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Life-changing brain injuries in domestic violence survivors going unrecognised

Wednesday, 22 December 2021

Family violence isn’t always a scene from Once Were Warriors. More often, it’s about men controlling women, sometimes without physical abuse at all. (Video first published in September 2020)

Think of concussion, and you jump to the rugby field, car accidents and nasty falls from ladders. But Aotearoa has the highest rate of domestic violence in the OECD, and research overseas shows three quarters of victims may suffer a brain injury at the hands of their abuser. Josephine Franks reports.

After 18 punches to her head, Beth* lost count.

Between the blows she yelled for help, hoping a neighbour would hear. It was her 5-year-old daughter who walked through the door, saw mum pinned to the floor by dad, his fists flying.

Beth says she owes her life to her daughter. Nothing else would have stopped her husband.

**READ MORE:

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* Disabled people report higher rates of sexual, physical violence, new research shows

Brain injuries caused by domestic violence can lead to a number of symptoms, including memory loss, confusion, anxiety and nausea that can have lasting effects on victims.
Brain injuries caused by domestic violence can lead to a number of symptoms, including memory loss, confusion, anxiety and nausea that can have lasting effects on victims.

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She called the police that night, but didn't go to hospital. She didn’t realise her husband had given her a brain injury that would keep her off work for more than two years and change the course of her life.

Beth is one of hundreds of thousands of women in New Zealand who will sustain a brain injury in their lifetime due to intimate partner violence.

Exactly how many women is hard to say. Research in Aotearoa is in its infancy, so experts look to data from overseas. A study in Australia found 40 per cent of domestic violence victims attending hospital had a brain injury. Other studies put it at 74 per cent.

Dr Eve Valera, an associate professor at Harvard Medical School who has spent more than two decades researching this, says the rate could be as high as 100 per cent, but she could confidently say a third of domestic violence will suffer at least one brain injury.

Symptoms include extreme fatigue, nausea, vision and hearing problems, poor concentration, anxiety and depression.
Symptoms include extreme fatigue, nausea, vision and hearing problems, poor concentration, anxiety and depression.

With almost one in three women in New Zealand experiencing physical violence from an intimate partner in her lifetime - the highest rate of intimate partner violence against women in the OECD - one in nine women could be expected to sustain a brain injury related to domestic violence. That’s about 200,000 women.

Rates of violence are higher for Māori, migrant and New Zealand born non-white women, and disabled women, so rates of brain injury are likely to be higher in these populations.

Many won’t realise it has happened. They might not seek medical treatment, and if they do the brain injury won’t always be picked up. They may experience confusion, memory loss and problems processing information: symptoms that keep them trapped and give more power to their abuser. The injury could affect them for the rest of their lives.

Beth doesn’t remember much from the days after the assault. “I was so broken,” she says.

“I couldn't walk without holding on to furniture and my blood pressure couldn't regulate itself. My circadian rhythms were all out so I didn't sleep well.”

Brain injuries affect everyone differently. People will have different combinations of about 20 symptoms depending on what part of their brain is affected, explains Professor Alice Theadom, director of the Auckland University of Technology’s TBI Network. They might experience extreme fatigue, nausea, vision and hearing problems, poor concentration, anxiety and depression.

Beth found any brain stimulation “horrific”. Her balance went, she was incredibly sensitive to light and noise, but worst was she couldn’t be around her children “even though they needed me so desperately”.

She couldn’t even change a nappy. Her mum moved in to look after the children, aged 5 and 1, while Beth lived in a motel for three weeks.

“I just had to totally let go.” It was heartbreaking, she says, “the hardest thing I've ever done in my life”.

Within 10 minutes of the assault she was dealing with police. Then there was ACC to navigate, doctors’ appointments, statements to give, lawyers, a protection order.

Women’s brain injuries aren’t being picked up by people who are supposed to help them, Dr Debbie Hager says.
Women’s brain injuries aren’t being picked up by people who are supposed to help them, Dr Debbie Hager says.

“Navigating all of that with a brain injury was nigh on impossible. I kept having lawyers ask me to give them an affidavit. I couldn't even remember what was in the fridge, or what the word for table was.”

She couldn’t read or write – looking at black on white made her want to vomit - so she was reliant on friends and family to record the details of eight years of abuse. The assault was the first instance of physical violence, but the aggression, threats and fights were longstanding.

Beth got a protection order two months after the assault, and her husband did not contest it.

Women who have brain injuries may find it harder to present themselves in court when fighting for protection orders or custody.

“If a woman is not articulate, if her stories about what happened change because she’s confused, she’s having memory problems … if she’s frightened and therefore less able to remember what she wants to say, I think she’s got practically no hope of being taken seriously in the Family Court,” Dr Debbie Hager of the University of Auckland says.

“What this means is that women, children, are put at risk constantly through this process, because they are given to the abuser who appears in these situations to be more credible.”

Holly Carrington says awareness about brain injury is growing, but there’s a lack of training around it.
Holly Carrington says awareness about brain injury is growing, but there’s a lack of training around it.

Women not being seen as credible is a barrier to them getting help at every turn: when police are called, when they access refuges, in the court system.

When Holly Carrington, now a policy adviser for domestic violence charity Shine, worked on its helpline, she’d often talk to women who had slurred speech. They sounded drunk, but probing would reveal a head injury.

“You can imagine how hard it would be to get help when everybody who first hears you talk, thinks that you're drunk. You’re just going to be dismissed,” she says.

Advocates talk of survivors saying things like “I lack a filter, I’m forever getting my mouth in trouble”, or “I have difficulty thinking, or I have difficulty remembering, or I get really confused”. These women are labelled as erratic, difficult, impulsive, not willing to engage.

That should be raising the alarm that someone has a brain injury, Hager says.

There’s growing awareness of brain injury in the sector, Carrington says, particularly since strangulation was criminalised in 2018. A brain injury can be caused by events familiar to advocates, people being punched in the head, slammed into walls, shaken, strangled. But there’s a lack of dedicated training about brain injuries, Carrington says, meaning stretched refuges won’t always spot the signs.

Members of AUT’s TBI Network, a group of academics and services researching traumatic brain injury, were involved in a project talking to domestic violence providers. They reported wanting to help women, but struggling as they weren’t trained medics and can’t diagnose, Theadom says.

When a woman with a brain injury seeks help to leave a relationship, it can be difficult for her to understand and assess what she’s being told, Hager says. She might be unable to remember an exit plan, or forget to return calls or meet people. It can trap women with their abusers.

“If services you’re trying to access aren’t perceiving you as credible … if the police, if the justice sector aren’t taking you seriously, then you are stuck – and you become increasingly stuck.”

Dr Doug King says little is understood about brain injuries in domestic violence victims.
Dr Doug King says little is understood about brain injuries in domestic violence victims.

Hager describes a conversation with a woman who had been struggling to leave a violent relationship, who displayed all the signs of brain injury. When Hager asked if she’d ever been hit in the head, the woman told her, “I've still got the hammer marks on my head”.

“Nobody had ever assessed that woman for a brain injury. Not even a doctor. No-one. And yet she was struggling with all of those problems, with memory loss, with confusion.”

She was trapped in a “perilous situation”, Hager says, “being treated as difficult by everyone she went to”.

“If she was playing rugby, she would have had fantastic services offered to her, but because she’s in a violent relationship there’s nothing.”

Dr Doug King has spent more than 20 years researching sports-related concussion and works as clinical nurse specialist at Hutt Hospital’s emergency department.

What we know about sports injuries dwarfs what’s known about domestic violence-related brain injuries 10 to one, he says.

Brain injuries may not be picked up in domestic violence survivors, even when they seek medical attention.
Brain injuries may not be picked up in domestic violence survivors, even when they seek medical attention.

A sports concussion is easier to deal with. Abuse survivors are likely to display the psychological impacts of trauma, including post traumatic stress disorder (PTSD) and anxiety, similar symptoms to brain injury.

Valera calls athletes the “luckiest people in the world to get brain injuries”. Where rugby players have rest time and return to play protocols after concussion, domestic violence victims may be assaulted regularly, without the chance for recovery.

There is hurdle after hurdle in the way of people getting a diagnosis, which impacts both their recovery and the ability to conduct research in the area. There’s a reluctance to talk about the violence, worry about being believed, difficulty accessing health services because the woman is isolated or her abuser prevents it, more pressing injuries such as a broken jaw or fractured eye socket that doctors might focus on, Theadom says.

That leaves people living with long-term disabilities with no idea what’s going on, Vikki Herdman from Brain Injury Association Northland says. She works with several women who have brain injuries as a result of domestic violence.

They share a long list of issues: seizures, loss of vision and hearing, poor speech, problems walking, damage to the nervous system, long-term memory problems. One lost her house to her abuser after the assault, another lost her job.

She reads out a text from one of the women: “I just remember feeling lost, confused, not knowing what was happening, like a drunk and then hearing you say it's normal was a relief.”

The women all suffered repetitive injuries. “They’ve never had time to recover from one event going into the next.”

As Theadom explains, if the brain hasn't recovered from the previous injury, the effects are cumulative.

“The second injury is likely to cause more severe and more frequent symptoms and take longer to recover from.”

Getting the cognitive rest necessary for recovery is impossible if you’re looking after children, or you’re at home with your abuser, or you’re moving to a refuge. Women might go to hospital after an assault, but the likelihood of them making follow-up appointments for rehab is slim.

For Māori, the response to the brain injury also needs to reflect the fact there has also been a “cultural injury”, says psychiatrist Dr Hinemoa Elder (Ngāti Kuri, Te Aupōuri, Te Rarawa, Ngāpuhi), Māori strategic leader at Brain Research New Zealand.

It’s crucial to acknowledge the head and brain are tapu, or sacred, to Māori, and a head injury also has an effect on the wairua (soul) of the person, she says.

The whānau is also affected, she says, and should be incorporated into the recovery to establish a culturally responsive rehabilitation plan.

Women describe “getting dumber”, not aware their symptoms actually point to a brain injury.
Women describe “getting dumber”, not aware their symptoms actually point to a brain injury.

Beth says her recovery took longer because she had to balance her needs with her children’s.

She had to reimagine the type of mother she could be. Not the one who would be at assembly or teach her kids how to ride a bike. Just one who was alive, that was all she could manage. “It was awfully, awfully difficult for all of us.”

In the two months after the assault, she didn’t realise how bad the concussion was. She tried to push through, until she ended up in hospital.

That time is a blur. She remembers writing down all the pills she needed to take in a day, crossing them off because she’d forget what she was doing. She counts herself lucky to have had help from her parents and through ACC.

“The domestic violence was tough but recovering from a concussion was the hardest thing I’ve done in my life.

“So many DV victims would have concussions they don’t even get help for.

“I can’t even imagine, they must just think they’ve gone stupid or something, rather than realising it’s an injury.”

That language is common among survivors. Women chalk their symptoms up to “becoming dumber”, King says.

Rachel Kain now works in Shine’s training and education team, but used to work as a Shine advocate in the emergency department of Auckland City Hospital, where she saw a lot of concussion and strangulation.

Women’s loss of cognitive function is used against them by abusers. “They’re told that they're stupid, or that they're dumb, and they're a bad mother and everything, because of the effects of the violence,” she says.

Clinical psychologist Dr Alison Towns says brain injuries are used alongside coercive control to trap women in relationships.

“As the woman becomes more competent and more able, and starts to feel yes, she can actually take a bit of control back in her life, then he whacks her again, to keep her down.”

Kain describes working with a woman regularly strangled and assaulted, to the point she was convinced her abuser would kill her if she left.

The woman gave up studying, which was initially her path out of the relationship, because she “just couldn't study, she couldn't think”.

“She directly attributed that to ongoing brain injuries from regular strangulation.”

While Beth got out of her relationship after the first violent incident, four years later the brain injury she sustained that night still affects her.

It’s changed her whole life: she moved cities to be close to her family because she needed their support. She changed careers.

She still can’t work full time. She gets bad fatigue, and when she ignores it the migraines come.

“I worked in IT and I couldn’t look at a computer screen for two years,” she says.

Beth went from being on the cusp of an incredibly successful career to being incapable of working, too broke to buy nappies, unable to keep up with the mortgage.

“He took away my ability to recover from domestic violence.

“Everything was taken away after him losing control for less than 10 minutes.”

*Name has been changed to protect victim’s identity.

Where to get help for domestic violence