Domestic violence (DV) is a common cause of brain injury in women, who constitute the vast majority of victims of severe physical violence by an intimate partner.
The head and face are common targets of intimate partner assaults, and victims often suffer head, neck and facial injuries.One study of women in shelter found that the vast majority had been hit in the head or severely shaken by their partners, most more than once. The more times they had been hit in the head or shaken, the more severe, and the more frequent, were their symptoms.1
What is Traumatic Brain Injury?
Traumatic brain injury (TBI) is an injury to the brain that is caused by external physical force.
- Penetrating injuries are caused when a foreign object (such as a bullet, knife, or blunt object) pierces the skull. This type of injury causes focal damage, limited to the specific parts of the brain that lie along the path that the object travels.
- Closed head injuries occur from blows to the head that do not fracture the skull, or from severe shaking. They can cause both localized damage and diffuse or widespread damage, due to bleeding, and to stretching, tearing and swelling of brain tissue – which can continue to damage the brain for hours or days after they originally occur. A DV victim can suffer a closed head injury when her partner hits her on the head with an object, smashes her head against a wall, pushes her downstairs or violently shakes her.
- Cutting off oxygen, as happens in strangulation, also injures the brain.
A victim of domestic violence may suffer a TBI without knowing it if she had no severe trauma or obvious symptoms at first, or if she did not lose consciousness, or received no medical care.
NOTE: While a TBI can lead to aggressive behavior, it does not cause or excuse the targeted pattern of coercive control usually seen in DV. If a woman thinks her partner is violent because he has suffered a TBI, she might want to try and get an evaluation for him, but she should also be helped to plan for safety.
Difficulties caused by Traumatic Brain Injury
TBI can lead to impairments, ranging from to mild to severe, in cognition (thinking), emotions, behavior, and physical functioning. The person with a TBI may or may not recognize that they are having problems. The most common symptoms reported are headaches, severe fatigue, memory loss, depression, and difficulty communicating. Other problems experienced by people who have brain injuries include:
- Cognitive difficulties, such as decreased ability to concentrate, pay attention and solve problems, and communication difficulties.
- Difficulty with executive functioning, such asdifficulty making decisions, considering long-term consequences, taking initiative, feeling motivated, and starting and finishing actions; disinhibition and impulsiveness.
- Changes in behavior, personality or temperament, such as irritability, difficulty tolerating frustration, and emotional expression that doesn’t fit the situation.
- Physical effects, such as vision problems, insomnia, loss of coordination, and seizures.
Information For Service Providers
TBI service providers. Living with domestic violence can make it harder to recover from a brain injury. You can more effectively serve your clients if you routinely screen for DV. Screening can help you identify clients who have been assaulted by intimate partners. Some may have suffered multiple brain injuries due to multiple assaults, and some may have partners who still assault them on an ongoing basis. Others may have partners who try to prevent them from accessing services, which is common among batterers.
When a victim discloses that she is being abused, support her right to make her own decisions as far as possible, even if living independently is not a realistic possibility for her. Don’t try to take control or tell her what to do. Connect her with domestic violence services. If she wishes, reach out to the domestic violence agency with information about TBI, what support she needs, and what services are available to her. Look for ways that you can work together to provide effective advocacy for both problems.
Brain injury can make it harder for a victim of domestic violence to:
- Assess danger and defend herself against assaults.
- Make and remember safety plans.
- Go to school or hold a job (increasing her financial dependency on the abuser).
- Leave her abusive partner and live on her own.
- Access services.
- Adapt to living in a shelter. She may become stressed, anxious and confused or disruptive, or have trouble understanding or remembering shelter rules and procedures.
- Retain custody of her children.
Domestic violence service providers. Screen everyone who seeks DV services for TBI. A brief screening tool that was designed to be used by professionals who are not TBI experts is the HELPS.2 HELPS is an acronym for the most important questions to ask:
If you suspect a victim has a brain injury, or she answers “yes” to any of these questions, help her get an evaluation by a medical or neuropsychological professional – especially if she has suffered repeated brain injuries, which may decrease her ability to recover and increase her risk of death. If she wishes, reach out to the TBI service provider with information about DV, what support she needs, and what services are available to her. Look for ways to work together.
Working with abused women who have a TBI
The following strategies can help when a victim has difficulties with attention, concentration information processing, memory and executive functioning.
- Minimize distractions, such as phone calls, interruptions and bright lights.
- Meet with her alone, unless she wants someone else included.
- Keep meetings short and build in breaks.
- Work on one task at a time and stick to the topic at hand.
- Be factual and concrete; break information down into small pieces.
- Double-check to be sure she has understood you – repeat, repeat, repeat.
- If safety allows, write important information down in a journal or calendar, such as court dates, contact numbers, directions, order of protection information, to-do lists, etc.
- Develop checklists.
- Help her prioritize goals and break them into small, tangible steps.
- Break tasks down into sequential steps; write out steps to problem-solving tasks.
- Help her fill out forms and make important phone calls.
- Allow extra time for her to complete tasks (e.g., to fill out a form).
- Point out possible consequences of decisions, short- and long-term.
- Provide respectful feedback on problem areas that affect her safety, if she thinks she is functioning better than she is.
Safety planning is a concrete, specific process. When working with a victim who has a TBI, you may need to:
- Break plans down into even smaller steps and put the steps in sequence: first do A, then B, then C, etc.
- Review plans frequently and in detail, to help compensate for problems with memory, motivation, initiative and follow-through.
- Find out what she needs in order to manage her life. Incorporate benefits, rehabilitation and support services, assistive devices (voice recorders, timers, PDAs, post-its, etc.) service animals, and her ability to drive, work and live on her own into safety planning.
- Be realistic about how much – or how little – she may be able to do in a given day. Depression and fatigue are common for people with TBIs
- Provide extra support and coaching when she has to deal with the justice system or Family Court. Role-play upcoming stressful situations, such as going to court.
- Encourage her to visit the Brain Injury Association of New York State, or call their Family Help Line at 800- 228-8201.
Brain Injury Information Network - links to many other online resources
Brain Injury Resource Center: information, links to online support, and tools for self-advocacy. Also offers a Head Injury Hotline, 206-621-8558.
CDC, National Center for Injury Prevention and Control, Victimization of persons with traumatic brain injury or other disabilities: A fact sheet for professionals.
Picard, N., Scarisbrick, R. & Paluck, R., (1999). HELPS (Grant # H128A0002). Washington, DC: US Department of Education Rehab. Services Admin., Intl. Center for the Disabled.