Shining a light on the darkness of abuse

October 26, 2020
Couple from behind, one with head on other's shoulder
Fewer than 50 of the country’s 500-plus trauma centers address mental health needs. MUSC is one of them. Photo by Kylli Kittus for Unsplash

Abuse often begins in the shadows. It happens in homes, away from the vigilant eyes of the community and law enforcement. And with a country in the grip of a pandemic – where people are encouraged to stay home when they can – experts are afraid those shadows might be deepening.

Local data seems to validate those fears. Since March, visits to MUSC’s trauma center have gone up by 10%. According to Tatiana Davidson, Ph.D., an associate professor in the College of Nursing and co-director of the Trauma/Telehealth Resilience and Recovery Program at MUSC, there has been an uptick in visits related to assaults, gunshot wounds and stabbings. Conversely, there has been a decrease in the number of patients admitted after car accidents. 

“We kind of thought this might happen,” said trauma surgeon Ashley B. Hink, M.D., an assistant professor at MUSC’s College of Medicine. “You’ve got a country dealing with uncertainty, economic distress, people being unemployed. This close life we’re living can cause things to explode.” 

According to the Centers for Disease Control and Prevention, 1 in 4 women and 1 in 10 men in the United States have experienced violence from an intimate partner in their lifetimes. The same can be said for the country’s older population, one that often relies heavily on help from others for their day-to-day activities. According to the National Institutes of Health, an estimated 1 in 10 older adults – defined as 60 years and older – experience elder abuse annually in the U.S. This includes physical, sexual or psychological abuse as well as financial exploitation or neglect by caregivers. Even in the best of times, elder abuse cases are rarely detected, with only 1 in 24 identified and reported to the appropriate authorities. 

“We don’t want just to fix them up physically and send them on their way. We are there with our patients long afterward, checking in on them daily to see how they are doing emotionally after their traumatic events.”


Ken Ruggiero, Ph.D., TRRP co-director and professor in the College of Nursing

These numbers are sobering, and they don’t even factor in the challenges introduced by COVID-19.

But for shadows to exist, there has to be light. And MUSC Health provides it in the form of a comprehensive array of abuse services, catering to all ages and all matters of abuse or trauma, immediately after an event as well as beyond. These services include the TRRP; the MUSC Advocacy Program (MAP); Elder/Vulnerable Adult Abuse Services, under the Clinical Forensics Program; Child Abuse Pediatrics; Pediatric Sexual Assault Nurse Examiners; and the National Crime Victims Research and Treatment Center. These programs offer an array of treatment options, counseling, therapy and support group services.

“We don’t want just to fix them up physically and send them on their way,” explained Ken Ruggiero, Ph.D., TRRP co-director and a professor in the College of Nursing. “We are there with our patients long afterward, checking in on them daily to see how they are doing emotionally after their traumatic events.”

“We’re the only full-scope forensic nursing program in the state,” said Julie Watson, R.N., a forensic nurse examiner and the elder and vulnerable adult abuse specialist at MUSC. “We have lots of great pieces in place, and we keep trying to get better. Most people think we only care for sexual assault victims, but we also provide care for victims of intimate partner violence, strangulation, human trafficking as well as elder and vulnerable adult abuse.”

Less than 10% of the country’s 500-plus trauma centers address mental health needs – something incredibly important to patients dealing with depression, anxiety or post-traumatic stress disorder – after their life-altering experiences.

The following is a more in-depth look at several of these services.

Vulnerable adults

According to the state of South Carolina, vulnerable adults are those age 18 years or older who have physical or mental conditions that make it difficult for them to care for themselves safely. 

“Say there is a patient that staff members are worried may be the victim of abuse or neglect, they could call me, and I would come in and do a consult,” Watson said. “It’s totally comprehensive. I’ll talk to the patient, complete an assessment based on the type of abuse suspected, complete forensic photography if needed for physical injuries. I work very closely with the MAP team to identify suspicions of abuse, in order to help determine if reports and/or referrals need to be made.”

Watson and the forensic nursing team are the experts who know how to identify the signs or symptoms as well as risk factors associated with abuse or neglect. Just like with domestic violence, according to the National Council on Aging, in almost 60% of elder abuse and neglect incidents, the perpetrator is a family member. 

Two people, one in a hospital bed, holding hands 
Older people are even more vulnerable to abuse. Photo by Julie Watson

Watson’s team has access to and relationships with a multitude of resource providers, including social workers, doctors and counselors, not to mention countless local organizations dedicated to helping protect the abused. Unfortunately, there are so many barriers involved. 

“We can do great work within these walls, and we do, but we are so often limited in the resources beyond those walls,” she said. “There are no emergency shelters for a vulnerable adult that has been abused. Many times, we get stuck here, especially when financial or caregiver options are limited. It’s a huge problem that has needed the spotlight for a long time.”

The factors that are often present in elder abuse – isolation, frustration, stress – have been at all-time highs during this pandemic, meaning one would expect to see higher instances of elder abuse. However, while the data doesn’t support that expectation, that might not be the full picture.

“We all suspected abuse would increase, but our numbers haven’t reflected that. We have a strong feeling it is worse; it’s just that these people have a harder time getting out of their abusive environments to come to see us,” she said. 

In pre-COVID times, many older adults previously turned to their health care providers for help, but with the cancellations of face-to-face visits and their unfamiliarity with the technologies needed to conduct remote health care visits, Watson and national experts fear things like these might be preventing older adults from receiving the care they need.

“That occasional visit to a doctor or ED might be the only opportunity for social interaction or a chance to get help,” she said. “Those face-to-face encounters are so important.”

Though the numbers aren’t necessarily higher these days, Watson said the presentation of symptoms she has seen are different because of COVID. For example, a woman was admitted to the hospital with what appeared to be signs of neglect, but as it turned out, she was getting fewer home visits by friends and church members due to the pandemic, and as a result, her health declined dramatically. Another concerning situation is the opportunity for abuse in skilled nursing facilities. When family members are only able to visit their loved one through a window or by phone – not getting an up-close look – any manner of abuse could be happening inside the facility without a family’s knowledge.

“This virus has changed how everybody does business,” Watson said. “It’s made an already complicated issue so much more complicated.”

But Watson and her team are still as busy as ever, trying to make a difference one patient at a time.

“We just keep trying to work our hardest to identify and serve these vulnerable populations, and especially during this most challenging of times,” she said. 

MUSC’s Advocacy Program

If you think of Watson as the one who gets the ball rolling, then Abby Steere-Williams with MAP takes that ball and runs with it. MAP’s mission is to provide direct support and interventions to patients and their families when there is a suspicion of abuse or neglect of a child or vulnerable adult, intimate partner violence, sexual abuse or assault or human trafficking. 

Five years ago, MAP – the vision of trauma surgeon Hink and many other colleagues – came to be. The idea was to provide a dedicated staff that comprises clinicians and social workers for these victims.

“These cases require a lot of time, so this allows us to focus on them and give them the time they deserve,” Steere-Williams said.

MAP provides education, counseling, safety plans, lethality assessments and referrals for the patients. 

“Abuse is such a scary thing,” she said. “For some people, it’s so ingrained, so much a part of their daily lives, they don’t even know that what’s happening to them is abuse,” she said. 

For most of these people – even though they are being abused – it’s difficult to leave the relationship. Increased risk of abuse, combined with lower self-esteem and limited resources due to COVID-19, makes leaving even harder. But once the patient decides it’s what’s best for them, the MAP team can help patients navigate the criminal justice system, coordinating with law enforcement or lawyers – whatever help they may need to be safe and establish their independence.

“Abuse is such a scary thing. For some people,
it’s so ingrained, so much a part of their daily lives,
they don’t even know that what’s happening to them is abuse.”


Abby Steere-Williams, social work coordinator

Much like Watson and her team, Steere-Williams leverages the rich network of support at MUSC Health. 

“Within the hospital, we work very well together. We have meetings to make sure we’re all aware of what each other has going on,” she said. “I think we provide a pretty comprehensive service for our patients. And it doesn’t just stop with patients. Most employees don’t know this, but we also provide services to staff and students.”

Trauma/Telehealth Resilience and Recovery Program

Once the violence or trauma ends, the person isn’t just magically better.

That’s where the TRRP comes into the equation. TRRP works with physical injury survivors and their families to overcome emotional challenges, like PTSD and depression, that can arise after injury.

Ruggiero and Davidson work with patients, families and trauma centers to aid with the emotional health recovery of patients after serious injuries.

Detail photo of sign saying an examination is in progress 
If abuse is suspected, MUSC Health's forensic team steps in. Photo provided

“Many hospitals and trauma centers focus on survival, but very few follow up with mental health,” Davidson said. “We start at the bedside, but our real work starts once they’re discharged.”

Ruggiero and Davidson don’t only rely on face-to-face visits and phone calls to stay in touch with patients. Patients are also given the option – an option that two-thirds of them take MUSC up on – to enroll in a text messaging program that asks them about their moods and levels of anxiety.

“They get a text every day asking them how they are feeling. The texts also have helpful information about common trauma reactions as well as coping tips that they can use to manage stress. We’re just finding they’re really great for our patients in helping them to be more aware of their emotions and in keeping them engaged in services,” Davidson said.

The program has been so successful that three other hospitals in South Carolina have worked with MUSC to adopt the same programs at their facilities. Recently, trauma centers in North Carolina, Florida, Vermont, Illinois and Georgia also have inquired about how they, too, could emulate MUSC’s system.

“We are finding that it makes it so much easier for us to stay connected to our patients,” Davidson said. “Before our program came along, there wasn’t anything like this. So to be able to see that we can meet them on the floor, and make and maintain a connection, it allows them to trust us. That’s huge. It’s been such a success because there was such a need. We are excited that we are able to help these patients who are going through so much.”

Patrick Cawley, M.D., CEO of MUSC Health added: “MUSC has long recognized the problems with abuse and instituted a variety of solutions over the years. As one can see from our recent efforts, we remain fixated on developing novel ways to address this difficult issue.”