IDENTITY CONSTRUCTION FOLLOWING TRAUMATIC BRAIN INJURY: A CASE STUDY

This construction o f s e l f identity p re and post-Traum atic Brain Injury (TBI) in a single case study is described. A life history research methodology was em ployed to explore the experience o f a survivor o f TBI, using a single case study design.. The participant was a 31 year old White South African m ale who sustained TBI while on duty in the army. M ultiple interviews were conducted with the participant to allow in-depth exploration o f his s e l f identity form ation preand post-TBI. Data analysis entailed transcribing the interviews, crafting a research story (narrative analysis) and an analysis o f the narrative. The results illuminated the emergence and development o f a resis­ tance identity as a product o f early p re-T B I experience, the loss o f se lffo llow ing TBI as well as the emergence o f a positive self-identity. The em bedded issues o f communication and self-identity are explained. The p a rtic ip a n t’s narrative espoused a hopeful optimism, strongly challenging the dominant disability discourse. The specific stj-engths and limitations, and potential value o f using life histories as both a m ethodological and clinical tool when working with TBI survivors is described. Implications fo r research and clinical practice in the f ie ld o f Speech and Language Therapy (SLT) is also provided.

This construction o f s e l f identity p r e -and post-T raum atic B rain Injury (TBI) in a single case study is described.A life history research m ethodology was em ployed to explore the experience o f a survivor o f TBI, using a single case study design..The p a rticip a n t was a 31 ye a r o ld White South A frican m ale who sustained TBI w hile on duty in the army.M ultiple interview s were conducted with the p a rticip a n t to allow in-depth exploration o f his s e l f identity fo rm a tio n p re -and post-TBI.D ata analysis entailed transcribing the interviews, crafting a research story (narrative analysis) and an analysis o f the narrative.The results illum inated the em ergence and developm ent o f a resis tance identity as a p ro d u c t o f early p re -T B I experience, the loss o f s e lffo llo w in g TBI as w ell as the em ergence o f a p o sitive self-identity.The em bedded issues o f com m unication and self-identity are explained.The p a rtic ip a n t's narrative espoused a hopeful optimism, strongly challenging the dom inant disability discourse.The specific stj-engths and limitations, and p o ten tia l value o f using life histories as both a m ethodological and clinical tool when w orking with TBI survivors is described.Im plications f o r research a n d clinical p ractice in the fie ld o f Speech and L anguage Therapy (SLT) is also provided.
Key w ords: Traum atic brain injury, narrative life history m ethodology, self-identity, life experience, resistance identity, loss o f self, com m unication im pairm ent.

IN TR O D U C T IO N
T raum atic brain injury (TBI) exerts a profound im pact on an ind iv id u al's life.The effects are pervasive and devastating.A com plex range o f com m unication difficulties, including specific disturbances such as aphasia and dysarthria, are produced (Hilari & Byng, 2001).In addition, TBI also results in cognitive, p h y si cal, em otional, behavioural, and psychosocial sequelae (Hartley, 1995).U ltim ately, the person who survives a TBI has to negotiate a series o f life-altering experiences.This paper draw s on the life experience o f a TBI survivor to explore the developm ent o f selfidentity pre-and post-TBI.
T here is a burgeoning interest in exploring changes in iden tity follow ing illness in the disciplines o f psychology, sociology and m edical anthropology (Frank, 1995).W ithin the narrative re search tradition, the subjective experience o f TBI (N ochi, 2000; 1998) has been explored.Speech-]anguage therapy (SLT) p ro fes sionals have also w itnessed a transition in research orientation tow ards the use o f qualitative research m ethods for exploring the consequences o f com m unication disorders, such as aphasia (Pound, Parr, L indsay & W oolf, 2000;D am ico, O elschlaeger, & Sim m ons-M ackie, 1999;and Parr, Byng, G ilpin, & Ireland, 1997).The current study is prem ised on the notion that know ledge o f self-identity inform s clinical practice.It is strongly aligned with the position taken by H agstrom and W ertsch (2004), w ho assert that clinicians need to understand w ho the person is in order to help him /her w ith com m unication.Services w ould be m ore rele vant if clinicians had the know ledge to understand the individual in the context o f his/her life circum stances.
Self-identity form ation is a com plex process shaped by personal, social and tem poral factors (Sarbin, 2000).Two subsys tem s underlie self-identity, nam ely personal identity and social identity.Personal identity refers to the unique constitution and biography o f the individual, such as preferences and personality traits, w hereas social identity refers to descriptions o f self, based on m em bership and identification w ith a certain social group (de la R e y , 1991).
Identity is a theory o f se lf that is developed and sustained through a process o f inner concurrence about w hat the s e lf is like (Schlenker, 1987).
The creation o f self-know ledge relies on several com po nents viz.personal m em ory o f the past, conceptualising societal roles and interaction with the environm ent (N eisser, 1988).A TBI survivor's m em ory o f pre-m orbid experience shapes his/her selfidentity, w hich often has undergone a critical change follow ing the head injury.Follow ing a m arked life-altering event, new m ean ings are assigned to the individual's social interactions, thus re shaping his/her identity developm ent.N eisser 's (1988) concept o f the extended se lf has im plications for a continuing life history in that individuals relate their past se lf during the construction o f their present and future notions o f their self-identity.As the m ean ing and status o f a life event changes for an individual over time, so does his/her definition o f the self, since a personal sense o f se lf contains past and present experiences and expectations for the future (Brum fitt, 1998).Thus, as self-identity is continuously co n structed and reconstructed, SLTs need to be sensitive to this p roc ess by understanding the individual as a dynam ic social being (H agstrom & W ertsch, 2004).
The experience o f com m unication im pairm ent is em bedded w ithin the process o f self-identity form ation.The irony lies in the problem itself, in that com m unication, w hich is required as a form o f expression o f self-identity, is com prom ised (B rum fitt, 1998).
A n individual w ho has sustained TBI has to negotiate new w ays o f com m unicating and engaging in various social activities, and re negotiate com plex challenges w ith reduced fluidity and flexibility (Shadden & A gan, 2004).They are ju d g ed by those w ith w hom they engage socially as either com petent or not by virtue o f the success o f their com m unicative interactions.Their self-identity rests critically on how w ell they are able to negotiate these interac tions, as their projected identities are subject to social evaluation.C om m unication is central in shaping self-identity form ation as the individual w ith TBI contends w ith an altered self, as characterised by new w ays o f thinking, understanding, expressing and sense making.
The South African Journal o f Communication Disorders, Vol.S3, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)What challenges may SLTs face when working with TBI survivors via a self-identity lens?Issues o f identity construction post-TBI may seem daunting, since identity constructs have typi cally not been within the traditional knowledge base o f SLTs.Self-identity is the traditional domain o f psychology in clinical disciplines and the inclusion o f self-identity in the SLT discourse creates the challenge o f negotiating boundary crossing across dis ciplines.Furthermore, SLTs may be reluctant to take on more than they should due to large caseloads and limited healthcare funding (Shadden & Agan, 2004).Finally, identity loss and reconstruction in the aftermath o f TBI is an elusive concept and may be difficult to target as a tangible therapeutic goal.However, given the inex tricable link between communication and self-identity it is neces sary to intervene within a framework that places the whole indi vidual at centre stage.The notion that a sense o f self is maintained in even the most impaired communicator (Brumfitt, 1998) sup ports the need to understand the preserved self o f an individual with acquired communication impairment Therapeutic intervention may be enhanced by understand ing the relationship between therapeutic outcome and selfunderstanding.Pound (1993) explored the attitudes o f aphasic speakers and their therapists to aphasia and found that SLTs who were interviewed focused almost exclusively on what they deemed the devastating consequences o f impaired communication follow ing stroke.On the other hand, people with aphasia reported both the negative and positive aspects o f their altered lives and equated the importance o f communication in their lives with other major life issues, such as driving, employment and the ability to execute activities o f daily living.Therefore, if clinicians are to provide a service that is person-centred, it is critical to acknowledge that it is not sufficient to focus exclusively on the individual's communi cation impairment but to gain a deeper understanding o f other per tinent life issues that feature robustly in his/her reality.Clinicians therefore should attempt to understand who the person is in order to effectively manage the consequences o f communication diffi culties.
Traditionally, research on the psychosocial issues pertain ing to TBI has been amassed within quantitative research frame works.As a consequence o f the methodological choices, the un derstanding o f TBI has been relayed from an etic (or outsider) professional perspective.M any o f these studies have utilised quantitative positivist research designs to explore complex con cepts such as the chronic physical, emotional, and social changes post-TBI; quality o f life following TBI; functional performance after TBI; and rehabilitation outcome following TBI (Corrigan, Bogner, Mysiw, Clinchot & Fugate, 2001).The process o f knowl edge production in the field is therefore likely to benefit from an epistemological shift which creates understanding o f the personal experiences o f people who live in the aftermath o f TBI.
The inclusion o f the experiential domain may assist in cre ating knowledge to support the current paradigm shift in the reha bilitation field from the medical model toward the social model o f disability, which emphasises the interaction o f disease and disabil ity within the larger ambit o f society (Jordan & Bryan, 2001).W hile the medical model has centralised the focus on impairment, the social model requires a deeper understanding o f disability within a social context o f disabling barriers.Social barriers must be removed as an essential prerequisite for empowering people with disability (Pound et al., 2000).The significance o f generating an integrated understanding o f disability has lead to the blurring o f boundaries between SLT, sociology and disability theory (Pound et al., 2000).
In light o f the foregoing discussion, a life history research methodology was utilized in this study to explore self-identity formation.The personal biography highlights the issues most im portant to the individual in his or her context (Atkinson, 1998).
The life history narrative allows participants to engage in a proc ess o f self-reflection, thus enabling them to explore and construct self-narratives about themselves located within a broader social, political, and historical milieu, thus generating broader contextual meaning from the individual's experience (Cole & Knowles, 2001).Life history research allows the opportunity for the indi vidual to ably foreground the self in relation to impairment over time (Kathard, 2003).
Life history research offers a heightened sensitivity to the complexity o f TBI by adding a human dimension to the experi ence o f TBI and is particularly valuable in understanding the changing dynamics o f individuals who experience fluctuating performance as they recover (Hartley, 1995).The story o f a TBI survivor purveys not only what the disability means to the indi vidual along a temporal continuum, but also conveys the rich per sonal meaning that s/he has attached to it.Critically, life history methodology has the potential to generate knowledge which SLTs can apply to their practice especially when working in a culturally and linguistically diverse context, such as South Africa.
This study responds to the following question: What is the nature and the process o f self-identity construction in an individ ual who has sustained traumatic brain injury?

Aims of the study
1. To explore the nature and process o f self-identity construction pre-and post-TBI 2. To consider the implications o f the findings for research and clinical practice in the field o f SLT

Research design
A qualitative, life history research methodology was util ized (Cole & Knowles, 2001) to explore the participant's selfidentity formation using a single subject case study design.Life history research values depth over breadth, thus the aim is not population representativeness (Cole & Knowles, 2001).Single subject methodologies are widely accepted and relevant as a le gitimate technique for exploring the depth o f experience o f apha sia and dysfluency (Kearns, 1999) and therefore also have appli cability for TBI.Importantly, single case study designs used in qualitative research can contribute to practice, theory, social is sues and action and thus hold value in facilitating a deeper under standing o f the complex process o f self-identity construction post TBI.

Participant selection criteria
Purposeful sampling was implemented to select an infor mation-rich case for in-depth study.This strategy is useful when the purpose is to gain a deep understanding o f the particular case, in the absence o f any desire to generalise the findings to all cases (McMillan & Schumacher, 2000).The participant was s e le c te d on the basis o f his experience and understanding o f TBI in his lifeworld.The participant was required to: • Be an adult who would have sustained a closed head injury at least two years prior to the interview and needed to have lived with TBI in order to relate pre-and post-TBI experience Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) .Have adequate cognitive ability that would enable him/her to provide a narrative account o f his/her experience o f TBI via a series o f in depth interviews (Nochi, 1998) .Have an information-rich story to share (Nochi, 1998) < Have a degree o f self-awareness and insight into the fact that s/he had sustained TBI in order to provide useful information for theory-building (Nochi, 1998) • Voluntarily participate in the study because life history meth odology necessitates a personal sharing o f life experience and sustained engagement with the research process (Cole & Knowles, 2001) • Be able to share his/her experience in English so that re searcher and participant could communicate in a common language for the purposes o f facilitating an in-depth explora tion o f his/her life experience • Be able to share his/her story with adequate verbal compe tency or via alternative or augmentative communication if considered appropriate

Method of data collection
Multiple in-depth interviews were conducted to enable the researcher to obtain meaningful insights that reflected how the individual made sense o f the event o f TBI in his/her life.The content o f the interviews was shaped by focussing on topics o f interest or significance to the participant (Clandinin & Con nelly, 2000).See Appendix A for the interview schedule used during data collection.The interview schedule was developed | using Atkinson's (1998) guidelines.
The interviews were video-and audio recorded, thus ena bling the researcher to observe the kinesics and non-verbal communication o f the participant, lending greater depth to the infor mation shared.Audio tape-recording o f the interview sessions allowed both the researcher and the participant to cross-check the data gathered, thus enabling a means o f validating the data.The interviews were supplemented by sources o f information from the participant's personal journal, photograph albums and m edicalrecords./

Research procedure
The procedure comprised three main phases, namely, a screening phase, a pilot phase, and main study (Table 1).All phases were implemented at ja rehabilitation institution in i KwaZulu Natal, South Africa for individuals who have sustained strokes and head injuries.Three participants were interviewed during the screening phase.Two participants met the criteria for selection as they had information-rich stories.One participant was chosen for the pilot and the other as the main case study.
During the pilot phase, the interview schedule, interview proc ess, logistics o f data collection and analysis procedures were refined.
In the main study the participant was interviewed on three occasions.Each interview was approximately ninety minutes.The interviews were audio and video recorded.The participant narrated his life story to the researcher.It was critical to establish a comfortable rapport with the participant, in light o f the sensi tive and intensely personal nature o f the interviews.Exposure o f oneself during the research process involves issues o f respect, trust, fairness, truth telling and justice (Cole & Knowles, 2001;Clandinin & Connelly, 2000).A semi-structured interview ap proach was adopted, thus promoting flexibility during the inter view process (Atkinson, 1998).The participant was able to move backward and forward along a temporal dimension as part o f the storytelling process (Clandinin & Connelly, 2000).

Description of the participant
The participant selected was a 31 year-old white South African male, Paul Carstens (name changed to protect identity), who sustained TBI on November 4, 1991 while on duty in the South African army.He was 18 years old at the time when he was involved in an explosion causing him to sustain a head in jury and killing his friend who was assisting him.Paul was in a coma for six months following the accident, having sustained severe brain injury.
Prior to the accident, Paul had just completed secondary school and embarked on military service.He described him self pre-morbidly as a relaxed, fun-loving, unconventional individual who possessed good communication and interpersonal skills.At the time o f the interviews, which were conducted in September 2003, at least 12 years post injury, Paul was receiving psycho therapy and speech-language therapy to address cognitive and communication difficulties.In terms o f cognitive abilities, Paul was experiencing subtle memory, attention, concentration and organisational difficulties.He also presented with moderate dys arthria, thus his speech intelligibility was compromised.Other conditions included arthritis; restricted mobility (he was using crutches); impaired vision in his left eye due to optical nerve damage; and permanent dental misalignment caused by injury to his mandible.The following aspects were pilot tested: interview schedule, interview process, logistics and data analysis procedures.
The participant was interviewed over three one-and-a-half -hour sessions.
The interviews were audio-and video recorded.The participant narrated his life story to the researcher.The data collected were qualitatively analysed.Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)

Ethical considerations
Qualitative researchers can be considered as guests in the private spaces o f the participants' world (Stake, 1994).There fore, it was imperative to adhere to a strict code o f ethics.Ethical Clearance was obtained from the University o f KwaZulu Natal Ethics Committee prior to the study.Informed consent was ob tained from the participant and ethical issues o f anonymity, con fidentiality, withdrawal and the role o f researcher and participant were highlighted.The participant was treated with fairness by promoting open discussion and negotiation.He was also in formed o f the intended (video and audio) recording o f the inter view sessions.W ritten informed consent to record the interviews was obtained from the participant at the outset.In order to ensure an authentic representation o f the participant's story, he was pro vided with the storied (recorded) representation o f his narrative to enable him to validate the information shared (Stake, 1994).

Rigour and trustworthiness
The researcher's reflexive position during the research process is valued as a critical technique for establishing trustwor thiness (Cole & Knowles, 2001).In order to achieve this, numer ous strategies o f trustworthiness were employed.Prolonged and persistent fieldw ork involved the use o f multiple in-depth inter views and ongoing contact with the participant over the course o f the process spanning two years.The interviews were conducted in the participant's language to ensure that the situation was con ducive to storytelling.Verbatim accounts o f conversations in the form o f direct quotes were representative o f the participant's meaning o f his experience.Low inference descriptors refer to literal descriptions used and understood by the participant, as opposed to the abstract language used by the researcher.These add more depth to the data (McMillan & Schumacher, 2000).Therefore, in portraying Paul's account o f his life experience, accurate descriptions from the interviews were used to enhance trustworthiness o f the data.
Furthermore, while in-depth interviews formed the core data collection technique, triangulation or multi-method strate gies o f data collection were also employed to increase validity (medical records, journals and photo albums).M ultimethod strategies increase the credibility o f findings by yielding different insights around the central topic (McMillan & Schumacher, 2000).Member checking was also employed.This entailed re turning the recorded version o f his story to the participant for validation and verification.Member checking is an important aspect o f life history methodology, as it indicates respect for the individual and enhances the truth-value or fidelity o f the narrative (Frank, 1997;Atkinson, 1998).

M ethodological challenges
The participant was able to narrate his story with consider able ease, despite the presence o f dysarthria and subtle cognitive difficulties.Organizational and memory problems were mildly evident during the narration.For example, at certain points in the narration, he reached a blank and was unable to continue with a certain thread o f thought and had to be prompted.At other times his narrative tended to be tangential and he thus needed to be re directed to the focus o f the question that was asked.Fortunately, memory blanks were rare as reliance on good memory is a criti cal aspect o f identity construction (Shadden & Agan, 2004;Neisser, 1988).
Interviews were audio_ and video recorded to facilitate the transcription process.The participant and researcher negoti ated methods o f clarification, which included requesting repeti tion and/or elaboration o f a spoken word(s) if they were unclear to the researcher and speaking at an increased vocal intensity to increase the clarity o f his speech.The option o f communicating graphically or via the written mode in instances o f communica tion breakdown was also available.However, the participant did not find it necessary to use these alternatives.In life history re search, particularly when working with people experiencing com munication disorders, it is critical that the researcher is a skilled listener to allow the personal story to unfold meaningfully.

Data analysis
The data analysis was conducted at three levels.The first level o f analysis entailed generating transcripts from the inter views conducted.This was followed by narrative analysis (Polkinghome, 1995), which produced the research story through meaningful interaction with the interview data (transcripts).The third analytical level involved an analysis o f the narrative (Polkinghome, 1995) in which the research story was examined for common themes and concepts in relation to the critical re search question.During this process the researcher steered clear o f imposing prior theoretically derived concepts on the data.Instead, careful inspection o f the narrative facilitated the genera tion and development o f new concepts from the research data via an inductive analysis.The emerging themes were then discussed in relation to available literature.

RESULTS AND DISCUSSION
For the purposes o f this paper, the results are presented as ex cerpts from the research story, as well as verbatim excerpts from the transcripts.The results and discussion are integrated.The emerging themes listed below describe the evolution o f the par ticipant's self-identity: 1. Developing a resistance identity as a product o f early pre-TBI experience 2. Moving from loss o f self to reconstruction o f self post-TBI 3. Constructing a positive self-identity post-TBI i Developing a resistance identity as a product o f early pre-TBI experience 1 I In attempting to understand the process o f identity forma tion and the shifts in self-identity, it was critical to explore the role that early childhood experiences have played in shaping Paul's self-identity.His early life experiences reflected a child hood characterised by disappointment, sadness, confusion and a sense o f abandonment.Paul experienced resentment and deep pain at being separated from his parents at an early age when he was sent to boarding school: 'We were sent up to Eshowe.I begged and pleaded fo r her (my mother) to take me back.I think I was causing her more pain than anything else.She drove all the way to Eshowe with us in the car, which made her happy.She drove back alone and she cried all the way home ... going to school, leaving home ... that had to have been the saddest experi ence o f my childhood.' Paul's feelings o f loneliness and sadness were further intensified Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) by the reality that his family unit had been split by his parent's divorce when he was four years old.This was clearly a traumatic experience for him, as reflected in the following excerpt: lM y parents were divorced when I was fo u r years old.I was too young to understand what was happening.I didn't even know it was happening.B ut soon enough, the reality o f It was etched into our lives.Forever.We worked around it though.M y parents made sure o f that.' Paul could not seek solace in his relationship with his older brother, as they were not close.As a result, he needed to adopt a strategy that would enable him to survive at boarding school away from all that was familiar and safe.He depended on him self.Paul developed a firm sense o f individuality that became central to his quest for survival at such a tender age, where paren tal love and support is so critical to one's feelings o f safety, secu rity and acceptance: Six year-old boy wants his mommy.Alone in a strange place.Begged and pleaded, please take me back.I hated being away fro m mom.I fe lt hurt, rejected, abandoned.I cried.I waited.They d id n 't come back f o r me.This was it.I had to be strong, smart, independent.Fight my own battles.B e my own person.Chris, my brother, and I w eren 't close.I couldn 't depend on him.We fo u g h t all the time.I built a protec tive wall around me.I needed to fe e l safe, in control.I needed to be Me.' His experience at school was challenging and mingled with a sense o f longing for his parents.Paul also had a dire need to prove his worth to a father who undermined his ability: 'Life at school was fu ll o f challenges, especially when mum and dad were so fa r aw ay...m y dad and I ju s t never clicked... it was a strange relationship that we shared.I think my dad ju s t demanded too much from me.I couldn 't deliver and he used to give me these lectures about not being good enough at anything.'Paul's initial reaction o f withdrawing into a silent safe space within him self to help him deal with the feelings o f abandonment he was experiencing, led to him developing a firm sense o f self-identity^ Defining one's self-identity is critical to determining how one acts in a given environment and relates to others (Schlenker, 1987) Paul's narrative thus spoke resolutely o f his need to locate him self in a world that he often encountered as unfriendly and cold.What Paul viewed as being different from the rest was later to become his way o f adapting to lifestyle changes as a person living with an acquired disability.His sense o f self-identity was thus valued as a means o f claiming his place in a hostile world.It was within this protective space that he retreated in order to feel safeguarded against sources o f pain and disappointment.Clearly, initial experiences had created a resistance identity; that is, nega tive experiences produced a sense o f resistance to convention and anything that undermined his self-worth.This resistance was ultimately embedded pre-morbidly in Paul's sense o f identity .This was his way o f surviving.
Although Paul retreated into a protective space, he devel oped skills that helped him survive in the face o f adversity.His encounter o f life as a young person fashioned a resilience that was going to prepare him for a greater challenge later in life.In a sense, Paul's resistance identity harboured strength o f spirit that led to the critical shift in the way he was to view his world and his place in it: with further intent to resist the restraints and inher ent expectations imposed by society on one who has a disability.Paul's process o f self-identity formation is thus best understood within the context o f his early life experiences.The emerging transition o f his self-identity was "normal" and expected, how ever it may not have taken the trajectory it did, had his life cir cumstances been different.

Moving from loss o f self to reconstruction of self following TBI
Paul's initial experience following TBI was characterised by a sense o f loss -a loss o f many functions, including his speech: 'all m y movements in the mouth, like moving my tongue from side to side were very slow there was absolutely nothing -coming o u t' He experienced the frustration at not being able to project his voice:

the stupid nurses, they used to run a cold bath and p u t m e in. I couldn't talk. I couldn't say anything. I used to try and hit them !'
Paul endured a transition at this stage from having a strong and The South African Journal o f Communication Disorders, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)boisterous voice to support his personality and define his sense o f self, to momentarily losing that voice.A t a broader level, Paul's sense o f self experienced a shift which was defined by loss fol lowing the TBI.Other losses included a certain degree o f loss o f mobility, partial loss o f independence and economic empower ment, loss o f former friendships as friends were uncomfortable about Paul's acquired disability and loss o f a certain public image that he always tried to project.
Sense o f self is dramatically affected by TBI and is experi enced by survivors o f TBI as a complex, multi-layered phenome non (Nochi, 1998).Individuals with TBI often experience conflict in trying to reconcile the disparity created by the self-image they maintain and society's perception o f who they really are.The dominant public narrative has the tendency to impose negative labels on people with TBI.This creates conflict within the indi vidual, leading to a sense o f loss o f self.Nochi (1998) has identi fied this phenomenon as loss o f self as perceived by others.La bels generally imply negative images o f disability and promote a deficit-based, pathologically oriented view o f people with dis abilities, thus discounting their individuality and casting them into pre-existing categories.This perspective o f people with dis abilities is espoused by the medical model, which perpetuates the notion that illness is a form o f social deviancy.Paul's resistance identity then gradually resurfaced as his recovery progressed and he began to challenge the public narrative.He regained his speech, his voice, which was a critical step in the transition.He spoke strongly o f his need to be acknowledged as an individual with unique traits that preclude any form o f categorisation:

am priceless. I am unique. Everything about me marks who I am. M y thumbprints. M y voice. I am an individual. A nd no one can take that away fro m m e.' [emphasis mine]
Paul thus once again asserted his identity foremost as an individ ual who has never blindly followed convention.The fact that he was physically challenged did not feature resolutely in his self appraisal.He spoke o f his frustration due to the limitations in curred by his injuries, such as not being able to drive or surf any more.Interestingly, he did not cite his remaining communication difficulties as a constraint imposed by the head injury.Instead, he chose to value his voice and saw it as instrumental in affirming his identity.Paul's communication difficulties and the utility o f speech-language therapy were raised by the researcher.However, he did not attribute much significance to these aspects, choosing to talk about other critical aspects which concerned him e.g.his limited mobility.W hilst his speech may have had a dysarthric quality, rendering it unclear at times, what mattered to Paul was that, ultimately, he was able to communicate his message.D e spite the consequences o f his impairment/s he did not view him self entirely as defined by a disability.The way that society per ceived him however, was apparent to him and to this end, Paul experienced the effects o f this negative perception, which con flicted with his own understanding o f him self and what he was capable o f achieving:

'Life isn 't always smooth sailing when you have a disability. People treat you differently. The trick is learning how to deal with prejudices. I t 's not easy. Sometimes I get really angry like when I go to the till to p a y and my fia n ce is with me and they ask her f o r the money. It is as though I d o n 't exist! Talk to the man! ... I have a short fuse! I do try to be patient sometimes. But I ju s t get so angry when people talk over me! I wish they would see me and treat me like they would any one else. I know that my body has been injured but my brain is still happening! ' [emphasis his]
Paul faced the challenges o f societal prejudice during his daily course o f events.It was perhaps because o f his perceived com munication (dis)ability and marked physical impairments, such as his unsteady gait whilst walking which necessitated the use of assistive devices like crutches, and his injured eye, that the cash ier in the above exchange treated him as described.However, Paul used his voice once again to speak out against the prejudice.He used his ability to communicate to his advantage.His experi ence o f disability and the subsequent restrictions it imposed on his movement was exacerbated by the discrimination displayed towards him, embodied in a form o f social prejudice that exists against people with disabilities: 7 see that I f i t in perfectly into society.But society, I feel, has a problem with me.I am a person!I think that people need to give us a chance.They have to learn to accept and adapt to people with disabilities.Society limits itself by lim iting us.'.
If Paul accepted the labels and associated expectations that soci ety imposed upon him and his disability, then he would have to relinquish the validation o f his self-image as a unique individual (Nochi, 1998).His narrative resonated with the sentiment that he was not willing to accept society's labels and was clearly deter mined to carve out a positive self-identity, and receive acknowl edgement for the person that he is; a determination historically rooted and linked to his resistance identity.Paul's construction o f self-knowledge and ultimately the reconstruction o f his self via new experiences is a deeply complex concept.Attempting to engage with this complex process can only serve to deepen an understanding o f the lived experience o f TBI in all its multifari ous components.

Constructing a positive self-identity post-TBI
In exploring the process o f positive identity construction post TBI, issues o f attitude, hope and illness as moral re awakening were central features.Moral re-awakening refers to a renewed sense o f spirituality that is drawn from an experience o f illness or disability (Frank, 1997).

Attitudinal dimensions
Paul's story resonated with courage, hope and an ultimate acceptance o f all that has occurred in his life thus far, with spe cific reference to the accident and resulting injuries.He ac knowledged, after an ongoing period o f grieving (at', least four years post injury), that life goes on.With this acceptance o f the way his life unfolded, Paul chose to adopt an attitude that would facilitate his transition into a new life with optimism and strength o f spirit:

have two choices: I can either be happy and accept what is happening and look forw ard to the future, or be sad and re gret what is done '
Paul's attitude was infused with hope.He chose to use the ex perience o f the accident in his favour.Instead o f allowing him self to be paralysed with sadness, resentment and regret at the course his life has taken, Paul resolved to pursue his^ challenges with courage and hope.Remarkably, the very event that had caused his life to be steered in a direction he did not anticipate, had also enabled him to discover certain truths about himself: Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)be a very negative guy. ' Evidently, the accident had changed Paul's life transforming the way he saw and experienced his world.He had been thrust from complacency to an appreciation o f life with all its complexity and contradiction.Paul felt that the accident had granted him the op portunity to reconstruct him self positively.Moreover, while Paul was initially plagued by feelings o f insecurity and loneliness fos tered by a less than ideal family dynamic, he later (post-TBI) experienced greater stability due to improved personal relation ships.
Paul's reaction to the accident, resultant injuries and the pervasive impact it had exerted on his life and sense o f self clearly contradicted the conventional notion that traumatic ex periences produce an ongoing sense o f loss and devastation (Schlenker, 1987).He chose to communicate his responses in a positive way, thus constructing a positive social identity, which in turn influenced his actions and responses to certain life events.While the experience o f loss is a real part o f the experience, Paul's story highlights the fact that it does not continue indefi nitely, thus contradicting the medical notion that people live in a continual state o f loss.

M oral re-awakening
Paul's self-narrative echoed with hope and optimism for the future.His plans included sharing his life with his significant other and creating vocational opportunities for himself.He em phasised the role o f spirituality in his positive reconstruction:

'The one and only thing I can remember fro m my coma is saying God, please d o n 't let me go. I was literally begging God ju s t to let me live, especially fo r my mother. Since then ' religion has become so important to me. I t 's brought my life into perspective. It has made me realise what is really impor tant to me. I value my mom and my fia n ce equally. A nd my religion supersedes them. I have also learned to take good care o f myself, to value my general well-being. A nd fam ily is the most important thing to me. '
In this vein, Paul's narrative is closely aligned with Frank's (1995) quest narrative, which encounters suffering boldly, ac cepts illness and uses it heroically.Quest narratives involve per severance and are oriented toward the future.Illness is thus not viewed as an interruption that m ust be overcome but rather as a challenge that must be met andj from which the individual can gain something meaningful.Illness is seen as a critical event that becomes an occasion to turn an inner gaze and to engage in a moral questioning o f who we arel (Frank, 1997).P aul's narrative reflects the polyphonic nature o f a quest narrative where multiple voices echo complex, interwoven and often contradictory values and stories and represent an affirma tion o f identity (Frank, 1995).Thus, in Paul's life story, living with an acquired disability was not viewed entirely as fatalistic but was embraced as part o f his complex life experience.The sense o f hope that Paul fostered represented new meanings that he created o f him self through the experience o f trauma.Kleinman (1988) contends that the experience o f a critical event need not be experienced as a self-defeating exercise but can be used as a con duit to deeper and better things.Hope is bom from the personal and cultural dilemmas that are induced by illness, forcing one to turn to sources o f meaning that are already present in our lives (Kleinman, 1988).Although Paul was often plagued by despair and repeatedly questioned his fate, there was an overriding sense o f resolution and motivation: (  (Frank, 1997).

IM PLICATIONS, RECOM MENDATIONS AND LIM ITATIONS
The study holds significant implications at various levels.The contributions o f life history research are linked to its intellec tual and moral purpose and its potential to provide insight into individual lives (Cole & Knowles, 2001).The present study holds the potential to provide a research methodological tool for exploring in greater depth the lives o f the people with whom cli nicians work.Life history research can be utilised to engage at deeper levels with individuals who experience TBI and its conse quences, as illustrated in Paul's case.
Importantly, the study has also shown that even when peo ple present with communication impairment they have stories to tell and as such should be granted the opportunity to be heard.
Life history research has the potential to provide a platform upon which discourse around individuals with disabilities, who have been marginalized from the dominant research dialogue, may be informed.Paul's story highlighted this notion and illuminated the complexity o f issues underlying self-identity and communication.
The use o f life histories as a clinical method can be ex plored within SLT contexts.W hile communication is the focus o f intervention, it is also pivotal to creating self-identity.Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)tion needs as they relate to the individual's sense o f self in his/her life context.W hen communication is viewed in this way, it may assist the clinician in thinking through intervention goals for the individual and to understand the types o f intervention that are necessary.
Clinicians who have read Paul's story at a general hospital in Johannesburg, South Africa and Sandwell, England have indi cated that life history has potential as a clinical tool.W hilst clini cians often use a case history, this tool traces the history o f the disorder while the life history interview offers potential to under stand how individuals live with disorders.By developing clientcentred therapy goals, the clinician is able to generate relevant functional communication intervention.They also reported that using life histories in therapy would highlight the importance o f other life issues (employment, housing, relationships, physical mobility, inability to drive) which are important to consider when setting intervention goals and strategies.Although communica tion was an important issue, it remained embedded within an identity frame.However, time constraints were cited as a con cern and limitation to the clinical implementation o f life histories.
Furthermore, the SLTs reported that reading this particular narrative challenged their perceptions o f people with disabilities as they acknowledged that positive experiences could emerge from an event such as TBI.This notion resonates with Pound's (1993) assertion that it is critical for SLTs to develop a height ened awareness and deeper understanding o f the multi-faceted nature o f individuals' responses to disability, in order to appreci ate a different perspective and to cultivate positive attitudes amongst professionals.She maintained that if therapists adopt negative attitudes to disability by focusing on impairment, it is likely to lead to negative stereotyping o f people with disabilities.This attitude hinders the recognition o f the potential o f people with disabilities to take control over their changing lives.Clini cians are encouraged to critically evaluate their own beliefs and attitudes to ensure that their practice removes, rather than creates, disabling barriers.W hen applied to Paul's case, it would have been easy to interpret Paul's experiences in general, and his com munication difficulties in particular, as negative events.His nar rative, however, proved otherwise.
In the field o f TBI particularly, SLTs must be cognisant o f what role they can play in strengthening the positive self-identity trajectory.The communication intervention program therefore depends on the clinician's ability to consider issues o f the client's potential and his/her understanding o f disability.In Paul's story for example, his optimistic appraisal o f experience could well be overlooked in a therapy program that is not sensitive to the com plex processes underlying the construction o f his positive selfidentity post TBI.It would be imperative to engage with Paul's affirming attitude and inner self if relevant therapy goals and in tervention plans are to be produced.The intimate link between his communication and self-identity would be the key to fostering optimal intervention.
Life history research also engages with the spiritual and moral dimensions o f the individual.As discussed, Paul's story resonated with a sense o f moral awakening.His experience o f TBI has ignited a deeper life meaning and spiritual awakening that forms the basis o f how he lives, communicates and interacts with people.Through understanding these deeper dimensions o f the individual, clinicians m ay be able to sharpen their insight into the multifaceted nature o f human experience.W hile the body/ impairment aspects o f interventions have received primary atten tion in the Speech-Language Pathology literature, issues o f spiri tuality would appear to have received marginal coverage (Jordan & Bryan, 2001).However, Paul's story implies that clinicians should understand and interact with issues o f spirituality where they are apparent if they are to engage with personally meaningful interventions.
The use o f narratives in aphasia therapy is endorsed by Pound et al. (2000) who encourage SLTs to sharpen their listening skills and hone in on their ability to facilitate storytelling, as the value o f narrative medicine can be used as a powerful tool for fuelling therapeutic interventions and measuring outcomes.The very act o f telling one's story has potential to produce a therapeu tic and cathartic effect for the storyteller.Empirical research that has been conducted on the use o f narrative constructions with diverse populations experiencing chronic conditions has indicated that narratives o f emotional experiences have produced positive changes in these individuals (Nochi, 2000;Parr et al., 1997).
Practically, for the individuals whose lives were irrevoca bly affected by the experience o f TBI, this study could be used to inform and educate the public about the issues raised.Societal notions o f disability need to be challenged to facilitate the suc cessful integration o f people with disabilities.Again, intervention should encompass the gamut o f the personal experience o f dis ability, extending beyond a focus on the personal to the social creation o f disability.The study has social and political implica tions in that the issues o f disability that have been raised have the potential to influence the way society perceives people with dis abilities.Instead o f viewing "pathology" and "normal" as dispa rate entities, they can be seen and appreciated as varieties along a continuum o f modes o f being-in-the-world (Papadimitriou, 2001, p. 10), thus encouraging clinicians as well as the public to appreci ate disability as a continuum o f human diversity.
At a theoretical level, the issues raised in the study are congruent with the move toward embracing the social model of disability and procuring subjective perspectives on the experience o f disability (Hilari & Byng, 2001;Frank 1997;Nochi, 2000;No chi, 1998;Parr et al., 1997).The study contributes to a growing body o f research on the personal meaning ascribed to certain life experiences, such as acquiring a disability.Furthermore, the study has highlighted issues o f communication that are embedded within a self-identity development.
The strengths o f the study include the data collection method, namely a series o f multiple, in-depth interviews, thus yielding value laden, information-rich data.
Furthermore, by virtue o f the life history methodology implemented, an emic (insider) perspective is provided, as the narrator was able to con struct his self-identity and life via the narrative process.A pilot study was conducted in order to evaluate the efficacy o f the inter view schedule (data collection tool), interview process, data analysis, and the overall logistics o f the interview procedure, thus enhancing the trustworthiness o f the main study.A single case study design facilitated an in-depth exploration and understanding o f what it means to be a survivor o f TBI.Moreover, the research story was analysed qualitatively, facilitating insight and a deeper understanding o f the experience o f TBI within the broader land scape o f the participant's lifeworld.
As described under participant selection criteria, the par ticipant was required to have sufficient cognitive and communica tive ability to be included in the study.These were not stipulated as exclusionary criteria, but rather to facilitate the process and provide relevant knowledge about the particular case.Since this is still a developing methodology, future research could look to including people with severe cognitive and communication diffi culties to expand the knowledge base.This would require refin ing the current methodology considerably.For example, encour Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)aging the narrator to employ Alternative and Augmentative Communication (AAC) devices, drawing, symbols, and ges tures to convey a meaningful story.The stance o f the re searcher in this instance m ay also change.Instead o f using open ended questions, s/he may need to use forced alternative questioning in order to procure information from the narrator.
A limitation worth noting is that imposed by the con straints o f language and text.However, even within linguistic and textual restrictions, it is possible to provide a meaningful representation o f one's life within the text (Clandinin & Con nelly, 2000).Memory also imposes restrictions on the narra tive, as events are selectively revealed, thus despite prolonged engagement with the participant, his/her revelations will always be constrained.This is, however, the nature o f retelling experi ence but should be considered particularly when interviewing participants who have memory problems.

CONCLUSION
This study explored the process o f self-identity construc tion pre and post TBI, using a life history methodology.The results highlighted the interaction o f complex variables underly ing the process o f self-identity formation in a survivor o f TBI.The self is seen as central to action.The role o f communication in negotiating and representing self-identity is illuminated.The participant's narrative highlighted his life experience in the pe riod preceding and following a head injury.The story revealed how critical early life experiences, fashioned through interac tion with significant others (family, peers), shaped self-identity and the ability to negotiate significant life changes incurred by the head injury.The evolution o f a positive self-identity is traced.Paul's self-identity was constructed via his dialogue.His communication was entwined with all aspects o f his life and served to present a particular social persona.Paul used his communication strengths positively in constructing and affirm ing his altered post injury self-identity.Illness as an experience o f moral awakening is highlighted, as Paul's deep spirituality enabled him to nurture hope for the future, to look forward to living and sharing his life with his significant other.In this re gard, Paul has become the ultimate architect o f his own social reality.
IDENTITY CONSTRUCTION FOLLOWING TRAUMATIC BRAIN INJURY: A CASE STUDY Ayesha Sabat*, Legini M oodley#, H arsha K a th a rd M ' ^D epartm ent o f Speech T herapy & A udiology, U niversity o f K w aZ ulu N atal, South A frica ^D epartm ent o f Speech Therapy & A udiology, U niversity o f K w aZ ulu N atal, South A frica > t ' D ivision o f C om m unication Sciences and D isorders, U niversity o f C ape Tow n, South A frica a b s t r a c t

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used to be very naive and'carefree.But the accident has transformed m y life, the way I see things.I fe e l more grounded.I 'm able to see the lighter side o f things.I used to Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol.53, 2006 Therefore, when applied to the understanding o f an individual who has sur vived a TBI, communication is the instrument used to generate a life story account o f experience.By understanding the critical dual role o f communication as both an intervention need, as well as in constructing self-identity, clinical interventions can become more client-centred.The knowledge produced in this study can thus encourage clinicians to understand their clients' communica The South African Journal o f Communication Disorders, Vol.53, 2006

Table 1 : Outline of research procedure PHASE 1: SCREENING PHASE 2: PILOT STUDY PHASE 3: MAIN STUDY
S Three participants were interviewed.Since they fulfilled the selection criteria em ployed, two were randomly selected for participation in the study.From these two participants, one was chosen for the pilot study and one for the main study. 1 S The participant was interviewed over one onehour and one two-hour sessions.The interviews were audio_ and video recorded.The participant narrated his life story to the researcher.
Kleinman's (1988)tual growth, Paul was able to reach out to others, sharing his experiences with them and strengthening his selfidentity.Paul saw his ability to do this as a divine gift and in so doing recognised that his own life experiences could be used as valuable lessons not only to others but to him self as well.His desire to help others resonates with.Kleinman's (1988)suggestion that illness heightens one's awareness o f other people's suffering, thus making one more inclined to behave in ways that would help to reduce the suffering o f others and allow one to assume respon sibility for others.The motivational talks Paul presented, pro vided a valuable opportunity for his personal growth following the accident.In giving to others, Paul's feelings o f self-worth were reaffirmed.He used his communication skills positively and to his benefit, despite the dysarthria.Paul was able to view the events o f his life as meaningful and purposeful, thus empow ering him with hope and the ability to perceive and maintain an important role in society.It is almost as if, in living a posttraumatic life, Paul's trauma has become the source o f his work, which in turn has become a source o f community, nurturing pos sibilities o f new role-taking and meaning-making believe that God is supreme.H e is in charge o f absolutely