Abuse, Aggression, Violence

Abuse

Systematic strategies used to obtain dominance and control over others. Abuse, aggression, and violence can have a significant influence on a person’s life. Clients experiencing abuse, aggression, or violence can develop mental health disorders, as well as being subjected to physical trauma.

• Psychological

• Physical

• Emotional 

• Economic 

• Sexual 

Physical Abuse

Perpetrators of physical abuse may use force, including kicking, hitting, slapping, pushing, strangling, or biting to control how others behave and think 

Physical Abuse signs

• General appearance

  • Ripped or torn clothing, broken eyewear, disheveled hair and clothing

• Body

  • Bruising, lacerations, burn marks, fractured bones, puncture wounds, wounds in various stages of healing

Emotional Abuse

• The person responsible for abusing others may use threats, insults, and intimidation to exert control 

• Individuals who have experienced abuse are at higher risk for developing substance use disorders, anxiety disorders, depressive disorders, eating disorders, borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD) (OASH, 2018). 

• May be harder for the nurse to recognize, as no physical evidence is apparent

• Potential signs

  • Changes in usual behavior, such as social withdrawal or non-responsive communication

    • Loss of self-esteem

    • Anxiety provoked by the presence of certain people

    • Claims of enduring verbal or mental mistreatment

Sexual Abuse

• Any forced, inappropriate, or unwanted sexual contact is sexual abuse. 

• Includes photographs that are sexually explicit, indecent exposure, unwanted touching, rape, forcing individuals to engage in sexual acts, or coerced nudity

• Digital media and online resources have simplified the grooming, luring, and exposure of children and adolescents to unwanted sexually explicit content

Sexual Abuse - Potential Signs

• Sudden changes in behavior such as fear of people or places 

• Sexually explicit behavior or sex play 

• Lack of desire to engage in sexual behaviors

• Regression to younger behaviors such as bedwetting

• Developmentally inappropriate interest in human sexuality

• Discomfort, bruising or bleeding around the breasts, anus, or genital area

  • Underclothing that is damaged or contains blood stains

• Unexplained or recurring sexually transmitted infections (STIs)

• Difficulty setting boundaries for sexual engagement with others

Neglect and Abandonment signs

• Unattended or untreated health problems

• Dehydration, malnutrition, untreated pressure injuries, and poor personal hygiene

• Hazardous living conditions include improper electrical work, no running water or heat

• Poor living conditions include visible dirt, insect infestation, soiled bedding, fecal/urine smell, insufficient clothing

• Desertion of a vulnerable individual 

• Client claim of being abandoned or mistreated

Financial Abuse

Misuse of another person’s financial resources, with or without permission

Financial Abuse signs

• *Sudden banking and accounting changes such as unexplained withdrawals, transfers, or the addition of unauthorized names onto accounts.

• *Abrupt changes in availability of funds, possessions, wills or other financial documents

• *Individual does not remember signing financial records 

• *Individual’s report of exploitation

Anger - an intense emotion with both positive and negative effects.

• Unrestrained it can result in harmful physical and emotional effects 

  • Hypertension 

  • Headaches 

  • Insomnia 

  • Digestive issues 

  • Possibility of harm to self and others

• May be displayed with cursing, sarcasm, yelling, breaking an inanimate object, or making a fist, but is not often followed by an aggressive act 

Aggression 

• Actions intended to harm 

• Can be either physical, psychological, or both

Using Coercion and Threats

(i.e., Threatening or performing acts to end a relationship, hurt someone, harm self, or expose private information about the victim.)

Using Intimidation

(i.e., Evoking fear through physical actions or verbal and non-verbal communication that includes weapon exhibition, destruction of property, or abusing pets.)

Using Emotional Abuse 

(i.e., Humiliating behaviors with the intention of affecting the victims’ self-esteem or causing the victim to question their reality.)

Using Isolation

(i.e., Controlling an individual’s physical and psychological contact with others and using jealousy as a justification for behaviors.)

Denying, Minimizing, & Blaming

(i.e.,  Denying intent of the abuse or shifting responsibility of the abuse toward others. Perpetrators will often minimize the victim’s concerns or claim that their feelings are not important.)

Using Children

(i.e.,  Using relationships with children as a means to cause the victim to feel guilty or through threats of removing children from their living situation.)

Using Privilege

(i.e.,  The victim does not participate in big decision making and feels as if they are not equal participants in the relationship.)

Using Exploitation of Resources 

 (i.e., Preventing an individual from working, control financial resources, and in some cases, assigning the individual an allowance.)

Violence

• Ultimate form of aggression such as murder, rape, or other forms of physical assault

• Increased risk for violent acts among the following individuals 

  • Substance use disorder 

  • Traumatic brain injuries (TBI) 

  • PTSD 

  • Bipolar I disorder

  • Impulse control disorders

  • Attention deficit hyperactivity disorder (ADHD

  • Exposed to violent situations

Risk Factors for Abuse, Aggression, Violence

• History of violence

• History of mental health disorder including substance use

• Being the victim of a crime

• Witnessing abuse or violence

• Poor self-esteem and inadequate coping skills 

• No presence of positive role models throughout childhood

• Adverse childhood experiences 

• The inclination to be violent, angry, or aggressive can occur when a person feels deceived, invalidated, frustrated, attacked, threatened, powerless, and/or treated unfairly. These behaviors can also occur when people believe their feelings or possessions are not being respected (Mind, 2018).

Clinical manifestations: perpetrator

• Defense mechanisms are often used to shield one from disagreeable or objectionable thoughts and sensations

  • Displacement

    • Example: Client may be angry with their coworker but expresses that anger toward their partner or child 

  • Undoing

    • Example: Client emotionally abuses their partner in front of others but the next day buys them the new piece of clothing they wanted

Abuse Warning Signs: Inpatient

• Declining to eat or drink

• Attempting to leave area before discharge 

• Verbally antagonistic toward staff or visitors 

• Harming self 

• Staring 

• Pacing 

• Destroying inanimate objects

• Nurses need to recognize warning signs to protect themselves and others from violent outbursts. 

Perpetrator

Develops an excuse, or rationalizes behavior

Noncommunicative; no attempt to cooperatively develop a solution.

Uses intimidation to control others and as a means of temporarily resolving unwanted feelings or emotions

Uses sex as a method to relieve unwanted thoughts or feelings; pornography

Victim

Blames self as the reason for abuse and often reports feelings of guilt

Feels like there is no resolution to behaviors

Does not feel like financial or emotional independence is possible

Lack of desire to engage in sexual behaviors and reports setting poor boundaries of sexual engagement with others

Childhood aces

Child Abuse Prevention and Treatment Act (CAPTA) defined child abuse and neglect as "any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm.”

ACEs - Potentially traumatic events that a child experiences before the age of 18 that can affect them later in life, both emotionally and physically. (CDC, 2021) 

• Experiencing violence, abuse, or neglect 

• Family member attempted or died by suicide 

• Observing violence in the home

• Unsafe or instable home environment (substance misuse, mental illness, parental or sibling separation)

bullying

• Uninvited behaviors from one youth or group of youths to another that are aggressive in nature. Can occur physically and electronically. Cyberbullying account for 15% of bullying

• Customary forms of bullying 

  • Kicking, hitting, tripping 

    • Teasing and name-calling 

    • Excluding targets from group or spreading rumors

    • Destruction of property belonging to target

• Core elements 

  • Repeated bullying behaviors 

  • Perceived or actual power imbalance 

  • Unwanted aggressive behaviors 

Intimate partner violence (IPV)

• Physical violence, sexual violence, stalking, or psychological aggression by a current or former partner or spouse 

• Does not require sexual intimacy 

• 25% of women and 10% of men in the United States 

  • Higher risk among LBQT+

• Three phases

• This cycle of violence is applicable in all instances of aggression or violent acts and is not limited to IPV. 

• Survivors of IPV may develop subsequent medical issues related to reproductive, cardiac, digestive, neuromuscular, and skeletal systems, in addition to PTSD or a depressive disorder. They are more likely to participate in behaviors detrimental to their health, such as unprotected sex, smoking, or excessive consumption of alcoholic beverages (CDC, 2021). 

Phase1: Build-Up

• Can last days, weeks or years 

• Breakdown in communication occurs

• Perpetrator initiates more arguments 

• Environment becomes more tense

• Abusive incidents begin

Phase 2:  Acute 

• Normally limited to a few hours up to 24 hr. 

• Abusive acts are filled with rage and intensity 

• Law enforcement may become involved

Phase 3: Honeymoon/reconciliation

• Perpetrator becomes very affectionate and apologetic toward survivor

• Regretful of actions and promises to change

• Will frequently continue to maintain control over survivor through economic and emotional abuse

• This phase can create a false sense of hope and reconciliation, which often leads back to the build-up phase, continuing the cycle.

Stalking

• Unwanted attention, such as threats or harassment

• Frequently involves individuals known to the person being stalked

• Approaches used by stalkers

  • Following and watching their target

  • Obtaining entry into target’s car or house and leaving items to let them know they can enter at any time

  • Showing up unannounced at target’s home, workplace, or school 

  • Nuisance phone calls, emails, text messages, etc. 

Elder Abuse

• The people experiencing neglect, abuse, or financial exploitation are often those who are more dependent upon others for daily care, including those with cognitive impairment, physical disabilities, and those with few friends or family members.

• Risk increases as dependency on others increases

Rape and Sexual Assault

• Rape includes forced sexual intercourse, including both psychological coercion as well as physical force

  • Forced sexual intercourse involves penetration by the offender(s)

  • 2/3 of victims know their assailant (acquaintance rape)

• Statutory rape is defined as an adult having sex with an individual younger than 18 years of age, even if the minor consents to the act 

• Sexual assault involves unwanted sexual contact between survivor and offender. 

  • Verbal threats, fondling, or grabbing

Sexual Assault Nurse Examiner (SANE)

• A registered nurse who has advanced education in forensic examination of sexual assault survivors and in some communities is referred to as a forensic nurse examiner (FNE) 

  • Conduct focused genital examinations 

  • Preserve specimens and collect evidence 

  • Debrief potentially traumatizing situations 

  • Administer medications to treat or prevent sexually transmitted illnesses

  • Focused on Client safety and protection from any further harm 

  • May provide expert testimony during legal proceedings based on objective findings

 Care for Survivors

Survivors may 

• Deny anything happened

• Be fearful of what will happen to them once they leave the facility

• Be wary of health care professionals

• Demonstrate lack of concern about their own needs

• Be sleep deprived or malnourished 

Nurse’s Role in sexual abuse

• Approach should be gradual and nonthreatening

  • Do not touch the survivor without asking for permission to do so

  • Allow the client to control the conversation

• Equitable and sensitive care 

  • Self-awareness

  • Client-centered care

  • Management of agitation

  • Prevention

• Remove the client from what may be annoying them and Allow the agitated client some space and time to regain a calm demeanor 

• Ask what you can do

• Respond in a calm manner 

  • Displaying any outward signs of anger or speaking in an angry tone can escalate the situation 

• Implicit bias

• Unconscious discriminatory attitudes

  • Trigger negative reactions/ fear

• Can create disparities in care

  • Ethic, racial, minority groups

• Stereotyping

  • Based on previous experiences with anger

• Situational awareness 

• Do not stand directly in front of or within arm's reach of a client and 

• Avoid having clients feel they are trapped by blocking the doorway

• Knowing the layout of the area and how to remove yourself, if necessary

• Habit-breaking strategies 

• Recognize inequitable effects of bias 

• Commit to breaking the habit 

• Practice the desired behaviors 

• Replace stereotypes 

• Practice mindfulness 

  • Focus on the present 

  • Take slow, deep breaths prior to entering client room

  • Become more deliberate in actions—pay attention to feelings and assumptions

Client-Centered Care

• Develop a therapeutic relationship

• Culturally relevant

• View illness from client perspective

  • Aggression can signify distress or unmet needs

Managing agitation

• Remove the client from what may be annoying them

  • Could be the staff or another client 

• Allow the agitated client some space and time to regain a calm demeanor 

• Ask what you can do

• Respond in a calm manner 

  • Displaying any outward signs of anger or speaking in an angry tone can escalate the situation 

• Situational awareness 

  • Do not stand directly in front of or within arm's reach of a client and 

  • Avoid having clients feel they are trapped by blocking the doorway

  • Knowing the layout of the area and how to remove yourself, if necessary

TAKE ACTIONS: NONPHARMACOLOGIC

• physical activity

• contingency management

• seclusion

• de-escalation

• restraints

De-escalation

• Engage.

  • Respect personal space and remain calm.

• Establish verbal contact.

  • Introduce self and say client’s name. May need to be repeated.

• Stay simple and concise.

  • Keep directions and questions simple. Wait for the client to respond.

• Identify wants and feelings.

  • Use reflections to help the client feel understood.

• Set clear limits.

  • Make sure the client understands what is acceptable and unacceptable.

• Offer choices and optimism.

  • Empowers the client with choices (food, water, space, blanket).

Seclusion and Restraints - Considerations

• Use of restraints is initiated only if other less restricting measures have been unsuccessful in mitigating the implied danger to self, client, or others.

• Typically applied to upper extremities first with five(5) staff (one for each extremity and one for the head)

• Requires a prescription. Prescription must include

  • Reason for the seclusion or restraint 

  • Length of time 

  • Type of restraints

  • Criteria needed for removal from seclusion or restraints

• Client is evaluated by provider, RN, or physician assistant within 1 hour

• Restrained clients are not to be left alone 

• Observe for any injuries, breathing or other physical difficulties. Ensure restrains are not impeding circulation or causing pain

• Anticipate need for comfort, hygiene, ADLs

• ROM exercises every 2 hours

• All interactions with the client should encourage behavior that will promote release from seclusion and/or restraint 

Long-term control of aggression

• Antipsychotics 

• Mood stabilizers 

• Anticonvulsants

• Antidepressants

• When oral meds fail, it is common to administer an intramuscular(IM)injection. 

NSSH

Coping mechanism

• Clients engaging in NSSH do so to cope with emotional pain and distress. Some clients say that the NSSH allows them to “feel something.” Loss of situational control, anger, anxiety, depression, and stress are common factors noted by clients who engage in NSSH (Astrup, 2019). May feel that they have no control of emotions

Intentional harming of self and involves

• Cutting (most prevalent) 

• Scratching

• Biting

• Carving words or designs into skin 

• Burning

• Hair-pulling 

• Head-banging 

• Other self-inflicted destruction of body tissue (ex. Hitting themselves)  

Risk Factors- sh

• ACES

  • Poverty

  • Abuse neglect

  • Unresolved family issues

• Usually starts in adolescence

  • School pressures

  • Unhappiness with appearance

• Associated mental health disorders

  • Eating disorders

  • Borderline personality disorders

  • Substance use disorders

NSSH Warning Signs and Long-Term Effects 

• Infections

• scarring

• excessive bleeding

• shame and guilt

• reduced sense of self

• social isolation

• suicide

  • Studies have shown that NSSH is one of the most dependable forecasters of a future suicide attempt and should be taken seriously

• Intent may not be death

NSSH Interventions

• Reaching out immediately (phone or text) to a trusted confidante or psychosocial professional/service . Early intervention is key to successful treatment

• Explore creative avenues of expressing emotions (coloring, drawing, journaling) or exercise

• Re-center thoughts and emotions by focusing on things that interest them 

• Developing action plan that can be implemented when the desire to engage in NSSH occurs 

• Educating clients and significant others about NSSH thought processes 

• Establishing a support system of trusted individuals 

• Clients use NSSH to deal with unpleasant emotions, so treatment should focus on addressing those underlying feelings.