KAITLIN SHETLER: Good afternoon, everyone. This is Kaitlin Shetler with the Vera Institute of Justice. This webinar will begin in about a minute. If you have a question or need any assistance, please send us a message in the Q&A or the chat pod. Thank you. Good afternoon again. Thank you for joining our webinar today. I'm Kaitlin Shetler with the Center on Victimization and Safety at the Vera Institute of Justice. I'm a white woman with long blond hair. I'm wearing a dark green shirt with an orange cardigan. And I am in my home office today with a cream background behind me. And I'd like to welcome you to today's webinar. We're pleased to bring you this as part of our 2021 End Abuse of People with Disabilities webinar series. Before we get started today, I want to provide some information about the accessibility features of our Zoom webinar platform as well as how you can interact with us throughout the session today. You should be in listen only, view only mode. 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In the upper right hand corner of your Zoom window, you should see a button that says View with nine small squares. You can select a side by side view, the gallery view, or the speaker view. Gallery view is the best selection to view the panelists today. We will be recording today's webinar. The webinar recording and materials will be posted on the End Abuse of People with Disabilities website within two weeks. A record of attendance will be available for download via link in the chat pod at the beginning and end of the webinar. A contact list will also be available in that folder. Please click on the link in the chat to find those materials for download. Our presenter for today is Rachel Ramirez. Rachel Ramirez is hoping to raise awareness on brain injury caused by domestic violence. Rachel is a licensed independent social worker and began her work in domestic violence at a large domestic violence shelter in Tampa, Florida, in 2004. After over a decade at the Ohio Domestic Violence Network doing training and statewide capacity building on trauma-informed initiatives, Rachel's life changed when she began a project in 2016 on addressing the intersection of brain injury and domestic violence. She has become a passionate advocate for bringing a brain injury-informed lens to all those who interact with domestic violence victims and better understanding the ways in which brain injury impacts victims and what service providers can do to better support them. She is looking forward to working with you and the skills and gifts you bring to this work to make this world a better, safer place for all people, especially at home and in their relationships. Our presentation today will be focused on serving domestic violence survivors with partner-inflicted brain injuries. We recognize that this topic is sensitive and may be triggering. We strive to be trauma-informed when presenting and interpreting. Please be aware that some ASL signs will address topics such as domestic violence, strangulation, and assault. Thank you for your attention. And if you would like to discuss with staff, please feel free to reach out to staff in email and the chat pod. With that, I'm going to pass it over to Rachel. RACHEL RAMIREZ: Hello, everybody. It's so nice to-- I guess I can't see you. I hope it's nice to have you all see me. But I really, really appreciate you. I would say good morning, good afternoon, good evening. I don't know if it's the evening for anybody. But thank you so much for spending time with me today. I know your time is valuable and important. There's lots of ways you could-- lots of things you could be doing with it. So I really appreciate and thank you very much, Vera, for inviting me to talk about work that has become very, very dear and near to my heart. So I am going to get us started and go ahead and share my screen. And give me just one second. And again, so you know, thank you very much for that introduction, Kaitlin. And just to give you just a little bit more background, coming at this topic, looking at the intersection of brain injury and domestic violence, I am coming from pretty exclusively the domestic violence side of things, the domestic violence perspective and background, which is where my background has been for a long time. Can I ask really quickly, could you tell me, can you see the presentation view? Or are you seeing my slides on the side? I have two monitors, so this didn't do this earlier when we were practicing. But I'm just not quite sure what you're seeing, so if somebody could let me know? [? SARADA: ?] This is [? Sarada ?] speaking. Yeah, we see the slides on the side. RACHEL RAMIREZ: OK, I am going to unplug my second monitor, which is what I always do. I'm sorry about that. It's funny because we literally just spent a bunch of time doing this. So now you can just see the presentation, correct? [? SARADA: ?] This is [? Sarada. ?] Correct, you're all set. RACHEL RAMIREZ: Thank you very much. All right, this is always the weird thing about being in your room talking to yourself, looking at what you see and never quite being sure what everyone else sees. But I did, and I thank you Kaitlin very much for just acknowledging from the very beginning of the presentation that what we'll be talking about today, domestic violence, traumatic brain injury, and strangulations are pretty terrible things. And they're terrible things that happen to people. They're terrible things to experience. And they really can be very, very difficult things to talk about. One of the things that I did want to also acknowledge is that whenever we're doing work in domestic violence, we always know that there are those of you who are on this call-- or I'm sorry, you can tell I'm old-- on this call-- on this webinar that have had our own personal experiences with domestic violence. And many people get into this work, get into victim service and domestic violence advocacy work and many other areas of work because of that personal experience. So this might also be something that as you're hearing this, every single training that I've ever done on this topic, on this intersection of domestic violence and brain injury, I've had at least one person, one person who was a professional working in domestic violence who has come up to me to talk to me after the training happened about their own experience in the past of being a victim of abuse and being hit and hurt in the head. So if you have been in an abusive relationship and have experienced head trauma, I just wanted to acknowledge that, that this might impact you in a different way. And please make sure to take care of yourself and use all of the self-care strategies that we know when we do this work with people who need us. I'm going to provide you with my contact information so please feel free to reach out to me if you have any additional pieces you want to talk to, you want to talk about. It's one of the things that I miss the most about training in person is that I get to come up-- people come up and talk to me and share some of their experiences and responses. So I'd really, really love to hear that. But I wanted to frame that today. And again, I really appreciate the attention to understanding what that could, for those of us who are seeing American Sign Language, what that could be and what that could look like. I also want to acknowledge, and I think that for those of us who work in the helping professions, sometimes-- I worked in a domestic violence shelter for a long time. And I think it's very, very easy to forget when all you do is help people all day long how amazing it is and what an amazing act of seeking help is, of strength, courage, and resistance. And I think sometimes when those of us who work with domestic violence or sexual violence or crime victims, people can come to us. And often, they're coming to us seeking help, and they're not in the best space they've been in their lives. They're often in a space that's very, very hard, very, very difficult, and very, very challenging. And when you do this work all day, it's easy to wonder, you know, why is someone having so many problems doing what we require them to do? Why are they having problems getting along with people? Why can't they just follow our policies and procedures? Why aren't they acting like the other people who came-- the people that I was working with yesterday? It's easy to forget that. So I just encourage us to really remember how important and how significant it is that someone is seeking help for their experience and how much courage that takes. So just talking a little bit about our time together, we're going to start by talking about the brain and just the brain and how it works and spend a little bit of time focusing on that larger picture, understanding the context of domestic violence, what domestic violence looks like and the role that that plays, those larger-- the larger world in which we exist. We'll talk about partner-inflicted brain injury and what it is, what are some of those signs and symptoms, how it impacts individuals, and then move into the approach that we developed in Ohio called CARE. Give a special shout out to anybody from Ohio so OH. I have some people that are putting in the chat box IO. I know, dang it. We have a few weeks coming up that we're not very happy about in Ohio with college football playoffs, but there's always next year. But really, we'll be talking about Ohio's CARE approach and how we can use that to support survivors in your services. And, hopefully, we're going to have some time for questions and answers at the end. So I look forward to also hearing from you and learning from you and thinking about how this work can be integrated into the work that you do. So I really wanted to start today by really thinking about framing, framing how we live our lives. And what are the different components and pieces of our lives that really make us able to live our daily lives and kind of be a whole complete person? And this is actually a framework that I've learned-- if anybody out of here, if we have any occupational therapists on this call-- I'm sorry, I keep saying on this call, on this webinar. If we have any occupational therapists on this webinar or any of you know occupational therapists, occupational therapists are going to be amazing allies and partners in helping figure out this intersection of brain injury and domestic violence. One of the things I learned-- and occupational therapists, one of the things that they're really responsible for in the work that they do is they help people either regain or develop skills that they need to live their daily lives. It's called activities of daily living. And I learned when we think about it-- now, I want you to think about it in your life, you can even think personally about your life. Think about some of the things in your life that you want or like to do, things that bring you joy. If anybody wants to put some of those things in the chat box, feel free. This is a really, really important part of our happiness. Just things, I mean, again, you might not need to do them. They might not be essential for survival or breathing. And I'll give you an example. I do CrossFit. Exercise is one of the things that is really important to me and really helps me stay balanced, helps me stay regulated. There are also things in life that we need to do, right? There are things that our life demands of us like the dishes. None of us like doing the dishes. None of us wants to do the dishes. But there are a lot of tasks that we have that we need to do in life. And again, if you want to, you can feel free to keep putting some of those thoughts and comments in the chat box. And then, we have things that we're expected to do. And any time that we're going, we have expectations from our families. We have expectations from our jobs. We have expectations from our friends. We have expectations from school. We have expectations from-- even when we think about service providers, we have very much, those of us who work in domestic violence or whatever service system we work in, we have expectations about how people access us, about what people do when they get into our services, about how people behave, about what kind of emotions are-- about what kind of emotions are-- what kind of emotions people display. So when we're thinking about that-- OK, thank you. Sorry, Kaitlin. I just got a text from you. I was trying to check on that. I'm sorry that I can talk fast. I do not have the chat boxes for those of you who are-- I don't have the chat box up because I don't really have a way to have it up without you having a big black block-- big black box on what you're able to see. But please let me know, and you can feel free to interrupt me, Kaitlin, if I need to slow down or there's something in the chat box that I need to know about. So I'll try to do that better. So when we think about all of these things that we talked about, things we want to do and like to do, things that we need to do, things that we're expected to do, it really is our brain, our amazing brain, that makes all of those different things possible. So we're going to spend just a few minutes talking about our brain and how it works and how it's organized and how that helps us, just the critical role it plays in our daily life. So when we think about, and I'm going to take you back for just a few minutes to high school science for those of you it's been a long time since you've opened up one of those textbooks. But the basic way in which our brain is organized-- brain cells are called neurons. You'll see on the screen a picture of a neuron. And what happens is these neurons connect together. And they connect together to form efficient pathways. And that's the reason why many of you are able to hear me, maybe put a message in the chat. Some of you might have kids home from school, and they're calling you for something. There might have been a noise outside that you recognized. We're able to do all of those things. And you're able to do all of this, maybe responding to an email, and you're able to say, whoa, she's talking too fast. Let me put this in here and slow it down. Those are all very, very advanced and complicated brain functions that are a part of those efficient pathways, that allow us to really be able to do things not only like this but allow us to be able to do different kind of things, to be able to do all of the things that we need to do in our daily life. So we want to think about a healthy brain being like a city with zero traffic jams. So we are able to go about our days. We're able to do the movement that is involved in our days. We're able to walk. We're able to talk. We're able to prioritize tasks and think what we're supposed to do next. We're able to organize our day, kind of time things out for where we need to be when in order to pick up kids or go to the grocery store or whatever else it is that we need to do. And if it's OK, we'll go ahead and do an interpreter switch if that works for you all. And if someone just wants to give me a thumbs up for when that interpreter switch is ready, that would be great. Am I good to go? Someone just raised their hand. Good to go? OK, bunch of people are raising their hand, so I'm assuming I'm good to go. If I'm not, interrupt me. OK, so the other thing about the brain is it's this very efficient pathway, this efficient city that we have with zero traffic jams. Our brain needs nutrients and needs protection. So blood vessels bring oxygen and nutrients to our brain. Our brain is very, very sensitive to oxygen. It needs a lot of oxygen. Oxygen is the main fuel of the brain. Our brain actually weighs about 2% of our body weight but uses 20% of our body's oxygen. So that's why it's so sensitive to getting those oxygen and nutrients through our blood and through our breathing. And you want to imagine the brain as kind of like a jello. It's got a gelatin texture. So if you imagine jello, our brain is packed tightly inside of our skull. Our skull protects it, but also around our brain keeping it safe are tissues and fluid. And that's what allows us to-- our brain is-- the skull is so hard because our brain is such an important part of our body that needs to be protected. And different parts, different lobes of our brains have different functions. So take just a minute and look at some of these different lobes and what it is that they do. And it also helps us understand when we see that we have a part of our brain that is very involved with sensation, involved with touch, involved with smell, involved with hearing, we have another part of our brain here in the back of the brain called our occipital lobe, which is our sight. If any of you remember the Wile E. Coyote, it was Looney Tunes, remember how Wile E. Coyote would run, run, run, and run into a cliff and then would fall, and he'd have the little stars above his head. Wile E. Coyote actually probably just had a concussion. I hope I'm not ruining Looney Tunes for anyone. But that seeing stars, that is evidence, sometimes our vision gets impacted when our brain is impacted. We have a part of our brain-- our cerebellum and our brainstem are really what we call kind of our survival part of our brain that really will get coordination and balance. Part of our brain does things like regulate our heart rate and our swallowing and our breathing. We have another part of our brain, our temporal lobe, which looks at language and hearing. It really processes and integrates memory, which is really, really important, because we can remember something, but if we have no context for what that memory is, if it doesn't mean anything, if we're not able to bring that memory into how it relates to today or what I'm doing, it's not very helpful. And comprehension, really being able to understand people, being able to comprehend people. So you can hear something and not understand it. If you ever think about if you have heard someone speak a different language, you're able to hear that. But that doesn't mean that you understand it. Then, we have the frontal lobe of our brain, which is the lobe of our brain that's very, very important, that has to do with things like our judgment and the movement of our bodies and how we remember things. Our frontal lobe actually plays a significant role in our personality and also is where executive functions are housed. And we're going to talk for just another minute about our executive functions. I don't know how many of you are familiar with this concept, but executive functions are really mental skills that develop slowly over childhood and continue to develop and mature as we grow into adulthood. And they're really these mental skills that are essential for everyday tasks. They include things like working memory. And working memory is the idea that sometimes there are things that I need to remember that might have just happened a couple of minutes ago that impact what I'm doing right now. Those of you who are using your working memory, who are remembering the things I talked about five minutes ago, and that's building on what's happening now in order for you to understand this presentation. Executive functioning also involves flexible thinking. Flexible thinking is the whole idea of being able to come up with different plans, different options. If you have an idea for one way your day is going to go, and let's say your car doesn't start, OK, how do we do things in a different way? If we have a problem or a thing that doesn't work out one way, what's another option? So being able to kind of adjust and think about things in different perspectives. Also, self-control, so being able to control any kind of emotions, reactions, instincts, you know, those kind of things that you have. And we can see how important these things are for everyday tasks and for being able to just do the things that we need to do to live our lives and to be able to behave appropriately at work, behave appropriately at school, behave appropriately in services. And for those of you who provide services, I want you to take a minute and look at this list of things where executive functions play a key role, things like problem-solving, things like time management, things like starting tasks, beginning to do something, initiating an activity, organizing, planning, managing emotions, controlling those impulses when we're really upset or we're really happy or we really want something that we don't have, being able to do that and control that. When I have a friend who has some candy that I really like and I really want it, I don't snatch it out of their hands. The social and sexual behavior, executive functioning plays a role in that along with self-awareness, even our ability to kind of be aware of our self and how we behave and how we should behave and how I'm coming off. And then, prioritizing. What's most important when I wake up today? Or when I have all of these things to do, when I don't know what to do first, what should I do first? What matters the most? What can wait till tomorrow? What can wait till later? I think for most of us who provide any type of services, these are pretty essential skills in order for people to be able to get our services, aren't they? And I think that one of the things when I talk about how game changing, and I really do say game changing without any joke, learning information about brain injury was for me as a long time domestic violence advocate is I think most of our services and most of our service systems have been set up really assuming, just kind of having a blanket assumption that people have the capacity and have really the brain functions to be able to do these things. And if you've ever worked with domestic violence survivors or worked with any other type of clients that are getting-- that are accessing your services, often we can get frustrated by some of the challenges people have with maybe thinking about that whole issue of prioritizing. Sometimes we would have survivors that were in shelter who would come get paid or get benefits and go out and just blow all of their money for the month on something. And we'd be like, oh, what is wrong with them? How come they have other priorities that they should? I think that one of the reasons I'm so passionate about sharing this information about brain injuries, I did not have this knowledge when I worked in a domestic violence shelter. And I think I would have had a totally different understanding about what it is that I'm seeing. I also think when we ask that question around many of us who have done trauma-informed work, you know, what's wrong with this person? How come they can't ever show up on time? How come they don't ever get anything started? We talk about these things and nothing ends up happening. How come they're always losing it? How come they can't keep their emotions under control? Not asking that question about how is that related to what's wrong with them but related to what happened to them, which is very much a trauma-informed informed framework and a trauma-informed approach. So I think, again, and I'm sorry, everybody, I'm sorry if my voice is a little scratchy. I was panicked yesterday that I was going to lose my voice. There's been some non-COVID-related germs around here. But I literally canceled meetings and didn't talk all of yesterday afternoon. So I don't usually sound this scratchy, but I hope it's kind of like a husky nice voice. But I'm sorry if I'm sounding a little weird. But so when we talk about it, when the brain is healthy again, it's this kind of system that just works together. All of the plugs are plugged in. Everything is kind of run smoothly. But when the brain gets hurt, it really creates-- you see, that message center gets all disconnected and the wires break and things stop working smoothly. And so we're going to spend some time today talking about what happens when the brain gets hurt, what's the role of domestic violence, and what it is-- what that all looks like. So I want to spend just a few minutes talking about domestic violence and the dynamics of abuse and the trauma that it causes. And I think what we're going to do now is I'm going to switch over, and we're going to hear from three domestic violence survivors who I've had the pleasure to meet personally talking about this. And give me just one second so I can share this correctly. I did want to let you know that these are not-- these are videos that are recorded on my iPhone, and we did test it, and it did look like things were working well. So once again, I am able to hear and see this fantastically on my end. Someone will let me know if it doesn't work. But this is just a couple of minutes of three domestic violence survivors describing kind of what their relationships were and what they looked like. So here we go. [VIDEO PLAYBACK] - There were so many things that when I look back now that I know, it just screamed, what was going on? And had somebody with some knowledge taken the time, my outcome and my life may be completely different. [MUSIC PLAYING] - My abuser did everything he could to hide it with a steel toe boot beating me on the head. Nobody can see what you're doing-- what they do here. You know you have lumps all over the place, but nobody can see it. So he was smart. - I had gone through a two and half year relationship, intimate partner violence, domestic violence, and of course, you know, knight in shining armor at first. And it soon escalated. But I basically went through two and half years. The physical abuse wasn't every day, but it was about every six-- it averaged out to maybe like every six weeks or so. But he would come at me. He would wrap his hands around my neck and try to strangle me. And then he would follow it with hits to the head either if I was standing up or over carpet, he would do closed fist punches to the back of my head. Last March of 2017, he was finally arrested. He attempted to strangle me twice. And then he closed fist punches and then he fractured my lowest three ribs. - The past can sneak up on you at any time. It can be a smell. It can be a sound. But it may be something as simple as I'm in-- I'm in Kroger's and somebody walks by with the same cologne or the same voice, and it's just like the brain, the body keeps score. It's just like for a minute I'm back to 2006. [END PLAYBACK] RACHEL RAMIREZ: So we will have an opportunity to hear from Nina, Paula, and Rebecca at a couple of different points throughout today. But I think that what that does is really thinking about the complex and complicated dynamics of domestic violence and that combination of a head trauma that Nina and Rebecca were talking about, assaults to the head, and then Paula talking about the psychological trauma and the trauma triggers and the reminders that she had. For those of you who aren't from Ohio, I don't know, Kroger is like-- she was talking about when she's in Kroger. It's a grocery store here. So if you're from Florida, it's Publix. But just talking about how that still continues to impact her life even a decade later. But when we look at domestic violence, we're really thinking of domestic violence as this pattern of assaultive and coercive behaviors that we often are, I often say for those of us who work with domestic violence victims or domestic violence survivors, we are often-- I want us to think about our interaction with individuals who have experienced domestic violence as walking into the middle of a movie. If you've ever walked into the middle of a movie and something's going on and something happened, and it looks weird and you don't know what happened and you don't know who the characters are and you don't know why that person said that and you don't know why that person did that, part of that is because you haven't seen the movie from the very beginning. And if you had seen the movie from the very beginning, it might make a lot of sense. So we want to remember that even if we are coming into a domestic violence survivor's life or are providing services after a thing that happened, an incident, that is often a part of a pattern of these larger behaviors. That incident, that survivors response to that incident might not make the most sense to us if we don't understand the whole movie. So I always tell domestic violence advocates, part of our job is to watch the whole movie, to understand the whole movie. But some of you might be familiar with this. This is called the power and control wheel. Everything we talk about today, my preferred training length is somewhere between like four and eight hours. So we could talk definitely more about all of these things. But this power and control wheel, for those of you who aren't familiar with it, was actually created by domestic violence victims and is this visual depiction of all of the different things that people who use violence or abusers do and use in order to kind of maintain and get that control over their partners. We see on the outside, we see physical and sexual violence. Many domestic violence victims have talked about and we heard Rebecca say, physical abuse doesn't happen all of the time. But when somebody has introduced that into your relationship and has really showed that they are willing to go to that point, that they are willing to physically or sexually assault you, assault your head, sometimes these other tactics, such as intimidation, such as throwing things at the wall next to your head or slamming doors, emotional abuse by calling you names and having you doubt your judgment and saying things didn't happen that did or saying you're so lucky that I'm still with you after all, that you're so stupid, and you're lazy, and you don't do anything, no one's ever going to love you, you're lucky, the isolation that's so common with domestic violence, the minimizing, denying, and blaming, the way in which economics are used, really thinking of this as this is a system. And a lot of these times, these are the things when we talk to domestic violence victims that can keep victims entrapped and make it very, very difficult to leave and also very, very dangerous. So that's what some of those different tactics of coercion and control look like. And we know when thinking about this concept of coercive control, we want to think about something that's coercive as being, and you could think about that in your own head and maybe put in the chat box like, how would you define something that's coercive? You know, with something that's coercive, it really means that you don't just kind of have free choice to do whatever you want. When we talk about it, and I that that's one of the big myths we have around domestic violence where you have people who have been in relationships that aren't abusive, and they say, well, if anybody ever said that to me or if anybody ever did that to me, there's no way I would put up with that. It's very, very easy to judge situations you aren't in. I will tell you, I am a mother to three wonderful children. I was a much better parent before I had kids. I had parenting all figured out. And there was no way I ever would have given my kid a treat to get in the car. All of you have done that too. But just really thinking about the whole idea when something is coercive, when you're in a relationship that's coercive, is that you can't just make decisions because there's consequences for everything that you do. There's consequences if you go along with your partner. There's consequences if you don't. But thinking about this control even over somebody's body and over their body and where they go and what they do and their body safety, control over movements and where people can go and who people can see. Control is over people's thoughts and people's feelings about themselves and others. So I mean, one of the things that-- I think some of the long-term legacies of domestic violence for many victims include the ways in which emotional and psychological abuse have played out where domestic violence victims even years later are still questioning their ability, still questioning their strength, still questioning their capacities as a parent, still questioning if they're smart, still questioning all of these things they used to believe about themselves. And then, the financial piece too, which can really, really impact, or kind of the financial control and the way in which often an abuser sabotages a person's financial reality. We also see coercion around things like mental health and substance use where abusers are doing things intentionally to make domestic violence victims think they're crazy, feel crazy. I worked with a domestic violence survivor who she used to put her-- she used to put her keys right next to the door. Like, you know how you put your car keys next to the door. And her husband used to take them and hide them. And she would go look all around the house. And then he'd put them back there. And then he'd say, see, you're an idiot. How do you think anyone else is ever going to be with you? They were right there all along. How could you not see it? So thinking about that and then thinking about substance use, the way in which substances are introduced in domestic violence. A lot of people are pressured to use substances. People are interfered with getting help for treatment. Physical health coercion which is around people are prevented from going to see medical professionals, from going to the doctor, from getting physical health needs taken care of. And then, reproductive coercion which is that coerce that is really around things like using birth control and pregnancy pressure and kind of making decisions about when and how to get pregnant and what it is that looks like. Lots of, if we had a baby, it would fix everything between us. So I see this coercive control happening in so many different areas of a survivor's life. And we're going to take just a quick minute to do an interpreter switch. And again, when we're all said and done with that, I know some of my friends out there did a great job and raised their hand so I knew we were good. All right, thank you, Terese. I appreciate that. It is driving me crazy not being able to see the chat, which you all are doing. So thank you all for that. Well, and I wanted to talk real quickly about this concept of gaslighting. Some of you might have heard of gaslighting. But it's really the attempt of one person to override another person's reality. And it's getting me to question what's real. And I think why this is so important when we hear domestic violence victims talk about their experience with head trauma and them knowing. We hear Paula say, you know, Paula said in her video like, I knew something. If somebody had brought this up, like, if I had known something was wrong, but I just didn't. Like, is it really wrong? You know, can I even trust my own judgment? So think about this. That says, for example, that didn't happen. Well, if it did, it wasn't that bad. And if it was, that's not a big deal. And if it is, it's not my fault. And if it was, I didn't mean it. And if I did, well, you deserved it. So you think about, again, that crazy-making behavior about that I'm just not sure. Maybe something's not wrong. And we'll hear Rebecca, Nina, and Paula talk about that in a little bit. We know that domestic violence causes trauma, psychological trauma. If any of you have been to training on trauma-informed care, thinking about psychological stress and trauma with trauma being an event series of events or set of circumstances that really overwhelms our ability to cope. We all have ways in which we cope with stress in less healthy, and some of us cope with stress in healthier ways. Some of us-- do we have any stress eaters out there? Anybody ever found themselves like eating when they don't even like what they're eating. They don't even like-- like, you're eating something, and you're like, I don't even like this. Why am I eating this? And you're still eating it. Yes. So not all of us-- we cope with stress. Some of us cope with stress in healthy ways. Some of us do other things. So I think, again, how many of us have been stressed out? Like, why do they call it happy hour? Thinking about that. But you know, it really overwhelms. All the happy hours and all of the chocolate and all of the running really isn't enough to help us cope. And it really impacts us. Trauma impacts us with physical, emotional, physiological, which is kind of body, body impacts, and thinking impacts, cognitive impacts can put us into that fight, flight, or freeze mode. And we know that trauma can affect people and make-- psychological trauma can affect people and make it harder to do things like manage and regulate feelings, to calm our self down, to trust others, to plan, to have energy, be able to tell stories. I don't know if any of you who work in the legal system thinking about that, being able to tell what happened to me in a cognizant, coherent manner where other people can understand is really, really important. It also increases chance of tension, anxiety, panic, and emotional volatility. Some of those-- avoidance, constriction, and disassociation. And many of us use-- I'm sorry. Think about the use of drugs, alcohol, or other addictions. Sometimes it's to cope with violence and stress and trauma. Sometimes it's to manage symptoms. I've worked with domestic violence survivors who have had terrible nightmares. And the only way-- those are trauma reactions, trauma responses, and the only way that they've been able to get sleep is, for example, by taking sleeping pills or drinking till they pass out. So we know psychological trauma. We've known this for a long time. In domestic violence, we've done a lot of training on this over the past years. And like I said, I did many, many years of that but without ever bringing brain injury into the fold. So we're looking at this intersection right here. We're thinking about this overlap of domestic violence-- for those of you working, you can sub domestic violence with sexual violence, with human trafficking, all of those different areas-- traumatic stress, and the way in which that stress level impacts us and then brain injury. And I think, again, in domestic violence for many, many years, we had the domestic violence and traumatic stress in our lap. We did a lot of talking and a lot of training about that. But this brain injury piece came out of nowhere. At least, it came out of nowhere for me, even somebody who's been doing this work for a long time. But it's more complicated, again, than just this overlap because we know different people live in different circumstances and different situations. We all interact with the world and the world interacts with us differently depending on our race, depending on our age, depending on our ethnicity, our national-- what country we are of origin, depending on our age, so many different things. So we have other things like historical and cultural trauma and stigma, the stigma in talking about domestic violence and sharing about domestic violence. Dealing with systemic prejudice, discrimination, and oppression, that affects different groups of people disproportionately and results in the unequal access to resource and all of the social determinants of health. And then, we have different cultural forces and pressures. So again, even among this person, there's all of these other things that are playing a role in this person's life and playing a role in our response to domestic violence. And so now we're going to watch one more video. This is a much better filmed video from the Ohio State University. And this is kind of what we learned. It's three minutes long. It's kind of the takeaways what we learned from our original project. We had no idea what we were getting into on looking at brain injury and domestic violence. So I am going to-- give me one second again here very quickly. And I'm going to pull this up for you all. And then, we're going to get about sharing this right now. And I'm going to start here. And again, if people can't see or hear, please let me know. [VIDEO PLAYBACK] - You hear people talk about evil in someone's eyes. Like, he looked through me like I wasn't even there. And I remember him putting his hands around my throat and thinking, like, I'm going to die. [END PLAYBACK] RACHEL RAMIREZ: Give me just one minute. I'm sorry. I didn't get the captions on. And I'm actually going to start it over. [VIDEO PLAYBACK] - You hear people talk about evil in someone's eyes. Like, he looked through me like I wasn't even there. And I remember him putting his hands around my throat and thinking, like, I'm going to die. - When we think about the first picture of a domestic violence victim, the kind of classic iconic image of a battered woman as a woman with a black eye, right? Which, one of the things that I realize now in the context of this work is she very well could have had a concussion in the context of that black eye. But it is something that none of us in the field have thought about. - And I don't remember much after that. But a nosy neighbor saved my life. Like, somebody had heard all the stuff going on and knocked on the door. And that was the only reason I'm still alive. - And how we hadn't, it's one of those things you say it, you look at the data, we talk about brain injury and hits to the head, and it becomes very obvious very quickly. But even in my role at my organization as a statewide leader having led a trauma-informed initiative across the state, trained in other states around the work that I was doing, never once had I mentioned brain injury. And how did we manage to miss that? - 81% had reported being hit in the head. 50% or so, so many times that they couldn't remember. And 83% of the survivors working with organizations reported that they had been choked or strangled so that their brains had been deprived of oxygen. - And the sad part for me is I'm an EMS educator. Like, I teach trauma. That's one of the things I love. And yet, even though as much as I know about trauma, I totally missed the strangulation part, the brain and the effects that it's had on my body. - Many survivors who have been living with unmet need regarding brain injury intervention for a long time do end up developing comorbid issues like mental health issues and substance use issues, struggles with suicide. So unless we're identifying the underlying brain injury early, there can be other long-term health impacts for survivors of domestic violence who are not receiving the services that they need. - At one point, I attempted suicide. And so it was like, if they would have found this earlier, like, my family has watched-- my friends and family have watched me try to end my own life and stuff. And it's like, that all could have been avoided had the right people had the right knowledge. - This has just kind of changed how we think about things and how we want to do things. And we're very, very hungry for helping us tackle this because this really hasn't been tackled in this way before and helping us from a practice level figure out what this needs to look like in the very complicated, very challenging work that domestic violence agencies do. [END PLAYBACK] RACHEL RAMIREZ: All right. I know that that is available on YouTube. Please feel free to use it, to share it. That is the same Paula from our discussion earlier. And I think that if anybody wants to put in the chat box kind of recommendations-- I don't know where that word came from. So think about my weird brain. Like, recommendations? I'm not even talking about that. Why did that word come out? But like, reflections on that, and I think for me, me and my research partner at Ohio State, we'd all had a very, very deep experience in domestic violence work and sexual assault work. We were just like, how did we do this work for as long as we did it and not even think about that when sometimes it's literally been in front of our face? And I don't think that this is not to make anybody-- nobody should feel bad about this. Like, you don't know what you don't know. But then you know better, and I feel like this is something you cannot unlearn this. Like, once you hear this, you can't think about the work that you do in the same way. So again, what we did is we went out, and we talked with survivors who were accessing five different programs in our domestic violence-- in our state, very varied programs. Different areas of the state, programs look differently. You'll see here, about 60% of them were getting emergency shelter but a whole bunch of other types of services. This was not just a only shelter population. This was people who were accessing domestic violence services. And when we asked, have you ever been hit or hurt in the head, 86% of domestic violence survivors said, yes, with 49% of them saying when we asked, how many times-- we actually didn't ask like, was it one? Was it two? We said, was it never, once, a few, or too many to remember? And half of the survivors said, too many to remember. And then when we asked, have you ever been choked or strangled, you'll see 83% said, yes, with 51% saying a few times and one out of five saying too many times to remember. And it was just this just holy moly moment. We also did focus groups with staff. And we talked to people who are working at domestic violence programs. We talked to different administrators. We talked to direct service staff. We asked them lots of questions about what they knew about brain injury, have they learned about brain injury? What have been their experiences? Do they have policies and procedures? And it came across very, very clearly that staff was not recognizing brain injury, and staff had very, very little knowledge or very, very little education on brain injury. So these are quotes from our focus groups that we did. One administrator shared, "I mean, I've been here 28 years, and we've truly only had a handful of true TBI clients." So we had some administrators at agencies saying that. And then, 85% of our survivors saying, I have been hurt in the head over and over and over again. It was this disconnect, which is why I'm here talking to you and why as long as I am able, I will continue to do this work and think about this. Again, even us at a professional level, when I got this grant, I had-- how well prepared was-- I taught the whole state about trauma-informed care. I didn't know a brain injury from a hole in the wall. I had never spent more than five minutes thinking about it. And it just, again, has shifted my views. We also heard staff say victims might be hiding symptoms, that some of these symptoms of brain injury might not be stuff that victims would want to talk about. One administrator shared, "Victims often try to compensate without telling people what happened to them. Often, you know, trying to keep it to themselves or hide it." The other thing that we realized is that victims themselves had never thought-- KAITLIN SHETLER: Hi, this is Kaitlin. It looks like we lost Rachel for a second. So we are going to wait maybe a couple minutes while I get in touch with her and see if we can get her back. So just hang, and remember, you can put your questions in the Q&A box. Thank you so much for your patience. OK, one more update, Rachel is going to try to get back on via her phone. Unfortunately, her internet just crashed, so we're going to see if we can get her on and just move on to the Q&A portion because I know she has a lot to say, and this has been a wonderful presentation. She told me that she could go for probably 12 hours. So I know that she was putting a lot of stuff in in the small amount of time. She has a lot of knowledge. And there is a lot to learn from this topic. So hopefully, we'll be able to get to Q&A. And if not, you will have access to the slides. We are making them completely accessible, so you should have that in a few days. And we will email those to you. And it looks like Rachel just popped back on. RACHEL RAMIREZ: Hi, everybody. I'm sorry. I just had a total heart attack. But you can't see me because the host has disabled my video, so I'm here on the phone. So you can hear me. But we'll get that on in a minute. I'm so very sorry. Like, the power just like went boom, and everything closed down in our house. So I'm sorry about that. And I probably-- at least, I didn't end up talking to myself for another few minutes. But OK, let's see. KAITLIN SHETLER: This is Kaitlin. Rachel, oh, there you are. RACHEL RAMIREZ: OK, I am here everybody. So I'm sorry. And I do a lot of training on this. So I will try to pick up where I left off, and we'll be able to talk you through some more of this. Everything's OK. It was just one of-- it's actually a beautiful day here in Ohio. It was just like when you have one of those boom, off, boom, back on, and then everybody's everything is fritzy for a minute. So again, talking about our experience in Ohio, we really went out to better understand what this is and what this looks like with domestic violence victims and what it is and what's going to happen. So I'm so sorry about this guys. So we ended up doing work. And I'm sorry. Of course, I have children at home. So as you all know, with this whole working from home thing, everything falls apart all at the same time. So what we did is we continued-- I'll make sure that you all have that PowerPoint. We decided that we would talk with staff. And we talked with survivors. And our real goal was figuring out ways in which to make domestic violence programs more accessible. And I'm going to spend just a few minutes talking, first, about when we think about domestic violence and traumatic brain injury and strangulation and what it is and what it looks like, understanding traumatic brain injury. And when we say traumatic brain injury, what it is and what it means. All a traumatic brain injury is-- a traumatic brain injury if you have heard the term concussion, if you have heard, concussion is just another term for a mild traumatic brain injury. And a traumatic brain injury is something that happens when there's a couple of things that need to happen. The first thing is that there's some kind of external force or external blow to the head. So the head is impacted in some ways, combined with disrupted brain function. So that means that our brain is-- there is some kind of sign that our brain's function has been disrupted. So it could be something like we become dizzy, we become dazed and confused, we are not comprehending things adequately, we are not remembering what happened. All of these different things can happen in domestic violence. And what that means when somebody has had that blow and then has had that disrupted brain function, that is what a traumatic brain injury or a concussion is. But it is obviously something that we don't routinely ask about domestic violence and brain injury. We don't ask about head trauma. What we realized is both domestic violence victims and the advocates that are working with them, we're not making the connection between the brain injury, between the possible impacts of brain injury and being hit and hurt in the head. So we see traumatic brain injury has very, very common consequences. There are things that it has cognitive symptoms. Cognitive symptoms can look like things like people are forgetting things, people might not have any kind of memory of what happened or memory of the event, that people are having a hard time-- we talked about some of these things earlier-- organizing tasks or figuring out what to do first. People might have a hard time focusing or paying attention. People, you might have meetings with them and then have another meeting with them next week, and they-- and I think this is something that has been so interesting is that they-- I think how we've thought about it in the past is we had this meeting with this person, and they're acting like we never met with them before, and they're acting like we didn't have this meeting. And we think that must be a sign that they are not wanting to be involved. They don't care about their case plan. They're pretending like we didn't tell them about court, and they just don't want to show up. I think that one of the things that this work has really done has really, really helped domestic violence advocates and those who work with domestic violence when we see people who might be struggling with our programs and our services, we are thinking about that in a different way, and we're incorporating that knowledge of brain injury. So you know, Lisa talks about reading and shopping. I mean, even when you think about a task as-- for many of us who maybe haven't had brain injuries-- as simple as you go to the grocery store, and you just make your list, and you get all your ingredients, and there you are, right? Ready, steady, set to go. That is an advanced brain function. You think about it. It takes planning, right? It takes organization. And we're going to take just a minute to switch interpreters. All right, we good to go? All right, so when we think about those, those can be some of the cognitive impacts of brain injury. When we think about that, I think that the reason that starting to introduce some of this information to domestic violence survivors is so important and so critical because many domestic violence victims, as we heard earlier, the staff was talking about domestic violence victims might not be up front, might not be forthcoming with some of these symptoms because they might be trying to hide some of these things because domestic violence victims themselves don't have any knowledge and don't have any context about what happened, about why they're having a hard time remembering things, about why they might be having problems doing a job or performing or doing an activity that they used to do pretty easily and used to do pretty regularly and used to do pretty routinely. And I think that one of the things that we've learned about domestic violence working with domestic violence victims is them having some idea or some knowledge about what could be contributing to some of their struggles is incredibly empowering, incredibly relieving, and really, really helps them understand some of their struggles in a different way. We have people like Paula who, like I said, struggled for years and years around her issues related to the brain injury. And she was diagnosed with so many different conditions and different medical conditions and different mental health conditions. And it was really impacting her ability to be able to do her work and do her job. But she had a different understanding when that information about brain injury, about the possibility of head injury, and having people understand that when you have head trauma, that it can do things like make it harder to concentrate. It can do things like make it harder to write down simple tasks, make it harder to do some of those things. So many domestic violence victims and people impacted by head injuries have told me, oh, my gosh, I thought I was crazy. I thought I was stupid. Like, I thought I was stupid. I thought I was stupid. I thought, like, my partner has told me that I'm stupid and told me that I can't do anything and told me I can't get anything right. And then I go out, and I've talked with domestic violence victims who used to be accountants and have a really hard time with numbers and can't figure out why that's happening. So being able to share some information about that is so critical and so important. The other thing I want to talk about quickly, and I know that we're going to have a question and answer time in just a few minutes, is when thinking about strangulation and strangulation and what it is and the role that plays in domestic violence victims' lives. I don't know how many of you on this call have had training on strangulation or have done any kind of-- had any kind of education or training on strangulation. But one of the things that I think-- we know strangulation. We hear strangulation, it's terrifying. It's terrifying for domestic violence victims to experience. It's absolutely a lethality factor. So for those of us who work with domestic violence and talking about cues and risk factors and warning signs for lethality, strangulation is definitely one of them. What happens when somebody is strangled, and there's pressure that's placed on their neck, it actually causes a different type of brain injury. It's not a traumatic brain injury. A traumatic brain injury is when there's, again, something external, some kind of bump, blow or jolt to the head that's external. The reason in which our brain gets damaged when we're strangled is because-- remember how important oxygen is to our brain? It's due to a lack of oxygen. And we don't have enough oxygen in our brain. And what happens is when our brain cells don't have oxygen, the brain cells die. So I think when we think about strangulation, it's really, really important that we talk with domestic violence survivors-- we talk with domestic violence survivors about strangulation really being something that's serious kind of in the short term where we know that it takes very little pressure on someone's neck for them to lose consciousness. People can lose consciousness in a few seconds. It can be as little as 5 to 10 seconds that somebody loses consciousness. It can take 15 seconds for somebody to-- if you ever work with a domestic violence survivor or other survivors, human trafficking survivors that have been strangled, often what happens when people are strangled, they actually-- and we thought about this a lot when we were working on this project-- but they pee or poop accidentally. And most domestic violence victims think that happened because they were super scared, and they don't ever tell anyone about it because they're very, very nervous. I mean, they're ashamed. They're embarrassed. Like, who does that? If somebody loses control of their bowels or their bladder, that meant that there was pressure placed on their neck past them being unconscious. So what happens when our body starts to die? We release all of our bodily fluids. But I think it's also important when we're talking about strangulation to domestic violence survivors, it's not rare that nobody has marks on their bodies. A lot of people think, like, all right, that was scary, and that was terrible. But I guess I'm OK. So I guess I'm OK. But we don't talk enough about the long-term consequences, about how that can impact things like your balance. That can impact things like your-- it can impact things like talking about seizures. It can impact your vision. It can impact your kind of-- we think about the emotional symptoms and some of the mood control. It can impact all of those things. And what we know with brain injuries is that sometimes symptoms can end up coming later on, that they can end up coming later after. It could be they're not super obviously connected to the events. It might be a couple of weeks. It might be a few months. And most people wouldn't think like, oh, maybe I was strangled a few months ago, so that's why I'm bumping into all of these different walls everywhere. I do want to spend the last-- I know we're getting ready to do some question and answer. And I don't know if you're able to do this, Kaitlin, or someone is able to share a screen and pull up, we have a website, the Ohio Domestic Violence Network Website. I don't know if I'm able to share a screen when I'm on my phone, and I don't want to get disconnected. But if you go to the Ohio Domestic Violence Network, ODVN.org, and under, there's a tab that says What We Do-- I'm pretty sure it's What We Do-- you will see the very first block under What We Do says, Brain Injury. And it talks about our CARE framework, which is a framework that if we have time, I'll talk about it a little bit in the questions, and some of the CARE tools that we have developed. We've developed educational tools for domestic violence survivors. We've developed tools for advocates. We've developed tools for advocates who [INAUDIBLE] work. And we've developed some promising practices. All of our materials that are for domestic violence and therefore domestic violence and advocates are available on our website in both English and Spanish. So I think that there's a lot of and what I want you to feel like-- oh, thank you so much whoever got my back. So yeah, click under Our Work. Thank you so much. And right on there, you'll see it says brain injury. And it will come up in just a minute. I see everybody's computer is not feeling it today. There we go. So if you look here, this is where all of our resources-- that's the video that you saw earlier from Ohio State. And if you scroll down a little bit more, you'll see on the CARE-- under CARE Brain Injury Materials, those are all of the materials that are available for you to click on. And you can download them. There's educational materials at the top. You'll see them in English and Spanish. And then, if you go down a little further, there's materials for service providers. And there's more information on our research, more information on what we do. So I encourage you to please take your time and spend some time on some of those different resources. Maybe we'll discuss those a little bit later. But I wanted to, and I want to take some time to get to some questions. But I think what I really want your takeaway from today to be is really, really thinking about the power that you have and the power that we all have to really think about how we're thinking about what we see in domestic violence programs or in any kind of services that you're providing, how we think about that in a different way. And if we are seeing people that are struggling, there are lots of reasons why people struggle. It's really, really hard to do things after someone has been traumatized. But if people are having problems, we should absolutely be thinking about and asking direct questions about if they've been hit and hurt in the head or if they've been choked and strangled. And there are some tools that are available. We kind of developed this project so training, of course, will help, but the other thing is you don't need to have 20 hours of TBI training to be able to talk about this. We're not diagnosing any brain injuries. That is something only a medical provider does. But raising awareness and sharing information really helps domestic violence victims better understand what happened to them, better contextualize what they're struggling with, and then we're able to work with them and provide accommodations around helping them get our services and helping them get the other services that they need. So I'm going to be quiet for just a minute, bring Kaitlin back on, and sorry, I sound-- I'm sounding more and more like a frog as we-- this is my-- I don't know. This is my tenor voice for choir or whatever. But I'd love to hear some of your questions. KAITLIN SHETLER: Rachel, first, I want to say this is Kaitlin. First, I want to say thank you so much. I mean, even in the midst of trying to deal with technical issues and losing your voice, this has just been a phenomenal presentation. And we can see that if you ever get a chance to look at the chat, we will save that for you because we have a lot of stories that are being shared. We are very grateful for those of you who have shared some of your experiences and stories. We've got great expertise also coming in in the chat, just talking about situations where people have worked with survivors and just their clients and the people that they have been able to serve. And so we have a lot. We have some resources also being shared in the chat. So for those of you who haven't had a chance to look at the chat, go ahead and do that because it is just full of really great information. I want to go ahead and move on to the Q&A. It's just filled with so many questions, so many great questions. We also got a lot of questions when people filled out the registration. And so I will be going back and forth, but I do want to let you know, most likely, we will not get to everybody's question. We will try. But if we don't, we will try to follow up with you so that we can get you connected with Rachel for further questions that you might have. Or we possibly can answer some of those as well. So we are looking at everything. We will address everything but possibly not in this time together. I want to take a second to do a final interpreter switch. We've got about 15 more minutes together. Great. Thank you. OK, Rachel, we have a lot of questions here. The first one that I wanted to talk about because I think that this is probably a very easy one to provide people information on is Kathleen had asked where you found your graphics on the brain to link to trauma. So you have some really great graphics in your presentation. And one of the things that people are wondering is how to get good visuals to help people understand trauma in the brain in context of DV. We have some other questions around the same thing. How do we bring this information in the most accessible way, not only to people who are working with this population but also to this population in general to help them understand. So I was wondering if you had an answer to that. RACHEL RAMIREZ: OK, well, I'm sorry. So I think that-- I mean, I know I did some of the graphics. Please feel free if anybody has questions about that, I'm going to make sure you have my PowerPoint to share. I always said, particularly when I'm talking about the brain, I don't know how many of you are old enough to understand the-- remember, Cliffs Notes? So if you remember Cliffs Notes, before the internet, there were these little books that was like, it was like eight pages about the Shakespeare play you had to read in high school that you didn't quite understand. But I think it's really, really thinking about making information, when we talk about making it accessible, making it concrete, making information-- not giving people more information than they really need, not that we shouldn't have that additional information available for people. But how is it that we really need to think about simplifying things? One of the-- and I think that with some of those CARE tools that Kaitlin shared with you that are available on our website, we spent a lot of time developing those, a lot of time. One of the things that we actually asked domestic violence programs when we were talking with them was, do you have any resources that specifically address the intersection of domestic violence and brain injury? And people said, well, I have this like concussion sheet from the Ohio Department of Health when a kid gets a concussion in soccer, and it just didn't really fit. But they said, information needs to be clear. It needs to be in plain language. We very intentionally avoided the terminology brain injury in all of our materials for two reasons. One, we had advocates tell us, that's freaking scary, and people don't know a lot about brain injury. And like I'm hearing now, someone's telling me I have brain damage, and what does that mean? Second is brain injury is also a medical condition that gets diagnosed by a medical professional of which none of us are. Just like I wouldn't ask a couple of questions about-- so again, I wouldn't say, somebody's got a-- you've got a sniffy nose, you've got this, oh, well, you must have COVID. Like, no. You know what I mean? That's something that needs to be diagnosed by a medical professional. But the other analogy I've used a lot when working in training and working with survivors is really thinking about one of the reasons why the information is so important to share with survivors is-- I use analogy a lot. Like, if people break their legs, they know that they can't walk as well, right? And they have a cast, and they're slower, and they have accommodations, right? And they have devices that help them. And if we see somebody with a broken leg, and we're behind them, we're not like, oh, my gosh, why are they taking forever? I don't know why it takes them so long. This is super annoying that I have to wait for them. They're like, hello, you have a broken leg. You can't walk as fast. Of course, you can't walk as fast. Nobody expects them to walk as fast. I don't expect myself to walk as fast. I don't expect the things I normally do to be as easy. And we often help people. If we see someone on crutches trying to open a door, we go help them, right? And I think having that same knowledge in thinking about our brains job-- like our legs' job is to walk and run and get us around, our brain's job is to think and focus and make decisions and prioritize. And when our brain is hurt, it just doesn't do it that well like any other part of our body. And again, when we break our legs, we don't walk as well. If we pull our back muscle, it's harder for us to sit. It's another body part, thinking about it like that. But what's important is when people don't have the expectation. Everybody's still having an expectation that that person with a broken leg is going to get out and run in gym class. No. And so really thinking about it from that way, I think that has been an analogy that has been really helpful and has helped people think about things. I also think that it is really important to just think a little more critically. This isn't something that I thought very critically about before I did this work. I just didn't even think about that whole thing about when we worked in domestic violence, and people are like, people just need to take the bus. Like, you don't just take a bus. You have to get to the bus. You have to get organized enough to get to the bus. And then, you have to get on, and you have to get off on the right stop. And you have to know how long it is. And you have to be able to use the turn. I mean, and that's something that I've really learned from friends in occupational therapy about how many things it takes to take the bus. So I think really thinking about those. But I think, again, it's just that whole piece where if anybody has ever had a health problem or not felt right, and they can't figure out what it is, and you don't know why, many domestic violence victims have gone to people and have been told that it isn't real knowing that it's real. And then when you know what your challenges or your sensitivities are, then we can plan around them. So if you're really sensitive to light, we'll help you with sunglasses. If you're really sensitive to hearing, we can think about noise. But then if you're feeling bad after that, you know why it is and you know it's not just you. KAITLIN SHETLER: Terrific. And I think you bring a lot of things up that are important to think about. I also think that that is coming into a few questions that we've seen. I've seen them asked a couple of times on the Q&A. And then, we had a lot of these questions come up during registration bringing up the point that, a lot of times, this is not a standard screening question when injuries are presented in the ER. And you talked about that. And a lot of medical providers are not quite sure about what this means in looking for it and all of that. So what would you suggest as people start thinking more critically about this? And as you're serving survivors in raising this conversation, how do you do that? How do you have these conversations within the medical field? Because, like you said, doctors are the ones who are going to diagnose. And people are worried about, if this isn't getting in people's histories or if this isn't written down for people, or they don't have the diagnosis, what do you as a service provider, how do you interact with that? How do you impact that? How do you make changes within the medical community? RACHEL RAMIREZ: Well, I think that there's a couple of pieces. First of all, I think that we're kidding ourselves if we think we can find this like perfect question that we ask and that everybody will say yes to. And that's something that we know about screening about domestic violence even in medical settings. We know that people disclose domestic violence very, very rarely. We know that many people who experience domestic violence say no if they're asked directly about domestic violence. So I think that there's a couple of different strategies. I think, first of all, providing education and information about brain injury, including some of our CARE tools that we have that are on our website that I showed you, having those available for people. So I think that one of the challenges that we have with screening is when we use a strategy that's screening, people only get information if they disclose. So if somebody says, have you ever been hit in the head? And you're like, no. Then, you're like, phew, don't need to talk about that. I won't share anything about that. Are you are you safe at home? Yes. OK, I don't get the phone number for the domestic violence program. I don't get those kind of things. I think that the other thing, though, what we've had some-- we've had some success with some of our tools that we have that are available on the website that lists symptoms. We've had some domestic violence survivors actually bring some of those. We have different tools that have like different places where you can write down your symptoms and chart them and those kind of things. And you can always follow up with me for more information about those. We've had some success with people actually taking those in to medical providers and being like, I have been-- but thinking about the stigma, like, I have been hit or hurt in the head this many times. I'm having problems seeing. I'm having this and that. We actually had a hospital that reached back out to us and was like, thank you for sending that because it's just not something that any of us have ever thought about. But I think, again, asking direct questions about, have you ever been hit or hurt in the head? I'm asking those questions about when we talk about choking or strangulation. We know a lot of people don't really identify with that strangulation language. And there's actually a tool that we have called Chats. That's, again, available on our website on that page. And you can follow up. I'll make sure you have my email address if you need any more direct links about that. That has direct kind of yes or no questions about this. But it includes asking questions about, you know, our choking question. People use the language choking a lot. Have you ever had anything done to you that made it hard to breathe because there's so many different ways in which the violence can happen to domestic violence survivors. They're choked. They're put in chokeholds. They're sat on. They're attacked from behind. They've got a hand put over their nose and mouth. So asking about some of those kind of behavioral pieces, thinking, have ever had a hard time breathing, has anybody ever done anything that had a hard-- that people had a hard time breathing, are questions that can be asked. But I think what's even more important is providing people with information and saying that we know that head injury in domestic violence is common. Here's some information about it. Having that available in waiting rooms, having that available in emergency rooms, having that available in domestic violence programs, so people don't have to disclose to us in order to get information because there are many, many, many reasons why people don't share that information. And it's not because they're lying. And it's not because they're hiding things from us. There's just a lot of-- anytime a domestic violence victim discloses abuse, they're taking a big risk. So I think that it is. But we know when we talk about how we don't ask these questions, not even on-- we have no population-based surveys that even ask questions about domestic violence directed at the head, neck, and face. We just don't ask, did the abuse happen here? So I think that really thinking about-- please, again, look at some of those educational tools that we developed. We also know that you all are really, really busy and don't have time to kind of invent totally new ways of doing things. So we have some. We've hopefully helped develop some tools that are useful to the field that you can just kind of pick up and spend some time with them. We are going to have an e-learning series that's going to be online, some short courses that are 10 or 15 minutes long that should be online at the beginning of the year that will be available for service providers to learn about too. KAITLIN SHETLER: Terrific. Thank you so much, Rachel. And I think definitely check out those resources. Rachel is also, and she mentioned it, but working on a project right now where she's collaborating with other programs across the state to have these conversations where it's not just in domestic violence program, but it's also working with a nursing network. It's also working with people who are in the medical field. And so those are-- that work is great. I'm excited to see what comes out of that. And I think that collaboration is really important. We have about three minutes, but I do want to lift up something that I have seen a lot in our Q&A and also some in our registration, talking about intersectionality and finding this-- finding this research that really speaks to the experiences of people who hold marginalized identities. So a lot of the discussion has been around cis white women who are experiencing this. And what research is there out there or programs out there that are going to focus on people who hold identities that are not that identity? Is there any? What kind of work exists? RACHEL RAMIREZ: Well, and I think, again, I think that it's a very important and very valid point and very critical that we're bringing in all those intersections. My research partner who works with Ohio State, her actually main population she works with is runaway and homeless youth, which is a largely-- and she actually, one of the things that she realized as she started asking questions about exposure to head trauma with work that would seem totally unrelated. She works developing behavioral intervention changes. And as she started to learn about work in domestic violence and the role of brain injury and thinking about all of the cognitive functions we need to be able to make behavioral intervention changes, she started asking these questions around her runaway homeless youth, the participants in her work that she was doing, which were largely gender and sexual minorities, and asking those questions around head injury, around both intentional and accidental head injury. We know people can also have-- people fall off their bike and get concussions. I mean, that can happen, too. But really, really looking at the role that structural violence plays. When individuals who have these intersecting identities come into contact with people, we know that anger looks different depending on how you look and how we interpret that and what that is and what assumptions we make about that. So I think that that's-- and I mean, I think that part of that work is really helping us think about how unidentified head injury really is fueling health disparities. So we're very-- and I think that it's one of the things that's-- and that's a part of the upcoming project that we're working on, Kaitlin, with the Brain Injury Association of Ohio and the Forensic Nursing Network is being very intentional about bringing those dialogues into it. Right now, I'm just kind of like, these random people who reach out to me, there's so little work in this. But I think that integrating that understanding. We still have-- it's like we're at the very tip of the iceberg on this, but at least we know there's an iceberg. I think that that's kind of where we are. We're starting to figure out what questions we need to be asking. We don't know the answer to those questions. So I'm hoping to be working with you all to continue to keep figuring this out as we move forward and move along and really grateful to the support that Vera has provided for us to be able to continue to further this work. KAITLIN SHETLER: Great. Thank you so much, Rachel. Thank you so, so much. I'm really excited that we are lifting up this topic to a large group of people. I hope you really enjoyed our webinar. Thank you so much for participating. We're going to ask you to complete a brief evaluation which should pop up when we end our webinar. We'd appreciate it if you could take a few minutes to share your thoughts with us so we continue to work to meet your needs. As a reminder, a recording of this webinar and a transcript will be posted to our website following the webinar. A link to the record of attendance is available in the chat. So thank you again. Have a great afternoon. We will keep the chat up for a few minutes. And thank you again, Rachel. We hope to see you soon. RACHEL RAMIREZ: Thanks. I'll still be here if anybody-- I'm going to look at the chat. And please feel free to reach out to me. As you can tell, a couple of days and my voice will be better. But I love talking about this more than anything else in the world. So thank you all for being here and hope to see you again soon.