Chapter 28: Child, Older Adult & Partner Violence

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Welcome back to The Deep Dive.

Today we're tackling a really important topic, something that touches pretty much every corner of healthcare,

family violence.

We're pulling our key insights directly from chapter 28 of our Corolla's foundations of psychiatric mental health nursing.

When you walk onto any floor, anywhere really statistically, you're quite likely to encounter a survivor of violence.

So the goal of this deep dive is to make sure you don't miss those often subtle, sometimes silent cues.

We want to give you the foundational psychiatric and nursing roadmap you need to identify, assess, and respond effectively to victims and perpetrators.

And that roadmap is absolutely vital.

Family violence, or domestic violence as it's often called, is just a huge public health issue.

What makes the nurse's role so unique, I think, is that we're often the very first person a survivor might feel safe enough to actually talk to, regardless of why they came in for care.

So understanding the definitions, the scope, that's really the necessary starting point for any kind of effective ethical intervention.

Okay, let's begin there then.

Let's unpack terms.

What exactly is family violence, according to this chapter?

Because it's definitely more than just, you know, physical hitting.

That's exactly right.

The source material lays out five major categories of abuse.

The most obvious one, of course, is physical abuse.

That's the intentional infliction of bodily harm.

So we're talking slapping, biting, choking, punching, that sort of thing.

Then there's sexual abuse.

That covers any kind of sexual contact or exposure without consent.

After that, you have emotional abuse.

And this one is really insidious because it's all about undermining a person's self -worth.

Constant criticism, humiliation, isolating them, name calling, it chips away at them.

Right, and often this abuse seems tied directly to power and control, especially maybe with the last two types.

Precisely.

The fourth type is neglect.

Now this is what the chapter calls an act of omission.

It's about failing to provide those needs.

Physical, emotional, educational, or medical.

And finally, there's economic abuse.

This is about controlling someone's access to resources, keeping them financially dependent, maybe forbidding them from going to school or getting a job.

It really creates this powerful financial trap.

And when we're talking specifically about children, about child maltreatment, the chapter draws a really specific line between commission and omission.

Could you clarify that?

Definitely.

So an act of commission is deliberate intentional harm.

That's the actual physical, sexual, or emotional abuse itself.

An act of omission, like we just mentioned with neglect, is the failure to act.

Failing to meet a child's basic needs or failing to protect them from harm.

Physical neglect, emotional neglect, medical, educational.

It falls under that umbrella.

That distinction feels critical, especially when you look at the numbers.

The 2018 data cited in the chapter is,

well, it's staggering.

It says the most common form of child maltreatment referred to services wasn't physical abuse, it was neglect.

73 % of victims.

That just completely flips the common assumption, doesn't it?

It absolutely does.

And that statistic really compels us as healthcare providers to be just as vigilant for those signs of neglect, the failure to act as we are for the signs of act of commission, the abuse itself.

Okay.

So once we kind of understand the types of violence, the next critical step is recognizing who's involved.

The chapter uses specific terms for the people in this dynamic.

It does.

It defines the perpetrator as basically any member of the household who is violent towards another member.

The person being victimized is often called the vulnerable person.

But importantly, the text also uses the term survivor.

And that's key because it acknowledges the healing and recovery process, which is a huge part of psychiatric nursing care.

It reframes them not just as a victim, but someone enduring and recovering.

And what about the perpetrators?

Are there common characteristics or patterns mentioned?

Yes, a pattern often emerges.

They tend to prioritize their own needs above all else and expect others to meet those needs.

They often perceive themselves as having poor social skills.

And critically, they usually lack strong supportive relationships outside of that intimate or family relationship.

This kind of intensifies their focus and control within their relationship.

So what does this violence tend to actually erupt?

The source mentioned certain stress factors or risk factors that push things into crisis.

Yeah, a crisis situation is often a major trigger.

Things like job loss, financial stress, illness.

These stressful life events can completely overwhelm someone's existing coping skills.

For child abuse specifically, a major risk factor can involve the child being seen as different.

Maybe due to congenital issues or temperamental traits, or even if the child somehow interferes with that early parent -child bonding, like in cases of premature birth, for instance.

And for intimate partner violence or IPV, the abuser often holds these really rigid beliefs, like in male dominance.

They frequently exhibit what's called pathological jealousy, and they actively try to control their partner's life restricting access to friends, controlling finances, limiting their freedom of movement, often while constantly accusing the partner of infidelity or betrayal.

That control aspect really brings us to the core structure of IPV described in the chapter, the cycle of violence.

This pattern identified by Walker back in 79, it sounds like the psychological engine driving this whole thing.

It really is the psychological blueprint.

It starts with the tension building stage.

This is characterized by minor incidents, maybe verbal abuse, insults, maybe some pushing or shoving.

The survivor often tries to minimize it, maybe walks on eggshells because they fear the inevitable escalation.

Meanwhile, the abuser is rationalizing their own increasing tension and behavior.

Then the acute battering stage.

The tension just peaks, often set off by some external event or internal state of the abuser.

And it culminates in a serious incident of violence.

This is the explosion.

And then comes the states that I think is so often misunderstood by people looking from the outside.

The honeymoon stage.

Yes.

This is where that psychological trap just springs shut.

The abuser becomes overly remorseful, incredibly kind, showering the survivor with apologies, gifts, making these really heartfelt promises that it'll never happen again, that they'll change.

The survivor naturally clings to the hope that this version, this loving person is the real person and that they can make it work.

They often believe those promises.

But what's fascinating and utterly tragic is that over time those calm loving periods, they get shorter.

The tension building and battering stages get more intense, more frequent.

And all the while the survivor's self -esteem is just systematically eroded.

That honeymoon stage is the glue.

It maintains the victim's hope and reinforces that psychological bond, making it so much harder to leave than just the fear of violence alone might suggest.

Wow.

That structural insight really changes how you think about assessment, doesn't it?

So what does the text emphasize as the single most critical step a nurse must take during routine screening?

Even if the patient comes in for something totally unrelated like chronic headaches or trouble sleeping.

The absolute nursing imperative is to screen all patients for possible abuse.

Period.

And doing this effectively requires creating a safe environment first.

The interview must be conducted in private.

Institutional policies really need to support and facilitate this privacy.

And the nurse's approach is key.

Sit near the patient, not across a desk.

Adopt a non -threatening open posture.

Really focus on building trust before diving into direct questions.

Yeah, the language you use here has got to be crucial.

You can't just jump in with, so are you being abused?

Exactly.

No.

You need to use open -ended, non -judgmental questions.

Instead of using words like abuse or violence initially, you might ask something like, how do you and your partner or caregiver resolve disagreements?

Or maybe, is there anything else happening at home that's causing you significant stress right now?

The text specifically highlights the abuse assessment screen, the AAS.

It's a quick five -question tool designed for routine screening for IPV.

It asks directly but gently about emotional, physical, and sexual abuse, and importantly, about fear of a partner.

Okay, so once that screening opens the door,

what specific physical or emotional signs should nurses be particularly attuned to?

Especially thinking about the psychological impact.

Well, for physical abuse, we're looking for inconsistencies between the injury and the explanation given.

Or seeing bruises in various stages of healing that suggests repeated trauma over time.

And while certain acute injuries in infants, like those potentially indicating shaken baby syndrome, demand immediate physical intervention and reporting, the nurse's psychiatric role immediately pivots too.

We need to think about parental mental health screening and, of course, immediate mandated reporting regarding the potential perpetrator.

With sexual abuse in children, assessment might reveal things like inappropriately sexualized behavior or knowledge that's way beyond their developmental stage.

And across the board, for almost all survivors, symptoms of post -traumatic stress disorder, PTSD, are really common.

Things like high anxiety, nightmares, flashbacks, being hypervigilant.

Maybe somatic complaints like headaches or stomach issues with no clear physical cause.

Emotional abuse, even though it leaves no visible marks, often shows up as chronic low self -esteem.

Maybe core impulse control, significant anxiety, even learning difficulties in children.

This kind of assessment work sounds incredibly emotionally taxing for the nurse doing it.

What does the chapter say about the nurse's own self -assessment, dealing with their own reactions?

It's absolutely mandatory to check in with yourself.

Nurses are human.

We often feel intense anger, fear, maybe helplessness, or even disgust when we're confronted with these situations.

It's really essential to recognize the risk, the very real risk, of falling into that blame the victim mindset, maybe subconsciously.

That completely undermines care.

So using peer support, supervision, debriefing, it's critical for processing these feelings and maintaining objectivity.

So when you're putting together the care plan after the assessment, what's the absolute number one priority?

Safety.

Full stop.

Safety is the number one concern, always.

Therefore, the priority nursing diagnoses, using that ICMT terminology from the book, they revolve around risk for violence.

Whether that's directed at a child, an intimate partner, an older adult, or even risk for suicide in the survivor.

Secondary diagnoses then address that psychological toll.

Anxiety, fear,

chronic low self -esteem, and impaired coping, both for the individual and sometimes the whole family unit.

And outcomes have to be patient -centered, focusing on measurable goals like simply no violence or decreased suicide risk.

Okay, moving to implementation then.

There's a crucial legal and ethical duty nurses have regarding certain populations, right?

Absolutely non -negotiable.

Nurses are legally mandated reporters.

That means if you suspect or have actual knowledge of child abuse or vulnerable adult abuse, you must report it to the appropriate state or county agency, usually child welfare or adult protective services.

And the threshold is reasonable suspicion.

You don't need absolute proof to make that report.

It's about protecting the vulnerable person.

And for survivors of intimate partner violence, the key intervention mentioned is developing a safety plan.

How do we actually help someone create one?

What does that involve?

Right.

The safety plan is essentially a personalized guide for escaping quickly and safely when the abuse starts up again or escalates.

The nurse needs to help the survivor identify their personal warning signs, those cues that tension is rising.

They need to figure out a safe destination beforehand, maybe a friend's house, family, or a formal shelter,

and arrange transportation.

How will they get there?

We also guide them in packing an emergency bag ahead of time.

This needs essential documents ID, birth certificates for them and kids, maybe bank cards, cash, house car keys, essential medications, and crucially figuring out where to keep this bag hidden so the perpetrator doesn't find it.

Knowing the number for a local shelter or safe house is also part of this planning.

Let's pull back for a second and look at the bigger picture, the public health strategy.

The chapter talks about three levels of prevention.

Yeah, frames it nicely.

Primary prevention is all about intervening before any abuse happens.

So this includes things like identifying families maybe at high risk, providing health teaching to reduce stress, maybe parenting classes, and generally trying to boost social support and coping skills within the community.

Then you have secondary prevention.

This is about early intervention once violence might be occurring to minimize the long term damage.

This is where those screening programs we talked about fit in.

Also immediate medical treatment for injuries, crisis intervention, and supportive therapy to manage acute stress.

And finally, tertiary prevention.

This happens after violence has occurred.

The focus here is on healing and rehabilitation.

Things like long term counseling, support groups for survivors, which are incredibly powerful and legal advocacy, helping survivors regain their footing and function as fully as possible.

Lastly, what about specific therapeutic approaches?

What's recommended and is there a big caution flag we need to know about regarding couples therapy?

Individual therapy is really key, especially for the survivor.

It focuses on empowerment, recognizing their own strengths, processing the trauma, and managing symptoms like PTSD.

For the perpetrator, therapy is often court mandated.

It usually involves cognitive behavioral techniques, teaching them to recognize their abusive thought patterns, understand triggers, and learn non -violent ways to manage anger and conflict.

And importantly, as therapists, we often have a duty to warn potential victims if we conclude a perpetrator poses an imminent danger.

But, and this is a huge but, we have to be extremely cautious about couples or family therapy in these situations.

The chapter strongly warns against it, especially early on.

Bringing the perpetrator and survivor together for therapy prematurely can actually increase the danger for the abuser to manipulate or further control them.

Conjoint therapy should really only ever be considered after the perpetrator has completed significant individual therapy and has demonstrated real sustained behavioral change.

Safety first.

This has definitely been a necessary, oh yeah, a tough deep dive.

I think the key takeaway here seems twofold.

First, your absolute priority is safety.

That translates directly into mandatory reporting for children and vulnerable adults and creating a concrete personalized safety plan for IPV survivors.

Exactly.

And second, really understanding those profound psychological traps, particularly the cycle of violence, is just essential if you want to provide non -judgmental, effective, trauma -informed care.

Family violence isn't just someone losing their temper because they're stressed or drunk.

It's a learned pattern of collusive control.

And we have to constantly challenge that default assumption that the family unit is always a safe haven.

Because for too many, it's not.

And that leads perfectly into a final provocative thought for you, the listener, to take away and maybe mull over in your practice.

The text implicitly asks us,

what are the bigger systemic changes we need to make as a society to truly make a dent in family violence?

We need to think about changing deep -seated beliefs like the subtle or not -so -subtle societal devaluation of older adults, for example.

Or maybe addressing the incredibly unequal burden of caregiving responsibilities that often falls on women, driving stress that can, in some situations, escalate to abuse.

Think about those wider systemic factors, even as you focus on caring for the individual patient in front of you.

Thank you so much for joining us for this Crucial Deep Dive.

We'll see you next time.