Mental Health Care for People Who Have Experienced Violence

Mental Health Care for People Who Have Experienced Violence

Overview of Violence

• Definition of Violence:
    - A form of abuse affecting intimate partners, children, and older adults.
    - Recognized as a national health problem.
    - Causes profound changes in the perception of life for victims, affecting core beliefs about the self, others, and the world.
    - Without intervention, can severely damage self-esteem and sense of security.

• Types of Violence and Abuse:
    - Intimate Partner Violence (IPV)
    - Child Abuse and Neglect
    - Elder Abuse

Intimate Partner Violence (IPV)

• Definition and Context:
    - Involves physical, sexual, and psychological abuse, or a combination, inflicted by a current or former spouse or partner.
    - Prevalence:
      - Most common form of abuse.
      - Affects one in four women and one in ten men.
  

• Continuum of Abuse:
    - Ranges from psychological abuse to lethal violence.

• Forms of IPV:
    - Physical Abuse:
      - Acts of aggression resulting in injury, pain, or impairment.
      - Examples include striking, kicking, shoving, choking, and burning.
  
    - Psychological Abuse (Emotional):
      - Use of threats, intimidation, or destructive behavior.
      - More prevalent than physical abuse.
     
    - Teen Partner Abuse:
      - Violence within intimate relationships among teenagers.
      - Sustains risks of depression, substance misuse, eating disorders, suicidal thoughts, and further abuse.

Comorbidities of IPV

• Chronic Conditions Associated with IPV:
    - Chronic stress
    - Anxiety
    - Depression
    - Post-Traumatic Stress Disorder (PTSD)
    - Substance Use Disorder
    - Medical Conditions:
      - Asthma, gastrointestinal issues, cardiovascular problems, bladder infections, migraines, joint pain, gynecological disorders, sexually transmitted diseases (STDs), and traumatic brain injuries.

• Risk Factors for IPV:
    - Younger women, recently divorced or separated.
    - Native American and Alaska Native women at heightened risk.
    - LGBTQIA+ couples experience similar rates as heterosexual couples.
    - Substance abuse, particularly alcohol.

• Characteristics of Perpetrators:
    - Low self-esteem
    - Traits of antisocial or borderline personality disorders
    - PTSD and depression history
    - History of violence
    - Abuse during pregnancy linked to adverse outcomes: miscarriages, low birth weight, low maternal weight gain, infections, and anemia.

Sexual Abuse

• Definition:
    - Any non-consenting sexual activity, ranging from verbal threats to penetration.
    - Rape as the most severe form of sexual assault and a criminal act.

• Victims of Sexual Abuse:
    - Children, adults, and older adults predominantly abused by family members, caregivers, or trusted figures.
    - Adolescents and young adults vulnerable to drug-facilitated assaults by acquaintances (e.g., date-rape drugs and alcohol).

• Connection to IPV:
    - Sexual assault often occurs alongside intimate partner violence.

Stalking and Human Trafficking

• Stalking:
    - Involves repeated unwanted contact and harassment, often increasing in frequency.
    - Cyberstalking:
      - Utilization of internet and telecommunications technologies.

• Human Trafficking:
    - Involves use of force, fraud, or coercion for labor or commercial sex acts.
    - Victims can be any age, race, ethnicity, gender, or nationality.
    - Traffickers target those emotionally, psychologically, or financially vulnerable.
    - Warning Signs:
      - Unexplained injuries, malnourishment, poor health, lack of identification, reluctance to communicate with providers.

Child Abuse and Neglect

• Definition:
    - Includes acts of commission and omission.
    - Acts of Commission: Intentional harmful behaviors (e.g., physical, sexual, psychological abuse).
    - Acts of Omission: Failure to meet a child's basic needs (neglect).

• Neglect:
    - The most common form of child abuse, particularly affecting children under four years of age.
  

• Risk Factors for Child Abuse:
    - Children from unwanted pregnancies
    - Children with developmental or physical disabilities
    - Young parents lacking resources or support
    - Stressors including emotional issues and substance misuse.

Elder Abuse

• Vulnerabilities:
    - Older adults with physical or mental disabilities are particularly susceptible.
    - Types of elder abuse include physical, psychological, financial, emotional, and sexual.
  

• Financial Abuse:
    - The most common form of elder abuse.
  

• Statistics:
    - One in ten individuals over the age of 60 suffer abuse, including neglect and exploitation.
  

• Risk Factors for Elder Abuse:
    - Aging, impaired activities of daily living (ADLs), cognitive disabilities, dependency on caregivers, isolation, stressful life events, and insufficient support systems.

Theories of Violence

• Intergenerational Transmission of Violence (Social Learning Theory):
    - Suggests children who witness or experience violence, including harsh discipline, are more likely to perpetuate or experience violence in their own families.

• Social-Ecologic Model of Violence Prevention:
    - Indicates communities lacking economic advantage, cohesion, and nurturing reduce social control over violent behavior.

• Gender-based Influences:
    - IPV manifested from gender imbalances in power dynamics within relationships.
    - Often explains violence against women as a result of gender inequality, patriarchal structures, and the subordination of women.

Cycle of Violence

• Phases of the Cycle:
    - Phase 1: Tension Building:
      - Minor incidents where the perpetrator establishes control through psychological means, involving verbal abuse and isolation.
  
    - Phase 2: Violence Erupts:
      - Severe violence occurs followed by a calming phase.
  
    - Phase 3: Remorse Ensues:
      - The perpetrator displays kindness and contrition, promising to reform; however, tension builds again, leading to the cycle's repetition.

• Factors Influencing Decisions to Leave vs. Stay in Abusive Relationships:
    - Fear of retaliation, economic dependence, concerns over child custody, emotional attachments, and safety issues.

Reporting and Safety Issues

• Mandatory Reporting:
    - Health care providers are mandated reporters for known or suspected abuse of children and vulnerable adults.

Therapeutic Relationship

• Establishing Trust:
    - Trusting nurse-patient relationships are crucial; begin discussions in less sensitive areas before addressing more sensitive topics.
    - Patients are unlikely to share sensitive information unless they feel validated and non-judged.

• Confidentiality:
    - Ensuring confidentiality and providing a private setting are essential.

Evidence-Based Nursing Care

1. Mental Health Nursing Assessment:
      - Conduct safety assessments, including the Danger Assessment (15-question tool for homicide risk in IPV) and the shorter Danger Assessment-5.
      - Use abuse assessment screens and the Burgers partner abuse scale for teen abuse detection.

2. Physical Health Assessment:
      - Document vital signs and note signs of PTSD or depression (e.g., sleep disturbances, startle responses).
      - Assess physical injuries with body mapping for documentation.
      - Conduct sexual assault examinations with evidence gathering and addressing psychosocial needs.
      - Training a Sexual Assault Nurse Examiner (SANE) is critical for proper assessment.

3. Psychosocial Assessment:
      - Evaluate fear, low self-esteem, feelings of guilt and shame, intimacy issues, revictimization, and social networks for support.

4. Development of Safety Planning:
      - Help survivors recognize danger signs and devise escape plans.
      - Basic needs must be met, such as nourishment and safety, prior to addressing psychological trauma.

5. Psychosocial Interventions:
      - Assist survivors in verbalizing experiences in a supportive environment and help children through techniques like play therapy.
      

6. Managing Anxiety and Anger:
      - Teach coping strategies and anger management techniques, including "I feel" statements.
      

7. Psychoeducation:
      - Educate on self-protection, healthy relationships, and provide resources for support.

Treatment for the Abuser

• Court-Mandated Programs:
    - Typically outpatient with duration from 36-48 weeks up to 1-5 years for chronic abusers.
    - Techniques used include cognitive-behavioral methods and psychoeducational topics.
    - Programs should incorporate criminal justice support and accountability for violent behavior.

Case Example and Discussion Questions

• Scenario Analysis:
     - A nurse assesses a woman whose husband fits the profile of antisocial personality disorder; the likely behavior includes risk for aggressive violence.
     

• Communication on Intergenerational Transmission of Violence:
     - An appropriate response emphasizes that individuals from violent homes are more likely to perpetuate violence in adulthood.

References

• Boyd, M. A., & Luebbert, R. (2022). Psychiatric nursing: Contemporary practice (8th ed.). Wolters Kluwer.

• RN Mental Health Nursing (12th ed.). (2021). Assessment Technology Institute.