Hidden Brain Injuries in the Women's Justice System

In this episode, we are joined by Dr Hope Kent, Research Fellow at the University of Exeter and a qualified Psychological Wellbeing Practitioner to discuss her groundbreaking research into the experiences of women in the criminal justice system. Dr Kent's work uses administrative data to examine why people with neurodisabilities, including acquired brain injuries, are disproportionately represented within the criminal justice system, and how public health approaches can help prevent this.

The conversation explores two recent publications:

• “Complex Lives”, which examines the vulnerabilities associated with care experience among women involved in the criminal justice system.
• “Acquired Brain Injury: An invisible consequence of domestic abuse for women in the justice system”, highlighting how it can be an often invisible consequence of domestic abuse and a significant yet overlooked factor affecting women in the justice system.

Transcript

SPEAKER_01 0:07

Welcome to this latest episode of the Free Speech Podcast brought to you by Bolt Bird and Kemp, a leading firm of solicitors for serious injury claims. My name is Siobhan Crawford, and I specialise in serious and catastrophic injury claims with a particular focus on acquired brain injury. In these podcasts, we explore a diverse range of topics and issues with lawyers, barristers, external experts, and the case of this episode, Dr. Hope Kent. Dr. Kent is a research fellow at the University of Exeter. Her work uses administrative data to understand why people with neurodisabilities and particularly those with acquired brain injury are overrepresented in the criminal justice system and what public health approaches could help to prevent this. She's a qualified psychological well-being practitioner with NHS experience, coordinates the Uckerbiff Acquired Brain Injury Justice Network, and is the UK representative of Pink Concussions. Welcome. It's a pleasure to have you here. Thank you so much for your time. Thanks for having me. It's really exciting to be here. So, what we'll be discussing today are two recent publications, one being Complex Lives, which looks at vulnerabilities associated with care experience for women in the criminal justice system. And also your paper on acquired brain injury, an invisible consequence of domestic abuse for women in the justice system. The papers explain why ABI, acquired brain injury, is one of the most significant yet least recognised factors shaping women's pathways into and experiences within the criminal justice system. You're here to discuss those publications and your findings today. So, for a start, your research focuses on ABI in justice-involved women. Can you start by explaining what do we mean by ABI in this context and why is domestic abuse such a significant cause?

SPEAKER_00 2:02

Absolutely. So ABI, acquired brain injury, is an umbrella term and it basically refers to any injury to the brain which happens since birth, so injuries that aren't congenital or acquired during birth, injuries that happen across the life course. And we usually think of ABI under two categories. So it could be traumatic injuries, which happen when there's a force to the head or an external blow to the head, and the brain kind of shifts around inside the skull, and you get bruising and swelling and damage to the tissue in the brain that changes how the brain is structured and functions. And traumatic brain injuries can come from things like sporting injuries, so a concussion is a traumatic brain injury. It can also come from road traffic accidents, assaults, falls, particularly in young children or older adults. But in the context of domestic abuse, we know that a lot of physical abuse is targeted at the head and neck. So a lot of women in the justice system have experienced blows to the head, which result in a traumatic brain injury. And what we also know about traumatic brain injury is that the effect of multiple brain injuries kind of accumulates over time. So if you experience one traumatic brain injury, you have effects from that. But if you experience multiple, those effects kind of accumulate and add up and become worse and worse over time. And in the context of domestic abuse, a lot of women have experienced abuse over a number of years, so that's really significant. The other sort of category of brain injury is non-traumatic brain injury. So most often that might look like brain injury from infection or illness, so things like brain tumour or strokes or meningitis and kephalitis can lead to brain injury. But also you can get brain injury from oxygen deprivation. So we call those anoxic injuries or hypoxic injuries where the brain is either wholly or partly starved of oxygen. And that can lead to kind of cell death in the brain, in the same way as with a stroke, if there's a clot and the cells aren't getting oxygen, that can lead to cell death. And so in the context of those anoxic and hypoxic injuries, domestic abuse is also really important because one thing that people don't think about is non-fatal strangulation. So if women have been held in a way that means they can't breathe, either through non-fatal strangulation or through incidents of near-drowning, things like that, then that can also lead to an acquired brain injury. And that is really under identified. It's such a hidden kind of epidemic. Because what is really unique about brain injury is that it can be associated with physical disability, but it can also be a really hidden condition. So women may have an acquired brain injury without any physical, kind of obvious signs of acquired brain injury, and they may not know about it themselves, they may not have identified that that's what they're experiencing. And so brain injury can lead to this really complex constellation of difficulties. So it could lead to difficulties with memory, with attention and concentration, all those kind of executive functions that let you sort of hold information in mind and then use that information. It can also lead to things like nausea, dizziness, those kind of somatic difficulties. It might lead to challenges with mental health. So acquired brain injury has been really associated with self-harm and suicidality, which again in women's prisons, that is a huge crisis at the moment. Our self-harm rates in women's prisons are so high. So I think acquired brain injury is really important to think about in that context too. The difficulties associated with brain injury as well might include emotional sort of regulation, impulsivity, so finding it really hard to kind of inhibit responses to situations. It can include social communication, so kind of understanding what other people are saying to you, speech language and communication difficulties, being able to sort of express yourself well. So it's a real mixture of consequences that acquired brain injury can lead to.

SPEAKER_01 5:55

And I think all of those things that you've just described, in one of the papers, you call it often a hidden disability. And I think that that is something that we also say in our work here at Bullbird and Kemp, that they are hidden disabilities, which means that if somebody was to come into contact with somebody with ABI, they might not at first blush realise that they are even injured. And I think that dovetails really well into your observation as well of that sometimes the women themselves don't realise that they're injured. And I think in your paper, you say 80 to 86% of women in contact with the criminal justice system have screened positively for history of ABI. And I wondered whether those numbers surprised you, given your background in this field.

SPEAKER_00 6:51

I think it's a really good question because those numbers are really striking. I think when you see it written down like that and you sort of start to understand the scale of the problem, it's always really striking. But when we start to connect the dots a bit more between what we know about how women reach the justice system, about the levels of domestic abuse, and then what we know about how much acquired brain injury is associated with domestic abuse, the picture all starts to sort of become clear. Feminist criminologists, for a long time, have talked about women's pathways into the justice system being characterized by polyvictimization, so victimization across the life course. And that was one of the key findings in that complex life study that I did with Brainkind was that a third of the women in contact with the justice system had been care experienced. So they've likely experienced really difficult situations at home growing up that have led to them going into care. They've had really complex lives, complex lives that are sort of characterized by this victimization and abuse across the life course. And that then reflects in adult relationships as well, and they're more likely to be victimized in those contexts. So that pathway into the justice system for women is really, really well established, but we need to just start to connect the dots to think about what the physical consequences of that abuse might be for women and how difficult that might make it to get out of the justice system as well. So things like being able to comply with probation conditions when you can't quite remember what the conditions are, or they're explained to you really quickly in a busy environment and you can't hold all those different instructions in mind all at the same time. And you need to be able to plan your time and make it to your appointment and work out which bus to get and have the sort of executive functionability to be able to organize yourself to get from A to B. That can become really, really challenging when you have an acquired brain injury, and that can lead to you getting back into more trouble. So you can sort of see how that cycle plays out for women and how women get then entrenched and stuck in the criminal justice system.

SPEAKER_01 8:52

I think that was something that you also light upon in your acquired brain injury invisible consequences paper, of how when possibly women themselves don't realise they have an ABI, but also people in the justice system who are trying to assist them, because really nobody wants people to return to the justice system. And I think that there is often more of a look at, for want of a better word, rehabilitation, I suppose would be the word used in the justice system. Correct me if I'm wrong. But it means that if the justice system, and I think people as a whole aren't recognising the impact of ABI, these people and women in particular are being therefore set up to fail almost because they're not being given the tools, and also the system isn't flexible enough as it stands, in from my reading of your paper, to ensure that they can be supported in a way that they are required. And I think also I work with brain injured clients, and what you say is almost word for word what I would observe with some clients in respect of their ability to engage with the legal process, because we have to take instructions from them, they might have wavering capacity, and you have to make an assumption that somebody has capacity, and then you get possibly a capacity report to say they either don't have capacity or they can for certain decisions, and we have to take instructions from them really carefully. The appointments that you mentioned is a really big thing. So in respect of that, how do you think that the brain injury manifests in ways that could be mistaken for non-compliance or dishonesty in, if possible, the civil system as well as the criminal system? Because I think there's actually, despite them being two different jurisdictions, I think there's a lot of overlap there when I read your report.

SPEAKER_00 11:07

Yeah, I mean, absolutely. So so you're definitely the expert in that area and in how those systems work. I think some of the key things to think about are credibility. So if a woman is perhaps struggling to answer a series of questions in a way that's consistent and across time telling the same story. So in the moment, like if there are questions coming quite quickly, it might be really difficult to follow those questions, hold them in mind, answer them in a consistent way, and all of that can kind of cast into doubt credibility. And that, I as I understand it, is quite an important part of those kind of proceedings. Um, I also think that there's difficulties with fatigue. So lots of the women that we speak to report that fatigue is a really big difficulty. So actually, whilst at the beginning of a conversation they might be able to deal with questions well, quite quickly, they become quite tired and not able to follow that conversation in the same way. And fatigue is something that is often not understood as a brain injury symptom, but it refers to these feelings of exhaustion that aren't associated with how much sleep you've had, and it's this sort of cognitive fatigue as well as just this physical exhaustion. So I think that's really important. The other thing that I thought might be relevant to mention is um a lot of the time what brain kind find when they speak to women in the justice system is that there are worries about how a diagnosis of brain injury or brain injury being identified could be used against them in family court proceedings. So something that might be used against them to say that they're perhaps not fit to parent or something like that. Um, and I think there's a big responsibility in how we use things like a knowledge of brain injury in justice proceedings to be supportive of people rather than using it as something that's punitive, because there's not really any evidence that acquired brain injury would mean you're not fit to parent, but it does genuinely get used against people. So that's quite important to think about. And there's a lot of thinking to do about how brain injury gets recorded and how that information gets passed between different parties who might be working with women to make sure it's being used responsibly.

SPEAKER_01 13:18

I think that is fascinating in respect to the family proceedings, because that is something that I've seen in my practice at BBK, because there is a real tension there. Because obviously, what we do is we bring claims for compensation to try as much as possible to put an individual back into the place that they were before the brain injury. But when you have these family proceedings, there is, as I say, this tension because there is, I think some of my clients would worry that there is an assumption that they are not fit to parent because of their brain injury. And so what they seek to do, rightly or wrongly, is possibly diminish the impact of their symptoms in order to convince a family judge that they are allowed to have access or independent access, so not going to a contact centre or overnight stays, because obviously there's different realms of access that can be provided by a family judge or ordered by a family judge. But then it's in direct opposition often to the reality. And as you say, it then opens up this avenue of credibility and dishonesty. And I think that finding that tension and being cognizant of it is really important, both as somebody who represents brain-injured people, but also across the systems, because very often what happens is they all dissect with one another, but they don't necessarily work in correlation with one another. I think that's a really interesting but also quite upsetting part of the work that I do is navigating those two systems in order to make sure that the people we represent are properly compensated. But ultimately, I think it's fair to say that most people would put their families and their children above any compensation, and that that's what they concentrate on, but it does them a disservice. Yeah. Um, I find that such a fascinating area. Um, speaking of brain kind, they developed a screening tool which is in your research, the BISI screening tool. And it's more of a screen, as I say, it's a screening tool as opposed to a diagnostic tool. So are you able to tell us a little bit about that and why it's so important, particularly for women who you observe in your papers don't necessarily attend hospital. So again, that's why they may not even realise that they have an ABI. But what can you tell us about that screening tool? And as I say, the importance for it in the work that Brainkind undertake and more generally for women in the justice system?

SPEAKER_00 16:18

Yeah, it's a really fantastic screening tool. Um, I think that the work that Brainkind do is absolutely brilliant. They developed it, it's sort of, I think it's 10 or 11 items, it's quite brief, but what it offers is a more structured way to ask those questions about brain injury and to open that conversation because it can be really overwhelming for a practitioner. I'm thinking in justice contexts, like a prison officer or something, to open that conversation about brain injury and be able to ask those questions. And the Busy provides a way to do that. Um, it's on their website, it's completely free to access, you just have to put in an email address so they can see sort of who's using it and where it's going. The point you make about it being a screening tool and not a diagnostic tool is a really, really important one, both for that point we were just discussing and sort of more broadly, we don't necessarily want people to be diagnosing brain injury all the time. It's actually just that screening tool to say, is this something that could be having an impact on what you're going through at the moment? Have you got a history that's indicative of brain injury? Have you experienced some of those things we talked about, the non-fatal strangulation and things like that, that might impact your ability to engage with what we're trying to offer, to engage with the rehabilitation or to engage with a justice process? Brain kind of also got a tool called Adapt, which is developed specifically for domestic abuse contexts. Um, and it's just a tool to support professionals to have that conversation about domestic abuse, to understand what kind of questions to ask and how to frame it in a way that is sensitive and not too traumatic for the person who's trying to answer the questions because that can be quite re-traumatizing to sort of go over again and again what's happened to you and why you might have a brain injury. I think a lot of the time there's sort of resistance to ask questions about brain injury in the justice system because it feels like it's too big of a box and it's too difficult, and it's um it feels like you've got to have lots of resources there afterwards if you do find out that that there might be a brain injury. But actually, women kind of do really benefit from just knowing that about themselves and having that information and being able to go away and research brain injury. There are some wonderful charities doing wonderful work. We've mentioned brain kind, also Headway have got a support line. Um there's places that women can be referred to for more support. Um, but also women uh will often say, like, oh, I thought I was going mad, I thought I had Alzheimer's, I thought I thought I had dementia, like I knew there was something wrong, but I didn't know what it was. And so giving them those words and that ability to kind of learn more about themselves is it can be quite empowering and can enable them to understand more about themselves and and why they're having the difficulties that they're having. So I think it's a good thing to have that conversation. I think the wariness comes around like formal diagnosis and that going on records, and that sort of um plays into that conversation we were just having. But yeah, the the process of screening is really, really important. And with the busy being so short and so easy to administer, um, it's something that can be really beneficial also for staff. So I think sometimes if you're trying to deliver an intervention for a woman who perhaps can't remember what you covered last week and hasn't done the homework tasks she was meant to do, and it can start to get quite frustrating, um, is missing appointments and doesn't give you the social cues that she's listening, or um, there's those kind of parts that are associated with brain injury that can become quite frustrating. So just having that better understanding between a person that you're working with and yourself as a practitioner can reduce that frustration and can possibly reduce some of the burnout and some of the like staff churn that you see in the justice system with that better understanding.

SPEAKER_01 19:53

So you've referenced Brainkind and the great work that they're doing, and what they've also done is the ask, understand, adapt framework, which is really straightforward. And I was wondering how you see it being applied beyond criminal justice settings. So, for example, in the work that I do with a client who might struggle with the demands of a personal injury claim. So, as I've referenced earlier, giving clear instructions, um, lots of appointments because they have lots of different experts that they have to see, and also they have to go see barristers, so on and so forth. So, how do you think, what is that framework, and how do you think that you might, we might be able to use it in our civil proceedings context?

SPEAKER_00 20:40

Um, so the ask understand adapt framework is absolutely brilliant. Brainkind developed it as part of some core training for criminal justice professionals to sort of work with people with brain injury. Um, but what it essentially involves is the first component is just ask. So being able to ask that question, whether that's using the BICE or the Brain Kind Adapt tool, and open that conversation about brain injury. So having the confidence that actually it's not going to do harm by asking the question and being able to do that in a sensitive enough way that's just sort of about professional curiosity and being able to understand whether that person's history might be having an impact on what's happening for that person. And then understanding is just about learning more about what that person might need, so what difficulties they have. There's definitely the case that no two people with a brain injury are going to present in the same way or have the same needs. Um it's about understanding what brain injury means for that individual person. Um, so it might be that one person is just really struggling with their memory, so they might be able to make their appointments on time if they have them written down and they know um when they are and they have like a clear planner, um, or some of those really simple um interventions that you were mentioning, and that might look different between different people. So it's just understanding what that person needs and having them. Knowledge of brain injury. And then adapting is just those simple changes to practice. So in our work in the justice system, it's about assuming that almost all of the women you're working with have probably had a brain injury, have probably been victims of domestic abuse or other kinds of abuse across the life course. So adapting just a universally more trauma-informed and neurodiversity-informed practice that is easier for people to engage with and remove some of those barriers to accessibility. So thinking about what might translate across to your work, things like simplifying the wording of things and simple language explanations and checks of understanding. So it might be that people with a brain injury are sort of socially able to engage and sort of nod along and say, yes, oh yes, I understand. But actually, if you do a check of understanding and see what that person has actually understood by what you've said, they may not have taken in some of the key points of information and may need them explained more slowly. So it's that sort of universal adaptation, that universal practice to just make the system a bit easier to navigate and a bit less rigid and complex.

SPEAKER_01 23:06

And I think it's also being aware of the communication that you're receiving back. So I always ask quite open questions to start with, because like you say, nobody is the same. So just how are you? Someone might say fine, and then someone might put it all out there. And I think once you get to know your clients, and probably the same in the justice system, in respect of people who are working with women routinely, you then start to tailor your approach because you know what they are like and what their personality is like. But I think it's really important to be aware of things like what might, on the face of it, seem to be a stutter. And actually, it's not a stutter at all, it's not a true stutter. What it is is the brain sort of ticking over and trying to think about what they're going to say next, but they fill that space with what appears to be a stutter. And I have a lot of speech and language experts who say this isn't a true stutter. This is the brain just trying to get in motion what the next thing is that they want to say. And I think it dovetails quite well with your observation, insofar as on a conversational level where it's not that deep, they don't appear to have a brain injury. But when they are asked to deeply consider something and provide a response, that is when those sorts of things can start to rise to the surface. And then I think it's really important that you have alternative ways of communicating to ensure that it's always tailored to the individual as opposed to people as a whole. So I guess you've just published these papers in fairly close succession. What's next for your research, and where can people find out more about you and Brainkind's work and resources?

SPEAKER_00 25:03

So, in terms of what's next for my research, I have a book hopefully coming out on this topic next year in collaboration with Professor Nathan Hughes at Sheffield. So we've actually the book is actually about the youth justice system. So it's about neurodisability, neurodiversity, and the youth justice system, sort of looking at children's pathways into the justice system. And the other big project I'm working on at the moment is around school exclusion and how that could contribute to pathways into the justice system for children. So trying to interrupt those pathways a little bit earlier, thinking about, for example, women's journeys through care experience through school and what leads them to the justice system, so that we can interrupt that before they ever reach it. So that's definitely something I'm interested in working on next. I have my university webpage, I am on LinkedIn. Um I've also just started a role at the University of Nottingham, so I have a Nottingham webpage as well. Um, and then all of Brainkind's fantastic work is on their website. Um, it's really easy to find and navigate, and they're also on LinkedIn and things like that.

SPEAKER_01 26:13

That sounds really exciting. I I I can't imagine what it's like to write a book because I just feel so overwhelmed. But I suppose you just start writing, and then when it's something you're really passionate about, which is obvious from the way that you speak about these things, I guess the words sort of write themselves.

SPEAKER_00 26:31

Um Yeah, I mean, I think um so Professor Nathan Hughes, I'm really fortunate to work with him. He's um a professor of adolescent health and justice, so he's been working in this space um I won't say how long, but for a while. And he he's just such an expert in this area and has been thinking about this for a really long time. Um so when I had the opportunity to collaborate with him, that was really exciting. And so the book is kind of um accumulation of a number of years of work, really, from from myself and and Nathan. Um, and we just thought we really need to bring this together and take all of these individual projects we've done and build it into a bigger picture of what is happening to children and young people who end up criminalized.

SPEAKER_01 27:12

Well, I look forward to reading that when it comes out. Thank you so much for your time. I really appreciate it. I know you're busy. Join us again on the next episode of the BBK Free Speech Podcast. Please click and follow wherever you are listening to this podcast from to be notified of all future episodes. Thank you for listening and goodbye.