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Christina Brown Fisher, journalist and traumatic brain injury survivor, speaks with Harvard Medical School associate professor in psychiatry, Eve Valera, PhD. Dr. Valera is a research scientist at Massachusetts General Hospital and has been investigating the impact of brain injury among those affected by domestic violence for more than 25 years.
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What is Me, Myself & TBI: Facing Traumatic Brain Injury Head On ?
Me, Myself & TBI: Facing Traumatic Brain Injury Head On provides information and inspiration for people affected by brain injury. Each episode, journalist and TBI survivor Christina Brown Fisher speaks with people affected by brain injury. Listen to dive deep into their stories and lessons learned.
Christina Brown Fisher:
Hello, everyone, welcome to the show, Me, Myself & TBI. I'm your host, Christina Brown Fisher. My guest is doctor Eve Valera, a Harvard Medical School associate professor in psychiatry and a research scientist at Massachusetts General Hospital. For more than 25 years, Dr. Valera has been working in the field of domestic violence and studying the consequences of traumatic brain injury as a result of intimate partner violence. Dr. Valera, thank you so much for coming on the program.
Dr. Eve Valera:
Thank you so much for having me. It's an honor and I'm always happy to spread the word. So thank you.
Christina Brown Fisher:
How do you describe, define intimate partner biolence or IPV? What is it?
Dr. Eve Valera:
Well, simply put, intimate partner violence is any violence physical, sexual, emotional, verbal that is perpetrated by a partner, a spouse, a boyfriend, a girlfriend. And it could be someone who you're living with or someone who you're not living with. And, but basically, it involves any of those things. It doesn't have to be physical. And there is a distinction between intimate partner violence and domestic violence, which I think people sometimes miss. It's not a huge deal necessarily, but domestic violence does include other forms of violence, like, elder abuse or child abuse and that typically is more confined to the home. In that context and intimate partner violence, it could be somebody you're dating. So not necessarily within the home or they're living with or something. So, so those are just some subtle distinctions that I like to point out when people talk about IPV or DV.
Christina Brown Fisher:
Dr. Valera, you published one of the first studies, and that was back in 2003, examining the prevalence of intimate partner violence, IPV. How did you get involved researching and examining this particular type of brain injury?
Dr. Eve Valera:
So it's a great question and it really happened because of my dual interests. Really, I, before going to graduate school, I was interested in very generally domestic violence or child abuse, partner abuse, etc. and when I went to graduate school, I was also deciding that was very interested in the brain and neuropsychology, and function structure relationships in terms of how the brain works and doesn't work and how that may manifest in behavior. And, so I was learning about the brain and what damage to the brain could do, and so about brain injuries. And I was also volunteering at a domestic violence shelter. And so when I would hear about the abuses that women experience, or they might be smashed at the head with somebody fists, or had their head stomped on or had their smashed against walls or floors or windows, and they were also experiencing problems with headaches or maybe dizziness or depression or irritability. And historically, we know that those are things that are commonly seen in women who have experienced intimate partner violence. So I was saying, well, most people kind of talk about the the behaviors and or emotions that women who are in partner violent situations, they typically refer to those things that are psychological consequences of being in a very abusive and stressful or scary relationship. And that certainly makes sense. So but what I'm seeing here could easily be brain injuries, because you have women who are being struck in the head very violently and they're also exhibiting symptoms that are very commonly seen after other populations that we know sustained brain injuries, also experience. So I said, let's see what we have in the literature. And so I did a little lit. search and there was nothing.
Christina Brown Fisher:
You couldn't find anything.
Dr. Eve Valera:
Nothing, not a single result came up. Nope, absolutely nothing. So at that point I said, "well," I said, "there's no question in my mind that, you know, this is there's got to be something going on here. So let's just look at this." And so then that's, that's what I chose to do, and luckily, my committee, the people, you know, my advisors and stuff had enough faith in me and that question, that they allowed me to pursue it, as kind of crazy as it sounded. But that, yeah, that's how it all started.
Christina Brown Fisher:
And what did you find when you studied it and explored it further?
Dr. Eve Valera:
I ultimately interviewed 99 women, and of those 99 women, about three quarters of them reported, you know, if you ask it a certain way. So I asked in a very special way, report at least one mild traumatic brain injury from their partners. So to me, the first, that was startling. You know, I knew this was happening. I expected the numbers to be high, but I was just like, that seemed crazy. But that was the first that was the first finding. So it was basically confirming what I believe. But then the other thing that I discovered, which was a little horrifying almost, is that about half of the women sustained repetitive brain injuries. So it could be two or three or four, but for some of these women, it was basically kind of like too many to count. So, you know, they may have their head smashed into the wall like a few times a week for years or something like that. So, basically what I found was that women were not just sustaining one, but they were indeed sustaining at least one, and in many cases, a lot of brain injuries. And then I also included measures of cognitive functioning. So some neuropsychological measures and some measures of the psychological functioning and in psychological distress like depression, anxiety and PTSD symptomatology. And I looked at the relationship between sort of a brain injury severity score that I created based on the number and frequency and severity of the brain injury, and I looked at that in relationship to these other variables. And I found that the more brain injuries a woman had, the more trouble she had because she would have trouble with memory learning and cognitive flexibility. And also the more brain injury she had, the higher her, or her scores were on measures of depression, anxiety, worry, PTSD, symptomatology. So really, in this sample I was showing, you know, in his first attempt to look at this, that not only were brain injuries happening at a really high rate, but that they were actually associated with the behaviors that were commonly considered to be sort of these things that would be because you're just psychologically, you know, stressed out or so.
Christina Brown Fisher:
People would assume that if they were having memory issues or the inability to focus or concentrate, the assumption is that it's because they're in this toxic relationship and not necessarily because there's been damage to the brain. How then, do you make that correlation?
Dr. Eve Valera:
In science we always look at associations and connections. I think most of the science that's actually done is not actually causal. So we never can actually say this specifically cause that, but we look for patterns and associations. And so we in terms of the question you just asked, we basically just use a simple statistical model and look at the association. But in terms of identifying a brain injury, we basically all you need to do is I mean, basically I would say I would look for any type of incident where there was some type of impact, strong impact to the head or the brain, some strong force. And then after that, some type of what we refer to as alteration in consciousness, or change in brain function, which could be measured by a loss of consciousness, a memory gap for part of what happened, a period of being really confused, dazed, disoriented, not quite knowing what was going on, or being fairly dizzy or seeing stars or spots. So that was if you can identify something like that, then right there you've had a brain injury. And so, so so you can say, you know, so for any particular woman who's had, say, for example, a broken arm from a partner had a brain injury or repetitive brain injuries, and you know something else, psychological abuse, which could be very it's certainly very damaging as well. You don't necessarily know for that one woman exactly what might be contributing to what later on down the road. But we can say that we know that women who have experienced brain injuries and the more you have, the more likely this is to happen that you may have problems with memory or learning or cognitive flexibility. And one of the things that it did in my study, which I think was really important, at least for me, was I, and again, you these are ways to do things statistically is that I looked at the relationship between the brain injury severity and these other variables, like attention. I'm sorry, like memory learning, cognitivee flexibility, and what we call, we parceled out the effects of partner violence itself.
Christina Brown Fisher:
How so?
Dr. Eve Valera:
So what we did is we got a measure of the abuse severity using the conflict tactic scale. And that asks Bell, how many times is your partner pushed, shoved or hit you? How many times has your partner threatened you with a knife or gun? How you it's it's it's a whole bunch of items, but basically it gets an index of the severity of the particular type of the violence that the woman has experienced from her partner. And so then we use that information in the model and we said, well, if we put this information in the model, does this account for this relationship? So we found that it didn't. So that that very convincingly tells me that, no, it's not just the amount of abuse severity is actually related to the number of brain injuries that you have had.
Christina Brown Fisher:
I see. I see. It's estimated, Dr. Valera, one in three women around the world experience some form of domestic violence, risking concussion, mild traumatic brain injury, along with a host of other physical injuries some of which you've already mentioned. Who is most at risk at suffering intimate partner violence?
Dr. Eve Valera:
So, basically a lot of us are at risk. Anyone is really at risk, if you ask me, because one in three is a really high number. So if you think of ten women, you can guess that approximately three of them have experienced some form of physical or sexual partner violence. So I would say really it's a high risk for everybody. Now, there are some people who are disproportionately affected. That's, you know, depends on geographically where you may be living. So some countries have higher rates of of partner violence. Some countries have lower rates of partner violence. But basically it's really risky everywhere. And other some type of demographics are disproportionately affected as well. That just means they're probably higher than the one in three estimate rather than lower. Partner violence absolutely occurs to men as well. And, you know, and at a reasonably high rate in general, however, the severity of the violence and the resultant injuries are proportionately higher in women. So overall, women are much more likely to sustain an injury than a male will. And another thing I'd just like to make really clear is that I think some people think that this may only happen to sort of poor people or kind of people over there. This isn't people that I know, and it may feel that way, in part, because partner violence is very stigmatizing and women don't necessarily want to come out and say, "yeah, by the way, I've experienced partner violence or by the way my husband hits me, but I still stay with him." No one wants to, you know, in general, no one really wants to say things like that. And if you're really well off, you have more means to potentially hide it or to potentially deal with it in a way that you're not going to need to end up in a shelter or, you know, try to get resources from somewhere else because maybe you can go to a hotel or maybe you have another, you know, wealthy friend that you can stay with or maybe he can go somewhere else. So so, you know, so some people are disproportionately affected, certainly in a sense, because they may have more to lose. They may not be able to get out as easily. But I would say partner violence is very prevalent. Unfortunately, some demographic groups are even more potentially, you know, at risk, and sort of a newer area that I'm sort of getting into right now is, I mean, even if we think about marginalized populations, I think they're almost always at higher risk. And unfortunately, people in the trans community seem to have higher rates of partner violence. And there's you know, there's been some an increase in research around the trans community just in general. And I recently came across a review about partner violence in the trans community, which was kind of exciting to see because it means there's actually some people who are studying it, but they didn't mention traumatic brain injury at all. So it's still even if someone's recognizing that unless you recognize the possibility of traumatic brain injury, you're missing a big picture, a big piece of the picture, in my opinion, of what's really important and understanding, because I think as we all can understand, a traumatic brain injury, you know, for most people, you don't want to experience that. That's kind of frightening, right? So, so, you know, if you have a broken arm or a broken leg, you know, it's not great, but you kind of think you can heal. But people have brain injuries, especially nowadays. That's that's you know, where at least for me, that's kind of terrifying. I don't want to have a brain injury and especially repetitive brain injuries because that's where we potentially get into really bad situations.
Christina Brown Fisher:
A broken arm, broken leg, some of those other physical injuries that you mentioned are just quite frankly obvious. Are women recognizing that some of these symptoms that they are experiencing could be linked to a brain injury and therefore know to get the appropriate support and help?
Dr. Eve Valera:
No, I think the short answer is, is overall, absolutely not. In the studies where I've asked if they've gone to the doctor after anything their partner ever did to them, if they, you know, women often don't seek medical help regardless of the injury. And when I asked if they did, it was more typically because like, oh, you know, I was there was something bleeding or something like it was like really they kind of really needed to go. For the most part, there was not I can't remember anyone who specifically went because they sustained what we might consider a mild traumatic brain injury. I can't I can't say for sure if anyone actually went for a moderate to severe brain injury. But overall, no women are, I mean, even if they I think overall, they don't necessarily recognize certain things as brain injuries. I think a lot of the general public doesn't necessarily know how easily you can sustain a brain injury. I think some people think that, oh, you have to have a loss of consciousness, you have to blackout or it's not a brain injury. And I'm like, no. Or they think, well, you have to get an MRI and if that there's something on the MRI, then your (unintelligible). No, in fact, most mild traumatic brain injuries will show. no, no, no, no, basically, they'll have a negative scan. It will not be showing up.
Christina Brown Fisher:
Nothing showing up on a on a CT, CAT scan on an MRI?
Dr. Eve Valera, PhD:
Will not be indicative of an injury, so, it'll be a negative finding. So unless it's a complicated, mild traumatic brain injury, so you absolutely cannot rely on that. And really, it's just how I defined it earlier, and I think most people don't realize that, including these women. And then I think some women, even if they realize, well, yeah, "he's hit me in the head, maybe it's messed up my head." I think they sort of see more globally as, "yeah, maybe my head's messed up from him or something," but I don't think there's never this real sense of, "oh my gosh, yeah, he is definitely give me brain injuries, and I know I need to try to get rehab for this." Or like you might if you knew you had a brain injury from something else, and I think part of it might be because they just have so many other things to deal with, too. But I think, you know, part of it is just not recognizing that this is something that's important to address. Even even when women go to shelters or if they go to a primary care provider or something, and they're seen there, they're not necessarily getting the question about like, "oh, did you get your head hit?" And if they did, you know, trying to figure out whether or not a brain injury had actually occurred.
Christina Brown Fisher:
And you've worked a lot in that area trying to raise awareness, particularly among first responders and social workers, people who might be interacting with women who have suffered. IPV. How do you explain to, again, the first responders or the social workers or the providers, what are the things that they should be looking for or asking a woman in order to perhaps figure out if her behavior is linked to IPV?
Dr. Eve Valera:
As you mentioned, I've spoken to police, I've gone to police departments and spoken to them about this and obviously have spoken to some of shelter advocates and workers and stuff like that. So what I basically say is, "you know, the first thing is if, if women have experienced some type of trauma to the head," so somebody might say, "oh, he hit me in the head." And so it's like, okay, well, that's one thing, but what does that really mean? So the next time I said, "did you lose consciousness? Did you blackout?" And if they say yes, well, right there, that's a brain injury, period. That's mild traumatic brain injury. If they say no, yes, you could. The next question could be, "do you remember everything that happened around that incident?" And if they say, yeah, "I remember everything," then that wouldn't be indicative of a brain injury necessarily. But if they say, "yeah, I can't really remember exactly what happened from when he hit me till when I was in the other room." That's a brain injury. Okay, so, and then there's a couple of other indicators. So one woman, she was just like, "you know, he hit me with his fist and I just remember that, that ring in this ring on his thumb, and I just always, you're not, not I'm sorry and, you know, basically close to his knuckles and I just always remember that, and then I just, I just wasn't myself, wasn't myself." Basically, she was saying, "I just wasn't myself." And she continued not to be herself for a very long time after that. So, and she was, it was a disorientation of, you know, an immediate disorientation that would indicate a brain injury. But she didn't necessarily link it to, "oh, yeah." Now, I mean, she may think that, "oh, yeah, something happened there," but she didn't know. So I said, "oh, this is a brain injury," and so now I should probably do this, this and this. And even when her primary care provider identified her as being someone who's experiencing partner violence and he really went to bat for her, he was, you know, he tried to figure it out and tried to help her. I'm pretty sure there wasn't ever one period, there was never a time where he said, you know, "you've had a brain injury and we should try to see if we can get help for that brain injury." And so I credit him tremendously for going the extra mile and not just seeing this woman, you know, who comes in and has these symptoms and just sort of pushing it under the rug. "I don't want to know if she's experiencing partner violence because that opens a can of worms," he went the extra mile and he figured it out and I love him for that. At the same time, because it's just not that consider and people don't really think of it that much. He didn't go, the, you know, another step not you know not through no fault of his really is you didn't but he didn't actually get there and say like oh, this was a brain injury. This is by contributing to some of these things that you're talking about. And I think that link is really important for so many people to understand why they may have these problems, not just, "oh, I'm in this relationship," or "oh, I'm stupid, he tells me I'm dumb and of course I can't get anything done."
Christina Brown Fisher:
Yeah, and I would just think that there's just a whole domino effect of problems and issues. And imagine that you're someone who's in a situation like this, you've suffered a brain injury. There's potentially memory issues, concentration issues, as you've mentioned, cognitive issues. How then if you've suffered a brain injury, are you supposed to be able to function, get yourself out of the environment? Perhaps you need legal protection, perhaps you need all sorts of different levels of support, but you just physically can't do it because you've suffered a brain injury. I mean, there's just a whole range of issues that can come out of it. If at a minimum it hasn't been identified, then certainly how do you get the appropriate support?
Dr. Eve Valera:
Exactly. I think you've hit the nail on the head. And one of the things that I think is really important to recognize here is that there's a lot of victim blaming that goes on in women who experience partner violence and you definitely hear people saying, why doesn't she just get out of the relationship? Or in this one, I can totally relate to it because for me personally, it just seems I mean, if I, if I didn't actually interview these women, and know, it would be hard for me to understand. But, these women experience such severe abuse, it seems hard to believe that they would continue to do this. But at the same time, you have to understand that it's not just them saying, "oh, I just I'm just going to be in here because I don't feel like getting out or because I like the abuse," as some people, you know, historically may have said, or because, you know, whatever or whatever reasons people may come up with. There are so many different reasons. A woman may be literally trapped in an abusive relationship. It could be economic. It could be her ability, her lack of ability to feel like she can get another job. She's lived with this person the entire time she's been on her own or with their family. He could be threatening her or.
Christina Brown Fisher:
There might be children involved.
Dr. Eve Valera:
Yeah, or her children or the pets. Exactly.
Christina Brown Fisher:
Yeah.
Dr. Eve Valera:
There are so many. I mean, I could. Yeah, that could you know, I could go on about that for at least an hour. And if you want to look at a power and control wheel, you can look it up on the Internet and you'll see and you can see all different reasons. You know, basically, those are some of the reasons that that may contribute to him being trapped in these relationships. And women are most likely to be murdered while they're leaving or after they've left an abusive partner.
Christina Brown Fisher:
So the most critical time when they attempt to leave and just after they've left is also when they are even that much more vulnerable.
Dr. Eve Valera:
Yes.
Christina Brown Fisher:
To attack?
Dr. Eve Valera:
So, so, yeah. So can you imagine trying to figure out a safe way to get out of this relationship without getting killed? And also on top of that, having all you know, you have to get all these different things together, figure out where you're going to go, how you get a different from finding you, how are you going to get the kids, how you going to get this document? How are you going to get the pet, whatever it may be? And on top of that, you may have just you may have recently sustained or have sustained one or potentially repetitive brain injuries. So, so if you put it all together, it's really just like this disaster in the making in terms of trying to help this woman, you know, lead a life independently of this other person, if that's what she chooses to do.
Christina Brown Fisher:
You talked about, Dr. Valera, the fact that there are just certain methodologies that one might assume would be able to determine whether or not a woman has suffered a brain injury, for example, an MRI or CAT scan, and how that doesn't always work. Can you explain then exactly how then does one get it confirmed that they have suffered a concussion or that they have suffered a mild traumatic brain injury?
Dr. Eve Valera:
It's confirmed, if you can answer those questions that I was mentioning earlier. So quite literally, if I hit my head. If I. Well, I'll give an example. I was racing my son on a little scooter that's too small for me. Not motorized, mind you, but I, I fell, and then the next thing I remember, I was picking myself up off the ground and, you know, blood was coming out of my head. I don't need anyone to tell me whether or not I sustained a brain injury. I know that's at least a mild traumatic brain injury because I smashed my head against the pavement. I didn't remember what happened or I was unconscious for a brief moment. Either or whichever one happened those two pieces of information means I have sustained at least a mild traumatic brain injury. And so you don't I think that's that's exactly it. People, people often think you need to confirm it with something and you don't. And it's interesting because there have been in the literature, if you follow the brain injury literature, especially the mild traumatic brain injury literature in terms of identifying concussions or whatever, people say, oh, there's a blood test that identifies concussions and no, no, no, no, no. That is not.
Christina Brown Fisher:
I was going to ask you about that, biomarkers and all of these different things that people are saying.
Dr. Eve Valera:
Yet right now there is there's nothing like that. I mean, there may be something, you know, that can get us, you know, that can identify certain pieces of information. But in terms of identifying if you've had a if you've had a concussion, all you need is those those pieces of information, some really strong trauma or force to the to the head, which ultimately means to the brain, because the brain is smashing around in the skull and then some type of alteration in consciousness. And if you've had that, that that's simply put, that's at least a concussion or a mild traumatic brain injury. However you want, however you want a phrase it.
Christina Brown Fisher:
You use a range of methods, including neuroimaging, to investigate TBI. Can you walk me through the process? What does neuro imaging mean and what is it revealing in your research?
Dr. Eve Valera:
Most, simply put, neuroimaging is when we conduct neuroimaging, basically we're putting someone in what we call an MRI scanner, magnetic resonance imaging scanner, and we can basically run an array or a number of different types of scans that will give us different information about what's going on in the brain. And so some of those scans may tell us something about what we refer to as structural connectivity, which is that so we have neurons in the brain and they have cell bodies and they have axons, and the axons are long. It's like think of a piece of hair, but even thinner. And those connect different cells in different regions of the brain. And so that, that we call structural connectivity. And one of the things we look for when we're doing a structural connectivity scan is how the water is move around is basically flowing down that axon, because that will tell us something about, you know, how well the neurons are functioning relative to how they function in somebody who hasn't brain experienced brain injury, for example.
Christina Brown Fisher:
So, it's like how two parts are speaking to one another?
Dr. Eve Valera:
Exactly, and so one of the things historically with respect to brain injury, an understanding like structure of function relationships, there is this focus on understanding specific regions in the brain. So the back of the brain is the occipital lobe, and that's responsible for vision. Or, you know, we have the prefrontal cortex, which is responsible for cognition and and thinking and planning. And what we've really realized in the more recent years, not super recent, but relatively more recently, is that one thing that's really important and more important, just one piece of the brain and how that's functioning is the connectivity between different regions of the brain. And we have networks within the brain, you know, networks meaning different kind of connections or activations between different brain regions that contribute to one cognitive or behavior or emotional process. And if you mess with those networks, if those networks get disrupted or disturbed or neurons get broken, then you will not necessarily have the behavior, the, the cognitive process or the emotion that you want, or it may not be as is optimal as you need. It depends on the severity of the potential damage to that network.
Christina Brown Fisher: And of course, the repetition, because you're saying that this group is also more often than not repeatedly subjected to intimate partner violence and therefore repeatedly subjected to multiple brain injuries.
Dr. Eve Valera: Exactly. Exactly.
Christina Brown Fisher:
Okay, so you mentioned cognitive, physical and emotional problems. Tell me, what is a cognitive problem? An example that would be what? A physical problem would be what? Emotional would be what?
Dr. Eve Valera:
So, so. So these are what are often considered post concussive symptoms. So concussion post-concussion post concussive symptoms and a cognitive problem, for example, could be trouble with attention or focusing, so, or, you know, you need to get something done. And you, you know, you know, it could be like planning, for example, or like follow through. So you just kind of you, you just sort of like, I know I need to do this, but I got to do that and you kind of can't prioritize or something. I mean, that could be an example of someone having difficulties know, doing normal everyday things because you can't, you know, focus on one thing or someone's telling you something and you realize, "oh, I just I have no idea what you just said because I was, you know, you know, thinking about something else for a minute." Those so problems with attention, memory, concentration, those are all, you know, potential cognitive issues. And when we talk about behavioral, you could also call that I mean, there's different terminology. You could say somatic or sort of bodily. So you can have problems with sleeping, for example. Sleep problems are huge when people have traumatic brain injuries. And you could also have headaches, for example. But that's one of the number that's definitely a really high one. When we look at women who have experienced partner violence, the report a lot of, had a lot of problems with headaches or a lot of women report problems with headaches, or potentially balance or dizziness. Those are sometimes things that come up certainly right after a concussion. And then if we go to the emotional domain, those are things like depression, feeling sad, down, or blue or feeling really anxious, or feeling kind of just irritable, and tense and or just maybe kind of behaving almost inappropriately. You know, you're just you're just kind of, you know, maybe too angry over things or doing things that don't really make sense because, like, "why is she so upset? Why she acting this way?" And these are all types of things that you may see. You know, obviously if you have the brain injury, but, you know, if you you know, in order to behave and act, etc., in a way that is what we consider normal, your functional and structural connectivity need to be intact and operating efficiently.
Christina Brown Fisher:
So what's so fascinating about all the things that you just mentioned, Dr. Valera, is that one might assume that if I'm having, let's say, issues with my sleep, maybe I'm having trouble focusing on having some difficulty with concentration and, and planning and executing my plan. And if I'm in an abusive, toxic, violent relationship, one might think, well, that's the reason. All of those are very valid reasons to have problems with sleep, to have problems with focus, to have problems with attention. You know, it would be very hard, I think, quite honestly, if I didn't have this kind of awareness to even think about the possibility that it might be connected to just having my head slammed up against a wall, I might look at these these issues, these problems that you listed, these examples that you've provided, and just think it's because I'm in this bad relationship and not make that connection.
Dr. Eve Valera:
When I started this, I feel like that's really where the field was, and a lot of it still is. But believe me, we have not come nearly as far as I would have liked us to come, since, you know, the first studies like this came out. But, but we are making progress, so I don't want to complain. But you're exactly right. And I think that is part of what happens. I can give you an example of a woman who, you know, many years and many years later, she was actually in a healthy relationship and she was still experiencing depression and some post-traumatic stress symptoms. And, and she was saying things like, you know, she used to have this really great, really strong reading level and now she is having trouble sounding out, trying to sound out words and need to go to a dictionary for words that she that she knew and just she was thinking she was dementing and then she saw something. She saw my work or whatever, and she was just like the light bulb went on and all of a sudden she realized, "oh my gosh, yeah, he wrapped my head against the doorjamb all the time. He smashed my head against the hard concrete floor and strangled me. He put my head under water." So, so, you know, basically it was many, many years later when she's trying to figure out, you know, like, you know, she's still having these problems, but she wasn't in this horrible relationship anymore. And so even now, I think can tell you, it definitely provides important evidence, even if you don't have other data. But, yes, not just being in the abusive relationship, you know, something else is contributing to this. And it's, you know, physical damage that's gone on in the brain.
Christina Brown Fisher:
Given the prevalence of traumatic brain injury in the intimate partner violence community. And you mentioned you've been doing this more than two decades now. Why is it that IPV is pretty much left out of the conversations and research surrounding TBI in comparison to, for example, athletes and, and military?
Dr. Eve Valera:
It's the million dollar question, isn't it? And I think it's the million dollar is part of the reason. Part of it, I think there's part, partly about money and where people can get money and money comes where things are valued in society. And very sadly, I think that, well, we kind of know that overall, women are not valued as much as men, and marginalized populations are certainly not valued. If you want to just take another quick example, homeless folks have high rates of traumatic brain injuries, but nobody wants to study them. What's the, where's the money in that? But in athletics, lots of money to be had there. In the military, they can drum up lots of money there, too. So, I think that part of the reason the recognition has come in athletics, in the military is because (a) there's money there. But I think even more so, it's largely men and people that we maybe admire or people that we have more respect for. But these women who are being abused, who are they? You know, and sort of a lack of understanding of just how prevalent it really is, the abuse itself and how many people it truly does affect. It's, it's really remarkable how many people have experienced partner violence because a lot of people think, oh, no, I don't know anybody who's experienced that. And I'll say to them, Yeah, I'm pretty sure you do. You may not know it, but I'm pretty sure you do. And I think, you know, but.
Christina Brown Fisher:
If the studies are largely centered on whether it be athletes, or military, or, or men, quite honestly, then the recommendations for how you treat and rehabilitate or from TBI, how then does that help and support women?
Dr. Eve Valera:
Yeah, that's a great question. You're preaching, my preaching to the choir. It's exactly right. And I think there you know, I you know, I think there may be some people out there who think, "oh, you know, we don't need to study these women." I mean, I heard this, you know, a little bit you know, most people are recognizing it, but some of them say, "oh, we don't that's been done before." And I and I say, "really? Who has it been done on? You tell me when has been done on even women. And then we can start to have a conversation." But I don't know the exact percentage, but probably 90, a lot. The vast majority of any type of traumatic brain injury research has been done on males, and in general, it's been on healthier males. Because if you think of who's in the military, who's in athletics overall, are going to be healthier. And then you think of the average woman who may be in a partner violence relationship. She's on average, going to be unhealthier because she may have more depression, she may have anxieties, she may have stress, she may have other broken body parts. So so we really don't know. And that's one of the things that I really think is critical. I'm so glad you asked that to recognize that we really don't know. So from my point of view, what I do in terms of studying this is I start with trying to look at some of the things we know have been affected in other groups of TBI populations that have been studied, because where else do we go, right? We can start with that or we can start with what we know women experience, you know, depression, anxiety. Is that related? You know, these problems with attention or concentration of memory, is that related? So we can start there, but then we need to go further and we really need to do you know, we can't just say, oh, well, we kind of know this is you know, this is how we treat TBI over here so we can bring it up here. And we can I mean, we can try to glean information from what we've learned from other populations, and I think that's totally appropriate. But we need to validate it, so to speak, in this population and make sure that it's going to be just as helpful or it will be helpful or it'll work. And yeah, I think that that's an incredibly important point that we absolutely need more research to understand what's going on. Even the prevalence of TBI and IPV is not well-established. Right now, I mean, I've done studies and others have done studies that show it seems really high, but we don't really have a good a really good number to say, "yeah, this is the numbers." I mean that right there. That's a study that needs to be done. Looking at the epidemiology.
Christina Brown Fisher:
I came across one of your studies. This one was the one that was published in the Journal of Neurotrauma in which you write along with the coauthors and estimated at 42 million women over the age of 15 in the U.S., just in the U.S. alone have experienced physical or sexual abuse. And that this would then translate into approximately 31 million women sustaining at least one TBI and 21 million sustaining repetitive traumatic brain injuries in the U.S. Those numbers, and in women are far more than just numbers, but that is startling. That is really just jaw dropping, especially given the scope and size of the population. The research certainly isn't comparable.
Dr. Eve Valera:
Exactly. No question. I mean, so so what your point about, you know, bringing up those numbers, I mentioned those numbers just for a couple of reasons. One, to say, you know, I don't we don't have enough. There hasn't been enough people or enough interest to get a really good epidemiological study looking at this yet. But we'll get there. But if we just take the information that we have, if we take one kind of large study and extrapolate from that, look at the numbers. They're crazy higher than what we see in these other populations. And so even if we slash that in half or in quarter, we're still talking way more than these other people. So sort of no matter how you slice it, the numbers are staggering, as you said. And one thing that I think is really important is that we do figure out what the actual epidemiology is so that we can say with certainty, you know, "when we've studied this really carefully at an epidemiological level using really sound methods and not just convenience samples, we see this and you're you know, we know that this is happening and we need to have more attention here."
Christina Brown Fisher: Dr. Velera, in your research, are you seeing any differences or consistencies? Is this something that you've looked at that differentiates a concussion or mild traumatic brain injury from IPV versus, say, one from a sports related brain injury or a fall that led to a concussion? Is that have you explored that at all? And is there, are there any differences?
Dr. Eve Valera:
I haven't actually explored that. I think that we should look at something like that. I mean, or I mean, at the very least right now, I think focusing on women and just understanding what's going on in women is critical because we really have a lot of data on men. We still don't have as much as we need, but ...
Christina Brown Fisher:
In some data, speaking to women recovering differently and certainly longer.
Dr. Eve Valera:
Yes.
Christina Brown Fisher:
Exactly. The men.
Dr. Eve Valera:
Exactly, so some of the data that we have in terms of just looking at gender, I think it's gender sex. There are there are hints the jury is is definitely a little bit out on that. But there are hints that women both will sustain a concussion or mild traumatic brain injury more easily than a man will, and that will take somewhat longer to recover. There is definitely, you know, a little bit of a consensus on that. So, so, yeah, right there there is evidence that what we would see in these women would be different. But the other reasons that it may be different is, and I kind of have a list when I talk about this. And the first one is whether or not, you know, sort of like the immediate care of the brain injury.
Christina Brown Fisher:
And so an athlete gets sidelined because of a concussion, he's immediately getting treatment, a service member get sidelined because of a traumatic brain injury immediately...
Dr. Eve Valera:
And a woman probably doesn't get treatment at all. And she's just you know, if you're an athlete, for example, they will say, "oh, nope, you got to start playing and you may not go to class. You have until you have, no, you know, you're going to just sit in it. Take it easy, lay low, don't do anything too strenuous. And then when you start to feel better, we're going to try to bring you back. If you if you still feel good, when you start doing more stuff, then you can do more stuff." And so there's this gradual return to play and general activities. And if they start getting symptoms back, then they dial it back, okay? So it's it's a very structured way of of getting individuals who have had brain injuries sort of back to their regular level of functioning. And women are not getting that by any stretch of the imagination, because for the most part, they're not recognizing they have brain injuries. And even if they did say a woman says, oh, my gosh, I think I just had a brain injury, is someone going to be there to say, "okay, oh, no, you can't, you're not going to take care of your kids for a little bit. You're not going to do X, Y, or Z for a little bit." You need to for the most part, that's not happening. Right, so if we just talk about the immediate treatment for the for a brain injury, that's very different. And then the other thing is whether or not you've sustained previous concussions or previous TBIs, because the more you have, the more likely you are to have more or longer term problems. And as I've indicated in at least in my work, many of these women have sustained repetitive brain injuries. And then also other things like if you have other bodily injury, so a broken leg or something like that, or if you have psychological trauma associated, you know, in your life, or if you have high levels of intense acute stress or chronic stress, all of those things are going to contribute to how well your brain can basically recover from that injury. So women who are experiencing partner violence are all on the bad end of these, of these, you know, recovery factors. Whereas folks in the military and athletics tend to be on a better end of all that. So, in terms of recovery, I would expect women who are experiencing partner violence to definitely not recover as well as the average person who has been studied with respect to, you know, traumatic brain injury or concussions.
Christina Brown Fisher:
But, but they can recover? You're not ruling that out even if the diagnosis and the treatment is months or years after the injury, there is still a way back to better health?
Dr. Eve Valera:
Yes.
Christina Brown Fisher:
Improved functioning?
Dr. Eve Valera:
I would say as much as anybody else. I mean, the there's there's nothing to say that if you've sustained a brain injury and you don't recognize it, you're not going to recover. It may make the recovery long, and I will say one other thing; if you sustained one mild traumatic brain injury, on the whole overall, you're probably to the best that we know. I mean, there's a study that shows that even one brain injury is associated with higher rates of dementia or something. But, but on the whole, when we just look at people the way we've studied them, people tend to recover and they don't necessarily say, "oh, yeah, I know that there's this, this or that, that's been different since that one brain injury." That said, there is a minority of folks who don't quite recover from even one brain injury. But when we get into the what I would call the much more serious potential danger zone is when you have people who are sustaining two or not just even two, but three or four or six or ten or 25, then you're getting into this cumulative brain injury area where you are decreasing your likelihood of recovering certainly quickly and potentially you may have more longer term negative consequences. But that said, if you're, you know, still in a relationship and you're still continuing to sustain brain injuries, well, that's absolute the worst case scenario, because you're definitely not going to get better there. If you've gotten out of the relationship and you're trying to recover, you want to make sure that you're addressing things that are related to the brain injury and not just, you know, other stuff, right? And then in terms of you know treatment, there are very, there's a lot of sort of standard ways you can address people who have it, not even necessarily from a brain injury, but like a cognitive deficit. So, if you just think, well, you know, "I'm just kind of stupid or whatever" and, you know, you don't really think, you know, it's because, you know, your partner's told you this for all this time and now you're in a new relationship, you know, that's safer, but you still don't think very highly of yourself because that's all you ever know and you've proven it because you can't do all this.
Christina Brown Fisher:
You've internalized it.
Dr. Eve Valera:
So, you won't necessarily seek out some type of neuro rehab, right? But there are a lot of things you can do that are kind of simple. I mean, it's you can structure certain things a little differently. You can have maybe Post-it notes somewhere. There are things that you can just borrow from that literature and introduce into your life. So, even if you're not necessarily getting you're not necessarily changing what's actually happened, you can change how you respond to things and how you interact with the world around you that can make a world of difference. But unless you recognize that that's a potential opportunity to help you, you're not going to take advantage of it. And so you're you know, it's it's not going to change.
Christina Brown Fisher: And that's the that's the big thing, it's the awareness and recognition. Where are we in your opinion, in terms of awareness?
Dr. Eve Valera:
So, I would say that I don't know if I want to say thrilled, but I'm very, very, very happy that at least in the past few years, we have seen a growing number of folks who are interested in this topic, recognizing it as being a problem and starting to study it. Now, by growing number, I mean it's more than like the people I can show on two fingers or, you know, because, I mean, you know, if you were to say how many people are studying athletes or the military, gosh knows, I mean, hundreds of thousands, you know, whatever. How many people are studying IPV and TBI? You know, many years ago, it would have literally been like a few, you know, like you could count them all. Now, I still probably know almost everybody. It's still a pretty small field, but there is definitely a growing appreciation, and I'm hoping, so, I see us gaining traction, and if we can keep the momentum up, I have to feel confident. I have to have hope because, you know, we need this so badly. We're nowhere near where we need to be. But I think especially if younger people are getting involved, we're definitely headed in the right direction. I have a surprising number of younger people reaching out to me. I had a high school student in Canada reach out to me a couple of weeks ago and say, "hey, we're, you know, I'm president of this club or something, and we're learning about brain injuries, and we thought we should learn about this, too. And can you please talk with us about this?"
Christina Brown Fisher: Oh, that's, that's wonderful.
Dr. Eve Valera:
I mean, that's really. Isn't that just amazing? I was just like, "absolutely, I will do it." Because, you know, if the younger you are trying to understand this, the better off we are. And that's one of the things that I really I feel very passionate about. It's sort of one of my really strong agendas is to increase education. I want education systems to say, okay, we have one in three people, one three women experiencing intimate partner violence, and this happens to men as well. And so why is that? What's going on? People shouldn't this shouldn't be happening. And I think women and girls and females don't realize that they don't have to sustain this abuse. It's not something that they should just accept.
Christina Brown Fisher:
I wonder, though, Dr. Valera, what can we do on an individual level. If I am in an abusive relationship or I know someone and suspect that they may be in one, what can I do?
Dr. Eve Valera:
That's a great question and there are things that you can do. So, I'm so glad you asked. So, if you suspect someone's in a relationship and they may not tell you because no one I mean, you don't want to admit this, you can reach out to them, you know, "are you okay? Do you feel safe? Is everything okay in your home? And, you know, if not, you know, you know, that's great, but I'm here for you," you know, and this happens a lot. So one thing you can do is just put yourself out there. I mean, so, you know, some people might feel funny saying, "oh, well, I don't want to say maybe it's kind of rude to say, oh, are you in abusive relationship? They may get offended." Well, first of all, I would say, "well, I don't really care if they get offended." If they get that offended, then are they you know, is it that much of a loss? You know, they should recognize there that you're trying to help them. You know, if you open up the conversation, I think that's going to help because part of the reason intimate partner violence is, is so pervasive is that it's invisible to a large degree because we don't it's not like we walk around with with, you know, like a dot on our head if we've ever experienced partner violence. And so people walk around all around us who've experienced it and currently experiencing it, and we don't know is because it's behind closed doors. And historically, partner violence or domestic violence is supposed to be like a family issue. That's not not appropriate for people to talk about that. No, no, no, no, no, if someone smashes a bottle over your head when you're in the street or if you're in the store, if you're in a bar, you can take legal action against that person and you probably should. So what's the difference if your partner smashes you over the head with a bottle in your home? Why should that be any less criminal? And it shouldn't be, so, the other thing is, is just if you start talking about it, it'll help destigmatize it. People are very uncomfortable talking about partner violence, and it's not going to get any better if people don't talk about it. So we talk about it. We say it happens all the time. This is nothing to be ashamed of. You know, this is something that unfortunately is really bad and we need to start talking about it so that people don't feel so uncomfortable talking about it. And if we reach out to other people, that's going to help that. If we offer assistance and you may not, you can say, "well, I don't have place to take them in," but you can give them someone to talk to. That may help. You can help provide them, you can say, "by the way, you know, there's domestic violence hotline." They can connect you with local resources in your area or, you know, you can, you know, maybe you can help them get a phone that can't be traced because a lot of times these people have their phones tracked and stuff like that. So so there's there's a myriad of different ways you might be able to help if they are in a situation and they're just not sure what to do. And then the other thing with respect to specifically TBI is basically helping to let them know that, you know, you know, I understand, you know, you're in this relationship and maybe this "well, I can't get out, there's too many things is too complicated." For me personally. I would feel it's an obligation to say, "you know, if you can't get out, that's okay, but I really need you to know that if you're sustaining brain injuries, that you need to be aware of this and this is all it means. You know, if he's hitting you in the head and you're feeling disoriented or something, that's not good for your brain. And so at the very least, we need to change something there, because that can have really long term consequences." But pretty much if you are putting yourself if you suspect somebody, at the very least ask for help and let them know it's very common, let them know it's not something to be ashamed of.
Christina Brown Fisher:
And you're there for them.
Dr. Eve Valera:
And I like to say, I mean, I think some people like, well, you know, I want to be around for my kids later or, you know, maybe this is easier, but but then if you factor in the potential brain injury, well, if you're just taking a bunch of them, you may not really be able to be around for your kids later if we don't know what the really long term effects are. But some of the women that I've spoken to many years down the road after having repetitive brain injuries, they're they're really upset because they're like, "I love I would love to hang out with my grandkids, but like, I'm finding now I'm just getting too irritable, like I can't be around them anymore." Or like this other woman who, like, she couldn't help her son with his second grade homework. So, I just think that the brain injury is just a whole 'nother component of it that may have a potentially more long term effect if it's not recognized and addressed and, you know, basically ultimately stopped.
Christina Brown Fisher:
And you're such a tireless advocate. Doctor Eve Valera, researcher, scientist, advocate of brain injury survivors from Intimate Partner Violence. Thank you so much for the work that you're doing to advance what we know about traumatic brain injury and for raising awareness about TBI and Intimate Partner Violence. And thanks for joining me on the show.
Dr. Eve Valera:
Absolute pleasure. Thanks so much for having me. I really appreciate your passion about this subject as well. It's very important to making changes. Thank you.
Christina Brown Fisher:
You can find more details about Dr. Valera's research and also information on how to get help if you or someone you know are in an abusive relationship on the Me, Myself and TBI website.
If you or someone you know is experiencing intimate partner violence, contact the National Domestic Violence Hotline at 1−800−799−7233 or TTY 1−800−787−3224. Spanish speakers are also available.