER RESULTS IN BOTH PSYCHOLOGICAL AND PHYSICAL ABUSE (From the Power and Control, Duluth, Minn, 1987, Domestic Abuse intervention Project) CYCLE OF VIOLENCE A. Build-up Phase/Tension Building  occurs along with anger and tension building together with minor incidents of violence. May include verbal abuse, threats and breaking of things. B. Abuse/ Violence  One loses control of behavior because of blind rage.  Seen as a major catastrophe. C. Sorry Phase or the Honeymoon and Loving Respite  The batterer is remorseful and afraid of losing his partner.  The batterer buys gifts, begs forgiveness and promises anything. FIRST THREE LIFE STAGES (Infancy, Early childhood middle childhood) Developmental Milestone • infants prefer primary care givers • communicate by crying • “strangers anxiety” at six months • Beginning of locomotion • Shows emotions such as fear, anger, jealousy • Toddlers reached the “terrible no, no age” • Temper tantrums are common • Beginning of toilet training • Preschoolers have overactive imagination • Curious about sex • Learning new things and new roles. • • Crisis mistrusts develop in infants if needs are not met basic aim of toddlers is autonomy and wants self-control and will power. Shame and doubt may arise if autonomy is not developed. Preschoolers are to be given direction, purpose and initiative so guilt does not arise. • Risk Factors unplanned babies are considered nuisance, burdens and hindrance to career plans. Crying which is the child’s way of communicating may test the patience of parents. Elektra and Oedipus complex are manifested by unusual closeness to parents of opposite sex. Difficult child behavior (tantrums, dawdling) Unrealistic expectations of children

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VIOLENCE DURING SCHOOL AGE AND ADOLESCENCE Schoolers Developmental Milestone • tattles because of strong sense of justice • has increasing awareness of family roles and responsibilities • some girls begin to menstruate Crisis considered to be in the latency stage so their libidinal energies are redirected basic task is industry but negative task is inferiority Risk Factors Influence of peers and school environment Hero worship Influence of television, computer games, video game, internet and others

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Adolescents Developmental Milestone • physical and psychologic signs of onset of puberty are evident • maturation of male and female reproductive system • increased range, skill and independence of mobility

Crisis • identity versus role confusion • belongs in the genital stage according to Freud

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Risk Factors need for peer acceptance actively seeking models/ mentor values are translated into behaviors beginning to consider sexuality and reproduction issues sexual experimentation vulnerability to drugs, alcohol abuse

SHORT TERM EFFECTS ASSOCIATED WITH VIOLENCE Behavioral Emotional Physical Regression/ Immaturity Anxiety Stomachache Social withdrawal Nightmares Genital pain Sexualized behavior Depression Genital odors Sexual preoccupation Guilt Problem sitting Precocious sexual knowledge Low self-esteem Eating disturbance Seductive behavior Phobias Encopresis Excessive masturbation Hostility/ Anger Headache Sex play with others Aggression Genital itching Sexual victimization of others Suicidal tendency Problem walking Genital exposure Sleep disturbance Delinquency Enuresis Stealing Poor peer relations Hyperactivity Self-injurious behavior Sexual language

Cognitive Learning difficulties Poor attention Poor concentratio n Declining grades

LONG TERM EFFECTS OF FAMILY VIOLENCE ACROSS THE LIFE SPAN Type of Effect Specific Specific Symptoms Problem Emotional Depression Depressed effect Suicidality Low selfesteem Guilt Poor self image Self blame Anxiety Fears/ phobias Migraine Stomach problem Aches and pains Skin disorders Interpersonal Difficulty trusting others Poor social judgment Difficulty forming relationships Parenting difficulties Sexual re-victimization Posttraumatic Stress Reexperiencing Intrusive thoughts Flashbacks Nightmares Disorder Symptoms Avoidance Amnesia for abuse events Spacing out Emotional numbling Sexual Adjustment Anorgasmia Arousal dysfunction Sexual anxiety Sexual guilt Promiscuity Prostitution Dissatisfaction in sexual relations Behavior Eating disorder Binging Purging Overeating Dysfunction Substance Alcoholism Elicit drugs abuse

9 Self mutilation Cutting body parts Carving body parts Hitting head or body with object

COMMON REACTIONS TO TRAUMA
A traumatic experience produces emotional shock and may cause many emotional problems. Many changes after a trauma are normal. In fact, most people who directly experience a major trauma have severe problems in the immediate aftermath. Many people then feel much better within three months after the event, but others recover more slowly, and some do not recover enough without help. Becoming more aware of the changes you've undergone since your trauma is the first step toward recovery. Some of the most common problems after a trauma are described below. 1. Fear and anxiety. Anxiety is a common and natural response to a dangerous situation. For many it lasts long after the trauma ended. This happens when views of the world and a sense of safety have changed. You may become anxious when you remember the trauma. But sometimes anxiety may come from out of the blue. Triggers or cues that can cause anxiety may include places, times of day, certain smells or noises, or any situation that reminds you of the trauma. As you begin to pay more attention to the times you feel afraid you can discover the triggers for your anxiety. In this way, you may learn that some of the out-of-the-blue anxiety is really triggered by things that remind you of your trauma. 2. Re-experiencing of the trauma. People who have been traumatized often re-experience the traumatic event. For example, you may have unwanted thoughts of the trauma, and find yourself unable to get rid of them. Some people have flashbacks, or very vivid images, as if the trauma is occurring again. Nightmares are also common. These symptoms occur because a traumatic experience is so shocking and so different from everyday experiences that you can't fit it into what you know about the world. So in order to understand what happened, your mind keeps bringing the memory back, as if to better digest it and fit it in. 3. Increased arousal is also a common response to trauma. This includes feeling jumpy, jittery, shaky, being easily startled, and having trouble concentrating or sleeping. Continuous arousal can lead to impatience and irritability, especially if you're not getting enough sleep. The arousal reactions are due to the fight or flight response in your body. The fight or flight response is the way we protect ourselves against danger, and it occurs also in animals. When we protect ourselves from danger by fighting or running away, we need a lot more energy than usual, so our bodies pump out extra adrenaline to help us get the extra energy we need to survive.

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People who have been traumatized often see the world as filled with danger, so their bodies are on constant alert, always ready to respond immediately to any attack. The problem is that increased arousal is useful in truly dangerous situations, such as if we find ourselves facing a tiger. But alertness becomes very uncomfortable when it continues for a long time even in safe situations. Another reaction to danger is to freeze, like the deer in the headlights, and this reaction can also occur during a trauma. 4. Avoidance is a common way of managing trauma-related pain. The most common is avoiding situations that remind you of the trauma, such as the place where it happened. Often situations that are less directly related to the trauma are also avoided, such as going out in the evening if the trauma occurred at night. Another way to reduce discomfort is trying to push away painful thoughts and feelings. This can lead to feelings of numbness, where you find it difficult to have both fearful and pleasant or loving feelings. Sometimes the painful thoughts or feelings may be so intense that your mind just blocks them out altogether, and you may not remember parts of the trauma. 5. Many people who have been traumatized feel angry and irritable. If you are not used to feeling angry this may seem scary as well. It may be especially confusing to feel angry at those who are closest to you. Sometimes people feel angry because of feeling irritable so often. Anger can also arise from a feeling that the world is not fair. 6. Trauma often leads to feelings of guilt and shame. Many people blame themselves for things they did or didn't do to survive. For example, some assault survivors believe that they should have fought off an assailant, and blame themselves for the attack. Others feel that if they had not fought back they wouldn't have gotten hurt. You may feel ashamed because during the trauma you acted in ways that you would not otherwise have done. Sometimes, other people may blame you for the trauma. Feeling guilty about the trauma means that you are taking responsibility for what occurred. While this may make you feel somewhat more in control, it can also lead to feelings of helplessness and depression. 7. Grief and depression are also common reactions to trauma. This can include feeling down, sad, hopeless or despairing. You may cry more often. You may lose interest in people and activities you used to enjoy. You may also feel that plans you had for the future don't seem to matter anymore, or that life isn't worth living. These feelings can lead to thoughts of wishing you were dead, or doing something to hurt or kill yourself. Because the trauma has changed so much of how you see the world and yourself, it makes sense to feel sad and to grieve for what you lost because of the trauma.

8. Self-image and views of the world often become more negative after a trauma. You may tell yourself, "If I hadn't been so weak or stupid this wouldn't have happened to me." Many people see themselves as more negative overall after the trauma ("I am a bad person and deserved this."). It is also very common to see others more negatively, and to feel that you can't trust anyone. If you used to think about the world as a safe place, the trauma may suddenly make you think that the world is very dangerous. If you had previous bad experiences, the trauma convinces you that the world is dangerous and others aren't to be trusted. These negative thoughts often make people feel they have been changed completely by the trauma. Relationships with others can become tense and it is difficult to become intimate with people as your trust decreases. 9. Sexual relationships may also suffer after a traumatic experience. Many people find it difficult to feel sexual or have sexual relationships. This is especially true for those who have been sexually assaulted, since in addition to the lack of trust, sex itself is a reminder of the assault. 10. Some people increase their use of alcohol or other substances after a trauma. There is nothing wrong with responsible drinking, but if your use of alcohol or drugs changed as a result of your traumatic experience, it can slow down your recovery and cause problems of its own. Many of the reactions to trauma are connected to one another. For example, a

11 flashback may make you feel out of control, and will therefore produce fear and arousal. Many people think that their common reactions to the trauma mean that they are "going crazy" or "losing it." These thoughts can make them even more fearful. Again, as you become aware of the changes you have gone through since the trauma, and as you process these experiences during treatment, the symptoms should become less distressing.

SUPPORTING THE SURVIVOR How Does Trauma Affect Survivors? Victims of violence often face a wide range of struggles. They often question what has happened or what they may have done to cause or prevent it. Many wonder how they will heal and why they cannot connect with their loved ones as they once did. It is also common for survivors to feel anger or frustration as they ponder whether they will ever feel “normal” again. While every survivor’s experience is unique, violent trauma is almost always a life-changing experience that can affect everything from one’s ability to sleep to his or her ability to concentrate at work. Understanding the nature and impact of trauma can be key to helping your loved one. Many survivors find themselves in unfamiliar and distressing psychological territory. It is common for them to endure intense feelings of isolation, insecurity, and fear, and their most treasured relationships often suffer as a result. Trauma can also lead to Post Traumatic Stress Disorder (PTSD), which may include both substance abuse and mental health problems. Violent Trauma, Substance Abuse, and Mental Health Concerns Many victims turn to alcohol or other substances in an attempt to get some relief from their emotional turmoil and suffering. All trauma survivors manage their experiences in different ways. However, substance abuse is not only ineffective in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult. Violence is also a widely recognized catalyst for mental health concerns such as PTSD, a condition that can be caused by experiencing or observing virtually any kind of deep emotional or physical trauma. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make a survivor feel isolated, disconnected, and “different” from other people, and it can even begin to affect the most routine activities of everyday life. Psychologists and counselors with experience in treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms. PTSD is a potentially serious condition that should not be taken lightly. According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can be helpful for a survivor to share experiences and concerns with a service provider who can assist in developing a plan to address these struggles comprehensively. How to Help Survivors of Violence and Abuse? Since each individual’s experience is unique, there is no one-size-fits-all remedy for victimized patients. For those who care about a person who has experienced a violent trauma, finding ways to be helpful and maintaining a healthy relationship can be challenging. Following are some tips to help your loved one who has been victimized.
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Listen . Talking about the experience, when the survivor is ready, will help acknowledge and validate what has happened to him or her and can reduce stress

12 and feelings of isolation. Let your patient take the lead, and try not to jump in with too many comments or questions right away. Research . If the victim wants more information, would like to report a crime, or has other questions, you can help find answers and resources. Reassure . As strange as it may sound, survivors often question whether an incident was their fault or what they could have done to prevent the crime against them. They may need to hear that it was not their fault and be assured that they are not alone. Empower . Following trauma, victims can feel as though much of their lives is beyond their control. Aiding them in maintaining routines can be helpful, as can offering survivors options or possible solutions. Be patient . Every journey through the healing process is unique. Try to understand that it will take time, and do what you can to be supportive. The healing process has no pre-determined timeline. Ask . Your patient may need help with any number of things or have questions on many different topics. Even a favor as mundane as running a few errands or taking the dog for a walk can be a big help, so consider lending a hand.

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* Nurses need to identify their personal values and determine if these will interfere with the ability to care for all members of the family. APPLICATION OF THE NURSING PROCESS Initial Assessment  is done to determine the presence of any serious injury. Questions to Ask the Woman on Initial Assessment 1. Where is the batterer now? 2. Where are the children? Are they safe? 3. How long ago did the abuse take place? 4. Who bought her to the hospital? 5. Is there some place where she can go to recuperate if it is too dangerous for he to return home? 6. Were there weapons involved in the battering incident? 7. Would she like to call the police or have they been notified already? History Taking A. 1. Description of the present incident. 2. Details of past incidents. 3. Presence of medical problems. 4. Emotional and Psychosocial Problems. Emotional problems: anxiety, sleep disorders, poor coping and parenting difficulty. Psychosocial problems: substance abuse, attempt suicide and depression B.          Recognizing Domestic Violence Related Behaviors recurrent episodes of injury attributed to being “accident prone”. repeated visits to health care facilities dependency on the partner to answer questions failure to keep appointments noncompliance with medical treatments decreased concentration self-blame complains of pain without tissue injury thoughts about suicide

13 Three Dangerous Things (that may happen if situation in violent homes become worse) 1. Abused women retaliate with violence thus injuring or killing her husband. 2. Abusive husband may kill the wife in a battering incident. 3. The abused woman feeling helpless and hopeless may kill herself. Risk Assessment The following are the critical signs that indicate increased risk for homicide: 1. Possession of weapons or past use of weapons. 2. Drug and alcohol use in a state of fury and depression. 3. Pathological jealousy in spouse. 4. History of mental illness. 5. Obsession about the partner ( I can’t live without her). 6. Situational stresses (ex. Loss of job). Caring Values During The Interview Process 1. The interview should be conducted in a private setting. 2. The nurse should remain nonjudgmental, gentle and direct in his/her approach. 3. The interview should be uninterrupted. (Interruptions may be construed as rejection or lack of interest). 4. The patient should be assured of confidentiality. 5. If patient appears reluctant to disclose the abuse, the nurse may start the interviews by acknowledging to the patient that the incidence of domestic violence is so prevalent that screening for it is becoming a routine part of the health care delivery for all women. 6. If culturally acceptable, the nurse maintains eye contact. D.              Recognizing Domestic Violence Related Injuries ruptured eardrums from severe slapping neck bruising from choking punch bruising to the upper arms “defensive posturing” injuries to the mid ulnar areas of the arms Whip or cordlike injuries to the back Punch and bite injuries to the breast and nipples Punch injuries to the abdomen especially for pregnant women Punch and kick bruising to the lateral thighs Facial bruising, abrasions and lacerations Telltale burns Skeletal fractures Internal injuries (blunt trauma) Head and Neurologic injuries Stages of Healing Bruises COLOR Red to red blue Purple to dark blue Green to yellow-green Yellow to brown Disappearance AGE Less than 24 hours 1 to 4 days 5 to 7 days 7 to 10 days 1 to 3 weeks

Primary Prevention Are measures that are taken to prevent or reduce the incidence of violence and abuse, promote growth and enhance a potential victim’s future resistance to abuse. Strategies: 1. Public education Focus: > Issues related to child, women and family health and welfare

14 > The negative effect of force and assaultive conduct. > Nonviolent conflict resolution strategies (counseling) > effective parenting and nonviolent discipline skills > awareness concerning the criminal nature of domestic/ family violence. 2. Training of community-based groups and grassroot women. 3. Networking and linkaging to achieve an ideal community response to the issue of domestic violence. Secondary Prevention The aim is to shorten the length of time a person may be disabled by abuse. Activities: > screening (assessment of women who seek care in the ER, referrals by friends, health providers) > crisis intervention Tertiary Prevention Involves interventions aimed at maintaining or reducing the severity of mental illness or handicaps resulting from chronic abusive trauma to battered women, children and the batterer. Activities: > long term therapy = physical care > counseling = psychological care > rehabilitation = empowerment Nursing Intervention During The Crisis Stage 1. Assist the woman through grief work around the losses experienced through battering. 2. Assure the woman of safety and protection and engage her in safety planning. 3. Provide the survivor with the information on how to access community resources. 4. Reinforce that we all expect to live free from violence. 5. Enhance the survivors assertiveness and promote her self-esteem. 6. Assist the women through the decision making process. 7. Refer the survivor to appropriate resources. Nursing Intervention During The stage of Internal Resolution and Rebuilding 1. Reiteration of information about abuse, the cycle of violence and the abuser’s accountability. 2. Building self-esteem and confidence. 3. Decreasing shame, quiet, embarrassment and isolation. 4. Confirmation of personal and legal rights. 5. Stress reduction or management techniques. 6. Conflict-resolution techniques. 7. Assertiveness training. 8. Decreasing co-dependency behaviors. 9. Building a new, improved support system. 10. Goal-setting, specific planning for immediate future. 11. Resolution of grieving.

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Empowerment Advocacy Empowerment advocacy believes that battering is not something that happens to a woman because of her characteristics, her family background, her psychological “profile”, her family of origin, dysfunction, or her unconscious search for a certain type of man. Battering can happen to anyone who has the misfortune to become involved with a person who wants power and control enough to be violent to get it.

Respect Confidentiality…
All discussions must occur in private, without other members present. This is essential to building trust.

Promote Access to Community Services…
Know the resources in your community. Is there a hotline and shelter for battered women?

Believe and Validate her Experiences…
Listen to her, and believe her. Acknowledge her feelings, and let her know she is not alone. Many women have similar experiences.

Help her Plan for Future Safety….
What has she tried in the past to keep herself safe? Is it working? Does she have a place to go if she escapes?

ADVOCAC Y

Acknowledge Injustice…
The violence perpetrated against her is not her fault. No one deserves to be abused.

Respect her Autonomy…
Respect her right to make her own decisions in her own life when she is ready. She WHEEL ADVOCACYis the expert in her life.

EMPOWERMENT ADVOCACY WHEEL Through empowerment advocacy, the abuse woman is given strength and determination. She will feel her independence and autonomy as a decision maker have been supported. She will be able to recognize her strengths and resources as a survivor.

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Case Study Luisa is 42 years old and has six children aging 4 to 20 years old. She works as a laundry woman for a number of students in a ladies’ dormitory in one of the universities in Dumaguete City. One late evening, she arrives in the Women Crisis Center with her 4-year old daughter and a neighbor. Three days ago she was discharged from a hospital after D & C was performed on her after an inevitable abortion. She related that her husband came home after a drinking spree with his barkadas and demanded to have her serve his supper. Since she was already upstairs resting, she ask her 15-year old daughter to do it for her. This irritated his husband and he started to shout angry words at her and called her name and threatened to hit her. When she heard him coming, she jumped from the second floor window with her daughter and ran to a neighbor a block away. Luisa further disclosed that her husbandhas been abusive since the early days of their marriage even if he was not drunk. He used his fists on her and threw things at her. One of the worst physical assaults done to her was when she obtained lacerated wounds after he hit her with a piece of firewood. Luisa wanted to leave but she cannot. They have three children under the age of fifteen which she cannot afford to feed if ever she leaves and brings them along . She also feared that her husband will kill her if she tries to escape.

NURSING CARE PLAN SUBJECTIVE OBJECTIVE NURSING OUTCOME CUES CUES DIAGNOSIS IDENTIFICATION
“I feel like smashing Face frowned the face of my wife!” as verbalized by the Walks back and client forth Clenched teeth and fists Potential for violence: Directed at others related to fears of abandonment. as evidenced by hostile threatening verbalization, clenched fists and teeth and rigid posture. Definition: A state in which an individual experiences behaviors that can be physically harmful either to That after two hours of nurse-client interaction, the client will be able to: 1. Demonstrate self control as evidenced by relaxed posture, non-violent behavior. 2. Acknowledge realities of the situation. 3. Use resources and support system in an effective manner. 4. Express realistic selfevaluation and increased sense of self-esteem.

17 the self or others.

INTERVENTION
Observe patient’s behavior

RATIONALE
Client at high risk for violence require close observation to prevent harm to self and others. Promotes sense of trust, allowing patient to discuss feelings openlyu./ May be afraid of own behavior or loss of control.

EVALUATION Anxiety is maintained at a level at which patient feels no need for aggression. Patient seeks out nurse to discuss true feelings. Patient recognizes, verbalizes, and accepts possible consequence of own mal-adaptive behaviors.

Develop therapeutic nurse-client relationship. Provide consistent caregiver when possible. Help client recognize that own actions may be in response to own fears, dependency, and feeling of powerlessness. Obtain verbal or written contract from patient agreeing not to harm self or others and agreeing to seek out staff in the event that such ideation occurs.

Discussion of feelings with trusted individuals provide a degree of relief to the client. A contract gets the subject out in the open and places some of the responsibilities for his safety. An attitude of acceptance of the client as a worthwhile individual is conveyed. Identifying own’s feelings enables the client to face his emotion and develop strategy to control one’s emotion and learn to accept it.

Assist patient when anger occurs and to accept those feelings as his own. Accept client’s anger without reacting on emotional basis. Give permission to express angry feelings in acceptable ways and let patient know that you are available in maintaining self control. Act as a role model for appropriate expression of angry feelings, and give positive reinforcement to client for attempting to conform. Remove all dangerous objects from patient’s environment.

Promotes acceptance and sense of safety. It is vital that the patient express angry feelings as suicide and other self destructive behaviors are often viewed as a result of anger turned inward to self. The patient’s physical safety and the safety of the other members of the family isof priority. Crisis situation can provide impetus for change

18 Motivate client for change in behavior. BIBLIOGRAPHY

Shives, Louise Rebraca. Basic Concepts of Psychiatric-Mental Health Nursing. 4th edition. Philadelphia: Lippincott-Raven Publishers, © 1998. Videbeck, Sheila. Psychiatric Mental Health Nursing. 2nd ed. London: Lippincott Williams and Wilkins, © 2001. Antai-Otong, Deborah, Psychiatric Nursing: Biological and Behavioral Concepts. Delmar Learning Inc. U.S.A. 2003. Lim, Patrice Grace. Nursing Care of Survivors of Domestic/Family Violence: A Student’s Module for NCM 102. Social Science & Reproductive Health; Social Developemnt Research Center. De La Salle University – Manila and Silliman University – Dumaguete City, Philippines. 2001. Tan, Phoebe. Analyzing Domestic Violence: The Individual Assaulter. A Student’s Module for SOAN 65. Social Developemnt Research Center. De La Salle University – Manila and Silliman University – Dumaguete City, Philippines. 2001.