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Transcript for April 7, 2017

>> Good afternoon and welcome to our [inaudible] lunch at the San Diego SDSU, and you guys are now considered the [inaudible] Institute. So today we're talking about a study that I did in 2014. My name is Dr. Lisa Cooley, and I'm a graduate from the educational leadership program at SDSU. The study that I conducted wanted to look at the social connection and social capital in post-secondary settings for students with traumatic brain injuries, primarily in [inaudible] college setting. The aim of the study is to understand how community college students with traumatic brain injury, and from here on I'll just refer to as TBI, how they perceive social capital and social engagement with friends, family, and their significant others, and so I'm here today with the people that were unlike many from our dissertation, and Dr. Gail Conrad, [inaudible] working with San Diego Foundation and [inaudible] Institute with [inaudible].

>> And this is Chuck [inaudible], professor of rehabilitation counseling and coordinator of the rehab counseling program at SDSU, and I had the good fortune to be the chair of Lisa's committee. And one of the things we're doing with this presentation is, you know, we're going to be presenting this in the poster session in a couple weeks with the National Council and Rehabilitation Education Conference, and then we're also working on a manuscript [inaudible] journal. So [inaudible] will be helpful to get feedback from everyone. You know, we'll take questions. This will be very, I think, interactive, and it'll be good preparation for us. And we've got one more key person on our committee, Dr. [inaudible].

>> Yeah, Dr. [inaudible] called me. I just talked to him. He's [inaudible] privilege of working with a number of fantastic students on the project, and I'm very excited to hear what [inaudible] did and how we [inaudible]. And so the first slide we're really talking about the [inaudible] aim of the study, and again, it is to understand how community college students with TBI perceive their social capital and social engagement with friends, family, and significant others. The first thing that I wanted to do was define what TBI is, and basically a TBI is considered to be an injury caused by an external blow to the skull resulting in damage to the brain. TBI [inaudible] regarding TBI. Okay. TBIs result in either closed or open head injuries. In the U.S., most TBIs are mild. Over 2.6 million of them happen each year in the United States, and it's really hard because, you know, professionals have a hard time predicting long-term function and recovery, and really there are no two alike, so it's really hard to say, okay, this is what you're going to be left with, and these are going to be your deficits because, again, there are no two alike, and so what I really wanted to look at was really the social aspect of this [inaudible] disability.

Next slide please. And if you have questions, [inaudible] little hands up from [inaudible] here, so I'll just keep going until I get questions. So post TBI capital and social capital and social engagement. So what I've referred to as social capital, as most people probably know, is really how we feel, where is our place in our social settings and how much capital and how much value do we place on that. [Inaudible] TBI and the nature of the injury and the ability of the injured person to cope [inaudible] barriers to effective social engagement and therefore social capital. Social engagement refers to social interactions and activities outside of the home setting. This can contribute to one of life satisfaction or life's purpose and self-realization. So [inaudible] really key and critical components, especially when you're trying to [inaudible] post-secondary setting such as a community college. [Inaudible] having a hard time with this word. Next slide please. Epistemology. We used what was called a phenomenological approach. It was chosen as the appropriate way to study this particular group of students. This was a qualitative study, so just to remind people what that is, that's where we actually are doing interviews, so we're getting the person's perceived, what they perceive as how their experiences and then what we do is we code them. Most rehabilitation counselors likely possess little knowledge on how persons with TBI in post-secondary setting experience [inaudible]. So at the time I thought this would be a really fascinating topic. I still do. I still think there's a lot more to learn in this study and a lot of ways that the study could go, but basically how do these students integrate into [inaudible] and again in post-secondary it's critical that they feel a sense of belonging and a sense of integration. Participants who entered this study had discussed a unique lived experience of a concept or a phenomenon, so that's where we get that phenomenological approach. We look at what kind of experience a similar thing or phenomenon if you will, and now they're going to describe their [inaudible] experience of it.

Next slide please. So this was something that I had been working with this population for over a decade. This was something that I used as a framework to worth with. It was a Native American medicine [inaudible]. It's nothing new that the, you know, as far as we look at the intellectual, the physical, the spiritual, and the emotional. That's how Native Americans really look at the whole person so it's a holistic model, and so the concept was that a person who experiences a TBI is affected on all four of those levels. Again, the physical, emotional, intellectual, and spiritual. And so that's really what I wanted to look at is the framework to go through this study. Next slide please. So my research questions, I came up with these as I looked again through this framework. How do persons with TBI perceive a sense of belonging with regard to relationships, with family, friends, and significant others. And also what factors contribute to positive and appropriate social interaction, and finally how do perceptions, social capital, and social interactions influence feelings of wellness and social connection, and again looking at how they feel a sense of belonging in a post-secondary setting. So the samples, so how I got my participants. They were recruited from the program, a cognitive retraining program.

At a southern California college this sample was 1.5 to 4.5 years post injury, so if you're thinking about TBI, you know that a lot of the, after the acute phase, a lot of the recovery really takes one to two years, sometimes upwards to five years. So I really wanted to look at what that post-acute person is experiencing. So the injury was not super [inaudible], and it was, you know, enough time for them to kind of grasp what their deficits were, so I thought that was a good timeframe to use. And then associated professor with this program, I screened perspective participants for my study. They were 18 to 36 years old, and 50 percent of them were in motor vehicle accidents, which is very much synonymous with brain and TBI in general, a bulk of them are through motor vehicle accidents. The participants I actually had 12 in total, I had eight males and four females, and they were 50 percent white. Out of that group, nine of them were single, and three were dating and in relationships. So you can just see that two-thirds of the population sample that I used, two-thirds, well three-quarters of them actually were single, so again I'm looking at integration and looking at connection, and I think that was significant in my study. Next slide please.

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>> [Inaudible] the title, the cognitive retraining title, that's a pseudonym [inaudible] protect the--

>> [Inaudible] actual program that exists but in order to protect the confidentiality of this group, we have used that.

>> Yeah, and I think--

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Yeah, I have no problem. I think, was it also the case nobody having married, or nobody was married, nobody had children, I don't think?

>> Right. No one had, none of the participants in my study had children or were married. Any other questions? Okay. Moving along. So, again, using the Native American medicine wheel, I kind of designed the interview questions [inaudible] looking at that medicine wheel. So the first question is related to the spiritual self, and I thought because this was a theme I kept hearing in my work with this population was the spiritual aspect of this disability and how many of them felt that spiritual side is what really helped them to recover. So my first question was how important is the idea of faith to your recovery and to your interpersonal connections. And number two, have you experienced a change in your role, in your community, or in your personal identity since your TBI? Number three, how hopeful are you about the future and your ability to maintain long-lasting relationships, and finally, how important are your personal relationships to your overall feelings of wellness. And again we kind of understand why that [inaudible] spiritual self because I think it's more a connection of feeling [inaudible] belonging, a sense of being a part of something greater than themselves [inaudible].

>> [Inaudible] got a question also. So, you know, see how this perceptual model of the medicine wheel, and how did you, what process did you use to come up with like these specific questions that were anchored in each of these four dimensions of the model?

>> Because I had been working with this population literally, you know, my whole career, so ten plus years working with them as a counselor and as a professor, I met with literally probably hundreds of TBI survivors, and that was the thing that kept coming up, is the spiritual connection and the social deficits and the feelings of not quite belonging and this sense of identity loss potentially, like who am I now after this life changing, life altering [inaudible]. So these questions for me became dictated by them really, the things that they wanted to share, the things that they wanted to tell me, the things that they wanted to talk about, and I felt like I want to act as their [inaudible] to get the word out to professionals and people, you know, especially in the school and the college setting. So people could kind of understand some of the limitations.

>> Really provide a voice that maybe hadn't been really heard before.

>> Right. And maybe not even thought about before.

>> Yeah.

>> I mean if you think about rehab and [inaudible], you know, we're really all about, you know, return to work and get back into your life and, you know, here's the recipe, let's do this, [inaudible] the recipe and things are fine, but we really don't look at the subtleties, you know, the social, the pragmatic of just conversation and those kinds of things, and I think that we forget that even trying to figure out how to do that for somebody with a brain injury is difficult. And I think that was where I was coming from.

>> I see.

>> So the emotional, the other paradigm, the next paradigm I covered was the emotional [inaudible], and number one, since your TBI, please describe your experiences in relating and/or communicating on a deeper level to others and how have things changed in your ability to articulate thoughts and feelings. So, again, all of these questions and these themes really came from my years of experience working with these populations. Number two, since your TBI, please describe your experience within your interpersonal relationships and the subsequent changes that may have occurred. So, again, thinking about your identity, your roles, who you are. Maybe you're the, maybe you're the football star, or maybe you're the A student, and people around you kind of look at you that way, and then you have this life-altering, life-changing event happen, and suddenly you're not that changing person anymore. So that was kind of the same, and that question really talked about that, like how are the current relationships [inaudible] the status that they've had, that the people they know now and the people they knew before [inaudible] changed. Number three, would you say that it's been difficult for friends, family, and significant others to fully accept and/or understand your TBI, and can you please explain. And I think a lot of us in the room know what that feels like. Again, because oftentimes brain injury is something we can't see on the outside, so, you know, I hear time and time again, well he or she looks normal, why can't I relate to this person anymore? Why are they so different? Why did they change.

And so again, looking at can the people around the person with the TBI accept that they are not the same person anymore and that they have changed, and oftentimes they've changed permanently. Because that was where that question was kind of going. And then lastly are the emotional, can you describe your emotional changes you have noticed since your injury. Oftentimes people with TBI explain or describe that they get easily frustrated. They cry easily and oftentimes they have issues with depression and anxiety, so that's where that kind of came in. So I will continue. The third paradigm is the physical paradigm. Number one, you know, my background is recreation and play, and I think that's really important, and oftentimes this population, because of their age group and because they're primarily males, you do see a lot of sport-related injuries. So the physical self, you know, can be damaged in a way that was due to their recreation and that's what led to their brain injury. So how have your recreational and leisure activities changed since your TBI? Please give examples of what to do now for fun post brain injury. Number two, please describe some changes in your level of fitness and/or physical appearance since your injury. So physical, not only [inaudible] the person's ability, but it's also in how they are perceived, how they're viewed, how they see themselves now when they look in the mirror. Number, three, last question on physical, so how do you feel about your body and your physical appearance now. So I thought that was really critical because again these changes are often permanent and, you know, I'm kind of contradicting myself now that brain injuries are invisible many times, but when you do have physical limitations and you can see them from the outside, again that changes the person's perception of self so [inaudible].

Lastly, so the final paradigm is a medicine wheel would be your intellectual [inaudible] although you can use that synonymously, if I can talk, with your cognition. Okay. So number one, where do you see yourself in the next five to ten years in relation to school, career, and relationships. And number two, would you say that you feel a strong sense of [inaudible] on the community college campus, please explain. Many, many studies have done, as far as cohort and [inaudible] community and those types of things, how we know as researchers and as people in education that when a student feels a sense of belonging, they have a higher success rate. So I really wanted to kind of get into that. And number three, have you had to change or rethink your vocational or academic goals as a result of your TBI, and if so, please describe how. So those were the four, those were the four paradigms, and then the underlying questions, usually three or four were [inaudible] paradigms.

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>> Lisa, could you go back to the medicine wheel because I think that was a key part of the study. You know, it's something that I haven't really seen in the study before. How did you find that, you know, the medicine wheel? Why does it speak to you as like a conceptual model for your study? You know, what was that process?

>> Yeah, it really is a personal, it was a personal journey for me. I was a student here at San Diego State, and I was in the therapeutic recreation program, and I don't know if anybody knows what a rec therapist is, but basically a rec therapist will work in the rehab setting, post-acute setting, helping people kind of reintegrate. So it's people that have, again, suffered a traumatic life-altering event such as a brain injury. It could have been a spinal cord injury. Those types of things. And so I felt that recreation and being a holistic person was really important to me, and as a rec major, we had [inaudible] great guest speakers, and we go camping for, you know, one of our classes and we write about it. So it was a very, it was a really holistic program that I went through. We had a teacher come in and facilitate a class on this particular topic. Her name was [inaudible], and she was from [inaudible] area, and she talked about this medicine wheel, saying that the Native Americans felt like this [inaudible] really the whole person, and when we start to find deficits in it like maybe we have some physical ailments or we might have some emotional imbalance, that this wheel no longer can role, and therefore we become out of balance, and as a result our lives and our relationships become out of balance.

So I thought a lot about that, and I kind of carried that with me through all the years of college and just kind of in our [inaudible] looking at trying to maintain that balance of what we think about it even as a noninjured or a nondisabled person is really measuring that work life playing a spiritual balance that we all, I think, as humans are the human experience that we all kind of crave to have that balance. So it was a personal thing for me meeting [inaudible], who has since passed. I tried to look her up for this study, and she actually, she [inaudible]. She was well into her 80s, and she has since passed, but she really inspired me with her knowledge, with her presentation.

>> Yeah, yeah.

>> I used that and kind of thought, and to be honest with you, even before I started my graduate program, my post-graduate studies, I always thought I would do a study somewhere, at some point in my life using her [inaudible]. It's kind of been something I've carried around a lot.

>> That's great. That's awesome.

>> Excuse me. And so I am moving past the [inaudible] and the questions that I used to talk about [inaudible], so data analysis. So I collected data, and you know, even some may think well there are twelve participants and there were 16 plus questions. That doesn't seem like a lot, but when you get into this [inaudible] and the collecting and the storing and the transcribing. I mean transcribing [inaudible] hundred hours because you have to verbatim write what you hear, and then you have to put it into a program [inaudible]. So I collected data to the point of saturation was reached. During an application for college [inaudible] researchers know [inaudible] and it's a free program, you can download it online as long as you have a Twitter account, which everybody does I'm sure, right. So I used this application, and so what I did is I transcribed everything and then basically it helps to organize the information so that you as the researcher can start to really look at what this [inaudible]. Okay. So basically, I did this for [inaudible] hours, and once the [inaudible] was complete and the information me [inaudible]. The data was coded and analyzed using a systematic approach, excuse me, to ensure the [inaudible] of the finding [inaudible]. Okay. So as you probably have seen using [inaudible], I had basically come up with seven primary themes--

>> [Inaudible] I think one thing that's also important to note, you know, this word trustworthiness. You know, in qualitative research you don't, you know, use terms like reliability like you would in a, or validity like you would in a--

>> Right, it's quantitative.

>> Quantitative, but you had a number of strategies like doing member checks. You looked at, you did other things to establish the credibility, to confirm [inaudible] trustworthiness of the data. What were some of those things you did as a researcher?

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>> Right. So once the person was finished, had completed the interview, they weren't off the hook. I mean, I would sometimes go back and check and ask questions and make sure I'd have it right. Before I put anything down, I wanted to again meet with the students maybe a second or third time just to confirm that whatever I was hearing is basically what they were perceiving and what they were relaying to me. There was a lot of questions, a lot of checking [inaudible] and a lot of looking for overlapping. And when you're doing qualitative research, it's really important not to insert yourself into this research and become kind of like, oh, I've heard this, and so I want to, I want to just put it in that category. I really had to stick myself and look through it in an objective [inaudible] just so that the [inaudible] kind of [inaudible]. And, you know, the program that I used, it didn't spit codes, and it wasn't like doing quantitative research where you could just do a few formulas and then get your answer. It was, you know, going through it over and over again, and sometimes moving things or taking a category out and putting a new category in or sometimes folding a category into another, you know, collapsing it into another theme.

And so I would say starting out I might have had, so I ended up with seven at the end, but I might have had 15 or maybe even 20 to begin with, but through [inaudible] and through again just going through this over and over, I was able to collapse a lot and really look at, okay, these are really the themes here. These are really the general consensus is what I got from each individual. So it just took, it took qualitative research space time. There's no easy way through it. But again that systematic approach really just kind of going, you know, like they say, how do you eat an elephant, one bite at a time. You really have to look at each step. You can't think of what the big picture is until you get through each little systematic step, so. Okay. So [inaudible] primary themes emerge that address the three essential questions. These things provided unique insight and understanding of the social experiences of people with TBI and post-secondary setting.

Overall, [inaudible] was social capital and social connection are complex and challenging for the population. Well, we knew that probably going in, but I think the reasons were kind of covered, why that is so difficult, and for me it really kind of sheds some light on not so much the what but the why. Why is this a continuing theme, why this continues to happen, and it's pretty across the board with that population. [Inaudible] participants provided a perspective that is lacking in the rehab counseling and literature and often not considered when assessing post-acute care recovery. Now I kind of just glazed over, and so, you know, it's what, it's the elephant in the room, it's what everybody sees but no one really wants to talk about because it's hard. It's a difficult topic to talk about. So the first thing I came up with is I what I call traumatic serendipity, and basically what that is, is although many participants reported an overall decline in their social circles and increased feelings of isolation, they stated that for the most part they're [inaudible] new positive change and a sense of new beginnings. This was huge. This was huge I should say because I don't think not one of the students that I interviewed have ever said I wish this never happened to me. All of them, even the ones that were just maybe 12 or 16 months post injury felt like this happened for a reason and that they are a better person for it and in some way they learned something more about themselves and to overcome this challenge made them feel [inaudible] they were a stronger person. So that was why I called this traumatic serendipity. [Inaudible] also, you know, there were some changes in life goals.

Obviously, I often say that we have to know what we value before we can set a goal, and I think with this group what they value changed so significantly that of course their goals would have to change. And the volunteer work and not returning to the pre-injury employment. That's always a theme, I think, with any life-changing, life-altering disability, is returning back to the old line of work, the old career, is a tall order for many, and I think that was a theme that came out in the studies that a lot of them, you know, did go back and feel a sense of productivity through either volunteering or maybe completely changing their career, but very few of them returned back to their old job. Some of the quotes, and these are straight up, straight from the actual participants in this study, [inaudible] described, as I don't know before, I just wasn't interested in education, but now I don't even know what happened. I woke up from a coma and wanted to have a future. I wanted to help people the way I was helped. Yeah, I just have something in my heart that just tells me I have to help people. Like I got an A in speech class and I hate talking in front of people, but somehow in the class I was really scared.

Actually, I hated it but ended up getting an A. My counselors say maybe I should be a public speaker now, and that was [inaudible] one, two, or three years post injury. So, again, you just never know where life is going to take you, and I think this is a perfect example of somebody who was not academic, who [inaudible] chosen that path, so it was a really cool thing to be able to listen to her. Theme two was social inequity. Participants experienced dramatic changes with social engagement and social capital when comparing to their pre- and post-injury lives. So again, we have this huge circle of friends. We have this life-changing, life-altering events. Some of them disappear, and that's just reality of life. A lot of, so part of social inequity is not always, they were not always aware of socially inappropriate [inaudible] comments. We see that a lot with persons with TBI. And they felt like a burden to family at times, and many of them were still in the grieving process [inaudible] social status.

>> Lisa, would you say pre-injury [inaudible] it seemed like a lot of them were pretty socially active, went to a lot of parties, were very popular, had a wide circle of friends.

>> Yeah. And that could be another study, to really look at that [inaudible] in life, maybe brain injury happens, because it tended to be [inaudible] outgoing who kind [inaudible] the party seen, who had this, you know, robust circle of friends and this robust social life, and, you know, boom, the injury happened, either through a motor vehicle accident, I think I had one student who feel several flights of stairs at a party. I mean so this was kind of [inaudible] theme that these were very social people to begin with. And again, this is just a sample of my participants, but I wonder, you know, if we, like quantitative, and we kind of spread it out even farther, we probably would see very similar types of results.

>> Well wasn't alcohol pretty common in terms of the injury caused?

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>> Yeah, fortunately it was, and I think, you know, we have heard enough about how alcohol impairs our judgment, and so this is, you know, the [inaudible] absolutely especially when you look at motor vehicle accidents and you look at, you know, people just taking risk, I think alcohol and at least the particular age group and the sample that I used plays a big role in their brain injury.

>> Yeah.

>> And I wasn't looking for that to begin with.

>> Yeah.

>> It just kind of happened [inaudible]. So I like this one because it really talks about social inequity and social status [inaudible], and this is from Mitch, who was 27 years old. He said, I have to deal with it. Yes, well whereas before I was like the Homecoming King, I was an all-star. Well I was a [inaudible] all-star, I was the MVP for track and field and football, but besides, I went from being an upstanding classman, sportsman, to now being the handicap in the court, and he laughed. Not necessarily saying come on, help me out, give me a shot, but no longer in the spot light, no longer making big plays, getting [inaudible]. It's just like here I am, fucked up, and I deal with it every day, like that. And that was, you know, [inaudible], so you think about somebody who has this status, and you know, and you can kind of, I mean when I read this over, and it's been a long time since I read it, I feel a little bit of anger, you know, I feel that he definitely, you know, regrets maybe this place where he is now, although, you know, he is where he is, and it sounds like he's accepted it, but I think that you can see where that [inaudible] status comes from and that feeling of inequity.

Okay, theme three, a desire to fit in. I think we all have that to some degree, but I think this is population again, there's some cognitive and physical and, you know, emotional barriers that keep us from that. So it's an essentially physical and psychosocial, emotional limitations created the biggest barriers to feeling included among their noninjured peers, and again we're looking at in a post-secondary setting. Difficulty controlling anger and frustration was a common complaint, and deeper connections with peers and TBI rather than the larger campus community. So again, were so fortunate to have this population that is in this program that had, you know, it's strictly for students with TBI, and they felt that deep connection with their peers in that group, and I think that was really helpful to them.

And I know, I mean this program, it doesn't exist anywhere else and not too many places that I know, but if you think about how they would have that sense of community we did have something along those lines maybe at every campus, either with a disability supporter or something where they felt a sense of belonging. And a lot of them were hesitant to use academic commendations. So we know that [inaudible] counselors are every campus as part of trial that that's something that's mandated, but it means this population again, [inaudible] maybe, not sure, you know, not sure about disclosing their disability, did not always want to use their academic commendations. So that's again that reason being that they want to fit in. So Karen, 31, three years post, says I feel I do belong here. I mean, and she's again talking about this brain injury program, I feel I do belong here. I mean everyone has their own issues, and it's not just me. We all have different problems and disabilities. It's not just my struggle.

They have issues. I mean like blindness for example. You know, they can't talk properly, or they can't hear properly. It means everyone, like I mean I'm probably the most advanced out of everyone here. It makes me happy that I'm here. I just love this program. I tried other therapies, and this is the one that has helped me the most so far. I love, and then she put the name of the program, wholeheartedly. So, again, that feeling of fitting in. Theme four, spiritual awakening. Some participants attributed faith, hope, and positive attitudes towards their miracle recovery. Again, some of these students were, you know, in comas for, you know, certain amounts of time. Maybe they're failing, maybe their doctor said we don't even know if they'll wake up. So, again, a lot of them feel the sense of a miracle recovery. It's not uncommon for survivors of a traumatic event to experience spiritual changes including greater appreciation for life, higher self-esteem, and a deeper compassion for others, elevated spirituality, and an increased sense of purpose. And so, I mean if you think about that, that's pretty much, you know, a little bit into who they are now, interwoven into their vocational choices, their academic choices, so it's really a sense of wanting to help or having a purpose.

>> It kind of relates to your first theme, right, I mean because they probably would think without this brain injury I never would have, you know, found my faith in God or my sense of spirituality.

>> Right.

>> Because it just wasn't part of my life at that point.

>> Right, again, that serendipitous experience where I was just minding my own business and this incident happened to me, but it changed my whole life, and here is now what I think the meaning in my life is all about. So, yeah, it's definitely an awakening. And then a belief about the power of loved ones and prayer from their survival and recovery. So everyone that I've worked with that has gotten to the point of recovery where they're actually able to come to these classes have said there was somebody there, there was a support network outside of themselves that was there for them, you know, praying for them or being with them or providing support. So I think that's important for us to remember that, that support that we give that person is essential to their feelings of recovery. And this [inaudible], who is 19. And he was a year and a half post. He says, faith is very important to me. I don't call myself religious, but I think some say that I am. The word religious takes away from the meaningfulness of God, but it's not religion in it's true form. I think Americans have made religion different than what it's supposed to be, but it is very important to me. So I thought that was great, because you understand the dogma sometimes of [inaudible] religion, but that spirituality is really what I was getting [inaudible].

So theme five, emotional expressionless. Some participants experienced difficulty to both feel and properly express their emotions. And then alternatively, some participants shared because of decreased function and judgment, abstract reasoning, impulse control and other characteristics, they struggled, keeping their emotions in check. So we kind of see the spectrum of either people who are flat and have no emotion to people who are completely labile and they can't get a gauge on their emotions and they're just expressing everything. So it's a spectrum that you'll see often with this population. And Jess, who is 21, three years post, says I cannot cry for the life of me. If you put the saddest thing in front of me, I would not cry at all, even though my heart would be breaking, I can't express it. I feel like I'm more in touch with everyone else's feelings. I feel like if you're happy, I'll be happy for you. I feel like if you're depressed then I will be depressed too. I am more than willing to give my heart to anyone that needs me. That's how I feel, but I just can't show it. So I thought that was really interesting. And again, if you think about the world of work and the world of, you know, social inclusion and all those things, the way we relate to people is how we feel that sense of capital, so if you got somebody with this [inaudible] you know, who is expressing somebody but showing another thing, it's very hard for us to understand who this person is.

So, I like that. Theme six, independence loss refers to the loss of capacity of some participants to live on their own and subsequently to return to living with parents and other family members. So you've got college students, maybe some of them were in college, they were in dorms, they were, you know, they were out of the home, and now they suddenly have to go back after their brain injuries. By returning home, participants share feelings of embarrassment, a lack of transportation and difficulty dating such as not feeling comfortable bringing dates [inaudible] understandable [inaudible] you know, if you live with your parents and you live on the couch, that might be a barrier.

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Paolo, 32, says, yeah, it would [inaudible] meet a beautiful girl and say I live with my parents and I'm 32. She be like what's going on, what is wrong with you. If they understand the situation then maybe it's a little better, but it's hard enough for people to understand brain injury [inaudible] and not all the things that go with it. And then lastly, the theme limited recreational choices, again I'm a recreational therapist, you know, [inaudible] I really wanted to look at that. Participants express feelings of disappointment and being unable to resume previous recreational activities due to behavioral, cognitive, and physical limitations, so all of those things had an effect on their physical outlets if you will. Many participants felt having limited recreational choices, and that led to a diminished quality of life and at times required letting go of previously held identities [inaudible]. For example, I'm a surfer, well can't do that anymore, and, you know, that kind of was their identity, or they were a soccer player, or whatever it is they do, and that was who they were based on their accomplishments. So again these things also changed who they were.

And again Karen, who is 31, says, in high school I used to be a basketball player. I was a point three guard for my team, and I led my team to two championships in high school against, and then she names the school. We kicked their butts. I used to shoot three pointers like it was my job. I loved it. Now I can still play, but I can't shoot a three at all, I can't shoot that far. I can shoot at the foul line, but that's about it. I never play anymore because it's depressing. So, again, looking at, you know, who we are and it's holistic and we are creatures of [inaudible] creatures of leisure and not having that takes away from who we, you know, how we integrate socially. So finally my reflections, participants appear to be acutely aware of their post-TBI limitations that challenge their ability to develop and maintain meaningful relationships with friends, family, and significant others. Most participants reach the state of acceptance about their post-injury lives and in some case an appreciation for a new identity. And then some participants experienced behavioral issues with inappropriate sexual behavior, reduced social inhibitions, impulsivity, behavior instability, executive functioning deficits, and a past of alcohol and drug use or abuse. And some participants no longer follow the social norms of their community college peers due to an increased sense of seriousness and their unwillingness to engage in superficial interactions.

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>> They had a sense of real frustrations with some of their peers, like they're kind of wasting their time--

>> Right, and, you know, working in a community college setting, you know, we call them drop-ins. And we'll have the student that just kind of drops in and checks out the social scene and it's not for them, they're out of there. And then you have the serious student. And I think many of our TBI, persons with TBI, they, you know, this time around they were a lot more serious about it, so I think they had less tolerance for this. So it's fair weather students, [inaudible]. So participants describe how they were more reserved post-injury, and due to the challenges with emotional control and expression found it difficult to connect with others. So, again, in a social setting, many of them describe maybe not knowing how to initiate a conversation or not knowing how to maintain a conversation, so they tended to be more quiet or be more [inaudible]. And so I saw a lot of that. Participants expressed little patience for others who were patronizing or superficial, and again this probably rings true with all persons with disability, you know, they know, and we know when we're being patronized or when we're, you know, again superficial kind of, oh, you know, that a girl or that a boy kind of stuff, and you know, they can see right through that. So it's, you know, something that we see probably [inaudible] institutions a lot.

So for the implications [inaudible] counseling, I basically thought that cognitive skills training program, such as the one that I worked at, basically these [inaudible] offer students with TBI a sense of belonging, a shared purpose, and a safe place to discuss peer, significant other, and family relationships. So maybe we can't all build one on each campus, but maybe we can have like a clubhouse setting or an association, student body group, or something where you can have this collection of folks who can talk about their experiences and that would feel, make them feel a lot more a sense of belonging in the other campuses. Students with TBI need to prepare, students with--

>> It should say rehabilitation counselors need to prepare students--

>> Rehabilitation counselors need to prepare students with TBI for social challenges they might encounter in post-secondary environments. But again this is something, you know, with our training, we don't really talk a whole lot about it. At least we didn't back when I was in the program, but I think it's something that should come up, I mean really talking about, you know, just conversation or [inaudible] or something that would be very beneficial for our students. Results from this study point to the value of helping persons with TBI process their experiences, challenges, losses, and aspirations regarding social engagement and social [inaudible]. So that was pretty much it in a nutshell.

>> [Inaudible] last point. You kind of talk about like, you know, when you did the interviews, did it feel like a therapy session at times, like what kind of affect did participants have as they talked about, you know, these questions you have raised.

>> Yeah, it didn't so much feel like a counseling session because I had a pretty long history with them, and so it was kind of like I've been there and done that with you type of thing because I've taught a lot of personal growth classes and anger management classes, so I knew these students pretty well. So when we were working in this study, it was just kind of matter of fact, and it was very unedited and raw and that's what I liked. You know, they didn't hold back on their answers, they told it like it was, and they weren't trying to impress me. So I think that was really important that I had that trust and that rapport with them, that I was able to really, you know, just have them just tell it like it was.

>> Yeah.

>> Now in the therapeutic setting, because I didn't give them any advice, I just kind of listened and transcribed and, you know, kind of, if I needed clarification, I would stop and ask a few questions and I might reflect a little bit back, but I offered no advice or anything like that during these interviews.

>> I think that your role with the participants is part of what helps with that really, the very, very rich data that you got out of this study. I mean, you know, the fact that you had that rapport, probably something that you should write a paragraph or two about because of your deep involvement with not just this population but these individuals, which I think was a powerful plus.

>> Yeah.

>> Certainly if I had gone into the situation [inaudible] that you would have had more of an edited response. And, again, I mean this is [inaudible] came out as they did in the themes [inaudible] and these are the things that they are experiencing, and the way I described to them is I just wanted to be their voice and share their experiences maybe with people who in the future could help people like that.

>> Yeah.

>> You know, so I think they were doing it really in a altruistic way, really wanting to help [inaudible] so. And another thought I had was that I think getting representation wouldn't be a bad idea at all. Because implications [inaudible] but there are some very specific things that your counselors can and should do because [inaudible] study.

>> Yeah.

>> That might be a final section to develop.

>> That's a good point, and I will, that's something we will consider.

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>> Yeah, kind of along that same line, I think when you're dealing with TBI and you're looking at the settings in the college, many of our students in dealing with the disabilities have a long-term involvement with the disability, and they've established [inaudible]. Our TBI folks know this [inaudible]. This is not something that they've had in training. So I think the role of the [inaudible] counselor in this setting is so much should be modeling, making those other connections and to help them to [inaudible]. They don't have time to do that. And I know, it's going to take longer, but if they really make that decision [inaudible] you've got to really help them deal with all the things because they haven't had the experience of, well, what did you do when that happened? [Inaudible] here. They just need so much more [inaudible] see that a little bit more with our [inaudible] very connected because of that, that sense of [inaudible], but TBI because of so many different kinds of ways, it takes them longer to connect into that group. That's why I think that the TBI program works so well.

>> Yeah.

>> Because it helps them all to pull together and see. Even though we're different we have some very similar issues--

>> And the fact that it's on a college campus is kind of the platform I think that primes us to be able to go, to look into that academic world, and again I have to think everybody can set up a brain injury program on their campus, but I mean just to kind of get [inaudible] clubs, other kinds of ways that people can do it on a smaller scale, I mean, you know, and still get those folks together and get them through. And we see that happening with all kinds of diverse groups and student equity being the [inaudible] community colleges, and you see all these small groups setting. I think this is very appropriate [inaudible] a lifestyle with that 18 to 25-year-old that just takes [inaudible] risks [inaudible] no sense of mortality, you know, and so you do, you know, just even to look at the large group of folks with concussions from sports and those kinds of things and where did they come together [inaudible] recognize those concussions [inaudible] you know [inaudible].

>> And again, that is part of the population. It's also a part of the personality, and so all of this is a perfect storm, so it's interesting that we don't have more, but we are kind of moving to that direction [inaudible] through continuing ed and what not [inaudible] an idea at least [inaudible] and this may or may not work out to be a good idea, but I'm thinking what if, what if those recommendations were framed around the [inaudible] and a recommendation or two in each of those categories to kind of bring it full circle.

>> I like that. I love the model. I want to be able to utilize it as much as possible, and I think that's something easily [inaudible] conceptualize what you could kind of look at.

>> Kind like a blueprint.

>> Yeah, [inaudible].

>> Yeah, [inaudible] really it's about the balance. You know, [inaudible] it's a really exciting study [inaudible].

>> It's great to hear after, what has it been like a year and a half, what two years [inaudible] graduated?

>> Three years.

>> Three years?

>> Yeah, 2014.

[ Inaudible Comments ]

>> Yeah, I think it's sounds good, and I have, I've looked through your manuscript, but I'm kind of waiting to see what my role should be so you guys can tell me how you want me involved.

>> Okay. Well, you guys have already been, had a major role in terms of helping with the study [inaudible] teaching the methodology that Lisa used, so I've been taking notes as far as the recommendations which you guys talked about [inaudible] in terms of the manuscript and try to reflect on, and I think at the conference it's really good preparation for the kind of questions that may come up as people, you know, take a look at the poster.

>> We've just got to work on that poster.

>> Yeah, exactly.

[ Inaudible Comments ]

>> Anyway--

>> Any questions for the people online? We've got a couple minutes. Anything you guys want to know or you want to reflect on? Somebody's typing right now.

[ Inaudible Comment ]

Let's see, we've got, one, two, three, four, five, seven, seven people online.

[ Inaudible Comment ]

Somebody said thank you, nice work.

>> You're welcome, you're welcome.

[ Background Noise ]

>> And then, one person asked can we get a copy of these recommendations. I mean I knew one thing, and maybe I can answer that, so Michele, this is Michele Force [phonetic], Michele, once the article is done, you know, we'll make it available to everyone who joined the presentation today, just so you can kind of see like how, how this is fully expressed in the article and how we incorporated the, you know, the recommendations that we talked about today.

[ Background Noise ]

All right, well, I think with that, we'll just say goodbye.

>> Signing out, thank you very much.

>> Thanks everyone.

>> Okay, I got to run to Mesa College now, yeah Mesa.

>> I was just going to say, you going over there?

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