Australia’s New South Wales government has promised to improve brain injury testing for domestic abuse victims after a psychiatrist drew attention to inconsistent care for vulnerable women. Psychiatrist Karen Williams urged the government to adopt a concussion protocol for family and domestic violence victims after doing her own research and being shocked at what she found.
It started when Williams noticed the disparity in how her patients were diagnosed and treated.Williams specialises in the treatment of post-traumatic stress disorders (PTSD), often with military, police, emergency personnel and other first responders.
But she also treats the general population, the vast majority of whom are women with histories of child and domestic abuse.
“I was getting two populations,” she tells NR Times. “The military patients, who are clearly identified as having PTSD, and the female population, who are mostly identified as having depression, anxiety and personality disorders, but had incredibly high rates of abuse in their histories.But Williams saw that whilst both groups had similar symptoms, and similar levels of trauma, they had very different treatment options.
“There’s a lot more funding put into supporting traumatised soldiers and first responders than there is for women who have experienced trauma within their home.
“In Australia, we don’t have much at all for women and children victims of abuse.”
This was a particular concern because of the amount of times Williams had heard about multiple head injuries and concussion among women who were victims of domestic abuse, which is similar to boxers and those player high contact sports.
“Women who’ve been unconscious several times or strangled have symptoms such as memory deficits, insomnia, migraine and mood swings, which all could be put down to PTSD and depression, but also brain injuries.”
But if Williams wanted to find out if a patient had a history of brain injuries, she would have to refer them for neuropsychiatric testing, which costs up to AUS$1000.
“This is completely unaffordable for many abuse victims so it just doesn’t happen, so we don’t investigate women who’ve had brain injuries.
“One brain injury unit told me they would consider taking on a patient if they could provide evidence that an assault happened – such as hospital records.
“This completely fails to take into account that the vast majority of domestic violence survivors will not report any assault to anyone and will not have so-called evidence.”
Then, Williams was speaking to a colleague whose son had had a head injury in a sporting field.
While they were together, a nurse rang to follow up the treatment he’d received in the emergency department.
“The nurse asked how her son’s personality and memory was, and gave a fantastic run-down of the symptoms that can happen after a concussion,” Williams says.
Williams was shocked – she’d never heard of someone ringing up women after a head injury in a domestic violence case.
She rang the local emergency department and asked about their protocol following a head injury obtained during sport.
She was given a detailed outline of the observations they take, their plan over the weeks following the patient’s injury and the advice they give the patient.
Williams called several emergency departments in other Australian states, and whilst all had a protocol for sports players following a concussion, none said they had a protocol for women who had been the victim of domestic abuse.
“There wasn’t one place that said they had a particular protocol.
“If they knew the woman had had a head injury they’d give them the basic head injury protocol, but nothing specific that took into account the very individual needs that a woman with a head injury in a domestic situation might have,” she says.
Williams says research indicates health care professionals correctly identify family violence victims about one per cent of the time.
“In sporting players’ protocol, there’s a recognition that says that your patient may not know what they’ve experienced in the past was a head injury, so the advice is to be really explicit. They’re given a list of questions to break it down with that player to make sure they understand what could be a head injury.
“There is opportunity for scanning, and neuropsychological testing if there is evidence of persistent symptoms.”
Williams says doctors should be going through the history of women, too, to see if they’ve lost consciousness in the past.
“There are a variety of mechanisms in which a woman experiences brain injuries in a domestic situation, many more than sporting probably, and the more head injuries a woman has, the greater her chance of long-term problems,” Williams says.
This includes a higher risk dementia, PTSD, migraines, learning problems and memory problems.
“But women aren’t told this, so many don’t know that they’re at risk of these things.”
Williams says there is a ’hidden epidemic’ of women in the community with brain injuries no one knows about, who could have been diagnosed with mental health issues instead.
In 2018, Brain Injury Australia released its findings after looking at the prevalence of brain injury in victims of domestic violence.
It found that 40 per cent of victims who attended hospitals in Victoria, Australia, for domestic violence had a brain injury and the majority were women.
But there’s no specific treatment for these women, Williams says, and many won’t even know they have a brain injury.
“Abused women are a very neglected population, and when you think about the money being spent on sports, and sports players, there’s no reason we can’t look after woman as well,” Williams says.
But despite these findings, Williams says it didn’t lead to any change.
“When I found all this out, I was angry and upset,” Williams says.
She arranged to meet New South Wales’s Labour MP Anna Watson in August, and when Williams told her what she’d found, she says Watson was ‘mortified’.
“She immediately got on the phone with the office of the minister for the prevention of domestic violence, and requested a meeting as soon as possible.
In the Zoom meeting a month later, Williams went over what she had found with Mark Speakman, Attorney General and Minister for the Prevention of Domestic Violence, and outlined the obstacles facing women.
But he made no promises, and Williams said she felt he didn’t understand the urgency or gravity of the situation.
Watson then went to the media, and the story was reported on. Within a week, the government produced a statement promising to investigate the issue.
“We’ll all be watching and holding them accountable,” Williams says.
“I will be trying to follow up, I won’t let it go.”
Williams is disheartened that it took media coverage to get the government to respond, but says she’s learnt a valuable lesson.
“Part of the reason I’ve spoken to the media and been vocal about it, is my experience is that when we do things quietly and ask for things politely, the government says there’s no money, despite being one of the wealthiest countries in the world. But when the voting population starts getting angry and asking what’s going on, that’s when we see an answer.
“It’s been a sad realisation for me to recognise that people don’t respond to do the right thing, they respond to winning the vote, so I will keep being as loud as possible in the media.”
Leaving brain injuries undiagnosed has significant consequences, Williams says.
“You’ve got women feeling like they’re a bit crazy, women wondering, ‘Why don’t I remember things, why have I got headaches all the time, why can’t I sleep?’
“It makes women feel worse, like something is wrong with them rather than identifying the underlying cause that we’re completely missing.
“If women are unable to work due to the physical and psychological side effects of a recurrent head injury, they need to be able to apply for NDIS funding (National Disability Insurance Agency). f they don’t know they have a brain injury they will be left to flounder – which is what is happening now.
“The vast majority of doctors don’t know about this. The medical system failing these women.”
There will be a lot to work out as support becomes available, Williams says, as some women could fear that having brain injury diagnosis could interfere with them getting custody of their children.
But, ultimately, change will benefit these women.
“All women deserve to know the truth about what’s happening to them,” she says.
“In some cases, their brain injury will be the final straw. They might think an act of violence isn’t a big deal, but if a doctor says, ‘Look how many times this has happened to you, you could end up long term brain damage’, that might be the final push that makes her take steps to leave. There’s no excuses to justify why these conversations aren’t had.”
Case Study: Lynda’s Story
Lynda’s story provides an uplifting insight into how neurorehabilitation following a brain injury can have positive, long-lasting effects on an individual’s physical and mental wellbeing. This is even when there is a significant time period between the brain injury occurring and starting rehabilitation.
Lynda was an independent woman who had a job, family and friends. However, she had a history of battling with substance misuse and was at risk to the influence of others. The exposure to these negative influences resulted in her suffering a hypoxic brain injury following an overdose in 2010, from which she remained in a coma for three months.
Lynda’s story highlights her dedication and the commitment of the specialist care team at Richardson Care in her rehabilitation journey.
Unique and Supportive Environment
Lynda was admitted to The Richardson Mews in December 2014, more than four years after sustaining her brain injury. The home is run by Richardson Care, a specialist residential care provider in Northampton. What makes it unique is the family atmosphere that is created and the uncompromising commitment to putting the service user at the heart of every decision that is made about their care. Richardson Care is an independent family business with a 30-year track record. Their expertise and experience in creating a homely and supportive environment encourages people with acquired brain injury to engage in their therapies. Combined with a person-centred and innovative approach to care delivered by a multi-disciplinary team, enables Lynda and others, to transform their lives.
When Lynda arrived at Richardson Care she was wheelchair-bound and she had been told that it would be very unlikely for her to walk again. Her ability to mobilise was minimal: she was only able to mobilise for extremely short distances and required a walking aid. She expressed her wishes to be as independent as possible and to walk again. However, she had little insight into her own physical limitations. Lynda also needed frequent prompting and encouragement with all aspects of daily living (such as personal care).
“The day Lynda arrived she was withdrawn, unable to walk and had limited speech. Lynda has shown great determination throughout her rehabilitation. Today, she has a voice. It is a pleasure to be part of Lynda’s journey.” – Jane Payne, Operational & Clinical Officer
Lynda’s personal care and treatment plan
In addition to her physical disabilities, Lynda presented with behaviours that could be described as challenging. The multi-disciplinary team at Richardson Care worked with her to devise a care and treatment plan that would address her physical, behavioural and emotional needs.
The following gives us an insight into some of the different elements of her care plan, that when consistently applied, lead to lasting benefits. They are helping Lynda towards her goal of independence.
- Psychology input – Cognitive Stimulation Therapy, Relaxation Group and 1:1 sessions that focus on improving and maintaining her emotional well-being. She is encouraged to use her coping mechanisms when facing challenges, and staff are aware of her early warning signs. These sessions also provide Lynda with the opportunity to discuss any issues or anxieties and receive reassurance and positive feedback on her behaviour.
- Physiotherapy input – weekly physiotherapy sessions to work on balance, strength and stamina and to help maintain flexibility. They focus on improving Lynda’s physical well-being and strength, working collaboratively to reach her goal of independence.
- Positive Behaviour Support (PBS) Approach – care plans, risk assessments and intervention guidance; working with Lynda to recognise and reinforce positive behaviours and increase her independence.
- Consistent support from care workers enables Lynda to develop and maintain a good therapeutic rapport with staff, helping her to manage her surroundings and behaviour.
- Social and environmental influences offered at Richardson Care allow Lynda to utilise her independence and build confidence. These include: meaningful activities, consistent structure and routine, trips to the community with staff support, opportunities to socialise and build positive relationships with other residents and staff.
Progress and Current Presentation:
Throughout her time at Richardson Care, Lynda’s strive for independence has been a prominent motivating factor for her. This is reflected in the significant progress she has made at every stage of her rehabilitation.
In 2019 (after being at Richardson Care for around four years) Lynda reached the stage where her strength, balance and confidence had been built to a level where she could walk independently with no aids. Throughout her physiotherapy sessions, staff adopted a person-centred approach to maintain engagement and compliance and to work with and around her cognitive difficulties. This approach has proved extremely effective with Lynda and has increased both her physical and mental well-being.
Timed Up & Go Test
“Lynda is the prime example of how a person living with a brain injury can still make considerable physical improvements given the right environment and therapy approach. Lynda was not in the early stages of her rehab and her injury was more than 12 months prior to coming to The Richardson Mews.” – Guy Stewart, Physiotherapist
The graph below provides a visual representation of Lynda’s substantial progress whilst at Richardson Care. The ‘Timed Up and Go Test’ is used to monitor Lynda’s improvements in walking 12 metres unaided, where the average time is taken from three attempts.
On admission in 2014, it took around 60 seconds for Lynda to complete the test. There was then a significant improvement in the following year and her average time decreased to 28 seconds. The years following have continued to see small improvements.
The most recent test, completed in January 2021, reported an average time of 14.90 seconds. Despite Lynda’s average time only being 0.35 seconds quicker than the previous year, it highlights how she is maintaining her mobility status and not showing decline. This is a vast achievement considering the restrictions in place due to the pandemic that has ensued between these two time points. Even with the limited access to physiotherapy and a reduced opportunity to go outside for walks, Lynda has remained consistent and motivated in her recovery with the support of her care team.
In addition to her physical progress, Lynda has been supported by care staff and the psychology team to ensure the quality of her emotional well-being and improve her resilience. Lynda still requires support to build a healthy resilience to stress by using effective management techniques, particularly regarding her experience of health anxiety, and this is less frequent.
Through psychology sessions, such as relaxation and 1:1 coping skills sessions, Lynda has developed a good inventory of skills to use when experiencing frustration or anxiety. She appears to have developed more insight into her emotions, knowing when to seek out staff support. This has aided in the development of self-esteem, confidence and resilience.
“Lynda has become a part of The Richardson Mews family and I have witnessed her growth since her admission. When Lynda first came, she was told she would not be able to walk and would be wheelchair bound. Now she can walk without any support. Lynda is very bubbly and always welcomes new residents with open arms. The day she leaves will be a sad day for The Richardson Mews, but it will be good to see her progress and she deserves to live the life she wants.” – Gill Ayris, Admissions & Referrals Manager
Daily Living Skills
Lynda continues to make significant improvements in her daily living skills; these include cooking her own meals with little support, and under normal circumstance, attending the local swimming pool, visiting the local shops to complete her shopping, going to cafes for coffee, going to bingo and socialising with staff and residents. She often encourages other residents during group activities.
Lynda secured a part-time paid job at Richardson Mews, where she completes office tasks. This is in line with her ASDAN (Awards Scheme Development Accreditation Network) courses, which she thoroughly enjoys and shows dedication to.
Challenging and Risk Behaviours
Lynda is a caring and empathic lady. She is usually calm and pleasant but at times presents with behaviours that can be described as challenging. These behaviours highlight her vulnerability and her impulsivity. However, the positive interventions and consistent staff support offered at The Richardson Mews is contributing to a reduction in such behaviours.
Lynda could be viewed as a model resident at The Richardson Mews where she continues to progress in her rehabilitation journey. The continued staff support she receives, coupled with her own determination means it is reasonable to say that her goal of moving on to supported living in the future is well within her reach.
“I love it here and I have grown as a person, but I am ready to move on all because of the decent services I have received here.”
“I love having physio, the food is lovely, and the staff are very friendly and I have achieved a lot with Sallie (ASDAN coordinator) and gotten loads of certificates.”
To find out more about the unique and specialist residential services provided by Richardson Care, call 01604 791266 or visit www.richardsoncares.co.uk
ABI and eating disorder
The impact of brain injury on a person’s life can be vast, with the effects many. But what if an eating disorder comes into the equation? Solicitor Ewan Bain explores the issue.
The effects of an acquired brain injury (“ABI”) are truly multi-faceted, ranging from dysexecutive syndrome, neuro-behavioural issues, to more obvious physical disabilities.
It is well known that mental health issues and conditions can arise from acquired brain injuries; the well-known ones being depression and anxiety. However, what about Eating Disorders arising from ABI; is that possible and are they linked?
Whilst there have been massive strides in the neurological sciences over the past half century or so, there is still much more we do not understand fully.
Eating Disorders (which encompass conditions such as anorexia, bulimia, amongst others) are yet to be truly understood; it is still difficult amongst clinicians treating in this area what is often the best method to treat people with such disorders.
The clinical studies and clinical treatment of Eating Disorders is still evolving; so what does one do when presented with an individual who has an ABI and has thereafter developed an Eating Disorder?
The short answer is: it’s complicated.
Treating Eating Disorders per se is phenomenally tricky and if it is compounded with someone who has an ABI, which can bring with it other co-morbidities associated with that, it makes for a very convoluted clinical mix and a huge challenge for those clinicians trying to treat the individual affected.
What is an Eating Disorder?
An Eating Disorder is when an individual adopts an unhealthy attitude towards food. It does not necessarily mean eating too little, it can also involve eating too much, or being obsessive with one’s weight and body shape.
The goal of any intervention towards an Eating Disorder is to essentially:
- Restore physical health
- Develop normal patterns of eating habits/attitudes;
- Reduce the impact of illness and day to day functioning.
The goal is fairly obvious but achieving it is not. For a start there a number of differing disorders:
- Anorexia Nervosa – this condition involves where one tries to keep their weight as low as possible. They do this through not eating enough, excessive exercise or a combination of both.
- Bulimia – with this condition, people lose control and binge eat before then being deliberately sick or using laxatives.
- Binge Eating Disorder – losing control of your eating by consuming large portions of food at once which leads to feelings of guilt
- Other specified feeding or eating disorder (OSEED) – this is where a person does not have what classically fall under the above conditions but nonetheless have an issue.
The above conditions have differing approaches ranging from pharmacological to the psychological, or a combined approach of the two. The environment and setting of how such treatment is delivered can differ too and depends largely on the person’s wishes, the availability of specialist services and the clinical presentation of the person affected.
The impact of Eating Disorders should not be underestimated. As well as the personal impact on the individual and their families, it has wider social and economic connotations as well. PwC recently conducted research and prepared a report on the commission of the Eating Disorder charity, “BEAT”. That report estimated that the cost to UK society of Eating Disorders was circa £15 billion per annum, which is simply staggering.
Eating Disorders tend to affect the younger population and young females are the more prevalent group. One study found that there was mean incidence for anorexia, as an example, of 4 to every 100,000 in people aged 10-39 years.
What is more disturbing, using Anorexia again as a graphic illustration, is that Anorexia is often reported to have the highest mortality rate amongst all of the psychiatric disorders.
ABI with an Eating Disorder
It is uncommon to find individuals who have sustained an ABI, with no previous history or risk factor for Eating Disorders, to then develop one post-accident.
However, whilst it is uncommon, suffice to say, it does not mean it does not occur.
The clinical community are aware of the link between ABI and Eating Disorders but it is perhaps not as clearly agreed or understood amongst them is how best to tackle it.
There have been some reports and studies but it is understood that these are not vast by any stretch of the imagination. There is little data that exists which concentrates on food behaviour patterns with this cohort of people with eating disorders.
In one particular case study, the authors found that the cases “all had a frontal subcortical syndrome, expressed by neuropsychologic dysfunction, neuroimaging (frontal and basal ganglia lesions) and also as personality changes.”
They went on to discuss how patients with cognitive deficits might not be affected by behavioural strategies to combat their eating disorder.
They ultimately concluded the following: “the eating disorders in patients with traumatic brain injury may be present from early phases and persist years after the lesion….Eating disorders in the TBI patient should be approached and treated in a different way to a typical anorexia and bulimia taking into account the cognitive impairment caused by traumatic brain injury. Prospective studies are required to determine the importance of the different factors influencing eating behaviour of these patients. Results enable us to understand the course and progression of these disorders over time and establish appropriate medication for their control.”
What is evident from the above is that field of Eating Disorders faces its own battles in understanding and tackling the competing factors, be it clinically, socially or even politically (with respect to funding).
The added layer of an ABI into the mix, convolutes the picture further, what with insight and cognitive deficits.
This will be to some therapists and clinicians in the ABI field relatively new ground to them; therefore, it is difficult to say (even if one was from a clinical background) how to approach this.
What can be said though is that input is almost certainly required between specialist clinicians practising in treating patients/clients with atypical ABI symptoms and with those from the Eating Disorder field. It is therefore of the utmost importance that, for instance, a case manager presented with such a client, considers specialist input from psychiatrists and clinicians from the Eating Disorder field.
They will need to work in conjunction with those treating the typical symptoms arising from the ABI; the priority of treatment will undoubtedly be the Eating Disorder and without tackling that firstly, it may not lead to progress in tackling other areas such as the client’s cognitive deficits and associated behavioural issues.
Case Managers, therapists and even legal practitioners practising in the ABI field, need to act quickly if there is an inkling that their client could have an Eating Disorder.
Regular contact/communication with your client and their family should allow you to be alive to such situations.
If such a situation does occur, then the case manager/legal team should consider arranging urgent discussions with those concerned in the care of the client; individuals with Eating Disorders may not accept that they have a problem and added with possible insight issues arising from a ABI, then this needs a careful approach so as not to disengage the client.
- Ewan Bain, specialist brain injury solicitor at Switalskis Solicitors, was assisted by Dr Matthew Cahill, Consultant Psychiatrist, in preparing this piece.
Brain injury charity to benefit from Raul Jimenez fundraiser
Footballer Raul Jimenez, who fractured his skull in a match last year, has chosen brain injury charity Headway as a beneficiary of a fundraising appeal on his behalf.
Wolverhampton Wanderers player Jimenez was knocked unconscious in a clash of heads while playing against Arsenal in November, prompting fans to launch a campaign to fund a banner in support of him at Molineux.
After hitting the initial target of £7,500 in a matter of hours, the JustGiving fundraiser remained open and now stands at over £22,000 of additional funds.
Jimenez has now decided to split the money evenly between Headway and the Mexican Football Federation’s initiative Jugamos Todos.
Headway supports individuals and families in the aftermath of brain injury, helping them to rebuild their lives, and has also been a vocal campaigner on the issue of being concussion aware in sport, with its ‘If in doubt, sit it out’ mantra resonating across sports from grassroots level upwards.
“My family and I were overwhelmed and truly humbled by the outpouring of support from the Wolves family, and football fans all over the world, in the days and weeks after my injury and surgery,” says Jimenez.
“The messages of support I received, across all channels, and from all corners of the globe, have been inspirational for me in my rehab and recovery, and the banner at Molineux is a truly special gesture.
“I want to thank the fans that came up with the idea for a banner and every single person who made a donation to fund it.
“I am delighted that we have such a large amount of money left over to give to organisations that will make sure that the right people benefit from all the love and generosity I received.”
Peter McCabe, chief executive of Headway, says: “The immediate aftermath following a brain injury can be very challenging for the loved ones of those affected, and I’m sure Raul and his family will have been through a very difficult time.
“We are therefore delighted to hear that Raul is making progress.
“We are also extremely grateful to Raul for recognising the work Headway does day-in-day-out to support families and individuals affected by brain injury from the moment the injury occurs through to helping them to rebuild their lives.
“I would also like to extend thanks to the club and its supporters for their generosity. To everyone who donated in support of Raul, I offer the heartfelt thanks of the charity and all those we support.”
The other beneficiary of the appeal, Jugamos Todos (Let’s All Play) was launched by the Mexican Football Federation (FMF) in 2016 to expand on its mission to use football and other sports at schools as a tool to improve children’s health and broaden their opportunities both in sport and society.
Wolves Matchday Experience Group member Kieran Newey, who set up the JustGiving page to fundraise the banner, said: “When Raul got injured at Arsenal, we saw the shock and worry for him and his young family all over social media.
“As a collective within the Matchday Experience Group, we wanted to come up with something to show Raul our support, and very quickly the idea of creating a banner with a fan design and fan donations came to life.
“We are really delighted that it captured the imagination of our fans and other football fans around the world, and that we have been able to raise enough money to cover the costs of the banner and have a substantial amount left over to give to charity.”
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