Traumatic brain injuries (TBIs) have been called the signature injury suffered by veterans of the wars in Iraq and Afghanistan and have been singled out as a risk factor for the development of dementing disease among world-class athletes.
With growing awareness of TBIs, assessing for and integrating TBIs into case conceptualizations may now be common practice when working with clients who have histories of contact sports, combat or serious motor vehicle accidents. But another group at high risk of unrecognized and repeated head injuries urgently needs our clinical attention: survivors of intimate partner abuse.
What is a TBI?
TBIs occur when an external blow to the head disrupts normal brain function. Disruptions are generally assumed to be present when clients report decreased consciousness, memory loss for events immediately before or after the injury, neurologic deficits (e.g., muscle weakness, disrupted vision) and/or alteration in mental state at the time of injury.
TBIs can range from mild to moderate or severe. Symptoms in the aftermath of a head injury can include cognitive problems with thinking, attention and memory; physical symptoms such as nausea and dizziness; emotional and mood problems, such as anger or irritability; and sleep problems.
Most people with mild TBIs recover without incident. However, severe and repeated TBIs are linked with serious and costly long-term health problems, including suicidality and an increased risk of developing dementing diseases later in life.
Though the vast majority of TBI research has been done with men who sustain injuries in combat or athletics, research that has included women suggests that they may have worse outcomes following TBI. Specifically, women experience more post-injury symptoms and have a higher rate of long-term disability. They report poorer physical health, more cognitive difficulties including executive dysfunction and memory deficits, and more severe mood disturbances including depression and suicidality. After a TBI, women are overrepresented on both ends of the health care usage continuum—using many more and far fewer services than other women. Notably though, 50% of women with TBIs report that they do not receive the care they need, particularly for their mental health complaints.
TBI and Intimate Partner Abuse
Recognizing the high stakes for women with TBIs, a handful of studies have now documented alarming rates of head injuries among women who have survived intimate partner abuse. Rates range from 38 to 92% among women seen in shelters and emergency room settings following severe intimate partner abuse.
High rates of head injuries have been documented outside shelters and emergency rooms. Among women who had a range of domestic violence incidents reported to police—from violations of protection orders and stalking to violence that resulted in minimal to severe injuries—13% percent reported being hit in the head or a loss of consciousness during the incident that prompted contact with law enforcement. Nearly one in ten women reported a head injury caused by an intimate partner in the six months before the police-reported incident. Women’s reports of lifetime head injuries were even more startling. The majority (80%) of women screened positive for a head injury and more than half (56%) met screening criteria for a mild TBI, defined as a head injury with a change in consciousness or a period of being dazed and confused. Another 12% of women did not report changes in consciousness but were concerned enough about the head injury to seek medical care.
Justice-involved women who are on probation or incarcerated also face high rates of intimate partner abuse and TBIs. Health care professionals in the criminal justice system estimate that 75% to 90% of incarcerated women have histories of intimate partner abuse, and research suggests that nearly all of those episodes of violence include blows to the face and head. In jails, women with TBI are more likely to have sustained their TBI prior to their first criminal offense and TBI is uniquely associated with an increased risk for violent behavior among women. Women in jail with a TBI history have a rate of violent infractions that is 144% higher than their peers in the facility without TBI.
In our research, the rate of reported TBI history in a women’s specialty court was 97%. Gender was significantly associated with multiple TBIs and multiple violence-related TBIs where women were twice as likely as men to incur multiple TBIs of any kind and six times more likely to have multiple TBIs related to violence. These violence-related TBIs were associated with more complaints about physical illness and these violently injured women had longer total incarceration times due to multiple rearrests.
Violence-related TBI is associated with much poorer outcomes than TBIs arising from nonviolent causes. Women with violence-related TBIs do not reintegrate into the community as well, show poorer social productivity and have higher rates of public sector income sources compared with survivors of nonviolent TBIs. In one prospective study of TBI survivors, the unemployment and divorce rate at one year increased more in a violently injured TBI group than any other group with TBI.
The long-term risks of violence-related TBI are compounded when those injuries occur in close proximity to each other. Women who are victims of intimate partner abuse are at risk of multiple head injuries within a single violent episode as well as repeated injuries over time. Repeated TBIs are associated with an increased risk for cognitive decline, poor physical health outcomes, poor mental health outcomes and increased risk of substance abuse. The accumulation of multiple injuries may also increase the risk of developing neuropathological conditions like dementing disease as these women age. In real time though, persistent TBI symptomatology may also affect women’s risk for intimate partner abuse; for example, neurocognitive or affective problems may create vulnerabilities that offenders seek to take advantage of.
And, as startling as these rates are, they likely underestimate the realities of brain injuries after intimate abuse because TBI measures have not typically included strangulation. Strangulation can also injure the brain by cutting off the flow of oxygen, though without a blow to the head. These acquired (ABI) or anoxic brain injuries are often ignored in brain injury research, so the true incidence of brain injury among these women remains unknown.
Aside from the potential health and victimization risks that brain injury may confer—whether arising out a blow to the head or strangulation—intimate partner abuse and brain injury also share common cognitive, emotional and behavioral correlates that are important for clinicians to consider given the potential for impact on survivors’ clinical presentation and their efforts to get help. For example, TBI and intimate partner violence share links to depression, PTSD, suicidality and emotion dysregulation. Unpacking whether symptoms are due to TBI or PTSD can be especially challenging. And attention and memory problems resulting from TBIs can make getting to and through the right doors for needed services even more difficult. After all, navigating criminal justice, health care and other systems can be challenging even on a good day.
Screening Considerations
The gold standard for the identification of brain injury is a medical records review and a neuropsychological examination. Because this approach is not always possible, identifying a brain injury history often relies on self-report and TBI screening measures. Similarly, the gold standard for the identification of cognitive deficits is a comprehensive neuropsychological evaluation that is often not universally available. As a result, TBI and neuropsychological screening batteries are often used to gauge a person’s head injury history and cognitive functioning.
Several TBI screening measures are available in the public domain. For example, the Ohio State University TBI Identification Method is a brief interview that helps identify the first, most recent and whether there have been multiple TBIs. The HELPS Screener, which has been used in intimate partner abuse research, includes three items on head injury and a list of potential symptoms (e.g., dizziness, headaches).
Treatment Considerations
Case conceptualizations and treatment planning should consider the unique vulnerabilities that may be conferred by the brain injury. Clients with histories of intimate partner abuse and TBIs will likely require additional supports. For example, clients might benefit from multiple reminders, having information written down, and care delivered in settings that minimize distractions. Integrating specialty brain injury services into care and modifying therapies to accommodate changes in clients’ cognitive or emotional functioning may both maximize therapeutic benefit.
Yet, clinicians will have to balance typical supports with safety considerations. For example, therapists often address safety planning with clients who are being or have recently been abused by partners, but clients with TBIs may have difficulty remembering or organizing safety plans. While writing down information is common for clients with TBIs to support their memories, clients and clinicians will need to evaluate whether writing safety plans down may inadvertently increase clients’ risks, say if abusers find the plans. In addition, clients with TBIs may face problems accurately appraising risky situations, potentially contributing to risk for ongoing or new victimization. Thus, integrating a focus on safety in many forms may be especially important.
Growing attention to intimate partner abuse and TBI has also inspired new resources available for clinicians as well as clients and their families. For example, the ABI Research Lab offers a website with toolkits on Brain Injuries 101 and Trauma-Informed Care.
About the Authors:
Anne P. DePrince, PhD, is a professor in the Department of Psychology at the University of Denver. Her research and clinical experience focus on the consequences of violence against women and children.
Kim Gorgens, PhD, is a clinical professor in the Graduate School of Professional Psychology at the University of Denver. Her research and clinical experience focus on the assessment and treatment of traumatic brain injuries.