1

INTRODUCTION

Violence is a leading worldwide public health problem (WHO, 1996). Violence also is
an inescapable public health problem, with an estimated 1.9 million women and 3.2 million men
being physically assaulted each year (Tjaden & Toennes, 2000b). Prevalence of some types of
violence varies based on race or ethnicity, with some minority women and men reporting more
frequent and more violent victimization.
The family is generally regarded as a basic social institution that must be cherished,
preserved and protected. The Family Code of the Philippines declares that no custom, practice
or agreement destructive of the family shall be recognized or given effect. The premise, of
course, is that the family is a haven where spouses and children expect to get protection and
security, a safe place of nurturing and growth. It is certainly the last place where one should get
physically, sexually, economically and emotionally abused. But the principle that the family is
all important as upheld in the Family Code has been misused and distorted to justify an endemic
Filipino culture or tradition of keeping the family intact at all cost, purportedly for the sake of
children. A restrictive culture maintains that whatever occurs in marriage – even if it takes on a
violent, criminal nature – is a private matter between husbands and wife. It is culture that
tolerates violence against children and considers it within a parent’s right to enforce discipline; a
culture of silence that is justified by another misused value – honor. The shame of the family
outweighs the abuse and violence being committed against its member, who, studies show, is
most likely a woman or a defenseless and innocent child.
It is understandable that since domestic violence occurs in the confines of homes, it
remains largely hidden and unrecognized as a problem. Only in 1985 did the United Nations
make its first resolution on the problem, calling in member states to undertake research and
formulate strategies to combat violence in the home.
Findings from Breaking the Silence: The Realities of Family Violence in the Philippines
and Recommendations for Change by Women in Development-Interagency Committee Fourth
County Programme for Children, U.P. Center for Women’s Studies Foundation, Inc. reveal that a
total of 1,000 documented cases of family violence obtained from files of both government and
non-government organizations – including shelters and transition houses, a government
hospital’s pioneering child protection unit, and private clinics – covering the period from 1994 to
the first quarter of 1996 was analyzed. The study found many forms and dimensions of family
violence.
Collaboration among health care professionals is recognized as the most effective way of
responding to the needs of survivors of violence. Nurses and other health care providers must
guard against insensitivity when working with survivors of violence. Making health care system
responsive and relevant to the needs of the client, assisting them to develop greater independence
and make accessible to them all the available health services to help them resolve their problems.
The basic requisite for a health advocate is time and commitment and the willingness to take the
risk in the process of advocacy.
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VIOLENCE & ABUSE
Definition of Terms:
Assaulter – men who abuse and control women through threats, physical, psychological,
verbal and sexual aggression.
Perpetrator - A person who inflicts abuse or injury on another
Child abuse – the act of deliberately inflicting or causing to inflict physical injuries upon
a child or unreasonably depriving him/her of basic needs for survival such as
food, shelter or a combination of both to a degree that if not immediately, could
seriously impair the child’s growth and development or result in permanent
incapacity or death. Includes any act which debases, degrades or demeans the
intrinsic worth and dignity of a child as a human being (Guerrero)
Elder Abuse – is the maltreatment of older adults by family members or caretakers. It
may include physical and sexual abuse, psychological abuse, neglect, financial
exploitation and denial of adequate medical treatment.
Economic Abuse – denial or withdrawal of financial support, prohibiting the wife from
handling money; forbidding her to work outside the home or controlling a
woman’s own earnings.
- having total control over conjugal financial resources; using household money for
drinking, gambling or drugs.
Domestic violence - physical, sexual or emotional and psychological abuse of men
or women, may they be related by blood or affinity or may not be related by blood
or affinity but lived in the same domicile or constitute a household.
Family violence - a specific form of violence, may it physical, sexual or emotional and
psychological abuse of men or women, where the perpetrator and the victim are
related to each other and may or may not live in the same household.
Physical Violence – may be a single manual act or a series of different acts or a
combination of assaults with use of weapons.
Psychological or Emotional Violence – involves threat or intimidation or verbal abuse;
verbal or gestured threats to kill or harm physically.
 Nagging, use of degrading words or insulting words
 Public humiliation, accusation of infidelity
 Prolonged silence after arguments, withdrawal of affection
 Openly siding with relatives against sudden abandonment
 Forcing to bear children or forcing her to have abortion
Sexual Abuse – could be demanding sex regardless of the partner’s condition, forcing her
to perform sexual acts that are hurtful or unacceptable to her
 forcing her to watch pornographic videos and other materials
 having sex with another woman in the marital bedroom
 forcing the wife and mistress to sleep with him in the same bedroom
Social Abuse – encompasses the many actions that a batterer can use to influence or to
limit his wife’s contact with society (isolation and public humiliation)
Violence – an action, policy or attitude that causes bodily or mental injury and debases or
dehumanizes a person.
Intimate Partner Violence: Physical, sexual, or emotional and psychological abuse of men
or women occurring in past or current intimate relationships, cohabiting or
not, and including dating relationship
Neglect - The failure to provide for the individual’s basic needs for subsistence, including
food, housing, clothing, education, medical care, and emotional care. At its
most extreme, neglect results in death, especially in the older adults and in
very young children.

A. TYPES OF ABUSE
I. Physical abuse – involves the intentional use of physical force against another person.
It encompasses child/sibling/spouse/elderly/homosexual abuse and battered child
syndrome.
A. Characteristics
1. Behavioral – pattern of behavior usually develops, the first incident maybe
precipitated by frustration or stress. If the pattern is to be avoided, the victim must
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immediately refuse to accept the violence. If the victim submits to the violence or
physical force, without the stimulus of frustration or stress, it becomes a way of
relating to one another and the pattern becomes difficult to change. Intrafamily
violence is typically cyclic.
1.1. Acts of violence within the family range from slight slaps to severe beatings
to homicide.
1.2. Women do more hitting, kicking and throwing of objects when involved in
violent conflict with men. Men are likely to push, shove, slap, beat up and
even use weapons ( e.g. knives, guns ) against their wives/girlfriends
1.3. Perpetrators lack impulse control and their behavior is immature and self-
serving.
1.4. Abused children often try to please the abusing parent and may become
overly compliant to all adults. They avoid peers and withdraw from outside
contact. When he grows up as an adolescent, he will act out with aggressive
behavior
2. Affective
2.1. Physically abusive people are often described as extremely jealous and
possessive
2.2. Some have strong dependency needs and fear the loss of intimate
relationships
2.3. Closely related to the dependency need is the feeling of inadequacy. Abusers
use violence in an attempt to prove to themselves and others that they are
superior and in control.
2.4. Victims maybe immobilized by a variety of affective responses to the abuse.
A study showed that 25% of the victims feel guilty, 50% felt helpless and
75% experienced feelings of depression.
2.5. Fear helps to keep a woman in an abusive relationship.
3. Cognitive
3.1. Many abusive people set perfectionist standards for themselves and members
of their families. They convey a sense of rigidity and have an obsession with
discipline and control. Some are self-righteous, believing it is their right to use
physical force to get others to comply with their wishes.
1.2. Many parents who abuse their children suffered emotional deprivation when
they themselves were children. As a result, they may have unrealistic
expectations of their own children.
1.3. Victims of abuse often develop low self-esteem.
1.4. Some victims believe they are helpless to change the pattern of domination or
to leave the relationship. Some rationalize that the behavior was due to
alcohol or stress.
4. Physiologic
4.1. Abuse children maybe retarded in the areas of growth and development.
4.2. In victims of all ages, any combination of the following :
- Bruised or swollen eyes, hemorrhage into the eyes or
petechiae around the eyes
- Bald patches where hair has been pulled out or subdural
hematomas from blows to the head
- Bruises, burns, scars of past injuries on the skin, genitals and
rectal areas
- Fracture or evidence of precious fractures, particularly of the
face, arms and ribs
- Dislocated joints especially in the shoulder when the victim is
grabbed or pulled by the arm
- Intra-abdominal injuries especially in pregnant women
- Numbness from old injuries and hyperactive reflexes due to
neurologic damage
5. Sociocultural
5.1. The experience of violence in the family of origin teaches that the use of
physical force is appropriate
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5.2. Abused children grow to become another abuser or another adult victim
5.3. The violent family is often socially isolated.
5.4. Violent families have experienced significant life stressors before the onset of
physical abuse
II. Sexual Abuse – inappropriate sexual behavior, instigated by an adult family member or
surrogate family member, whose purpose is sexual arousal of a child or adult,
exhibitionism, peeping and explicit sexual talk to touching, caressing, masturbation and
intercourse.
- abusive sexual contact, completed, attempted, against the will of the other, or in
circumstances in which the other is unable to understand, refuse or communicate
unwillingness to engage in the sexual activity.
A. Characteristics
1. Behavioral
1.1. Adult perpetrators believe in extreme parental restrictiveness and
domination.
1.2. Children victims exhibit regressive behavior, most common of which is
bedwetting. Sleep disturbances are common, some are clinging, others
isolate themselves.
1.3. Children victims may act out sexually with other children and adults.
1.4. Adolescent victims may run away from home to escape
1.5. Long-term behavioral effects include indiscriminate sexual
activity/dysfunctions, sleeping problems, chemical abuse, social isolation
and suicide.
2. Affective
2.1. Perpetrators often feel weak, afraid and inadequate. They are unable to
distinguish between sexual and non-sexual affection for children.
2.2. Incest victims experience many fears : loss of parental love, being blamed
or thrown out of the house, physical abuse
2.3. Extremely prevalent is the feeling of powerlessness
2.4. Long term effects – are fear of sex and distrust and fear of men. They
suffer from chronic anxiety attacks or demonstrate borderline personality
disorder symptoms. Anger maybe the only emotion they experience and
express.
3. Cognitive
3.1. Dissociation is the victim’s major defense mechanism.
3.2. Children molested during the night experience nightmares.
3.3. Adult survivors have total amnesia for episodes of incest.
3.4. Self-blame and self-hatred contribute to low self-esteem in adult survivors.
4. Physiologic
4.1. Irritated or swollen genitals or rectal issue in children or presence of
sexually- transmitted disease
4.2. Some become pregnant
5. Sociocultural
5.1. It is difficult for a child for a child to protest any type of abusive
treatment in highly structured, authoritarian family system.
5.2 Chronic stress in the family can contribute to abuse.

III. Emotional or psychological abuse - usually verbal abuse designed to control another
through use of intimidation, degradation or fear.
- It refers to acts or behaviors or omissions by primary caregivers that result in or increase
the risk of serious behavioral, cognitive, emotional, and mental disorders. This
definition includes, but is not limited to psychological, verbal and mental injury.

IV. Neglect - The failure to provide for the individual’s basic needs for subsistence, including
food, housing, clothing, education, medical care, and emotional care. At its most
extreme, neglect results in death, especially in the older adults and in very
young children.
Types of Neglect:
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1. Failure to protect – ingestion of poison, accidents and disregard for the
child’s safety. Lack of appropriate supervision.
2. Physical neglect – failure to provide food, clothing, and shelter. Failure to
provide adequate healthy diet, and hygiene.
3. Medical neglect – failure to provide for the medical needs of the child,
including failure to seek timely intervention or failure to comply with
prescribed medical treatment.
4. Emotional neglect or non organic failure to thrive – failure to provide
nurturing and psychological support.

B. FAMILY CHARACTERISTICS VULNERABLE TO DOMESTIC VIOLENCE

1. Alcohol Abuse – the habitual alcohol intake leading to drunkenness
- the perpetrator is more prone to uncontrolled violent outbursts
- alcoholism is used as an excuse for an abusive behavior, therefore it is dangerous
because treatment will be toward alcoholism and not the behavior. Thus victims
of the abuse still continue to suffer.
2. Cultural Stereotypes
- the use of physical force as contributing to the attainment of the family structure
- the husband as the head of the family, the disciplinarian, the one in authority,
assertive and aggressive (macho image)
- the use of spanking as a culturally accepted behavior (legitimizes domestic
violence)
3. Jekyll and Hyde personality - both husband and wife has low self-esteem;
Man: uses violence as manifested in an explosive temperament accompanied by physical
blows and other forms of abuse, ex. Isolation
Woman: blames one’s self as deserving the violence secondary to one’s failure to meet
the husband’s expectations; has low self-esteem and low self image.
4. Family at or below the poverty level – violence is five times greater compared to other
strata due to poor cooping from lack of financial resources well as related stress.
5. Pregnancy – creates an increase stress in the family and provokes attack of battering.
6. A childhood history of witnessing/ being a victim of violence - both have low self-esteem
attributed to their childhood history (spanking as a way of instilling discipline).
7. Ineffective family functioning – ineffective coping to stress (hostility and displacement)
8. Family with elderly members – being frail and weak
9. Homosexual unions

C. PSYCHODYNAMICS
1. Biologic Theories
1.1. People possess a natural fighting to preserve the species
1.2. The neurophysiologic theory proposes that the limbic system and then
neurotransmitters are implicated.
1.3. Substance abuse especially alcohol is often implicated.
2. Interpersonal Theories – suggest that violence has its roots in the individual
personalities of the abusers. Aggression is seen as a basic drive within the
personality and violence is the result of the inability to control the impulsive
expression of anger and hostility.
2.1. Rejection of the child and failure of bonding between parents and child.
2.2. Abusers are often obsessive-compulsive, jealous, suspicious, paranoids or
sadistic
3. Social Learning Theory – proposes that violence is a learned behavior rather than an
instinctive one. It is believed that stimulation of the neurophysiologic
mechanisms for violence is under cognitive control. Both the abuser and the
victim learn their roles during childhood.
4. Sociologic Theory – the social environment can place additional stress on the family.
Violence tends to occur in multiproblem families that have experienced a
prolonged series significant stressors ( e.g. unemployment, economic crises )
5. Family Systems Theory – violence does not occur in isolation but results from the
interrelationships between people, events and behavior.
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6. Feminist Theory – the patriarchal organization gives dictatorial authority over women and
children. Women are viewed as childlike, passive, unreasonable & overly emotional individuals
who need to be dominated and controlled.
Theories that describe the causative factors for abusive behavior toward spouses and
elderly parents:
1. The abuser is deprived of nurturing and mothering as a child.
2. The abuser may have a history of antisocial behavior.
3. Specific behaviors learned during various developmental stages become part of person’s
interactions with spouse and family. Inadequate family functioning contributes to neglect
and child psychopathology (Moss, Lynch, Hardie & Baron, 2002).
4. Poor socio-economic conditions resulting in increased stress, anxiety, or frustrations may
precipitate abusive behavior within the family unit.
5. Poor communication skills may result in the use of verbal or physical abuse.
6. Abusive behavior may increased after the death of a significant family member, the loos
of job, geographic move, the onset of physical or mental illness, developmental change,
or a family change such as pregnancy or the birth of a child.
7. Violent acts generate positive feedback.

WHEEL OF POWER AND CONTROL

EMOTIONAL
ISOLATION ABUSE
Controlling what she Putting her down or
does, who she sees & making her feel bad about
talks to or where she herself; calling her names,
goes making her think she is
crazy., playing mind
games.
ECONOMIC
INTIMIDATION ABUSE
Trying to keep her from
Putting her in fear by using
getting or keeping a job,
looks, actions, gestures, or making her ask for
loud voice, smashing things, money, giving her an
destroying her property allowance, taking her
money

POWER
USING MALE SEXUAL ABUSE
AND
PRIVILEGE Making her engage in sexual
Treating her like a servant; CONTROL acts against her will, physically
making all the “big” decisions, attacking the sexual parts of her
acting like the “master of the body, treating her like a sex
castle” object

THREATS USING
Making and/or CHILDREN
carrying out threats to Making her feel guilty
hurt her emotionally, about the children;
threatening to take the using the children to
children, commit give messages,
suicide or report her visitation as a way to
to the welfare agency harass her
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THE DESIRE FOR CONTROL AND POWER RESULTS IN
BOTH PSYCHOLOGICAL AND PHYSICAL ABUSE
(From the Power and Control, Duluth, Minn, 1987, Domestic Abuse intervention Project)
CYCLE OF VIOLENCE
A. Build-up Phase/Tension Building
 occurs along with anger and tension building together with minor incidents of violence.
May include verbal abuse, threats and breaking of things.
B. Abuse/ Violence
 One loses control of behavior because of blind rage.
 Seen as a major catastrophe.

C. Sorry Phase or the Honeymoon and Loving Respite

 The batterer is remorseful and afraid of losing his partner.
 The batterer buys gifts, begs forgiveness and promises anything.

FIRST THREE LIFE STAGES (Infancy, Early childhood middle childhood)

Developmental Milestone Crisis Risk Factors

• infants prefer primary care • mistrusts develop • unplanned babies are
givers in infants if needs considered nuisance,
• communicate by crying are not met burdens and
• “strangers anxiety” at six • basic aim of hindrance to career
months toddlers is plans.
• Beginning of locomotion autonomy and • Crying which is the
• Shows emotions such as wants self-control child’s way of
fear, anger, jealousy and will power. communicating may
• Toddlers reached the Shame and doubt test the patience of
“terrible no, no age” may arise if parents.
• Temper tantrums are autonomy is not • Elektra and Oedipus
common developed. complex are
• Beginning of toilet training • Preschoolers are to manifested by
be given direction, unusual closeness to
• Preschoolers have
purpose and parents of opposite
overactive imagination
initiative so guilt sex.
• Curious about sex does not arise. • Difficult child
• Learning new things and behavior (tantrums,
new roles. dawdling)
• Unrealistic
expectations of
children

VIOLENCE DURING SCHOOL AGE AND ADOLESCENCE

Schoolers
Developmental Milestone
• tattles because of
strong sense of justice
• has increasing
awareness of family
roles and
responsibilities
• some girls begin to
menstruate
Crisis Risk Factors
• considered to be in the • Influence of peers and
latency stage so their school environment
libidinal energies are • Hero worship
redirected • Influence of
• basic task is industry television, computer
but negative task is games, video game,
inferiority internet and others
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Adolescents
Developmental Milestone Crisis Risk Factors
• physical and • identity • need for peer acceptance
psychologic signs of versus role • actively seeking models/ mentor
onset of puberty are confusion • values are translated into
evident • belongs in behaviors
• maturation of male and the genital • beginning to consider sexuality
female reproductive stage and reproduction issues
system according to • sexual experimentation
• increased range, skill Freud • vulnerability to drugs, alcohol
and independence of abuse
mobility

SHORT TERM EFFECTS ASSOCIATED WITH VIOLENCE

Behavioral Emotional Physical Cognitive
Regression/ Immaturity Anxiety Stomachache Learning
Social withdrawal Nightmares Genital pain difficulties
Sexualized behavior Depression Genital odors Poor attention
Sexual preoccupation Guilt Problem sitting Poor
Precocious sexual knowledge Low self-esteem Eating disturbance concentratio
Seductive behavior Phobias Encopresis n
Excessive masturbation Hostility/ Anger Headache Declining
Sex play with others Aggression Genital itching grades
Sexual victimization of others Suicidal tendency Problem walking
Genital exposure Sleep disturbance
Delinquency Enuresis
Stealing
Poor peer relations
Hyperactivity
Self-injurious behavior
Sexual language

LONG TERM EFFECTS OF FAMILY VIOLENCE ACROSS THE LIFE SPAN

Type of Effect Specific Specific Symptoms
Problem
Emotional Depression Depressed effect Suicidality Low self-
esteem
Guilt Poor self image Self blame
Anxiety Fears/ phobias Migraine Stomach problem
Aches and pains Skin disorders
Interpersonal Difficulty trusting others Poor social
judgment
Difficulty forming relationships Parenting
difficulties
Sexual re-victimization
Posttraumatic Stress Reexperiencing Intrusive thoughts Flashbacks Nightmares
Disorder Symptoms Avoidance Amnesia for abuse events Spacing out
Emotional numbling
Sexual Adjustment Anorgasmia Arousal dysfunction Sexual anxiety
Sexual guilt Promiscuity Prostitution
Dissatisfaction in sexual relations
Behavior Eating disorder Binging Purging Overeating
Dysfunction Substance Alcoholism Elicit drugs
abuse
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Self mutilation Cutting body parts Carving body parts
Hitting head or body with object

COMMON REACTIONS TO TRAUMA

A traumatic experience produces emotional shock and may cause many emotional

problems. Many changes after a trauma are normal. In fact, most people who directly experience

a major trauma have severe problems in the immediate aftermath. Many people then feel much

better within three months after the event, but others recover more slowly, and some do not

recover enough without help. Becoming more aware of the changes you've undergone since your

trauma is the first step toward recovery.

Some of the most common problems after a trauma are described below.

1. Fear and anxiety. Anxiety is a common and natural response to a dangerous situation.
For many it lasts long after the trauma ended. This happens when views of the world and
a sense of safety have changed. You may become anxious when you remember the
trauma. But sometimes anxiety may come from out of the blue. Triggers or cues that can
cause anxiety may include places, times of day, certain smells or noises, or any situation
that reminds you of the trauma. As you begin to pay more attention to the times you feel
afraid you can discover the triggers for your anxiety. In this way, you may learn that
some of the out-of-the-blue anxiety is really triggered by things that remind you of your
trauma.
2. Re-experiencing of the trauma. People who have been traumatized often re-experience
the traumatic event. For example, you may have unwanted thoughts of the trauma, and
find yourself unable to get rid of them. Some people have flashbacks, or very vivid
images, as if the trauma is occurring again. Nightmares are also common. These
symptoms occur because a traumatic experience is so shocking and so different from
everyday experiences that you can't fit it into what you know about the world. So in order
to understand what happened, your mind keeps bringing the memory back, as if to better
digest it and fit it in.
3. Increased arousal is also a common response to trauma. This includes feeling jumpy,
jittery, shaky, being easily startled, and having trouble concentrating or sleeping.
Continuous arousal can lead to impatience and irritability, especially if you're not
getting enough sleep. The arousal reactions are due to the fight or flight response in your
body. The fight or flight response is the way we protect ourselves against danger, and it
occurs also in animals. When we protect ourselves from danger by fighting or running
away, we need a lot more energy than usual, so our bodies pump out extra adrenaline to
help us get the extra energy we need to survive.
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People who have been traumatized often see the world as filled with danger, so their
bodies are on constant alert, always ready to respond immediately to any attack. The
problem is that increased arousal is useful in truly dangerous situations, such as if we find
ourselves facing a tiger. But alertness becomes very uncomfortable when it continues for
a long time even in safe situations. Another reaction to danger is to freeze, like the deer
in the headlights, and this reaction can also occur during a trauma.

4. Avoidance is a common way of managing trauma-related pain. The most common is

avoiding situations that remind you of the trauma, such as the place where it happened.
Often situations that are less directly related to the trauma are also avoided, such as going
out in the evening if the trauma occurred at night. Another way to reduce discomfort is
trying to push away painful thoughts and feelings. This can lead to feelings of numbness,
where you find it difficult to have both fearful and pleasant or loving feelings. Sometimes
the painful thoughts or feelings may be so intense that your mind just blocks them out
altogether, and you may not remember parts of the trauma.
5. Many people who have been traumatized feel angry and irritable. If you are not used to
feeling angry this may seem scary as well. It may be especially confusing to feel angry at
those who are closest to you. Sometimes people feel angry because of feeling irritable so
often. Anger can also arise from a feeling that the world is not fair.
6. Trauma often leads to feelings of guilt and shame. Many people blame themselves for
things they did or didn't do to survive. For example, some assault survivors believe that
they should have fought off an assailant, and blame themselves for the attack. Others feel
that if they had not fought back they wouldn't have gotten hurt. You may feel ashamed
because during the trauma you acted in ways that you would not otherwise have done.
Sometimes, other people may blame you for the trauma. Feeling guilty about the trauma
means that you are taking responsibility for what occurred. While this may make you feel
somewhat more in control, it can also lead to feelings of helplessness and depression.
7. Grief and depression are also common reactions to trauma. This can include feeling
down, sad, hopeless or despairing. You may cry more often. You may lose interest in
people and activities you used to enjoy. You may also feel that plans you had for the
future don't seem to matter anymore, or that life isn't worth living. These feelings can
lead to thoughts of wishing you were dead, or doing something to hurt or kill yourself.
Because the trauma has changed so much of how you see the world and yourself, it
makes sense to feel sad and to grieve for what you lost because of the trauma.

8. Self-image and views of the world often become more negative after a trauma. You may
tell yourself, "If I hadn't been so weak or stupid this wouldn't have happened to me."
Many people see themselves as more negative overall after the trauma ("I am a bad
person and deserved this."). It is also very common to see others more negatively, and to
feel that you can't trust anyone. If you used to think about the world as a safe place, the
trauma may suddenly make you think that the world is very dangerous. If you had
previous bad experiences, the trauma convinces you that the world is dangerous and
others aren't to be trusted. These negative thoughts often make people feel they have been
changed completely by the trauma. Relationships with others can become tense and it is
difficult to become intimate with people as your trust decreases.
9. Sexual relationships may also suffer after a traumatic experience. Many people find it
difficult to feel sexual or have sexual relationships. This is especially true for those who
have been sexually assaulted, since in addition to the lack of trust, sex itself is a reminder
of the assault.
10. Some people increase their use of alcohol or other substances after a trauma. There is
nothing wrong with responsible drinking, but if your use of alcohol or drugs changed as a
result of your traumatic experience, it can slow down your recovery and cause problems
of its own. Many of the reactions to trauma are connected to one another. For example, a
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flashback may make you feel out of control, and will therefore produce fear and arousal.
Many people think that their common reactions to the trauma mean that they are "going
crazy" or "losing it." These thoughts can make them even more fearful. Again, as you
become aware of the changes you have gone through since the trauma, and as you
process these experiences during treatment, the symptoms should become less
distressing.

SUPPORTING THE SURVIVOR

How Does Trauma Affect Survivors?

Victims of violence often face a wide range of struggles. They often question what has happened
or what they may have done to cause or prevent it. Many wonder how they will heal and why
they cannot connect with their loved ones as they once did. It is also common for survivors to
feel anger or frustration as they ponder whether they will ever feel “normal” again. While every
survivor’s experience is unique, violent trauma is almost always a life-changing experience that
can affect everything from one’s ability to sleep to his or her ability to concentrate at work.

Understanding the nature and impact of trauma can be key to helping your loved one. Many
survivors find themselves in unfamiliar and distressing psychological territory. It is common for
them to endure intense feelings of isolation, insecurity, and fear, and their most treasured
relationships often suffer as a result. Trauma can also lead to Post Traumatic Stress Disorder
(PTSD), which may include both substance abuse and mental health problems.

Violent Trauma, Substance Abuse, and Mental Health Concerns

Many victims turn to alcohol or other substances in an attempt to get some relief from their
emotional turmoil and suffering. All trauma survivors manage their experiences in different
ways. However, substance abuse is not only ineffective in healing from trauma, but it also can
present a host of additional problems that make the healing process even more difficult.

Violence is also a widely recognized catalyst for mental health concerns such as PTSD, a
condition that can be caused by experiencing or observing virtually any kind of deep emotional
or physical trauma. Millions of people in the United States suffer from PTSD, resulting from
many different types of trauma—from enduring years of domestic violence to a single violent
attack that lasts but a few seconds. PTSD is characterized by both emotional and physical
suffering; many afflicted by it find themselves unintentionally revisiting their trauma through
flashbacks or nightmares. PTSD can make a survivor feel isolated, disconnected, and “different”
from other people, and it can even begin to affect the most routine activities of everyday life.
Psychologists and counselors with experience in treating trauma survivors can be very helpful in
working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.
PTSD is a potentially serious condition that should not be taken lightly.

According to a recent study conducted by the U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, the most effective way to combat
trauma, substance abuse, and mental health problems is through an integrated, holistic approach,
taking into account how each individual problem affects the others. To begin, it can be helpful
for a survivor to share experiences and concerns with a service provider who can assist in
developing a plan to address these struggles comprehensively.

How to Help Survivors of Violence and Abuse?

Since each individual’s experience is unique, there is no one-size-fits-all remedy for victimized
patients. For those who care about a person who has experienced a violent trauma, finding ways
to be helpful and maintaining a healthy relationship can be challenging. Following are some tips
to help your loved one who has been victimized.

1. Listen . Talking about the experience, when the survivor is ready, will help
acknowledge and validate what has happened to him or her and can reduce stress
 12
and feelings of isolation. Let your patient take the lead, and try not to jump in
with too many comments or questions right away.
2. Research . If the victim wants more information, would like to report a crime, or
has other questions, you can help find answers and resources.
3. Reassure . As strange as it may sound, survivors often question whether an
incident was their fault or what they could have done to prevent the crime against
them. They may need to hear that it was not their fault and be assured that they
are not alone.
4. Empower . Following trauma, victims can feel as though much of their lives is
beyond their control. Aiding them in maintaining routines can be helpful, as can
offering survivors options or possible solutions.
5. Be patient . Every journey through the healing process is unique. Try to
understand that it will take time, and do what you can to be supportive. The
healing process has no pre-determined timeline.
6. Ask . Your patient may need help with any number of things or have questions on
many different topics. Even a favor as mundane as running a few errands or
taking the dog for a walk can be a big help, so consider lending a hand.

* Nurses need to identify their personal values and determine if these will interfere with the
ability to care for all members of the family.

APPLICATION OF THE NURSING PROCESS

Initial Assessment
 is done to determine the presence of any serious injury.
Questions to Ask the Woman on Initial Assessment
1. Where is the batterer now?
2. Where are the children? Are they safe?
3. How long ago did the abuse take place?
4. Who bought her to the hospital?
5. Is there some place where she can go to recuperate if it is too dangerous for he to return
home?
6. Were there weapons involved in the battering incident?
7. Would she like to call the police or have they been notified already?

History Taking

A.
1. Description of the present incident.
2. Details of past incidents.
3. Presence of medical problems.
4. Emotional and Psychosocial Problems.
Emotional problems: anxiety, sleep disorders, poor coping and parenting difficulty.
Psychosocial problems: substance abuse, attempt suicide and depression

B. Recognizing Domestic Violence Related Behaviors

 recurrent episodes of injury attributed to being “accident prone”.
 repeated visits to health care facilities
 dependency on the partner to answer questions
 failure to keep appointments
 noncompliance with medical treatments
 decreased concentration
 self-blame
 complains of pain without tissue injury
 thoughts about suicide
 13
Three Dangerous Things (that may happen if situation in violent homes become worse)
1. Abused women retaliate with violence thus injuring or killing her husband.
2. Abusive husband may kill the wife in a battering incident.
3. The abused woman feeling helpless and hopeless may kill herself.

Risk Assessment
The following are the critical signs that indicate increased risk for homicide:
1. Possession of weapons or past use of weapons.
2. Drug and alcohol use in a state of fury and depression.
3. Pathological jealousy in spouse.
4. History of mental illness.
5. Obsession about the partner ( I can’t live without her).
6. Situational stresses (ex. Loss of job).

Caring Values During The Interview Process

1. The interview should be conducted in a private setting.
2. The nurse should remain nonjudgmental, gentle and direct in his/her approach.
3. The interview should be uninterrupted. (Interruptions may be construed as rejection or
lack of interest).
4. The patient should be assured of confidentiality.
5. If patient appears reluctant to disclose the abuse, the nurse may start the interviews by
acknowledging to the patient that the incidence of domestic violence is so prevalent that
screening for it is becoming a routine part of the health care delivery for all women.
6. If culturally acceptable, the nurse maintains eye contact.

D. Recognizing Domestic Violence Related Injuries

 ruptured eardrums from severe slapping
 neck bruising from choking
 punch bruising to the upper arms
 “defensive posturing” injuries to the mid ulnar areas of the arms
 Whip or cordlike injuries to the back
 Punch and bite injuries to the breast and nipples
 Punch injuries to the abdomen especially for pregnant women
 Punch and kick bruising to the lateral thighs
 Facial bruising, abrasions and lacerations
 Telltale burns
 Skeletal fractures
 Internal injuries (blunt trauma)
 Head and Neurologic injuries

Stages of Healing Bruises

COLOR AGE
Red to red blue Less than 24 hours
Purple to dark blue 1 to 4 days
Green to yellow-green 5 to 7 days
Yellow to brown 7 to 10 days
Disappearance 1 to 3 weeks

Primary Prevention

Are measures that are taken to prevent or reduce the incidence of violence and abuse,
promote growth and enhance a potential victim’s future resistance to abuse.

Strategies:
1. Public education
Focus: > Issues related to child, women and family health and welfare
 14
> The negative effect of force and assaultive conduct.
> Nonviolent conflict resolution strategies (counseling)
> effective parenting and nonviolent discipline skills
> awareness concerning the criminal nature of domestic/ family violence.
2. Training of community-based groups and grassroot women.
3. Networking and linkaging to achieve an ideal community response to the issue of
domestic violence.

Secondary Prevention

The aim is to shorten the length of time a person may be disabled by abuse.

Activities: > screening (assessment of women who seek care in the ER, referrals by
friends,
health providers)
> crisis intervention

Tertiary Prevention

Involves interventions aimed at maintaining or reducing the severity of mental illness or

handicaps resulting from chronic abusive trauma to battered women, children and the batterer.

Activities: > long term therapy = physical care

> counseling = psychological care
> rehabilitation = empowerment

Nursing Intervention During The Crisis Stage

1. Assist the woman through grief work around the losses experienced through battering.
2. Assure the woman of safety and protection and engage her in safety planning.
3. Provide the survivor with the information on how to access community resources.
4. Reinforce that we all expect to live free from violence.
5. Enhance the survivors assertiveness and promote her self-esteem.
6. Assist the women through the decision making process.
7. Refer the survivor to appropriate resources.

Nursing Intervention During The stage of Internal Resolution and Rebuilding

1. Reiteration of information about abuse, the cycle of violence and the abuser’s
accountability.
2. Building self-esteem and confidence.
3. Decreasing shame, quiet, embarrassment and isolation.
4. Confirmation of personal and legal rights.
5. Stress reduction or management techniques.
6. Conflict-resolution techniques.
7. Assertiveness training.
8. Decreasing co-dependency behaviors.
9. Building a new, improved support system.
10. Goal-setting, specific planning for immediate future.
11. Resolution of grieving.
 15

Empowerment Advocacy

Empowerment advocacy believes that battering is not something that happens to a

woman because of her characteristics, her family background, her psychological “profile”, her
family of origin, dysfunction, or her unconscious search for a certain type of man. Battering can
happen to anyone who has the misfortune to become involved with a person who wants power
and control enough to be violent to get it.

Respect
Confidentiality…
All discussions must
occur in private,
without other members
present. This is
essential to building Believe and
Promote Access trust. Validate her
to Community Experiences…
Services… Listen to her, and
Know the resources believe her.
in your community. Acknowledge her
feelings, and let her
Is there a hotline and know she is not
shelter for battered alone. Many women
women? have similar
experiences.

Help her Plan for ADVOCAC

Y Acknowledge
Future Safety….
What has she tried in the Injustice…
past to keep herself safe? The violence
Is it working? Does she perpetrated against
have a place to go if she her is not her fault.
escapes? No one deserves to
be abused.

Respect her
Autonomy…
Respect her right to
make her own decisions
in her own life when she
ADVOCACY
is ready. She isWHEEL
the
expert in her life.

EMPOWERMENT ADVOCACY WHEEL

Through empowerment advocacy, the abuse woman is given strength and determination.
She will feel her independence and autonomy as a decision maker have been supported. She will
be able to recognize her strengths and resources as a survivor.
 16

Case Study

Luisa is 42 years old and has six children aging 4 to 20 years old. She works as a laundry
woman for a number of students in a ladies’ dormitory in one of the universities in Dumaguete
City. One late evening, she arrives in the Women Crisis Center with her 4-year old daughter and
a neighbor.

Three days ago she was discharged from a hospital after D & C was performed on her
after an inevitable abortion. She related that her husband came home after a drinking spree with
his barkadas and demanded to have her serve his supper. Since she was already upstairs resting,
she ask her 15-year old daughter to do it for her. This irritated his husband and he started to shout
angry words at her and called her name and threatened to hit her. When she heard him coming,
she jumped from the second floor window with her daughter and ran to a neighbor a block away.

Luisa further disclosed that her husbandhas been abusive since the early days of their
marriage even if he was not drunk. He used his fists on her and threw things at her. One of the
worst physical assaults done to her was when she obtained lacerated wounds after he hit her with
a piece of firewood.

Luisa wanted to leave but she cannot. They have three children under the age of fifteen
which she cannot afford to feed if ever she leaves and brings them along . She also feared that
her husband will kill her if she tries to escape.

NURSING CARE PLAN

SUBJECTIVE OBJECTIVE NURSING OUTCOME

CUES CUES DIAGNOSIS IDENTIFICATION

“I feel like smashing Face frowned Potential for That after two hours of
the face of my wife!” violence: Directed nurse-client interaction, the
as verbalized by the Walks back and at others related to client will be able to:
client forth fears of 1. Demonstrate self
abandonment. as control as evidenced
Clenched teeth and evidenced by by relaxed posture,
fists hostile threatening non-violent behavior.
verbalization, 2. Acknowledge
clenched fists and realities of the
teeth and rigid situation.
posture. 3. Use resources and
support system in an
Definition: effective manner.
A state in which an
individual
experiences 4. Express realistic self-
behaviors that can evaluation and
be physically increased sense of
harmful either to self-esteem.

INTERVENTION
Observe patient’s behavior
Develop therapeutic nurse-client
relationship. Provide consistent
caregiver when possible.
Help client recognize that own
actions may be in response to own
fears, dependency, and feeling of
powerlessness.
Obtain verbal or written contract
from patient agreeing not to harm
self or others and agreeing to seek
out staff in the event that such
ideation occurs.
Assist patient when anger occurs
and to accept those feelings as his
own.
Accept client’s anger without
reacting on emotional basis. Give
permission to express angry
feelings in acceptable ways and let
patient know that you are available
in maintaining self control.
Act as a role model for appropriate
expression of angry feelings, and
give positive reinforcement to
client for attempting to conform.
Remove all dangerous objects
from patient’s environment.
17
the self or others.
RATIONALE EVALUATION
Client at high risk for
violence require close Anxiety is
observation to prevent harm maintained at a level
to self and others. at which patient feels
Promotes sense of trust, no need for
allowing patient to discuss aggression.
feelings openlyu./
May be afraid of own Patient seeks out
behavior or loss of control. nurse to discuss true
feelings.
Discussion of feelings with Patient recognizes,
trusted individuals provide a verbalizes, and
degree of relief to the client.
A contract gets the subject accepts possible
out in the open and places consequence of own
some of the responsibilities mal-adaptive
for his safety. An attitude of
acceptance of the client as a behaviors.
worthwhile individual is
conveyed.
Identifying own’s feelings
enables the client to face his
emotion and develop
strategy to control one’s
emotion and learn to accept
it.
Promotes acceptance and
sense of safety.
It is vital that the patient
express angry feelings as
suicide and other self
destructive behaviors are
often viewed as a result of
anger turned inward to self.
The patient’s physical safety
and the safety of the other
members of the family isof
priority.
Crisis situation can provide
impetus for change
 18

Motivate client for change in

behavior.

BIBLIOGRAPHY

Shives, Louise Rebraca. Basic Concepts of Psychiatric-Mental Health Nursing. 4th edition.
Philadelphia: Lippincott-Raven Publishers, © 1998.

Videbeck, Sheila. Psychiatric Mental Health Nursing. 2nd ed. London: Lippincott
Williams and Wilkins, © 2001.

Antai-Otong, Deborah, Psychiatric Nursing: Biological and Behavioral Concepts. Delmar

Learning Inc. U.S.A. 2003.

Lim, Patrice Grace. Nursing Care of Survivors of Domestic/Family Violence: A Student’s

Module for NCM 102. Social Science & Reproductive Health; Social Developemnt
Research Center. De La Salle University – Manila and Silliman University – Dumaguete
City, Philippines. 2001.

Tan, Phoebe. Analyzing Domestic Violence: The Individual Assaulter. A Student’s Module
for SOAN 65. Social Developemnt Research Center. De La Salle University – Manila
and Silliman University – Dumaguete City, Philippines. 2001.