ANGER, ABUSE AND VIOLENCE MANAGEMENT

COURSE TITLE
MENTAL HEALTH NURSING

COURSE CODE
NSG 416
ANGER.
Definition:
Anger is an emotional state that varies in intensity from mild irritation to intense fury and
rage. It is accompanied by physiological and biological changes, such as increases in heart
rate, blood pressure, and levels of the hormones epinephrine and norepinephrine (American
Psychological Association, 2006a).
Anger is a normal human emotion, it is a strong, uncomfortable, emotional response to a real
or perceived provocation. Anger results when a person is frustrated, hurt, or afraid. Handled
appropriately and expressed assertively, anger can be a positive force that helps a person to
resolve conflicts, solve problems, and make decisions. Anger energizes the body physically
for self-defense, when needed, by activating the “fight-or-flight” response mecha-nisms of
the sympathetic nervous system. However, when expressed inappropriately or suppressed,
however, anger can cause physical or emotional problems or interfere with relationships
(Koh, Kim, Kim, Park, & Han, 2008).

Warren (1990) outlines some fundamental points about anger:

1. Anger is not a primary emotion, but it is typically experienced as an almost automatic inner
response to hurt, frustration, or fear.

2. Anger is physiological arousal. It instills feelings of power and generates preparedness.

3. Anger and aggression are significantly different.

4. The expression of anger is learned.

5. The expression of anger can come under personal control.

PREDISPOSING FACTORS

A number of factors have been implicated in the way individuals express anger. Some
theorists view anger as purely biological, and some suggest that it results from individuals’
interactions with their environments. It is likely a combination of both.

1. Modeling: Role modeling is one of the strongest forms of learning. Children model their
behavior at a very early age after their primary caregivers, usually parents. How parents or
significant others express anger becomes the child’s method of anger expression.

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2. Operant Conditioning: Operant conditioning occurs when a specific behavior is
reinforced. A positive reinforcement is a response to the specific behavior that is pleasurable.
A negative reinforcement is a response to the specific behavior that prevents an undesirable
result from occurring. Anger responses can be learned through operant conditioning.

3. Neurophysiological Disorders: Some research has implicated epilepsy of temporal and

frontal lobe origin in episodic anger (Sadock & Sadock, 2007). Clients with episodic
dyscontrol often respond to anticonvulsant medication. Tumors in the brain, particularly in
the areas of the limbic system and the temporal lobes; trauma to the brain, resulting in
cerebral changes; and diseases, such as encephalitis (or medications that may effect this
syndrome), have all been implicated in the predisposition to aggression and violent behavior.

3. Biochemical Factors: anger behavior may be associated with hormonal dysfunction

caused by Cushing’s disease or hyperthyroidism (Tardiff, 2003). Studies have not supported a
correlation between violence and increased levels of androgens or alterations in hormone
levels associated with hypoglycemia or premenstrual syndrome.

4. Socioeconomic Factors : High rates of anger exist within the subculture of poverty in
the United States. This has been attributed to lack of resources, breakup of families,
alienation, discrimination, and frustration (Tardiff, 2003). An ongoing controversy exists as
to whether economic inequality or absolute poverty is most responsible for violent behavior
within this subculture.

5. Environmental Factors: Physical crowding may be related to anger through increased

contact and decreased defensible space (Tardiff, 2003). A relationship between heat and
aggression also has been indicated (Anderson, 2001).

TYPES OF ANGER
According to Professor Ephrem Fernandez's psychological research, he divided anger into 10
types.
1. Assertive anger: Assertive anger is the most constructive type of anger expression. If one
expresses this type of anger, one uses feelings of frustration or rage as a catalyst for positive
change. Rather than avoiding confrontation, internalising anger, or resorting to verbal insults
and physical outbursts, one expresses anger in ways that create change in the worl without
causing distress or destruction.

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2. Behavioural anger: Behavioural anger is expressed physically, and is usually aggressive.
If one is experiencing this type of anger, one may feel so overwhelmed by one's emotions that
one lashes out at the object of one's rage. This might involve physically attacking someone,
or breaking or throwing things. This type of anger can be highly unpredictable, may be
fuelled by alcohol or drugs, and often has negative legal and interpersonal consequences.

3. Chronic anger: Chronic anger is an ongoing, generalised resentment of other people,

frustration with certain circumstances, and anger towards oneself. It’s characterised by
habitual irritation: the prolonged nature of this type of anger can have profoundly adverse
effects on one’s health and wellbeing.

4. Judgmental anger: Judgmental anger is righteously indignant, this type of anger is

usually a reaction to a perceived injustice or someone else’s shortcoming. Although
judgmental anger assumes a morally superior stance of justified fury, it may alienate potential
allies by invalidating their difference of opinion.

5. Overwhelmed anger: Overwhelmed anger is an uncontrolled type of anger. It usually

occurs when one feels that a situation or circumstances are beyond control, resulting in
feelings of hopelessness and frustration. This type of anger is common when one has taken on
too much responsibility, or unexpected life events have overthrown his usual capacity to cope
with stress.

6. Passive-aggressive anger: Passive-aggressive anger is an avoidant type of anger.

Someone experiencing this mode of anger expression tries to evade all forms of
confrontation, and may deny or repress any feelings of frustration or fur. Passive-aggressive
anger may be expressed verbally, as sarcasm, pointed silence or veiled mockery, or
physically in behaviour such as chronic procrastination at work.

7. Retaliatory anger: Retaliatory anger is usually an instinctual response to being confronted

or attacked by someone else. It’s one of the most common types of anger, and is motivated by
revenge for a perceived wrong. Retaliatory anger can also be deliberate and purposeful. It
often aims to intimidate other people by asserting control over a situation or outcome, yet
may only serve to escalate tensions.

8. Self-abusive anger: Self-abusive anger is a shame-based type of anger. One experiencing

this type of anger feels hopeless, unworthy, humiliated or ashamed, such person might
internalise those feelings and express anger via negative self talk, self-harm, substance use, or

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eating disordered behaviour. Alternatively, you may find yourself lashing out at those around
to mask feelings of low self-worth, increasing your sense of alienation.

9: Verbal anger: Verbal anger is often seen as less dangerous than behavioural anger, but it
can be a form of emotional and psychological abuse that deeply hurts the target of one’s
anger. Verbal abuse may be expressed as furious shouting, threats, ridicule, sarcasm, intense
blaming or criticism.

10. Volatile anger: Volatile anger seems to come out of nowhere: one experiencing this kind
of anger is very quick to get upset about perceived annoyances, both big and small. Volatile
anger can be incredibly destructive, as those around you may feel they need to walk on
eggshells for fear of triggering your rage. If left unchecked, volatile anger may eventually
lead to violent outbursts.

Functions of Anger
There are positive and negative functions of anger:

Positive functions
1. Anger energizes and mobilizes the body for self-defense.
2. Communicated assertively, anger can promote conflict resolution.

3. Anger arousal is a personal signal of threat or injustice against the self. The signal elicits
coping responses to deal with the distress.

4. Anger is constructive when it provides a feeling of control over a situation and the
individual is able to assertively take charge of a situation.

5. Anger is constructive when it is expressed assertively, serves to increase self-esteem, and

leads to mutual understanding and forgiveness.

Negative Functions

1...Without cognitive input, anger may result in impulsive behavior, disregarding possible
negative consequences

.2. Communicated passive–aggressively or aggressively, conflict escalates, and the problem

that created the conflict goes unresolved.

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3. Anger can lead to aggression when the coping response is displacement. Anger can be
destructive if it is discharged against an object or person unrelated to the true target of the
anger.

4. Anger can be destructive when the feeling of control is exaggerated and the individual uses
the power to intimidate others.

5.Anger can be destructive when it masks honest feelings, weakens self-esteem, and leads to
hostility and rage.

CULTURAL CONSIDERATIONS

What a culture considers acceptable strongly influences the expression of anger. The nurse
must be aware of cultural norms to provide culturally competent care.

In the United States, women traditionally were not permitted to express anger openly and
directly because doing so would not be “feminine” and would challenge male authority. That
cultural norm has changed slowly during the past 25 years.

Some cultures, such as Asian and Native American, see expressing anger as rude or
disrespectful and avoid it at all costs. In these cultures, trying to help a client express anger
verbally to an authority figure would be unacceptable.

Ethnic or minority status can play a role in the diagno sis and treatment of psychiatric
illness. Patients with dark skin, regardless of race, are sometimes perceived as more
dangerous than light-skinned patients, and therefore more likely to experience compulsory
hospitalizations, increased use of restraints, higher doses of medication, and so forth

One study found that Caucasian children and adolescents were more often diagnosed with
depression or substance abuse disorders, while African-American and Hispanic/ Latino
patients received psychotic or behavioral disorder diagnoses (Muroff, Edelsohm, Joe, & Ford,
2008).

The European Board of Medical Specialists recognizes cultural awareness issues as a core
component of psychiatry training, but few medical schools provide training in cultural issues
(Qureshi, Collazos, Ramos, & Casas, 2008). These authors propose that education to develop
culture

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ANGER MANAGEMENT

Introduction

In order to maintain safety and self-esteem of clients, you must intervene effectively with
clients who express anger. Remember that every person has the right to feel every emotion
they are experiencing. However, no one has the right to be aggressive toward others. Using
the nursing process as the framework for delivery of care to angry or aggressive client results
in continuity of care, which improves the quality of care.

Assessment

Assessing clients for anger is an ongoing process and occurs across the continuum of care (in
both inpatient and community-based settings). The determination of who in a given setting
poses a risk for anger and aggression. During

 History of anger and aggression

 Severity of psychopathology
 Higher levels of hostility–suspiciousness, thinking disturbance, and agitation (as
measured on the Brief Psychiatric Rating Scale [BPRS])
 History of hospitalization
 Length of time in the hospital
 Early age of onset of psychiatric symptoms
 Frequency of admission to psychiatric hospitals.

It is important to begin your assessment by taking a comprehensive anger history on

admission. The goal of history taking is to find patterns or trends in behaviors in order to
identify the conditions under which an individual is likely to act aggressively. Assessment
Approach lists factors for which to be alert when eliciting anger history. Clients and
significant others are important sources of information. Interview questions about the client’s
history should be open and direct. “Tell me what you do when you feel angry? Do not,
however, rely on client responses as the sole basis for your assessment. Also review the
client’s history, as stated by significant others and in the clients’ medical record.

Managing and reducing the risk of anger is based on careful assessment of client behaviors.
In addition to interviewing, observation is a most useful tool for gathering data about client
aggressiveness. Assessment Approach lists behavioral and verbal clues that indicate anger.

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Determining the potential for anger helps one to anticipate and prevent aggressive outbursts.
Some agencies have a structured violence assessment tool that can be helpful in identifying
the likelihood of anger. Substance abuse increases the potential for aggressive behavior.
Determine whether the client is under the influence of drugs including CNS depressants (e.g.,
alcohol, benzodiazepines), stimulants (e.g., cocaine, amphetamines), hallucinogens (e.g.,
PCP, LSD), and narcotics (e.g., morphine, oxycodone). A thorough assessment also collects
data about the client’ sleep pattern, nutritional status, and history of medical problems such as
temporal lobe epilepsy. Also note the client’s ability to solve problems and cope with
stressors. It is important to note how the client expresses anger. Does verbalization decrease
the intensity of anger, or is the client showing signs of escalating violence? Once these
questions have been answered, you can then establish appropriate nursing diagnoses.

The following questions can be asked during assessment:

 How do you know when you are getting angry at others? Or at yourself?
 On a scale of 1 to 10, with 1 meaning not angry to 10 meaning extremely angry, how
would you rate your anger right now?
 Describe one instance in which you have had a problem with anger.
 What types of things trigger anger in you?
 Tell me what you usually do when you feel angry.
 What do you do to help decrease your feelings of anger?

Nursing Diagnoses of client with Anger

The possible nursing diagnosis for a client with anger include:

 Ineffective Coping
 Chronic Low Self-Esteem
 Situational Low Self-Esteem
 Anxiety

Expected Outcomes of management

Client will be able to

 Identify events precipitating anger

 Practice effective anger management techniques

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  Identify alternative methods for expressing anger
 Achieve impulse control

Nursing Interventions for Angry Client

Intervention Rationale

1 Use a calm, unhurried approach. Calmness promotes security.

2 Do not touch client indiscriminately. Touch may be misinterpreted as aggressive

or Sexual

3 Use statements to provide feedback and Feedback on feelings increases client

identify sources of anger: “I notice your awareness.
fists are clenched—what’s happening?”

4 Observe for escalation of anger (increased Early awareness prevents crisis.

activity, verbal and nonverbal acting out).

5 Provide physical outlets to reduce tension, Exercise releases anxiety/tension

such as exercise, gardening, clay work,
music, art (avoid competitive or contact
sports).

6 Role-model appropriate assertions of New behaviors can be learned by watching

angry feelings: “I dislike it when—” others.

7 Teach assertiveness skills, relaxation, This defuses anxiety and reinforces the
imagery, thought stopping, thought ability for self-control.
control.

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 ABUSE

Definition

Abuse is defined as any action that intentionally harms or injures another person. It also
encompasses inappropriate use of any substance, especially those that alter consciousness e.g
alcohol, cocaine, methamphetamines, etc.

Description

There are different forms of abuse. They are;

 Physical abuse
 Psychological or emotional abuse
 Sexual abuse
 Substance abuse
 Child abuse
 Elderly abuse

1. Physical abuse

Physical abuse is the infliction of injury by another person. Both children and adults can be
victims of this abuse and either of the genders can be involved. Injuries can be inflicted by
punching, kicking, biting, burning, beating, or use of weapon such as knife, wood, etc.
physical abuse can result in bruises, burns, poisoning, broken bones or fractures, and
hemorrhage or bleeding.

2. Sexual Abuse

This refers to acts of sexual exploitation of a not consenting victim. Or sexual advances or
behavior with/ or a person who is not willing to participate, or ignorant of the act as in the
case of children. Such acts include; exhibitionism, penetration of vagina or anus with sexual
organs or objects, touching etc. sexual abuse also involves rape.

3. Elder Abuse / Child AbuseThis category of people are highly dependent on their caregivers
for support care in daily living. Hence, the reason they are more prone to abuse. Abuse
inflicted on them include; beating, starvation, abandonment, sexual exploitation, labour,
confining and isolation. etc.

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4. Psychological Abuse

This form of abuse is often difficult to prove and involves; threatening, manipulation and
blackmail, harassment, use of harsh words, etc. this leads to untable emotions in the victim.
Statistics show that most abuse is perpetrated by someone the victim knows. Victims of abuse
are found across the life span, and they can be spouses or partners, children, or elderly
parents. Survivors of abuse suffer long-term emotional trauma, and are more predisposed to
disorders associated with abuse and violence: posttraumatic stress disorder (PTSD) and
dissociative disorders. Other long-term problems associated with abuse and trauma include
substance abuse and depression.

Victims of abuse certainly can have physical injuries needing medical attention, but they also
experience psychological injuries with a broad range of responses. Some clients are agitated
and visibly upset; others are withdrawn and aloof, appearing numb or oblivious to their
surroundings. Often, domestic violence remains undisclosed for months or even years
because victims fear their abusers. Victims frequently suppress their anger and resentment
and do not tell anyone. This is particularly true in cases of childhood sexual abuse. Survivors
of abuse often suffer in silence and continue to feel guilt and shame.

Children particularly come to believe that somehow they are at fault and did something to
deserve or provoke the abuse. They are more likely to miss school, are less likely to attend
college, and continue to have problems through adolescence into adulthood. As adults, they
usually feel guilt or shame for not trying to stop the abuse. Survivors feel degraded,
humiliated, and dehumanized. Their self-esteem is extremely low, and they view themselves
as unlovable. They believe they are unacceptable to others, contaminated, or ruined.
Depression, suicidal behavior, and marital and sexual difficulties are common (Child Welfare
Information Gateway, 2008). Victims and survivors of abuse may have problems relating to
others. They find trusting others, especially authority figures, to be difficult.

In relationships, their emotional reactions are likely to be erratic, intense, and perceived as
unpredictable. Intimate relationships may trigger extreme emotional responses such as panic,
anxiety, fear, and terror. Even when survivors of abuse desire closeness with another person,
they may perceive actual closeness as intrusive and threatening. Nurses should be particularly
sensitive to the abused client’s need to feel safe, secure, and in control of his or her body.
They should take care to maintain the client’s personal space, assess the client’s anxiety level,
and ask permission before touching him or her for any reason. Because the nurse may not

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always be aware of a history of abuse when initially working with a client, he or she should
apply these cautions to all clients in the mental health setting.

THEORIES OF ABUSE

These theories were derived while analyzing cases of different types of abuse such as child
abuse, elderly people abuse, sexual abuse and exploitations. The theories have been used as
conceptual frameworks to research and analyse abuse situations;

Psychodynamic theories

Psychodynamic Models Early research identified parental psychopathology as the cause of

child maltreatment that needed to be treated psychiatrically (Ammerman 1990). There was
little empirical support for this theoretical view and it was flawed with methodological issues.
The model was criticized when studies showed that only a small percentage of maltreating
parents actually experienced any psychopathological disorder (Kempe et al. 1985). However,
some specific forms of parental psychopathology are risk factors for child maltreatment
(Institute of Medicine and National Resource Council 2014). Maternal depression and anxiety
have been associated with physical abuse and neglect (Brown et al. 1998). Antisocial
personality disorders are also a risk factor (Belsky and Vondra 1989).

It has been argued that the consequences of child maltreatment such as mental health issues
function as risk factors for the cycle of maltreatment continuing (Frias-Armenta 2002).
Several studies found that depressive symptoms linked a history of child maltreatment and
perpetrating child maltreatment (Banyard et al. 2003; Dixon et al. 2005a, b; Pears and
Capaldi 2001; Thompson 2006). Dixon and colleagues (2005a) found parental mental illness/
depression partially mediated intergenerational transmission child maltreatment (ITCM).
Jaffee and colleagues (2013) found the mothers in their study sample with a history of child
maltreatment were more likely to have mental health problems, and those with a history of
maltreatment who maltreated their children experienced more depression and antisocial
behavior.

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Social Learning Theory

Social Learning Theory is primarily concerned with an individual’s learning through

cognitive processes, modeling, and social observation (Bandura 1977). The basic principle is
that humans can learn through observing models. Social Learning Theory provides a
framework for understanding child maltreatment, especially in terms of its transmission
across generations. For example, if a child experiences violence or maltreatment from a
parent, the child learns that this is an acceptable interaction and may in turn imitate or exhibit
similar behavior within similar and other situations. Behavior can also be reinforced through
observation of rewards and punishments following the behavior.

Social Learning Theory has been used to understand patterns of child maltreatment among
individuals who have experienced abuse and/or neglect themselves as children. It is believed
that children learn adaptive and maladaptive parenting practices from their own experiences
of being parented. It could also be argued that the lack of a positive parenting model could
cause a person to be unaware of necessary parenting skills to care for a child, potentially
causing harm or neglect. The relationship between childhood history of abuse and the
perpetration of abuse/neglect has been established; however, there is no causal link, and a
history of abuse is not a necessary factor, nor is it the only factor.

Social Learning Theory also fails to acknowledge many of the environmental factors that
may shape parenting attitudes and contribute to child maltreatment and ITCM. Studies
examining ITCM both explicitly and implicitly incorporate Social Learning Theory. The
transmission process is often implicitly based in Social Learning Theory. Studies may not
necessarily cite Social Learning Theory, but they use terms that are consistent with Social
Learning Theory such as “learned behavior” and “behavior modeling.” However, some
scholars explicitly ground their studies within Social Learning Theory (e.g., Marshall et al.
2011; Renner and Slack 2006; Widom and Wilson 2015).

Social Information Processing Theory

Social Information Processing Theory is concerned with all of the mental operations that are
deployed to generate a behavioral response during social interaction. The theory seeks to
understand how behavior results from peoples’ understanding and interacting with their
surroundings. The mental operations that are considered include selective attention to social
cues, attribution of intent, generation of goals, accessing of behavioral scripts from memory,

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decision-making, and behavioral enactment. There are five stages that progresses where
information is obtained and processed that ultimately leads to action. The stages are
encoding, creating mental representations, response accessing, evaluation, and enactment.

Social Information Processing Theory has implications for understanding child maltreatment
(Milner 1993, 2003). Specifically, researchers have examined social information processing
as it relates to aggressive behavior of children who have been maltreated (Burks et al. 1999;
Dodge et al. 1990) as well as their social adaptation (Price and Landsverk 1998). Studies
have also used social information processing as the foundation of studies examining how
parents perceive children’s behaviors and attributes (Dadds et al. 2003; Montes et al. 2001).
For example, Montes et al. (2001) compared mothers at low risk and high risk for child
maltreatment and found evidence for social information processing of child physical abuse.
They concluded that mothers in the two different groups processed information related to
children differently and used more power-assertive discipline.

As Social Information Processing Theory has been used to examine both the outcomes of
children who have been maltreated and parents who are at risk for maltreating their children,
the theory can be seen as relevant to ITCM. When examining ITCM, Berlin and colleagues
(2011) used Social Information Processing Theory to understand how we behave based on
how we selectively attend to and respond to social cues. Berlin and colleagues (2011)
conducted research to better understand aggression, child maltreatment, and ITCM through
how individuals cognitively process social cues and act on their understanding of others and
their behavior. Scholars believe that it is possible that children who experience physical
maltreatment may be more likely to develop “biased patterns of processing social
information” (Berlin et al. 2011, p. 164). Kim (2012) compares Social Information
Processing Theory with Nisbett’s Cultural Cognitive Theory and Turiel’s Social-Cognitive
Domain Theory to understand the role of culture in the intergenerational transmission of
violence.

Attachment Theory

Attachment between a child and caregiver begins at birth when a child is completely
dependent on the caregiver for survival and relies on the caregiver to provide consistent and
responsive care. Through this process, an attachment is formed between the child and the
caregiver that is reciprocal in nature, where a behavior from one evokes a response from the
other. For example, a hungry child cries and the caregiver responds either by meeting the

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child’s needs or not. According to Attachment Theory, the attachment relationship which
continues through the first years of a child’s life serves as the template for future
relationships and interactions in the social world (Bowlby 1982).

Attachment security is the basis for a child’s psychological growth and the development of
mental representations that are subsequently applied to the child’s current and future
environment (Bowlby 1982). The attachment between caregiver and child becomes the
foundation for the child to develop a sense of trust and security, a sense of self, and an ability
to explore his/her environment (Ainsworth 1989; Bowlby 1982). When a secure attachment is
not established between the caregiver and child, a child may develop an internal working
model that reflects an inconsistency and unresponsiveness in others that translates into
unrealistic expectations of others. The child may also experience adverse developmental
consequences related to physical, behavioral, cognitive, and social functioning, such as
aggressive behavior.

Attachment Theory helps us understand how individuals with a history of child maltreatment
can experience various challenges related to interpersonal relationships, parenting, and
psychosocial functioning in adulthood. Maltreated children may experience instability in the
home, distant and inconsistent parenting, and inconsistent supervision and discipline.
Children who have been abused and neglected tend to show insecure–avoidant attachment
patterns and may experience difficulty in future intimate relationships (Baer and Martinez
2006; Crittenden 1992; Hildyard and Wolfe 2002). It might then be postulated that maltreated
children who have experienced a dysfunctional attachment may then display similar
attachment patterns with their children and others. Research has shown that parents who
experienced childhood maltreatment may have inconsistent parenting patterns and the
children of parents who have experienced maltreatment and poor attachment with their
caregivers exhibit the same parenting behaviors, possibly placing their children at risk of
abuse (Robboy and Anderson 2011).

Despite the relevance of Attachment Theory in understanding the experiences of abused

children, methods in measuring and testing this theory have significant limitations. Youth and
adults have a difficult time recalling their own attachment experiences as infants and young
children, and most interactions between caregiver and child are experienced privately and are
difficult to observe in a natural environment. Another limitation in the application of
Attachment Theory to child abuse is that cultural differences are often not considered in

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experimental studies and/or when determining what constitutes ‘normal’ parent–child
interactions.

In addition, most of the research in attachment in the 1970s and 80s was conducted with
mothers as caregivers with young toddlers and did not include fathers, grandparents, siblings,
or other caring adults in the child’s life. Considering the importance of attachment and
relationships as they relate to ITCM, measuring and documenting these patterns has been
lacking in the ITCM research literature. An exception is Egeland and colleagues (1988) who
used Attachment Theory in their examination of mothers who were maltreated as children
and found that those who received emotional support from a non-abusive adult during
childhood were more likely than the mothers who did not receive emotional support during
childhood to break the cycle of abuse.

Zuravin and colleagues (1996) also examined attachment and found that parents who
experienced abuse as children and had poor quality attachments with their caregivers were
more likely than those with quality attachments to abuse their children. Lounds and
colleagues (2006) provided one of the more comprehensive uses of Attachment Theory in
their ITCM study through using video interactions between mother and child to assess
parent–child attachment. More recently, Thornberry and colleagues (2013) examined parent–
child attachment as a protective factor in ITCM, although there was no evidence that
attachment served as a protective factor. Thus, there is some support for attachment playing a
role in ITCM. While scholars have identified Attachment Theory as a construct that can help
understand ITCM, empirical studies have not adequately applied the theory.

Ecological Models

The ecological perspective posits that humans are active in the developmental process and are
constantly affecting and being affected by their environment (Bronfenbrenner 1979;
Bronfenbrenner and Morris 2006). Brofenbrenner’s(1979) ecological model typically
involves four types of systems that interact and contain distinct but related roles, norms and
rules, each nested within the next, that influence development and behavior: the microsystem,
the mesosystem, the exosystem, and the macrosystem. The nature of the parent–child
relationship is dependent on the interaction between factors in the child’s and the parents’
maturing biology, the immediate family and community environment, as well as the social
landscape. In order to capture the multidimensional concepts of parenting, child abuse, and

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ITCM, Bronfenbrenner’s(1979) ecological model is a helpful and commonly used framework
to understand ITCM (e.g., Leve et al. 2015; Sidebotham 2001; Valentino et al. 2012).

Within this context, the microsystem is the individual (as parent or child) and the individuals’
resources and characteristics that impact parenting. For example, the parent’s, in addition to
the child’s, disposition and temperament will influence parental functioning. The mesosystem
refers to the individual’s active interaction within microsystems or the connections between
contexts. The exosystem includes the link between a social setting in which the individual
does not have an active role, nor is it within the individual’s immediate surroundings
(Bronfenbrenner 1979).

For example, the relationship between family experiences and school or church experiences
is part of the mesosystem, while the exosystem includes support networks and influences as
well as the social context to which the parent has been exposed. The mesosystem and
exosystem consist of the immediate family and household, as well as the systems in which
the individual and/or family are embedded. Finally, the macrosystem consists of larger
cultural and societal influences with the individual being active inForehand (2002) also
contend that the use of an ecological perspective allows us to conceptualize “parenting as a
process…that will facilitate a more sensitive approach to interventions and public policies”
(p. 256). An ecological perspective allows for a multidimensional approach to understanding
parenting, child abuse, and ITCM and is most appropriate in guiding study’s research
questions, methodology, and analysis.

Understanding the Social Ecological Model

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The above diagram shows the levels of the ecological model- individual, family, community
and society. The Social Ecological Model is a comprehensive public health approach that not
only addresses an individual’s risk factors, but also the norms, beliefs, and social and
economic systems that create the conditions for child maltreatment or abuse to occur.

Individual Level: At this level are parent and child characteristics—emotional and
psychological characteristics, temperament, behavior, problem-solving skills, health
conditions, and beliefs—that can affect the rearing of children.

Family / Relationship Level: the family level contains factors such as family size, cohesion,
communication, support, conflict, and stability that directly affect the child and influence the
way in which parents care for their children.

Community Level: families operate within neighborhoods and communities. Factors that
characterize a neighborhood such as availability of supports (governmental and community),
stability, violence, poverty, disorganization, and isolation, all affect the ability of families to
nurture their children.

Societal Level: the larger culture in which families operate and children are raised plays a
significant role in how families care for their young. Religious or cultural belief systems,
values such as self-reliance and family privacy, and the cultural acceptance of media violence
and corporal punishment of children affect the way in which parents raise their children and
the ways in which communities support families

CLASSIFICATION OF ABUSE

Child Abuse

Child abuse or maltreatment generally is defined as the intentional injury of a child. it can
include physical abuse or injuries, neglect or failure to prevent harm, failure to provide
adequate physical or emotional care or supervision, abandonment, sexual assault or intrusion,
and over torture or maiming (Bernet, 2005).Children who live in a n abusive parents are
1,500 times more likely to be abused than the national average. Younger parents are more
likely to be abused against children than older parents, and the abuse is often disguised as
discipline.

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Types of child abuse

Physical abuse of children often results from unreasonably severe corporal punishment or
unjustifiable punishment such as hitting an infant for crying or soiling his or her diapers.
intentional, deliberate assaults on children include burning, biting,

Sexual abuse involves sexual acts performed by an adult on a child younger than 18 years.
Examples include incest, rape, and sodomy performed directly by the person or with an
object, oral–genital contact, and acts of molestation such as rubbing, fondling, or exposing
the adult’s genitals.

Neglect is the most frequently reported type of child maltreatment. It differs from abuse in
that it is an act of omission that results in harm. Neglect includes lack of adequate physical
care (including not medicating as prescribed), nutrition, and shelter. It also includes
unsanitary conditions that often contribute to health and developmental problems. Lack of
human contact and nurturance is considered emotional neglect.

Psychological abuse (emotional abuse) includes verbal assaults, such as blaming, screaming,
name-calling, and using sarcasm; constant family discord characterized by fighting, yelling,
and chaos; and emotional deprivation or withholding of affection, nurturing, and normal
experiences that engender acceptance, love, security, and self worth.

Emotional abuse often accompanies other types of abuse (e.g., physical or sexual abuse).
Exposure to parental alcoholism, drug use, or prostitution and the neglect that results also fall
within this category.

ASSESSMENT

The first step to assessment is identification. The nurse should be able recognize signs that
might lead to suspecting neglect or abuse. This includes:

• serious injuries such as fractures, burns, or lacerations with no reported history of trauma

• delay in seeking treatment for a significant injury

• child or parent giving a history inconsistent with severity of injury, such as a baby with
contrecoup injuries to the brain (shaken baby syndrome) that the parents claim happened
when the infant rolled off the sofa

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• inconsistencies or changes in the child’s history during the evaluation by either the child or
the adult

• unusual injuries for the child’s age and level of development, such as a fractured femur in a
2-month-oldor a dislocated shoulder in a 2-year-old

• high incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising
of rectum or vagina

• evidence of old injuries not reported, such as scars, fractures not treated, and multiple
bruises that parent/caregiver cannot explain adequately

The key is to recognize when the child’s behaviour is outside what is normally expected for
his or her age and developmental stage. seemingly unexplained behavior, from refusal to eat
to aggressive behavior with peers, may indicate abuse. The nurse does not have to decide
with certainty that abuse has occurred. nurses are responsible for reporting suspected child
abuse with accurate and thorough documentation of assessment data.

Treatment and intervention

The first part of treatment for child abuse or neglect is to ensure the child’s safety and
well-being (bernet, 2005). This may involve removing the child from the home, which also
can be traumatic. A relationship of trust between the therapist and the child is crucial to help
the child deal with the trauma of abuse.

Long-term treatment for the child usually involves professionals from several disciplines,
such as psychiatry, social work, and psychology. The very young child may communicate
best through play therapy, where he or she draws or acts out situations with puppets or dolls
rather than talks about what has happened or his or her feelings.

ELDERLY ABUSE

The mistreatment of elders is a serious, underreported, under detected phenomenon.is the

maltreatment of older adults by family members or caregivers. it may take any form which
include physical and sexual

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 abuse, psychological abuse, neglect, self-neglect, financial exploitation, and denial of
adequate medical treatment. Elder mistreatment may takemany forms, including physical
abuse, neglect, exploitation, abandonment, and psychological abuse

ASSESSMENT APPROACH FOR ELDERLY ABUSE

Forms of mistreatment of elders

In assessing the state of the elderly and confirming whether or not he or she is being
abused, the following can be observed;

Physical abuse

 direct beatings
 inflicting pain
 coercion (abrasions, sprains, dislocation)
 withholding fluids
Neglect

 withholding medication/treatment
 withholding medical
 Attention
Exploitation

 taking social security or pension checks

 taking possessions against elder’s will
 removing excess funds from elders’ account when purchasing items for them

Abandonment

 dropping off elder at hospital or other health care facility

 leaving incapacitated elder alone at home failing to provide for basic services
Psychological Abuse

 degrading comments
 threatening comments
 using scare tactics when the elder cannot provide for his or her own needs.

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Emotional Abuse.

Elders who are at greatest risk for abuse and neglect are those who are dependent on others
for care (centers for disease control [cdc], 2010).

NURSING DIAGNOSIS

Once appropriate assessment has been done, a nursing diagnosis (NANDA) likely to be
associated with DSM-IV-TR disorders in elders will be considered:

 major depression
 chronic or situational low esteem
 Disturbed Thought Processes
 Sleep Deprivation or Insomnia
 Activity Intolerance
 Adjustment Disorder
 Dysfunctional Grieving
 Self-Care Deficit
 Ineffective Role Performance
 Activity Intolerance

Planning and Implementation: NIC

The following psychiatric–mental health interventions are frequently effective when working
with elders.

 Reminiscence Therapy and Life Review

Reminiscence therapy and life review are useful interventions for elders who are
experiencing self-esteem disturbance, grief, hopelessness, powerlessness, altered role
performance, and social isolation

Reminiscence therapy uses the recall of past events, feelings, and thoughts to facilitate
pleasure, quality of life, or adaptation to present circumstances. Although it can be used
throughout the life span, it is of special significance when working with elders.

 Reality Orientation

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Reality orientation emphasizes awareness of time, place, person, and purpose. The approach
provides consistency and a constant reminder to clients of where they are, why they are there,
and what is expected. The periodic use of reality orientation tests the elder’s level of
confusion and disorientation.

The rationale for reality orientation is the need to use the part of the person’s mind that
remains intact.

 Socialization Enhancement
Socialization enhancement with elders usually takes place in resocialization groups
conducted in senior centers, adult daycare, rehabilitation, and long-term care facilities. The
goal of resocialization groups is to facilitate the elder’s ability to interact with others and to
renew interest in his or her surroundings.

 Animal-Assisted Therapy
Animal-assisted therapy or pet therapy involves the purposeful use of animals to provide
affection, attention, diversion, and relaxation to clients.

The Cycle of Abuse

The domestic violence cycle of abuse diagram helps to understand the different phases which
typically occur in abusive relationships before, during, and after an abusive episode. Most
abusive relationship display a distinct pattern, known as cycle of Abuse or Violence. Abuse
is rarely constant but alternates between: tension building, actingout, the honeymoon
period and calm.

Each stage of the cycle can last from a few minutes to a number of months, but within an
abusive relationship. This stage usually repeats themselves over and over again, no matter
how many times the abuser promises to change or stop.

The 4 Stages of An Abusive Relationship

1. The tension-building stage

This is when stress and strain begin to build between a couple just before an abusive acts
occurs. The abuser’s behavior may become passive aggressive, and s/he may become
poor( er ) in communicating.

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  Tension starts and steadily builds
 Abuser starts to get angry
 Communication breaks down
 Victim feels the need to concede to the abuser
 Tension becomes too much
 Victim feels uneasy and a need to watch every move.

2. Incident or ‘Acting Out’ Phase

This is the stage when the act of violence takes place.
 Any type of abuse occurs
 Physical e.g hitting kicking, biting etc.
 Sexual
 Emotional
 Or other forms of abuse as found in the power and control wheel

3. Honeymoon
This stage is also known as Reconciliation phase. In this stage, abuser becomes overly
attentive and affectionate. Some abusers may threaten suicide to stop their victim from
leaving
 Abuser becomes contrite and apologizes for abuse, some beg forgiveness or show
sorrows.
 Abuser may promise it will never happen again.
 Blames victim for provoking the abuse.
 Minimizing, denying, or claiming the abuse wasn’t as bad as the victim claims.
4. CALM before the tension starts again
This stage is considered as extension of the reconciliation phase. During this stage, the
abuser tries hard to show kindness to the victim and resist the urge to fall back into the
abusive behaviors. The following also are likely to occur;

 Abuses become slow or stop.

 Abuser acts like the abuse never happened
 Promises made during honeymoon stage may be met
 Abuser may give gifts to victim
 Victim believes or wants to believe the abuse is over or the abuser will change.

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 DISORDERS RELATING TO ABUSE
Impact of abuse depends on the type and severity of the abuse, relationship between the
abuser and victim, environment, history, support and care gotten. Related disorders include
and are not limited to:

 Post-Traumatic Stress Disorder

This is a psychological condition that develops after a person has been harmed or exposed to
danger and were unable to protect themselves. It is common with people who have
experienced fear, helplessness and powerlessness which is very common in child abuse.
There are 3 major symptoms of PTSD. They are Hyperarousal (is hyper activity, it is
commonly known as a state of ‘flight or fight’, it may be experienced as giddiness, anxiety,
agitation or irritability), Intrusions (flashbacks, when a daunting experiences from the past
break through into present consciousness and seem they are occurring presently) and
Avoidance (a defense mechanism which involves withdrawing from others or narrowing
one’s thoughts and feelings, it may occur as denial, dissociation, repression, amnesia and
maybe employed subconsciously). Others signs may include sleep disorder, Nightmares,
panic attacks, uncontrollable crying and raging, addiction, extreme mood swings, stigma,
suicidal feelings, somatic pain etc.
 Panic Attacks
Occur when an individual experiences a sudden period of intense fear or generalized
discomfort. Some symptoms are sweating, palpitations, trembling, nausea or abdominal
distress, feeling dizzy, fear of dying, numbness or tingling, chills or hot flushes,
breathlessness or choking.
 Depression
This is very common in victims of abuse. There is a feeling of lack of energy, dissatisfaction
with life, lethargy, worthlessness, isolation from others, lack of motivation, hopelessness,
insomnia or hypersomnia, suicidal ideation or attempts. It becomes a major depressive
disorder when this signs last more than 2 weeks.
Other Disorders include Eating disorders, Personality disorders, Schizophrenia, Bipolar
disorder, Dissociation etc.

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 VIOLENCE
Violence is defined by the World Health Organization as "the intentional use of physical
force or power, threatened or actual, against oneself, another person, or against a group or
community, which either results in or has a high likelihood of resulting in injury, death,
psychological harm, mal-development, or deprivation." Violence is the use of force with the
intent to harm. Violence could be self - directed, interpersonal or collective.
 Self-directed :Self-directed violence: is further divided into suicidal behaviour and self-
abuse. Suicidal behaviour includes suicidal thoughts, attempted suicides – also called
deliberate self-injury – and completed suicides. Self-abuse, on the other hand, includes acts
such as self-mutilation.
 Interpersonal violence : violence largely between family members and intimate partners,
usually, though not exclusively, taking place in the home and violence between individuals
who are unrelated, and who may or may not know each other, generally taking place outside
the home. It includes child abuse, intimate partner violence, abuse of the elderly, youth
violence, random acts of violence, rape or sexual assault by strangers, and violence in
institutional settings such as schools, workplaces, prisons and nursing homes.

Violence and abuse may occur only once, can involve various tactics of subtle manipulation
or may occur frequently while escalating over a period of months or years. In any form,
violence and abuse profoundly affect individual health and well-being. The roots of all forms
of violence are founded in the many types of inequality which continue to exist and grow in
society.
Violence and abuse are used to establish and maintain power and control over another person,
and often reflect an imbalance of power between the victim and the abuser.

The Brøset violence checklist (BVC)

The Brøset violence checklist (BVC) is a short-term violence prediction instrument assessing
confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects
as either present or absent. It is hypothesized that an individual displaying two or more of
these behaviors is more likely to be violent in the next 24-hour period. BVC is a useful
instrument in predicting violence within the next 24-hour period and the psychometric
properties of the instrument are satisfactory.

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 Forms of violence
Violent acts are actions carried out to harm others. It could lead to death, physical or
psychological injury. Forms of violence include:
Physical violence
Emotional violence
Sexual violence.
Psychological violence
Cultural violence.

1. Physical violence:
occurs when someone uses a part of their body or an object to control a person’s actions.
Physical violence includes, but is not limited to:
 Using physical force which results in pain, discomfort or injury
 Hitting, pinching, hair-pulling, arm-twisting, strangling, burning, stabbing, punching,
pushing, slapping, beating, shoving, kicking, choking, biting, force-feeding, or any other
rough treatment
 Assault with a weapon or other object
 Threats with a weapon or object
 Deliberate exposure to severe weather or inappropriate room temperatures
 Murder.

Medication abuse
Inappropriate use of medication, including:
 withholding medication
 Not complying with prescription instructions
 Over- or under-medication.

Restraints abuse
 Forcible confinement
 Excessive, unwarranted or unnecessary use of physical restraints
 Forcing a person to remain in bed
Unwarranted use of medication to control a person (also called “chemical restraint”)

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 Tying the person to a bed or chair.
2. Sexual violence
Sexual violence occurs when a person is forced to unwillingly take part in sexual activity. It
includes, but not limited to:
 Touching in a sexual manner without consent (i.e., kissing, grabbing, fondling)
 Forced sexual intercourse
 Forcing a person to perform sexual acts that may be degrading or painful
 Beating sexual parts of the body;
 Forcing a person to view pornographic material; forcing participation in pornographic filming
 Using a weapon to force compliance
 Exhibitionism
 Making unwelcome sexual comments or jokes; leering behaviour
 Withholding sexual affection
 Denial of a person’s sexuality or privacy (watching)
 Denial of sexual information and education
 Humiliating, criticizing or trying to control a person’s sexuality
 Forced prostitution
 Unfounded allegations of promiscuity and/or infidelity; and,
 Purposefully exposing the person to HIV-AIDS or other sexually transmitted infections.

3. Emotional Violence
Emotional violence occurs when someone says or does something to make a person feel
stupid or worthless. It includes, but is not limited to:
Name calling
Blaming all relationship problems on the person
Using silent treatment
Not allowing the person to have contact with family and friends
Destroying possessions
Jealousy
Humiliating or making fun of the person
Intimidating the person; causing fear to gain control
Threatening to hurt oneself if the person does not cooperate
Threatening to abandon the person.

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4. Psychological Violence
Psychological violence occurs when someone uses threats and causes fear in a person to gain
control. It includes, but is not limited to:
 Threatening to harm the person or her or his family if she or he leaves;
 Threatening to harm oneself
 Threats of violence
 Threats of abandonment
 Stalking / criminal harassment
 Destruction of personal property
 Verbal aggression
 Socially isolating the person
 Not allowing access to a telephone
 Not allowing a competent person to make decisions
 Inappropriately controlling the person’s activities
 Treating a person like a child or a servant
 Withholding companionship or affection
 Use of undue pressure to:
 Sign legal documents;
 Not seek legal assistance or advice;
 Move out of the home;
 Make or change a legal will or beneficiary;
 Make or change an advance health care directive;
 Give money or other possessions to relatives or other caregivers; and,
 Do things the person doesn’t want to do.

5. Cultural violence
Cultural violence occurs when a person is harmed as a result of practices that are part of her
or his culture, religion or tradition. It includes, but is not limited to:
 Committing “honour” or other crimes against women in some parts of the world, where
women especially may be physically harmed, shunned, maimed or killed for:

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 Falling in love with the “wrong” person
 Seeking divorce
 Infidelity; committing adultery
 Being raped
 Practicing witchcraft; and,
 Being older.
 Cultural violence may take place in some of the following ways:
 Lynching or stoning;
 Banishment
 Abandonment of an older person at hospital by family
 Female circumcision
 Rape-marriage
 Sexual slavery;
 Murder.

All of these forms of violence could cause imbalance in an individual's state of mental health.

INTERGENERATIONAL TRANSMISSION PROCESS

The Intergenerational transmission process shows that patterns of violence are perpetuated
from one generation to the next through role modeling and social learning. Intergenerational
transmission suggests that family violence is a learned pattern of behavior. For example,
children who witness violence between their parents learn that violence is a way to resolve
conflict and is an integral part of a close relationship. Statistics show that one third of abusive
men are likely to have come from violent homes where they witnessed wife-beating or were
abused themselves. Women who grew up in violent homes are 50% more likely to expect or
accept violence in their own relationships. Not all persons exposed to family violence,
however, become abusive or violent as adults.

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Therefore, this single factor does not explain the perpetuation of violent behavior.

DISORDERS RELATING TO VIOLENCE

SUBSTANCE ABUSE
People who abuse substances are very prone violent and aggressive behaviours. Studies have
shown that people with primary diagnosis of substance abuse were 240% more likely to
commit violent acts than mentally ill patients without substance abuse issues. Violent attacks
are promoted by intoxication or withdrawal from substances of abuse eg. Alcohol sedatives,
cocaine, opiates etc.
Other related disorders may include psychotic disorders, affective disorders, Cluster B
personality disorders, delirium, dementia, Posttraumatic stress disorders, sexual sadism, and
intermittent explosive disorders. Hallucinations and delusion also motivates violent
behaviours. Medical disorders related to neurotransmitters imbalance eg. Thyroid storm,
Cushing’s disease, androgen or estrogen dysregulation etc, systemic infections,
environmental toxins, complex partial seizures etc.

MANAGEMENT OF VIOLENCE
There are several methods of managing violence. They include but are not limited to:

PHYSICAL BEHAVIOURAL/PSYCHOLOGICAL MANAGEMENT

This is the process of altering the physical environment to stop violent behaviours of patients.
It may include
 removal of an actual threat or trigger e.g. separating 2 people fighting;

30
  giving the patient a sense that he has an ally through establishing some shared goals
and interest with the patient and working towards achieving them.
 Group therapy
 Simple concrete redirection of situations and discussions.
 Maintaining therapeutic environment
 Confidence body language, calm responses and good eye contact, but avoiding
intimidating direct eye contact.
 Positive reinforcement of adaptive behaviour

Pharmacological Management
Antipsychotic medications are effective in managing violent behaviours in clients. Drugs
such as Benzodiazepines e.g. Lorazepam, Selective Serotonin Reuptake Inhibitors (SSRIs),
mood stabilizers, tricyclic antidepressants, fluoxetine, haloperidol, fluphenazine, risperidone,
olanzapine etc. Non adherence, substance abuse and residual symptoms may affect the
effectiveness of these drugs, so long-acting depot antipsychotics, clozapine may be
considered.

Implications of Abuse, violence and abuse on Nursing practice

Psychiatric nurses play a vital and central role in the health care team, so are particularly
more vulnerable to violence from patients in adult mental health inpatient settings.
Workplace violence against health care workers is a common and widespread phenomenon
but there are limitations due to lack of consensus amongst health professionals about what
constitutes violence, and the lack of clear, accepted definitions.
In an integrated review of literatures from 2001 to 2013 conducted by Ronak Singh, it was
discovered that psychiatric nurses are likely to have at least one encounter of violence in the
workplace, of which physical assault, verbal abuse and threats are the most common. The
nurses experience various somatic and psychological effects as a result of this violence.
These effects contributes to reduced productivity, decreased job satisfaction, burn-out,
increased use of sick days, and drug and alcohol abuse among the nurses all of which has an
impact on patient care and consequently the effectiveness of the health care system. The
review also showed that Male psychiatric nurses experienced higher rates of violence
compared to their female counterparts and so may discourage male nurses from choosing this
specialty.

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Also, the psychiatric nurse should always be alert and watch for violent behaviors in patients
and no ways to disarm and calm patients.

On Nursing Education
As workplace violence and abuse are almost inescapable for nurse, student nurses may be
prepared to deal with the issue of violence and abuse in the health care setting through
various teaching strategies for nursing education which include role playing, videotape
playbacks, and debriefing sessions etc. Suggested content consists of student self-awareness,
assessment, and diagnosis of violent or potentially violent clients, and nursing care planning,
interventions, and evaluation for the immediate situation, as well as long-term treatment
goals.

On Nursing Research
Previous studies have helped to understand the violence and abuse the nurses face in place of
work. More studies may be done to test interventions and various ways to cope with angry,
violent and abusive patients.

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Carol Ren Knëisl & Eileen Trigoboff

Diagnosing and Managing Violence. Prim Care Companion Disord, 2011; 13(5):
PCC.11br01144.
https://medical-dictionary.thefreedictionary.com

https://www.blueknot.org.au/Resources/General-Information/Abuse-related-conditions
https://www.springer.com

Margaret M. Ross, R.N., Ph.D. Nursing Education and Violence Prevention, Detection and
Intervention A Report Prepared for Health Canada Family Violence Prevention Unit Healthy
Communities Division.
Marie E. Rueve & Randon S. Welton. Psychiatry (Edgmont). 2008 may 5(5): 34-38.
Ronak Singh, charge nurse manager of the Otago Regional Forensic Mental Health Services,
(2015). https://www.tepou.co.nz/news/nursing-research-masters-thesis-workplace-violence-
against-psychiatric-nurses-and-the-impact-on-nursing-practice-an-integrated-review-/734.
Retrieved 08/07/2018.
Sheila L. Videbeck, Textbook of Psychiatric- Mental Health Nursing

Steadman HJ, Mulvey EP, Monahan J, et al. Violence and homicidal behaviours in
psychiatric disorders Psych Clin N AM.199720405-425.
Whitley GG1, Jacobson GA, Gawrys MT. The impact of violence in the health care setting
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