Chapter 33: Survivors of Violence & Trauma

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Hello everyone and welcome back to the Deep Dive.

We're doing something a little different today.

We are on a specific mission.

We're calling this the Last Minute Lecture Series.

Which I love, by the way.

It sounds urgent.

It is urgent.

It sounds like we are cramming, which, let's be honest, is the natural state of every nursing student I have ever met.

It really is.

We know who is listening to this right now.

You are likely a nursing student.

You probably have a massive exam on the horizon, or maybe you are literally driving to your first clinical rotation in a psychiatric unit.

Oh, that's feeling.

And you are realizing you haven't reviewed the material on trauma.

You have your textbook, Psychiatric Nursing, Seventh Edition.

Maybe it's on the passenger seat.

Maybe it's buried under a pile of laundry.

But today we are going to crack it open for you, specifically Chapter 33.

Survivors of Violence and Trauma.

It is one of the heaviest chapters in the book, but also one of the most critical.

And when you say heavy, you mean it covers the entire spectrum of human cruelty, basically.

It does.

I mean, we are going to be talking about rape, childhood sexual abuse, partner abuse, torture,

terrorism.

It is a lot.

But here is the mission for today.

We need to synthesize this.

We aren't just reading the book to you.

No.

We are going to extract the clinical pearls, the exam -worthy concepts, and the practical, what do I actually say to the patient?

That advice.

Because I think the misconception, especially when you are just starting out in nursing, is that trauma is an ER issue.

You think, okay, someone gets attacked, they go to the ER, we fix the broken bones, we stitch the cuts, and we are done.

That is the medical model.

Sure, fix the hardware.

But this chapter is arguing that the nurse's role goes so much deeper than that.

You can stitch up a laceration in 20 minutes.

But how do you stitch up a shattered sense of safety?

How do you treat a patient who believes that the world has fundamentally stopped making sense?

That is where the psychiatric nursing component comes in.

And honestly, that recovery process, the psychological one, is often where the real battle for survival happens.

So, to keep us on track, because this is a massive topic, we are going to follow the structure of the text pretty closely.

We will start with the big picture,

how people react to crime and violence in general.

Then we are going to break down the three stages of recovery.

Which is absolutely high yield for exams.

If you take nothing else away from this, learn those stages.

We will definitely flag that when we get there.

Then we are going to move into specific populations, survivors of terrorism, the hitting crimes like torture and human trafficking.

And then we will spend a good chunk of time on sexual assault and partner abuse.

And through all of this, we need to keep looking through what the text calls the forensic lens.

We will talk about what a forensic nurse actually does, and specifically the end nurse, the sexual assault nurse examiner.

Right, the bridge between healthcare and the legal system.

An incredible bridge, yeah.

So let's dive in.

The chapter opens with a statistic that honestly I had to read twice.

It says over 11 million people in the U .S.

experience violent victimization annually.

11 million.

And you have to remember, in epidemiology and public health, we always assume the reported numbers are just the tip of the iceberg.

So the real number is probably way higher.

Almost certainly higher, yeah.

That is just a staggering amount of pain.

But the text moves pretty quickly from the stats to the psychology.

It introduces this concept of the assumptive world.

This is such a foundational concept for this entire chapter.

It sounds a bit abstract.

The assumptive world.

What are we actually talking about?

Well, think about your morning.

You woke up.

You probably made coffee.

You walk out your front door.

Maybe you got in your car.

In doing all those simple things, you're relying on a massive set of unconscious assumptions.

You assume your neighbors aren't going to, snipe you from the window.

You assume the car isn't rigged to explode.

You assume that because you are a good person who follows the rules, you are generally safe.

Right.

I don't actively think I am safe.

I just operate.

I assume it.

Exactly.

It's this bubble of invulnerability.

We need it to function.

If we were constantly aware of every single potential danger, we'd be paralyzed.

We'd never leave the house.

Never.

What crime does, especially violent crime, is it pops that bubble.

It shatters the assumptive world.

Suddenly the victim realizes,

I am not safe.

I am not in control.

Bad things can happen to me regardless of what I do.

So it's an existential crisis as much as a physical one.

It is.

The text talks about the destruction of trust and autonomy.

If someone holds a gun to your head or assaults you, they are forcing their will upon you.

They are proving in that moment that you have zero autonomy.

That realization is what leads to the trauma response.

And the text mentions that the emotional reaction to this isn't just fear, it highlights a very specific sensation, contamination.

Yes.

This is crucial for nurses to spot.

It's such a key symptom.

It's just literal, like feeling physically dirty.

It feels literal to the patient.

We see this even in crimes that aren't sexual.

Yeah.

You could be mugged at knife point, never touched inappropriately, and you will still feel dirty.

Survivors often talk about scrubbing their skin in the shower until it's raw.

They are trying to wash off the feeling of violation, the feeling that the perpetrator's intent has somehow stained them.

That connects to the shame and guilt the text discusses, the whole what did I do wrong reaction.

Which is so tragic, isn't it?

The brain, it's a meaning -making machine.

It tries to make sense of the trauma by looking for a cause.

If I can find the cause, like I wore the wrong shirt or I walked down the wrong street, then I can fix it and prevent it from happening again.

So paradoxically, blaming yourself is a way to try to regain control.

It's a distorted attempt to regain a sense of agency, yes.

But then we have the external blame, the blame the victim phenomenon.

And this is where I think we need to be really real with the nursing students listening.

We like to think we are the good guys, we are the helpers, but the text suggests that hospital staff, nurses, doctors can be part of the problem.

We absolutely can be.

And it's usually not malicious, which makes it even more insidious.

It's often accidental.

Okay, give me an example.

How does a nurse accidentally blame a victim?

Okay, picture this.

You're in the ER,

a young man comes in.

He's been beaten up pretty badly outside a bar.

You're cleaning his wounds and you're trying to get the history.

You ask, so why were you at that bar so late?

Or did you have a lot to drink?

Or why didn't you just walk away when the guy started yelling?

Exactly.

Those sound like logical questions.

You're just gathering data.

Yeah, you're trying to understand the events.

To you, they are logical.

To the patient who is currently in shock and pain, those questions sound like accusations.

Why were you there?

Implies, you shouldn't have been there.

Did you drink?

Implies, you brought this on yourself.

Wow.

Okay.

So it shifts the responsibility from the attacker to the victim.

Precisely.

And that can be incredibly damaging.

It reinforces that internal shame we just talked about.

As a nurse, you have to be so disciplined with your language.

The message has to be unequivocal.

This is not your fault.

The person who hurt you is responsible for their actions.

Period.

That's a good script to memorize.

This is not your fault.

Now, sadly, the hospital itself isn't always a sanctuary.

The chapter pivots to workplace violence.

And this hits close to home because it's not talking about patients attacking each other.

No, it's talking about nurses getting hurt.

The statistics are sobering.

The text says 13 % to 21 % of nurses report physical violence in a given year.

And that's just physical.

If you look at emotional or verbal violence, the number jumps to over 50%.

Over half the workforce.

That is unacceptable.

It is.

And we need to distinguish between the types of violence the text defines.

There is the violence from patients or intruders, which is a huge issue.

But then there is horizontal violence.

Horizontal.

So peer to peer.

Yes.

This is the clinical term for bullying among colleagues.

Is this the famous nurses eat their young concept?

It is, unfortunately.

And I want to be clear.

The text doesn't frame this as just personality clashes.

This is violence.

It's intimidation.

It's withholding information so a new nurse fails.

It's rolling your eyes during report.

It's exclusion.

It sounds like high school, but with life or death consequences.

That's the problem.

It destroys the safety culture.

If I'm afraid you're going to mock me, I'm not going to ask you for help when my patient is crashing.

And that's horizontal violence.

Yes.

Then you have vertical violence, which is the power dynamic abuse.

Managers or doctors bullying staff.

And the text also brings up sexual harassment and stalking in this context.

There was a myth buster in there about stalking that I found fascinating.

I think when most of us hear stalker, we think of the celebrity stalker.

The fan who is obsessed with the movie star.

Right.

The John Hinckley Jr.

type, the person they've never met.

But the text clarifies that.

It's actually pretty rare.

The vast majority of stalking involves people who know each other.

Really?

Yeah.

Usually it's someone trying to end a relationship and the partner, the stalker, refuses to let go.

Obsessional pursuits.

That's the term they use.

Yes.

And it's dangerous because it often escalates.

It's not just annoying.

It's often a precursor to physical violence.

So what is the takeaway for the institution?

What should a hospital do about all this?

Zero tolerance.

That's the phrase the text uses.

You cannot have a culture where, oh, that's just how a doctor so -and -so is or toughen up rookie.

There needs to be systematic education and a clear, enforced policy that if you are being harassed or stalked, the institution will protect you.

Okay.

So we've established the landscape of violence.

It's everywhere.

Streets, homes, and hospitals.

Now let's get into the clinical meat and potatoes.

Part two, the model of recovery.

Okay.

Yes.

If you have a highlighter, uncapping it now would be a good idea.

The text outlines a three -stage model of recovery.

Why is this model so important for a nurse to know?

Because trauma recovery isn't random.

It's not chaos.

It follows a predictable trajectory.

If you know where the patient is in the cycle, you know how to help them.

You know what interventions are appropriate.

And if you don't.

If you try to use stage three interventions on a stage one patient, you're going to fail.

You might even do more harm.

So let's walk through them.

Stage one, impact.

The text calls this initial disorganization.

This is the acute phase.

Minutes, hours, maybe a few days after the event.

The world has just exploded.

The brain is completely overwhelmed.

What does the patient look like here?

What am I seeing in the exam room?

Well, this is where it gets tricky for new nurses.

The textbook answer is shock,

denial,

disbelief, confusion.

You might see someone who is hysterical, screaming, crying.

That's easy to spot.

But, and listen closely here, you might see the exact opposite.

The deceptive calm.

Yes, yes.

The frozen fright.

You walk into the room and the patient is sitting there, totally still.

They answer your questions in a flat, monotone voice.

They seem fine.

They might say, I just want to go home.

I have to feed my cat.

And a novice nurse might write, patient is coping well in the chart.

Which would be a massive error.

That calm is a defense mechanism.

They are dissociating.

Their mind has checked out because the reality of what just happened is too big to process.

They are on autopilot.

So what is the nursing intervention in stage one?

Do we start therapy?

Do we ask them to tell us how you feel?

Absolutely not.

They don't know how they feel yet.

In stage one, the intervention is all about safety and security.

We go right back to Maslow's hierarchy of needs.

The basics.

The absolute basics.

Are you warm?

Here's a blanket.

Here is some water.

I am going to stay with you.

You give simple, clear, concrete directions because their brain is not processing complex information.

Sit here.

Drink this.

You are acting as their external ego because theirs is temporarily offline.

Simple and safe.

That's stage one.

Now we move to stage two.

Recoil.

The text calls this the struggle to adapt.

So now the immediate shock has worn off.

The adrenaline is gone.

The patient is home.

The police have left and it hits them.

The full weight of it.

They realize, oh my God, this actually happened.

This is the why me phase.

This sounds like the painful part.

It is the most emotionally turbulent part.

The text describes patients who might look normal on the outside.

They might be back at work going through the motions, but inside they are just churning.

They are exhausted.

They have nightmares.

They have flashbacks.

And this is where we see the fantasy of revenge.

Yes.

The text mentions that specifically.

It's extremely common and it can be terrifying for the patient.

Imagine you are a gentle, law -abiding person and suddenly you are spending your commute planning in graphic detail how to torture and kill the person who hurt you.

You'd think you were losing your mind.

You'd think you were becoming a monster.

Exactly.

Patients will come in and say, I think I'm going crazy.

I'm having these horrible thoughts.

The nurse's job here is validation.

You have to normalize it.

What does that sound like?

You say, it makes perfect sense that you are angry.

Fantasizing about revenge is a way your mind is trying to regain power over the person who took it away from you.

It doesn't mean you're a bad person.

That reframing is powerful.

You aren't bad.

You are hurt.

Right.

This is also the stage where support groups and short -term counseling are most effective.

They need to talk now.

They need to process the why me and hear from others who get it.

And finally, stage three, reorganization,

the reconstruction phase.

This is the long game.

This can take months, even years.

The goal here isn't to forget.

You never forget a trauma like this.

No.

The goal is to integrate the trauma into your life story.

So that is just one chapter, not the whole book.

The text distinguishes between being a victim and a survivor here.

That's the key shift.

That's the goal of this stage.

The victim is defined by the crime.

Their life revolves around what happened to them.

A survivor has moved past it.

They might still have scars.

They might still have bad days.

But they have regained their autonomy in their sense of self.

And if they get stuck before this?

If a patient gets stuck in stage two, that's where we see long -term PTSD, chronic depression, anxiety disorders.

And that's where we might need long -term pharmacotherapy or psychotherapy to help them get unstuck.

That's the roadmap.

Impact, recoil, reorganization.

Now, let's apply this framework to some of the specific populations of chapter covers.

Part three, terrorism.

This is a section that unfortunately has become more and more relevant in recent decades.

The text highlights a shift that happened post 9 -11.

Before that, for many Americans, terrorism was something on the news happening over there.

Now, it's a domestic reality.

How is terrorism different from, say, a natural disaster like a hurricane?

Both cause mass destruction.

It comes down to intent.

A hurricane doesn't hate you.

A hurricane isn't trying to send a political message.

Terrorism is intentional human -caused destruction designed specifically to create fear.

Right.

It's meant to break you psychologically.

Exactly.

It targets that assumptive world we talked about.

But on a societal level, it destroys the collective sense of safety.

And the text notes that the scope of victims is massive.

It's not just the people who are physically there.

No, it's a ripple effect.

It's the first responders who see things no human should see.

It's the families waiting for phone calls that never come.

It's the people across the country watching it unfold on live TV who develop vicarious trauma.

The circle of victims is huge.

The chapter has this box, box 33 -1, that lists specific responses to terrorism.

There was one term that stood out to me.

Body kinesthetic memories.

That is a very visceral symptom.

It's when the body remembers what the mind might try to suppress.

So it's like a physical flashback?

Exactly.

Survivors of bombings often report feeling the heat on their skin years later, or the sensation of the ground shaking, or the smell of gunning rubber.

It's a somatic flashback.

The body relives the trauma.

And there is a spiritual dimension, too.

A huge existential distress.

How could God allow this?

How can human beings be this evil?

It shakes your moral foundation to its core.

So how do you help someone recover from that?

Recovery in this context is tricky because you can't promise the patient it will never happen again.

Because in the world of terrorism, we don't know that.

You have to help them find a way to live despite the uncertainty, to regain a sense of personal safety while acknowledging the reality of external threats.

Moving on to part four, the text groups a few things together under what we might call hidden crimes.

Torture, ritual abuse, mind control, and human trafficking.

Yeah, these are the topics that most people, even medical professionals, want to look away from.

They seem too horrific to be real.

But the text is clear.

These are happening, and nurses are often the first to see the victims.

Let's start with human trafficking.

The text calls it modern -day slavery.

It is.

The text cites it as a $32 billion industry.

And it targets the most vulnerable populations.

Runaways, refugees, women and children in poverty.

These patients might show up in your clinic with repeated STDs, or multiple pregnancies, or vague injuries with inconsistent stories.

And they will likely be accompanied by a controlling person who won't let them speak.

That's a huge red flag for nurses.

The partner or friend who answers for the patient, who never leaves their side.

So then the text goes even darker, discussing ritual abuse and mind control.

It mentions things like MK Ultra and gang initiations.

Yeah, seeing MK Ultra in a nursing textbook was a surprise for me, too, the first time I read it.

It seems like something out of a spy movie.

It's there to illustrate the extreme end of psychological manipulation.

The goal in these cases is total subjugation.

The tactics described are their nightmare fuel.

Sensory deprivation, forcing the victim to participate in crimes so they are implicated and can't go to the police.

Sleep deprivation, drugging.

And the text mentions triggers.

Yes, conditioning.

Using specific words, hand signals or sounds that have been programmed into the victim to induce a state of fear or silence.

It's a way to maintain control even when the abuser isn't physically present.

Now, there's a fascinating intellectual debate in this section regarding diagnosis.

The text says some professionals argue against giving these victims standard psychiatric diagnoses like schizophrenia or borderline personality disorder.

Why would they say that?

This is such a critical point for clinical thinking.

Think about the symptoms.

If a patient comes in and says, People are watching me.

They are hunting me.

They can read my mind.

What's the first diagnosis you think of?

Paranoid schizophrenia, right?

But if that patient is a victim of organized ritual abuse or trafficking,

people really are hunting them.

Their paranoia is based in reality.

If you slap a schizophrenia label on them, you are invalidating their reality.

You're saying it's all in your head, which is exactly what their abusers told them for years.

Wow.

You're re -traumatizing them with the diagnosis.

You can be, yes.

And what about the BPD diagnosis?

Borderline personality disorder is characterized by unstable relationships and a lack of trust.

Well, if you have been tortured and betrayed by every adult figure in your life, of course you don't trust anyone.

That's not a personality disorder.

That's a learned survival strategy.

So the text calls these normal responses to abnormal situations.

Exactly.

The argument is don't pathologize their survival.

Treat the trauma, not the illness.

But treating the trauma requires trust.

That seems like the one thing they can't possibly give you.

It's the catch, Connie, too.

Trust has been weaponized against them their entire lives.

Treatment is incredibly slow.

It has to be trauma -informed, culturally sensitive, and completely patient -paced.

We often see profound self -mutilation and alters dissociative identities in this group.

We're going to talk more about self -mutilation in a bit, but let's pivot to part five, rape and sexual assault.

This is a massive section of the chapter.

First, we need to get our definitions straight.

Correct.

And the text is very specific here.

Rape is defined as forcible perpetration.

That means penetration of the body.

Sexual assault is a broader term for any unwanted sexual contact.

But here is the sentence that every student needs to underline, highlight, and basically tattoo on their brain.

Rape is not sexually motivated.

It's not about sex.

No.

It is a crime of power, control, and humiliation.

The perpetrator uses sexuality as a weapon, just like they might use a knife or a bat.

But the drive isn't desire.

The drive is dominance.

That reframing is so important for the survivors, too, because they often feel that sexual shame.

Exactly.

And the underreporting is just massive.

The text says only 20 % to 33 % of rapes are reported.

So for every survivor you treat in the ER, there are three or four out there suffering in silence.

Let's talk about the nurse's role here.

Specifically, the seining nurse.

The sane sexual assault nurse examiner.

This is a specialized certification.

These nurses are trained to do one of the most difficult jobs in medicine, to collect forensic evidence from a human being who has just been traumatized.

The text mentions a conflict between the patient's needs and the legal system's needs.

A huge conflict.

Imagine you have just been assaulted.

You feel filthy.

You feel contaminated.

What is your most primal biological imperative?

I want to shower.

I want to brush my teeth.

I want to burn my clothes.

You want to erase the event physically.

But the legal system.

The legal system needs the DNA.

It needs the fibers from the perpetrator's clothing.

It needs the bruising documented under special lights.

If you shower, you wash the case down the drain.

That is a horrific choice to have to explain to a patient.

It is.

The send nurse has to be incredibly gentle and patient.

I know every cell in your body wants to shower right now.

That makes perfect sense.

But if we want to catch the person who did this, I need to ask you to wait.

I need to collect swabs.

I need to take photos.

Does the patient have to say yes to that?

No.

Absolutely not.

That is box 33 to 2, the rights to the survivor.

They have the absolute right to refuse the exam.

They have the right to have an advocate present.

And legally, they have the right not to be asked about their prior sexual history with anyone other than the suspect.

The rape shield laws.

Yes.

We don't put the victim on trial, ideally.

Let's talk about the medical side.

What are we actually treating in the acute phase?

Physically, we are treating injuries, lacerations, bruises, and then we do prophylaxis.

We give antibiotics to prevent STDs like chlamydia and gonorrhea.

We offer emergency contraception for pregnancy prevention.

What about the psychological symptoms?

The anxiety, the sleeplessness?

We treat the symptoms, but we have to be careful.

We might use benzodiazepines, like Ativan, for acute anxiety, but only for a very short term because of the addiction risk.

For sleep, which is huge because these patients are terrified to close their eyes, we might use trazodone.

It helps with sleep, but isn't addictive.

The text also mentions prazocin.

Isn't that a blood pressure medication?

It is.

It's an alpha blocker.

But it has this fascinating off -label use for PTSD.

It suppresses the adrenaline surge that happens during REM sleep.

So it effectively stops the nightmares, or at least dials down their intensity so the patient doesn't wake up screaming.

For many survivors, it's a game changer.

That's a great clinical pearl.

Prazocin for nightmares.

Now let's transition to part six.

Adult survivors of childhood sexual abuse.

This is a heavy pivot.

When we talk about childhood abuse, specifically incest, we are talking about what I call a foundational trauma.

What do you mean by foundational?

I mean, it happens while the personality is still being built.

If you were raped at age 30, you have 30 years of I am safe experiences to fall back on.

If you were abused at age five,

the abuse is built into the very basement of your psyche.

The text emphasizes the betrayal of trust.

The abuser is almost always someone the child knows, loves, and depends on for survival.

A father, an uncle, a coach, a family friend.

And the secret.

The coercion.

The text explains how abusers ensure silence.

If you tell, I'll kill your puppy.

If you tell, mommy will get sick and die and it will be your fault.

If you tell, they will take you away to a foster home.

The child is forced to become an accomplice in their own abuse to protect the family.

That is incredibly twisted logic, but for a five -year -old, it's absolute.

It is.

And it manifests throughout development.

As a child, you might see sexualized play or extreme withdrawal.

As an adolescent, you see running away, substance abuse, early pregnancy, and self -mutilation.

Box 33 -3 lists the adult manifestations.

I feel like this is a checklist that every psych nurse sees constantly.

It is.

And often, the patient doesn't connect the dots.

They come in for depression or chronic pain or an eating disorder.

They don't walk in and say, I was abused.

Then you show them this list from the text.

What's on it?

What are some of the key things?

Well, there are the body symptoms,

vague pains, chronic pelvic pain, gagging sensations.

Gagging.

Why gagging?

It's a somatic memory, the body remembering forced oral sex.

The throat closes up when they are stressed, even 20 years later, and they don't know why.

And the control issues.

The text says, need to be perfect or perfectly bad.

That's the black and white thinking.

It's a trauma response.

If I am perfect, maybe I won't get hurt.

If I am perfectly bad, at least I am controlling how bad I am.

There's no middle ground.

We need to talk about self -mutilation, cutting,

burning.

This is something that scares a lot of new nurses.

It seems so counterintuitive.

Why would you hurt yourself to feel better?

The text gives us a very clear analysis here.

It usually serves one of two functions.

First, it's an anti -dissociation technique.

Explain that.

What does that mean?

Imagine you feel numb,

dead inside, like you are floating in space and your body is miles away.

You don't feel real.

That feeling is terrifying.

So you cut your arm.

You see the blood.

You feel the sharp stings.

Suddenly, boom, you are back in your body.

You exist.

Pain is proof of life.

So it's a grounding technique, a destructive one, but effective in the moment.

Yes.

The second function is distraction.

The emotional pain, the shame, the flashbacks, the memories is a category five hurricane.

The physical pain of a cut is a manageable problem.

It's sharp.

It's located right there on the arm.

You can bandage it.

It converts overwhelming emotional pain into manageable physical pain.

That makes a tragic amount of sense.

So as a nurse, what is the intervention?

What do you do?

First rule, and the text is clear on this, believe them.

When the memories start coming out, they can be fragmented and weird and confusing.

Believe them anyway.

Accept the ambivalence.

They might hate their abuser, but also still love them.

That's normal for this kind of trauma.

And the book says don't force them to confront the family.

No, that is dangerous.

The text is very firm on this.

Confrontation is not always therapeutic.

And it can lead to massive re -victimization when the family denies it.

Let the patient lead.

I want to touch on the Jan Lester case study from the text, because I think it really illustrates how tricky this memory recovery is.

The Jan Lester case is a classic example of delayed recall.

So Jan is a 30 -year -old woman.

She is admitted to the psych unit because she's suicidal.

She's a high -functioning professional, a lawyer, I think, but her life is falling apart.

But she doesn't mention any history of abuse.

Not a word.

She doesn't remember it.

It's completely repressed.

But then, in the safety of the hospital,

the nightmares start.

And they aren't clear movies.

They are abstract.

She dreams she is being crushed.

She dreams she can't breathe.

She wakes up with severe vaginal pain.

But the doctors find nothing physically wrong.

The body keeps the score.

It does.

The text says it took nine months of therapy before the actual memory of her father abusing her surfaced.

Nine months.

If a nurse had tried to push her in week one, she probably would have shut down or attempted suicide again.

The lesson here is patience.

You cannot rush the timeline of trauma.

All right.

We are heading into the final stretch, part seven, partner and elder abuse.

Another epidemic.

The stat from the text.

A woman is beaten every nine seconds in the US.

Every nine seconds.

So in the time we've been talking, just hundreds and hundreds of women.

Exactly.

And to understand it, we have to use the power and control wheel.

That's figure 33 and one in the book.

Students often think abuse just equals hitting.

But the wheel shows us all the other spokes.

Economic abuse.

Controlling all the money so she can't leave.

Isolation cutting her off from her mom and her friends.

And gaslighting, telling her she's crazy, she's imagining things, making her doubt her own sanity.

The big question, the one everyone always asks, is in box 33 to 4.

Why do they stay?

I hate that question.

But we have to answer it because your patients will be asked it.

Yeah.

To understand why she stays, you have to understand the cycle of violence.

That's box 33 to 5.

This is critical for any exam.

Okay, paint the picture of the cycle.

What are the phases?

Okay, phase one is tension building.

This is walking on eggshells.

The abuser is moody, irritable, nitpicking.

The victim is desperately trying to keep the peace.

Cooking his favorite meal, keeping the kids quiet.

She thinks, if I just do everything right, he won't explode.

But he explodes anyway.

Yeah, always does.

That's phase two.

The serious battering incident.

The release of tension.

The acute explosion of violence.

And then phase three.

The one people forget.

The honeymoon.

And listen to me, everyone listening.

Phase three is why she stays.

In the honeymoon phase, the abuser is sorry.

He is on his knees.

He is crying.

He brings flowers.

He says, I don't know what came over me.

I love you so much.

I'll never do it again.

And he believes it in that moment.

He might.

And she definitely wants to believe it.

Yeah.

In this moment, he's the man she fell in love with.

She stays because she hopes this version of him is the real one and the violence was the aberration.

It's an incredibly powerful psychological trap.

It is.

And practically, she stays because she has no money.

Right.

The economic abuse.

She has nowhere to go because he's isolated her.

And she is terrified.

The text notes that the most lethal, the most dangerous time for a victim is when she tries to leave.

That is when the abuser realizes he has lost control.

And that is when they escalate to murder -suicide.

That brings us to nursing interventions.

If a patient comes in and admits to abuse, do we call the police?

This is where you have to know your local laws, but generally.

For a competent adult, no, you do not.

Wait, really?

Even if she's been beaten up?

If there is no weapon involved, like a gunshot, and no children are in immediate danger, we usually cannot call the police against her will.

Think about it.

Her core trauma is a loss of control.

If you, the nurse, force the police on her, you are taking control away from her again.

And you might be signing her death warrant if the police go to the house, talk to him, and then leave her there with him.

So what do we do instead?

We empower.

We do safety planning.

We help her pack a go -bag with keys, copies of birth certificates, cash, and help her figure out where to hide it.

We help her memorize the hotline numbers because she can't write them down or put them in her phone where he might check.

We help her plan the escape for when she decides she is ready.

That leads to the Rachel Benton case study.

Rachel's story is a perfect example of a successful safety plan.

It was some dramatic movie scene where she runs out in the rain.

It was a four -month operation.

She had to skim money from the grocery budget a dollar at a time.

She had to coordinate with a friend across the state.

She had to wait for the exact moment he was away on a trip.

Leaving is a process, not a single event.

We have to mention elder abuse briefly before we wrap up.

Yes.

The dynamic is often different.

It's frequently neglect or financial exploitation.

The perpetrator is usually a family member, an adult child, or a spouse, which makes it so hard for the elder to report.

They don't want their son to go to jail.

But the reporting laws are different here, right?

Crucial distinction for the exam.

Reporting elder abuse is almost always mandatory, just like child abuse, because elders are considered a vulnerable population.

If you suspect it, you must report it to adult protective services.

You do not need the patient's permission.

So let me get this straight.

Competent adult partner abuse, usually voluntary reporting.

Elder abuse, mandatory reporting.

Correct.

Memorize that distinction.

It will be on the test.

We have covered a massive amount of ground.

From the shattering of the assumptive world to the detailed logistics of a safety plan.

It's a lot to absorb.

But if you take one thing away, let it be this.

Violence is a health issue.

It is not just a legal issue or a social issue.

And recovery is a journey.

Remember the stages.

Impact.

Recoil.

Reorganization.

And remember that your role as a nurse is not to fix the trauma.

You can't erase what happened.

No.

Your role is to be a witness.

To be a safe container.

To listen without judgment.

And to empower them to take the first step from victim to survivor.

And I want to leave you with one final thought from the text that I found really provocative.

It mentions that specialized trauma care, like those Cyene nurses, is often concentrated in big cities.

Yes, that's true.

But the text notes that 40 % of women in rural areas experience sexual violence.

If the nearest Cyene nurse is three hours away,

what happens to that evidence?

What happens to that survivor?

It's a massive gap in our system.

It's a healthcare disparity.

Access to trauma care is a form of justice.

And right now, justice is geographically distributed.

It's something for you future nurses to think about.

Maybe you can be the advocate who brings those services to a rural hospital.

That is a powerful mission to end on.

Thank you for listening to this Deep Dive last -minute lecture.

Good luck on your exam.

You are going to crush it.

Breathe deep.

You've got this.

From the whole team here at the last -minute lecture.

Thanks for listening.

We'll see you next time.