1. Safety Planning for Victims with TBI
Safety planning is a very concrete, specific process, but you may need to break plans
down into very small steps when working with a victim who has a TBI. Questions about
specific TBI-related issues may be useful.
Protecting her head
• Are there any steps she can take to protect her head from future assaults?
• Are there steps she can take to protect her head from accidental re-injury? Ideas
may include:
o Removing tripping hazards such as throw rugs.
o Keeping hallways, stairs and doorways free of clutter.
o Putting a nonslip mat in the bathtub or shower floor.
o Installing grab bars next to the toilet and in the tub or shower.
o Installing handrails on both sides of stairways.
o Improving lighting inside and outside her home.
o Always wearing a helmet when bike riding, rollerblading, skiing, etc.
Accessing services
• Is she aware of, and able to access, TBI-related medical care, rehabilitation and
support services?
• Does she depend on her abusive partner for any disability or health-related
assistance?
• Does the abuser exploit barriers created by her TBI?
• What assistive devices does she use? Some people with TBI use wheelchairs, but
most do not. Many use memory aids, such as voice recorders, timers and
blackberries.
• Is it safe for her to take notes or keep notepads by the phone?
• Does she have a way to keep her service animal safe, if she has one?
Managing her mood and energy
• Is she short-tempered, irritable or aggressive? If so:
o Does she pick fights with her partner that he uses as an excuse to become
abusive?
o Has it strained her relationships with family and friends, depriving her of
needed support?
• Has she been depressed? Depression may be related to the TBI, the abuse, or
both. Remind her of her strengths, which depressed people tend to forget.
• Is she tired all the time? Fatigue is common, and may be related to the TBI, the
depression, or both. Be realistic about how much – or how little – she may be
able to do in a given day.
© 2009 New York State Office for the Prevention of Domestic Violence

2. Financial independence
• Is she able to work? If so, how supportive is her employer in terms of both the
domestic violence and the TBI?
• Does she have difficulty holding a job?
• Is she getting whatever benefits she might be entitled to?
• Has she filed an application for state crime victims compensation? It may pay for
services if the TBI was caused by a criminal act. Help her fill out an application
and compile needed documentation.
Leaving
• Does she have a plan to take her service animal and assistive devices with her?
• Is she able to drive or use public transportation on her own? If not, how will she
access transportation?
• Does her emergency escape bag include (as needed):
o Spare batteries for assistive devices?
o Back-up assistive devices, and specific information on how and where to
get replacements or repairs?
o Instructions for use of technical equipment?
o Medications, medical information, and medic alert systems?
o Contact information for medical personnel, TBI advocates and other
service providers?
o Social Security award letter, payee information and benefit information?
o Supplies for her service animal – food, medications, leashes, vet’s contact
information, etc.? 1
Hints to Remember
• Safety plans should be reviewed frequently and in detail, to help compensate for
problems with memory, motivation, initiative and follow-through.
• An action plan that involves several steps should be sequenced: first do A, then B,
then C.
• A victim who has a TBI may not be aware of how it is affecting her, and may think
she is functioning better than she is. Provide respectful feedback on problem areas
that affect her safety.
1
Empire Justice Center, Building Bridges: A Cross-Systems Training Manual for Domestic Violence
Programs and Disability Service Providers in New York, 2006
© 2009 New York State Office for the Prevention of Domestic Violence

3. Domestic Violence & Traumatic Brain Injury
Bibliography
Arosarena, O.A., Fritsch, T.A., Hsueh, Y., Aynehchi, B., & Haug, R. (2009).
Maxillofacial injuries and violence against women, Archives of Facial Plastic Surgery,
11(1): 48-52.
Corrigan, J.D., Wolfe, M., Mysiw, J., Jackson, R.D. & Bogner, J.A. Early identification
of mild traumatic brain injury in female victims of domestic violence. American Journal
of Obstetrics and Gynecology, 188, S71 – S76.
Empire Justice Center, Building Bridges: A Cross-Systems Training Manual for Domestic
Violence Programs and Disability Service Providers in New York, 2006
Funk, M. & Schuppel, J. (2003). Strangulation injuries, Wisconsin Medical Journal: 102
(3), 41-45.
http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/issues/wmj_v102n3/f
unk.pdf
Jackson, H., Philp, E., Nuttall, R.L. & Diller, L. (2002). Traumatic Brain Injury: A
Hidden Consequence for Battered Women. Professional Psychology: Research &
Practice, 33, 1, 39-45.
Monahan, K. & O'Leary, K. D. (1999). Head injury and battered women: An initial
inquiry. Health and Social Work, 24, #4, 269 278.
Mechanic, M.B., Weaver, T.L., & Resick, P.A. (2008). Risk factors for physical injury
among help-seeking battered women, Violence Against Women, 14 (10), 1148-1165
(relevant page is 1160).
Picard, N., Scarisbrick, R. & Paluck, R., (1999). HELPS (Grant # H128A0002).
Washington, DC: US Department of Education Rehabilitation Services Administration,
International Center for the Disabled.
Stern, J. (2004). Traumatic brain injury: An effect and cause of domestic violence &
child abuse. Current Neurology and Neuroscience Reports, 4, 179–181.
©2009, NYS Office for the Prevention of Domestic Violence

4. Traumatic Brain Injury
&
Domestic Violence
Sue Parry, Ph.D.
NYS Office for the Prevention of
Domestic Violence
1

5. Overview
Overview of traumatic brain injury.
Child abuse & domestic violence.
Effects of TBI.
H.E.L.P.S. – a TBI screening tool.
Strategies for working with crime victims who
have a TBI.
2

6. www.bianys.org
3

7. Crime & Brain Injury
Assaults.
Intoxicated driving crashes.
Child abuse: Shaken Baby Syndrome (Abusive
Head Trauma).
Domestic violence - DV assaults on head & face
are a major cause of TBI in women.
4

8. Traumatic Brain Injury
Caused by external physical force.
Penetrating injuries mostly damage specific areas
of brain.
Closed head injury, from blow to head or shaking,
causes 2 kinds of damage:
Focal damage, usually to frontal or temporal regions,
from brain banging on skull.
Diffuse damage from stretching, tearing & swelling
of brain tissue.
5

9. Mild TBI / Concussion
Often treated in outpatient setting or not at all.
Symptoms may be:
Slow to appear – days to months after the injury.
Mild, moderate or severe.
Subtle - slow & inefficient thinking, rather than
specific dysfunctions.
Hard to diagnose with CAT scan or MRI.
Similar to those of PTSD, depression, & headache
syndromes – all common in DV victims.
6

10. Crime Victims & TBI
TBI may not be not identified & victim’s behavior
will not be understood.
Victim needs:
Emergency services.
Specialized evaluation.
Rehabilitation.
People can suffer a serious TBI w/o knowing it, &
may only find out later what services they need –
file a CVB claim.
7

11. TBI & Child Abuse
TBI is leading cause of death in abused children,
especially those under age 1.
Shaken Baby Syndrome – injury pattern includes:
Retinal hemorrhages.
Fractures of ribs & the ends of long bones.
Recognizable patterns of TBI: diffuse axonal injury;
coup / contrecoup injuries.
30%-40% of newly diagnosed SBS cases had
medical evidence of previously undiagnosed MTBI.
8

12. TBI & Child Abuse
With equivalent force, children suffer worse
injuries than adults
In babies:
Skull is only 1/8 as strong as that of adults.
Head is relatively large & heavy – about 25% of
total body weight.
Neck muscles are too weak to support head.
Brain is more easily injured by shaking.
Blood vessels around brain tear more easily.
9

13. TBI & Child Abuse
Fatigue & inability to tolerate stimulation may
make school difficult.
Some deficits may not show up for years.
Injury to language centers may show up when child
shows delays in reading & writing.
Frontal lobe injuries may become apparent in
adolescence, when the survivor faces more psycho-
social demands & less structured environments.
10

14. TBI & Domestic Violence
Among women in DV shelters…
92% had been hit in the head in the past year –
most more than once, 8% over 20 times.
83% were also severely shaken. (Jackson et al, 2002)
Among battered women, both in & out of shelter:
75% sustained at least one partner-inflicted TBI.
Half sustained multiple TBIs. (Valera & Berenbaum, 2003)
11

15. Multiple TBIs & DV
Repeated TBI may result from repeated violence –
long-term CA / DV may increase risk of TBI.
If one TBI has not fully healed, it takes less force to
cause another that is worse or even fatal.
After one TBI, the risk of a 2nd is 3x greater; after
a second, the risk of a third is 8x greater.
Repeated assaults on head repeated brain
injuries to more severe & frequent problems.
12

16. Multiple TBIs & DV
Effects may be cumulative, especially if injuries
occur close together.
Severity of TBI was associated with:
More severe abuse.
Poorer memory, learning & cognitive flexibility.
More distress, depression, worry, anxiety, & PTSD.
(Valera & Berenbaum, 2003)
13

17. Strangulation
Can cause:
Obstruction of blood flow to & from brain.
Obstruction of oxygen to brain & lungs.
Loss of consciousness.
Brain cells start to die after 4 minutes w/o oxygen.
Recovery depends on length of time w/o oxygen
& how much damage has occurred.
May be no immediate external signs.
Swelling in neck & brain may follow days later &
may be fatal.
14

18. Effect on DV Victims
Headaches Blurred vision
Dizziness Hearing problems
No initiative Confusion
Can’t retain info Can’t process info
Can’t concentrate Can’t follow directions
Irritability Mental fatigue
Apathy Can’t make decisions
Agitation Depression
Memory loss Insomnia
Can’t think abstractly Poor judgment
Can’t tolerate frustration Can’t project into future
(Monahan & O’Leary (1999)15

19. www.state.sc.us 16

20. www.state.sc.us 17

21. www.state.sc.us 18

22. www.state.sc.us 19

23. www.state.sc.us 20

24. TBI causes problems with…
Mobility & sensation; physical functioning.
Cognition.
Communication.
Judgment.
Emotional, behavioral & psychosocial issues.
Activities of daily living.
21

25. Physical & Sensory
Double or blurred vision; light sensitivity.
Hearing impairments, tinnitus.
Difficulty swallowing.
Difficulty coordinating mouth & speech movements
& using muscles to form words.
Fatigue – mental & physical.
Headaches.
Mobility problems.
Seizures 22

26. Cognition
Memory problems.
Short attention span; easily distracted.
Confusion.
Slow reaction time.
Less awareness of self & others, time & space.
Information processing:
Trouble following complex directions.
Trouble understanding abstract concepts.
Problem solving deficits. 23

27. Communication
Difficulty speaking, understanding, reading &
writing (aphasia):
Cannot speak, understand, read or write.
Understands, but can’t speak or write.
Speaks in gibberish.
Has trouble finding words, forming sentences that
make sense, identifying objects & their function.
Symptoms may improve with recovery. 24

28. Implications for Victims
Recognizing abuse as such.
Verbalizing what is happening.
Communicating with people outside their
immediate environment – including law
enforcement & service providers.
Getting others to believe them.
In DV, the abuser may speak for the victim.
25

29. Executive
Planning & organizing.
Taking initiative & staying on task.
Tolerating frustration.
Handling change, changing plans.
Predicting outcome of choices.
Solving problems.
Recognizing own deficits.
Understanding & monitoring own behavior. 26

30. Judgment
TBI-related Safety-focused
Bases decisions on Focuses on immediate &
immediate needs, not short-term needs.
long-term
consequences. Traumatic response also
narrows time focus.
May lack insight into
own behavior. Focuses on abuser rather
than self.
May not see potential
outcome of choices. Safety strategies may not
make sense to others.
Impacts ability to plan. 27

31. Emotional & Behavioral
Low self-esteem.
Rapid mood & emotional swings.
Irritability, anxiety.
Depression.
Impulsivity & disinhibition.
Aggression.
“Not the same person.”
Often leads to interpersonal problems. 28

32. Behavioral Problems
Due to damage to the frontal lobe.
Can persist over time.
May not be identified or treated – especially if there
are no physical problems.
No more under the survivor’s control than are the
other effects of TBI.
May decrease victims’ credibility & the support
available to them.
29

33. Working with Victims
with TBI
30

34. Check Your Assumptions
“Caregiver stress” causes abuse.
Being the underdog in a relationship is normal for
someone who has a disability.
TBI is the main obstacle to leaving or safety.
Self-determination is impossible – she needs you
to make decisions for her.
31

35. Identifying TBI: “HELPS”
Hit in the head?
ER treatment?
Loss of consciousness?
Problems?
Sickness?
32

36. Identifying TBI in DV Victim
Did he:
Hit you in the head?
Slam your head into an object?
Make you fall & hit your head?
Try to strangle or suffocate you?
Shake you?
Did he do these things more than once?
33

37. Identifying TBI in DV Victim
Did you:
Lose consciousness?
Feel dazed or confused?
Did you get medical attention:? If so…
What did you tell them?
What did they tell you?
34

38. Identifying TBI
Are you experiencing:
Trouble concentrating, organizing or remembering?
Irritability?
A loss of motivation?
Headaches?
Vision or hearing problems?
Loss of balance?
35

39. Communication Strategies
Maximize structure & minimize distractions.
Don’t rush – one thing at a time.
Stick to the main points & repeat as needed.
Check for understanding.
Write things down & make checklists– if it’s safe.
Outline steps necessary to complete tasks.
36

40. Advocacy Strategies
Discuss specific choices & help victim set priorities.
Point out possible long-term effects of decisions.
Give clear & specific feedback.
Build TBI issues into safety planning.
Help victim communicate with other agencies, fill
out forms & make phone calls.
Help victim deal with attitudes of CJ personnel.
37

41. TBI Implications for DV Victims
May not be taken seriously as a victim.
Financial dependency.
Deciding to stay or leave.
Caring for kids.
Safety.
May not be able to live independently.
38

42. Implications for Leaving
Abuser may provide needed transportation, child
care, personal assistance, health insurance, etc.
She may not be able to live independently, find
accessible housing or support herself.
May be greater risk of losing her children.
Stress can impair functioning in court.
May not seem like a credible witness.
May not have money to pursue a custody case. 39

43. Important Resources
Brain Injury Association of New York State
www.bianys.org
518-459-7911
NYS Office for the Prevention of Domestic Violence
www.opdv.state.ny.us
40

44. Thank You!
New York State
Office for the Prevention of Domestic Violence
518-457-5958
41