Occupational Therapy in Health Care, 26(4):270282, 2012 C 2012 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.

com/othc DOI: 10.3109/07380577 .2012.726759

Occupational Identity Disruption After Traumatic Brain Injury: An Approach to Occupational Therapy Evaluation and Treatment
Glen S. Cotton, OTD, OTR/L
Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

Department of Occupational Therapy, University of Illinois at Chicago, Chicago, Illinois, USA

ABSTRACT. People with traumatic brain injury (TBI) represent a significant population for occupational therapy practitioners. The long-term physical, cognitive, behavioral, and psychosocial symptoms of TBI can contribute to the experience of occupational identity disruption and affect participation outcomes in community living. Although occupational therapy scholars have studied the topic of identity, there appears to be a gap in the education and research literature regarding the topic of post-TBI occupational identity disruption. This article describes theoretical perspectives on identity, summarizes evidence regarding post-TBI identity disruption and the transition process, and examines the role of occupational therapy in evaluating and treating identity disruption. KEYWORDS. Adaptation, disruption, identity, occupation, traumatic brain injury

A traumatic brain injury (TBI) is an alteration in brain function, or other evidence of brain pathology, caused by an external force (Brain Injury Association of America, 2012). Every year, an estimated 1.7 million Americans sustain a TBI, most often due to falls, motor vehicle-traffic-related injuries, being struck by or against objects, and assaults (Faul, Xu, Wald, & Coronado, 2010). The incidence of TBI is high among young children, adolescents, young adults, and older adults, and males are 1.5 times more likely to experience a TBI than females (Faul et al., 2010). Depending on the severity and location of the injury, people with TBI may have a wide range of symptoms with potentially long-term functional implications. Physical and behavioral impairments may include hemiplegia, hypertonicity, apraxia, impulsivity, disinhibition, and emotional lability. The more hidden impact on cognition includes impairments in attention, memory, perception, and executive functioning (Golisz, 2009). An estimated 5.3 million US citizens are living with impairments as a result of a TBI (Centers for Disease Control and Prevention, 2010).
Address correspondence to: Glen S. Cotton, OTD, OTR/L, Department of Occupational Therapy, University of Illinois at Chicago, 1919 W. Taylor Street, MC 811, Chicago, IL 60612, USA. E-mail: gcotto2@uic.edu (Received 11 June 2012; accepted 30 August 2012)

270

Occupational Identity Disruption

271

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

The long-term symptoms of TBI often contribute to the experience of occupational identity disruption. The experience of identity disruption can leave a person in a tenuous state of uncertainty about who they were, who they are, and who they project themselves to be in the future. This state of uncertainty can lead to depression and decreased motivation (Ownsworth & Oei, 1998), and interfere with occupational adaptation. Long after functional recovery has plateaued, people with TBI continue to struggle to rebuild their identity. Scholars of psychology and occupational therapy have examined occupational identity and post-TBI identity disruption; yet there appears to be little application of these theoretical constructs to actual practice in interventions for adults with TBI. As the domain of occupational therapy reflects (American Occupational Therapy Association, 2008), practitioners are in a unique position to help their clients with TBI achieve occupational adaptation by supporting the rebuilding of occupational identity. The purpose of this article is to: (1) explore the definition and theoretical perspectives on occupational identity; (2) describe post-TBI identity disruption and the transition process; and (3) examine the occupational therapists role in evaluating and treating post-TBI occupational identity disruption.

OCCUPATIONAL IDENTITY Psychology scholars have studied the topic of identity extensively and offered a variety of perspectives on when and how identity is formed. In his theory of personality development, Erikson (1963) described eight stages of human personality development corresponding to specific age ranges. One of Eriksons eight stages of psychosocial development, or crises, is identity versus confusion, when adolescents are faced with both physiological changes and future adult tasks and responsibilities. Research studies confirm Eriksons initial assertion that adolescents actively engage in activities that shape their identity; however, the period of identity development appears to extend into young adulthood (McDevitt & Ormrod, 2007). Marcia (2002) expanded upon Eriksons perspectives on identity development. He proposed that identity formation is ongoing and identity reconstruction occurs with each life cycle stage in response to the demands and rewards of each developmental era (p. 14). From this perspective, identity reconstruction is a naturally occurring event; as an adult person progresses through life, each reconstructed identity builds upon the other. Scholars of occupational therapy have primarily focused on the study of personal identity and social identity. Christiansen (1999) defined personal identity as the person we think we are (p. 548). He explained that identity is a composite definition of the self that includes: an interpersonal aspect (e.g., roles and relationships); an aspect of possibility or potential (i.e., who we might become); and a value aspect that provides a basis for choices and decisions (Christiansen, 1999). In addition to a personal identity, people have a social identitya persons sense of who they are in relation to how they are viewed by others (Laliberte-Rudman, 2002). From this theoretical perspective, social interaction is an essential component of identity (Griffith, Caron, Desrosiers, & Thibeault, 2007). As Christiansen (1999) explained, our lives are interwoven within the lives of others (p. 550). Not only

272

Cotton

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

is our identity influenced by our perception of how others view us, it is influenced by how others treat us, based on their perception of who we are. Occupational therapy theories suggest a strong relationship between identity and meaningful occupations (Christiansen, 1999; Griffith et al., 2007; LaliberteRudman, 2002). Meaningful occupations are those activities that are especially enjoyed and considered important by a person (Griffith et al., 2007). Meaningful occupations allow expression of an identity that each person holds dear and wants to convey to others (p. 83). Identity is central to a persons engagement in life through meaningful occupations (p. 87). We express our identities every day by the activities we choose to do and how we perform them (Laliberte-Rudman, 2002). Thus, identity and meaningful occupations appear to be mutually dependent (Griffith et al., 2007). In his Model of Human Occupation (MOHO), Kielhofner (2008) defined occupational identity as a composite sense of who one is and wishes to become as an occupational being generated from ones history of occupational participation (p. 106). According to Kielhofner (2008), occupational identity evolves over time. It is an integration of a persons motivation for occupations; habits and routines; experiences of being and interacting with the world; and self-awareness of life roles. Similarly, Unruh (2004) proposed that occupational identity is shaped by life choices, experiences, environment, and beliefs and values. POST-TBI IDENTITY DISRUPTION Scholars of psychology have found that TBI is commonly followed by the experience of identity disruption, which is reflected in the literature as changed identity, or loss of self (Carroll & Coetzer, 2011; Coetzer, 2008; Klinger, 2005; Muenchberger, Kendall, & Neal, 2008; Nochi, 1998). There appear to be three different ways in which people may experience loss of self after a TBI (Nochi, 1998). First, they may not remember major aspects of their life prior to their injury (e.g., their job). Second, they may experience loss of self when they compare their new self-image with their memory of who they were. Third, family, friends, and acquaintances may treat them differently. Self-awareness is a key factor in a persons ability to recognize identity disruption, to adapt to identity changes, and to rebuild identity (Carroll & Coetzer, 2011; Cloute, Mitchell & Yates, 2008; Coetzer, 2008). The incidence of impaired self-awareness of deficits among adults with TBI is significant (Gillen, 2009). Focusing therapies on increasing self-awareness can facilitate acceptance of client issues influencing identity (Coetzer, 2008). When addressing self-awareness with clients, therapists must be ready to provide additional support if increased selfawareness creates emotional distress. Studies have found an association between depression and increased self-awareness after brain injury (Malec, Testa, Rush, Brown, & Moessner, 2007; OCallaghan, Powell, & Oyebode, 2006). As impaired self-awareness of deficits decreases, depression can increase. Since social interaction is commonly disrupted after TBI (Chamberlain, 2006; Muenchberger et al., 2008; Tasker, 2003), managing ones social identity is considered to be critical to psychosocial adjustment (Cloute et al., 2008). Acceptance of post-TBI changes is also seen as a significant step. Studies have shown that people

Occupational Identity Disruption

273

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

with TBI need to accept identity change or loss before they can begin the process of adapting to and rebuilding a new identity (Coetzer, 2008; Klinger, 2005). The process of rebuilding identity after TBI is ongoing and extends beyond functional recovery. Muenchberger, Kendall, and Neal (2008) found that the process is largely influenced by meaningful events. The authors identified a dynamic process of post-TBI identity transition that includes contraction of self, expansion of self, and tentative balance (Muenchberger et al., 2008). Contraction of self occurs when people have incomplete memories of their personal history, lack a continuous sense of self, and adopt the sick role. Expansion of self occurs when people make a purposeful effort to redefine their identity, find meaning from the experience of TBI, set goals for the future, and pursue alternative life roles. Tentative balance is the state between contraction and expansion when people experience tension over a desire to move forward and feelings of self-doubt. ROLE OF OCCUPATIONAL THERAPY The MOHO provides occupational therapy practitioners with a framework for understanding and addressing occupational identity disruption with their TBI clients. According to MOHO, participation in occupations results in occupational adaptation and its key components, occupational identity, and occupational competence. Occupational competence is the degree to which one sustains a pattern of occupational participation that reflects ones occupational identity (Kielhofner, 2008). Occupational competence and occupational identity co-developeach contributing to the other. Evidence supports the concept that identity and competence are maintained through a persons narrative or life story (Kielhofner, 2008). Narratives reflect how occupational identities evolve, provide a coherent life story (Christiansen, 1999), and reveal an awareness of self over time (Howie, Coulter, & Feldman, 2004). Occupational adaptation is the process of constructing a positive occupational identity and achieving occupational competence within the context of ones physical and social environment (Kielhofner, 2008, 2009). Achieving occupational adaptation enables a person to respond to internal or external pressure to maintain occupational participation (Klinger, 2005). A persons ability to adapt to lifes marker events (e.g., TBI) requires that they rebuild their occupational identity and competence (Kielhofner, 2008; Marcia, 2002). The uniqueness of each TBI, in combination with the uniqueness of each person and the contextual factors of their life, results in a multitude of variables (e.g., severity of injury, age of client, time since injury, etc.) to consider when evaluating and treating for occupational identity disruption. Traditionally, occupational therapy practitioners focus on deficits in performance of activities of daily living (ADL) and instrumental activities of daily living (IADL); however, a more holistic approach is warranted. Knowing that occupational identity and core meaningful occupations appear to be mutually dependent (Griffith et al., 2007), practitioners need to identify their clients core meaningful occupations (e.g., parenting, socializing with friends, and making music or art). Practitioners need to find out why they are meaningful, assess their clients ability to participate in those occupations, and determine their clients level of satisfaction with individual performance of the

274

Cotton

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

occupations. Also, they must evaluate those client factors that influence participation and performance in core occupations. Common client factors affected by TBI include: mental functions (e.g., self-awareness of deficits and memory); performance skills (e.g., motor, communication, emotional regulation); environmental (social and physical); context (e.g., cultural); performance patterns (e.g., life roles); and activity demands. In addition to core meaningful occupations and client factors, occupational therapy practitioners need to assess their clients past and present life narrative so that they can help their client develop their future narratives. One assessment that practitioners can utilize for this purpose is the Occupational Performance History Interview (OPHI-II) (Kielhofner et al., 2004). The MOHO-based OPHI-II is a comprehensive semistructured interview developed to assess a clients life history narrative, occupational identity, and occupational competence. Evidence supports the OPHI-II as a valid measure of occupational adaptation (Kielhofner, Mallinson, Forsyth, & Lai, 2001). Although the OPHI-II has been designed to accommodate the varying needs of occupational therapy practitioners in different practice settings, because of its length, practitioners may choose to adapt this tool to specifically (1) assess the extent to which their clients occupational identity has been disrupted and (2) inform appropriate treatment strategies for helping them rebuild their occupational identity. An example of adapted OPHI-II interview questions that may be used to evaluate identity disruption is listed in Table 1. Supporting participation in meaningful occupations central to identity can help clients with TBI rebuild their occupational identity. The Canadian Occupational Performance Measure (COPM) (Law et al., 2005) is another example of an assessment that occupational therapy practitioners can use to identify their clients challenges in performing important occupations and to guide treatment. The COPM is a valid and reliable outcome measure (Carswell et al., 2004) that can be used with clients with TBI in establishing client-centered treatment goals (Doig, Fleming, Cornwell, & Kuipers, 2009; Phipps & Richardson, 2007). Delivery of the

TABLE 1. Example Interview Questions for Evaluating Identity Disruption

Describe your identity. Describe yourself now versus how you were before your injury? How would the people close to you describe you? Describe yourself as a (insert key role here [e.g., job position title, parent, friend, etc.]). How has your role as a (insert role) changed since your TBI? Since your injury, do you get to do the things that you think are really important? (If yes) what are some of the things that are really important to you? (If no) tell me about the things you do not get to do, and why. Who are the most important people in your life? How have your relationships with others changed since your injury? (If changes) why do you think these changes have occurred? Since your injury, do you ever plan for the future? Are you able to follow through? (If yes) can you give me an example when you were able to follow through? (If no) can you give me an example when you were unable to follow through? What do you think is the biggest challenge you are facing right now? How do you think you will adjust to/handle this? If you could make your future turn out as you wanted, what would you be doing?

Adapted from the Occupational Performance History Interview (OPHI-II) (Kielhofner et al., 2004).

Occupational Identity Disruption

275

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

COPM begins with the therapist and client collaborating on identifying problem areas of occupational performance in areas of self-care (personal care, functional mobility, community management), productivity (paid/unpaid work, household management, play/school), and leisure (quiet recreation, active recreation, socialization). The client identifies the five problems they would like to focus on. Using a 110 rating scale, the client self-evaluates performance and satisfaction for each problem. Higher total rating scores indicate greater performance and satisfaction. To measure treatment outcomes, the therapist asks the client to rate the five problem areas again and the total rating score is compared with the initial score. The change score indicates an outcome (Carswell et al., 2004). In addition to collaborating with clients on treatment goals designed to support participation in meaningful occupations, occupational therapy practitioners may need to address issues common to the experience of identity disruption after TBI, including: grief over loss of self; difficulty accepting identity change; depression; impaired self-awareness of deficits; and feelings of isolation from others. Approaching occupational identity disruption treatment holistically will help clients with TBI increase occupational participation, derive meaning from life, and experience an overall sense of well being (Christiansen, 1999; Kroger, 2008; Laliberte-Rudman, 2002). Since all clients with TBI have a unique post-TBI experience, practitioners must apply treatment strategies that are tailored to their individual needs. Still, there are several fundamental treatment strategies that emerge from the psychology and occupational therapy literature examining post-TBI identity disruption (refer to Table 2). Clients may experience profound grief over changed identity. For example, an accomplished concert violinist who suffers severe vision impairments and left upper extremity hemiparesis due to TBI instantly loses the ability to perform a meaningful occupation that is central to his/her identity and experiences the classic stages of grief, including anger and depression. Occupational therapists need to be aware and observant of the signs of grief. When there are signs, practitioners should encourage their clients to reflect on their experience and invite them to express their emotions. When clients appear to be oscillating between the transitional experience of contraction of self and expansion of self, practitioners should encourage and support them in envisioning and planning their future self. To support a sense of identity

TABLE 2. Example treatment strategies for supporting identity redevelopment after TBI
Encourage clients to self-reect on their experience of loss and to express their emotions Collaborate with clients on goal setting Incorporate core meaningful occupations in therapy activities Support a sense of identity coherence that bridges the past, present, and future self Encourage clients to plan their future self Support the reframing of occupational competence by encouraging clients to explore modied or alternative ways to express their identity Teach clients skills to support endeavors to manage their impairments and to rebuild their identity (e.g., problem solving, action-planning, accessing resources) Incorporate signicant others (e.g., spouse, parents, friends, children) in treatment sessions to provide external validation and to support clients sense of self Include clients in group treatment sessions to increase self-awareness of impairments and to encourage acceptance of post-TBI changes

276

Cotton

coherence, practitioners need to help clients bridge their past, present, and future selves by weaving past, present, and future occupations into therapy activities. As clients begin to rebuild their occupational identity, occupational therapy practitioners need to support the reframing of occupational competence to explore alternative ways to express their identity. For example, practitioners may need to collaborate with their clients on adopting compensatory strategies to engage in core occupations or alternative modes of participation that allow them to continue to express their identity. Also, practitioners need to support the development and application of key self-management skills, including: problem solving, decision making, resource utilization, and taking action (Lorig & Holman, 2003). Successfully teaching clients skills to manage their TBI-related impairments and their environment gives them valuable tools they can use to achieve occupational competence with their new identity. For instance, an initial step clients may take toward rebuilding identity could be to resume a meaningful occupation. To support their effort, therapists will need to help clients learn how to identify their strengths and challenges, establish achievable goals for resuming the occupation, identify short-term actions for achieving goals, and research and utilize resources that support participation in the occupation. The value of social interaction after a TBI cannot be overly stressed. Occupational therapy practitioners need to look for opportunities to facilitate client social interaction. An example might be including clients in group activities that encourage members to collaborate on planning, as well as to participate (e.g., special event parties, recreational outings, shopping for a group project, etc.). While clients are adjusting to their changed identity, they may look to others to validate that they continue to be who they think they are. Incorporating family and friends in therapy activities can provide clients with the positive external validation they are seeking. For all clients, participating in group treatment sessions and peer group activities can serve to increase self-awareness of deficits and facilitate the process of acceptance. Both awareness of deficits and acceptance of a changed identity are vital to the process of occupational adaptation. The following case is compiled from the literature on the lived experience of adults with TBI and the authors own experience treating such clients. It describes the post-TBI experience of a young adult male in the midst of achieving important adult milestones and forming his identity. The purpose of the case is to illustrate the role of occupational therapy in addressing occupational identity disruption among clients with TBI. The case is an example of an evaluation and treatment approach that addresses common barriers to rebuilding identity. THE CASE OF ANDY Andy, a single 23-year old male, was hired as a junior account executive at a marketing firm shortly after graduating from college, about 8 months ago. Not long after beginning his new job, Andy proposed to girlfriend Kate and they planned to marry next year. When he was not spending time with Kate, he devoted his free time to working out at the gym, and socializing and playing sports with his friends. Andy has always participated and excelled in sports, his calendar was always full, and he enjoyed a fast-paced lifestyle. Just recently, he had moved from his parents suburban

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

Occupational Identity Disruption

277

home to a downtown studio apartment in a large east coast city. Just 3 months after his move he was hit by a taxicab while driving his motor scooter to work. Andy was diagnosed with a subarachnoid hemorrhage, shear injury to the corpus callosum, multiple rib fractures, and a broken left arm. He was in a coma for 3 days. After a 17 day stay in acute care, Andy was transferred to an inpatient rehabilitation hospital where he received multiple therapies for 3 weeks. Andy was then discharged to his parents home where he could receive the supervision and support required for his care, as he needed minimal assistance with most basic ADL. He immediately began an intensive day rehabilitation program where he attended a day rehab clinic 3 days a week for 34 hours, receiving therapy from a multidisciplinary team that included occupational, physical, speech therapy, and psychotherapy. After Andys initial occupational therapy evaluation, the occupational therapist concluded that he required supervision for all basic ADL and most IADL, due to inattention, impulsivity, and impaired self-awareness of deficits. The occupational therapist identified specific problems with expression, memory, attention, problem solving, decision making, as well as vision (scanning and spatial perception), balance and coordination, endurance, and left upper extremity strength. The therapist believed Andy would likely meet long-term goals for return to work activities and IADL (e.g., money management, community mobility, and leisure activities), but many activities would require more than reasonable time to complete and might require assistive aids and some supervision for safety. After 4 weeks, the occupational therapist consulted with Andys psychologist because of his concerns regarding observed behavioral and mood changes. He summarized a recent conversation with Andy. Andy stated, My life is horrible. Ive probably lost my job. . . I never see my friends. . . and my mom is always hovering over everything I do. In addition, Andy said, when Im around Kate, I feel like Clearly, Andy was expressing feelings common her little brother. . . not her fiance. to the experience of occupational identity disruption. At the next interdisciplinary team rounds, team members agreed that Andy had exhibited steady improvement in his endurance, memory, and problem solving abilities. Despite this, they had observed that Andy was generally less motivated to participate in therapy. Also, he was less social during group treatment sessions, experienced more frustration, and exhibited more anger outbursts during the most challenging treatment activities. The occupational therapist believed that Andys decreased motivation and increased frustration might reflect increased awareness of his impairments after he reconnected with friends and began resuming IADL at home and in the community. The psychologist observed that Andy exhibited signs of moderate depression. Andy was to be discharged in 8 weeks; however, the occupational therapist was concerned that Andy was struggling to adapt to both internal changes (e.g., cognitive, behavioral, psychosocial) and external changes (e.g., participation in meaningful occupations). Based on the therapists understanding of Andys narrative story, observations during treatment, and conversations with Andy and his family, the therapist believed that he was experiencing contraction of self. The occupational therapist decided to evaluate Andys occupational identity disruption with questions adapted from the OPHI-II (as in Table 1).

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

278

Cotton

Andy described his identity as a marketing executive who loved and excelled in sports, enjoyed socializing with friends, and looked forward to beginning a new chapter in his life with Kate. He thought that people would describe him as social, fun, and active, prior to his TBI. Now they might describe him as quiet and moody, irritable at times, and unmotivated to do anything. He shared that he was anxious to return to work; however, he was worried that his problems with attention, memory, and anger management might affect his ability to do his job. He wanted to initiate a meeting with his supervisor to discuss returning to work but he was not sure when he would be ready to perform his job. Andy was trying to stay in regular contact with his college buddies, but felt increasingly isolated from them. Most of their social interaction had revolved around playing sportsactivities he knew he was not physically able to perform. Getting together with friends was challenging because he was dependent on others for transportation. Also, he felt that his friends treated him differently and seemed uncomfortable around him. For example, his friends tended to cut their visits short when Andy had an especially hard time following a conversation topic, or when he became agitated and frustrated during activities. Andy believed that his behavior and difficulty in remembering and doing certain things affected his relationship with Kate. He missed their physical intimacy and the fun times they shared prior to his TBI. He blamed himself for his accident and felt guilty about the ordeal he had put her through. Andy shared with the occupational therapist that he was feeling down lately, and that he yearned for his previous lifeprimarily, his career, social life, and independence. Andy explained that he felt like he was 13 years old, because he was living with his parents and was completely dependent on them. Lately, he had been trying to come to terms with his TBI occurring at a time in his life when everything was going as planned. Andy explained how he wondered if there was a spiritual explanation for what had happened to him, stating, maybe I had my accident for a reason. Maybe I am supposed to learn something from this experience. After all, some good has come out of it. Andy explained that he now had a greater appreciation of his relationships with Kate, his friends, and his parents. The occupational therapist administered the COPM to clearly identify the challenges/problems influencing Andys capacity to rebuild his occupational identity. The COPM revealed five occupational performance problems Andy wanted to address: (1) not working; (2) isolation from friends; (3) changed relationship with Kate; (4) dependence on others for transportation; and (5) dependence on parents. After administering the COPM, the therapist reflected on the types of support Andy would need for the remainder of therapy and strategies to support him in achieving his goals and rebuilding his occupational identity. The therapist recognized Andys need for a therapistclient relationship that provided opportunities for Andy to express his feelings of grief, to experience and accept his post-TBI changes, and to envision and plan for the future. The occupational therapist understood that for Andy to adapt to his changed life and to overcome challenges identified during the COPM, he needed certain skills. He believed that Andy was now exhibiting adequate self-awareness of deficits to benefit from interventions that supported learning and applying key

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

Occupational Identity Disruption

279

self-management skills (e.g., resource utilization and taking action). Applying these skills on a daily basis would help Andy manage the long-term impairments resulting from his injury, help him cope with the experience of occupational identity disruption, and increase participation in meaningful activities. The therapist incorporated one or more of these skills in all treatment activities. For example, to support Andys return to employment, the therapist helped him to establish goals and supported the development of a personal action plan of realistic steps to transition back to work. Also, the therapist provided support for Andy to access the Americans with Disabilities Act (U.S. Department of Justice, 2008) on the Internet, so that he could learn about his rights to receive reasonable accommodations. To support increased participation in meaningful occupations other than his work and to validate both social and gender identity, the occupational therapist guided Andy in changing his perception of how he might resume participation in valued activities, such as those that would help sustain valued relationships. For example, although Kate had to drive, Andy was able to plan a romantic dinner date. Afterward, he felt more confident planning date activities with Kate. Also, although Andy did not feel that he was physically ready to play a basketball game with his friends, he invited them to his home to play digital sports games and initiated a group activity where he and his friends went to a college basketball game. To provide additional external validation of his personal identity, the occupational therapist encouraged Andy to invite Kate and his friends to join some of his therapy sessions. Initially, all parties were concerned that they may not feel comfortable with this; however, the therapist incorporated activities of interest previously shared by Andy and Kate, or his friends. After one such session, Andy expressed to the therapist that he felt that including his peers in sessions helped them better understand some of the challenges he faced. As a result, he felt less need to try to hide his cognitive issues. In addition, Andy was included in more group sessions to support increased self-awareness of impairments and to encourage self-acceptance of his new self. As the occupational therapist began to plan for Andys discharge, intervention included activities that addressed greater autonomy and a sense of control. Occupational therapy intervention continued to address Andys executive function issues. The goal was to increase his independence in all IADL and ultimately to return to independent living (e.g., activities to support community mobility and home maintenance tasks). In addition, Andy and his family were educated about community resources, including state brain injury association support groups and TBI peer mentors. Prior to discharge, the occupational therapist readministered the COPM. Results revealed that Andys overall rating of performance and satisfaction of previously identified occupational performance problem areas had increased. This was especially true for isolation from friends and relationship with Kate. Also, during the discharge interview, the therapist asked the same questions used to evaluate identity disruption. Andys answers indicated that he had taken steps toward rebuilding and accepting his new occupational identity and was setting long-term personal goals for himself. The COPM reassessment and the follow-up interview helped the therapist determine the efficacy of the treatment strategies utilized to support Andys occupational identity redevelopment.

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

280

Cotton CONCLUSION

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

Occupational identity disruption is a likely outcome of TBI that contributes to decreased quality of life. Although scholars from the disciplines of psychology and occupational therapy have made significant contributions to the literature regarding personal and social identity, occupational identity, and post-TBI identity disruption, there is limited application of these theoretical constructs to practice. In the case described, the MOHO (Kielhofner, 2008) offers a multidimensional definition of the concept of occupational identity, and clarifies its relationship to occupational competence and its importance to occupational adaptation. This case illustrates the important role that occupational therapy practitioners have in helping clients rebuild their identity after a TBI. Clearly, there is an essential need for practitioners to identify those meaningful occupations that are part of a clients identity. Understanding the motivation, values, and beliefs influencing these occupations is critical to assessing and treating occupational identity disruption. The issue is complex. Due to the uniqueness of each client with TBI and the ongoing, dynamic process of identity redevelopment, there is not a singular occupational therapy protocol for assessing and treating occupational identity disruption. However, a synthesis of existing evidence on the experience of post-TBI identity disruption, theoretical models, and evidence-based assessments offers occupational therapy practitioners information they can use to apply a holistic approach to treating occupational identity disruption. This holistic approach needs to reflect the broad domain of occupational therapy practicenot just the physical impairmentsto assist clients with TBI in rebuilding their occupational identity and drawing renewed meaning from life.

ACKNOWLEDGEMENTS The author would like to acknowledge the steadfast support, encouragement, and advisement of Marcia Finlayson, PhD, OT(C), OTR/L, during his exploration of the topic of post-TBI occupational identity disruption. Further, the author would like to thank Dr. Finlayson and Laura Vanpuymbrouck for their helpful input during the writing of this article. Declaration of interest: The author reports no declarations of interest.

ABOUT THE AUTHOR Glen S. Cotton, OTD, OTR/L, is adjunct clinical instructor for the Department of Occupational Therapy at the University of Illinois-Chicago, where he recently completed his occupational therapy doctorate (OTD). Cottons OTD work focused on the topic of occupational identity disruption after TBI. REFERENCES
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625683.

Occupational Identity Disruption

281

Brain Injury Association of America. (2012). About brain injury. Retrieved April 25, 2012 from http://www.biausa.org/about-brain-injury.htm Carroll, E. & Coetzer, R. (2011). Identity, grief and self-awareness after traumatic brain injury. Neuropsychological Rehabilitation, 21(3), 289305. doi:10.1080/09602011.555972 Carswell, A., McColl, M. A., Baptist, S., Law, M., Polatajko, H., & Pollock, N. (2004). The Canadian occupational performance measure: A research and clinical literature review. Canadian Journal of Occupational Therapy, 71(4), 210222. Centers for Disease Control and Prevention. (2010). Traumatic brain injury in the United States: A report to congress. Retrieved September 9, 2011 from http://www.cdc.gov/ traumaticbraininjury/tbi report to congress.html Chamberlain, D. J. (2006). Issues and innovations in nursing practice: The experience of surviving traumatic brain injury. Journal of Advanced Nursing, 54(4), 407417. Christiansen, C. H., (1999). Defining lives: Occupation as identity: An essay on competence, coherence, and the creation of meaning. American Journal of Occupational Therapy, 53(6), 547558. Cloute, K., Mitchell, A., & Yates, P. (2008). Traumatic brain injury and the construction of identity: A discursive approach. Neuropsychological Rehabilitation, 18(5/6), 651670. doi:10.1080/09602010701306989 Coetzer, R. (2008). Holistic neuro-rehabilitation in the community: Is identity a key issue? Neuropsychological Rehabilitation, 18(5/6), 766783. doi:10.1080/09602010701860266 Doig, E., Fleming, J., Cornwell, P., & Kuipers, P. (2009). Qualitative exploration of a clientcentered, goal-directed approach to community-based occupational therapy for adults with traumatic brain injury. The American Occupational Therapy Journal, 63(5), 559568. Erikson, E. H. (1963). Childhood and society. New York: W. W. Norton & Company, Inc. Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 20022006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Gillen, G. (2009). Cognitive and perceptual rehabilitation: Optimizing function. St. Louis: Mosby Elsevier. Golisz, K. (2009). Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda, MD: AOTA Press. Griffith, J., Caron, C. D., Desrosiers, J., & Thibeault, R. (2007). Defining spirituality and giving meaning to occupation: The perspective of community-dwelling older adults with autonomy loss. Canadian Journal of Occupational Therapy, 74(2), 7890. doi:10.2182/cjot.06.0016 Howie, L., Coulter, M., & Feldman, S. (2004). Crafting the self: Older persons narratives of occupational identity. The American Journal of Occupational Therapy, 58(4), 446454. Kielhofner, G. (2008). Model of human occupation: Theory and application. (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Kielhofner, G. (2009). Conceptual Foundations of Occupational Therapy Practice. (4th ed.). Philadelphia, PA: F. A. Davis Company. Kielhofner, G., Mallinson, T., Crawford, C., Nowak, M., Rigby, M., Henry, A., & Walens, D. (2004). A users manual for the occupational performance history interview (OPHI-II). Chicago: The Model of Human Occupation Clearinghouse. Kielhofner, G., Mallinson, T., Forsyth, K., & Lai, J. S. (2001). Psychometric properties of the second version of the occupational performance history interview (OPHI-II). American Journal of Occupational Therapy, 55(3), 260267. Klinger, L. (2005). Occupational adaptation: Perspectives of people with traumatic brain injury. Journal of Occupational Science, 12(12), 916. Kroger, J. (2008). Identity development during adolescence. In G. R. Adams & M. D. Berzonsky (Eds.), Blackwell Handbook of Adolescence (pp. 205226). Oxford, UK: Blackwell Publishing Ltd. doi:10.1002/9780470756607.ch10 Laliberte-Rudman, D. (2002). Linking occupation and identity: Lessons learned through qualitative exploration. Journal of Occupational Science, 9(1), 1219. Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (2005). Canadian Occupational Performance Measure (4th ed.). Ottawa, ON: CAOT Publications/ACE.

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

282

Cotton

Occup Ther Health Downloaded from informahealthcare.com by EBSCO on 03/24/14 For personal use only.

Lorig, K. R. & Homan, H. R. (2003). Self-management education: History, definition, outcomes, and mechanism. Annals of Behavioral Medicine, 26(1), 17. Malec, J. F., Testa, J. A., Rush, B. K., Brown, A. W., & Moessner, A. M. (2007). Self-assessment of impairment, impaired self-awareness, and depression after traumatic brain injury. Journal of Head Trauma, 22(3), 156166. doi:10.1097/01.HTR.0000271116.12028.af Marcia, J. E. (2002). Identity and psychosocial development in adulthood. Identity: An International Journal of Theory and Research, 2, 728. McDevitt, T. M. & Ormrod, J. E. (2007). Child development and education. (3rd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Muenchberger, H., Kendall, E., & Neal, R. (2008). Identity transition following traumatic brain injury: A dynamic process of contraction, expansion and tentative balance. Brain Injury, 22(12), 979992. Nochi, M. (1998). Loss of self in the narratives of people with traumatic brain injuries: A qualitative analysis. Social Science & Medicine, 46(7), 869878. OCallaghan, C., Powell, T., & Oyebode, J. (2006). An exploration of the experience of gaining awareness of deficit in people who have suffered a traumatic brain injury. Neuropsychological Rehabilitation, 16(5), 579593. doi:10.1080/09602010500368834 Ownsworth, T. L. & Oei, T. P. S. (1998). Depression after traumatic brain injury: Conceptualization and treatment considerations. Brain Injury, 12(9), 735751. Phipps, S., & Richardson, P. (2007). Occupational therapy outcomes for clients with traumatic brain injury and stroke using the Canadian occupational performance measure. The American Journal of Occupational Therapy, 61(3), 328334. Tasker, S. L. (2003). Acquired brain injury: Meaning-making out of lived trauma. Illness, Crisis & Loss, 11(4), 337349. doi:10.1177/1054137303256585 Unruh, A. M. (2004). Reflections on: So. . .what do you do? Occupation and the construction of identity. Canadian Journal of Occupational Therapy, 71(5), 290295. U.S. Department of Justice. (2008). Americans with Disabilities Act: Questions and answers. Retrieved December 9, 2011 from http://www.ada.gov/q%26aeng02.htm