- Traumatic brain injuries can have lifelong impacts on cognitive and psychological function.

Today's guest studies these injuries among survivors of domestic violence, and says they have serious mental health impacts.

She's Dr. Eve Valera this week on "Story in the Public Square."

(upbeat music) Hello, and welcome to "Story in the Public Square" where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salva Regina University.

- And I'm G. Wayne Miller with the Providence Journal.

- This week, we're joined by Dr. Eve Valera, an associate professor of psychiatry at Harvard Medical School and a research scientist whose work over the last two and a half decades is focused on the impact of brain injury resulting from domestic violence.

Eve, thank you so much for being with us.

- Thanks so much for having me.

- You know, this is a serious topic, and it blends both sort of human behavior and brain science.

How did you get into this work in the first place?

- I got into this because like you said, I had a little bit of a double interest.

Basically when I was interested in going into graduate school, I was very interested in neuropsychology, so understanding how the brain does things to make the body do things, right, so brain behavior relationships.

And when I went to graduate school, I also was interested in the idea of domestic and family violence.

And so I was teaching a child abuse prevention program while at the same time volunteering at a local women's shelter.

And so, as I was volunteering at that shelter, I would hear stories of the women who might have been like hit repeatedly in the head with fists, or hit in the head with a bat or something really pretty traumatic that could cause damage to the brain as I'm learning about this in my studies, 'cause I'm learning neuropsychology and how the brain can have problems if you get hit and the effects of brain injuries.

And I'm like, wow, you know, these women certainly seem to be sustaining brain injuries.

And a lot of the things that they have problems with seem consistent with what people might see following a brain injury.

So I said, what do we know about this?

And when I looked at the literature, I didn't find a single article.

There was nothing on the intersection of partner violence and brain injury.

And so I basically said, I got to find out what's going on here and decided to do that for my dissertation.

- I think most people are familiar with traumatic brain injury, either through if they have haven't been affected or someone that they love has been affected, they're at least familiar with the studies around NFL players.

And maybe they've heard about America's veterans who suffered from traumatic brain injury in the wars of the last two decades.

Are there insights from those experiences that are specifically applicable to the work you do?

- So I mean the insights from there, I mean, yeah, the insights might be that repetitive brain injury is certainly bad, right?

I mean the data that we have collected, you know, as a field in terms of brain injury is largely focused on male data.

And a lot of it's based on athletes or military folks, as you said, and a lot of the focus has been on repetitive brain injuries, and it's become pretty clear that, you know, if you have one brain injury, one, we call, you know, a moderate to severe brain injury, that's a whole different story, but if we're talking about what people think about in the NFL are athletes, these concussions or these mild or traumatic brain injuries, if you have one, you know, most people will recover, you know, eventually.

They'll eventually go on and you know, there's some data that suggests even one brain injury may have some long term effect down the road, but overall, you're gonna look like you did before you ever had the brain injury.

But once we have repetitive brain injuries, then we start getting more concerned about long term effects.

And a lot of that has been studied in athletes, et cetera.

And for the women who I'm studying now, we know that they're sustaining repetitive brain injuries as well.

So there's no reason to think that they are not experiencing potentially negative long term sequela as well.

And in fact, based on what we know about brain injuries or what I may have, you know, looked at in my data, it seems that, you know, if anything, women who are experiencing brain injuries from partner bonds are probably gonna fare worse than athletes, maybe even military folks for a couple of different reasons.

- So talk- - I would love to know what do you think those reasons are?

- So for one, well there's a couple, so if you're an athlete you for the most part now, I mean, not historically, but now you will automatically get access to care.

You'll get treatment.

You'll get sidelined.

You cannot go back into the game until you have successfully gone through your return to play protocol, right?

So you're insured that your brain has time to heal, not only before your doing strenuous, you know, activity or things that may aggravate the symptoms of your brain injury, but you're not gonna sustain a second injury before that one's healed for the most part, whereas women, they often don't report their brain injuries at all.

They either can't get access to care or they're afraid to, or they don't recognize that it's something that's important to do.

So that's one thing.

The other thing is that if we look at athletes, athletes tend to be healthier people because by definition, they're playing a game.

They have to be able to do certain things, you know, to be in the game.

And so if you have a healthier body that's gonna be more likely to recover well than a body that's not as healthy.

And it's not like a one-to-one relationship or anything like that.

But certain things, you know, like in terms of recovery from a brain injury, you know, if you have other negative things that are going on, that may slow down your recovery, like if you have another bodily injury, for example, like if you have like a broken arm as well.

Your body has so many resources, right, and so if your body's only trying to repair the brain and not repair something else, you're better.

And if you have a stronger body, you might be better off as well.

And then there are some data that suggest that there are differences in men versus women in terms of recovery of function after brain injury.

So there's a number of different things, but I would say that overall women who are experiencing partner violence are on the negative end of that spectrum, unfortunately, in terms of recovering well and quickly.

- So can you talk to us about some of the effects of brain injury, particularly among women and the people you study.

I guess you could break those down into two categories.

One would be the immediate effect, what happens after a woman is punched or kicked or hit in the head.

And then the longer term that you mentioned before.

A long conversation, but talk about that.

- Sure, I mean, we don't have a lot of data on exactly the immediate effects in terms of who I have studied so far in terms of like right afterwards.

Like I may know that they sustained a concussion because either they lost consciousness or they couldn't remember part of what happened or they're really dazed and disoriented, et cetera.

And then they may have had symptoms for a while after that, may have had headaches, but we haven't been able to study that really well because we don't usually see these women right after their brain injuries.

The data that I have collected has been collected based on women who have come in and their most recent brain injury may be five years or something or it's typically a range.

So some people are a little more recent, but some people are down the road, but a lot of them, the majority of the women who I've interviewed have sustained repeated brain injuries and the data that I've collected show that the more brain injuries a woman sustains, the more difficulty she has learning a list of words and remembering that list of words later on, and then also doing a task, we call it a cognitive flexibility task.

We have to sort of change what you're doing cognitively quickly back and forth from one to the other.

And so we show a relationship there.

And then we also show a relationship where the more brain injuries a woman has, the higher score she may have on, unfortunately, psychological distress scales, like depression, anxiety, PTSD, symptomatology, and worry.

So really when we look at this more as a whole, and not just the one specific brain injury, but her history of brain injuries, we see elevated levels of psychological distress and a relationship between those brain injuries and memory learning and cognitive flexibility.

- Eve, can you talk about strangulation.

That is another type of injury or related injury that certainly has an effect on the brain that you have studied, and I think perhaps is lesser known than some of the more obvious types of violence.

- Absolutely, and that's a really good question.

Strangulation is important to understand in a lot of ways.

One reason it's important to understand is because it's a strong lethality indicator.

So women who are strangled are much more likely to be murdered by their partners.

And so it's a good thing to recognize, certainly if you're worried about the safety of the woman.

And that's been something that's been talked about and discussed for a long time now.

What's been less discussed about strangulation is the possibility that it may be causing basically a brain injury via an alteration in consciousness.

So when you're strangled, you know, it's an external attack on the neck and it's depriving the brain of oxygen and potential nutrients that the blood may bring to the brain.

And that type of lack of blood or oxygen to the brain, basically asphyxiates the brain at least briefly, right, while the strangulation is going on.

And it's hard to study because, you know, like in science, we can sometimes do experiments, understand exactly what happened, but we can't, you know, ethically, and who would want to do this, strangle people and find out exactly what happens when you keep strangling them.

But in my data, I have looked at the potential effects of strangulation-related, what we call, alterations in consciousness.

And what that means is if they reported some type of either loss of consciousness or loss of memory for the event or confusion around the incident right after they were strangled, I do show that that is related to negative cognitive and psychological outcomes as well.

And what we don't know as much is how the interaction between strangulations and other types of brain injuries may be affecting the brain.

Because if you think, you know, you have one type of insult to the brain, okay, you might get some type of problems.

Now you have another type of insult to the brain that may have sort of an overlap.

But then when you have both of those, which a lot of these women do have, then it's gonna be potentially even worse.

So we're at our infancy in trying to understand that.

- Eve, I'm curious as I'm listening to this conversation, does the source of the injury matter?

I guess is the fact that the people that you're studying are victims of domestic violence or intimate partner violence, does that produce a different set of outcomes and consequences than someone who's, you know, in a Humvee that got blown up or playing tackle and taking too many blows to the head?

Is there something materially different in the outcomes of people who are victims of violence?

- So in terms of what's going on at the time, I mean, we know that there are some similarities right now, because when I study this, I can see some of the same types of things that we see in other brain injured victims, right?

But if you think about the differences between women and these folks that you just mentioned, so if you're in football, you may have a helmet.

So there's some protection to the head.

If you're playing football, you have stronger neck muscles, so that may help prevent you from getting a concussion as well.

So there's certain differences in the structure or the let's just say uniform between women and some of the most commonly studied folks.

And the other thing is the psychological context within which the brain injury occurs.

And so for folks in the military, they may be traumatized as well.

You know, I don't know exactly how everything works, but it could be pretty traumatic obviously to be blown up in a Humvee or to be driving through and being afraid you're gonna get blown up.

But when you're on the sports field, you're not gonna have that type of fear, right?

I mean, you're playing your game.

You're probably happy, et cetera.

But women who are experiencing partner violence are often walking on eggshells.

Some of them have described it as like being in a war zone, being in the ring with a boxer.

And so it's very terrifying.

And many of these women have high levels of posttraumatic stress.

So in that way, the context of the brain injury is actually quite different, because extreme stress is gonna affect how your brain is working as well.

So these are just a number of the different factors that may change the way your brain responds to that injury and consequently it's ability to recover effectively from that brain injury or quickly from that brain injury.

And that's a really good point and one which we're hopefully gonna be finding out more and more as we study these women because the field is in such an infancy right now that we know sort of the bare bones, but certainly we know there's negative outcomes and the psychological stress is certainly not gonna help that.

- So Eve how do you find the people you study?

I mean, you mentioned earlier and of course this is well known and intuitive that many victims of partner violence don't tell anyone.

It's their secret.

How do you find the people that you do study?

- Yeah, so that's another good question and hasn't always has been easy.

So the first study that I did, I would say two thirds of them were actually from the shelter within which I was volunteering.

And so you know, it's not as if somebody can just walk into a shelter and say, oh, we would like to study you.

I mean, that's just not gonna happen.

It's not acceptable for a number of different reasons.

But since I was already associated with the shelter and volunteering there, they knew who I was.

They trusted me.

So I was able to have women who were coming into that shelter, I could tell them about the study et cetera.

And so sometimes it's from a shelter and then other people, there was word of mouth, people getting orders of protection, et cetera.

In other studies I've waited, you know, a very, very long time before one person came in.

And then again, it was because a shelter said, oh, here's this study.

And one person came in, and they're like, oh yeah, like she's cool, you can go.

And then more recently we've sort of advertised and we've gotten other women who are in the community and they may not have told other people necessarily, but they are signing up for the study because we're specifically saying what we're doing.

And I think it's a little bit different now.

I mean, we're still way behind where we need to be in terms of accepting partner violence.

It's still very stigmatizing, et cetera.

But we operate under the context of confidentiality, et cetera, so they don't have to worry about this, you know, getting out to anybody else.

- Do you do any postmortem work?

You know, it's well known that, you know, in the NFL, a number of people have donated their brains to research.

And I think there's a center at Boston University actually that does some of this work if I have that correct.

And some brains have been donated.

And when people who are going to donate die, those brains will go there.

Have you done any work along those lines to actually look at the neuroanatomy of the brains of the people you're studying?

- Yeah, so I have not done that.

So by training, I wouldn't be able to do that, but I have very, very much wanted to collaborate with somebody who can do that and I might.

I mean, there's a couple of things in the works.

I think it's really important to do.

Right now, as you said, the group at BU has looked at a lot of football players.

There's a couple of other athletes' brains who have sustained repeated head impacts and they found high levels of tau.

And Aaron Hernandez who was here, I guess, with the Pats for a little bit, he committed suicide in jail, and I looked at his brain and found tau.

And so the next question is, well, do we think we might find that in women?

And we don't have a good answer right now.

I will tell you that there are two documented cases though.

One from 1990 and one more recently in the past couple of years where there were case reports in which there were women who had been beaten by their partners.

And when they did autopsy, they did find basically the signature CTE tau in the brain.

And so it would've been diagnosed as a CTE case.

But other than those two cases, we don't have that.

But I think it's really important.

And I actually have been trying to get the right connections, find the right people to do this.

It seems so simple, like we should be able to do this, but despite lack of interest, it's not necessarily simple 'cause it involves, you know, victims and donating brains and the neuropathologist, et cetera.

But I think it's a great question and I would love to see what we might find if we were to start looking at women who had histories of head injuries from partner violence.

I think it's a really important thing that we should do.

- Eve, in getting ready for this interview, I read a piece in the New York Times magazine that cited a CDC estimate that one in five American women experience "severe intimate partner violence over the course of their lifetimes."

One in five is an astounding number.

Do you have any sense of sort of the societal factors that are at play there?

- Why partner violence is so common?

- Yeah.

- Well there's a lot.

I mean, part of it is, I mean I think, overall the world largely is part patriarchal and there's a lot of misogyny, and you know, women are often second class citizens or not citizens at all.

So I mean, we can talk about the United States versus other parts of the world, but women are generally not necessarily safe overall.

It's very common for women to be abused.

I mean, it happens to men as well, but men are less likely to be injured from the violence, partly probably because of the physical difference in structure and strength.

But another reason I think partner violence is so pervasive is because it happens behind closed doors a lot and it's very stigmatizing.

And so people don't want to admit to it.

And other reasons is because people may not feel they're going to be believed.

There's, you know, a lot of reasons why women may be stuck in a relationship with her partner and have to, you know, feel like she has to stay there, economic abuse, threats, et cetera.

And women are murdered by their partners all the time unfortunately.

And they're most likely to be murder either when they're leaving the relationship or after they've left the relationship.

So there's reasons why women may end up being trapped in relationships for extended periods.

And I could probably talk about that for a very long time, so I'm trying to dial it back.

And then just because people don't want to talk about partner violence.

I mean, it's not like it's a fun thing to talk about.

And so, if I were to mention it to somebody, I might be uncomfortable even mentioning it to somebody for fear, I would make them uncomfortable.

And I think people do get uncomfortable talking about it.

So it's kind of hidden.

And so it's sort of like a crime that can just keep occurring with few ramification because people don't want to admit it.

And then I think some people may not even recognize that it's really violence.

I mean, they think, well, he loves me.

It's just this thing that he does or whatever it might be.

But yeah, I wish we knew.

But I mean my only solution or what I would hope will eventually change is that we basically have a core curriculum that includes healthy relationships as one of the staples.

That's not just like one course every year or something.

For some reason, we, as human beings are not understanding what healthy relationships mean overall.

And I think the idea is that, oh, parents should be teaching that themselves.

We don't need to teach that in the schools.

But clearly when kids are witnessing their parents beat up on each other or the father beat up on the mother, they're not understanding how relationships should be.

And as a woman, if you see your mother always being treated, you know, poorly, you may think that that's just the way you're supposed to be.

It's normalized.

And so I think until we change the socialization of little boys and girls at a young age, I think this is just gonna continue and continue.

And then we also need to make this a bigger conversation, open up the conversation.

Don't be afraid to talk about partner violence.

And one of the, if you will, silver linings of COVID is that you can say, you know, I know partner violence has gone up during COVID.

I've been learning this, and I just wanted to check in with you.

Are you safe at home?

Because some people might feel like, oh, I don't want to ask my friend that, because that would be insulting to say that their husband or whatever may be beating up on them or whatever, and they may think they're gonna offend them.

But this is one way you could potentially do it.

You could say, well, I just know it's happening.

I'm asking everybody.

I just want to make sure that you're safe.

And then who knows?

Maybe you'll find somebody who wasn't safe and you'll be able to help them out.

But I think those are the things we need to change.

- What advice would you have for someone watching or listening to the show who is in a situation where this violence is continuing?

What would you say to that person?

- [Jim] You've got about a minute and a half, Eve.

- I would say that this isn't just normal behavior.

It's not something that has to keep occurring.

I would say there are places that can offer help and it may not be easy.

There may be a lot of different factors that are basically making it very difficult to get out of that situation, but with planning and a better infrastructure, I think that it is possible to get out and to get out safely, you know, if that's what they desire.

If for other reasons they feel like they need to stay, there are probably other things that you can say, well, at the very least create a safety plan in case things get really bad and you need to get out.

Or in my case, when I think about brain injuries, you know, specifically, I'd want to say, try to protect your brain.

If nothing else, like, you know, cover your brain or, you know, if there's gonna be abuse, I mean, obviously you can't like decide what's gonna be hit, but maybe try to protect your brain.

And just know that there may be a lot of reasons that make it very hard to get out of these situations, but knowing that, you know, your brain is very, very special and we don't want to keep getting hits to it and that may have long term effects down the road.

And it may be contributing to your ability, the woman's ability to get out without her even recognizing it.

Maybe she thinks, oh, of course I can't do it.

I can't even balance a checkbook.

How am I supposed to survive on my own?

Well, maybe part of the problem is that you're dealing with post-concussive symptoms that do make it harder for you to do certain things.

But once you get out of that relationship, once you're not sustaining these blows to the head and the anxiety, et cetera, associated with it, you'll be better able to deal with those things.

Maybe you're headaches will subside, et cetera.

And so I would say that we want to offer help, and then there are places that you can get assistance.

- Eve, we can't thank you enough for sharing some of your work with us and for the work that you do.

She's Dr. Eve Valera.

That's all the time we have this week, but if you want to know more about "Story in the Public Square," you can find us on Facebook and Twitter.

For G. Wayne Miller, I'm Jim Ludes asking you to join us again next time for more "Story in the Public Square."

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