**4. Design**

Authors obtained IRB approval before distributing a general call to university coaches and athletic trainers who supplied contact information for athletes interested in participating in a PCS study. Authors followed up with prospective participants and arranged interviews with three athletes. Participants 1 and 3 were males whose concussions had forced an early retirement from careers in football. Participant 2 was a female mountain climber. Interviews were recorded using a digital recording device and subsequently transcribed into text. Transcripts were analyzed using the descriptive phenomenological method [25]. Authors identified common themes across each interview and used free imaginative variation to describe the dimensions of the PCS experience.

### **5. Results**

The participants who volunteered for this study had different experiences in recovery from TBI. Each participant succeeded in rehabilitating from injury but took very different paths in doing so. Common across each was a modification of personality and routine. Participant 3 had a complete recovery and full amelioration of symptoms in a relatively timely manner. He was able to do so with the least amount of adjustment. Participant 1, in comparison, had a long and turbulent recovery that involved the extension of symptoms over time and a severe and prolonged impairment in his psychosocial well-being. His recovery required a significant change to personality. Participant 2 made immediate adjustments in the wake of her injury and relied on social support to complete the readjustment and rehabilitation process.

As mentioned in the introduction and literature review, this examination of TBI and PCS focuses on the phenomenological dimensions of PCS—that is, how PCS is lived. Such examination requires we look closely at the meaning-centered aspects of recovery from head trauma, and examine how purpose, desire, and goal-orientation are adopted anew. Important themes during this process are identity formation, solidarity with others, and meaning. For our participants, psychosocial support proved to be the most significant factor affecting the severity of PCS and its rehabilitation.

The results are broken into two major subsections. The first is devoted to psychosocial factors which exacerbate PCS; the second to psychosocial factors which ameliorate PCS.

#### **6. Impaired well-being**

German hermeneutic philosopher Hans Georg Gadamer (1996) has found health a peculiar concept because it is not a good to be bought or sold. It is only when one is suffering that one comes to notice health at all. Illness and disease are impairments to health, but what is health itself but well-being? Each of our participants

experienced an impairment to his or her well-being. Routines that marked ordinary life were upset by persistent concussion symptoms, impairing relationships and identity. Attempts to ignore or overcome the disruptions through willpower only increased the disruption.

#### **6.1 Difficulties shifting identity**

A significant problem of TBI is that the activity during which it occurs is itself one that brings a person fulfillment and pride. This was the case for our participants. Two were NCAA scholarship student-athletes, and the third was an amateur rock-climber. The injury threatened the continued enjoyment each participant could find in their chosen activity.

The participants who volunteered for this study had relatively different experiences in the recovery from a traumatic brain injury. Generally speaking, the three participants' experiences covered a wide swatch of the spectrum regarding the amelioration of symptoms, health, and life satisfaction in recovery. In terms of this spectrum of health and wellbeing, one participant (P3) had what we would describe as a full recovery and full amelioration of symptoms in a relatively timely manner. A second participant (P1) had what we would describe as a long and turbulent recovery that involved the extension of symptoms over time, as well as severe and prolonged impairment in his psychosocial wellbeing. Finally, the third participant (P2) had what we would term as a moderate recovery; one that involved significant challenges early in the process but, over time, turned to a full recovery after certain psychosocial factors came into place to support her through her PCS recovery.

Of the three participants in this study, P1 (whom the authors will call Roger) struggled the most as he faced the end of his career as a football player. Roger teared up as he described this realization: "It's like, I play football, I'm the alpha male and it's a scary feeling and it's like, 'what's going to happen?'"

Roger expresses clearly the difficulty that many athletes face when injured, deselected, or forced to retire. For Roger, the multiple concussions forced an abrupt retirement from football. Perhaps for the first time since late childhood when he realized his skill as an athlete, Roger is faced with the question of identity. Who is he if not alpha male?

During the interview, Roger vacillates between recognizing then ignoring the serious difficulty transitioning out of football. In a revealing statement, Roger admits that the loss of identity continues to be a source of anguish. "I can't just hop up and say, 'oh I'm going to be an athlete again.' That's something I worked forever to be. And that's not something that I can just wake up and be […] again."

Like Roger, P3 (whom the authors will call Philip) was a division one NCAA football player. Philip must also face the loss of his identity as a football player, a consequence that occurred in the middle of his senior season. The depth of loss was exacerbated by a game where he would have played in front of 45,000 spectators. Philip explains;

That day was really, really tough for me emotionally. […] Besides my family, football has been the one thing in my life that I have loved endlessly, and I'm never going to stop loving it, but you know I've been playing since elementary school and it's so tough to just immediately stop when I thought I was going to have 11 more games guaranteed. […] And I think after this season I would have been content with stopping. At times I just felt like I was letting people down. I know I did not actually quit but it kind of felt that feeling of being like a quitter for the first time in my life.

Philip experiences a complicated blend of feelings about retiring from the sport and abandoning his team. Head injuries are less conspicuous than torn ligaments and broken bones, and this means the athletes have more responsibility in decisions *Social Support, Identity, and Meaning: A Phenomenological Analysis of Post-Concussion… DOI: http://dx.doi.org/10.5772/intechopen.95541*

to dis/continue. With a broken femur, suiting up for a game is out of the question. But with a lingering threat of another and possibly more severe concussion, the decision to play is left to the athlete, and Philip expressed guilt about his lack of commitment. To complicate this concern, upon returning to practice Philip had to wear a special uniform during practice indicating he was not to be hit. He explains, "It's like you've got this label on you that you're the kid that's injured that's no able to do the full practice. I don't want to say I felt weak but that's kind of how I felt." As a middle linebacker, Philip had a reputation of being tough. Vulnerability replaced toughness.

So too is it with the non-football player, P2 (whom the authors will call Maryann), who experienced a shift in identity following a rock-climbing headinjury. As a young college professor, Maryann prided herself in performing brilliantly and creatively in the classroom. Her brilliance was owed to endurance and focus during preparation, traits she lost after a concussion. She described the brilliant teacher as one who could roll into a classroom prepared to answer any question with ferocity and confidence. No longer able to rely on her cognitive agility, Maryann reports having to adjust to become "an economical teacher." As an economical teacher, Maryann has to ask for help in advance of, and leaned on her students during, her courses. However, she views this as a normal progression of becoming more mature as a professor. The concussion expedited this transition, but it was one towards which she found herself heading all along:

*I am a little sad to lose the brilliance. I am a little sad to move out of that phase of my life. [However,] I almost wonder if it's not time to move into a different phase. And, so, this concussion just helped me to, like, stop, reconsider what's going on and then move in a different direction.*

All three participants experienced a loss of confidence in their identities where vulnerability supplanted strength. While the football players worry about how their weakness will be interpreted by others, Maryann sees the identity transformation as normal, even salutary. Her ease of transitioning to a post-injury life is owed to her willingness to experience vulnerability, and her openness to adopt a new professional identity. This may be compared to Roger and Philip who shared thoughts about transitioning to coaching, but who struggled to reconcile the new position on the football team with their alpha male identities (which they were unable to abandon).

#### **6.2 Social isolation and support**

Another significant factor working against participants during their recoveries was the absence of social support from peers, family, neighbors, and/or loved ones. When Roger had little to no social support for extended periods of time during his recovery, PCS symptoms were at their worst.

Roger was offered the least amount of social support across the three participants. He describes his experience of social isolation and perceived lack of social support from coaches after a serious concussion while playing for his university team:

*I just felt as though they did not care. I was just like, they do not give a fuck about me. […] They do not call me. The only time they called me is if I did something wrong. I got a concussion, you calling me about missing something called breakfast check (where players meet with coaches)? Like, I really did not care. I was just like, I'm not going to go to anything. I'm not going to do anything and they are going to have to find me if they want me.*

As a university athlete, Roger is away from his social support structure at home, and his new support structure is made entirely of teammates and coaches—people he believes do not value him outside of his contributions on the field. The athletic relationship between players and coaches is predominantly utilitarian. It is of deep value to consider the level of perceived isolation and dehumanization that is present in his social experience after high school.

It is difficult to separate actual from perceived social support. Roger seemed incapable of recognizing support when present. For example, he felt like his mother did not care about him even though she was regularly calling. "I'm like 'mom, I don't even want to be on Earth and you're not even asking me anything.' And she's like, 'but I am, I'm calling you everyday.' And I'm like, 'but you're not, you're not here.' It was never enough." The primary shortcoming of social support may not be from Roger's social environment at all, but his willingness to recognize support when present:

#### *A second form of social isolation came with treatment itself. Roger explains:*

*I went to the psychiatric facility for four days and I mean all they did was we would be in groups, we could be playing cards, we could be watching TV, and they say they were evaluating you but they were just writing is he walking or is he sitting. It wasn't that much of an evaluation, there wasn't that many people to evaluate 60 people in the place. There's no way everyone can be evaluated and keyed in on. They were just doing what they were supposed to be doing, writing little notes, writing little notes. […] It can be a weekly visit with a psychologist or a counselor. I know that's what got me through, just talking to my friends and talking to my counselor. Because I can always talk to someone that has like a point of view because you go talk to that counselor, he does not know you really, so he's going to give you the raw of what's going on.*

The psychiatric facility is Roger's final place to turn for social support. However, just as he perceives apathy from coaches, loved ones, and family members throughout this process, the overworked and understaffed nature of the psychiatric facility is unable to meet his needs. It is the desire for interpersonal connection with and empathy and support from others that Roger seeks. The absence of such support is what stands out most significantly in Roger's experience with PCS.

Maryann's situation is similar. Her dependence on others reaches its peak following her injury. "In the aftermath," she explains, "I felt so lost. It was really, really astounding. Luckily I was able to stay with a friend for weeks, so I had somebody that I knew from before the accident." But then Maryann had to move, and she rented an apartment for a few weeks in a new town which was disorienting. "Nothing smelled like me. And I thought that I was losing my mind like, I really thought that I was going crazy because I had nothing, nothing that reminded me. [My partner at the time] took off, like didn't answer calls; just disappeared."

Knowledgeable about TBI, Maryann was looking for evidence that her personality had not changed. But her new environment and social isolation provided little in the way of homogeneity. Furthermore, she describes how the social nature of her life as an academic was not conducive to her recovery process:

*I think the hardest part about academia for me is isolation. There's no question. I played team sports my whole life, I know teams. That's how I know how to function. Nobody here knows teams. Nobody here knows teams. I know like the idea of helping each other instead of getting ahead of each other. There is no doubt that my job made the recovery more difficult because of this.*

*Social Support, Identity, and Meaning: A Phenomenological Analysis of Post-Concussion… DOI: http://dx.doi.org/10.5772/intechopen.95541*

#### **6.3 Resistance to personality change**

Though each tried, all three participants were limited or unable to continue their pre-injury commitments and routines, leading to frustration and exhaustion. The longer the commitment lasted before the injury, the greater the severity of PCS.

It wasn't until he lost blocks of time and bits of memory during a phone conversation that Roger began to suspect he had suffered his fifth concussion. This occurred during a typical phone conversation when he had trouble remembering his previous day. He was also unable to read his notes without the words dancing around on the page. The impairments to his routine were considerable.

Philip was worried he would be unable to get through a workout without passing out. Even standing up too quickly resulted in light-headedness. This was a significant change. Philip reported being the strongest member of the football team during training. He had spent years of his life repeatedly training his muscles to engage in specific exercises. The fast-twitch anaerobic muscular strength upon which he relied was no longer there for him. His body was unfamiliar.

Maryann experienced trouble looking at the computer screen for long periods of time without getting dizzy, and this impaired nearly every aspect of her occupation as professor. Inability to concentrate affected normal daily activities like driving and grocery shopping. Indeed, it was her experience of dizziness while checking items off her grocery list that prompted her to see a physical therapist.

As with all illnesses [26], PCS is experienced through disruptions to routine. In the midst of routine, the body is taken for granted and absent to experience. It is only once these routines break down that the body is noticed at all. Attempts to continue the impaired routine results in disorientation and suffering—Roger studying for an exam, Philip finishing one more workout, and Maryann reviewing a course syllabus. It is only in the midst of such routines that one feels at home, and it is upon such routines that one builds one's identity and sense of life-satisfaction. To lose these routines is distressing, but it can also interrupt one's sense of time and space. It is as Maryann describes her routines: as "anchor[s] in the day to keep me moving from one point to the next. So that even if it's disorienting in between I know where I'm supposed to be when I'm supposed to be there and that's the foundation." Without routines one is adrift.

The desire to return to their pre-injury state is understandable, but impossible. It is only once the routine is adjusted that rehabilitation may begin. For Maryann, this started with adjustments in the classroom:

*I was just honest with the students right up front and I said "you know I have a concussion. I can't use the computer and I need the lights to be off in the room because it's making me sick having the lights on." And they were really great about it, I mean, I got a lot of athletes in my class as well so hearing "concussion" they know what that means. Yeah, and then the other thing is I usually push too hard and with a concussion you cannot.*

Maryann recognized and accepted her newfound shortcomings which she was then able to strategically address. Strategies included being more patient with her work, taking breaks, and stopping to nap when necessary. These strategies are helpful not in recovering the pre-injury personality, but in developing a new one post-injury. To that end, Maryann was able to view these personality changes as important ones—changes the injury helped her make. Even before the injury, she recognized a needed help with work/life balance. The concussion helped her back off what she described as a tendency to be a "workaholic," and pay special attention to diet, nutrition, and social networks. "So one of the things that I've noticed is that I have to make time for my hobbies and I have to make time for other people. […] I needed to reexamine my sense of identity and commitment to priorities. I needed to make time away from work to be with others."

Finding meaning in injury and illness is an important part of what physician and philosopher of medicine Aaron Antonovsky has called sense of coherence (SOC). Patients that have a high SOC rehabilitate more quickly and live longer and more satisfying lives.
