A new approach to trauma-informed care developed by domestic violence survivor advocates and researchers at The Ohio State University has been found in a new study to improve support organizations’ care for survivors by better recognizing brain injury and addressing its often long-lasting repercussions.
The study appears in the Journal of Head Trauma and Rehabilitation.
CARE is the first trauma-informed approach that considers brain injury in the complex set of circumstances to be addressed and accommodated in order for domestic violence survivors to access safety, health and social services. It was created in response to 2019 work by Ohio State researchers and the Ohio Domestic Violence Network that found 8 in 10 survivors seeking help have suffered head injuries and strangulation by their abusers.
“Given the pervasiveness of the problem, agencies should be ruling brain injury out, as opposed to ruling it in, and approaching their work with tools to appropriately support these survivors,” said Julianna Nemeth, the study’s lead author and an assistant professor in Ohio State’s College of Public Health. 
“These injuries are contributing to common struggles experienced by survivors, including engaging and following through with services and planning for significant life changes. And they are contributing to mental health, substance use and other health concerns.”
The CARE model is based on four cornerstones:
- Connect with survivors by forming genuine relationships and learning what survivors value, want, need and expect.
- Acknowledge that head trauma and strangulation, and related challenges, are common, including brain injury, mental health struggles, substance use and suicidal ideation.
- Respond by collaborating with survivors to develop accommodations for challenges related to suspected brain injury caused by violence and provide effective, accessible referrals and advocacy.
- Evaluate services provided by establishing a strong feedback loop with survivors to see how, and to what extent, the support, accommodations, resources, referrals and services are meeting their needs.
“CARE tools are intended to be used flexibly by domestic violence program staff to open conversations and provide information about head trauma, strangulation and mental health struggles – and help survivors identify short-term and long-term consequences of brain injury and trauma,” Nemeth said.
The research team interviewed 53 staff members, including some volunteers, at five Ohio domestic violence organizations prior to implementation of CARE, and 60 staff members a year after the organizations implemented the approach. The majority of staff indicated that after CARE implementation they felt more confident and comfortable and had more conversations with survivors about head injuries and strangulation.
“These tools help staff proactively recognize these injuries, which can manifest themselves in a variety of ways that present challenges in the daily lives of survivors, and in their ability to access lifesaving services,” Nemeth said.
Though there is growing evidence of brain injury among domestic violence survivors, and recognition of the pervasiveness of the problem is growing nationally, agencies that serve survivors largely still have a long way to go to fully and effectively address brain injury, Nemeth said. The CARE tools are free for download, were designed to be used by people with no formal health training and now have evidence to back them up, she said.
Nemeth said she and her colleagues are hopeful that the CARE framework can help not only staff who work in domestic violence shelters, but those who come in contact with survivors elsewhere and play a role in their health, safety and life circumstances – including the justice system, health care providers and social service organizations.
“Trauma-informed care, including the CARE model, is marked by the entire organization’s ability to be flexible with people and recognize that their current situation may have to do with both traumatic incidents that have happened directly to them and also inter-generational trauma and community trauma,” she said.
“If we want to help them, we have to be flexible with people, and realize that their behavior may also be the result of coping with the troubles arising from an invisible injury.”
The success reported in this study is also important because it speaks to the ease of implementing and sustaining use of the CARE framework, Nemeth said.
“There’s a high degree of turnover in these agencies and while they received training at the beginning, sustaining the work was left to the agencies themselves. We saw that the agencies were able to take the information they had, and the support materials, and train new staff as they came in,” she said.
“All organizations that are working with survivors of violence really should consider the possibility of brain injury in providing services and accommodations. We know that one in four women in her lifetime will experience severe violence. This is a community problem. This is a public health crisis. This is not something that’s just for domestic violence shelters to address.”
Other researchers who worked on the study are Rachel Ramirez, Cathy Alexander and Emily Kulow of the Ohio Domestic Violence Network and Christina Debowski, Alice Hinton, Amy Wermert, Cecilia Mengo, Alexis Malecki, Allison Glasser and Luke Montgomery of The Ohio State University.
