The Invisible Injury: Understanding Partner Inflicted Brain Injury

Partner inflicted brain injury is an incredibly common yet often overlooked consequence of intimate partner violence. In this episode of Seeding Safety, we sit down with Rachel Ramirez and Kasey Holderbaum from The Ohio Domestic Violence Network to explore how brain injuries occur in abusive relationships, including through strangulation and repeated head trauma. We discuss the ways brain injury can affect memory, cognition, emotional well-being, and safety, as well as the challenges survivors may face when seeking support and healthcare. Rachel and Kasey share insights for advocates, healthcare providers, and anyone working to better understand and respond to the lasting impacts of abuse. Join us for an important conversation about recognizing the invisible injuries of IPV and building systems that better support survivor healing and safety. 

Center on Partner-Inflicted Brain Injury at the Ohio Domestic Violence Network 

Acknowledgement: This podcast was made possible by Grant Number 90EV0529 from the Administration for Children and Families, Office of Family Violence Prevention and Services, U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services.

Transcript

SPEAKER_02 0:05

Welcome to Seating Safety, a podcast on cultivating conditions for health, healing, and violence prevention from futures without violence. I'm your host, Kate Vanderg. Today on Seating Safety, we're talking about partner-inflicted brain injury, an often overlooked but deeply important consequence of abuse. We're joined by Rachel Ramirez and Casey Holderbaum from the Ohio Domestic Violence Network to help us better understand how brain injury shows up in the context of IPV, what survivors experience, and how advocates and healthcare providers can better respond. All right, I'm so excited to be here with you both today. Rachel and Casey, if you could each just uh start by sharing a little bit about your work and how you came to focus on partner-inflicted brain injury.

SPEAKER_00 0:59

Wow, my name is Rachel Ramirez. Um, Casey and I are joining you all from what today is a rainy uh cold Ohio. Two days ago it was a sunny 90-degree Ohio. So welcome to spring in Ohio. Um, we're not quite sure if it's spring or winter or fall. It might be summer again tomorrow. But um, but yeah, so um I work with the Ohio Domestic Violence Network. We both work with the Ohio Domestic Violence Network, which is the statewide coalition on domestic violence here in Ohio. And we're a membership organization of 76 domestic violence programs across the state. I have been in domestic violence services since my very first job in a 103-bed domestic violence shelter in 2003 in Tampa, Florida, and have been at the statewide coalition for 19 years in counting. Um, I first spent uh a few years coordinating all of our training, spent several years working on a trauma-informed capacity building project with our member programs, and then in 2016, we got our very first grant to focus on what we'll be talking about today on partner-affected brain injury. Um, one of the things I'm really, really excited, we've partnered with Futures on many projects over the almost two decades I've been at the coalition, but very, very excited um to talk about this because uh this is an issue that was not um even in my universe. It was not a speck in the in the sky of my universe of doing domestic violence services for almost the first 15 years of my work. And now we'll talk to you today about how some of the ways in which it really has transformed how we think about domestic violence services. So um it's what we do here in Ohio, and the longer I do it, the more significant I think that this is to the entire field of people who work with victims of violence.

SPEAKER_01 2:54

Right on, Casey. Yeah, thanks. So first, thank you for having us. Really excited to share here today about our work. Um my name is Casey Holderbaum, and I am the Health and Disability Project Coordinator with the Ohio Domestic Violence Network. So I get to work with Rachel at the intersection of domestic violence and brain injury. Um and my background comes from direct victim services. So, you know, like Rachel mentioned, it was a brain injury and partner-inflicted brain injury was largely a missing piece. Um, I can't tell you how many survivors we had that, you know, would come into shelter or we would talk over hotline or any other capacity in which we saw survivors and those incidences of injuries and assaults to the head, neck, and face and how prevalent those were, but we weren't having those conversations that we're having today about what are those impacts? How can we make services better and what does that really mean for a survivor who's navigating those injuries and those complexities of brain injuries? So um yeah, my background comes from direct service and my focus on on partner-inflicted brain injury um comes from yeah, years of direct service and then getting to work with Rachel. And I uh back in one of my direct service roles, I had a really eye-opening experience with a survivor who um was really special to me. And she came back from an appointment and she was so excited, and Miss Casey, Miss Casey, Miss Casey, yeah. She said, I have a brain injury. I said, Oh, you know, I didn't have the tools, the knowledge, the language to be able to respond to that in the ways that I do now. So I just said, What are we gonna do about that? And she just looked at me right in the eye and she said, I'm not stupid. They told me I was stupid, my brain has been hurt. And it was so empowering for her to get that information. And it truly like I reflect on that often and how much that really swayed and influenced where I am today, and just that conversation was so meaningful. So um that particular person that I I was able to work with years ago has definitely um helped me, helped me focus on partner-in afflicted brain injury. So um, yeah, that's a little bit about me.

SPEAKER_02 5:04

Thanks for sharing that story, Casey. I'll I'll stay with you and just kind of ask, I think, um, a question that when I mention brain injury, even when I'm talking with friends or family, I think, you know, when a lot of people hear brain injury, they often think about sports or accidents. What does brain injury look like in the context of intimate partner violence?

SPEAKER_01 5:30

Oh gosh, it looks so different. It looks so different. Um the it looks different for a lot of reasons. Um it looks different because in the context of domestic or sexual violence, um, these injuries and these assaults are one, not what they signed up for. You're not getting a helmet before an assault to protect your head from the impacts that it's going to leave. Um another difference for domestic and sexual violence is that these assaults are often inflicted by somebody that you know, somebody that there is some piece of love, commitment, and you know, care for in some way. It may not be the love and care that that you and I look to, but it in some capacity it is filling that that role. So there's a there's a connection piece there, and this is being inflicted by somebody that they they know and they care about. So there's a trauma piece there. And so what does that look like when somebody who says they love you is causing you such severe harm? Um and so it it's traumatic in that way, and it's also consecutive. So we know that in in sports, when you get hit and you go down and there's a head injury or there's a suspected concussion, there's a whole protocol that has to go in before you can return to play. And that doesn't, that same uh protocol doesn't translate into parenting, work, making dinner, caring for yourself, caring for your children. So there's a lot of differences there. And also we know with domestic and sexual violence that unfortunately we're looking at more than just traumatic impacts to the head and the brain. We're also looking at incidences of strangulation, which is very common. So often it looks different because these things are happening at the same time. Football players aren't getting tackled to the ground and then strangled afterwards. So, what does it look like for a survivor who's experiencing these concurrent injuries and then has to get right back up and take care of their job, their home, theirselves, their partner, and their children? Um so these cases are really complex and they do look a lot different than sports or military, and and we don't really have all of the studies and the information about what does that look like for women's brains.

SPEAKER_00 7:44

And is it okay for me to add just one little piece of that? I think you did get in there. Great, great job talking about that case. I think the other thing about that is often different with domestic violence and sexual violence when you look at military, you look at sports, even though we know one of the main causes of concussions is people have accidents. People, you know, slip on the ice and people, you know, are jogging and fall and those kind of things. Um, in case you talked a little bit about the intentionality, but also because this this violence often occurs in privates, there's nobody around to witness it. When we think about often in sports, there are almost always people watching. I know I have three kids in something in Ohio. When you register any kid for any type of rec sports or, you know, five-year-old soccer, you get a fact sheet about concussion because guess what? There are people who watch their kids play sports. You know, there are people who watch there almost always is an audience, or you have team members, or you have someone else around. And the same thing that is true, you know, in in the military. And we've actually done a lot of, you know, for those of us who might be in this field, a lot of like in in concussion and and brain injury, a lot of almost like bystander education and intervention. So when I'm going to watch my kid, my daughter, play volleyball, I'm aware of what that is. Um, that's something that is also very different and unique about um about domestic violence and sexual violence, is it occurs without an audience. There is also a different level of safety concerns when we're disclosing, there's a different level of stigma around that. And I mean, I think one of the things that I always reflect on um there's a different level of blame associated with that. So, I mean, I always say nobody has uh, you know, when we see famous people or, you know, people you might know who are playing sports and get a concussion, you know, nobody is like, well, you deserve to have that concussion because you knew I mean you really played this sport that was so dangerous that they even gave you a helmet. Right. You signed up for the military and you had a helmet because you knew that this was something that could happen to you. Nobody sees a football player in a concussion, like, oh well, well, that was what they signed up for. So I think that there's also a whole different host of considerations around how brain injuries even get identified because you don't have a parent or a fan who can be like, hey, look at what just happened. You also have a multiple, multiple considerations and challenges and barriers to telling someone about that concussion. And I think that, you know, one of the biggest issues we see in this space when working with brain injury providers who are like, no, domestic violence, you know, we don't get that many calls from people who have domestic violence. They don't really reach out to us. It's because it has never been, I mean, you're obviously, if you've ever, you're not gonna reach out about diabetes if you don't know you have it. So um I think that there's that. How do we even, we don't have a coach, we don't have a player, we don't have the sideline staff, we don't have those people, those bystanders um in the moment when these things happen that can provide some of that intervention, that can provide some of that education, that could even say, hey, whoa, something happened to my kid or something happened. I'm gonna watch out for those kind of things. So I think that that's another significant difference.

SPEAKER_02 11:08

There's no sports medicine team doc standing on the sidelines. No, that's no. I never even thought about that. That's that's so true, Rachel.

SPEAKER_00 11:17

Um, and I really see in the NFL, even when there is, and we think NFL players are trained to take tackles, like they know they're gonna be tackled, they practice being tackled in ways that are safe. They have a helmet on, they get immediate medical attention and still can have long-term problems. Like, even with all of that, they have access to all of the rehabilitation. They have every incentive, they have the most advanced science, and that can still be things that take people out of their career for weeks or for months and potentially have long-term consequences later on in their lives.

SPEAKER_02 11:55

Absolutely. That was super helpful, just kind of grounding for us as we're thinking about this in a little bit different a perspective than how maybe most people think about brain injury. Rachel, can you briefly just explain to us what is a brain injury and how does it impact survivors? What symptoms should advocates and survivors be paying attention to? What is often missed? Just what is it?

SPEAKER_00 12:21

Yeah, thank you for that. And I think that that's a really important, just important question. First of all, when we hear the term, some of the times of us have here brain injury, traumatic brain injury, concussions, um, a TBI or a concussion, first of all, are two words for the same thing. Um, just those terms can be used interchangeably. But it really is when there's some kind of bump blow or jolt to the head or body that disrupts, disrupts your normal brain function. So it means that your brain is not working correctly in the way your brain usually works. Um, when we think about the other types, and this is, you know, Casey discussed this is one of the unique pieces of brain injury, partner-afflicted brain injury and brain injury and domestic and sexual violence. You also have other types of brain injuries, like strangulation, where people's brains are deprived of oxygen, which is actually called a hypoxiconoxic brain injury. So hypoxia is when oxygen is deprived to the brain. Um, anoxia is when oxygen is totally cut off to the brain. So, another example of that type of brain injury, if you, if anybody's ever known anybody who's had a stroke, for example, is when part of your brain doesn't get oxygen. Um, we know when we think about that again, and it's that combination that we often see survivors of violence maybe experiencing both anoxic and hypoxic brain injuries as well as traumatic brain injuries in a single abusive event. We often see those abusive events happening again and again. Um, and think it is also just really important to um to highlight a couple of other things. When we talk about the hypoxic andoxic injuries, of which people often think of strangulation, there also are a lot of other different ways in which domestic violence survivors are hurt that can deprive their brain of oxygen. People can be put in chokeholds, people can be suffocated, have something put over their mouth or nose, people can be sat on. So, really thinking about when we're talking, sometimes when we're talking to survivors, sometimes when we're listening to survivors, we're listening to all the different types of violence that can just make it hard to breathe for someone or that can interfere with our blood flow to the brain, which is another way in which um our brain can get can can lose oxygen. We also want to be aware of whiplash type when we think about traumatic burdeners or concussions, like if people are shaken severely, um if people are, you know, kind of pushed up against something. I think that that's something that really um one of the ways in which our work has evolved over the almost decade we've been doing this work is we talked a lot about head injuries at the beginning, but really thinking about those head, neck, and facial injuries and strangulation, you can. We know often when people are strangled, they are also, you know, hit or hurt, you know, punched in the head, have something done to their head. But you can have, you know, a brain injury when you think about like a whiplash or a severe shaking, and your head can actually not be hurt or you can be strangled in a way. I mean, sometimes these aren't injuries that are directed at our head. So we've been really been very intentional about updating our language to talk about head, neck, and facial injuries, because also one of the things that we see is facial injuries are a very, very common reason in which domestic violence survivors access um particularly emergency medical services. But when asking about head injuries, like your face isn't really your head. Um, so that's kind of what a brain injury is. And then when we look at what some of those was that, is that was there a second part to that question? Is it worth talking about like some of those signs and symptoms yet?

SPEAKER_02 15:43

Or yeah, side effects, symptoms, like what how would a brain injury show up for a survivor?

SPEAKER_00 15:49

Well, and this is one of the things that Casey and I hear very clearly whenever we because we've developed very, very deep relationships in the brain injury world. Um, uh a whole universe, as I said, that we didn't even know existed um before we started this work. But something we hear very clearly from the brain injury community, and what they say all the time is that if you've seen one brain injury, you've seen one brain injury. Um, our brain is very complex and complicated and literally has everything to do with everything our body does from regulating our breathing and our digestion, things we don't even notice, to our very, very advanced um figuring out how to put on a podcast and developing IAI and sending people to the moon and everything in between. Our brain controls our movement, our brain controls our thought processes, our brain is our personality is in our brain and our sensory, kind of our sensory experiences. So it can, I think that that's one of the reasons why it brain injury has gone um, you know, very kind of unnoticed and unidentified, is there isn't like, and we know that's true with domestic violence, right? There isn't like one way it looks. And if you see this, this means it's domestic violence. But when we think about buckets of signs and symptoms, generally they can be put in kind of there's physical, there's a like a physical impact where we can see things headaches, we see problems with balance or with kind of motor coordination. Many of us, I want some of you, most people's connections that they have with brain injuries or concussions is generally through sports. So if any of you, you know, watch football, watch hockey, there have been very, very public cases of football players getting hit and they're stumbling around after they're hit, or you know, they're shaking their head, or those kind of things where it looks obvious some of those things are happening. People can have um be dizzy, there can be sleep problems related to that. Um, sensitivity, sensory sensitivity is a really big deal. So you're sensitive to lighter noise. So there can be physical components of brain injury. Important to know that sometimes those signs and symptoms can appear right away, sometimes they can be delayed. That happens all the time in sports where people pass concussion protocols right after they take, take uh tackles, and then they fail those very same concussion protocols just a couple of days later. We also see emotional, we think about kind of some of that emotional and behavioral piece with, you know, worries and fears and kind of the lack of ability to control my emotion, um, and some of those um those kind of issues that kind of like enhanced um sensitivity to emotion, or people, you know, busting out crying and they're not quite sure why, or um, kind of what that looks like. And then there's also some of the cognitive pieces. So when we think about thinking, our brain, again, is what helps us think, it's what helps us make decisions, it's what helps us communicate. It controls, you know, my ability to kind of I'm I'm I'm talking to you all and I'm thinking about my next thought and I'm organizing that. That's all of my brain doing all of those different types of things. So we can see people, a lot of people talk about, you know, after they maybe have um had a potential brain injury, they feel like they're in a fog. Or I don't know how many survivors that I've talked to in in my career um who say, I just I need to think, but I just can't think. Um, that they have problems with attention or concentration. Um, they feel kind of slowed down or foggy and groggy. They have problems with shorter long-term memory, they have problems taking clear thinking clearly. Um, so really thinking about that, and you know, we see memory problems being one of the one of the the biggest issues and the biggest challenges. Um finally there are issues related to sleep. And I think that, you know, getting back to anybody who works in a shelter environment knows that that um that sleep can be a huge issue. I know Casey talked about how important it is to maintain our our trauma-informed framework when we do this work, because getting intentionally assaulted in the head by your partner is very traumatic, and that can absolutely interfere with sleep. But sometimes we see people sleeping more than usual, sleeping less than usual, having a hard time waking up, those kind of things. So some of those sleep disturbances can be very common.

SPEAKER_02 20:00

Thanks so much, Rachel. That's so fascinating. And I think back to when I was working as an advocate and how helpful it would have been to have that information of just some of the impacts, you know, if the majority of survivors are experiencing something like this and could have been impacted in those different ways, just how helpful for me it might have been to kind of reframe my work and also, you know, slow down. And I think it does come back to trauma-informed care, but it's you know, trauma on a physiology, uh, physiological level as well.

SPEAKER_00 20:34

So we like to call it what we're trying, what Casey and I are trying to sell is the whole kind of I don't want to think as you know, as we learn more, we know more, and our understandings deepen and sometimes change a little bit. But we're really trying to talk with our programs here across the state really about brain injury aware trauma-informed care. It's kind of that enhancement to just as we think about how we understand trauma, bringing brain injury, we're not taking the trauma away, we're not replacing it, but just enhancing it in and recognizing how common brain injury is also. And we need to work that that knowledge and that awareness into those trauma-informed frameworks.

SPEAKER_02 21:10

Because it really is impacting all of the things one needs to be able to do to survive violence and deal with systems that you come into contact with as a survivor of violence. So, yeah, I really appreciate that. I'll stay with you, Rachel, for this next question. Um, and it's really kind of coming back to something you were bringing up earlier around strangulation, how that can cause brain injury, which maybe is not something everyone knows. Can you talk a little bit about how common the experience of strangulation is for survivors and maybe what is its connection around future lethality and just maybe why it's important for advocates and healthcare workers to be aware of that particular kind of brain injury?

SPEAKER_00 21:58

Absolutely. And I think in that it must Violence space, particularly. And I'll I'll talk from that lens because that's that's that's that's my lens and where where my work has been. I mean, we've been talking about strangulation for a very, very long time. Um, and about just kind of recognizing we've been talking about, you know, the strangulation as a tactic of coercive control. We think about strangulation being one of those that's absolutely terrifying. Um, I hope none of you or few of you have ever had the experience where you haven't been able to breathe. But it is very little that can uh freak your body out more because, you know, of course, oxygen is just the key to our survival. Um we've talked a lot about like kind of the immediate impacts of strangulation, about how it can be very, very dangerous. That a lot of we, you know, we know that a lot of times strangulation might not leave a lot of external marks or bruises. It might not look from the outside, it might not look like something that bad happened, but a lot of the damage can happen internally. And we've talked about kind of the acute response and and what that means. Uh, but we have not really thought about the ways in which strangulation, I would again take this opportunity to think, you know, whenever we're talking about strangulation, we're also talking about concussion and TBI because most people who have been strangled, even in an assault where they've been strangled with our research, hardly anybody has been strangled, did not also have a TBI in that same assault. So they might have been punched in the face and then they were strangled, or they were, you know, pushed down the stairs and then they were strangled, or their head was thrown, they were their head was banged against the wall. That's a concussion, and then they were strangled. So that duel on my brain is literally getting, you know, bruised and it's getting deprived of oxygen. Um, but really thinking about what the long-term impacts of that are in our research. When we talked to individuals who were accessing domestic violence programs across Ohio, 83% of survivors said that they had been choked or strangled. We don't have really good. And in remember, when we said choked or strangled, it's not just choking or strangulation. Unfortunately, I've worked with survivors who have been waterboarded. When we think about brain injury, it's any, it's I think when we think about even how we're talking about that. Um, there was a, you know, like strangulation is not usually what most survivors call what happened to them. Right. Um, a lot of survivors we hear say that they were choked out or blacked out, or you know, he put his hands on my neck, um, those kind of things. A lot of times that word strangulation isn't used. And it's also important for us as advocates to, to, to sometimes it's digging a little different, deeper, and sometimes it's listening a little deeper, where, you know, if somebody is it talks to us about, you know, being sat on in a way that they passed out. I mean, that is not strangulation in any way, shape, or form, still can cause a hypoxicanoxic brain injury that we were talking about earlier. Um, but it is very, very common, and I think particularly we don't have good like um population-based data on this, but when we think about we often know that people who approach some kind of service for their experiences with violence abuse, be it they reach out to crime victim services, a rape crisis center, a domestic violence program, they get a protection order, they call the police, um, you know, they they go get medical care for um their violence. Those are often people who have experienced the most severe violence because a lot of times so it very, very, very likely. Uh one of the things that we just recently did in Ohio, um, we had a we did commute a needs assessment for one of our state administrators, and we had 400 and 40 and some people, I guess, in our survey, including people who accessed services and some people who did not access services, and 79% of them reported being physically assaulted. Um of those 79%, so it was was 346, I think, survivors reported being physically assaulted. Of those, 97% of them reported that that violence included head necrofacial injuries or strangulation. So when we think about when people are being physically assaulted, it is highly, highly likely if we have a relationship that has turned physically abusive, highly, highly likely one of those tactics is being hit or hurt in the head. Um, so and we just the more that we learn about strangulation when talking about, you know, the connection to lethality, just people who we have a lot still left to learn about people who use violence and why people who use violence and who are the really, really dangerous people and what makes it, you know, you know, what that is. But we the research is starting to emerge that there is a difference between someone's strangulation is a very personal, a very intimate crime. Um, it is something that a lot of people, I mean, it just is it, it, it, it, people who do that to others is just are are really, really dangerous. And I think that that's one of the things that we really are encouraging anybody who has had experiences of head, neck, or facial injuries or been strangled or had something done to them, made them hard to breathe, have to, we have to be safety pointing with those survivors around some of the other lethality factors that we know. We need to be asking if their partner has access to firearms, we need to be thinking about separation and all of those things because we know that while people do die by strangulation, um the vast majority, at least in Ohio, of our fatalities that we had last year, 87% of them involved firearms. So if you have somebody who has a strangulation history and has access to a firearm or could get access to a firearm, that's when it's really dangerous.

SPEAKER_02 27:38

That's super helpful for breaking that down because I I had known that stat, but I I think it's helpful for folks to hear, you know, really it's about a larger um likelihood of other forms of violence, particularly when there's a dangerous weapon around. Um, I'm gonna come back to you, Casey, now, um, and just kind of ask you a little bit. I know, you know, I've learned from you all in Ohio that experiences of brain injury in an intimate partner violence situations often are overlapping or cause folks to have ongoing mental health, um, mental health concerns, and also maybe are overlapping with folks who are using substances more often or less safely than they want to be, um, or maybe they're even experiencing substance use coercion or mental health coercion. And I'm just um hoping maybe you can talk a little bit about those intersections and really like what is the important takeaway for advocates or healthcare workers to kind of better understand that and really how they can support those folks who have kind of overlapping things a part of their experience.

SPEAKER_01 28:57

Yeah, so I do have a couple of thoughts about it, and and I I know there there's so much to say about the intersections of domestic violence, violence, brain injury, substance use, mental health, all of these things come together just to create this really complex, um, really complex ball of impacting everything that we do. And so what's also important to note is like as service providers, maybe we want to understand like where are these things coming from and what caused this, or maybe the survivor wants to understand what's causing this. But a lot of the time we can't really parse out like, is this a mental health issue? Is this stemming from brain injury? Is this just because of the way that we are and what we're exposed to on a day-to-day basis? So trying to understand, you know, what is this exact cause can get a little convoluted. It gets a little messy. Um, so I think what's important too with mental health and brain injury is a lot of those signs and symptoms overlap. So when we're talking about, you know, lack of attention or sensory issues or memory issues or communication um problems when it comes to substance use and mental health coercion, I think that's what you asked. There are so many dynamics in that that are really complex. For some survivors, it's much safer to use substances than it is to have their lives, you know, be be harmed. And so that's something that we talk a lot about too, is maybe for someone returning home, um, returning back to their abuser, which we know is happen, we know happens a lot. Um, but maybe for that person, we talk about safety planning. And, you know, while um abstaining from substances might be the goal, um, in some situations, it might be safer to have some extra and other plans to learn how to navigate those situations.

SPEAKER_00 30:41

Yeah, I think, I mean, I think one thing is I'm listening to you, Casey. Maybe this is connects back to how we were, you know, talking at the beginning about, you know, one of the things that what is really unique about this whole issue of partner afflicted brain injury, I think it also is is that there is always so much going on. Um, when we look at sports, when we look at the military, often when people have brain injury concussions, like that is the thing going on. When we have a professional athlete that has had a concussion, they are working on their concussion. We have so many of our concerns around safety, around housing, around relationships, around court proceedings. And I think that that's one of the things that sometimes stumps some of my uh brain injury colleagues who are they're like, oh, we, you know, want to work on this brain injury project with domestic violence programs, and they get all excited about brain injury, and we talk to survivors who probably have had a pretty severe, I mean, I mean, particularly like a pretty, pretty significant brain injury. And it they're like, mm-mm. Like not in a bad way, but like I'm gonna, I've got all these other things on my plate. Right. This is not even on my radar and my list of 10 most important things. This is like not even in the top five.

SPEAKER_02 31:48

I'm trying to keep my school, I'm trying to keep my housing, I'm trying to make sure my kids are super if I made this great decision.

SPEAKER_00 31:54

So I think that that's I always talk about brain injury being a really important piece of the puzzle that we have been missing, but the puzzle continues to be there. Um and we have to understand that complexity. But I think when we talk about, you know, so much of the mental health coercion we hear from survivors say that um, and most survivors, I think, again, because remember how we were talking earlier, there's there's nobody to see, there's not any wider awareness. You never see, you know, any anybody, you know, talking about concussions are come from violence. You know, people just don't even consider that. And I mean, I I myself was in the field for almost 15 years, literally leaving and breathing, living and breathing domestic violence and trauma. And it never once occurred to me, even though I talked to people who had been hit in the head all the time. After the fact, it doesn't seem like that big of a leap that, of course, that the violence you have been sharing with me since literally the week I started in shelter over 20-some years ago could cause a brain injury. But we have not made that connection. So a lot of survivors, we know one of those tactics of abuse is, you know, really teaching survivors to not trust themselves, to not trust their perceptions, really telling survivors that they're crazy or that they're stupid. And I think, you know, as Casey talked about, that's you know, the story with her survivor that she worked with when when you know she was in shelter, about how, like, I mean, there are times when survivors are really they're having a harder time reading, they're having a hard time remembering to do what they used to do, they're having a harder time at work than they used to. And maybe they are going to get medical care and nobody's asking about it, but they themselves are thinking, well, this must be mental health, this must be trauma. Obviously, you know, we've been talking a lot about uh for for you know decades about trauma and its impacts. So I think it's one of those things it can really be reinforced. Survivors themselves are often calling potential brain injury symptoms, um, mental health symptoms. And you know, even I think we we see that in the medical system, you know, kind of so consistently that once once we talk about, you know, domestic violence, like, okay, the medical system's job and domestic violence is like if there's an injury or a broken blow bone or something that we need to fix, but then all the rest of that is in the behavioral health space. Um, so I think that we really see that as one of the and as you know, Casey talked about, lots of these signs and symptoms overlap. Um, but I think one of the things that we're really working, you know, with programs and in and with um, you know, with advocates and with survivors themselves to really understand, you know, it's less about and I mean there might be a point where sometimes this this really matters, but maybe it's a little less about the the goal is not to identify, you know, is 40% of your memory problems brain injury, and 30% is trauma, and 20% is substance use, and 10% is like some people just don't have as great memories. But like you've got to remember to do things, like we gotta, in order to be able to access services, in order to be able to be safe, in order for you to be able to, you know, move on your your your journey towards safety. Like, so how do we help you? You know, how do we support you? And what kind of strategies can we use? What kind of strategies can you use? How can we help you remember these very important things? So, um, but I think it's I mean, I think again, that's one of the other very, very unique issues with this whole um with this whole part of afflicted brain injury. I call it it's a three-legged stool of course of control and those abuse dynamics, psychological trauma and then neurological trauma through brain injury, and you really you really can't get get getting a brain injury, especially intentionally, from somebody who also tells you that they love you is very, very traumatic. Um and absolutely has a mental health impact, can have a mental health impact and can absolutely cause some of those trauma symptoms and trauma responses and might need behavioral health support. We're never gonna be able, like partner-afflicted brain injury is inherently traumatic. So those are not, and I think that that's what you know, moving forward, you know, in the future is really understanding what does that, you know, trauma-based treatment, what does mental health services and supports, how do those potentially maybe, you know, need to look different if I'm also a person who um might have severe cognitive impairments due to my brain injury. Um, but also might maybe really struggle with my mental health.

SPEAKER_02 36:10

Mm-hmm. Mm-hmm. And that kind of brings me really well to our next question, thinking about all of those impacts is, you know, really, so what how can we make sure that anti-violence advocacy programs, DV shelters, rape crisis programs, how can we make sure that they're really um set up well to support survivors who who have the experience of brain injury? And I'd be curious to hear from both of you on this one.

SPEAKER_00 36:39

Casey, can I say something first? Um and then I promise I will. Um, I I I want to start with hope. And I want to really say I think that we in the domestic violence and you know, sexual violence and gender-based violence field are uniquely equipped to handle this. Because I think when we think about our trauma-informed services and our trauma-informed frameworks, that there are a lot of those tools and a lot of those changes and a lot of those adjustments that we have made to our services that can very, very, very effectively support um domestic violence survivors who have experienced brain injuries. Um, we do know that there are, you know, when we think about all of those ways that we have always worked, we say one in one brain injury is a one-brain injury. We use survivor-defined services. We know we don't work with every survivor the same. Um, I think that the other, our understanding of trauma, I really want us to really understand. This is why we've really been pushing this concept of enhancing our trauma-informed approaches with brain injury awareness, this brain injury aware of trauma-informed care, because we have never approached trauma like in a framework. Oh, what do we do with trauma? We identify if somebody has a trauma history, and then we send them to a therapist, and then they fix their trauma, and then they come back to us. That's not what it, and that's like, I think that's one other thing, and maybe you know, you asked an earlier question about brain injury. But I think that's one other thing we have to understand about brain injury as a medical condition. It's not like this thing you identify, and then you go to the doctor, and then they give you a shot, or you and then they fix it, and then it's better. It is a complex chronic condition that has varying symptoms that takes different times of healing, that looks different for different people. But what we did in our programs is we are we don't expect people to come in and you know, all we've got to do is identify the trauma, and then we send it off to someone else to fix that trauma stuff, and then they come back to us. That's not how we do it. We think about how does that impact how they work with us, how does that impact how we have to set up our services. Yes, and I think that that's I think that so and I think we know how to do that. And I think that that's something that's very, and yes, there is absolutely a role for support from you know, providers. We're not gonna diagnose anybody with a brain injury because it really is a medical condition that 99% of us in this field, myself included, do not have the expertise to to treat. Like I don't diagnose brain injuries, I don't treat them, I don't know what that is, I don't know what that looks like. That's not my role. But but we think we also, I think where the hope is in this is we also know as well, trauma can continue to impact people throughout their lives. We know people heal and recover from trauma, and after experiencing really traumatic events, people do go on to live their lives are different, but they go on to live fulfilling lives and they go on to live um, you know, satisfying lives. And when we think about how we can help people, but one of the things that we do is we help people understand trauma, that role of psychoeducation. We help people become aware of their triggers, we help people develop strategies to address their triggers, we help people understand all of those things in those contexts. So I think that, but I think it's really, very much starts with awareness. But I think um we are actually much better equipped than we than maybe many of us think we are. Um, that you do have some of those tools. And I would love, you know, Casey, like thinking about that. Like you do have some of those tools. And yes, we have to learn some new information, um, but but I think that there's a lot of ways in which we really have um kind of the the the the the winded our backs a little bit on this issue.

SPEAKER_01 40:18

And I think when it comes to like advocacy, domestic violence, and sexual violence advocates, like the you know, when when I got into this work, I didn't know brain injury was a thing. I didn't know that I'd be signing up to support brain injury survivors. And it's a it's a beautiful thing that I'm able to do that now. But I think it's one of those kind of scary things that's like, oh, well, we never learned about that. We've never talked about that before. What is that gonna open up for the survivor? How do I even talk about that if I'm not a doctor? But we can have common language around when our brain has been or when our head has been hurt in this way, or whenever we get injured and there's an impact to our head, we know that there can be consequences. We know that there can be short or long-term impacts to our behavior, our personality, how we treat others, our memory, our cognition. And so even just having that understanding about what are those experiences, um, we can start to have those conversations in a way that doesn't feel overwhelming to us as advocates and that doesn't feel overwhelming to survivors. So, my hope is that we can maybe start there as just kind of that conversation piece. Um and then supporting brain injury or supporting survivors with brain injury is kind of similar to how we support survivors in any other capacity. We want to understand those unique experiences, we want to understand those unique situations and complexities that this person is bringing into our services with us, and we want to be able to tailor our services so that it's successful for them. Um so when it comes specifically to brain injury, uh, we hear a lot in the brain injury world about accommodations or about compensatory strategies. We know that accommodations are things that we can do for others, um, ways that we can change our own services to make it more accessible for someone else. We know that compensatory strategies are strategies that we can take on our own. So, for example, an accommodation could be, you know, making sure that we provide calendars to every survivor that comes into our shelter services. A compensatory strategy would be making sure that that person knows how to use that calendar, making sure that they have the tools and resources to be able to fill out that calendar, have the reminders to look at that calendar. So it's kind of just this all-around piece, right? Like we can provide these things, but how are we also empowering and uplifting those who are accessing services to be able to navigate those things on their own? Um, as Rachel said, being in domestic violence services, it's just such a beautiful, privileged space that we get to be in to hear these stories, work and walk alongside behind survivors, let them lead, but really understanding um what are they what are they dealing with? And so when we're walking alongside survivors, we can understand that they might need some special accommodations while they're in our services, but we also know that the other services might not act like that. And so while we can hold hands and provide these really comfort things, we also have to set up the expectations that other services might not be as accommodating. So, what can we do for ourselves? How can we help build up your strategies so that when you go into these other spaces that aren't so um trauma informed, that you can still be successful, can still navigate that that service or that area and be able to come home, decompress and and get the support you need from our domestic violence shelter or or services. So I think for Yeah. So I think for advocates, like it really is building expectations for what are these other spaces going to need? What are they going to look like, feel like? Um, what do you need to do so that you're successful in those areas? And then for us in our own agencies, how are we adjusting our environments? Um, our you know, of kind of a low-hanging fruit, I guess, is overhead lighting. Overhead fluorescent lighting can just drain you. And so, what can we do as an agency to make things just a little bit easier for individuals coming into our services? We can look at our environmental, um, we can look at our environment in our programs, we can look at the sensory um opportunities. Are we providing things to um get out some of that nervous energy or to have a good distraction? Are we setting up our services that folks have time? Are we communicating things in multiple ways? Are we handing them a packet and saying, fill out this intake and return it to me? Well, we know that brain injury can impact how somebody reads, processes information.

SPEAKER_02 45:00

Excellent. Thanks so much, Casey. I love those really specific strategies and things to think about for advocates. Um, kind of thinking more, um, my next two questions I want to get into are kind of the same questions about healthcare workers and health systems and you know, what is important for them to be thinking about, and you know, what are um what are strategies for them to be able to better support survivors? And I'm I'm definitely thinking of, you know, stories I've learned from you, Rachel, um, of it being diagnosed as a different health condition, or even worse, not considered a health condition at all, and you know, overlooked as quote unquote non-compliance or you know, other kind of harmful, harmful labels for a patient. And so, yeah, just curious kind of the same question for for healthcare workers and systems. How can how can we be better on that end for for those survivors with that experience?

SPEAKER_00 45:59

Well, I mean, I think first of all, it is just an awareness that domestic violence and violence causes brain injuries. All different types of violence causes brain injuries. And when you are working with people who have experienced violence, um, bring concussion into whether it's a differential diagnosis, whether it's, you know, you know, whether people need to have a concussion evaluation, uh, you know, an ACE evaluation or the Rivermead post, you know, concussion symptom questionnaire, kind of what that is. It is still, I think, somewhat, I don't know, I want to sound judgmental, but like I have worked with domestic violence remembers who have had their jaws broken and have had even when having severe injuries to the head, neck, and face, have never been talked to about concussions, never been provided any information about concussions, never been assessed for a concussion. So I think really one of those things is, you know, what I hope is, you know, as I was talking about earlier, I think that often in the healthcare space, as soon as people hear domestic violence, they think, oop, behavioral health. I think the other thing we need to start thinking is oop, can possible concussion. Um, particularly if they are coming into your services. And with that, and I mean, and particularly if they're coming into your services literally for head injuries or they have facial injuries, or they have, I mean, just that. And I am not a healthcare provider, so I don't know what kind of protocols you have. If somebody has a car accident and has severe head injuries, like you do that stuff, you know what I mean? So I think it is really just thinking about that piece. And healthcare providers have a lot to contribute because, again, I think that that's one of our challenges that we've had on this work is we do well, we're doing a lot of awareness building among, you know, crime victim services and places like that, but we're not asking people to diagnose concussions at all because that's not our job. But then we get them to providers and trying to figure out who the right provider is, you know, also recognizing that concussions and brain injuries are really complex and complicated. A lot of the ways, there's no like one way you treat them. A lot of times it is about symptom management. But I do think that that whole role of symptom management, you know, not everything can be treated medically, but there are when people are having severe sleep disturbances, like there are ways that your doctor can help with that. If people are dizzy, um, you know, whenever they get up, that's something we talk to a doctor about. So I really think just that awareness, if we have anybody particularly, you know, anybody who's coming in, particularly for any kind of physical violence or assault or whatever that is, thinking about including some type of concussion assessment or evaluation, kind of a neurological evaluation is a really, really important component, um, just as kind of a standard of care for working for this population.

SPEAKER_02 48:48

That's so important, Rachel. Thank you. Um I think my last question here is just thinking about kind of zooming out a little bit. Is there a systems change or a structural change that we should be advocating for, either, you know, to support folks who have the experience of brain injury or to prevent brain injury? Um, is there anything at the systemic or structural level that you are seeing momentum around to address these intersections?

SPEAKER_00 49:22

Well, I guess I I I mean, I think one of the things is just even thinking about the fact that I, you know, again, even somebody who has been very, very deep in the domestic violence field for my entire career had no awareness of this issue for over a decade. Um, the fact that we're having this podcast, the fact that I was in um Washington, D.C. at a congressional briefing on the intersection of intimate partner violence and brain injury um just a couple of months ago, that was sponsored by some of the leading brain injury organizations, include the, including the congressional uh brain injury task force. I think is really encouraging and promising. I think that when we talk about, and I think it's, you know, I think that we will get to the point someday where we think about the systemic or structural changes, but I think it there's so much more that we still need to know about and understand about this issue. But we do not address things that we aren't even aware of, you know, and before things have to be named, we have to have an understanding. And I remember, you know, when we first started this research and we, you know, we got our our first data back, we went out to these programs, and we were like, holy moly, like we don't have we didn't have any idea what to do. We didn't have any idea what to do, but we didn't even know that we had to do something about this, right? So I think that that is, you know, we have to create the awareness first that this is even something that needs to be addressed. And I think that it has been, it is a very, you know, what we have learned in our initial research about bringing brain injury uh into the puzzle, into this already very complex and complicated reality, is not only the power of how this can help shift the attitudes of individuals who work with domestic violence survivors, as you said, Kate, where often it can be frustrating. These people, like they don't even tell us what's going on and they can't keep their train of thought, and they don't show up for appointments, and they can't get along with anybody. And, you know, we had this whole meeting and they're acting like we didn't even talk about anything. It has given us a different awareness and understanding of what we're seeing and help us really think about how we can support survivors in a different way. I also think that there is a tremendous power. You know, there are a lot of things that domestic violence survivors need that are very structural, that are very big, that little me and my little program, I'm not gonna fix the affordable housing crisis, you know, I'm not gonna fix the, you know, the like a lot of the barriers that domestic violence survivors have, particularly related to social determinants of health, are really problems for like our entire society. They're not unique to domestic violence survivors. But guess what? I can do. I can, when somebody calls me on the hotline and I ask what's going on, and they say, I need to, you know, get a protection order because my my husband slammed my head into the wall. I can say, I can say, tell me a little bit more about that experience. Did you know that when those kind of things happen, it could cause a concussion or brain injury? Are you noticing anything different about yourself? Are you having any of these physical problems? And some of that, again, that psychoeducation, we know the power of psychoeducation around trauma. We know the power of psychoeducation around domestic violence, which is really how the whole domestic violence movement is founded. There is a lot of research around the value of psychoeducation in behavioral health, people understanding themselves and their health. And when we talk about health literacy, I think that's another piece is having people in the health literacy space, understanding your health conditions, can play an enormous role in people improving their health. And that is something we can do. That is something that all of us have the power and the ability. And then from a systems level, like I said, starting to thinking about that integration of brain injury awareness and enhancing our trauma-informed services. I think that's the other thing I want. I know that programs out there and everybody out there already has too much work to do and too many things going on. And this is not, we are not telling everybody we've got to throw in everything we know and learn this whole new framework, and we gotta start all over, and you guys have to be in training. Like nobody is really thinking about how are we adjusting and enhancing our work and how are we doing the same work that we've done in very intentional ways. Um, but I think that that is, I think that that's I've uh one of the things I always talk about is the longer I get in this work, the more I'm like, I think everything we do should be evaluated on doability. Like, how realistic is us is it for us to do this? And I think sometimes it is. It's that providing people with information. We have a lot of tools. We have psychoeducational tools that are available for free. We have brain injury awareness posters that just say things like, have you been hit or hurt in the head, neck, and face? That could cause a brain injury. Here's some more information. Please talk to us about it. Those are things that don't have any costs that are really, really easy to start this conversation. Um, I think the other piece, you know, Casey talking about the accommodations that you talked about, working with survivors on strategies, those are things that don't cost money. Right. We're not asking people to buy a whole bunch of things. We're asking, just thinking about a survivor. I always say my story that I remember is when I worked in shelter, the number of survivors who would come back to shelter. This was back before, you know, everybody had cell phones and everything, it would get routinely lost coming back to shelter. And it was very, very frustrating with for them. Um, very, very it reinforced all that thing that their abusers had told them that they're stupid and they would come back and they would come back in shelter. They'd be like, I've been living here for six freaking weeks. How come I still can't get here? We know spatial awareness is one of the things that our brain is in charge of. And think about how if we were able to normalize that and we were, and then again, so it wasn't just you know getting lost, it was getting lost, and I'm stupid, and maybe this was a bad decision, and I can't do anything right, and things are never gonna be okay in that spiral. And maybe if it was like, do you know that when people have been hit or hurt in the head a lot, sometimes things are harder for them. We all have things where things are harder than us. You have things that you're good at, Kate, and you have things that you're not that good at. I have things that I'm good at. I have things that I'm not that good at. But there are things that we can do, and there are things that you can do in order to help you manage some of those things better. And so let's think about how we can think about directions differently. Let's think about those kind of things. So I think that that for me, um, that is just one of the really hopeful pieces about this work.

SPEAKER_02 55:49

That brings me kind of to my last question for you guys. Um, what is giving you hope in this work? Kesi, go for it. Do you want me to take it?

SPEAKER_01 55:59

Um for me, um, hope in this work is community and people like Rachel and like you, Kate, and all of the wonderful professionals that we get to work with. Um, this work is really, really hard. What survivors experience is infinitely harder. Um, so I think for me, the hope in this work is working alongside everyone who I get to work with that is so passionate and dedicated to making our little sliver of this world just a little bit better. So raising awareness about this and finding others who care about it like I do, um, that truly brings me hope because I know that that means that there's going to be better paths for survivors.

SPEAKER_00 56:44

I think for me, what brings me hope, much of what Katie said, but it also is just a recognition that there's a lot we can do. And this is not there is a lot we can do, and that brain injury is treatable. A lot of the symptoms are treatable. And again, might not mean that you're just like back to where you were before that happened, but we bringing back our trauma, we don't expect people to be the exact same people they were before they're from they're through their abusive experiences. So I think again, it is that the ways in which this information and this work really, really helps people be safer and understand themselves better and sets them on a path where they can live the lives that they want in the future. So um, and I think again, I think for me, this is not one of those issues where I don't know if you ever had a time where you learn about this thing and you're like, oh my gosh, there's nothing I can do. I mean, it's just so big and it's so like, I'm not gonna save the rainforest. I've never even been to a rainforest. I don't know what trees are, I don't know how to keep, you know. But it's like, wow, there is something I can do every day in my interaction with survivors. There is something I can do to really uh advocate for this issue within my system. There is something that I can do to bring awareness to this that can really have pretty profound positive effects on um not only survivors, but on organizations um and other systems that serve survivors.

SPEAKER_02 58:12

Perfectly put. That was making me feel hopeful too, Rachel. Thank you for sharing that. And it has been such a pleasure to have you both here today. Thank you so much for this always, as always, enlightening conversation. I learned something new about brain injury every time I meet with you, Rachel and Casey. So this has been a true pleasure. Thank you so much for coming.

SPEAKER_00 58:36

Thank you for having us. Yes, and please don't hesitate. We do have a website at odvn.org backslash brain. And I don't know if that's there's lots of materials, lots of resources. Our contact information is on there. So as you can tell, Casey, and I really, really like to talk about this. Do not hesitate to reach out to us if you have any additional comments, thoughts, questions, or need any more support from us. Um, thank you very, very much for the sometimes difficult but life-saving work you all do.

SPEAKER_02 59:05

You've been listening to Seating Safety. For resources and information from the National Health Resource Center on Domestic Violence, visit ipv health.org. Thanks for listening.