By stroke of good luck, I met Lee Schecke (SHWEHkey) at a SMART conference. She retired from the Indianapolis nursing faculty of Indiana University a semester before my own retirement. Semester after semester, she agreed to come to my classes to introduce especially the topic of multiple personalities, now psychiatrically labeled dissociative identity disorder. She continues her own work at an Indianapolis hospital that has become known as a place where trauma is noticed and respected. Lee has just sent me the copy of the latest edition of her chapter. She has become a leading authority to me and countless students on realities of trauma and the defenses it produces...and suggestions for treatment.
Feel free to e-mail firstname.lastname@example.org anytime. She is a wonderful speaker.
In the past Lee gave me permission to share revisions of her chapter with students. I'm presuming she won't sue me if I distribute this latest writing of hers. Happy new year Lee! Love and peace--hal
Survivors of Violence and Trauma
Lee H. Schwecke
After reading this chapter, you should be able to:
• Recognize the seriousness of violence and trauma in the United States.
• Describe the emotional reactions of adult victims of crime, workplace violence, terrorism, torture, ritual
abuse, mind control, human trafficking, rape and sexual assault, childhood sexual abuse, and partner and
• Recognize the dynamics involved in interpersonal violence crimes.
• Analyze the way in which the cycle of violence inhibits individuals from leaving abusive relationships.
• Identify the needs of victims of violence and trauma.
• Describe strategies for facilitating the transition from victim to survivor of violence or trauma.
• Develop a nursing care plan for survivors of violence and trauma.
he victimization of any individual by another creates serious mental health, social, community, and
legal problems. Violence in all forms is prevalent in this society. Nurses, regardless of their areas of
practice, will come into contact with the victims—as inpatients, outpatients, home care patients,
emergency care patients, parents of patients, friends, and relatives. Although the victims are typically
seen initially for physical injuries, their psychological needs require attention if long-term mental health
problems are to be prevented.
Forensic nursing,(including sexual assault nurse examiners-SANE) is emerging as a vital aspect of the
holistic care of victims and perpetrators of violent crimes and their families (Peternelj-Taylor, 2001). This care
includes obtaining clinical histories, documenting evidence, including photographs of injuries, and carrying
out quality nursing interventions in a holistic care framework, which includes consideration of all the medicallegal
aspects of the patient’s problems (Hammer, 2000). The rights of the alleged perpetrators of crime,
suspects, and victims must be protected so that the legal cases will not be jeopardized (Piercy and Greenwood,
This chapter focuses on victims of violence and trauma, beginning with a brief overview of general
reactions to any crime, workplace violence, terrorism, torture, ritual abuse and human trafficking, followed by
a more in-depth look at rape survivors, adult survivors of childhood sexual abuse, individuals abused by their
partners and abused elderly. A small number of perpetrators of rape, sexual abuse, and partner abuse are
female, but the more common pattern of this victimization is males against females. The short- and long-term
reactions of victims described in this chapter are generally true for both male and female victims; however,
men sometimes have a more difficult time admitting to and dealing with their emotional victimization than
women. The added impact on males of sexual violation by other males, both as children and as adults, is a
result, in part, of their fears about homosexuality (Maso and Anderson, 2008; Shea, 2008).
If ever there was a timely topic, this is it. I read just this morning in my local paper about a
husband and wife who were arrested on child pornography charges. The national evening news yesterday
centered on a report about a sophisticated ring of child pornographers who committed deeds so barbaric
that the newscaster refused to describe them on the air. The victims, when they survive such abuse, are
potentially scarred for life. How in the world do they ever learn to trust again? Lee Schwecke has had a
lot of experience with survivors of violence and trauma, and has a lot to share in this chapter.
Beyond the scope of this chapter are the issues of natural disasters (see Chapter 31), peer victimization and
crime and violence by children and adolescents, despite national attention to gangs, school shootings,
bullying, hate crimes against certain populations, robbery, property damage, fighting (with or without
weapons), cyber sex, cyber bullying, and drug related crimes.
VIOLATION BY CRIME
EFFECTS OF CRIMES
At least 1.6 million individuals were seen in Emergency Departments for physical injuries caused by assaults
in 2005 (Simon, Kresnow, Bossarte, 2008). Not all crimes involve physical violence, injury, and threat to life;
however, all crimes involve emotional violation and trauma. The victim’s identity is affected, even with the
loss or destruction of possessions and property, because these are a representation of an individual’s identity
and have personal significance. Crime undermines foundations formed in the first two stages of human
development, regardless of the victim’s age when the crime occurred (see Chapter 4). There is a loss of trust,
not only in the criminal, but also to some degree in all other individuals. Victims also lose self-esteem, a sense
of ability to control their own lives and themselves (autonomy issues), as well as having identity issues
Emotional reactions to crime vary greatly according to the individual, his/her resources and past history,
the situation, and the meaning of the crime to that person. However, common reactions are denial, fear,
anxiety, anger, powerlessness, and depression. A sense of failure and guilt is common; victims wonder what
they did to cause the crime and how they might have prevented or stopped it. Victims usually feel ashamed and
unworthy, as well as contaminated or dirty, whether or not they were physically touched by the perpetrator.
Fantasies of revenge or a wish for legal retribution are typical. The relationships of victims to family and
friends can be disturbed, in part, because of the loss of trust, but also because of the response of others. Caring
individuals often imply that the victim was responsible for the crime, with questions such as, “Why were you
there alone at night? Why were you carrying so much cash? Why didn’t you install that burglar alarm?” The
victim might feel alienated and isolated. Hospital personnel, the police, and the legal system might also
unwittingly convey what could be called a "blame the victim" attitude in their manner of questioning and in
focusing only on the facts, without any emotional support or empathy. Long term effects of crime may result in
prolonged stress, PTSD, depression, substance abuse, suicidality, and unhealthy weight control (Amar and
Workplace violence is a particular crime that is getting increased employer and media attention recently and
is included here because, in 2 surveys in nonpsychiatric and psychiatric settings, 13%-21% of nurses report
incidences of physical violence and 34%-55% report emotional/verbal violence in the past year (Lanza, Zeiss,
Rierdan, 2008). Workplace violence includes verbal abuse, sexual harassment, stalking, assault and battery,
rape, and murder perpetrated by patients or their visitors, other employees, former or current partners of
employees, and intruders from the outside looking for specific items, such as money or drugs (Gilmore-Hall,
2001; Institute for Safe Medication Practices, 2004). One study by the National Institute of Occupational
Safety and Health in 2006 found that "nearly 5% of the 7.1 million private industry business establishments
had an incident of workplace violence within the 12 months (Amar and Clements, 2009). According to the
study by Nursing Management, 80% of nurse leaders have experienced some form of workplace violence at
work. Of these nurse leaders, 73% reported that "workplace violence is experienced occasionally";
"frequently" was reported by 19%; and 1.7% said "always" (Hader, 2008).
Verbal abuse by other employees includes intimidation, condescending language or tone, reluctance or
refusal to answer questions, withholding Information, negative or threatening language, angry outbursts, rude
gestures, property damage, threats to or actual reporting of the nurse to a manager, ostracism, offensive notes
or e-mail, criticism, humiliation, screaming, sabotage, and threats with weapons (APNA, 2008; Center for
American Nurses, 2008; Institute for Safe Medication Practices, 2004; Hader, 2008; Leiper, 2005). Verbal
abuse, especially when the abusers are physicians, nurse managers, or supervisors, has been linked to the high
turnover of nursing staff (APNA, 2008; Center for American Nurses, 2008; Gates, 2004; Hader, 2008; Leiper,
2005)and, indirectly, to the nursing shortage.
Sexual harassment is defined as "an unwelcomed sexual advance or conduct on the job that creates an
intimidating, hostile, or offensive working environment...[ranging from]...repeated offensive or belittling jokes
to pornography or outright sexual assault" (Farella, 2001, p. 14). According to a 1988 survey of the federal
workforce, 42% of all women and 15% of all men have experienced some form of harassment (Farella, 2001).
Stalking is a crime that can occur anywhere but often occurs in the workplace. Stalking is obsessional
pursuit, harassment, and intimidation by a person who has or believes that he or she has a significant personal
relationship with the object of his or her unwanted attention. Stalkers might send letters, packages, or e-mails;
make harassing phone calls; or follow and/or appear repeatedly at the victim’s home or workplace. Sometimes
they kill pets, vandalize or destroy property, and physically or sexually assault, or even murder their victims
(Hughes, Thom, Dixon, 2007; Muscari, 2005). Surveys indicate that 2%-7% of all men and 8%-16% of all
women have been stalked at least once in their lifetimes (Amar and Clements, 2007; Hughes, Thom, Dixon,
2007). Men account for 87% of the stalkers, and women are their victims in 60% of cases. However, some
cases involve female-male, male-male, or female-female stalking (Muscari, 2005).
The media tends to focus on the stalking of celebrities and public officials by strangers. The stalkers in these
cases tend to be psychotic or have delusions about their victims and the supposed love relationship. However,
most cases of stalking occur as the victim is trying to end a casual, dating, or marital relationship. This pattern
is more likely than celebrity stalking to involve physical violence (80%) and sexual assault (30%) and to be
carried out by nondelusional individuals (Mawson, 2005).
The Occupational Safety and Health Administration (OSHA) encourages voluntary compliance by
employers with their workplace violence guidelines, published in 1998. Briefly, these and other guidelines
suggest the following: (1) systematic education of all employees about verbal abuse, sexual harassment, and
other forms of violence, along with ways to prevent and deal with them, Including conflict resolution and
negotiation skill training; (2) development of corporate policies and procedures related to workplace violence
and reporting procedures; (3) definition of roles for supervisors, employee health staff, and security personnel;
and (4) provision for treatment and counseling for employee victims (APNA, 2008; Miller, 2008; Morrison
and Love, 2005; Trossman, 2001). Counseling is most often provided by Employee Assistance Programs
(EAPs) (Paul and Blum, 2005).
RECOVERY FROM VIOLENCE AND TRAUMA
Many models have been formulated about the process of recovery from traumas such as crimes and disasters.
Most researchers agree that the duration and severity of the trauma, the victim’s resources, and the nature of
help available during and immediately after the crime, trauma, or disaster influence recovery. Typically, three
stages of recovery are defined: (1) initial disorganization (impact), (2) a struggle to adapt (recoil), and (3)
reconstruction (reorganization). The brief summary here is derived from the views of Foa (2005), Lacy and
Benedek (2003), Pasquali (2003), and Tynhurst (1951). The stages are not clearly separated, and the
readjustment process is not smooth. Vacillation among the stages might occur, and recovery might take
months or years, especially if revictimization/secondary victimization (due to involvement with the criminal
justice system) continues after the crime (Baliko and Tuck, 2008).
The initial reaction to a single-event trauma usually lasts from a few minutes to a few days. Common
responses are shock, denial, disbelief, and confusion. There might be paralyzing fear, hysteria, horror, anger,
rage, shame, guilt, a sense of helplessness and vulnerability, physiologic responses, and disturbed sleeping and
eating. These reactions might occur for a longer time when the trauma is ongoing, such as harassment,
stalking, or disaster. Some victims react less visibly or in a delayed manner; they look calm, organized, and
rational, and take all the necessary actions initially needed. Later, the other reactions might occur.
Occasionally, the victim’s reaction might include dissociative symptoms (amnesia, depersonalization,
numbing, detachment), intrusive memories (nightmares, flashbacks), and severe anxiety. These symptoms
might indicate that the victim is experiencing acute stress disorder (ASD) (see Chapter 31).
In the recoil stage, victims begin the struggle to adapt. The immediate danger might be over, but a great deal of
emotional stress remains. In the beginning of this phase, there are periods in which victims look and act normal
and are able to carry out daily routines at home and at work. Activity helps suppress fears, anger, and sadness.
Later in this phase, there is a desire to talk about all the details of and feelings about the trauma (“What
happened?”). Victims often have a need for support and to be temporarily dependent. Fantasies of revenge for
the crime are natural during this stage. In the weeks and months following trauma, victims gradually become
aware of the full impact that the event has had on their lives.
Reorganization might take months or years to accomplish. Although the trauma is not forgotten, the anxiety,
fear, and anger diminish, and victims reconstruct their lives. The beginning of this phase includes reviewing
and organizing what happened and why (“Why me?”); attributing blame to self, others, or both; justifying
one’s own actions at the time and later (“Why did I act the way I did then and since then?”); and regaining a
sense of control and self-protection. Grief over losses resolves slowly. Lingering nightmares, frustrations, and
disillusionment might occur; however, these subside as victims become reengaged in life and activities. If
reorganization is not effective, victims might experience degrees of symptoms that, in some cases, are
clinically diagnosable (e.g., posttraumatic stress disorder [PTSD]) and need appropriate treatment (Alim, et al,
2008; Lacy and Benedek, 2003; Naifeh, et al, 2008; Roberts, et al, 2009). See Chapter 31.
Even with satisfactory recovery, victims sense that they and their lives are, and always will be, different as a
result of the crime (“What if it happens again?”). Moving from victim to survivor or victor status is the goal for
those experiencing trauma (Rowell, 2005), which can be accomplished by integrating the memories of the
trauma and moving on in life with restored functioning, a reasonable sense of safety and security, healthy
relationships, improved self-esteem, and a sense of purpose in life (Alim, et al, 2008).
PUTTING IT ALL TOGETHER
Although trust, empathy, emotional support, and a willingness to listen are important in all stages of recovery,
specialized care is needed in each stage. During the impact stage, the focus is on the survivor’s need for
physical safety and emotional security (see Chapter 10 for these crisis intervention strategies). Reassurance,
protection from further harm, and sometimes medical care are needed. Survivors might need clear, simple
directions on what to do, where to go, and what to avoid. It is crucial that nurses avoid accusations (blaming),
intimidations, unnecessary intrusions, and invasion of privacy. In most instances, crisis intervention occurs
face to face at the scene of the trauma or in the emergency room. For survivors who are superficially calm and
in control, the crisis intervention might be needed a few hours or days later, when the trauma reality hits.
Phone numbers for crisis telephone or walk-in services can be given to survivors before they leave the police
interview at the scene or the emergency room.
During the recoil stage, survivors need validation of their worth and rights as victims. Referrals can be
made to a victim’s assistance program and for legal, insurance, or financial assistance, if needed. If family and
friends are not fully available during the episodes of emotional turmoil in the recoil phase, then short-term
counseling might be beneficial. During the struggle to adjust, support groups with other survivors can be
useful. Whether the group is of short duration (6 to 8 weeks) or ongoing, and whether the group is
professionally led or self-led, there is value in receiving information, encouragement, and companionship from
others “who have been there.”
During the reorganization stage, most survivors are able to recover and grow with minimal assistance.
Appropriate humor might play a role in decreasing aggression and stress (Dietz, 2007; Pasquali, 2003). Longterm
counseling is sometimes needed to overcome anxiety, phobias, depression, suicidal ideation, or other
posttraumatic symptoms. It is uncommon for survivors to need hospitalization beyond initial medical care.
Exceptions include survivors who are unable to function or meet their basic needs, or those who become
Survivors of crime do not generally need medications. Antianxiety agents (benzodiazepines) are prescribed
occasionally for short-term use to decrease anxiety and facilitate sleep.
Many communities have temporary or ongoing groups for survivors of disasters, divorce, death of a loved one,
sudden infant death syndrome (SIDS), rape, incest, and physical and emotional abuse, as well as for those
affected by suicide/homicide, mass murders, torture, and abduction of children.
NATURE OF THE PROBLEM
September 11, 2001 is the day that awakened the United States to the realities of terrorism and its
unpredictability and devastation. Before this day, terrorism was a news story about terrible acts in foreign
countries. Terrorism can be perpetrated under the justification of various military, political, social, cultural, or
religious reasons. Acts of terrorism can involve plane crashes, bombings, military warfare, biologic and
chemical agents, trained or programmed assassins, and suicide/homicide bombers. Terrorism rarely affects
only a single individual; victimization can involve thousands who have been injured or killed in a single event.
The victims of terrorism include those who were injured or killed; police, fire, and rescue personnel;
businesses and their employees; the friends and families of all the victims; and potentially anyone who
witnessed the tragedy (directly or through the media).
Terrorism can have more devastating results than natural disasters or major accidents because terrorism is not
only perpetrated by humans, but it is also not accidental. The purpose of terrorism is to terrorize, kill, or injure
targeted groups and to generate fear that it will happen again (Foa, 2005; Pasquali, 2003). The trauma of
terrorism is more pervasive, long-lasting, and severe than other violent crimes. Survivors typically experience
some degree of grief and mourning and acute or posttraumatic stress symptoms, which are expected reactions
to an abnormal and horrifying event. See Box 41-1 (p. 608) for a list of typical reactions to terrorism. The
event might also retrigger memories of previous traumatic experiences or lead to new or exacerbation of preexisting
disorders (Ai et al, 2005).
Most individuals will recover with the support of loved ones, co-workers, and friends; memorial or religious
services and community meetings; sleep, stress management techniques, relaxation techniques, physical
activities; and a return to normal activities (Dietz, 2007; Foa, 2005; Miller, 2005). Critical incident stress
management strategies (described with PTSD in Chapter 31) can also facilitate recovery and prevent other
untoward consequences (Dietz, 2007; Lacy and Benedek, 2003; New York Academy of Medicine, 2005;
A major goal of recovery is to regain some sense of trust, safety, and security while acknowledging that
future terrorist attacks are possible. In general, recovery will parallel the stages of recovery described earlier
(impact, recoil, and reorganization) but might be lengthier and more complicated, depending on the severity
and duration of the trauma. On a larger scale, most cities and hospitals are reviewing their disaster plans for the
capability to respond to terrorist attacks, biologic and chemical warfare, large-scale bombings, and other
disasters. For many cities, an effort has been made to improve city-wide, coordinated plans among police, fire,
and rescue agencies, as well as hospitals, mental health facilities, and local, state, and federal emergency
management administrations. Psychiatric nurses and mental health personnel with mental health disaster
management skills are included in the planning.
Specific Responses Resulting From Terrorism, Torture, Serial Ritual Abuse, Mind Control, Human Trafficking
Shock, disbelief, fear, anxiety, powerlessness
Insecurity, guilt, shame, spiritual distress
Unresponsiveness, dissociation, numbness
Decreased concentration, confusion
Panic, terror, sense of violation, anger, rage
Aggression, fantasies of revenge, impulsiveness
Helplessness, hopelessness, despair
Suicidal or homicidal ideation, self-mutilation
Mistrust, suspiciousness, paranoia, alienation
Estrangement, withdrawal, isolation
Fatigue, insomnia, nightmares, flashbacks
Memory disturbances, amnesia
Hyperarousal, stress sensitivity, startle response
Denial, repression, suppression, intellectualization
Body kinesthetic memories, psychosomatic symptoms
Extreme passivity, loss of self-esteem
Depression, prolonged grieving, substance abuse, PTSD
Sexual dysfunctions, eating disorder, anxiety disorder
Labile emotions, personality changes
Modified from van der Kolk B, McFarlane AC, Weissaeth L: Traumatic stress: the effects of overwhelming experience on mind, body, and
society, New York, 1996, Guilford Press; Turkus JA: The treatment challenge, Many Voices 12:6, 2000; Anorexia Nervosa and Associated
Disorders (Indianapolis Chapter of ANAD): Personal interviews: Indianapolis, 2002, ANAD; Valente S: Controversies and challenges of ritual
abuse, J Psychosoc Nurs 38:8, 2000; Miller MC: Disaster and trauma, Harv Ment Health Lett 18:1, 2002; Lacy TJ, Benedek DM: Terrorism and
weapons of mass destruction: managing the behavioral reaction in primary care, South Med J 96:394, 2003; Cole H: Human trafficking:
Implications for the role of the advanced practice forensic nurse, J Am Psych Nurses Assoc 14:6, 2009; Wessels S: Issues up close: The costly
business of human trafficking, Amer Nurse Today 3:12, 2009; Trossman M: Supporting the mental health and psychosocial wellbeing of former
child soldiers, J Am Acad Child Adol Psychiatry 48:6, 2009; Sarson L, MacDonald L: Behavioural Harms: enforced and survival tactics in ritual
abuse-torture victimization, Paper Presentation at the 31st SALIS Conference, May 8, 2009.
TORTURE, RITUAL ABUSE, MIND CONTROL, HUMAN TRAFFICKING
NATURE OF THE PROBLEM
Public and professional attention to the effects of torture, serial ritual abuse (SRA), mind control (MC), human
trafficking (HT) on mental health has waned in recent years, although the crimes have not, according to the
victims. These crimes might be perpetrated by individuals, relatives, gangs, cults (satanic or nonsatanic), hate
groups, organized crime, work/sex trade traffickers, or military-political organizations (e.g., Al Qaeda, the
Taliban regime, Abu Ghraib Prison). Gangs are responsible for an increased number of homicides, other
physical violence, and intimidation, according to the FBI (Ragavan and Guttman, 2004). The actions of
members of drug cartels in Mexico are another example of the destruction that can occur in a country. The
effect is more severe because they involve multiple, calculated, and organized crimes against each victim or
group of victims. This type of crime is used to create fear, humiliation, and submission in individuals,
communities, and societies and is usually done for power and/or profit.
Statistics on the prevalence of torture, SRA, and MC are not readily available because of the problems in
acknowledging, reporting, and proving occurrences. The threat of further harm to the self, family, or pets tends
to keep victims silent. Especially in SRA and MC, perpetrators might use triggers to maintain victims’ silence or
to control their actions, such as special words, hand signals, or greeting cards (Anorexia Nervosa and Associated
Disorders [Indianapolis], 2002).
Drug and MC experiments began before the 1970s (e.g., LSD experiments and covert military-political
operation [MK-ULTRA] programming that trained or programmed assassins for U.S. security forces) (Katchen,
2005; McGonigle, 1999). MK-ULTRA operations (noted in movies—Conspiracy Theory, The Bourne Identity
series) are becoming more widely known, because the Freedom of Information Act has resulted in the
declassification of military and political documents.
"Human trafficking (HT) is the equivalent of modern-day slavery" (Cole, 2009). It involves the transportation
and harboring of individuals for the very profitable purpose of slavery, sex, forced labor and/or organ harvesting
(Cole, 2009). Women and children, especially those in poverty, are particularly vulnerable. The kidnapping and
holding of Elizabeth Smart may not have been for profit. Estimates for international trafficking are from 4-27
million (Cole, 2009).
According to survivors, torture involves physical, psychological, pharmacologic, MC, or sexual manipulation,
or any combination of these aimed at damaging the victim’s identity, personality, emotional stability, spirit, and
physical integrity. HT tactics may include recruitment based on offers of money (to the victims and/or their
families who sell the individual), a "better life", deceptions, threats, coercion, force, or kidnapping (Cole, 2009).
Torture, SRA, and MC can begin with abduction and detention and end with execution, or can be ongoing over
time. Tactics also can include using hot irons, electric shock, submersion, suffocation, large doses of
drugs/alcohol, beatings, physical restraint, confinement in cramped or buried containers, watching or forced
participation in others’ torture/killings, gang rape, sexual and physical mutilation, being tied and/or hung in the
air, being photographed during the abuse, starvation, and sensory and sleep deprivation. There might also be
prolonged interrogation, brainwashing, indoctrination, personality destruction/creation of multiple personalities,
programming, threats to or lies about the safety of loved ones and pets, over-stimulation, mock executions,
cannibalism, electronic harassment (microchip implants, as in the movie Manchurian Candidate), and threats
with weapons (ANAD, 2002; Dowbecko, 2005; McCollough-Zander and Larson, 2004; Sarson and MacDonald,
2004 and 2009; Tolces, 2005; Valente, 2000).
Common outcomes of torture, SRA, MC, and HT are injuries to the head, teeth, and genitals, as well as bone
fractures, dislocations, scars, burns, pain, chronic headaches, and forced pregnancies/abortions (Sarson and
Macdonald, 2009; Wessels, 2009). There may be disruptions in the functioning of the prefrontal cortex due to
the prolonged stress (Liston, 2009). The emotional and other effects are more severe and longer lasting than
those caused by other crimes. They include a sense of violation, dehumanization, humiliation, horrification,
compulsive spending, guilt about harming others or animals, identity and personality changes, and damaged
social and family relationships. In addition victims may reveal a fear of leaving home/work, of authority,
revealing personal information, infections, STD's malnutrition, poor hygiene, and reproductive problems
(Cole, 2009; Sarson and Macdonald, 2009; Trossman, 2008; Wessels, 2009). Trauma-specific fears (e.g., small
dark spaces or nudity), hypersexuality, and obsessions with rituals, magic, or devils are common. Victims
might have been forced or programmed to commit crimes against others. They might talk about topics that do
not make sense to professionals, such as the Greek alphabet, sex trade, white slavery, drinking blood, satanic
rituals and holidays, and the Satanic Bible (written by Anton LaVey) (ANAD, 2002; Valente, 2000). Other
specific responses resulting from torture, SRA, MC, and HT are listed in Box 41-1.
There is much controversy about assigning psychiatric diagnoses (e.g., PTSD, adjustment disorder, major
depression, dysthymia, anxiety disorder, dissociative identity disorder, or other dissociative disorders) to
victims who are having typical reactions to horrific crimes (Torem, 2000). The major concern is that diagnosis
is another form of victimization, stigmatization, and discounting of the validity of reports of these crimes.
Blaming the victim draws attention away from the individual, social, cultural, and political variables creating
and fostering torture, SRA, MC, and HT and from research on strategies for prevention. Some professionals
even view PTSD as insufficient for acknowledging the catastrophic effects experienced by victims and their
families. The Salvation Army and the U.S. Department of Health and Human Services have developed guides
for Identifying and assessing HT victims. Another resource is The Crime of Human Trafficking (Office on
Violence against Women, date unknown).
Because torture, SRA, MC and HT tend to be ongoing, the impact stage of recovery persists but might wax and
wane over the years. In the recoil stage, adaptation is difficult because of the severity of the emotional stress
remaining after these crimes end. Although supportive, cognitive-behavioral, psychodynamic, and
pharmacologic approaches (Lacy and Benedek, 2003; McCollough-Zander and Larson, 2004) are useful in
helping these survivors reorganize their lives, this stage is likely to be prolonged, with more relapses during
other life crises. Admission to a specialized program or psychiatric unit might be needed during intense
therapy periods, when the risk of self-mutilation, suicide, or increased substance abuse is present. The major
goals for recovery (Alim, et al, 2008; Cole, 2009; Howe, 2003; Lacy and Benedek, 2003; McCollough-Zander
and Larson, 2004; Sarson and Macdonald, 2009; Wessels, 2009) include the following:
1. Decreasing, and eventually eliminating, self-destructive behaviors (self-mutilation, suicide attempts,
substance abuse, and manipulation)
2. Developing emotion management skills and acknowledging the thoughts, feelings, and behaviors as
“normal reactions to abnormal situations”
3. Expressing and dealing appropriately and safely with the intense emotions, especially anxiety, guilt, anger,
rage, and desire for revenge
4. Becoming aware of suppressed or repressed thoughts and feelings, positive emotions, and body memories
5. Allowing oneself to grieve for the variety of losses experienced
6. Processing and integrating the memories of the experiences, often from the least to the most bizarre
experiences (as in the recovery from PTSD and the integration of multiple personalities)
7. Developing or re-establishing healthy relationships with family, friends, and the community
8. Developing boundaries, a sense of privacy, self-integrity, and empathy
9. Using complementary or alternative medicine and spiritual practices that are helpful
10. Developing occupational and community living skills that lead to economic and social independence
11. Becoming aware of new perspectives in life and reasons to live, in spite of the past
12. Regaining a sense of hope, personal power, and control over oneself and one’s life
PUTTING IT ALL TOGETHER
Conveying acceptance, caring, and support; ensuring confidentiality; and believing what is being described are
crucial if survivors are going to trust someone enough to discuss their experiences (Cole, 2009; McCollough-
Zander and Larson, 2004; Sarson and Macdonald, 2009). Survivors must have time and space to process the
issues at their own pace and within their own cultural framework. Survivors might need prompting, which also
conveys understanding, such as, “It sounds as if you have been traumatized in some way” or “I wonder if you
have experienced activities using rituals.” Strategies used with patients experiencing PTSD are particularly
useful for survivors of torture, SRA, MC, and HT (see Chapter 31). Depending on the origin of the torture,
SRA, MC or HT (individuals, relatives, gangs, hate groups, cults, organized crime, traffickers, militarypolitical
organizations), it might be crucial to understand the survivor’s family, religious, cultural, and political
background. Referrals for treatment or correction of physical injuries and other outcomes might be appropriate,
such as dentists, plastic surgeons, gynecologists, neurologists, or gastroenterologists (Turkus, 2000). Survivors
may also need support and protection while they are involved with the criminal justice when their perpetrators
are being investigated and prosecuted. Foreign survivors may require the use of translators and face
immigration charges and deportation (Cole, 2009; Trossman, 2008).
Using medication for treating survivors of torture, SRA, and MC is highly controversial, especially because
drugs were often a part of the abuse as it occurred. Sometimes the medications used in treating PTSD, anxiety
disorders, depression (especially selective serotonin reuptake inhibitors, SSRIs), sleep disturbances, and
psychosis are effective (Lacy and Benedek, 2003; McCollough-Zander and Larson, 2004).
Specialized treatment centers, such as the Center for Victims of Torture in Minnesota (McCollough-Zander and
Larson, 2004) and The Center: Post-Traumatic Disorders Program in Washington, DC, use a multidisciplinary
approach in providing treatment and rehabilitation for survivors and their families. Some of the 30 centers and
programs use bicultural counselors to facilitate counselling with immigrants and former gang members. Selfhelp
and therapy groups might be useful for survivors with similar experiences and needs, such as political
refugees; rape, childhood sexual abuse, and partner abuse survivors; and former cult and gang members.
Nurses and survivors of HT can access information and resources from the national hotline (888-373-7888) of
the U.S. Department of Health and Human Services or The Trafficking in Persons and Worker Exploitation
Task Force (888-428-7581).
For further information about torture, SRA, MC, and HT, the following auto biographers have written their
own personal stories:
Family torture: David Pelzer, Richard Pelzer, deJoly La Brier
Fundamentalist/polygamous cults: Brent Jeffs, Carolyn Jessup, Flora Jessop, Elissa Wall
Military-political SRA and MC: Carol Rutz, Kathleen Sullivan
RAPE AND SEXUAL ASSAULT
NATURE OF THE PROBLEM
Statistics indicate that rape is an underreported crime in the United States; probably only 1/3 of rapes are
reported (Amar and Clements, 2009; Jordan, 2004). Valid statistics are not available for sexual assault and rape
because of this lack of reporting. It is estimated that one in four adult women have been raped in their lifetime
(Campbell and Wasco, 2005). In one survey, 14.8% of the females and 2.1% of the males reported having been
raped in the past year (Courey, et al, 2008). The elderly are vulnerable at home and in extended care facilities,
especially if they have medical conditions, a physical or mental disability, or dementia (any of which might
result in their reports being discounted by caregivers, family, and officials) (Burgess et al, 2005). Rape of men
by men is increasing [an estimated 1 in 10 rape victims is male (Amar and Clements, 2009)], but is rarely
reported. Of the reported sexual assaults and rapes, probably 90% involve a male perpetrator and a female
victim (Brown, 2001). The increasing availability of adult and child pornography through electronic media
may be playing a role in the increasing rate of rape, sexual assault, and child sexual exploitation (Alexy,
Burgess, Priestly, 2009; Burgess, et al, 2008; Courey, et al, 2008)
One major problem in reporting rape is that laws and attitudes vary in different states and communities. In
general, rape is considered forcible penetration of the victim’s body by the perpetrator’s penis, fingers, or
object without consent (Martin et al, 2000). Any other form of forced sexual contact (from touch to mutilation)
is considered sexual assault. Despite sexual contact, it is generally acknowledged that rape is not sexually
motivated, but involves a desire for power and control, a wish to humiliate the victim, and the playing out of a
(sexual) fantasy (Brown, 2001). Some police and prosecutors still do not pursue rape as a charge if the two
individuals know each other (Jordan, 2004), despite the fact that, in 90% of reported rapes, the victim knows
the offender at least casually (Brown, 2001). In a longitudinal study of adolescents, findings were that 46%
experienced sexual aggression and 65% of those experienced a repeated incident of sexual aggression (Young
and Furman, 2008). Date or acquaintance rape might be complicated by the use of amnesiacs (date rape drugs),
other drugs, and alcohol, which interfere with remembering the rape (Osterman et al, 2001). Some states lack
marital rape statutes, or prosecutors are reluctant to charge husbands with raping their wives. Unfortunately,
many in our society ignore rape or convey the message that anyone who is raped asked for it (blaming the
Similar to all crime victims, the rape victim experiences a severe violation and all the possible emotions of the
impact stage. In addition to internal and external bodily injuries, there might be a threat to life with weapons,
to return and rape again, or to kill the victim if the rape is reported, or the perpetrator might kill the victim
during or after the rape (Brown, 2001). Victims usually live but wish they had died. The traumatic memories
of the rape usually include tastes, smells, sounds, and sights, as well tactile sensations and physical pain
(Brown, 2001). These memories and the powerlessness, loss of control, fear, shame, guilt, humiliation, rage,
and feelings of being contaminated or dirty might be overwhelming. A typical reaction of the victim is the
wish to regain a sense of control and retreat to a safe place, take a thorough shower, and destroy any damaged
belongings. To do this, however, would destroy most of the evidence that is required if the victim decides to
report the rape and prosecute. Avoiding medical attention also places victims at risk for acquired
immunodeficiency syndrome (AIDS), hepatitis B infection, sexually transmitted diseases (STDs), pregnancy,
and improper healing of any physical injuries (Campbell and Wasco, 2005; Piercy and Greenwood, 2002).
Beyond the injuries, there may be long term effects of headaches, gastrointestinal disturbances, chronic pain
depression, anxiety, substance abuse, and/or PTSD (Courey, et al, 2008)
Despite an outward appearance of calm composure and a denial at times of the need for help (as in silent or
delayed reactions), the rape survivor needs assistance, information, and support. It might not be until the
survivor begins the up and down struggle of the recoil stage that the losses, anger, and needs are recognized. In
an emergency department, collecting evidence, taking away clothes, and other procedures might be a priority
for staff but, for the survivor, it is perceived as further intrusion and violation (Courey. et al, 2008). To staff,
survivors might seem resistant and uncooperative, whereas survivors are trying to protect themselves and
regain a sense of control (Brown, 2001). Box 41-2 lists some of the needs and rights of rape survivors.
Needs and Rights of Rape Survivors
1. Crisis intervention: information, counseling, and referrals
2. Help with basic needs: housing, transportation, child care, safety
3. Medical information and care: information about pregnancy prevention, testing for sexually transmitted diseases, follow-up care, and
4. Advocacy for whatever choices are made about reporting or prosecuting
5. Protection of rights: to privacy, confidentiality, gentleness, sensitivity, and explanations of procedures and tests
6. Protection of rights: to refuse collection of evidence, to determine who will and will not be present during examinations, to get copies
of all medical and legal reports, and to apply for reimbursement through victim’s compensation
7. Fairness, information, and protection of legal rights during investigations, hearings, and trial, including not being asked about prior
sexual experiences with anyone other than the suspect or defendant
8. Reasonable protection against further harm: escorts to court, restraining order, additional patrols, even relocation, if necessary
Many communities have developed specialized services for rape survivors (e.g., Centers for Hope) within
clinics or emergency departments. Sexual assault nurse examiners (SANE) have skills in collecting forensic
evidence while providing empathy, support, and information (Campbell and Wasco, 2005). Nurses also can
encourage the beginning of the recovery process by avoiding a "blame the victim" attitude and by challenging
any myths stated by the survivors, such as, “I should have fought him off” or “I shouldn’t have been drinking”
(Brown, 2001; Girardin, 2001; Piercy and Greenwood, 2002; Willis, 2009).
Specialized rape services have information packets prepared for rape survivors and staff in hospitals,
counseling centers, and other crisis areas. Survivors can be encouraged to keep the information sheets, as well
as phone numbers of resources, for later use. The temporarily composed and calm victim who denies the need
for help should be especially encouraged to take materials home. A SANE might also call a sexual assault
advocate, an advocate from a victim’s assistance program, or a rape crisis counselor to initiate contact with the
survivor and make periodic follow-up contact days, weeks, and even months later, when emotional, physical,
or legal issues and concerns might arise (Brown, 2001; Campbell and Wasco, 2005).
In the recoil stage, most survivors begin to react to the significant effect that rape has had on their lives;
they might alternately deny and admit to experiencing turmoil. Fear and mistrust are major issues and might be
directed toward individuals resembling the perpetrator or toward everyone around them, especially if others
convey any hint of blaming the victim. Survivors might be afraid to leave the one place they designate as safe.
They might be able to go out with family and friends, but they more often avoid strangers, places similar to the
rape scene, and intimacy, especially sexual relationships. If the rapes occurred in their residence, survivors
might move or at least make safety-related changes to prevent recurrence, or they might ask for someone to
stay with them at night for a while. Being alone and unprotected is usually frightening, especially when
nightmares and traumatic memories occur. Survivors need help in reaffirming that they are worthwhile
individuals, with dignity and rights, who did not cause and did not deserve the rape. They need to know that
their anger is natural, especially about the violation of person and privacy, the humiliation, and the sense of
powerlessness. Survivors often question whether they might have fought off the attacker. Survival is most
important; if the victim survived the rape, then he or she did exactly what was necessary to stay alive.
RAPE TRAUMA SYMPTOMS
One way to monitor and evaluate the rape survivor’s responses to the trauma and recovery process through the
recoil and reorganization stages is to assess periodically for improvements in the rape trauma symptoms
• Sleep disturbances, nightmares
• Loss of appetite, somatic symptoms
• Fears, anxiety, phobias, suspicion
• Decrease in activities and motivation
• Disruptions in relationships with partner, family, friends
• Self-blame, guilt, shame
• Lowered self-esteem, feelings of worthlessness
It is important to remember that survivors vacillate in the recoil stage between repression or suppression and
dealing with the trauma. Even progress in the reorganization stage is not smooth; backslides occur at times,
especially if new situations trigger memories of the rape. Survivors might avoid future routine gynecologic and
rectal examinations to avoid re-experiencing the trauma (Osterman et al, 2001). The use of restraints during an
inpatient stay might also reactivate the trauma symptoms (Chandler, 2008). The goals of recovery from rape
and sexual assault are the same as those for all survivors of crime. In addition, rape survivors might need to
develop or regain healthy sexual functioning and relationships (Osterman et al, 2001). Victims need to transfer
traumatic memories to narrative or past memories by processing the sensory memories and decreasing their
strength and influence, enabling them to move from victim to survivor status (Brown, 2001).
PUTTING IT ALL TOGETHER
The rape or sexual assault survivor needs continual empathy, support, and an opportunity to process the events
and manage the intense feelings, as well as to regain a sense of psychological and physical safety (Osterman et
al, 2001). Although it is more time- and energy-consuming, the best approach in collecting evidence and
providing nursing care is to move slowly and supportively at the individual survivor’s pace and to give
rationales for and descriptions of procedures and referrals. Nurses can be particularly helpful to rape survivors.
Male and especially female survivors tend to feel safer with a woman and might refuse to talk to a man,
especially alone. The presence of a SANE or sexual assault advocate during examinations and interrogations
can be reassuring. Survivors might or might not choose to have a friend or family member stay with them for
additional support or help them get home. A sense of shame or guilt might interfere with reaching out for
support (Osterman et al, 2001).
Crisis intervention is the most appropriate approach during the impact stage. Short-term counseling and a
rape support group can be beneficial during the recoil stage. Long-term counseling might be needed during the
reorganization stage, especially if the survivor decides to prosecute the perpetrator. A lengthy legal process can
seriously delay recovery because of having to relive the events and emotions. In many trial situations, the
survivor is still treated as a criminal during cross-examinations. On the other hand, conviction and
imprisonment of the perpetrator can help survivors feel vindicated, compensated, and safer in their
If the symptoms of rape trauma do not gradually diminish and if reorganization of lifestyle does not seem to
occur, the survivor needs to be assessed for and helped with any new problems, such as posttraumatic stress,
anxiety, excessive anger and guilt, depression, acting out, isolation, suicidal thoughts, self-destructive
behaviors, eating and sexual disorders, substance abuse, phobias, and/or negative or destructive relationships
with others, as well as reactivation of childhood sexual abuse memories (Campbell and Wasco, 2004; Faravelli
et al, 2004). With any of these behaviors, longer term counseling might be a necessity and hospitalization for
safety becomes essential.
Although rarely prescribed to rape survivors, benzodiazepines to reduce anxiety and provide for sleep might be
used on a temporary basis. Alternatively, an antidepressant taken at bedtime (especially trazodone [Desyrel]),
might be ordered if symptoms of depression exist with a sleep disturbance. If nightmares or traumatic
memories are severe, a low dose of an atypical antipsychotic such as risperidone (Risperdal) or quetiapine
(Seroquel) might be indicated.
Referral can be made to a rape support group or center, which encourages expressing anger safely, overcoming
guilt and shame, building self-esteem and trust, and assisting in regaining control of the survivor’s life and a
sense of safety. Support groups are sometimes available for relatives, especially partners, of rape survivors to
help them deal with the trauma, stereotyping and myths, and changes occurring in the survivors, themselves,
and their relationship with the survivors. Also available are The Rape, Abuse and Incest National Network
(RAINN) National Sexual Assault Hotline (800-656-Hope) and the National Sexual Assault On-line Hotline
(http://rainn.org) (RAINN, 2008).
A 24-year-old woman called a rape crisis line complaining of anxiety at work, not sleeping, fear of being out at night,
overwhelming anger, and feeling dirty and ashamed. For several weeks she thought that a co-worker was watching her. Last
Friday, as she was leaving work late, the co-worker pushed her into her car and raped her. She did not report the rape and hid
in her apartment all weekend. She forced herself to go to work on Monday. The man acted friendly toward her, as if nothing
ADULT SURVIVORS OF CHILDHOOD SEXUAL ABUSE
NATURE OF THE PROBLEM
Approximately 1 million cases of child abuse (including sexual abuse) are reported each year. However, child
abuse is grossly underreported (Rick and Douglas, 2007). It is likely that the internet is compounding the
problem. One study found that approximately 14% of the 10-17 age group who were online, received a sexual
solicitation (Burgess, et al, 2008). The CSA crimes of child pornography, childhood sexual abuse (by nonrelatives)
and incest (by relatives) are especially destructive for two major reasons: the crimes are not one-time
occurrences, and the perpetrators may be known and trusted. Unfortunately, these crimes are common. Studies
have indicated that 15% to 30% of all girls and 4% to 16% of all boys have experienced childhood sexual
abuse (Cook, 2005; Valente, 2005). The incidence of sexual abuse of boys might actually be much higher. One
estimate is that 25%-35% of all CSA victims are male (Maso and Anderson, 2009). It is sometimes harder for
men to reveal the abuse because of the fear of being seen as unable to protect themselves, weak, or gay (Cook,
2005; Maso and Anderson, 2009; Shea, 2008; Valente, 2005). However, the number of children who have
been sexually abused and never reported it, even when they became adults, is not actually known.
Sexual abuse and incest include voyeurism and exhibitionism, which can lead to intercourse and mutilation,
but always involve a younger victim who is not capable of giving consent to the older, more powerful
individual. For 75% of the adult female survivors in one study, the abuse began before the age of 7 years and
62% had multiple perpetrators (Jonzon and Lindblad, 2005; Valente, 2005). Male perpetrators are commonly
fathers, uncles, stepfathers, older brothers, cousins, grandfathers, neighbors, scout leaders, camp counselors,
coaches, and religious leaders. Less frequently, the perpetrators are females—mothers, older sisters, other
relatives, day care workers, teachers, coaches, neighbors, and babysitters. Perpetrators tend to choose either
male or female victims, so there can be male to male, male to female, female to male, and female to female
abuse. However, 92% of the females were victimized by male perpetrators and 38% of the males were
victimized by female perpetrators (Lie and Barclay, 2005a). Victims are from every social, cultural, ethnic, and
economic group (Cook, 2005).
Although sexual abuse can be violent, it often is not. Coercion is possible because of the victim’s
dependent, trusting, or loving relationship with the perpetrator. The victim is urged to maintain the secret with
various threats, such as the following: the victim will be taken away from the family; the perpetrator will be
put in a mental hospital or jail; the parents will divorce; the other parent will get sick; there will be no abuse of
siblings if the victim is compliant; love will be withdrawn; no one would believe the victim anyway; or there
will be physical abuse if the victim does not comply. Even when no physical violence takes place, victims
usually fear that it will occur if they resist the perpetrator. Factors such as family conflicts or disorganization,
witnessing violence, parental loss, parental mental illness, economic instability, secrecy and communication
difficulties, substance abuse, and other forms of abuse (emotional, verbal, physical) and neglect seem to
correlate with sexual abuse (Davis and Petretic-Jackson, 2000; Gladstone et al, 2004; Goodwin, 2005).
Even if the young victims want to disclose the abuse, it is difficult for them because they lack the words and
concepts to describe the event. An emotional reaction of fear and confusion usually occurs, and some physical
pain, but not a moral, ethical, or legal concept of right or wrong. Most victims who, as children, tried to tell a
parent or other adult were often met with disbelief, denial, or pressure to retract their accusations. It is difficult
for a parent to believe that the partner they love or a respected member of the community is capable of sexual
abuse. Police, prosecutors, judges, mental health professionals, and the general public might discount a child’s
report as unreliable, a fantasy, distorted, or faked at the urging of a parent, especially if there is a custody
dispute in progress (Davis and Petretic-Jackson, 2000). There are also potential benefits from the sexual
relationship; the child is made to feel special, with extra attention from and time with the perpetrator that other
children do not enjoy. A certain power comes from pleasing the adult and receiving a degree of (distorted)
affection (Davis and Petretic-Jackson, 2000). At times, the child might even have the physical experience of
sensual pleasure (Valente, 2005). However, the emotional pleasure and concept of adult sexual love are absent.
(It should be noted that all children make bids for attention and affection. Even if they are cute, coy, or
flirtatious, these desires should not be viewed as seduction. Perpetrators of sexual abuse choose to misinterpret
the child’s behavior to meet their own needs and should still be held responsible for the crime.)
EFFECTS OF CHILDHOOD SEXUAL ABUSE
On the Child
For the victim, the prolonged stress of the abuse might lead to changes in his or her neurobiology, as in the
stress response described in Chapter 10. "Stress hormones affect myelination, neural morphology,
neurogenesis, and synaptogenesis" (Rick and Douglas, 2007). Specific areas of the brain likely to be affected
by childhood trauma include the amygdala, cerebellar vermis, cerebral cortex, corpus callosum, and
hippocampus (Rick and Douglas, 2007). Other results are disturbed growth and development (beginning with
trust and autonomy issues), ambivalence about the experience (both the benefits and the pain), and denial of
what is happening to protect the whole family or the community. The young child is fulfilling the roles of child
and lover to the perpetrator, and roles of child and protector to the rest of the family or community (protecting
them from the horrible secret). As a result, the child begins a long-term process of taking care of others to the
exclusion of personal needs. Basically, the child wishes for love, not sex, but eventually feels guilty, exploited,
betrayed, angry, dirty, helpless, and responsible. Denial, repression, suppression, rationalization, and
dissociation are mechanisms used by young victims to cope with this no-win situation. Sleep and eating
disturbances, enuresis, anxiety, depression, aggression, an active fantasy life, masturbation, sexualized play,
sexual aggression, poor impulse control, cruelty to animals, spiritual distress, somatization, alienation, fear,
shame, self-blame, self-destructive behaviors, running away, and truancy are common (Cook, 2005; Davis and
Petretic-Jackson, 2000; Valente, 2005). The more severe the abuse, the more likely that repression will begin
near puberty. If the sexual abuse continues throughout adolescence, repression is less likely. Repression
normally lasts until victims are in their 20s or 30s and are having trouble with intimate relationships and/or
Children who were examined following ritual abuse in a day care center reported being locked in a cage, put in a coffin, held
underwater, injected with needles, tied and hung from hooks, sexually assaulted, and threatened with guns and knives. The
children were told that if they told anyone about the abuse, their parents, siblings, or pets would be killed.
On the Adolescent
As adolescents, sexual abuse victims show mostly overt methods of dysfunctional coping, such as impulsive
acting out, violence toward or abuse of others, cruelty to animals, self-destructive behaviors, sleeping and
eating disorders, suicide attempts, running away, truancy, delinquency, substance abuse, spiritual distress,
sexual acting out, prostitution, early pregnancy, and early marriage (Cook, 2005; Davis and Petretic-Jackson,
2000; Valente, 2005). For victims who cope through self-mutilation, these behaviors tend to begin between the
ages of 12 and 14 years (Cerdorian, 2005).
Adolescents might have fantasies of revenge and wish for the perpetrator’s death. The anger toward the
perpetrator and other adults (for not protecting them) approaches rage but is not directly expressed. Victims
might not even be aware of the reason for their rage, shame, guilt, confusion, sense of alienation, and isolation
and might not realize that their acting-out behaviors are related to the abuse. Regression, depression,
depersonalization, dissociation, manipulation, low self-esteem, impaired social skills, spiritual distress, thought
and memory disturbances, self-neglect, aimlessness, and withdrawal are common. Sexual abuse survivors are
also more likely than the general population to be raped and battered by partners in adolescence and later in
life (Davis and Petretic-Jackson, 2000; Gladstone et al, 2004; Kreidler et al, 2000; Valente, 2005).
On the Adult
For many victims of childhood sexual abuse, the process of surviving childhood and adolescence and
becoming an adult is similar to delayed PTSD responses: repression of memories (even nonsexual ones),
followed by a breakthrough of unwanted, intrusive memories. The memories might begin as nightmares,
kinesthetic sensations (such as flinching or vaginal pain when touched by a partner in the same way as the
perpetrator), or flashbacks. The memories might return gradually, in pieces, or in a sudden, overwhelming
flood. Victims cannot be rushed to remember the abuse before they are ready to cope with it.
On the surface, adult victims might look relatively uninjured because of denial, dissociation, amnesia,
emotional deadening, or repression. They enter counseling for manifestations of the abuse rather than for the
incest or sexual abuse itself. The list of typical reactions in Box 41-3 can be used as a checklist to identify the
issues to be addressed in counseling. Victims who see this list typically express amazement (that so much has
resulted from the sexual abuse) and relief (that there is finally an explanation for all their “craziness”). Up to
this point, victims might tend to deny or minimize the relationship of the sexual abuse to any of their current
problems. It then becomes evident to victims that the event has disturbed their entire growth and development
process and their self-esteem, and has set them up for other abusive relationships. Only one third of victims
ever receive counseling specifically focusing on the childhood sexual abuse (Gladstone et al, 2004). Until
counseling finally focuses on the anger and underlying cause of their reactions, victims tend to seek treatment
repeatedly, without relief.
The inability to handle the memories of abuse and the painful emotions, especially anger, often induces
thoughts of suicide to escape the pain and depression, to die with the secret, to avoid conflict with the family or
perpetrator, to stop feeling “crazy,” and to end the nightmares and flashbacks that are so frightening. Self-harm
or mutilation, without even feeling the pain, is a common way of dealing with the emotional pain, loss, rage,
and abandonment. Dissociation during the mutilation is common. Victims describe various patterns of their
mutilation (ANAD, 2002; Cerdorian, 2005; Starr, 2004; Williams and Bydalek, 2009):
1. When feeling overwhelmed, they inflict harm as a cry for help when they believe that no one is listening or
2. When emotions build up, they go numb or dissociate and have to inflict pain to make sure that they can still
3. When they are feeling unreal (depersonalization), they draw blood to make sure that they are alive.
4. They cause physical pain so that they do not have to focus on the emotional pain.
5. They punish themselves when they are feeling self-loathing, guilt, shame, or fear.
6. They use the mutilation as a way of avoiding suicide.
7. They use the mutilation to relieve the anger or rage toward self and others.
8. They might use the mutilation as an attempt to manipulate others.
9. The mutilation might become chronic and addictive, especially if it produces a high (related to endogenous
Adult Manifestations of Childhood Sexual Abuse
Amnesia about the abuse
Memory gaps about childhood
Inability to think straight
Keeping Unnecessary Secrets
Trouble connecting with others
Running away from others
Fear of men or fear of women
Trouble trusting others and their motives
Fear of intimacy, inability to maintain intimacy
Fear of abandonment and rejection
Trouble giving and receiving affection
Feeling alienated from others
Fear of being used/abused
Trouble saying “no”, taking care of others
Trouble with parenting
Entering abusive relationships
Poor choices of partners
Vague and transient pains
Memories of physical pain
Chronic pain or migraine headaches
Gagging, nausea, vomiting
Unpleasant sensation when touched
Negative, distorted body image
Self-conscious about body
Overly conscious of appearance
Fear of expressing anger
Holding anger in
Crying instead of being angry
Fantasies of revenge
Feeling violent, full of rage
Fear of violence
Easily startled, inability to relax
Fear of being attacked, exposed
Feeling like a frightened child
Fear of the dark
Panic attacks, phobias, agoraphobia
Alcohol/drug abuse or dependence
Intrusive Thoughts and Memories
Intense nightmares, unwanted thoughts
Flashbacks: feeling, seeing, smelling, tasting, hearing
Feeling numb, unreal
Disconnected from feelings from body
Feeling as if there are “personalities” inside
Fear of authority, rules
Need to be in control, feeling out of control
Pretending to be out of control (or helpless)
Fear of being vulnerable
Ambivalent about being taken care of
Letting others be in control or trying to control others
Allowing children to be abused
Confusion about identity or roles
Need to be perfect or perfectly bad
Underachievement or overachievement
Need to be totally competent
Concealing sexual feelings, feeling nonsexual
Discomfort with sexual touching
Lack of orgasms, sexual dysfunctions
Confusion about sexuality/sexual identity
Feeling “dirty”, contaminated
Trading sex for favors
Wondering if one is gay
Suicidal thoughts, attempts
Wanting to die or to be dead
Compulsive eating or dieting
Low self-esteem, guilt, shame
Fear of feelings
Feeling like a failure
Lack of a sense of humor
Feeling walled in or "crazy"
Some evidence has suggested that suicide attempts might have share similar, as well as unique, dynamics as
self-mutilation and also might become a chronic pattern or addiction (Mynatt, 2000). Whether or not
adolescents have experienced CSA, 4%-38%, use self harming behaviors for stress relief according to U.S.
studies (Williams and Bydalek, 2009).
Alcohol and drugs are often used to avoid or numb the pain and memories and to bring fleeting pleasure that
is otherwise elusive (Davis and Petretic-Jackson, 2000; Gladstone et al, 2004). Food might also provide brief
pleasure or fill emptiness inside (bingeing), but leads to feeling bloated and guilty and a need to purge.
Although sex is not usually enjoyable, it can bring relief from loneliness, temporary attention, affection, and
approval. On the other hand, sexual encounters might trigger traumatic flashbacks, anxiety, fear, shame,
disgust, or a sense of helplessness. Healthy adult relationships and sexual intimacy are difficult because of
problems in trusting anyone and the history of linking abuse and love. Victims have boundary issues, trouble
setting limits with others, and difficulty with asking for what they really need (Davis and Petretic-Jackson,
2000). Victims also tend to be caretakers, rescuers, and co-dependents.
Victims’ reactions to the trauma (see Box 41-3) are often labeled as clinical symptoms. In addition, other
problems resulting from the effects of trauma on the brain may include temporal lobe epilepsy or EEG
changes, autism, and ADHD (Rick and Douglas, 2007), as well as migraines, irritable bowel syndrome, and
fibromyalgia (Cassels and Vega, (2007), and chronic fatigue syndrome (Heim, et al, 2009). When an Axis I
diagnosis is given to patients, it is commonly depression (atypical type), PTSD, substance abuse disorder,
eating disorder, anxiety disorder, somatoform disorder, dissociative disorder (including dissociative identity
disorder), bipolar disorder, schizophrenia, or impulse-control disorder. Axis II personality disorder diagnoses
are commonly borderline, narcissistic, histrionic, avoidant, dependent, atypical, or mixed disorders (Davis and
Petretic-Jackson, 2000; Kreidler et al, 2000; Rick and Douglas, 2007).
Receiving a diagnosis is a major problem, not only because of the stigma and blaming the victim, but also
because the diagnosis often becomes the focus of treatment rather than the underlying issues. This is especially
true when the symptoms of CSA are labeled as a diagnosis of borderline personality disorder instead of PTSD
(Schwecke, 2009). Lack of appropriate treatment carries a major risk, not only for adult survivors but also for
their children, especially if the survivors are still in a stage of repression. Evidence has suggested that untreated
or improperly treated victims occasionally set up dysfunctional, disorganized families, in which there is
incestuous abuse of the children. With their own denial, repression, amnesia, or other mechanisms, survivors
have trouble relating to their partners and are unable to see the partners’ involvement with their children.
Perpetrators (and occasionally victims) might sexually abuse their younger siblings, children, grandchildren,
nieces, nephews, and others. Examples of incest have surfaced within three and four generations of a family.
Breaking this cycle is of crucial importance.
Jan Lester, 30 years of age, was admitted to a psychiatric unit as a result of suicidal ideations and 12 superficial cuts on her
wrists. Nine months ago, she began having nightmares about being awakened at night as a child with someone on top of her.
During the nightmares, she would wake up crying with strange body sensations, gagging, pressure on her chest, and vaginal
pain. As the nightmares and memories became more complete and vivid, she realized her father had frequently had sex with
her while her mother was asleep. As her father’s fiftieth birthday approached, she felt as if she could not tolerate going to his
party. She wanted to be dead but was unable to force herself to cut her wrists more deeply. She wanted help.
In some ways, recovery from childhood sexual abuse or incest is similar to recovery from all crimes and/or
from PTSD, but it tends to be more complex, difficult, and lengthy by comparison, especially if emotional
abuse by the family is ongoing or if the survivor still lives with the abuser. The memories and emotions are
strong, painful, and confusing. The intense anger and ambivalence toward the perpetrator (because the victim
is still seeking approval and love from the perpetrator) are hard for both the survivors and nurse to handle.
Survivors need to know in the beginning that the symptoms and emotional pain will probably worsen before
they improve as the experiences are reviewed. Therefore, survivors need to learn emotion
management/regulation to tolerate the distress and use safety measures prior to using imaginal exposure
techniques (Dunbar, 2004; Goodwin, 2005; Spinhoven, et al, 2009). (See the discussion of dialectical
behavioral therapy [DBT] in Chapter 4 and systematic desensitization in Chapter 38.)
Although outpatient counseling often takes 2 years or longer, survivors tend to engage in treatment
sporadically. It is common for survivors to initially disclose, discuss, vent, and feel cured. Then, as new crises
or relationship problems emerge, survivors return to counseling to deal with each issue and its possible
connection to the original trauma. Getting a patient to commit to continuous, long-term counseling is
sometimes difficult, but the nurse can emphasize the desirability and value of at least sporadic counseling.
The overall goals of recovery are safety and security, rebuilding trust, improved self-esteem and selfacceptance,
forgiveness of self, adaptive coping with life and its stresses, assertiveness skills, the capacity for
intimate relationships and genuine sexual pleasure, improvements in affect, and reduced anxiety, anger, shame,
guilt, fear, and dissociation, as well as the prevention of suicide and sexual abuse of future generations (Davis
and Petretic-Jackson, 2000; Kreidler et al, 2000).
PUTTING IT ALL TOGETHER
Much depends on the nurse’s ability to develop a trusting relationship with the survivor quickly. Empathy,
active support, compassion, warmth, and being non-judgemental are crucial. Survivors need to be calmly and
matter of factly asked about childhood sexual abuse, because they are not likely to reveal it spontaneously. The
old and perhaps current coercions to keep the secret remain strong in the minds of survivors; they need to feel
safe about confidentiality and the nurse’s acceptance before disclosure can occur. How much detail is revealed
and how soon depends, in part, on the nurse’s ability to be receptive to the experiences without being critical of
the perpetrator, of other adults in the family, or of the survivor’s loyalty to them. The survivor needs to be
reassured that all the experiences and emotions (positive, negative, and ambivalent) are valid and that
exploring them is the beginning of the process of working through recovery (Davis and Petretic-Jackson,
2000). It is usually helpful for survivors to be reminded periodically that they were not responsible for and did
not deserve the sexual abuse, are not to be blamed, were not in control of the situation, and that the way they
coped in the past was the best they could do at the time. Cognitive-behavioral approaches and education about
the dynamics of sexual abuse and reassurances about recovery can be useful in correcting faulty perceptions
about the abuse, decreasing self-blame and guilt, and instilling hope for the future despite the inability to
change the past. (See Key Nursing Interventions for Survivors of Childhood Abuse box.)
Mentally and emotionally reexperiencing traumatic events (see discussion of imaginal exposure in Chapter
38) is disturbing; only periodic, small doses might be tolerable. In contrast excessive rumination on events can
be counter productive (Schwecke, 2009). It is helpful to remind survivors that they went through the abuse
alone, but do not have to remember it alone. If traumatic flashbacks or dissociation occur, it is important to
bring the survivors back to the present by reminding them where they are and that the nurse is with them now.
The nurse and survivors can monitor their safety and tolerance of the process to prevent becoming
overwhelmed, retreating, attempting suicide, or self-mutilating. Anger release strategies, such as using a foam
bat (batacca) while talking to a chair that represents the perpetrator or non-protective adult, often help the
survivor express thoughts and feelings that could not be expressed in childhood. Play therapy, therapeutic
stories, and art therapy can be especially useful in helping children process their abuse (Bennett, 1997; Hinds,
1997; Rick and Douglas, 2007). Writing memories and painful feelings in an ongoing journal and writing
“letters,” which will not be sent, to the perpetrator and non-protectors can be useful (Cerdorian, 2005).
Key Nursing Interventions for Survivors of Childhood Abuse
• Contract for safety and control of impulses to harm self or others.
• Set limits on self-destructive or self-harm patterns.
• Establish a trusting and supportive environment.
• Accept all feelings and reactions as normal responses.
• Ask permission before touching survivors.
• Reinforce that recovery is possible, even if it is difficult.
• Educate about the dynamics of abuse and recovery processes.
• Assist survivors in understanding current behaviors as reflections of survival strategies used in childhood.
• Facilitate re-evaluation of the sexual abuse, its circumstances, and its effects, but without pressuring or excessive
• Encourage coping choices that are in survivors’ best interests.
• Discuss safeguarding other children if the perpetrator still poses a risk.
• Support choices about future disclosures, confrontation, or reporting.
• Be aware that family members and others might feel split loyalty and engage in dysfunctional roles and interaction patterns.
• Decrease feelings of isolation, shame, and stigma.
• Encourage self-acceptance.
• Facilitate acknowledgment, forgiveness, and love for the child within.
• Teach and encourage stress management and anger reduction.
• Facilitate the transfer of responsibility and anger to the perpetrator but set limits on acting out fantasies of revenge.
• Foster separation and individuation from the family and its patterns.
• Help to find meaning in the experience and mourning of all the losses (grieving is a very painful experience).
• Facilitate the change from victim to survivor status (reexperiencing and integrating the positive, negative, and ambivalent
feelings and memories).
• Facilitate reexperiencing and reworking of maturational tasks that were missed or experienced prematurely.
• Educate about life skills, communication skills, coping skills, assertiveness, decision making, conflict resolution, boundary
setting, friendship, intimacy, sexuality, and parenting.
• Refer to outpatient counseling and appropriate support groups.
Confrontation of the family or perpetrator by the survivor is not necessarily a desired outcome or safe
option. Confrontation might be done symbolically or verbally with the nurse and/or in the letters, rather than
directly with the perpetrator and other family members. If survivors choose to confront directly, much
preparation is needed before this can happen. Survivors need to consider, plan for, and rehearse their reactions
to all the typical responses of family members, such as denial, rationalization, and blaming the victim.
Confessions and apologies are unlikely. (See the family issues box.) Survivors can be helped to debate the
benefits and risks of confrontation, as well as the degree and type of contact they want to have with the family,
even if they do not confront them or if the survivors need to protect their own children. An important
consideration for the nurse and survivor to discuss is the mandatory reporting of child abuse if younger
children are currently victims of abuse by the same perpetrators. This type of reporting is understandably
difficult for both the nurse and the survivor, but needs to be carefully and directly addressed.
When survivors are in outpatient counseling, it is important to consider priorities in each counseling session.
Current crises and problems need to be addressed (instead of the sexual abuse) as they arise. For example,
gynecologic and physical examinations might be distressing and trigger flashbacks (Roberts, 2000). This
aspect is also critical for self-destructive behaviors that are increased because of counseling, such as suicidal
ideation, self-mutilation, and substance abuse. Hospitalization might be necessary if the crisis is severe. Again,
staff should avoid use of restraints that could cause retraumatization (Chandler, 2008). Although survivors
view recovery as frightening and painful, they also experience relief that they are making progress.
Medications are not always needed or desirable for adult survivors of childhood sexual abuse, especially if
substance abuse is a problem or potential problem. For the small number of survivors with serious
psychopathology, medications should be given according to the Axis I diagnosis, such as depression. An
antidepressant such as trazodone (Desyrel) might be used if the depressive symptoms are interfering with
sleep. Benzodiazepines or clonidine might be given on a short-term basis to help control the emotional or
autonomic arousal that occurs during the reexperiencing of traumatic memories. Occasionally, low doses of
risperidone (Risperdal) or quetiapine (Seroquel) are given for persistent and severely disturbing nightmares,
flashbacks, and/or agitation.
On an outpatient basis and during any brief hospitalizations, cognitive-behavioral and affect management
groups can be a useful adjunct to nursing care (Kreidler et al, 2000). If available, a short-term or ongoing
sexual abuse or incest recovery group is beneficial. Some self-help groups include Incest Survivors
Anonymous, Survivors of Sexual Abuse, and Daughters and Sons United. Parents United (for the
nonperpetrator parent) can be suggested, if appropriate. The perpetrator might also be referred to counseling.
Family therapy is sometimes appropriate.
Other groups that might be recommended, depending on the symptoms and needs of the survivor, are Codependency
Anonymous, Adult Children of Alcoholics, Alcoholics or Narcotics Anonymous, and Emotions
Anonymous. Survivors might also be directed to classes or short-term groups that address issues such as
decision making, problem solving, communication or relationship skills, conflict resolution, anger
management, parenting skills, and human sexuality.
CRITICAL THINKING QUESTION
You are working with a patient who was sexually abused as a child by her father. The father insists on visiting his daughter
and telling you about her history of emotional problems and lying about the family. What is your approach in working with
PARTNER AND ELDER ABUSE
NATURE OF THE PROBLEM
Estimates are that more than 7% to 21% of men and women have suffered physical assault by a partner in the
past year. In a national survey, young adults reported violence in the past year toward an intimate at 35% for
women (often in self defence) and 37% in men (Carretta 2008; Gratz, et al, 2009). The number is even higher
when psychological abuse and other violations of rights are considered (Figure 41-1; Daniels, 2005; Dutton
and Nicholls, 2005). It is difficult to collect statistics on female to female, female to male, and male to male
abuse because of the lack of reporting (Brown, 2008; Dutton and Nicholls, 2005). Women are abused, raped,
tortured, or beaten by their husband, boyfriend or girlfriend, male or female lover, former partner, or estranged
partner (Carretta, 2008; Daniels, 2005), and most of this abuse goes unreported, even when injuries are severe
enough to require treatment. Prior partner abuse increases the risk of it occurring during pregnancy (Tilley and
Brackley, 2004). In primary care practice, it has been estimated that 34% to 46% of the female patients are
victims of partner abuse (Lie and Barclay, 2005b).
Dating violence in the adolescent population is estimated to be 10% to 35%. Up to 20% of children (ages
11-14) are being affected as they get into emotional and sexual dating relationships (Surprising New Research,
2008). Contributing factors for these children include witnessing parental violence, prior victimization or
abuse, earlier puberty, typical stresses and issues of early adolescence, earlier use of drugs and alcohol, and
exposure to media violence (Close, 2005; Gratz, et al, 2009; Miller, 2004).
"Finally, among older adults, sexual, physical, and psychological abuses exist as well as forced suicide or
homicide of widows for economic reasons" (Carretta, 2008). Elder abuse also includes violation of personal
rights, abandonment, and material and financial exploitation (Baker, 2007). It is estimated that 3.2% of those
aged 65 and older are abused while they still live in a private home, but only 1 in 5 are probably reported
Family Issues: False Memories? False Allegations?
Some families, including members of the False Memory Syndrome Foundation, claim that they have been wrongly accused of
sexual abuse by their children or adult children. These families and some professionals especially challenge the validity of the
processes of repression and delayed recovery of memories of abuse. They warn that those who interview children, those who
counsel children and adults, and members of support groups can implant false memories and provide support for false allegations.
These families and professionals question the credentials and training of many who counsel children and adults who claim that
they were abused. They cite studies of recent and long-term memory to support their views about distorted and false memories.
They sometimes question the claims of serious emotional damage to victims as a result of actual sexual abuse. They support the
premise that false memories and false allegations are destroying the families of these children. At the same time, the North
American Man Boy Love Association (NAMBLA) wants legislation that permits sex between boys and men.
Other professionals and adult survivors of childhood sexual abuse maintain that the graphic details of children’s traumatic
memories and the use of sexual descriptions, very advanced for their age at the time, support the credibility of the abuse charges.
These professionals and survivors claim that denial, repression, amnesia, and dissociation are real and are used by children,
adolescents, and adults to protect themselves emotionally from the abuse as it was happening and from the later realization of its
moral, legal, ethical, and emotional significance. These individuals maintain that 75% or more of survivors are able to collect
strong corroborating evidence of their abuse and recovered memories. They cite recent neurochemical studies of traumatic
memory processes, stress, and PTSD (see Chapter 31) to support their view of the validity of repression, dissociation, and
recovered memories. They acknowledge that 2% to 10% of claims of sexual abuse by children and divorcing parents might be
false, but report that perhaps 75% to 90% of valid child abuse is never reported by children, agencies, and professionals. They
point out that the False Memory Syndrome Foundation admits that it collects only information on denials of charges of abuse but
has no way of knowing if these denials are true or false. Survivors and professionals contend that those who molest children
typically threaten the victims to “keep the secret” and use denial, minimization, and rationalization when charged with abuse.
They also express concern that claims of false memories and false allegations are efforts to disconfirm and “blame the victim,”
protect abusers (and society), and minimize the severity of the short- and long-term effects of abuse. They contend that families
are being destroyed by interfamilial violence (not the reports of abuse) and that abused children suffer emotional pain and a wide
variety of problems throughout childhood, adolescence, and adulthood.
As a result of this controversy, it is recommended that those working with possible survivors of childhood sexual abuse do the
1. Allow patients’ memories to emerge without pressure and leading questions.
2. Avoid specific sexual abuse explanations for patients’ symptoms.
3. Follow established guidelines for interviewing child victims and others to assess the credibility of memories and testimony.
4. Interview anyone who might provide corroboration or disconfirming evidence.
5. Use established therapeutic techniques rather than nonestablished methods.
6. Avoid using hypnosis and sodium amytal injections as a way of recovering repressed memories.
Modified from Gardner RA: True and false accusations of child sex abuse, New York, 1992; Leavitt F: Iatrogenic memory change:
examining the empirical evidence, Forensic Psychology 19:21, 2001; Loftus EF, Potage DC: Repressed memories: when are they real?
Psychiatr Clin North Am 22:61, 1999; Valente S: Controversies and challenges of ritual abuse, J Psychosoc Nurs 38:8, 2000; Satel SL:
Who needs trauma initiatives? Psychiatr Serv 52:815, 2001; van der Kolk B, McFarlane AC, Weissaeth L: Traumatic stress: the effects
of overwhelming experience on mind, body, and society, New York, 1996, Guilford Press; Anorexia Nervosa and Associated Disorders
(Indianapolis Chapter of National ANAD): Personal interviews, Indianapolis, 2002, ANAD; Katchen MH: Ritual abuse vs. religious
abuse: the development of an artificial distinction, MKzine 3:9, 2005; Shea DJ: Effects of sexual abuse by catholic priests on adults
victimized as children, Sexual Addiction & Compulsivity 15:250, 2008.
Partner abuse victims tend to conceal their victimization. They are acutely aware that disclosure of their
plight will be met with denial or be minimized by the partner, friends, and relatives and by increased abuse by
their partners (Merrell, 2001). As abused women become more independent (both emotionally and financially),
the incidence of violence by their partners increases as well. The fact that 30% to 50% of all women killed in
the United States are killed by a partner as they tried to leave or had left supports women’s fears (Carretta,
2008; ; Jordan, 2004; Logan and Walker, 2004). About 50% of victims murdered by partners were seen in the
emergency departments for injuries at other times before they died (Gerard, 2000). Men are also killed by their
partners (4% of all male homicides) (Carretta, 2998; Daniels, 2005). Homicide occurs, sometimes in selfdefense
during the abuse or after a history of beatings.
Studies have shown that partner abuse crosses all social, racial, cultural, and economic classes, including
both homosexual and heterosexual relationships, but is more often reported by individuals on welfare. This
tendency is because the victims are more likely to be in contact with reporting agencies, such as public health
nurses, welfare offices, public clinics, and emergency rooms. Individuals with higher incomes are likely to
obtain private services that do not report the abuse (Poirier, 2000). Nurses in any setting need to screen patients
for any past or current abuse (Lewis-O’Connor, 2004).
The relationship of alcohol and drug abuse to violent behavior has been the subject of many studies on
partner abuse. Some abusers are abstainers, but more are substance abusers (Murphy et al, 2005). The victim’s
view is that the abuser uses alcohol and drugs as an excuse for their violence and drink when they are about to
become violent. Victims have also reported a correlation between increased intake of alcohol and the severity
of violence (Murphy et al, 2005). The combination of substance abuse and violence encourages victims to
blame the substance rather than hold the batterers accountable for their violent behaviors. Women often
describe their abusers as Dr. Jekyll and Mr. Hyde, with changing personalities—gentle, loving, and kind at
times; rude, uncaring, and violent at other times. This change is explained, in part, by the cycle of violence
In some relationships, violence is mutual (Dutton and Nicholls, 2005; Whitaker, 2007) and is the result of
efforts to resolve negative communications and escalating conflicts. These couples are often motivated to
change and can be taught more effective skills for handling conflict and anger. This mutual violence pattern
differs from, but can become, the more common pattern of using violence to exploit and control a partner,
often arising out of anger, fear of abandonment, and jealousy (McClellan and Killeen, 2000). This second
pattern almost always involves a man abusing a woman, and the man has little motivation to change. Separate
interventions and therapy with the man, such as motivational interviewing, might interrupt the cycle of
violence (Alexander and Morris, 2008). Other studies have reported that men and women use violence almost
equally in the non mutual abuse pattern and those with Axis II personality disorders have somewhat higher
rates of violence with their partners (Dutton and Nicholls, 2005).
The nature of modern society is a factor to be considered in partner abuse. The portrayal of physical and
sexual violence in the media (e.g., the Internet, television, music videos, and films) continues to increase in
frequency and severity. Women are still portrayed by the media as second-class citizens at times. However,
women younger than 30 are more aggressive in their intimate relationships than women older than 30 (Dutton
and Nicholls, 2005). In addition, it is well documented that witnesses of family violence and victims of child
abuse and neglect tend to become perpetrators of other violence or the abusers and partners of abusers (Hill
and Nathan, 2008; Stith, et al, 2004; Woods and Wineman, 2004).
In elder abuse and neglect, 90% of the perpetrators are family members, especially adult children and
spouses. Other relatives, grandchildren, friends, neighbors and home service providers may be abusive or
neglectful (Baker, 2007). Unfortunately elder abuse, sexual abuse, and neglect also occur in long term care
facilities by staff and other residents (Ramsey- Klawsnik, et al, 2007). Elder abuse shows similar power and
control dynamics (Box 41-5) as dies partner abuse (Spangler and Brandl, 2007).
Most experts acknowledge the development of learned helplessness, hopelessness, isolation, and resignation in
response to ongoing emotional and physical abuse. Abused women report that they fear and hate the abuse, but
have a tendency to believe their partner’s view that they deserve the abuse. Box 41-4 presents common reasons
why women endure long-term abuse. Another accepted view of why women endure abuse is the cycle of
violence (Box 41-5). During the honeymoon stage, the good side of the man is evident, and the woman is
reminded of their love and the happy potential of the relationship (Farella, 2000; Gerard, 2000; Walker, 1979).
Women report thinking that they can help their partners overcome their problems and violent behaviors. There
is still a shortage of safe places to go, as well as a shortage of services to help victims become independent.
Many states still have ineffective or outdated laws that indirectly perpetuate abuse rather than foster arrest of
the abuser for assault and battery. Arrest is a way that batterers get the message that their violence is a crime
and not their right (Jordan, 2004; Williams, 2005).
Why Women Stay as Long as They Do
• Economic dependence; lack of job skills
• Fear of greater physical danger to themselves and their children if they attempt to leave or have partner arrested
• Fear of emotional damage to children because of being without a father
• Fear of losing custody of children
• Lack of alternative housing
• Social isolation; lack of support from family or friends
• Lack of information regarding alternatives
• Fear of involvement in court processes
• Fear of retaliation from partner or partner’s family
• Poor self-image; fear of being alone
• Being in a state of denial and living a secret
• Personal embarrassment and protecting the image of husband and family
• Insecurity over potential independence and lack of emotional support
• Guilt about failure of marriage or relationship
• Fear that partner is not able to survive alone
• Belief that partner is sick and needs her help
• Belief that partner will change
• Ambivalence and fear about making formidable life changes and having increased responsibility
• Knowing that batterers are not held accountable for their violent actions
• Believing that the abuse is her fault
• Being raised to be passive and submissive
• Developing survival skills instead of escape skills
• Recognizing that the legal system is a male-dominated system
Plus: She Still Loves Him
Modified from Julian Center Shelter, Indianapolis ,IN, and Task Force on Families in Crisis, Nashville, TN.
Battered woman syndrome has been suggested as a sub-classification of PTSD because repetitive abuse is a
serious threat to the victim’s health and life. Victims often report nightmares, flashbacks, recurrent fears of
more violence, emotional detachment, numbness, startle response, sleep problems, guilt, impaired
concentration, and hypervigilance. However, there are other symptoms, such as depression, hostility, low selfesteem,
self-blame, relative passivity, impaired decision making, psychosomatic complaints, fatalism, social
isolation, and an unwillingness to seek help (ANAD, 2002; Carretta, 2008; Logan and Walker, 2004). As with
PTSD, battered women show typical reactions to a chronic trauma, not symptoms of psychopathology.
Labeling and blaming the victims again shifts responsibility away from the perpetrators.
Box 41-5 Cycle of Violence
I. Tension building
He has excessively high expectations of her.
He blames her for anything that goes wrong.
He does not try to control his behaviors.
He is aware of his inappropriate behaviors but does not admit it.
Verbal and minor physical abuse increase.
Afraid that she will leave, he gets more possessive to keep her captive.
He gets frantic and more controlling.
He misinterprets her withdrawal as rejection.
II. Serious battering incident
The trigger event is an internal or external event or substance.
The battering usually occurs in private.
He will threaten more harm if she tries to get help (police, medical).
He tries to justify his behaviors but does not understand what happens.
He minimizes the severity of the abuse.
His stress is relieved.
He is loving, charming, begging for forgiveness, making promises.
He truly believes that he will never abuse again.
He feels that he taught her a lesson and she will not act up again.
He preys on her guilt to keep her trapped.
I. Tension building
She is nurturing, compliant, and tries to please him.
She denies the seriousness of their problems.
She feels she can control his behaviors.
She tries to alter his behavior to stay safe.
She tries to prevent his anger.
She blames external factors: alcohol, work.
She takes minor abuse, but does not feel she deserves it.
She gets scared and tries to hide (withdrawal).
She might call for help as the tension becomes unbearable.
II. Serious battering incident
In cases of long-term battering, she might provoke it just to get it over with.
She might call for help if she is afraid of being killed.
Her initial reaction is shock, disbelief, and denial.
Fearing more abuse if police come, she might plead for them not to arrest him.
She is anxious, ashamed, humiliated, sleepless, fatigued, depressed.
She does not seek help for injuries for a day or more and lies about the cause of injuries.
She sees his loving behaviors as the real person and tries to make up.
She wants to believe that the abuse will never happen again.
She feels that if she stays, he will get help; the thought of leaving makes her feel guilty.
She believes in the permanency of the relationship and gets trapped.
Modified from Walker L: The battered woman, New York, 1979, Harper & Row; Gerard M: Domestic violence: how to screen and intervene, RN
63:52, 2000; McFarlane J, Malecha A, Gist J, et al: Increasing the safety promoting behaviors of abused women, Am J Nurs 104:40, 2004.
According to victims, it is unlikely that abused women will leave their partners until they realize that the
cycle is not going to stop and they have the emotional support to leave and a safe place to go. Fearing that the
next beating might be fatal, finding that their partners are physically or sexually abusing their children, and
realizing that their children are learning to be abusive are incentives for leaving permanently (ANAD, 2002;
Immediately preceding or at the beginning of a serious battering incident, victims are frightened, amenable to
crisis intervention, and more likely to call the police or a crisis service agency for help. Getting victims and
their children to a shelter or other safe place, if they will go, are desirable when immediate danger of injury is
present. If injuries have occurred, victims should be encouraged to go to an emergency department. In any
case, crisis workers, shelter workers, or nurses can begin the important process of assessment and providing
information that can make a dent in the cycle of abuse. Even if the survivors are not yet ready to leave their
partners, they can be given an easily concealed card with telephone numbers of police, prosecutors, crisis
services, victims’ assistance, shelters, and support groups, and perhaps a short message about the inevitability
of the cycle of violence and the fact that no one deserves to be abused. If contact is only by phone or if they are
worried that the abusers will find the card, they can be asked to write down the phone numbers on the back of a
picture in their wallets or be told to call 911. (In some cities, such as Indianapolis, dialing 211 provides a direct
connection to the Domestic Violence Network.) Survivors can also be given ideas for developing a safety or
escape plan (Daniels, 2005), such as packing a bag with medicines and clothes for them and their children,
house and car keys, money and change for the pay telephone (if they don’t have a cell phone), and important
phone numbers and papers (e.g., bank account numbers, birth certificates, social security numbers, medical
insurance cards, no contact/protective orders). They should also be informed of the protections afforded by
legal statutes, protective orders, and more recent antistalking laws. Also keep in mind that in elder
abuse/neglect situations, all states have mandatory reporting laws and procedures and the survivors need to
know this. These affect confidentiality and may pose more safety issues. Adult protective and advocacy
services and the judicial system are essential resources (Spangler and Brandl, 2007). Long-term goals for
survivors of partner abuse are to develop self-confidence, self-respect, independence, healthy support systems,
and a sense of freedom, safety, and empowerment.
PUTTING IT ALL TOGETHER
Because most abused women seek help for their injuries and somatic symptoms at least once, nurses can be
instrumental in offering information and assistance. Nurses in emergency departments, clinics, physicians’
offices, and community health agencies need to know how to recognize a survivor, make an assessment, offer
support and make a referral to available services (Carretta, 2008). Some common cues to abuse are listed in
Box 41-6. In the elderly, there also may be malnutrition, frailty, immune suppression, pressure ulcers, and
early mortality (Baker, 2007). Inadequate provision of safety, clothes, shelter, food, water, hygiene,
medications, glasses, hearing sides, dentures, and comfort are also common (Alexander and Fulmer, 2007).
The assessment process is often difficult because survivors fear disclosure, are embarrassed about the situation,
desire to be treated quickly and leave, and sometimes the abusers are present. It is important to interview the
victim privately and with sensitivity, empathy, and compassion. Box 41-7 describes other responses that
survivors consider helpful.
The most crucial information to document in an initial contact is the following:
1. Identity and current location of the abuser
2. Location and safety of any children
3. Length and frequency of abuse
4. Types of abuse (physical, psychological, sexual, financial) and use of weapons
5. Types and locations of injuries (photographs and body maps are preferred)
6. Availability of weapons at the place of residence
7. Use and abuse of substances and medications by victim and abuser
8. Active and passive suicidal ideations (with or without a plan or a wish to be dead)
9. Types of service desired (police, legal, shelter, crisis counseling, knowledgeable clergy, social service
agencies, and transportation)
10. Referrals made
Common Cues to Partner Abuse
• Repeated, vague symptoms or illnesses that are not confirmed by tests, such as backache, abdominal pain, indigestion, headaches,
hyperventilation, anxiety, insomnia, fatigue, anorexia, heart palpitations
• Unexplained injuries or ones with unlikely explanations and embarrassment about them
• Hidden injuries such as those in areas concealed by clothes or visible on physical or x-ray examination only—for example, head and
neck injuries, internal injuries, genital injuries, scars, burns, joint pain or dislocations, numbness, hearing problems, or bald spots
• Injuries with recognizable marks such as those from a belt, iron, raised ring, teeth, fingertips, cigarette, gun, or knife
• Multiple fractures or bruises in various stages of healing
• Jumpiness or flinching in the presence of the abuser
• Substance abuse and suicidal thoughts or attempts
• Attempts to conceal fear of the abuser
• Continual efforts to keep the abuser from getting angry
• Denial of any problems in the relationship
• Lack of relationships with family or friends
• Isolation or confinement to home
• Guilt, depression, anxiety, low self-esteem, sense of failure, concealed anger
• Continual justification of own actions and whereabouts of the abuser
• Continual justification of the abuser’s actions in public; excusing or rationalizing the behaviors
• Believing in family unity at all costs and in traditional stereotypes
• Believing in managing alone, even when help is offered
• An over solicitous abuser who does not want to leave the victim alone with hospital or agency staff or even with family and friends
Modified from Constantine RE, Bricker PL: Social support, stress, and depression among battered women in the judicial setting, J Am Psychiatr
Nurses Assoc 3:81, 1997; Merrell J: Social support for victims of domestic violence, J Psychosoc Nurs 39:31, 2001; Miller MC: Countering
domestic violence, Harv Ment Health Lett 20:1, 2004; Carretta CM: Domestic violence: A world wide exploitation, J Psychosoc Nurs 46:3, 2008.
Even if the initial contact is brief, it is important to convey to survivors that they are not alone in their abuse
and that there are those who are willing and able to help when they are ready. Survivors also need to be told
more than once that they do not deserve the abuse. The nurse must convey to survivors that they are important
and have dignity and worth. They need acknowledgment of their mental and physical exhaustion, fears, and
ambivalence about the abuser, leaving, and their wish to help the abuser, as well as themselves. It is difficult
for nurses and all professionals to accept that survivors cannot be pushed, rushed, or coerced into leaving the
abuser before they are ready. In fact, survivors might want to try couples/family counseling and even personal
counseling (when the abuser refuses counseling) more than once before giving up hope of saving the
relationship and of helping the ones they love. It is important to recognize and to acknowledge that it is
common for survivors to leave and return several times; it is a process, not a single event (Leone, Johnson,
Coban, 2007; Spangler and Brandl, 2007). Survivors need not feel guilty or ashamed for trying to improve the
relationship. In fact, the guilt of leaving will be lessened if they believe they have tried everything and are
finally able to acknowledge that nothing will change, because the abusers are the only ones who can control
the violence and stop the abuse.
Helpful Responses to Partner/ Elder Abuse
• Be non-judgemental, objective, and nonthreatening.
• Ask directly if abuse is occurring.
• Identify the abuser’s behavior as abusive.
• Acknowledge the seriousness of the abuse.
• Assist the victim in assessing internal strengths.
• Encourage the use of personal resources.
• Give the victim a list of resources: shelters, financial aid, police, and legal assistance.
• Allow victim to choose own options.
• Offer names of relevant support groups.
• Help victim to develop a safety or escape plan.
• Tell the abuser to stop the abuse and get help.
• Do not disbelieve or blame the victim.
• Do not get angry with the victim.
• Do not refuse to help if the victim is not ready to leave the abuser.
• Do not align with the abuser against the victim.
• Do not push the victim to leave the abuser before ready.
When an abused woman does leave her partner, the problems are not over. Box 41-8 describes some of the
common reactions the abuser might have and ways in which he might behave. Psychological and physical
abuse might continue after separation (Logan and Walker, 2004). Survivors frequently need longer term
counseling and social services to recover and become independent, especially if the abuser is unwilling to
participate in couples’ counseling or an abusers’ program (often a court-ordered program of group education
and counseling lasting 26 weeks or longer). Nursing interventions for survivors (individually or in groups,
using cognitive-behavioral techniques) generally focus on the following:
If You Have Left an Abusive Man...
1. Your problems are not over.
2. Your abuser will try to locate you through family and friends. He will play on their sympathy or intimidate them.
3. He will repeatedly apologize, make promises about changing, and give gifts.
4. Next, he will threaten or intimidate you, your children, family, and/or friends.
5. He might threaten to kill himself because of you.
6. He often threatens to take your children away.
7. In another step, he will enter counseling and/or will express religious fervor.
8. He might try to find a counselor or religious leader to try to convince you to return to him.
9. Next, he might harass and stalk (begging, crying, phone calls, written or verbal threats, legal actions, or following you from location
Regardless of his tactics, take advantage of legal, community, and personal resources to protect yourself and your children.
Modified from the Salvation Army Domestic Violence Program, Indianapolis, IN.
1. Monitoring safety from partner abuse and preventing suicide
2. Reiterating information about abuse, the cycle of violence, and the abuser’s accountability
3. Building self-esteem, confidence, independence, and sense of hope
4. Sharing of feelings, especially anger, frustration, fear, and anxiety
5. Decreasing shame, guilt, embarrassment, manipulation, and isolation
6. Confirming personal rights, as well as legal rights
7. Teaching stress management techniques
8. Teaching communication techniques
9. Teaching conflict resolution techniques
10. Teaching assertiveness training
11. Teaching parenting techniques
12. Decreasing co-dependency behaviors
13. Building a new, improved support system
14. Setting goals and specific plans for immediate future
15. Resolving grief
Referrals might also be needed for job counseling or training, legal assistance, financial aid, child care, and
permanent housing. At any stage during working with survivors, brief hospitalization might be needed because
of injuries, suicide attempts, self-mutilation, or substance abuse and for treatment of serious problems such as
depression, anxiety, or panic attacks. Assessment and treatment for ongoing headaches, gastrointestinal
complaints, back and pelvic pain, hyperventilation or chest pains, and insomnia is also needed (Amar and
CRITICAL THINKING QUESTION
Your co-worker is sharing with you that she is thinking about leaving her husband because of his drinking and long-term
emotional abuse of her. She expresses a fear that he might try to kill her and a fear of raising her two children alone. What
information would you offer her?
Medications normally are not needed but are commonly given to survivors. Often misprescribed medications
are antidepressants, benzodiazepines, and hypnotics. These same medications might be used appropriately if
the survivor’s symptoms of depression, anxiety, sleeplessness, or nightmares or flashbacks are severe.
Continual assessment is needed to determine when medications are no longer needed to prevent abuse and
Groups in inpatient or outpatient settings that might be relevant for survivors are those focusing on selfesteem,
problem solving, assertiveness, relationship issues, stress management, and co-dependency. Substance
abuse groups should be recommended, if necessary. In the community, a group for abused women is desirable.
One form of intervention is a telephone support program that focuses on safety-promoting behaviors. Six calls
over 8 weeks have encouraged increased use of these behaviors, which were more likely to be practiced even
18 months later (McFarlane et al, 2004). The National Domestic Violence Hotline is also available (800-799-
SAFE) and online (www.ndvh.org) (Phillips, 2008).
CRITICAL THINKING QUESTION
As an emergency room nurse, you are treating a 19-year-old male victim who was tortured and raped by a local gang. The
victim refuses to give any details or to identify members of the gang. Describe what information you would give him about
being a victim and the benefits of follow-up counseling.
1. Not all crimes involve physical violence and injury; however, all crimes involve emotional violation and
injury. Victims lose a sense of the ability to control their own lives, as well as losing trust in others.
2. Progression through the stages of recovery from a crime might take years. Crisis intervention and group
meetings with other survivors can facilitate recovery.
3. In assisting survivors, sensitivity to their needs is crucial to build trust and to avoid blaming the victim.
4. Information about counseling resources and support groups can be given to the survivors of any crime or
trauma for later use, even if there is an initial denial of the need for help.
5. The reexperiencing and working through of any trauma/crime memories is a painful, lengthy, and
sometimes sporadic process that requires intense support and empathy.
6. Adult survivors of childhood sexual abuse might repress memories for years as a result of the emotional
turmoil and sense of being betrayed by the abuser and others.
7. Adult survivors of childhood sexual abuse typically enter counseling for a variety of overt problems,
unaware of how these are related to childhood trauma.
Rachael Benton, a 26-year-old survivor of incest by her father, is married to Richard. She has an 8-year-old child, Matthew;
Richard has three boys, Robert, James, and Daniel, ages 11, 8, and 7, who live with them. Angela, age 5, was born after Rachael
and Richard were married. Matthew was removed from the home after being abused by Robert. Rachael sought help by attending
a battered women’s group.
Rachael’s situation was difficult to resolve. Because of heavy drinking, Richard was missing work and changing jobs. His
income declined and was sporadic but expenses did not decline. Without insurance, Rachael’s repeated treatment of menstrual
irregularities, back pain, chronic and severe headaches, and diarrhea were not paid for. She avoided treatment for bruises, a
superficial knife wound, head cuts, and contusions. Richard repeatedly punched her stomach during a pregnancy, causing a
It was when Richard raped her that Rachael realized that there was no hope for change and that she had to leave. As Rachael
became more assertive and independent, Richard demanded that she stay home, bought a shotgun to convince her to stay, and
took the starter off the car. He rode to work with co-workers. Rachael had not adopted Richard’s boys, so she could not take them
with her. She was afraid that his verbal abuse of them would turn to physical violence when she left. Richard knew about all the
places she thought of going.
It took 4 months to develop, coordinate, and implement arrangements so that Rachael and Angela were safe in leaving
Richard. Neighbors, friends, and teachers were warned of the potential abuse of the boys and given the phone number for
anonymously reporting child abuse. Rachael’s mother rented her a small trailer in a rural town and obtained forms for Aid to
Families with Dependent Children. Rachael secretly and gradually packed clothes and important documents in the trunk of a
group member’s car.
One night (14 months after the group began) Richard got drunk, beat Rachael, and tried to rape her again. She fought him off
and waited until he passed out. The group member with the packed car drove her to the new trailer. As expected, Richard got his
shotgun and went to every friend of Rachael’s, but none knew where she was. He drove to Rachael’s mother’s home, and she
called the sheriff when his car pulled into the driveway. Richard was escorted out of the county and warned not to return. Within
a week, Daniel’s teacher filed a child abuse report about bruises found on him. Within 2 weeks, the boys were removed from the
home and returned to their natural mother.
Rachael has received proper medical treatment and feels healthier. She is now divorced, going through a job training program,
and maintaining her secret location. She feels safe but is still in counseling once a month to complete her emotional recovery. She
attends a support group for battered women once a week.
Name: Rachael Benton Admission Date:___________________
DSM-IV-TR Diagnosis: Physical abuse of an adult by partner
Assessment Areas of strength:
Bright, articulate, and capable of problem solving; mother and one friend willing to help;
developing trust in group and beginning to process her feelings and rights.
Lack of safe housing and employment; inability to remove husband’s children from the house
and fear he will abuse them; fear of increased abuse of her, even death, if she tries to leave;
Diagnoses • Decisional conflict related to dysfunctional marriage, as evidenced by attendance in a battered
women’s support group.
• Posttrauma syndrome related to previous sexual abuse and physical, emotional, and economic
abuse, as evidenced by physical wounds, fear, and emotional trauma.
• Fear (of leaving husband) related to potential abuse of sons, as evidenced by reluctance to leave
Outcomes Short-term goals: Date met
• Patient will remove bullets from gun; design an escape plan. ____________________
• Patient will verbalize ability to survive on her own; confirm ____________________
Housing in rural county.
• Patient will enroll in job training program. ____________________
• Patient will obtain legal assistance for divorce. ____________________
• Patient will seek medical treatment for chronic problems. ____________________
Planning/ Nurse-patient relationship: Listen nonjudgmentally and empathically; accept strange
Interventions behaviors related to secrecy and self-protection; avoid disparaging spouse and pressuring to leave;
locate resources for training, finances, counseling, and medical care in rural county.
Desyrel, 50mg at bedtime, to alleviate moderate depression and improve sleep; ibuprofen prn for
Encourage continuing in local support group; locate support group in rural county; continue
assessment of safety of patient and children.
Evaluation Patient has moved to rural county and joined support group; is receiving counseling and medical
care. Husband’s children were removed and placed with natural mother.
Referrals Has an appointment with a job training program in the rural county.
8. The concepts of learned helplessness, the cycle of violence, and other situational, emotional, and cultural
factors help explain why survivors often remain with their abusive partners.
9. Immediately preceding or at the beginning of a serious battering incident is when abuse victims are most
amenable to crisis intervention and referrals for needed services.
10. Patience, support, and information are critical aspects of nursing interventions with all survivors.
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