Family Violence and Abuse - Helping Victims and Survivors

Introduction
Abuse and violence in the family refer to physically and emotionally harmful behaviors that occur between family and household members. It includes child abuse, child neglect, intimate partners abuse and violence, marital rape, and elder abuse. It could be a learned behavior that can be unlearned through therapy. Perpetrators try to isolate the family to keep it secret and avoid sanctions. They usually have some power and control over the other members of the family. They may rationalize the violence with their drug use. The use of cocaine, PCP, amphetamine etc may increase violent behavior.

Forms of Abuse
Physical abuse includes hitting, punching, shoving, stabbing, shooting, kicking, and withholding medication, wheelchair, food, and fluids. Sexual abuse includes coercion, marital rape, and withholding sex. Psychological abuse includes threat, harassment, and blackmail. Emotional abuse includes name-calling, insults, and ridicule. Economic abuse includes total control over finance, running up bills, forbidding school or work.

Reality About Violence
Family violence occurs at all levels of society. Separation or divorce may not end violence. Abuser does not need to be provoked. Some survivors wrongly tend to blame self. Treat the violence but also the alcohol, drug, stress, and mental health problems if any. Violence occurs between gays and lesbians too. Abused women are discouraged from disclosure by threats, fear, denial and disbelief expressed by 'confidants'.

Models of Intervention
The Paternalistic model assumes that the clinician has more knowledge than the patient; that the survivor is responsible for ending the violence; that the clinician should give advice and sympathy; and see the patient as a victim. Whereas, the Empowerment model, which is better, assumes that the clinician should mutually share knowledge with the patient, plan strategies with the patient, respect patient's competence, experience and strengths, and see the patient as survivor.

Response of Survivors to Violence
Physical signs of abuse include injuries at multiple sites in various stages of healing (head, neck, face, throat, sexual organs), headache, insomnia, and stress. Behavioral sign is that the individual does not leave the abuser or leaves and returns before making a final break. Psychological signs include delayed reaction, depression, lowered self esteem, attributions e.g. self-blame, impaired school or work performance and conduct, poor concentration and poor problem solving.

Why Doesn't The Individual Leave the Abuser?
Abused individuals do not leave the abuser for variety of reasons, which include fear of being stalked and killed (which is a realistic fear), strong emotional attachment to the abuser, determination to end the abuse, sanctions present in the couple's culture, fear of stigma, lack of resources to live away from the abuser, and consideration of what will happen to her children if she leaves. She may leave and return, thinking, "Maybe he will change".

Child Abuse & Neglect
In every state, child abuse and neglect are must be reported. Types of abuse include child sexual abuse, child physical abuse, child emotional abuse, and child neglect. Child that witnesses family violence may also suffer abuse.

Child Sexual Abuse
This is the involvement of children in sexual activities that they do not fully comprehend and to which they do not or cannot freely give consent. This violates child's trust in the adult that is supposed to protect him/her. Threat to the child, pet, and others keeps the child quiet. It results in confusion, shame, and helplessness. Its effect may last a lifetime and affect mental health. It may be guarded as a family secret.

Observable Signs of Sexual Abuse
The observable signs of child sexual abuse include physical aggression, excessive masturbation, social withdrawal, low self esteem, impaired school performance, sleep disturbance, STD's, bleeding, soreness, itching, UTI, pregnancy, bruises, swelling, redness, fracture, burns, and unkempt appearance.

School Violence
School violence is usually due to child drug use, child's access to guns, antisocial and impulsive behaviors, family dysfunction, community unresponsiveness, interpersonal disputes, and bullying and harassment by peers.

Child Abduction
Most abduction is done by a parent. 70% are by fathers, 25% by their mothers. Parents that are likely to abduct include those that have threatened or attempted it in the past, suspect abuse by the other parent, may be paranoid, may intend to use it as revenge, punishment, trophy, or one that strongly believes that child be raised in his or her home country.

Child Abuse Assessment and Intervention
Explore and be aware of your own attitude to abuse survivors so as not to be judgmental. Do a thorough history & physical assessment. Use private, quiet uninterrupted environment. Honestly state the purpose of the interview. Inform victim of the pending physical assessment. Use a calm and supportive approach. If possible, interview child separately first before joint interview with parent or guardian. Pay attention to child's affect (look) and behavior, mother's understanding of the problem, discrepancies in their stories, and parent's emotional responses. Document your assessment fully. Report suspected abuse to CPS. Coordinate services such as further assessment, psychological testing, individual psychotherapy, family psychotherapy, and group psychotherapy.

Intimate Partner Violence (IPV)
IPV is a pattern of coercive and assaultive behavior between intimate and dating partners. Abuse of female partners is the more prevalent IPV. Female violence is more often in self-defense. Many IPV end in homicide or homicide-suicide. Leaving or an attempt to leave by the victim increases homicide risk. There is a higher homicide risk with handgun, history of suicidal ideation or attempt, battering during pregnancy, sexual abuse, substance use, extreme jealousy, and controlling behavior ("if I can't have you, no one can"). Few women kill their abusers if there is no intervention. Assessment of IPV should be part of mental health assessment. Ask partners about history of conflicts, "pushing and shoving", and quality of relationship. Observe for hesitation, looking away, and unease. Be supportive, let victim know she is not alone. Describe and map the extent of injuries. Assess for attribution e.g. self-blame. Assess for depression, PTSD, and anxiety. If patient is the abuser, assess potential for further violence. Consult legal advisor for "Duty to Warn". Courts have made it mandatory abusers (happens to be mostly men) to be treated. Treatment includes confronting the violence, affirming that responsibility lies with the abuser, behavior therapy, anger control, attitude change to women, couple counseling, and cognitive behavior therapy (CBT). Empower the woman, using laws, community resources, support groups, and safe shelters. Mutually set goals with the victim. Mutually consider and choose from options. Help mobilize natural, social and professional supports.

Rape and Sexual Assault
This affects men, women and children, especially women and children. Sexual assault is a forced act of sexual contact without consent. It is usually done to humiliate, defile or dominate the victim. Rape is a felony, yet majority is unreported. Survivors of marital rape do not seek care because of embarrassment and humiliation. Careful assessment and questioning is needed. In caring for the victim, listen, be nonjudgmental, and provide emotional support. Document your observation and assessment fully. Help collect evidence if patient chooses to litigate. In the acute stage, assess for fear, disorganization, shock, and restlessness. In the second stage, assess for flashbacks, phobias to places and people, and sexual difficulties. Encourage the victim to discuss feelings. Explore options e.g. changing phone number. Explore available community services and support groups. Refer for physical treatment and psychotherapy. Plan for a follow-up phone contact in a few days.

Elder Abuse
There are about 5 million abused elderly persons in the US annually. Spouse abuse overlaps with elder abuse. The abused does not report for fear of being abandoned to a nursing home or being isolated. Signs include bruises on arms, wrists, ankles, face lacerations, vaginal lacerations, fractures, malnutrition, poor hygiene, dehydration, flinching and shrinking away in the presence of abuser. Help and care include reporting a suspected abuse to the Adult Protective Services (APS), counseling, psychotherapy, substance abuse and treatment of the abuser, if necessary.

Reference: Stuart, G. W. & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.). St. Louis, MO: Elsevier Mosby.