For USC Suzanne Dworak-Peck School of Social Work alumna María E. Garay-Serratos, MSW ’92, PhD ’03, a career in service has come full circle with a quest to uncover the connection between domestic violence, traumatic brain injury and chronic traumatic encephalopathy (CTE), a progressive and fatal brain disease associated with repeated sub-concussive brain injury. Her search for the reasons behind her own mother’s cognitive decline and ultimate death after 40 years of domestic abuse serves as the backdrop for the groundbreaking feature documentary This Hits Home, released in May 2023 and available to stream on Amazon Prime.

The film, conceived and developed by Garay-Serratos and director Sydney Scotia, shares the stories of domestic violence survivors from all walks of life, and includes interviews with prominent traumatic brain injury experts and domestic violence researchers, all uncovering a little-known public health epidemic.

Even as a child, Garay-Serratos made the connection between the “punch drunk syndrome” she saw in boxing matches her father watched and the symptoms she would see in her mother after he inflicted repeated blows to her head.  She chose to study social work, in part, to develop the tools to better understand and heal her family. When she began working directly with survivors of domestic violence a decade ago as president of an emergency shelter, she observed that they often presented with similar cognitive and behavioral symptoms to those she observed in her mother, but evaluating survivors for possible head trauma was not part of standard domestic violence treatment protocol. She decided to change that.

Garay-Serratos began what has become her life’s work by reaching out to several leading neurologists. One of them invited her speak at a brain injury conference and publicly disclosed her own personal history with domestic violence and traumatic brain injury for the first time.

“I thought, ‘what is a domestic violence services provider going to say to brain scientists to make them understand the connection between traumatic brain injury, chronic traumatic encephalopathy and domestic violence?’” Garay-Serratos said. “I decided there was no other option than to share my story. People listen to stories; they don't listen to numbers and statistics.”

As Garay-Serratos was speaking, the room grew silent and when she finished she received a standing ovation. She had not even made it back to her seat before she was asked if she and her mother, who was in hospice by then, would consider donating her brain to science after her death.

“I didn’t disclose my story because I needed help,” Garay-Serratos said. “I did it because I think the world needs my help. No other family should face what my family did.”

Worse than any NFL player

Sharing her family story at the conference began Garay-Serratos’ journey to confirm her suspicion that her mother suffered from CTE, which can only be definitively diagnosed after death by examination of the brain. CTE differs from other traumatic brain injury in that it comes from repeated sub-concussive, asymptomatic blows to the head, so the recipient often does not realize they are injured. This may also mean that the injured individual fails to adhere to the suggested protocol of rest following a known concussion. Because victims of domestic violence do not have control over when the next violent episode will occur, they may suffer multiple brain traumas within a short period of time.

Following the death of their mother, Garay-Serratos and her siblings made the difficult choice to donate her brain to be scientifically studied. They endured several inconclusive neuropathology examinations before Garay-Serratos sought the counsel of Dr. David Dodick, chair of the American Brain Foundation. who suggested she seek a conclusive examination with Dr. Ann McKee, director of the Boston University CTE Center and a world-renowned leader on CTE and uncovering the effects of repeated head trauma on contact-sport athletes and military veterans. Dodick also urged Garay-Serratos to consider educating the public about the connection between domestic violence and traumatic brain injury on a larger scale through a documentary film, and introduced her to Scotia. Garay-Serratos followed his advice on both counts. 

In This Hits Home, Garay-Serratos learns from McKee, in real time, that her mother’s brain did exhibit the damage associated with CTE. McKee further explains that the case is extreme, worse than any former NFL player’s brain she has examined.

“We know domestic and intimate partner violence are tragically underreported, but this type of brain trauma is also under-researched,” Scotia said. “The link between these injuries and neurodegenerative diseases like CTE and dementia is an urgent research priority.”

Additional research presented in This Hits Home suggests that as many as 80% of domestic violence survivors sustain at least one traumatic brain injury, and up to 50% receive repetitive traumatic brain injuries. Symptoms of CTE may include memory loss and confusion, personality changes, impulse control and mood disorders that can incite aggression, depression, anxiety and suicidality. Eventually, it leads to progressive dementia, often years or even decades after the individual experienced their last brain trauma.

“I remember my mother saying, ‘My head doesn’t work anymore,’” Garay-Serratos said. “I knew this response was common among veterans and professional athletes, but in my family’s case the war was in my home.”

“We need more scientific light shed on this connection to get attention in the field,” said Concepcion Barrio, associate professor at USC Social Work and longtime mentor of Garay-Serratos. Barrio says she always knew Garay-Serratos would find a way to significantly give back and impact her community. “She has really used her doctoral education in a very applied, integral and community-oriented way. Her work embodies the personal, the scientific and the advocacy – everything that makes up social work.”

Education is power

In 2018, Garay-Serratos founded Pánfila Domestic Violence HOPE Foundation to increase education and awareness about the link between domestic violence and traumatic brain injury, but with a global orientation that transcends cultural and socioeconomic boundaries. She is seeking to form meaningful partnerships to address this epidemic.

In order to make substantial progress on this issue, a combination of policy, science, brain research and education is needed for people living with domestic violence as well as the frontline workers who interact with them, including first responders, medical professionals, social workers, judges, shelter workers, police officers and advocates. Shelters and community clinics need to go beyond asking “Do you feel safe at home?” and include brain injury evaluation as standard practice when examining anyone who is known, or suspected, to have experienced domestic violence. Including domestic violence survivors in CTE research as well as in traumatic brain injury studies could also further understanding of this progressive neurogenerative disease and others.

Based on CDC data on intimate partner violence showing that one in three women experience severe violence at the hands of a partner in their lifetime and the research presented in the film on concussions among domestic violence survivors, Garay-Serratos estimates there may be as many as 44 million domestic violence survivors who demonstrate signs of traumatic brain injury or CTE. Garay-Serratos hopes that greater generation of knowledge around this issue will help people who experience domestic violence to recognize these invisible injuries and the profound long-term consequences of remaining in a physically abusive situation.

“I wonder if my mother would have left earlier if she had known,” she said.

Today, Garay-Serratos and her six siblings have broken the cycle of domestic violence that goes back generations on her father’s side. But she remains haunted by the families around the world who do not yet have this information, as well as the lack of research being conducted.

"Why are we just beginning to look at this issue?” Garay-Serratos said. “Why is my mother the first publicly recognized case of domestic violence CTE directly related to the trauma she sustained? Education is power. It’s rare that you have the opportunity to change the world in a meaningful way.”