This article originally appeared Brain Injury Association of America: By Fern Gilkerson
Brain injury professionals inevitably come into contact with domestic violence survivors. Causing traumatic brain injury (TBI) as a tactic of abuse has been significantly overlooked, putting people at risk for problems right away – and potentially in the long-term. Domestic violence is a common cause of TBI for women in particular, who constitute the majority of victims. It is important to remember that there also exists an inclusive spectrum of people who may have TBI from domestic or other types of relationship-related violence. This spectrum includes but is not limited to: children and teens who are abused in the home; men and teens experiencing domestic or dating abuse; those who are LGBTQ+; women who are pregnant; and victims of human trafficking. It is imperative that providers “screen in” rather than “screen out” who may live with abuse or have a history of being abused. Any type of person may have a domestic violence head injury, and may need treatment and resources regardless of a past or recent experience with abuse.
Abusers will often hit their victims on the head to conceal bruises. An estimated 36% of domestic violence survivors have sustained injuries to the head, neck, or face.1 Women seeking medical attention for these injuries are 7.5 times more likely to be survivors of domestic violence than women with other bodily injuries.2 TBI may also be associated with sexual assault with or without the experience of domestic violence.
A domestic violence survivor with TBI may not be able to make safe choices or hold a job. It may seem impossible to pay attention and complete tasks. Survivors may have anxiety or depression, and as a means of coping develop a substance use disorder. TBI may affect how they relate to their children and other family members. They may have trouble with finding the right words, having patience, and managing stress and emotions. Other symptoms may include reduced memory, thinking speed, confusion, and sleepiness. Pregnant domestic violence survivors may not be able to meet nutritional requirements due to appetite changes from TBI, and they may have trouble remembering prenatal appointments because of cognitive changes. A survivor whose brain has been injured may be at risk for other types of overlapping abuse and the compounding effects (ex. neglect, isolation, sexual abuse, and blocked access to appointments, food, or other resources). It is important not to blame domestic violence survivors for their issues as a result of being abused. The trauma-informed perspective of what has happened to them not what is wrong with them is most helpful in what can be a healing partnership between a service provider and a domestic violence survivor receiving services.
Survivors may not readily share with providers that they experience or have experienced relationship violence, and if their TBIs are injuries related to this violence. Causes of TBI among survivors include being hit on the head, slammed, shaken, or thrown. Causes of anoxic brain injury-related to violence may include loss of oxygen through suffocation, strangulation, asphyxiation (erotic or not erotic), or attempted drowning. TBI from sports and dating or family violence combined may result in ongoing and compounding re-injury of the brain. Undetected and untreated TBI may mean lifelong behavioral, emotional, and cognitive struggles. These are struggles that could cause homelessness, trouble with obtaining or keeping a job, substance use disorder, loss of children, or loss of life.
Domestic violence is ubiquitous and TBIs are invisible. It is best practice to a) universally assess for domestic violence and b) establish an ongoing working relationship with local domestic violence program advocates to streamline a two-way ‘warm’ referral process where provider partners personally know and trust each other’s staff, agencies and services. It is helpful, when assessing for domestic violence, to first inform an individual that because injuries to the head are so common in relationships, you are now discussing these important issues with all patients. It may take time for a survivor to trust a provider enough to disclose how the TBI occurred. In fact, a provider may be the first and only person a survivor will have or may ever tell about the abuse. Domestic violence assessment questions must be asked, sometimes multiple times, and always with trauma-informed compassion. Never assess for domestic violence in front of a dating or marital partner, as this person may be the cause of the TBI and there may later be retaliation for the survivor.3 There are two best-practice ways to assess, based on tools that can be found in the PCADV toolkit listed in the resources at the end of this article:
HELPPS Tool (adapted for domestic violence from the original HELPS tool) for brief encounters;
Medical or Program Assessment Guides that walks the service provider through a trauma-informed conversation.
Brain injury providers are in a unique position to make a meaningful difference for survivors of domestic violence by administering opportunities to heal. Assessing all patients or clients for domestic or dating violence may enhance medical assessments and diagnoses. Doors may open further, enabling a provider an opportunity to tailor a rehabilitative plan to the true nature of an injury and to make warm referrals for domestic violence services, and these additions to service provision can be profound for domestic violence survivors with TBI, their families, and the community.
Domestic Violence Hotline: 1-800-799-7233 or text LOVEIS to 22522