A Cry For Justice

Awakening the Evangelical Church to Domestic Violence and Abuse in its Midst

Wound healing

This post has been written by one of our readers.

For months now I have been seeing connections between physical wound healing and healing from abuse. The analogies seem to leap at me from all sides. I am sure that engineers see analogies from building, and mechanics can see analogies from car repair.  I understand neither of those fields of endeavor but I do understand a bit about how our physical body works and heals. God created us physical and spiritual and He often uses physical word pictures to describe spiritual things. In a similar way, we can take principles of physical wound healing and apply them to victims of abuse.

What is a wound? A wound is any breakdown or opening in your skin. It compromises the integrity of your skin which is Godʼs design to keep your internal workings healthy and functioning and to keep internal and external separate. Proverbs 27:6 says that “Wounds from a friend can be trusted.” I would compare this to surgical wounds that remove a cancerous growth, or like the appendectomy my son had when his appendix was inflamed and ready to burst. Surgery creates wounds that need healing, but the wound edges are often easily drawn together, and if this is done properly the chances of infection and complications are slim. Surgical wounds can easily heal from the deepest point up, and from the outside in.

Pressure ulcers are also wounds, and are sometimes called “bedsores”. Pressure ulcers develop when pressure is continually applied on one area so that blood flow is compromised. Because it is under relentless pressure, the tissue no longer gets all the oxygen, food and trash collection that is needed to keep it healthy, so over time it breaks down. As health professionals we “stage “ wounds such as these. Stage one is just reddened skin that wonʼt “blanch” (when you briefly press it with a finger then release your finger, the tissue stays red, it doesn’t look white as it normally would after that press/release test). If we intervene quickly when we’ve discovered a stage one pressure ulcer and keep pressure off this area the tissue goes back to normal.

Stage two to four involve increasing degrees of skin break down. Pressure has been applied for so long that internal tissue, muscle and bone is now exposed to the outside world. This is scary and often ugly to the general public. These wounds can give off odor, drain blood and ooze “exudate”. They will not easily heal by themselves as their edges are not close and they often need to heal from the deepest point upwards. More intervention needs to occur than just re-positioning the patient’s body to removing the pressure!

How do we heal these wounds? I am not wound care certified, but I have learned many “tricks of the trade” and sound principles to help treat these wounds. It may seem obvious, but the first thing that must be done is remove the pressure. Remove what is causing this breakdown, that is compromising the integrity of the barrier God designed to protect the individual. Secondly we need to assess the damage. It is easier said than done sometimes, due to dead tissue and an abundance of garbage (called slough and eschar) and therefore we canʼt do a complete assessment with all that muck blocking our view of what is going on underneath. With a stage two, we often just have lost the first layer of skin, obviously easier to asses and heal. At stage four we have tissue breakdown to the bone. This kind of pressure ulcer has been going on for a long time with no one noticing and has compromised the entire person. Assessment is often difficult and smelly and is often done in combination with healing strategies and will take a lot longer.

After assessing what we can see and smell of the wound we now are ready to choose our strategy for healing. Some principles apply when we are choosing what products to use and how often are we to change the dressing.
1. Wounds heal best in a moist environment.
2. We need to be aware of the surrounding tissue that can become compromised from the exudate (think extra garbage that isnʼt being picked up by regular trash collection).
3. We need to get the dead tissue out and keep the healthy tissue healthy.
4. We need to know that every time we do a dressing change the wound will take four hours just to get back to homeostasis, so we need to change the dressing often enough that infection is not occurring but not so often that all the wound is doing is coming back to stasis.

Now apply these principles to spiritual, psychological and emotional wounds that victims of abuse have. There are so many, many ways to compare.

First we need to get the pressure off the wound. Pastors, counselors, friends of victims: Donʼt tell the victim they need to go back to the abuser, where the pressure that made the wound is still there. Stage one can so easily become stage two, three and four if the pressure is not removed. And none of these wounds will heal while the pressure is still on them.

Second, assessing the wound. This takes time, itʼs dirty and smells. I have to be careful with my gloves and make sure I donʼt introduce infectious agents as I measure. Often I donʼt know how deep the wound is because of dead tissue. I have apply a silver alginate product to break down the dead tissue and get it removed. (As an instructor said, “when you see Ag, think money”…this process costs something!) This does not happen overnight. This is not one of those cases of ripping off a bandaid quickly. The product has to be in the wound for awhile, undisturbed to do its job. When we are healing from abuse, we often donʼt know how deep it is, sometimes dead areas need to be dealt with and time is involved. Plan on lots of time to heal, healing that might involve breaking down and hauling out trash, dead stuff, stuff that is interfering with healthy tissue granulating … growing new cells from the outside in across the wound. Notice the would heals from the bottom to the top and outside in; the wound is going to be open for a long time if it is to heal properly.

Third, we also need to keep healthy tissue healthy. We need to be so careful to not introduce another source of infection. The person needs to increase their protein consumption to help their compromised body heal. More protein is more of the building blocks needed to replace the wounded, dead tissue. We need something to replace what is gone; and if we want it to be healthy it needs to be good solid building blocks not more garbage. I think this is true in two ways for victims of abuse. We need to up our consumption of the Word, to have the Bible filling our mind and hearts but we also need good physical nutrition.

Fourth, how often do we reopen this wound, remove the garbage that has collected and reapply a fresh dressing? Many of the products we use for physical wound healing need to be on undisturbed for days. How often do we revisit this incident of abuse or this strategy or this fear. It does need to be often enough that further damage does not occur but not so often that we compromise the healing!

This is much longer than I planned and I have so many other things I could say. How wounds needs a moist environment, so the Holy Spirit, our well spring of pure water can cleanse and maintain a healing environment. How pressure ulcers heal but the skin at that point will always be weaker. I have toyed with these comparisons for quite a few months now and every time something new strikes me. Today itʼs the exudate, garbage that needs to be removed. How much daily garbage collection needs to be part of our regular life and what that means in our souls and families. Another thought is that if the wound opens again it is staged (called) as it was at its worse because it will much more easily go back to that compromised place. As victims we have wounds that can be healed, Isaiah 53:5, “by His wounds we are healed” but it is often not instant nor easy. Time, proper care, support and nutrition need to happen.

During my first year separated from my abuser I had a bevy of Biblical counselors trying to help ( I canʼt even write “us” ) be reconciled. One of the pastors would quote things like ”perfect love casts out fear” and that was supposed to remove all my fear. He did not get these principles of wound healing. He was giving me scripture, the extra protein I needed, but the garbage hadn’t been removed. These counselors kept telling me that I was to put the pressure back on (“Family dinners are a great idea once a week”), stopping the blood flow, causing more damage. My body and spirit knew that this was the wrong idea.

Pain is a healthy thing, it lets us know not to touch something. Unfortunately in wound healing pain is often stimulated when we clean out the wound, we need to get rid of the trash and pain tells the body to increase the blood flow. So it is a balancing act, there are times when the dressing needs to be changed more often. Times when we need to revisit the abuse and really see what happened. There are also times when the wound needs to be bandaged well so everything is contained and the patient can go out to dinner and forget they have this gaping hole in themselves. They need a moment to feel whole, to understand why they need to endure the pain of dressing changes because the goal is that wholeness. I could keep writing, drawing analogies but I am not a writer and I know all of you have your own stories that you can put into this analogy and expand out understanding.

38 Comments

  1. Wow. This is really good!

  2. This is an excellent analogy for abuse. Abuse is a wound which requires no pressures and a process of many steps to heal.

    • Hi Aberratus, I gather you are new to our blog. Welcome! Hope you hang around. We love hearing from new people. (((hugs))) to you.

  3. Jeff Crippen

    Excellent! Perfect love casts out fear, alright. But that love is Christ’s love for us and thus in the case of abuse it needs to be the abuser who needs to repent and start actually loving or the fear, rightly, will remain as a warning – run!

    • Still scared

      I was just gently told by a friend that I should not ever call my abuser an “idiot” because he was a brother in Christ and I was in sin to say this. She was being gentle and loving but I think she has no clue how long healing from this takes. And as I prayed about it and called a friend who is walking a similar path. She agreed. What to call him is so difficult. I suggested “tormentor” or “captor” !! There is so much fear still there and the pressure is reapplied every time I have to deal with him. And he finds ways to make me have to deal with him with stupid court cases or not paying child support. When the pressure is applied, blood flow stops to the area, more garbage builds up and healing can’t continue for that time. What do you call your abuser? “Ex” implies two things, a casualness in the world, and I didn’t divorce casually, or it implies a partnership that was never a partnership. Idiot at least reduces the fear , makes him less scary because what he is doing is idiotic and nonsensical. I don’t use it all the time, though I do think it would help healing, gets the blood flowing to the area! …Thoughts?

      • ‘abusive ex-husband’ is a pretty good label if you want to be factual and dispassionate.
        ‘anti-husband’ is good if you are venting to friends who get it.
        likewise, ‘the beast’ is a good way of letting off some steam.
        ‘silly silly man’ is nice and handy, because it diminishes his power.

        I agree that ‘Ex’ can sound casual, almost flippant. And it fails to recognise the ongoing post-separation abuse. It makes it seem like he is out of your life and you’re therefore free as a bird. Not so, for so many of us.

      • Still scared

        “silly, silly man” sounds like it would work…that is kinda what was in my mind when I used “idiot” but I guess some people think that is a harsher word than I do. :)

      • SS – I, too, avoid the term Ex, mostly because it implies some form of relationship. If I said, “my ex-wife” the possessive “my” would indicate that I am still in relationship with her.

        That covenant of abusive bondage has not been modified. Rather, it has been dissolved. I have been redeemed from that covenant, and am no longer in relationship with her.

      • MeganC

        Joe — I love that. “I have been redeemed from that covenant”. Amen!!

        Barb — Those titles are VERY helpful. Who would think it would be such a struggle for us to come up with a name for those who abused us in the past?

      • Still scared

        I know Megan, never entered my mind as I was separating that what to call him would be something I struggled with!

      • SS – More often than not, I simply use her name when speaking of her. If the individual to whom I am speaking does not know her name, then I usually refer to her as my children’s mother.

      • I will no longer refer to the monster as “”my ex”” he does not deserve any kind of status. I really do not think its wrong to call it what ever YOU want….Idiot is ok. Was your friend worried you might offend? The idiot I mean? ……lol

      • Jeff S

        I tend to use “his mother” a lot since that is generally the context in which she comes up in normal conversation. I have no problem using “ex” though. Honestly, in any conversation where I’m talking about her as something other than my son’s mother either a) people know the situation and it really doesn’t matter how I refer to her, or b) they don’t need to know about the situation.

      • I have tried to just call him “the kids’ dad,” but the kids take great offense at that! They have a very unpleasant name for him that they use in private. It really isn’t right, but I don’t stop them. I figure it’s just a way to let off some of the anger they feel. Besides, for them, the word Dad denotes a loving protector, provider, and leader, not a self centered, rip off abuser, so, as far as they’re concerned, in their minds, he isn’t a dad. Courtesy of other comments on here made by Megan and Barb, I have just started calling him “my abuser.” It fits. I hope my kids will eventually follow my example in that. My 6 year old simply calls him by his first name though he calls all other adults by Mr. or Mrs. and their last name. I think that is his way of showing a little disrespect to someone he finds not deserving of respect. (I do really love ‘the beast’ though, Barb!)

  4. This was excellent! You are a writer! This spoke to me in such a HUGE way! I’m going to print it out and really mull it over. I’d love to reblog this on to my blog if that’s okay, and I have never done that before. I thought your analogy was PROFOUND and would absolutely love to hear more from you regarding your thoughts on healing from abuse and wound cleaning.

    • Ya I never REALLY refer to him at all. Only on this blog. But I did like the feeling of not ever using him as “”MY”” anything.

  5. Being a nurse, this post really got my wheels turning.

    When I’ve nursed patients who have developed pressure sores, and I’ve tried to re-position them, sometimes the patient has groaned and fought resistively against being re-positioned. They don’t like to lie any way in bed except the way they habitually lie. Try to roll them onto the other hip and they create a big scene and shuffle back to where they were, with all the pressure back onto the body prominence where it was before. Try to move that leg whose heel has a stage one pressure sore, and they move the leg back again in five minutes. Grrr.

    Not all patients do that. Only a minority. But I’ve seen it done occasionally. And those patients go from stage one to stage two or three in a few days.

    How does this relate to abuse? Maybe if we think about victims whom we try to help, we try to help them to recognize that they are being abused, we offer non-judgemental help, but they stay stuck in the abuse. Why, we can only speculate. But the pressure is not relieved, and the wound gets worse, and their ability to get free is further compromised because the wound gets so bad it affects the health of the whole body. The nutrition is compromised, the mobility is compromised, the immune system is overworked and depleted, the mental state gets more fragile…

    • Still scared

      excellent analogy

    • Wow!

  6. On a more positive note, I’ve seen pressure sores heal.
    If the wound had gone down below to the tissue below the skin so there was quite a hole, and it is gradually healing, the new tissue that starts to grow from the bottom and sides of the wound is called “granulation”.
    Let me tell you, granulating tissue is pink, shiny, fresh, bright and really healthy looking. You may not see it until you’ve washed and gently wiped away the slough and exudate (the yellow-clear stuff that was on top of the wound bed) but when you see that granulating tissue peeping through the slough, it’s like looking at new shoots in the garden. Those new cells buidling together to make new flesh: it’s amazing. It’s exciting.
    The granulating tissue glints at you – it almost winks at you, no kidding! It speaks promise and the certainty of healing. The fact that it is there reminds you that the body has amazing healing powers: written into the DNA and all the body systems is this complex ability to create a chain of chemical and biological events to make new tissue.
    I just get so excited when I see granulation happening!

  7. Still scared

    I was thinking today about how often you investigate all the dark corners of the wound. You clean it, clean it well every time you change the dressing BUT you don’t measure everything and check the length of the deepest tunnel, except what is required by policy. Thinking how this applies to us. Are we in the cover everything and get on with life while the silver nitrate breaks down the dead stuff. Are we having granulation tissue popping and growing and shiny new skin developing? We still have to be careful, we still need to eat more protein, but we’ve got healthy boundaries and good support system . Or, are we in the measurement stage? Are we looking at every crack and crevice assessing where we’ve healed and where we’ve maybe not. Do we need to rethink our wound care supplies, are we using the right treatment?

    • Still scared

      Do I mention, you need a REALLY good light to assess a wound well….especially when measuring.

      • Good point, SS. And when assessing it, you need to look carefully at it from all angles, and you also need to gently (ever so gently) probe the tissue around it, because sometimes the wound forms ‘sinuses’, that is, tunnels under and into the surrounding tissue deep below the surface. Sorry to get graphic, here, readers who don’t have nursing or medical training, but this happens. Think of a these tunnels like the tentacle of the octopus, and the main wound hole like the body of the octopus. Got it? So if there are sinuses, you need to take that into account in your assessment, and plan your strategy for healing accordingly. The healing will likely take longer if there are sinuses. But it can all be healed eventually, if all the right things are done and IF the patient doesn’t have too many other co-morbidities that are going to compromise his or her ability to heal. co-morbidities? Think things like cancer, diabetes, heart disease, immune disorders, disabilities that restrict movement, etc.

  8. Another point. I can’t tell you how many times I’ve seen a patient with a wound that has been quite longstanding, and if you look at the patient’s file and ask the patient what’s been done to the wound, you discover that many different nurses (and maybe a few doctors) have chopped and changed the strategies for healing. Very often you can deduce that the strategy was changed simply because that practitioner had the opinion “I know what is best to do here.” How do I know it’s a mere opinion? Because if I have been to latest wound-care training updates, I will know that many of the strategies that have been used on this wound by other practitioners are downright bad practice. They are old hat now. Some practitioners have been doing things to this wound that have now been proven less effective or even totally counterproductive to wound healing.
    Sometimes it even seems like they have not learned or have forgotten what they were taught in their basic training, however many years ago that was.

    I’m sure I don’t need to explain how this applies to domestic abuse!

    Medicine and nursing are fields where evidence-based best practice is always what is aimed for, and practitioners are supposed to keep up with the latest findings from research so they can apply them on the job. Wish that were so for all counselors and therapists especially those in the Christian world!

    • Still scared

      Amen! Yes the interns who are just learning their job who belong the “drug of the month club”, they get excited about some new drug and ALL their patients are on it. Or the ones who have never changed from what they learned eons ago. Yes, those work for some people…but usually because the wound is not deep or complicated. Just because applying boundaries and pastor accountability worked for your aunt Sue thirty years ago doesn’t mean it works in all ( most) cases of domestic violence.

  9. Ya know, I have been thinking that since it’s been a year and a half since he left, I’ve completed counseling, I’m writing my blog and purging my demons there, and I’ve done a lot of reading that I’m doing pretty well with the healing process. However, this hits me at my core. (I did home health care for elderly patients then worked in acute care as a transcriptionist and coder before doing a brief stint as an MA–you are speaking my language! I get this!) Thanks to you guys I’ve realized that I really am still assessing (that’s what I’m doing on my blog) and I’ve been finding some deep reaching sinuses (wounds from my family of origin). I’m going to need more recovery time than I have been willing to give myself. In fact, I don’t think I’m anywhere near ready for treatment yet! Gosh, the damage I could have done by rushing this process! You guys are great physicians! So glad you are on my team of doctors! ; )

    • The nice thing with pressure sores and other difficult to heal wounds is that you can be assessing and treating at the same time. In fact, it’s an iterative cycle: you assess to determine the appropriate treatment. Then when you re-dress the wound you assess again, and determine the appropriate treatment again. The treatment may stay the same for quite a long time, over several dressing changes, and then it may change, depending on various things:
      – the amount of blood, slough and exudate that is coming out of the wound
      – whether there is or is not dead tissue that needs to be removed before granulation can begin
      – whether or not there are signs of infection
      – whether the patient’s co-morbidities or mobilty has changed

      While there is a lot of exudate, liquid given off from the wound, you might need to spread vaseline (petroleum jelly) on the good skin at the margins of the wound, to prevent that skin from macerating. (Maceration? think how your skin looks like a prune when you’ve lain in a bath for an hour.)

      When the wound becomes less moist, you won’t need to use vaseline round the edges, but you may actually need to add a bit of moisture to the wound, to make sure it has the right amount of moisture to continue to heal in an optimum environment. Nurses have special wound gels that we can put on the wound before we apply the final dressing, to provide this moisture back to the wound.

      The silver dressing (Ag) that was mentioned in the post is the greatest dressing to deal with infection (if my memory serves me correctly). As the infection recedes, the amount of exudate will diminish. You still need a silver dressing (or silver paste) to conquer the infection, but you no longer need a highly absorbent outer dressing that will soak up all that exudate.
      When the infection is all gone, the wound will still need further healing. So you don’t need any more sliver dressing, but you still need some kind of dressing, even if only a light one.

      So you get the picture? The assessment determines the treatment strategy, and as the wound heals you continue to re-asses and re-assess, and each time you may need to modify your treatment strategy according to what the wound is requiring at the time.
      Assess, treat… assess, treat… assess, treat… eventually it is all healed and all you have is some scar tissue.

      Scar tissue: now that’s a whole new analogy. Did you know that scar tissue cannot sweat? It may have diminished nerve supply, so less sensation. And it is always less elastic (less stretchy) than real skin. And sometimes it gets lumpy, itchy and even knobbly (some people are more genetically predisposed to lumpy scarring than others; it’s called hyperkeratosis, as far as I can remember).

    • Barnabasintraining

      What’s an MA?

      • Barnabasintraining

        Wait. I think I figured it out. Medical Assistant?

      • To me, MA means the qualification Master of Arts, but I think in ANFL’s comment she probably means medical assistant.

  10. Okay just cause you guys are all asleep over in the US, I’ll have to entertain myself by writing another comment! (joke)

    Dead tissue in a wound is something we haven’t mentioned all that much in this thread, so I’m going to give you a bit of background about how we deal with dead tissue in a wound.

    Firstly, how do we recognise dead tissue? It is black, or a very dark purple that is nearly black. Sometimes the black is on the surface, sometimes is is under the surface but you can see it through the surface tissue. We call it necrotic tissue, which is just a fancy word for dead tissue. And dead tissue stops granulation, it gets in the way of healing, it means that new healthy tissue will not grow from the bottom and sides of the wound bed, because the dead tissue is in the way.

    We have to get rid of dead tissue if it is present, so that granulation can occur without impediment. The process of getting rid of necrotic tissue is called debridement, and we can achieve debridement in different ways:
    1. Chemical debridement involves breaking down the dead tissue with special dressings or pastes that soften and eat it away – turn it into stuff that we can wash out when we clean the wound, or stuff that the body’s circulation systems can remove and metabolise through the body’s excretion systems like the kidneys.
    2. Mechanical debridement means using mechanical means to break down and remove the dead tissue.
    a) If the dead tissue is hardened and stiff we have to cut it out with sterile scissors or a scalpel.
    b) If it is not too hard, we can subject it to a strong pressurised stream of sterile water or saline solution. Thirty pounds per square inch of pressure is the ideal. You fill a giant syringe with the water, and (with your gloves and goggles on) expel the syringe onto the wound tissue that needs to be removed. Under this pressure, the dead or dying tissue will be pressure-washed away. Think of high-pressure cleaning of old stone buildings: same principle.

    Once the dead tissue is gone, that wonderful granulation process can begin in earnest.

    How does this relate to healing from domestic abuse? Well I guess many of us can all think of applications from our own experience, but here is one.
    The survivor has survived for some time under post-separation abuse with no support from the church because the church has allied with the abuser. So the survivor naturally has a lot of anger and resentment against the primary and secondary abusers, and a natural frustration (rage) about the injustice she or he has suffered. The anger can be like a hardened piece of dead tissue. Hey, I’m not trying to denigrate the emotion of anger – anger is one of the emotions God in His good design has equipped us to have, and anger is a good motivator for social justice. But anger can become a plug that holds us back from healing, especially if has been buried and hardened into a fixity of resentment. (Please don’t take offense anyone, if you can think of better wording for this, please tell me…)

    So the anger, the dead tissue, may need to have the gentle and skilled hand of the physician or nurse who can cut it out carefully without removing any healthy tissue. Or it may need chemical debridement, with a special dressing to soften and breakdown the anger so it can be metabolized away. Or it may need a high pressure stream of the water of the Holy Spirit (not getting Romanist here!) to clean it away.

    • Still scared

      Amen, and note…dead tissue once had a purpose, it is not an invader, it just is not doing it’s intended job anymore and is interfering with healing…get it gone!

    • Barnabasintraining

      Barbara,

      Is it typically painful to have this dead tissue debrided? Or is it more of a relief?

      • Still scared

        Painful…usually I have family medicate the patient and hour before I get there. It’s not fun! But it gets the blood flowing to the area so healing can happen. Chemical debridement is not as painful but takes much longer and sometimes is what is needed and sometimes not.

      • Others with nursing and medical experience may want to jump in here and help me as I’m not all that much of an expert, but in my experience of using scissors or the syringe to debride, it wasn’t that painful for the patient. The dead tissue, is, after all, dead; so the nerve endings it had are dead too. If you cut or put pressure on the non-dead tissue that is near the dead tissue, you may cause some pain.

        Where I worked, if the debridement needed to be done with a scalpel that was usually the job of a doctor, not a nurse. I guess in some instances they might give a mild or local anaesthetic before doing the procedure.

      • Obviously SS has more experience than me on this. (I just read her comment above). She must have been debriding more serious / complex wounds than the ones I’ve dealt with.

  11. Still Healing & Growing

    I needed to read this, the way you wrote it was just what I needed at this time. After being married for more than 25 years, I finally left. I was blessed with a counselor who saw through the hollow words and actions of the man I was married to. I was advised to begin planning to leave before the abuse turned physical. It’s been several years now and I’m still healing from various wounds. Haven’t heard his voice in my mind for a year and a half – what a relief! I am still learning about the healing process; how to step back and let the tears flow; to let God work out the details. Every day I am reminded of the love God has for me. Thank you for doing this ministry!

    • Still Scared( but getting angry)

      It’s it amazing how LONG the process is!!

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