When we think of common causes of concussions, we typically think of falls, motor vehicle accidents, or sports injuries. However, there’s another significant cause of concussions and traumatic brain injuries (TBIs) that often get overlooked: domestic violence.

The Ohio Domestic Violence Network (ODVN), a statewide coalition that works to support and strengthen the state’s response to domestic violence, is actively working to change that by shining a spotlight on the intersection of domestic violence and brain injury.

The organization, which is also a Concussion Awareness Now (CAN) Coalition member, works with 76 domestic violence programs across 88 counties, building the capacity of Ohio’s domestic violence shelters, programs, and allied professionals through training, public awareness, technical assistance, and promoting social change through the implementation of public policy.

“One misconception about domestic violence organizations like ours is that we’re solely focused on shelters,” says Rachel Ramirez, ODVN’s Director of Health and Disability Programs and the Founder of the Center on Partner-Inflicted Brain Injury. “Sheltering is important, but there are also a lot of people we work with through our crisis hotlines, text and web chat; through legal advocacy, support groups, safety planning, counseling, and other services, and mobile advocacy.”

Many more, in fact. Last year, all of ODVN’s statewide programs combined to shelter 9,707 people—3,743 of those children—and provided additional services to 98,143 domestic violence survivors with over 121,000 crisis contacts answered through phone, chat, or text.

A Silent Epidemic

Domestic violence is alarmingly common, affecting one in three women and one in seven men at some point in their lives. What’s less known is how frequently these abusive situations lead to concussions and other types of brain injuries from oxygen deprivation to the brain caused by violence such as strangulation. ODVN’s own research into the connection began in 2016 when the organization was given a grant to look at increasing access to domestic violence services, particularly when it came to working with survivors who have been hit or hurt in the head, neck, or face–including strangulation.

“We had written in Ohio State University as an evaluation partner on that grant, and after it was awarded, and sat down with a professor at the College of Public Health there,” Ramirez says. “It became clear that we needed to do more research. We went and talked to several local domestic violence programs—members of ours—and also talked to survivors who were accessing those services. When we asked ‘Have you been hit in the head, or hurt in the head?’ 86% of the survivors said yes. 83% of the same survivors said they had been choked or strangled, resulting in their brains being deprived of oxygen.”

The research uncovered a simple, yet profound discovery: domestic violence causes concussions and other types of brain injuries. “It’s something that seems obvious, right? And yet it’s only been recently that it’s been part of our framework in the domestic violence space,” says Ramirez.

The nature of domestic violence makes brain injuries particularly insidious. Unlike sports-related concussions, where trained professionals are often on hand to recognize symptoms and chart a course for next steps, domestic violence typically occurs in private. “These head injuries happen at home,” Ramirez says. “There’s nobody to say, ‘Hey, you need to get that checked out.”

Concussions & Brain Injuries = Compounding Challenges for Survivors

The combination of domestic violence trauma and concussion symptoms creates a complex set of challenges for survivors. Kasey Holderbaum, ODVN’s Health and Disability Project Coordinator, gives a sobering example. “I was working with a woman who had been subjected to an extensive history of violence and trauma by her partner,” she said. “She went to the doctor multiple times. Multiple visits to the ER. At one point, I met with her and she said, ‘I’ve been diagnosed with a brain injury. I’m not stupid—my brain has been hurt.” This survivor found the information to be empowering, relieving, and gave a name to the struggles she had been experiencing for years. It helped make what happened to her real and valid.

Many domestic violence survivors struggle with cognitive issues, problems with their memory, or difficulty focusing on simple tasks, without understanding why. “It’s not just the trauma,” Holderbaum says. “Their brains have changed as a result of the abuse.”

And, the impacts of concussion or TBI can extend far beyond the physical aspects. Concussions can affect a domestic survivor’s ability to maintain employment, secure housing, navigate the legal system, retain custody of their children, follow through with safety plans, get into a shelter, and much more.

At the same time, helping survivors understand the connection between domestic violence and brain injury can be affirming for them. “We don’t have medical backgrounds, so of course we aren’t diagnosing survivors with concussions or brain injuries,” Holderbaum says. “But when folks are struggling in services, struggling in shelters, struggling to maintain custody of their children, it’s validating to them that this might be a key reason why they’re struggling. It can help put a name to what they’re experiencing.”

While identifying a brain injury can also be a difficult reality for domestic violence survivors to absorb, the overwhelming response to increased awareness of this intersection has been positive for both professionals and survivors. When issues are identified, they can be addressed.

Breaking the Silence, Addressing the Trauma

Both Ramirez and Holderbaum say that one of the biggest hurdles in addressing concussion and brain injury in domestic abuse survivors is the silence surrounding it. Many survivors never disclose their abuse while it’s happening, even to close friends or family. “The stigma and shame associated with domestic violence can prevent people from seeking help—or even recognizing the full extent of their injuries.

“86% of the people we surveyed said yes, they had been hit or hurt in the head, neck, or face,” Ramirez says, pointing back to the research they conducted. “If we had asked, ‘Have you ever had a concussion?’, 86% would have probably answered ‘no.’”

Supporting Survivors Through the CARE Framework

Recognizing the need to equip their partner programs and advocates with an intentional and specialized approach to working with survivors who might have experienced concussions and brain injuries, ODVN developed the CARE Framework in partnership with Ohio State University.

The framework was designed around working with survivors who have experienced struggles with their mental health or have been hit in the head or strangled—and was developed as a result of the research ODVN and Ohio State’s College of Public Health conducted with domestic violence program staff and in-depth interviews with survivors accessing services.

The framework guides advocates in supporting survivors through a trauma-informed and brain injury-informed lens:

• Connect: Build trust and create a foundation for survivors to work with advocates.
• Acknowledge: Recognize the challenges and successes survivors are experiencing.
• Respond: Provide trauma and brain injury-informed care, including appropriate accommodations and referrals to healthcare and brain injury support and services.
• Evaluate: Continually check in with survivors to assess what’s working and adjust as needed.

The CARE framework emphasizes flexibility and individualized support. It recognizes that every brain injury is unique and that survivors’ needs may change over time. “If you’ve seen one brain injury, you’ve seen one brain injury,” Ramirez says. “This model is a critical part of adjusting our services to make sure that we’re being the most supportive and brain injury-informed that we can be.”

There are so many accommodations we can make for survivors as they’re working through their own care and safety plans,” Holderbaum adds. “It might be something as simple as providing calendars or alarms to help with memory issues, adjusting lighting to reduce sensory overload, or simply allowing them more time for rest and processing information.”

The CARE framework and other domestic violence-related resources can be found at the CAN Healthcare Professionals Resource Hub.

Raising Awareness Across Systems

Both Ramirez and Holderbaum appreciate that ODVN’s work and partnership with the CAN Coalition allow them to extend their work beyond direct survivor support and “unsilo” themselves. They’ve actively been working to bring domestic violence awareness into spaces where it’s historically been absent—healthcare environments, organizations like CAN, and even fields like speech-language pathology.

“The fact that domestic violence is at the brain injury and concussion table, so to speak—and vice versa—it’s critical for us to increase awareness and learn from one another,” Ramirez says. “All of these topics are incredibly complex issues on their own, so why not combine our expertise and what we’ve learned to help more people?”

Holderbaum agrees. “We’re all on the same mission… serving and supporting individuals who’ve been through something. How can we do that better and support each other in the process?”

A Call to Action for Domestic Violence Awareness Month

With October being nationally recognized as Domestic Violence Awareness Month, both Ramirez and Holderbaum stress that everyone plays an important role in addressing this critical public health issue.

“People who are experiencing abuse are going to talk to their family, friends, and coworkers before they contact a domestic violence program,” says Ramirez. “You’re an important part of the solution because you can raise awareness and connect people to resources that can help them.”

Ramirez also has a message for anyone who might be experiencing domestic violence. “You are not alone. You deserve to be in a safe relationship, and you deserve support. And there are domestic violence programs available to support you on your path to safety.”

Resources:

• National Domestic Violence Hotline: 1-800-799-SAFE (7233) or visit www.thehotline.org
• For Domestic Violence Professionals: ODVN Brain Injury Resources
• For Survivors: 10 Things to Know About the Connection Between Brain Injury & Violence