Invisible Injuries: Traumatic Brain Injury, Domestic Violence and Strangulation

Rachel Ramirez, LISW-S, RASS
Ohio Domestic Violence Network

Image: Being choked, strangled, or hurt in the head can cause a brain injury. Getting help can save your life. Learn more by scanning the code or visit www.odvn.org/brain-injury-survivors.

What Do You Think? (1) 

What is different about an acquired disability than a disability present at birth? 

Fact
This is terrible violence to experience, hard stuff to discuss, and itÕs us too. 

Intersections
Image: A Venn diagram with one side labeled DV/SV/HT/Violent Crime and the other side labeled trauma.

Definition of Domestic Violence 
¥A pattern of behavior in any relationship that is used to gain and maintain power and overt control over their partner.
¥Coercive controlÕs goal is to strip away a personÕs freedom and sense of self. It can often include degradation, mind games, surveillance and micro-regulation of a personÕs life. 
Image: A power and control wheel. ÒPower and control,Ó Òphysical violence,Ó and Òsexual violenceÓ are at the center. The spokes are Òusing coercion and threats,Ó Òusing intimidation,Ó Òusing emotional abuse,Ó Òusing isolation,Ó Òminimizing, denying, and blaming,Ó Òusing children,Ó Òusing male privilege,Ó and Òusing economic abuse.Ó

Types of Domestic Violence
Economic Abuse
Sexual Abuse
Psychological Abuse
Physical Abuse
Emotional Abuse

Substance Use/Mental Health Coercion
¥Used by abusers to maintain power and control, increase dependence on abuser, and decrease credibility 
¥Use of substances or maintenance of mental health may not always be in a personÕs control.  
¥Punitive behaviors addressing what appears to be non-compliance can be retraumatizing and defeating.

What Do You Think? (2) 
What are some examples of mental health coercion and substance use coercion? 

What Do You Think? (3) 
How often are the domestic violence survivors you work with hurt in the head, neck, and faceÑincluding strangulation? 

A Significant Missing Piece
Video: Brain Injury Common in Domestic Violence
www.youtube.com/watch?v=zp7uBCJ6Sko&t=85s

What Do You Think? (4)  
How often do you work with people using substances or who have overdosed? 

The Missing Piece
Image: A Venn diagram with three circles: domestic violence, trauma, and brain injury.
WeÕve missed that repeated head injuries and strangulation lead to brain injury. 

What causes concussions or traumatic brain injuries?
Image: A car.
Image: Two veterans in suits and medals, one sitting in a wheelchair and one standing.
Image: Two football players running on a football field.
Image: A dark-skinned survivor sitting with lightning shapes fracturing her shadow.
For every 1 NHL player:
5,500 survivors of DV sustain a brain injury each year

Every Brain Injury is Unique
Image: A model of a brain.
ÒWhen youÕve seen one brain injury, youÕve seen one brain injury.Ó 

Strangulation

Significant safety and lethality risks
Terrifying and traumatic tactic of coercive control
Very dangerous abusers
Increases lethality risk 7.5 times (once) to 10 times (repeatedly) 
Safety planning is very important!
Often no external signs or marks

Other lethality factors
Abuser uses or threatens with a lethal weapon, owns a gun or can get one easily
Abuser tried or threatened to kill survivor or children
Increase in violence severity or frequency
Constant jealousy, control of activities, following or stalking
Abuser threatened or tried to commit suicide

Strangulation is traumatic & a cause of brain injury
Restricting oxygen and nutrients to the brain causes hypoxic-anoxic brain injury
Survivors donÕt call it strangulation: choking, put hands on neck, grabbed me, etc. 
Survivors often unsure if they passed out or lost consciousness
Survivors have signs and symptoms of brain injury as well as strangulation  
Strangulation is often minimized and brain injuries are unidentified and unaddressed

Traumatic Brain Injury (TBI)

What Do You Think? (5)
What do you know about concussion or traumatic brain injury? 

A TBI Involves:
External force to the head or body and disrupted brain function 
Image: A Black woman touching the sides of her head and grimacing.

Traumatic Brain Injury (TBI) or Concussion (1)
Mild TBI and concussion are two terms for the same thing
Clinical diagnosis-there is no conclusive test
Victims are unaware 
It looks different with everyone, and impact varies greatly
Effects can be temporary or permanent

Traumatic Brain Injury (TBI) or Concussion (2)
Signs and symptoms donÕt always appear right away
Repetitive head trauma is particularly damaging
Sub-concussive hits have a significant impact
Imaging is not reliable to diagnose brain injuries
Managing symptoms is key to treating brain injuries

Impacts and Symptoms

Brain Injury Changes How Survivors Think, Feel & Act
Thinking/Cognitive
Physical
Emotional/Behavioral

Voices of Survivors
Nina
Image: A tan woman with wavy brown hair and glasses.
Rebecca
Image: A white woman with red hair in a floral shirt.
Paula
Image: A white woman with a brown bob wearing a cardigan.
Signs and symptoms that were noticed but not connected to brain injury
https://vera.wistia.com/medias/a5ifq26rn6

Cognitive Impairment
Problems with a personÕs ability to think, learn, remember, use judgment, and make decisions. 
Image: A head silhouette with question marks where the brain would be. The head is facing towards more question marks.
How someone processes information and thinks.

Functional Limitations
Restrictions in performing everyday activities due to physical or mental impairments. 
Image: A head silhouette with question marks where the brain would be. The head is facing towards more question marks.
What someone can do.

Concussion Symptoms
Survivors may experienceÉ
¥Physical symptoms
¥Cognitive symptoms
¥Emotional symptoms
¥Behavioral issues
¥Sleep based issues
Image: Rivermead Post Concussion Symptoms Questionnaire, which lists symptoms and asks the survivor to compare their symptoms before and after the injury.

Strangulation 
Survivors may experienceÉ
¥Neurological changes (brain injury)
¥Voice and throat changes
¥Breathing changes
¥Injuries to scalp, mouth, neck, face, eyes and eyelids, and ears, and chest
Image: A poster titled Signs and Symptoms of Strangulation, which lists a number of symptoms and shows them illustrated on a white woman in the center.

Common Brain Injury Symptoms 
Difficulty understanding directions
Appears to be slow or non-responsive to requests
Trouble remembering things
Rapid mood swings with no apparent reason
Difficultly with organization and multitasking
Acting impulsively with others
Responding too aggressively to others
Anxiety, depression and withdrawing from social interaction
Being more sensitive to lights and sounds 

Supporting Survivors with Traumatic Brain Injuries

Won't or Can't? 
Changes how we see things
Service Provision Perspective
Image: Two wooden mannequins pointing at a number on the ground between them. From the left mannequinÕs perspective, the number is a 6, and the mannequin has a speech bubble saying 6. From the right mannequinÕs perspective, the number is a 9, and the mannequin has a speech bubble saying 9.

Ohio Domestic Violence Network
Image: A printable card reading Òbeing choked, strangled, or hurt in the head can cause a brain injury. Getting help can save your life. Learn more by scanning the code or visit www.odvn.org/brain-injury-survivors.Ó

CARE Framework
Image: To the right, the CARE logo, a heart with several connected dots inside it over the word CARE. To the left, the words connect, acknowledge, respond, and evaluate form the acronym CARE.
A brain injury aware, trauma-informed framework focusing on awareness, accessibility, and accommodations. 

Next Steps
Educate: Yourself, survivors, colleagues, and others
Accommodate and Strategize: Provide services and support survivors in a way  that meets unique needs
Collaborate: With each other, DV programs, brain injury services, and other partners
Image: The CARE logo and acronym.

Pink Concussions
Image: The webpage Pink Concussions, with the tagline Female Brain Injury from Sports, Violence, Military Service.

What Do You Think? 
What is one next step for you?

Contact
Rachel Ramirez, LISW-S
Director of Health and Disability Programs
Founder of The Center on Partner-Inflicted Brain Injury
RachelR@odvn.org

Image: The Ohio Domestic Violence Network logo, the state of Ohio with several connected dots inside, next to the letters ODVN.