PSYCHOSOCIAL REINTEGRATION OF VETERANS WITH MILD

TRAUMATIC BRAIN INJURY UTILIZING TAI CHI CHUAN

Doctoral Dissertation Research

Submitted to the Graduate Faculty of

Argosy University, Denver Campus

College of Psychology and Behavioral Sciences

In Partial Fulfillment of

the Requirement for the Degree of

Doctor of Education

Counseling Psychology

By

James Pinkney III

April, 2018

ii

PSYCHOSOCIAL REINTEGRATION OF VETERANS WITH MILD

TRAUMATIC BRAIN INJURY UTILIZING TAI CHI CHUAN

Copyright ©2018

James Pinkney III

All rights reserved

iii

PSYCHOSOCIAL REINTEGRATION OF VETERANS WITH MILD

TRAUMATIC BRAIN INJURY UTILIZING TAI CHI CHUAN

Doctoral Dissertation Research

Submitted to the Graduate Faculty of

Argosy University, Denver Campus

College of Psychology and Behavioral Sciences

In Partial Fulfillment of

the Requirement for the Degree of

Doctor of Education

Counseling Psychology

By

James Pinkney III

iv

ABSTRACT

The purpose of this study was to ascertain the efficacy of Yang Style Tai Chi Chuan

practice as a holistic augmented therapeutic intervention to treat veterans with mild

traumatic brain injury (mTBI). Current neuroscience research indicates that Movement

Therapy facilitates neuroplasticity and development of neuropathways in the brain. The

practice of Tai Chi Chuan stimulates neuronal development in the prefrontal cortex and

contributes to a relaxation response in the limbic system. United States military veterans

have been and are now experiencing challenges with familial and social integration after

their military service in Operation Iraqi Freedom and Operation Enduring Freedom.

Some United States military veterans, who experience a mTBI, have sought and do seek

alternatives to drug treatment for traumatic brain injuries, such as a non-poly pharmacy

intervention. The Yang Style Tai Chi Chuan practice is one such potential non-poly

pharmacy intervention. The overarching goal of such a treatment modality is to facilitate

the veteran’s psychosocial reintegration into family life, social support systems, and

employment. The goal is to understand the application, efficacy, and therapeutic value of

Yang Style Tai Chi Chuan practice in the psychosocial reintegration of veterans with

mild traumatic brain injury. Because of the goals of the research, the research method

chosen for this study is a qualitative descriptive phenomenological analysis and method.

Phenomenology methodology describes a lived condition or experience of a research

participant.

Keywords: family reintegration, social identity, social integration, tai chi chuan, tai chi chuan psychosocial reintegration model, traumatic brain injury

v

ACKNOWLEDGEMENTS

The following list my acknowledgement and gratitude of the persons who

facilitate this journey to achieve this milestone in my life.

Ruth Ballard: Mother, thank you teaching the importance of being a leader not a

follower.

Valorie Pinkney Worthington: Sister, thank you for the examples of hard work,

commitment to achievement, and overcoming adversity to achieve your goal.

Jeffery B. Worthington: Brother-in-law, for modeling the command of leadership

and demonstrating consistency of commitment to excellence.

Dr. Anissa Rene Butler: Who served as a lighthouse during challenging of starting

and completing this academic endeavor. Thank you for the inspiration, guidance,

confidence, and honest feedback of my academic journey notwithstanding the medical

hardships experienced in pursuit of this goal.

Dr. Michele Post: Who shared the value of persistence, openness, being self-

driven, and tenacity with a teaching style that reflects the wisdom of the Book of Job.

Dr. Charles Howard: An example of a clinician who taught that healthy outcomes

and wisdom applies to realistic decisions.

Dr. Maurice Ivy: A professor who encourage innovation, value, the yearn to learn,

offered counsel in the doctoral journey.

Dr. Giorgio D. RaShadd: Brother, who encouraging and motivating the effort to

complete the academic journey and showing the value of family support in a crisis.

Dr. Reo Leslie: Who offered constructive feedback and suggestions in preparing

the proposal and dissertation defenses.

vi

Dr. Robert Atwell, Dr. Denise Leadon, and Dr. Anthony P. Young of the

Association of Black Psychologists for the unwavering encouragement and support.

Dr. Lawrence Habuchak: The VA Medical Center Psychologist who inspired the

aspiration to earn advance degrees in the field of clinical and counseling psychology.

Michele Breckenridge: 2BFIT Master Tai Chi Chuan instructor who supported

the research by instructing the veteran participants in the research study.

The Rowe Family: Jaketa Rowe, Owner of Coulture Boutique and James Rowe

Owner of Snap Shot Photography Studio, provided training space and video

documentation of the research study at no cost to the participants.

Mindee Diehl: VA Medical Center medical professional who help with

rehabilitation and fitness training to manage this researcher cardiac condition.

The Gavin Family: Colonel James H. Gavin Sr. (U.S. Army Retired) and Kathryn

Bates Gavin (Educator) who provided encouragement and motivation to succeed.

Veterans Participants: Thank you for participating in the research study. Your

commitment to completing the study will provide individuals with a mild traumatic brain

injury with a complementary therapeutic approach for treatment of their condition.

Yolanda Dandridge: Somatic movement therapist, thank you for providing your

knowledge, experience, and insight on the importance of movement therapy.

Mental Health and movement clinicians: Thank you for providing your clinical

insight on the value of psychosocial reintegration utilizing and familial support system

utilizing Tai Chi Chuan.

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DEDICATION

The follow is a dedication to persons who have experienced a traumatic brain

injury during their life time.

There is an alternative complementary treatment for an external and internal

traumatic brain injury. Movement therapy in the form of Tai Chi Chuan is an approach

to facilitate connection with yourself and your support system. Human biological

systems are in a continuous state of movement. Movement in the form of bioelectrical

communications to physical movement is vital to healthy quality of life. By increasing

movement and being aware of how movement impacts your health, contributes to better

health outcomes. Tai Chi Chuan increases the possibility of improvement of managing

your traumatic brain condition. This researcher encourages an “Appeal to Heal and

Move to Improve” with a purpose to empower yourself and have a better quality of life.

viii

TABLE OF CONTENTS

Page

LIST OF TABLES ............................................................................................................. xi

LIST OF APPENDICES .................................................................................................. xvi

CHAPTER ONE: INTRODUCTION ................................................................................. 1 Problem Background .......................................................................................................... 4 Purpose of Study ............................................................................................................... 12 Research Question and Hypotheses .................................................................................. 12

Research Questions ................................................................................................... 13 Null Hypotheses ........................................................................................................ 13 Alternative Hypotheses ............................................................................................. 13

Definitions......................................................................................................................... 13 Significance of the Study .................................................................................................. 17 Summary ........................................................................................................................... 18

CHAPTER TWO: REVIEW OF THE LITERATURE .................................................... 20 Tai Chi Chuan Psychosocial Reintegration Theory Cycle ............................................... 24

Veteran Participants .................................................................................................. 24 Tai Chi Chuan Psychosocial Reintegration Theory Cycle (TCCPRT) ............................. 25 Tai Chi Chuan Psychosocial Reintegration Theory (TCCPRT) ....................................... 26 Benefits of TCCPRT in a Group Setting .......................................................................... 27 TCCPRT Theories ............................................................................................................ 28

Social Integration Theory.......................................................................................... 28 Psychosocial Development Theory ........................................................................... 28 Traumatic Brain Injury Theory ................................................................................. 29 Family Reintegration Theory .................................................................................... 29 Social Identity Theory ............................................................................................... 30

The Interpersonal-Intergroup Continuum ......................................................................... 32 Group Therapy .......................................................................................................... 32

Explanation of TCCPRT Cycle ........................................................................................ 34 Tai Chi Chuan Intervention ...................................................................................... 35

Explanation of TCC Intervention...................................................................................... 35 Mild Traumatic Brain Injury ............................................................................................. 36

Mild TBI ................................................................................................................... 36 Tai Chi Chuan ................................................................................................................... 37 Impact on Clinical Care .................................................................................................... 38 Self-management for Mild TBI ........................................................................................ 39 Mechanisms of Injury ....................................................................................................... 39 Relationship of Neurobiology to Mild TBI ...................................................................... 40 Physical Symptoms ........................................................................................................... 41 Affective Symptoms ......................................................................................................... 41 Cognitive Symptoms ......................................................................................................... 43

ix

Effectiveness of Tai Chi Chuan ........................................................................................ 43 Importance of Topic .......................................................................................................... 44 Gaps in the Literature........................................................................................................ 45 Summary ........................................................................................................................... 46

CHAPTER THREE: METHODOLOGY ......................................................................... 47 Research Design................................................................................................................ 47

Subjects ..................................................................................................................... 47 Instruments ................................................................................................................ 49

Methodological Assumptions, Limitations, and Delimitations ........................................ 53 Assumptions .............................................................................................................. 53 Limitations ................................................................................................................ 54 Delimitations ............................................................................................................. 55

Data Processing and Analysis ........................................................................................... 56 Process ...................................................................................................................... 56 Data Analysis ............................................................................................................ 58

Summary ........................................................................................................................... 59

CHAPTER FOUR: FINDINGS ........................................................................................ 61 Introduction ....................................................................................................................... 61 Purpose of Study ............................................................................................................... 61 Research Question ............................................................................................................ 62 Organization of the Chapter .............................................................................................. 62 Researcher’s Proclivities Prevention ................................................................................ 63

Removing Bias with Research Design ...................................................................... 63 Removing Bias from Veteran Participant Selection ................................................. 63 Removing Interview Bias ......................................................................................... 64 Removing Researcher’s Belief System Bias through Supervision ........................... 64

Data Presentation .............................................................................................................. 65 Research Interview Questions........................................................................................... 66 Readiness to Participate .................................................................................................... 67

Veteran Participant’s Pre-intervention Questions ..................................................... 71 Veteran Participant’s Pre-intervention Questions ..................................................... 72 Veteran Participant’s Progress-intervention Questions ............................................ 76 Progress-intervention Questions ............................................................................... 78 Surveyed Veterans Participant’s Progress Interview ................................................ 84 Post-Intervention Interview Questions...................................................................... 85 Post-Intervention Interview Questions...................................................................... 86 TCCRM Reintegration Questions ............................................................................. 90 TCC Reintegration Questions ................................................................................... 91 Surveyed Veterans Participant’s TCC Reintegration Interview Summary ............... 94 Clinician Reflection Questions ................................................................................. 96 Somatic Movement Therapist Questions ................................................................ 106

Demographics ................................................................................................................. 111 Data Analysis .................................................................................................................. 113

Qualitative Interview Results .................................................................................. 114 Emergent Themes ................................................................................................... 117

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Summary ......................................................................................................................... 121

CHAPTER FIVE: SUMMARY, FINDINGS, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS ................................................................................................ 123 Introduction ..................................................................................................................... 123 Findings........................................................................................................................... 123

Questionnaires ......................................................................................................... 124 In-depth Interviews ................................................................................................. 125 Tai Chi Instructor .................................................................................................... 127

Conclusions ..................................................................................................................... 128 Implications..................................................................................................................... 128 Recommendations ........................................................................................................... 130

Recommendation 1 ................................................................................................. 130 Recommendation 2 ................................................................................................. 130 Recommendation 3 ................................................................................................. 131 Recommendation 4 ................................................................................................. 131 Recommendation 5 ................................................................................................. 131 Recommendation 6 ................................................................................................. 131

Summary ......................................................................................................................... 131

REFERENCES ............................................................................................................... 133

xi

LIST OF TABLES

Page

Table 1. Military Core Values by Service Branch ........................................................... 25

Table 2. Question 1: What is Your Knowledge of Mild Traumatic Brain Injury? .......... 67

Table 3. Question 2: What is Your Understanding of Mild Traumatic Brain Injury? ..... 68

Table 4. Question 3: What is the Level of Biopsychosocial Awareness? ....................... 68

Table 5. Question 4: What is Your Understanding of Self-Efficacy? ............................. 69

Table 6. Question 5: What is Your Level of Motivation? ............................................... 69

Table 7. Question 6: What is Your Level of Engagement to Participate in Therapy? .... 70

Table 8. Surveyed Veteran Participant’s Readiness to Participate Results ..................... 70

Table 9. Question 7: What is Your Level of Knowledge of Tai Chi Chuan? .................. 72

Table 10. Question 8: Do You have Factors that brought You to Consider Tai Chi

Chuan? .............................................................................................................................. 73

Table 11. Question 9: What is Your Motivation Level to Consider Tai Chi Chuan as a

Treatment for mTBI? ........................................................................................................ 73

Table 12. Question 10: Do You have Barriers that would Prevent Tai Chi Chuan

Practice? ............................................................................................................................ 74

Table 13. Question 11: Do You have any Symptoms You now Notice and Experience?

........................................................................................................................................... 75

Table 14. Question 12: Do You have Conditions that will Affect Your Ability to

Perform Tai Chi Chuan? ................................................................................................... 75

Table 15. Surveyed Veteran Participant’s Six Pre-intervention Questions Readiness to

Participate Results ............................................................................................................. 76

xii

Table 16. Question 14: What was Your Motivation Level since Your Participation in the

Tai Chi Chuan Group? ...................................................................................................... 78

Table 17. Question 15: Do You Continue to Experience Barriers in Communicating with

Your Social Support System? ........................................................................................... 79

Table 18. Question 16: What Types of Symptoms do You Now Notice and Experience?

........................................................................................................................................... 80

Table 19. Question 17: Have any of Your Symptoms Affected Your Ability to Perform

Tai Chi Chuan? ................................................................................................................. 80

Table 20. Question 18: Do You Think Tai Chi Chuan Affects Your Rehabilitation

Process?............................................................................................................................. 81

Table 21. Question 19: Explain precisely What Symptoms Were Affected by Tai Chi

Chuan Practice? ................................................................................................................ 82

Table 22. Question 20: What did You Enjoy about Tai Chi Chuan Practice? ................. 82

Table 23. Question 21: Would You Recommend This Therapy or do it Again if You had

the Chance? ....................................................................................................................... 83

Table 24. Question 22: Would You Recommend this Therapy or do it again if You had

the Chance? ....................................................................................................................... 83

Table 25. Surveyed Veterans Participant’s Progress Interview Results (N=10) ............. 84

Table 26. Question 23: What is Your Motivation Level Upon Completion of the Tai Chi

Chuan Therapy Group? ..................................................................................................... 86

Table 27. Question 24: What Barriers do You Experience? ............................................ 87

Table 28. Question 25: Do You Think Tai Chi Chuan Affected Your Rehabilitation

Process?............................................................................................................................. 87

xiii

Table 29. Question 26: What did You Enjoy about the Tai Chi Chuan Practice? What

did You Not Enjoy? .......................................................................................................... 88

Table 30. Question 27: Do You Think You will Continue to Practice Tai Chi Chuan? . 88

Table 31. Question 28: Would You Recommend this Therapy or do it again if You had

the Chance? ....................................................................................................................... 89

Table 32. Question 29: How has Your First Impression of Tai Chi Chuan Practice

Changed during the past Eight Sessions? ......................................................................... 89

Table 33. Question 30: How do You Feel about Tai Chi Chuan as an Exercise

Intervention? ..................................................................................................................... 91

Table 34. Question 31: How do You Feel about Group Interaction during Therapy? .... 92

Table 35. Question 32: Are You Comfortable in a Social Setting? ................................. 92

Table 36. Question 33: How Prepared are You to Connect with Your Social Support

System? ............................................................................................................................. 93

Table 37. Question 34: Are You Comfortable in a Social Setting? ................................. 94

Table 38. Surveyed Veterans Participant’s TCC Reintegration Interview Summary

(N=10) ............................................................................................................................... 95

Table 39. Question 35: What is the Relationship between an Individual’s Social Support

System and Mental Health? .............................................................................................. 97

Table 40. Question 36: Does a Social Support System Improve an Individual’s Well-

Being? Why? ..................................................................................................................... 99

Table 41. Question 37: What is the relationship between an individual’s social support

system and their personal identity? ................................................................................. 101

Table 42. Does a Social Support System Improve an Individual’s Well-Being/ Why? 102

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Table 43. Question 39: What is the Importance of Social Connection? ........................ 104

Table 44. Question 40: What is the Relationship between Movement and Mental Health

of an Individual? ............................................................................................................. 107

Table 45. Question 41: What is the Relationship between Movement and Mental Health

of an Individual? ............................................................................................................. 108

Table 46. Question 42: What is the Relations between Movement and Mental Health of

an Individual’s Personal Identity? .................................................................................. 109

Table 47. Question 43: What is the Relations between Movement and Mental Health of

an Individual’s Personal Identity? .................................................................................. 110

Table 48. Question 44: What is the Importance of Movement? .................................... 111

Table 49. Q45 - Interviewed Veteran Population (N=23) ............................................. 112

Table 50. Q46 - Age of Veteran Participants (N=10) .................................................... 113

Table 51. Ethnicity of Veteran Population (N=10) ........................................................ 113

xv

LIST OF FIGURES

Page

Figure 1. TCCPRT Cycle. ................................................................................................ 25

Figure 2. Process of which participant navigation social interaction in a group setting. 34

Figure 3. Process of participant engaging in changing behaviors in a group setting. ...... 35

Figure 4. Tai Chi Chuan Instruction Interview. ............................................................. 128

xvi

LIST OF APPENDICES

Page

Appendix A. Interview Checklist .................................................................................. 142

Appendix B. Dissertation Background .......................................................................... 145

Appendix C. Age Verification ....................................................................................... 149

Appendix D. Permission to Record ............................................................................... 151

Appendix E. Demographic Form ................................................................................... 153

Appendix F. Interview Questions .................................................................................. 155

Appendix G. Demographic Form .................................................................................. 157

Appendix H. GMX......................................................................................................... 159

Appendix I. Brief Traumatic Brain Injury Screen ......................................................... 161

Appendix J. Readiness to Participate ............................................................................. 163

Appendix K. Pre-intervention Interview Form .............................................................. 165

Appendix L. Progress Interview Form........................................................................... 167

Appendix M. Post-Intervention Interview Form ........................................................... 169

Appendix N. TCCPRT Reintegration Questionnaire..................................................... 171

Appendix O. Conceptual Framework ............................................................................ 173

Appendix P. Figure 5 ..................................................................................................... 178

1

CHAPTER ONE: INTRODUCTION

This study described the lived experiences of disabled veterans who served in

Iraq, Afghanistan, and other American wars and conflicts (or police actions) who have

been rated as disabled by the Department of Veterans in which they previously served or

presently serve. Moreover, the disabled veterans have experienced with a treatment

intervention, which is Tai Chi Chuan (TCC), as a possible positive program in their

psychosocial reintegration to school, employment, and family life.

Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom

(OIF) veterans of the United States military are selected to understand the traumatic brain

injury challenges in this study better. This chapter presents the problem, the problem

background, and the purpose of the study. The treatment of veterans in the United States

is examined to develop an understanding of how the additional challenge of disability is

affected using TCC in a rehabilitative, reintegration, and re-socialization program. TCC

originated in China as a martial art is sometimes called moving meditation. The

practitioners move their bodies slowly, gently, and breathe deeply.

Many people practice TCC to improve their health and well-being. Scientific

research is learning more about how TCC may work. TCC have positive outcomes on

health, disease, and other medical conditions. TCC developed in ancient China. It

started as a martial art and a means of self-defense. Over time, people used it for health.

Accounts of the history of TCC vary. A popular legend credits its origins to Chang San-

Feng, a Taoist monk, who developed a set of 13 exercises that imitate the movements of

animals. He also emphasized meditation which is a conscious mental process using

certain techniques such as (a) focusing attention, (b) maintaining a specific posture to

2

suspend the stream of thoughts, (c) relax the body and mind, and (d) the concept of

internal force. TCC is an internal system of martial arts which differs from external

systems of martial arts such as Karate and Tae Kwon Do.

The term “Tai Chi” (shortened from “Tai-chi Chuan”) has been translated in

various ways, such as “Internal Martial Art” and “Supreme Ultimate Fist.” Tai Chi

Chuan in Mandarin Chinese is spelled Taiji and Taiji Quan. TCC incorporates the

Chinese concepts of Yin and Yang. The concept of two opposing yet complementary

forces described in traditional Chinese medicine. Yin stands for cold, slow, or passive

aspects of the person while Yang stands for hot, excited, or active aspects. A major

theory is that health is achieved through balancing yin and yang. The disease is caused

by an imbalance leading to a blockage in the flow of qi (opposing forces within the

body). Traditional Chinese medicine proposed to regulate a person's spiritual, emotional,

mental, and physical health by balancing Yin and Yang (a vital energy or life force).

Often, the rehabilitation programs are advanced by governmental entities

including the military services, the U.S. Department of Veteran Affairs, the Federal

Legislature, and the EEOC. First, Title I of the Americans with Disabilities Act (ADA),

which the U.S. Equal Employment Opportunity Commission (EEOC) enforces, prohibits

private, state, and local government employers with 15 or more employees from

discriminating against individuals because of disability.

Title I of the ADA also requires covered employers to make reasonable

accommodations for physically challenged individuals (Pub. L. No. 101-336, 104 Stat.

327, 1990). Second, the Uniformed Services Employment and Reemployment Rights

Act (USERRA) set forth the requirements for reemploying veterans with and without

3

service-connected disabilities. Therefore, USERRA prohibits employers from

discriminating against employees or applicants for employment because of their military

status or military obligations. The USERRA also goes further than the ADA by requiring

employers to make reasonable efforts to assist veterans returning to employment in

becoming qualified for jobs.

As of July 4, 2015, the American combat presence (ground forces) in Iraq had

ceased to exist as a designated combat component. The forces which remain are

designated as trainers. However, the IED danger to them remains. As of July 4, 2015,

the war in Afghanistan was winding down and coming to an end.

According to Felbab-Brown (2014) and Miller (2013), the instability of the

Afghan government. The instability of military and the threat of forces like ISIS/ISIL

increases the nature of the danger of IED attacks to Allied forces, American military

trainers, and advisors. The Department of Defense’s monthly casualty reports indicates

that the impacts of roadside bombs. Improvised explosive devices, and ambushes

continuing to take a toll on the lives of American service members (Felbab-Brown,

2014).

Islamic State in Iraq and Syria (ISIS) or "Islamic State of Iraq and al-Sham,"

which is an old Arabic term for the area. The Islamic State of Iraq and the Levant (ISIL)

translates to the militant group, which began as the Iraqi branch of al Qaeda during the

U.S. occupation, gained this name after it invaded Syria in 2013. The Levant is a

geographical term that refers to the eastern shore of the Mediterranean -- Syria, Lebanon,

Palestine, Israel, and Jordan. It is the term the U.S. Government uses since the "Levant"

is a better translation for al-Sham, the Arabic name for the region (Vultaggio, 2015).

4

Problem Background

Veterans experience both Post Traumatic Stress Disorder (PTSD) and mild,

moderate, and severe Trauma Brain Injury (TBI) symptoms. TBI occurs from the blast

(pressure wave), explosions, motor vehicle accidents, and gunshot wounds. Mild TBI

symptoms can resolve in three to six months. Symptoms may continue to develop into

the chronic post-concussive syndrome (Wayne et al., 2014).

Cognitive symptoms can include memory deficit, attention difficulties, and a

decrease in processing speed. Emotional difficulties manifest as irritability, depression,

anxiety, impulsivity, and aggression, which overlap with symptoms of PTSD. Somatic

symptoms of tinnitus, blurred vision, sensitivity to noise, seizures, and insomnia can

worsen cognitive and emotional symptoms (Wayne et al., 2014).

Traumatic Brain Injury (TBI) is damage to the brain from an injury caused by an

external or internal event. A TBI results from a violent blow that causes possible

permanent or temporary damage to cognitive, physical, and psychosocial functions

associated with differentiated states of consciousness. The definition of TBI varies

dependent upon the physiological circumstances (O’Neil et al., 2013).

Re-integration into active civilian life is worsened by veterans' suffering from

TBI often suffer from PTSD that inhibits their ability to become employed immediately

after leaving the military. The veteran has both a physical and an emotional

/psychological injury (Crocker, Powell-Cope, Brown, & Besterman-Dahan, 2014;

Ostovary & Dapprich, 2011). Researcher in TBI community agrees to two types of TBI:

(a) external and (b) acquired. External TBI is an insult to the brain derived from an

5

external force. Acquired TBI is a medical condition that results from an event other than

a physical insult to the head.

An example of external TBI is blunt trauma or impact to the head (Hyatt, Davis,

& Barroso, 2015). Acquired TBI is an internal non-traumatic. Examples of acquired

brain injury are a stroke, near drowning, tumor, neurotoxins, electric shock, or lightning

strike (Coleman, Frymark, Franceschini, & Theodoros, 2015). This study addressed an

external TBI experienced by veterans in the form mild traumatic brain injury (mTBI).

According to Martinez (2011) and Yost and Taylor (2013), approximately two

million U.S. service members have been deployed to Iraq and Afghanistan. There are

3,000 soldiers in Operation Enduring Freedom (OEF), and 33,000 in Operation Iraq

Freedom (OIF) that have been wounded by an improvised explosive device (IED). IEDs

and flying debris have increased the probability of service members sustaining a head

injury (Crocker et al., 2014).

Stress is a major problem in today's fast-paced society and can lead to serious

psychosomatic complications. The ancient Chinese mind-body exercise of TCC may

provide an alternative and self-sustaining option to pharmaceutical medication for

stressed individuals to improve their coping mechanisms. The protocol of this study

evaluated whether TCC practice equals standard exercise and whether the TCC group is

superior to a wait-list control group in improving stress coping levels. This study was an

eight-week, three-arm, parallel, randomized, clinical trial designed to evaluate TCC

practice as a therapeutic modality over six weeks with a six-week follow-up.

According to the September 2014 report published by the U.S. Department of

Labor Bureau of Labor Statistics, the total payroll employment increased by 209,000 in

6

July, and the unemployment rate was 6.2%. However, as of July 2013, the

unemployment rate of Iraq and Afghanistan veterans 18 years and over was 7.7%, and in

2014 it was 9.2%. The unemployment rate for men was 8.8% in July 2014. For women,

the unemployment rate was 0.7% in July 2014 (Blames, 2007). Martinez (2011) argued

that approximately two million U.S. service members have been deployed to Iraq and

Afghanistan.

Mild traumatic brain injury (mTBI) is a new crisis plaguing familial systems,

medical facilities, the Armed Services, and sports organizations (Yost & Taylor, 2013).

Variants of injury-induced neurotrauma are called Chronic Traumatic Encephalopathy

(CTE) and TBI. For example, athletes and service members who experience head trauma

will present characteristics of impaired affective and cognitive abilities. The presentation

of memory loss and depression manifests within hours or days of an injury (Nelson,

Davenport, Sponheim, & Anderson, 2015). Patients range from infants to mature adults

with experienced injury-induced neurotrauma resulting from accidents and physical

activity (Center for Disease Control, 2012).

Mild TBI is a growing concern for the VA Medical Centers and contracted

medical providers who treat service members returning from overseas deployments

(Chapman & Diaz-Arrastia, 2014). Service members experience multiple head injuries

(CTE) and comorbid conditions such as anxiety disorders. Holistic augmented treatment

approaches to mitigate mTBI calls for more research to improve and develop preventive

measures to help patients manage mTBI symptoms.

This study highlighted a potentially complementary therapeutic approach for

treating veterans with MTBI. A non-pharmacological treatment modality to treat brain

7

can save money and reduce side effects of medication that manages antidepressant,

antipsychotic, pain, and motor system medications. The increasing involvement of U.S.

forces in deployment operations calls for the need for an innovative and cost-effective

health care approach to address the myriad facets of recovery (Yost & Taylor, 2013).

TCC is an exercise intervention that may benefit victims of neurotrauma and

facilitate the integration of familial support systems (Chang, Tasi, Beck, Hagen, & Huff,

2011). Using TCC as a complementary intervention is important for five reasons. First,

this research is a personal experience of using TCC as a therapeutic intervention.

Second, the existing research suggests that TCC is effective in treating deficits in

cognitive function and improving health outcomes for patients with chronic health

conditions (Chang et al., 2011; Wang et al., 2010). Chang et al. (2011) argued TCC is

safe, effective, and has benefits (physiological and psychosocial) by promoting quality of

life for patients.

Third, according to Lan, Chen, Lai, and Wong (2013), TCC improves aerobic

capacity, reduce blood pressure and stress, improve sleep quality, and increase leg

strength. The benefits to service members and veterans could be improved neurological

health in areas as physical activity, education, social interaction, intellectual pursuits, and

cognitive remediation (Vance, Roberson, McGuinness, & Fazell, 2010). In addition,

TCC provides an opportunity to veteran participants to develop a social skill that

enhances the probability of re-integrating to their social systems.

Fourth, mild traumatic brain injury causes damages to areas of the brain that

fosters cognitive, affective, and psychological. The deficits are seen in patients engaged

8

in rehabilitation resulting from a form a head injury. Traumatic brain injury in its various

forms has become the norm for veterans requiring treatment (Yost & Taylor, 2013).

Fifth, mental health professionals and social support systems offer continuous

support and abetment as patients reassemble their lives and reintegrate into society

(Crocker et al., 2014). TCC is an intervention through physical movement has physical,

emotional, and psychological benefits (Lan et al., 2013). The practice of TCC can

complement conventional medical and psychotherapies. Conjointly, TCC is low cost

allow for implementing an exercise program in austere environments such as

predeployment and deployment conditions. TCC is a consequential holistic augmented

treatment to treat service members and veterans with mild traumatic brain injury (Yost &

Taylor, 2013).

Physical movement in TCC is an approach used to facilitate neuromuscular

memory and neural pathways development in the brain (Marques et al., 2016). Research

in neuroplasticity is advancing evidence that the brain recovers and develops adaptive

strategies after a brain injury (Marques et al., 2016). For example, the brain, through the

process of neuroplasticity, will produce and increase connections between neurons and

promotes cognitive function. The body will access other areas in the brain to compensate

for degraded cognitive function (Marques et al., 2016). The research suggests that motor

skills could be reacquired through practice after experiencing a traumatic brain injury.

This research promotes recovery possibilities for individuals with mTBI.

TCC optimizes the functional organization of the intrinsic human brain

architecture in older adults (Wei, Dong, Yang, Luo, & Zuo, 2014). Whether TCC can

influence, the intrinsic functional architecture of the human brain remains unclear. To

9

examine TCC-associated changes in functional connections, resting-state functional

magnetic resonance images were acquired from 40 older individuals. This included 22

experienced TCC practitioners (experts) and 18 demographically matched TCC-naïve

healthy controls, and their local functional homogeneities across the cortical mantle were

compared. These findings provide evidence for the functional plasticity of the brain's

intrinsic architecture toward optimizing locally functional organization. This revealed

implications for understanding the effects of TCC on cognition, behavior, and health in

the aging population.

Abbott and Laveresky (2013) and Solloway et al. (2016) evaluated the importance

of exercise, social problem-solving ability, gender, and age in relation to daily quality of

life (QOL) challenges. Adult participants were classified into categories as moderate

aerobic exercises, Tai Chi exercises, or sedentary via completion of a questionnaire.

Social problem-solving ability, state and trait anxiety, and frequency and severity of daily

hassles were measured (Wang et al., 2010).

Scores indicating effective social problem-solving ability were associated with

fewer reported severe daily hassles and with lower scores on state and trait anxiety. A

three-way interaction involving age, gender, and exercise mode suggested that age and

gender moderate the effects of exercise on anxiety, the stress-reducing efficacy of

different exercise modes may depend on a person's age and/or gender. Implications for

theory, research, and practice are discussed (Wang et al., 2010).

TCC as a therapeutic intervention promotes cognitive stimulation, physical

activity, and social interaction. Specifically, the physical activity of TCC increases

neural cell growth (neurogenesis), induce growth of blood vessels (angiogenesis), and

10

reduce brain inflammation. The active process of psychosocial interaction through TCC

can improve life-coping skills and facilitates familial reintegration. In addition, TCC

reduces stress related conditions resulting from a head injury (Chang et al., 2011).

The body will access other areas in the brain (neuroplasticity) to compensate for

degraded cognitive function resulting from mTBI (Marques et al., 2016). In addition,

Stevinson and Li (2010) argued in a research study, that motor skills could be reacquired

through TCC after experiencing a traumatic brain injury. This research promotes

recovery possibilities for individuals with mTBI (Stevinson & Li, 2010).

TCC is a Chinese Martial Art considered as the Grand Ultimate Fist (Reb et al.,

2016). Tai Chi is one of five internal systems of the Chinese Martial Arts system. The

five internal systems are Baguazhang, Liuhebafa, Tai Chi Chuan, Xingyiquan, and

Yiquan. Wu Shu is known in the United States as Kung Fung. Experienced practitioners

of TCC define TCC as meditation in motion. The practice of this system of Martial Arts

develops balance, coordination, focus, and strength (Reb et al., 2016).

TCC as an exercise intervention combined with traditional therapeutic treatments

that improve emotional well-being and eclipses sadness, confusion, anger, tension, and

fear (Reb et al., 2016). TCC has been the subject of an investigation to ascertain the

efficacy as a treatment modality for mTBI. Psychometric instruments such as the

Medical Outcome Scale, Rosenberg Self-esteem Scale, and the Visual Analogues Scale

will be used to measures a participant’s medical condition, self-esteem, and emotional

states before and after participating in a TCC therapeutic intervention program (Reb et

al., 2016).

11

National Center for Complementary and Integrative Health (NCCIH) has

funded research studies of TCC's effects on bone loss in postmenopausal women cancer

survivors; depression in elderly patients; fibromyalgia symptoms, such as muscle pain,

fatigue, and insomnia; osteoarthritis of the knee; patients with chronic heart failure; and

rheumatoid arthritis (NCCIH, 2015). According to Long (2014), TCC participants

experienced improvement general health, self-esteem, and mood at the end of the TCC

Intervention program. These positive outcomes suggest that TCC affects the clinical care

of participants (Reb et al., 2016).

Wu Shu is known in the United States as Kung Fung. The word Wu is translated

as ‘martial’ in English, however, in etymology, this word has a slightly different

meaning. In Chinese, Wu is made of two parts; the first meaning “stop” and the second

meaning “invaders advance.” This implies that “Wu’ is a defensive use of combat. The

term “Wushu” meaning 'martial arts' goes back as far as the Liang Dynasty (502-557)

(Reb et al., 2016).

A succinct review of the literature suggests that TCC has therapeutic value in

treating mTBI Psychometric instruments such as the Medical Outcome Scale, Rosenberg

Self-esteem Scale, and the Visual Analogues Scale measures a participant’s medical

condition, self-esteem, and emotional states before and after participating in a Tai Chi

therapeutic intervention program. The researchers experienced improvement general

health, self-esteem, and mood at the end of the program. These positive outcomes

suggest that Tai Chi affects the clinical care of participants (Reb et al., 2016).

12

Purpose of Study

This study ascertained the efficacy of Yang Style Tai Chi Chuan practice as a

holistic augmented therapeutic intervention to treat service members with mild traumatic

brain injury (mTBI). Previous neuroscience research that Movement Therapy

demonstrated that Movement Therapy facilitates neuroplasticity and development of

neuropathways in the brain (Hawkes, 2012). The practice of TCC stimulates neuronal

development in the prefrontal cortex and contributes to a relaxation response in the

limbic system (Hawkes, 2012).

The goal of this research was to inform future non-pharmacologic research in

brain injury. The specific aims were (a) ascertain the perceptions of veteran's experiences

living with mild TBI, (b) analyze veteran's learning and practicing TCC as a treatment for

mild TBI, and (c) chronicle the experience during the intervention period regarding the

efficacy of TCC on psychosocial reintegration of the veteran.

Research Question and Hypotheses

Before an appropriate research question was formulated, it was important to

understand how the researcher arrived at this research topic and the meaning behind it.

The researcher admitted a bias in this study resulting from prior military service and

being a student of TCC. Observing Veterans at the VA Medical Center engendered the

research idea. Theories of psychosocial development, social identity, social integration,

and conversations with veterans solidified the research topic. Eventually, the challenge

became constructing a research question or questions that would do justice to

investigating the experiences of veterans with mTBI.

13

This study explored life experiences and challenges derived from veterans’

personal stories. It focused on the central research question designed that captured

qualitative data to evaluate the overall impact of the life experiences of veterans with

mTBI. Therefore, this research question with subquestions was formulated as the guiding

focus of the study:

The research question for this dissertation focused on the perception of veteran's

understanding and efficacy of TCC.

Research Questions

The research questions drove the methodology of the study. They addressed the

purpose of the study, identifying the specific variables to be investigated from the larger

research question/objective. They were the smaller questions that guide this study.

RQ1: How does TCC facilitate psychosocial reintegration?

Null Hypotheses

H0 1: There is no relationship between TCC and psychosocial reintegration of

veteran participants with mild traumatic brain injury.

Alternative Hypotheses

HA1: There is relationship between Tai Chi Chuan and psychosocial reintegration

of veteran participants with mild traumatic brain injury

Definitions

Angiogenesis: The process to induce the growth of blood vessels (Wei et al.,

2013).

Clarification Probes: Queries are communicated so makes clear that neither the

interviewer nor the interviewee is the crux of the problem (Patton, 2002).

14

Cognition Function: The active process which knowledge is produced and

utilized in accordance with a required or specific action. Cognitive function is

diminished when a traumatic brain injury has occurred (Chang et al., 2011).

Disabled American Veterans: Former U.S. military personnel suffering a

disabling condition acquired while in service they did not have during military

enlistment, and which results in eligibility for disability payments by the American

military and or the United States Department of Veterans Affairs (Department of Veteran

Affairs, 2014).

Holistic: The process of addressing the emotional, physical, psychological, and

social aspects of an individual where manifest illness is apparent. Integration of the four

dimensions improves the probability of therapeutic intervention (Cicerone et al., 2007).

Improvised Explosive Device (IED): A homemade device designed to cause

death or injury by using explosives alone or combined with toxic chemicals, biological

toxins, or radiological material.

Intervention: Is the active participation in demonstrating hope and a positive

outlook on life in order to enhance self-reflection and improve health conditions (Blake

& Batson, 2009).

ISIL: ISIL translates to the “Islamic State of Iraq and the Levant.” The Levant is

a geographical term that refers to the eastern shore of the Mediterranean -- Syria,

Lebanon, Palestine, Israel, and Jordan. It is the term the U.S. government uses since the

"Levant" is a better translation for al-Sham, the Arabic name for the region (Vultaggio,

2015).

15

ISIS: The militant group, which began, as the Iraqi branch of al Qaeda during the

U.S. occupation, gained this name after it invaded Syria in 2013. ISIS is short for

"Islamic State in Iraq and Syria," or "Islamic State of Iraq and al-Sham," which is an old

Arabic term for the area (Vultaggio, 2015).

Line-by-line Coding: Researchers define line-by-line coding as naming each

line of written data (Charmaz, 2006). Line-by-line coding assists researchers to

“remain open to the data and to see nuances in it” (Charmaz, 2006, p. 50).

Mild Traumatic Brain Injury: A person who has had a traumatically induced

physiological disruption of brain function as manifested by loss of consciousness, loss of

memory, alteration in mental state, neurological deficit, and loss of consciousness for 30

minutes or less (Chang et al., 2011).

Movement Therapy: Is the rehabilitative approach designed to reduce

incapacitating motor deficits in patients after a neurological injury, increase their

functional independence and facilitate neuronal development to access executive

functions in the brain (Shaw et al., 2005, p. 770).

Neurogenesis: Is the increase neural cell growth? (Wei et al., 2014).

Neuromuscular Memory: Process of neuromuscular system memorizing motor

skills (Chang et al., 2011).

Neuron: Is basic unit of the nervous system (Chang et al., 2011).

Neuropathways Development: Connects one part of the nervous system with

another and usually comprises bundles of elongated, myelin-insulated neurons, known

collectively as white matter (Chang et al., 2011).

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Neuroplasticity: Physiological changes of the nervous system, due to changes in

behavior, environment, and neural processes, and cortical remapping in response to

injury. Neuronal stimulation through cognitive exercises and exercise therapy facilitates

brain recovery (Vance et al., 2010).

Neurotrauma: Injuries to the central nervous system resulting in traumatic brain

injury, especially part of the brain and spinal cord, include severe neurotrauma which can

be a serious medical emergency and leads to paralysis, brain damage, and death (Center

for Neuro Skills, 2012).

Physical Activity: The planned, structured, and repetitive bodily movement done

to improve or maintain a component of physical fitness. This activity is exercises such as

swimming, tai chi, and walking (King, 2006, p. 27).

Tai Chi Chuan: A Chinese system of slow, meditative physical exercise

designed for relaxation, balance, health, and which stimulates cognitive function by

increasing neuronal connection in the brain (Chang et al., 2011). TCC is the

national exercise in China and provides a sense of well-being and social connection

in a group setting.

Textural-structural Description: Textural-structural description of the

meanings and essences (the “whats” and “hows”) of the experience are developed

by incorporating the invariant constituents (relevant codes) of each participant

and by company type and the population served (Moustakas, 1994).

Transtheoretical Stages of Change: A theory of change that includes five stages

of which an individual will progress. The stages are pre-contemplation, contemplation,

preparation, action, and maintenance (Rooney et al., 2007; Bowles, 2006).

17

Treatment: Stabilizing an individual and minimizing secondary injury and life

support after a traumatic brain injury. Treatment can encompass physical exercise,

cognitive behavioral therapy, and psychopharmacology (Reis et al., 2015).

U.S. Army Wounded Warrior Program (AW2): On April 30, 2004, the Army

introduced the DS3 initiative to provide it's severely physically challenged soldiers and

their families with a system of advocacy and follow-up with personal support to assist

them as they transition from military service to the civilian community. On November

10, 2005, the Disabled Soldier Support System (DS3) officially became the U.S.

U.S. Department of Veterans Affairs Seamless Transition Program: This

Department of Veterans Affairs (VA) website is for returning active duty, National Guard

and Reserve service members of Operations Enduring Freedom and Iraqi Freedom.

Significance of the Study

This study is a potential complementary therapeutic approach for treating service

members and veterans with mTBI. Medical care for service members and veterans with a

TBI is a significant concern for the military, Veterans Administration, and contracted

civilian health care providers. The increasing involvement of U.S. Forces in deployment

operations calls for the need for an innovative and affordable health care approach to

address the myriad facets of recovery. TCC as an exercise intervention will benefit

victims of neurotrauma and facilitate the integration of domestic support systems.

Implementing TCC as a complementary intervention is necessary for several

reasons. First, this research is a personal experience of using TCC as a therapeutic

intervention.

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TCC is not contraindicated with other therapeutic therapies such as cognitive

behavior and dialectical behavior therapies. The practice of TCC complements

conventional medical and psychotherapies without the possibility of harm. Conjointly,

TCC is a low cost and portability allow for implementing an exercise program in austere

environments such as predeployment and deployment conditions. TCC is a consequential

holistic augmented treatment to treat service members and veterans with mild traumatic

brain injury.

Summary

The purpose of this research was to examine and better understand the

psychosocial reintegration of veterans with mild traumatic brain injury through the

physical activity of Tai Chi Chuan. Mild Traumatic Brain Injury (mTBI) is a growing

concern with service providers who treat former service members returning from theaters

of operations who experience various forms of Neurotrauma. Physical movement such as

Tai Chi Chuan can augment evidence-based psychotherapy treatment modalities,

facilitate neuroplasticity, and develop preventive measures to help individuals manage

mTBI.

Mild traumatic brain injury is an emergent crisis plaguing familial systems,

medical facilities, the Armed Services, and veteran service providers. Veterans who

experience neurotrauma will show characteristics of degeneration affective and cognitive

abilities. Physical movement in the form of Tai Chi Chuan is an approach to facilitate

neuromuscular memory and neuropathways development in the brain. Research in

neuroplasticity is advancing evidence that the brain recovers and develops adaptive

strategies after a brain injury. Motor learning after TBI can be reacquired through

19

repetition. This research promotes recovery possibilities for individuals with mTBI and

provides an additional treatment modality for veterans and service providers (Adams &

Dahdah, 2016).

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CHAPTER TWO: REVIEW OF THE LITERATURE

Traumatic Brain Injury (TBI) is damage to the brain from an external or internal

event. TBI results from a violent blow that causes possible permanent or temporary

damage to cognitive, physical, and psychosocial functions associated with differentiated

states of consciousness. The definition of TBI varies dependent upon the physiological

circumstances of the brain injury patient (Yost & Taylor, 2013). Traumatic brain injury

is an insult to the brain caused by external events such as falls, vehicular accidents, and

assaults to the head. This often causes mild to severe damage to the brain (Bagalman,

2015). For veterans who served in an operational environment, the injury may derive

from improvised explosive devices, mortars, grenades, bullets, or mines (Bagalman,

2015). An acquired brain injury is a non-operational environment injury to the brain that

has occurred after birth such as stroke, brain tumor, hemorrhage, viral infection (e.g.,

meningitis, encephalitis or septicemia, and lack of oxygen to the brain; Headway, 2011).

MTBI is a new crisis plaguing familial systems, medical facilities, and the Armed

Services. A variant of injury-induced neurotrauma is Chronic Traumatic Encephalopathy

(CTE) and TBI. For example, service members who experience head trauma will present

characteristics of impaired affective and cognitive abilities. The presentation of memory

loss and depression manifests within hours or days of an injury (Nelson et al., 2015).

Patients range from infants to mature adults with experienced injury-induced

neurotrauma resulting from accidents and physical activity (Center for Disease Control,

2012).

MTBI is a growing concern for the VA Medical Centers and contracted medical

providers who treat service members returning from overseas deployments. Service

21

members experience multiple head injuries (CTE) and co-occurring conditions such as

anxiety disorders (Chapman & Diaz-Arrastia, 2014). Holistic augmented treatment

approaches to mitigate mild TBI warrants more research to improve and develop

preventive measures to help patients manage mild TBI symptoms.

Movement therapy in TCC is an approach used to facilitate neuromuscular

memory and neural pathways development in the brain. Research in neuroplasticity is

advancing evidence that the brain recovers and develops adaptive strategies after a brain

injury. The brain through the process of neuroplasticity will produce and increase

connections between neurons and promotes cognitive function. The body will access

other areas in the brain to compensate for degraded cognitive function (Marques et al.,

2016). Stevinson and Li (2010) argued that motor skills could be reacquired through

practice after a traumatic brain injury. This research promotes recovery possibilities for

individuals with mild TBI.

For example, athletes who compete in sports such as football, soccer, and boxing

will present characteristics of impaired affective and cognitive abilities. The presentation

of memory loss and depression manifests within hours or days of an injury (Nelson et al.,

2015). Patients range from infants to mature adults with experienced injury-induced

neurotrauma resulting from accidents and physical activity (Center for Disease Control,

2012).

The concern results from timely access to treatment, identification, and evaluation

of the brain injury, treatment, and enough clinicians to provide services (Bagalman,

2015). Service members, who become veterans, experienced multiple head injuries and

comorbid conditions such as anxiety disorders (Chapman & Diaz-Arrastia, 2014).

22

Complimentary treatment approaches such at TCC to mitigate mild TBI warrants more

research to improve and develop preventive measures to help veterans manage mild TBI

symptoms.

Movement therapy in TCC facilitates cognitive stimulation, physical activity, and

social interaction. For example, the physical activity of TCC increase neural cell growth

(neurogenesis), the growth of blood vessels (angiogenesis), and reduce brain

inflammation. The added benefit of TCC practice is improved neuromuscular memory

and neural pathways development in the brain (Chang et al., 2011).

Research in neuroplasticity is advancing evidence that the brain recovers and

develops adaptive strategies after a brain injury. Neuroplasticity is a physiological

change in the neuronal pathways and synapses due to changes in behavior, the

environment, and neural processes in response to injury. Neuronal stimulation through

cognitive exercises and exercise therapy facilitates brain recovery (Vance et al., 2010).

Traumatic Brain Injury (TBI) is damage to the brain from an injury caused by an

external or internal event. TBI results from a violent blow that causes possible

permanent or temporary damage to cognitive, physical, and psychosocial functions

associated with differentiated states of consciousness. The definition of TBI varies

dependent upon the physiological circumstances of the brain injury patient (Yost &

Taylor, 2013).

Mild traumatic brain injury is an emergent crisis plaguing familial systems,

medical facilities, the Armed Services, and sports organizations. Variants of injury-

induced neurotrauma are Chronic Traumatic Encephalopathy (CTE) and TBI. For

example, athletes and service members who experience head trauma will present

23

characteristics of impaired affective and cognitive abilities. The presentation of memory

loss and depression manifests within hours or days of an injury (Nelson et al., 2015).

Patients range from infants to mature adults with experienced injury-induced

neurotrauma resulting from accidents and physical activity (Center for Disease Control,

2012). Figure 5 illustrates the movements in the Yang Style Family Form TCC in

Appendix P.

The literature on TBI is broad and encompasses many areas in which to focus a

research topic. This annotated literature review frames and focused the discussion on

treating mild TBI utilizing TCC as a treatment modality. The literature review addressed

the topics of Mild TBI, Tai-Chi Chuan, Impact of Clinical Care, Self-management,

Mechanism of Injury, Neurobiology of Mild TBI, Neurological Function, and

Effectiveness of Tai-Chi Chuan.

The focus of this study was to ascertain to what extent therapeutic perception,

therapeutic engagement, and therapeutic group therapy (TCC) contribute to and or

facilitate the familial reintegration of individual military veterans suffering from Mild

Traumatic Brain Injuries (MTBI). MTBIs can sometimes produce certain symptoms that

engender self-imposed social isolation from family and friends. The study explored

whether military veterans suffering from Mild Traumatic Brain Injuries (MTBI) believe,

conclude, and/or demonstrate that “Tai Chi Chuan” facilitate veteran’s health and e-

integration into family life and psychosocial environments. Also, this study aims to

understand if, how, and if to what extent the intervention of TCC works to regulate the

symptoms that may be experienced by military veterans because of suffering from a TBI

or sometimes, multiple TBIs because of multiple deployments.

24

This study employed multiple theorists, including Blau (1960), Erikson (1997),

Henry (2006), Hinojosa and Hinojosa (2011), Tajfel and Turner (1979), and Yalom

(1995). Their theories were applied to the accumulated study data to better analyze any

psychosocial and cultural presentations of veterans with mTBI. The resulting data may

then provide a guide to mental health therapist's attempts at addressing veteran MTBI

presentations and guide the intervention of TCC in later group settings.

Moreover, the researcher used the theories of Blau (1960), Erikson (1959), Henry

(2006), Hinojosa and Hinojosa (2011), Tajfel and Turner (1979), and Yalom (1995), and

the noted conceptual framework diagram to guide this research. The researchers/authors’

theoretical perspectives provided a structure that enhanced an understanding of

presentation and relationships among the theories as they related to the mild traumatic

brain injury and individual veterans with mild traumatic brain injuries.

Tai Chi Chuan Psychosocial Reintegration Theory Cycle

Veteran Participants

Veterans with MTBI volunteer to engage in TCC as a therapeutic modality to

address social isolation. The literature reports that former service members self-isolate

after an experience with neurotrauma such as mild traumatic brain injury. Co-occurring

conditions such as Post Traumatic Stress Syndrome worsen social isolation and cause

stress on the psychosocial systems (Yost & Taylor, 2013).

25

Figure 1. TCCPRT Cycle.

The TCCPRT uses the veteran's previous military service expressed values and

ideas to encourage self-improvement. These core values from each branch of the military

can serve as a motivator to improve and manage their MBTI. The following are

examples of the few core values part of the veteran's schema and an integral part of

military service in Table 1 (Pinkney, 2016).

Table 1

Military Core Values by Service Branch Army Navy Air Force Marines Coast Guard Honor Honor Integrity Honor Honor

Personal Courage

Courage Service before self

Courage Respect

Integrity Commitment Excellence Commitment Devotion Duty

Respect Note. Source: http://www.mentalhealth.va.gov/communityproviders/docs/values.pdf

Tai Chi Chuan Psychosocial Reintegration Theory Cycle (TCCPRT)

The theme that can contribute to veterans participating in a TCC therapeutic

intervention is personal responsibility. Each branch of the military expects and reinforces

26

the value of personal responsibility. The value of personal responsibility is generalized to

the overall population of service members. The researcher knows that any human social

system that includes patterned series of interrelationships existing between individuals,

groups, and institutions and forming a coherent whole will have outliers.

For this study, "Personal Responsibility" is a volitional choice to understand,

accept, and live by personal and societal standards and not search for factors outside

oneself to blame. The researcher adopted this definition from military core values, life

experiences, and personal philosophy to navigate through lifespan developmental

process. Lifespan development is the physical and cognitive changes that occur

throughout a person's life (Santrock, 2012).

Tai Chi Chuan Psychosocial Reintegration Theory (TCCPRT)

Tai Chi Chuan Psychosocial Reintegration Theory is a synthesis of six theories

including: Social Integration Theory Blau (1960), Psychosocial Development Theory

(Erickson, 1959), Theory, Traumatic Brain Injury (Henry, 2006), Family Reintegration

(Hinojosa & Hinojosa, 2011), and Social Identity (Tajfel & Turner, 1979), and Group

Theory (Yalom, 1995). Each theory was discussed and relevant portions highlighted as

to reflect perceived impact on veteran reintegration post-Mild Traumatic brain injury.

TCCPRT posited that TCC addresses three aspects of MBTI: (a) cognitive

stimulation, (b) physical activity, and (c) social interaction. Cognitive stimulation for this

study is defined as an activity providing general stimulation for thinking, concentration,

and memory, usually in a social setting such as a small group (Hannan, 2014). Physical

activity for this study requires body movement that works your muscles and requires

more energy than resting (Ward, 2014). TCC is an example of physical activity. Social

27

interaction is the process of an individual who understands their contextual dynamic,

internal representation, and generates an acceptable response (Nichols & Kosciulek,

2014).

The study focuses on the TCC as an intervention to facilitate improving veteran's

social interaction in a group environment. An exercise group activity such as TCC

resembles the veteran's daily physical fitness route when they served in the military.

Social identification and social support are essential to group participation and

engagement.

The importance of improving social skills is part of a group dynamic in

supporting individual participation in TCC practice. Social skills are defined as

behavioral presentations that facilitate interaction and communication with others

(Vygotsky, 2014). TCC Group therapy (close group) inherently creates social rules,

social relations, willing communication, and trust within the group. Learning these skills

is called socialization or called group cohesion in the group therapy context (Yalom,

1995).

Benefits of TCCPRT in a Group Setting

Groups can act as a support network and a sounding board. Members of the

group often help you come up with specific ideas for improving a difficult situation or

life challenge and hold you accountable along the way. Social interaction and listening

can help others in managing their perspective. Veterans with MBTI experience mental

health challenges, but few speak openly about them to people they do not know well. It

can be a cathartic experience to hear others veterans discuss what they are going through,

and realize you are not alone (APA, 2016).

28

TCCPRT Theories

Social Integration Theory

According to Blau (1960), Social Integration Theory is the connections and

similarities that unite members of a group. His researched this interaction with the status

and power structure of the group. Status and power structure of a group are flows of

advice, esteem, and reputation (Blau, 1960). Veterans who share a common experience,

training and values that create camaraderie is an example of social integration theory.

Psychosocial Development Theory

According to Erikson (1997), psychosocial development is a psychoanalytic

theory that encompasses eight stages of development from infancy to late adulthood.

Healthy develop occurs when the individual transition through each stage by mastering

challenges within each stage. Social skills are developed to negotiate challenges in the

next psychosocial development stage. Veterans with MBTI with challenges in Stage 5

(Intimacy vs. Isolation) can learn skills to move the individual from isolation to intimacy.

This is an example of Erickson (1997) theory can be applied to TCC group therapy.

According to Erickson (1997), there are eight stages of development. The

Psychosocial Stages of Development are in Appendix TBD. The veteran's age of MBTI

occurrence, determine the stage of psychosocial development. TCCPRT suggest that

returning veterans with MBTI present have arrested development at Stage 5 and Stage 6.

Arrested development is being anchored to an emotional state of development

from a life experience. The results are negative beliefs that engender an internal dialogue

such as "I am not good enough," and " No one understands me." This is a form classical

29

conditioning behavior called anchoring (SAMSHA, 2014). MTBI is one such anchor that

cause challenges for veterans

Anchors are learning that derive from a single learning experience. One defining

moment is such at MBTI that creates the anchor in the subconscious. The learned

response is repeated and conditioned while creates behavioral patterns for the individual

(SAMSHA, 2014). TCCPRT can address these stages and facilitate strategies to

reintegrate the veterans with MBTI into a psychosocial environment such a familial unit.

Traumatic Brain Injury Theory

According to Henry (2006) and McCall (2016), traumatic brain injury is a

primary or secondary disorder to executive function impairment (EFI). Executive

function impairment has been acknowledged as a deficit in cognitive capacity and can

lead to challenges in social functioning (McCall, 2016). There is evidence that MTBI is

associated with changes in social relationships and considered distressing and disabling

aspects of MTBI (McCall, 2016).

Importantly, McDonald, Flanagan, Martin, and Saunders (2004) found that

interviews with TBI participants indicated deficits in social behavior and social

interaction. The research suggests that more attention should be focused on assessment

of social and emotional problems. There is a need to further inquiry on the link between

MBTI, executive function, and social reintegration.

Family Reintegration Theory

According to Hinojosa and Hinojosa (2011), the role of social relationships in

health outcomes is an area of growing research importance. The Veterans Health

Administration (VHA) has encouraged research programs that explore the role of family

30

members in veterans’ health outcomes, particularly after the deployed veteran has been

away from the family for an extended time. The research shows that contentious post-

deployment interactions with family members are linked to poor mental health outcomes.

Veterans with supportive familial seem to protect against mental health problems.

Family therapy has been shown to improve returning veterans’ mental health outcomes

(Hinojosa & Hinojosa, 2011). Post-deployment family reintegration literature focuses on

the family’s role in helping the veteran transition from military service to civilian life.

Returning veterans cited that family members who service in an operational environment

could be an impediment to psychosocial reintegration (Hinojosa & Hinojosa, 2011).

There is a need to continue to research and address this concern to produce favorable

outcomes for veterans with MTBI.

Social Identity Theory

According to Tajfel and Turner (1979), social identity theory explains that part of

a person’s concept of self comes from the groups to which that person belongs. An

individual has identities associated with their affiliated groups. A person might act

differently in varying social contexts according to the groups they belong. This is called

code switching which permits the individual to function within a specific social context.

Another phenomenon is the concept of in-group and out-group (IGOG). IGOG is

an affiliation mindset of individuals who perceive themselves as part of a group. The

adaptive process is multi-facet that includes acceptance, fitting in, success, and survival.

There are advantages to understanding the concept of IGOG as it applies to social

interaction (Pinkney, 2016).

31

According to Tajfel and Turner (1979), Social Identity Theory has three cognitive

processes that define an individual's social identity. They are Social Categorization,

Social Identification, and Social Comparison. Their hypothesis suggests that individuals

have an inherent drive to belong to a group or social system. Affiliation with a social

system depends upon the individual identity, perceived benefit, or survival. Individuals

not part of the elite in-group are an out-group member. The same cognitive processes for

the same for the in-group and out-group. The following are examples of in-group and

out-group social identification: ISIS and the United States, Kurdistan and Turkey, and

India and Pakistan. Each group is engaged in armed conflict and detention based upon an

ideology and their social identity.

Social categorization is a term used by people to understand and identify

themselves. Some examples of social differentiation are psychosocial categories such as

race, class, engender, and political affiliations (e.g., black, white, professor, student,

Republican, and Democrat). By identifying social affiliations, the individual can

understand himself or herself, and define behavior acceptable to the group. An individual

can belong to several groups simultaneously (Tajfel & Turner, 1979).

Social identity is the ability to adopt the identity of the group we belong to, and

we behavior in ways expected and accepted by the members of that group. For example,

if you identify as a Democrat, you will most likely behave within the norms of that group.

As a benefit of your identification with that group, you will develop emotional

significance to that identification, and your self-esteem will depend on it (Tajfel &

Turner, 1979).

32

Social comparison is categorizing and identifying ourselves as being members of

that group. The individual compares their group (the in-group) against another group (an

out-group). To maintain self-esteem, the individual and group members will compare the

group favorably against other ones. This helps explain prejudice and discrimination since

a group will view members of competing groups negatively to increase self-esteem

(Tajfel & Turner, 1979).

Intergroup comparison is comparing an in-group to an out-group, as mentioned

above. Members of an in-group favor the in-group over the out-group. The goal is to

maximize the differences between the in-group and the out-group. The group will

maintain that the groups are distinct if a person is favoring their group over the other.

The group dynamic minimizes the perception of differences between in-group members

and increases in-group cohesion (Tajfel & Turner, 1979).

The Interpersonal-Intergroup Continuum

Another main aspect of social identity theory is its explanation that social

behavior falls on a continuum that ranges from interpersonal behavior to intergroup

behavior. Most social situations will call for a compromise between these two ends of

the spectrum. As an example, Tajfel and Turner (1979) suggested that soldiers fighting

an opposing army represent behavior at the extreme intergroup end of the interpersonal-

intergroup spectrum.

Group Therapy

According to Yalom (1995), group therapy and counseling emphasize members of

the group learn from each other in an environment that accentuates the present moment.

The group therapy environment offers feedback and perspective of individual distortions

33

and an opportunity to engage in therapeutic remediation. Members of the therapy group

share as a foundation for interpersonal, intrapersonal learning, and a vehicle for change

(Yalom, 1995).

Yalom (1995) promoted 11 factors that facilitate the process of change in group

therapy. The factors are indicators that contribute to enhancing the quality of life for an

individual and participants in the group. The interaction of the factors creates a group

environment that contributes to the growth and improvement. For example, two-factor

interpersonal learning and cohesiveness encourages a sense of belonging to the group.

Seven factors motivate participants to consider a change in their behavioral presentation.

The remaining two factors provide an opportunity to reframe the life experience and

consider empower alternatives (Yalom, 1995). The 11 factors are delineated and detailed

in Appendix TBD.

Tai Chi Chuan Psychosocial Reintegration Theory Symbols Reintegration Indicator A (RI-A) Traumatic Brain Injury Henry (2006) Key Terms Theory of Mind Emotional Identification Executive Function Reintegration Indicator B (RI-B) Psychosocial Development Erickson (1959) Key Terms Ego Identity Identity Crisis Unfinished Business Reintegration Indicator C (RI-C) Social Identity Theory Tajfel and Henry (1979)

34

Key Terms Categorization Social Identity Social Comparison Reintegration Indicator D (RI-D) Group Theory Yalom (1995) Key Terms Interpersonal Learning Cohesiveness Reintegration Indicator E (RI-E) Social Integration Blau (1960) Key Terms Social Position Social Status Reintegration Indicator F (RI-F) Family Reintegration Key Terms Emotional support Family reintegration Social support Tai Chi Chuan Psychosocial Reintegration Theory Cycle (TCCPRT) Figure 2. Process of which participant navigation social interaction in a group setting.

Explanation of TCCPRT Cycle

The TCCPRT cycle is assessing and evaluating an individual for participation in

TCC group therapy. Each step of the evaluation process RI-A through RI-F determines

RI-A RI-C

RI-D RI-E

RI-F RI-B

RI-A RI-C

RI-D RI-E

RI-F RI-B

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the individual state of psychosocial reintegration to participate in therapy and their ability

and willingness to participate in group therapy and connect with the family system.

Tai Chi Chuan Intervention

Figure 3. Process of participant engaging in changing behaviors in a group setting.

Explanation of TCC Intervention

TCC intervention is an exercise modality to treat MTBI in a group setting. There

is an initial and periodic assessment of the individual stage of reintegration based upon

the TCCPRT Cycle. RI-A is an assessment of the effect MBTI through the participants

self-report. RI-B is the behavior presentation stage of psychosocial development. RI-C

is an assessment of how the participant self-identity with the social environment. RI-D

assesses the participant's readiness to engage in group therapy. RI-E reflects participation

in group therapy. RI-F is the desired outcome of the participant reintegrating into the

family system. Success outcomes are predicated on the participant's ability and

willingness to change.

According to Prochaska and Decremented (1983), Transtheoretical Model of

Change (TTM) describes the steps of individual change. TTM is an integrative,

biopsychosocial model to conceptualize the process of intentional behavior change. The

theories of TCCPRT and tailoring TTM can be applied to behavioral presentations of

RI-D

RI-A RI-C RI-D R

RI-F RI-B

RI-A RI-C RI-B

RI-E

RI-F

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MTBI. TCCPRT addressed the psychosocial aspect of familial reintegration and

accommodate the participant's recycling or fear escape through the TCCPRT Cycle.

Fear escape is a normal response of participants involved in the change process.

Fear escape is the participant's ambivalent, fear of the change process, and need for

catharsis through avoidance (Pinkney, 2016). The researcher created this term from life

experiences, doctoral education, and theoretical orientation to facilitate clients navigating

through lifespan developmental process. The tailoring of the TCCPRT can accommodate

a participant's ambivalent if the need arises. Using Motivational Interviewing will be

aspect screen process to select participants for the TCC therapeutic intervention.

Mild Traumatic Brain Injury

Mild TBI

TBI is defined as a variant of neurotrauma resulting from external and internal

events to the brain. TBI is a disruption of neurotransmitter activity that affects

physiological and psychological functions of the brain. Accidents, intracranial pressure,

and sporting activities contribute to the incidents of TBI reported by medical facilities

(Bruns & Jagoda, 2009).

A few recent studies of mild TBI are based on Bruns and Jagoda’s (2009)

research on emergency room incidents of mild TBI in the United States. Clinicians have

found mild TBI as a subgroup of TBI. Associated risks of cognitive degradation are

prevalent among TBI patients resulting from a traumatic event to the brain. The

Department of Defense and Veterans Administration has identified TBI as a frequent

injury among service members and veterans.

37

Returning service members and veterans are experiencing a new asymmetric war.

This conflict is not against a human assailant. The battle for these brain injury patients is

health concerns and social reintegration. Service members and veterans are not familiar

with this adversary. Health and social reintegration challenges resulting from TBI is an

unexplored landscape and engenders challenges for the medical and social supports

systems.

Advanced and formidable tools are available to treat service-related TBI. These

treatments include behavioral therapy, exercise therapy, and neurological therapeutics.

Exercise therapy such as TCC is an example of a complementary approach used to

mitigate conditions of mild TBI. TCC as a treatment intervention is creating an interest in

the therapeutic community.

Tai Chi Chuan

TCC is a Chinese Martial Art considered as the Grand Ultimate Fist (Reb et al.,

2016). TCC is one of four internal systems of the Chinese Martial Arts system. Wu Shu

is known in the United States as Kung Fung. Experienced practitioners of TCC defined

the martial art as meditation in motion. The practice of this system of Martial Arts

develops balance, coordination, focus, and strength. TCC as an exercise intervention

combined with traditional therapeutic treatment that improves emotional well-being and

eclipses sadness, confusion, anger, tension, and fear. TCC has been the subject of an

investigation to ascertain the efficacy as a treatment modality for mild TBI.

A succinct review of the literature suggests that TCC has therapeutic value in

treating mild TBI Psychometric instruments such as the Medical Outcome Scale,

Rosenberg Self-esteem Scale, and the Visual Analogues Scale measures a participant’s

38

medical condition, self-esteem, and emotional states before and after participating in a

TCC therapeutic intervention program. TCC participants experienced improvement

general health, self-esteem, and mood at the end of the program. These positive

outcomes suggest that TCC affects the clinical care of participants (Blake & Batson,

2009; Gemmel & Leathem, 2006).

Impact on Clinical Care

Physical trauma is one component of treating patients. Comorbid conditions such

as anxiety disorders are prevalent in TBI patients. Post-traumatic stress disorder (PTSD)

is also associated with service members and veterans. Mild TBI is the signature injury of

returning service members and veterans who served in Iraq and Afghanistan (West et al.,

2011; LaDue, 2009). The Veterans Administration Medical Center has determined that

comorbid conditions of mild TBI and the cluster of anxiety disorders associated with

mild TBI are clinically challenging. The significant rates of mild TBI and PTSD have

economic and financial implications of long-term health options for patients (Nelson et

al., 2015).

Cost and benefit are the first consideration prior to implementing the therapeutic

intervention. A cost-benefit analysis is conducted to ascertain the return on investment

(ROI) because of declining budgets and limited staff. The benefits of an intervention

depend on an outcome analysis, patient improvement, and sustainability. The benefits of

instituting a program must be economically and financially feasible to justify the

expenditure. Interventions that facilitate a patient’s self-care, self-management and

reduce cost legitimizes an agency’s decision to implement a therapeutic intervention.

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Self-management for Mild TBI

Reis et al. (2015) research topic Recovery from brain injury: Finding the missing

bits of the puzzle offers a perspective on patient recovering from TBI. Patients develop

cognitive constructs of their experiences to manage life challenges after a brain injury.

The researchers postulate that the client’s identity is fragmented after a TBI. The

reintegration of the sense occurs when the client assembles aspects of self and form a

homogeneous identity (Reis et al., 2006).

Reis et al. (2015) ascertained that participants developed common themes relevant

to their experience. Patient’s themes were related to finding a part of the puzzle, filling in

the holes of memory, and redefining the self. Patients differentiated in their recovery as a

function of self-protection during earlier stages of rehabilitation. Patients were motivated

to answer questions to create a favorable assessment (Reis et al., 2015). For example,

patients who participate in therapy engaged in perception management to minimize the

reasons for attending therapy. There is a propensity to influence the opinion of

individuals when a power differential is present. The therapeutic relationship between

TCC instructor and the patient would be an example of a power differential.

Mechanisms of Injury

Contact and inertial injuries are two biomechanical effects related to TBI. A

contact injury occurs when an event causes the brain to strike the inner cavity, and this

disrupts cranial activity. An inertial injury is an acceleration (falling) and deceleration

(cessation) of movement. When a cranial movement exceeds the brain’s tolerance to

absorb the event, this results in an injury to the brain. There is a cellular response to a

40

TBI event, and the resultant response is the release of neurotransmitters (McAllister,

2011).

The mechanisms of injury (contact and inertial) create cellular events that disrupt

the activity of the brain at the cellular level. For example, calcium enters the damaged

cell and accelerates the release of neurotransmitters (McAllister, 2011). Four of 10

neurotransmitters are Dopamine, Epinephrine, Norepinephrine, and Serotonin. Each

neurotransmitter has an exclusive function to regulate brain activity and is an integral part

of the brain’s neurobiology (McAllister, 2011).

Relationship of Neurobiology to Mild TBI

TBI affects the cognitive functions of the brain and contributes to PTSD. Trauma

to the head produces a diverse range of symptoms and neurobiological effects because of

neurostructural changes in specific areas of the brain such as the corpus callosum,

prefrontal cortex, amygdala, and hippocampus (Weber & Reynolds, 2004). Physical

damage to these areas of the brain leads to a functional disruption of brain activity and

causes psychiatric challenges for the patient (Mathias, Beall, & Bigler, 2004). The

researchers suggested limited information is the correlation between cognitive

impairment and behavioral health (Mathias et al., 2004).

There is substantial psychological and neurobehavioral evidence available to

support that TBI is a risk factor for psychological disorders. The outcome of a brain

injury will cause a predisposition, susceptibility, and vulnerability to cognitive

impairment. Service members and veterans with TBI experience anxiety disorders,

depression, and personality disturbances resultant from their tours of duty in Iraq and

41

Afghanistan. Physical, affective, and cognitive components are areas that need attention

when addressing the neurobiology of TBI.

Physical Symptoms

The physical symptom of TBI includes a headache, dizziness, neck pain, sleep

deprivation, and visual difficulties (West et al., 2011; LaDue, 2009). Physical complaints

result from the mechanism of injury. Patients with mild TBI represented are 36% of all

TBI patients. Physical symptoms manifest as problems with movement, gait, gross motor

movement, and fine motor movements are more prevalent with severe TBI compared to

those with a milder injury. Patients with mild injuries do not have movement disorders

noticeable to themselves or new service providers.

Mild TBI patients were identified with impartment in oculomotor and visuomotor

measures up to one year following mild TBI. This suggests that methods used to assess

physical symptoms and limitations following even mild injury are not being sensitive

enough to detect subtle symptoms. Mild TBI assessment and questionnaires need

additional refinement to detect problems with movement and balance that could lead to

further injury (West et al., 2011; LaDue, 2009).

Affective Symptoms

Mild TBI patients experience affective symptoms like depression, anxiety, and

stress (West et al., 2011; LaDue, 2009). The citizenry is not knowledgeable of these

symptoms. Information about the possibility of experiencing this symptom should be in

the management of patients with mild TBI. Depression in post-TBI patients is described

as a combination of neuro-anatomic, neurochemical, and psychosocial factors (West et

al., 2011; LaDue, 2009). Depression is associated with post-injury stress and sense of

42

belonging and with pre-injury psychosocial factors as employment, living situations, and

previous psychological treatment (West et al., 2011; LaDue, 2009).

Emotional symptoms as irritability, mood changes, anxiety, and stress are

common among injury groups with post-TBI conditions. West et al. (2011) and LaDue

(2009) reported irritability (56%) and anxiety (51%) are among the top five symptom

complaints in their mild TBI population. They found a significant relationship between

symptom frequency and tens*-ion-anxiety, anger-hostility, and perceived stress among

the community sample of mild to moderate post-TBI patients. Rates of PTSD for

patients with mild TBI range from 12-39%, compared to soldiers returning from duty

without mild TBI possessing 11% prevalence of PTSD. Affective symptoms are

common following mild TBI (West et al., 2011; LaDue, 2009).

In summary, affective symptoms such as depression and PTSD affect symptom

reporting. Both depression and PTSD should be measured and considered in mild TBI

research. Management of affective symptoms is important for patients to return to pre-

injury roles. Depression and PTSD are associated with a signification degradation of

function and quality of life. There is a relationship between the cognitive presentations

of depression and PTSD. Given the research on these conditions, they can serve as

predictors to in functional outcome and HRQoL. The cause-effect relationship between

depression and/or PTSD and impaired functional outcome and HRQoL should be further

investigated, and predictors of depression and PTSD to ameliorate early diagnosis and

treatment (Haagsma, Scholten, Andriessen, & Polinder, 2014).

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Cognitive Symptoms

The cognitive symptoms of TBI are memory loss, attention, concentration,

problem-solving, and executive functioning. Executive functions in the brain are

processed by the frontal lobes. This part of the brain decides what information,

cognitions, or stimuli are relevant. An injury to the brain degrades the patient’s

capability to manage information and execute decisions (Giola, Isquith, Guy, &

Kenworthy, 2000). Pervasive cognitive impairments are prevalent with patients who

experience severe TBI. The same symptoms are generalized and present in patients with

mild TBI injuries (West et al., 2011; LaDue, 2009).

Cognitive impairment has social ramifications for patients with TBI.

Neurological assessment and testing provide a baseline of these potential impairments.

Clinicians know of the challenges and concerns of TBI patients. Self-management tools

for patients to mitigate cognitive impairment include traditional and alternative therapies

such as psychotherapy and mindfulness. Given the increase in mild TBI patients,

additional approaches warrant research and implementation.

Effectiveness of Tai Chi Chuan

The research of Blake and Batson (2009) and Gemmell and Leathem (2006)

suggested that TCC is a safe form of exercise to improve balance and mobility. TCC

strengthens the muscular and skeleton structure of participants engaged in continuous

practice beyond the initial exposure of this exercise intervention. Evidence-based

research confirms that 15% of patients with mobility devices discontinue use of these

devices during indoor activity. TCC is a recreational activity, and this perception

facilitates participation over traditional exercise routines (Blake & Batson, 2009;

44

Gemmell & Leathem, 2006). Research is ongoing to ascertain the efficacy of using the

TCC as an exercise intervention to treat mild TBI patients.

Importance of Topic

The statistics related to TBI support the importance and benefit of studying this

topic. For example, the Center for Disease Control (2012) estimated the medical cost of

brain-related injury was 76.5 billion dollars between 2002 and 2006. The Center for

Disease Control (2012) states 1.7 million people sustains a TBI each year. Seventy-Five

percent of TBI are the mild variations of TBI. Adults over the age of 75 account for the

highest rate of TBI. Mild TBI impairs individual cognitive functioning and psychosocial

interactions. Disrupting cognitive function and social intelligence suggests that mild TBI

is a challenge for individuals who desire to reintegrate into the societal mainstream

(Center for Disease Control, 2012).

TBI has become a signature affliction for service members and veterans who

served in Iraq and Afghanistan. TBI differentiates in the level of severity, from mild to

pernicious and engenders neurological deficits. There are physical, psychological, and

social ramifications from mild TBI to severe TBI.

Veterans with mild TBI experience health conditions such as headaches,

depression, anxiety disorders, cognitive deficits, and Meniere’s disease. As this

population with neurotrauma increases, the VA medical system is exploring innovative

approaches to treating and manages TBI complications. According to Yost and Taylor

(2013), the Department of Defense is sponsoring research to study complementary and

alternative therapies to treat TBI. TCC is a complementary therapy that shows promise

45

for its effects on a medical condition such as anxiety, balance, hypertension,

neuropathway development, and stress.

TCC is a form of Chinese medicine used as a health promotion invention since its

origins in India. TCC movement focuses a practitioner’s bioelectrical field by slow,

routinized movement, diaphragmatic breathing, and meditation. The practice of TCC can

benefit health and improve the quality of life.

Gaps in the Literature

A succinct review of the literature revealed an absence of studies on the utility

and feasibility of the adoption of TCC practice as a therapeutic model. According to

Klein and Adams (2004), needed research is on exercise adherence, exercise compliance,

and financial analysis regarding implementing TCC in treating mild TBI. The financial

investment in an exercise program must be evidence-based and demonstrate: (a) cost

reduction in treatment, (b) positive outcomes for participants, and (c) utility for

participants after the exercise program. Cost is a prime consideration when selecting an

intervention by an agency treating mild TBI.

For example, the direct cost of a TCC Exercise Program based on two one-hour

classes twice a week for one year is $9,000. The net saving to an institution is $1,274 in

the prevention of falls and other injuries. This analysis suggests that an exercise program

such as TCC is economically feasible, and has utility in a therapeutic setting. A financial

model to predict cost-effectiveness will facilitate an agency’s decision to implement a

TCC exercise program to treat mild TBI (Polito, Thompson, & Defina, 2010).

The traditional treatments such as cognitive behavior therapy, physical therapy,

and occupational therapy are the common therapeutic models to treat TBI. Evidence-

46

based research in alternative and complementary approaches has shown TCC’s ability to

optimize the therapeutic environment and achieve gains in assessment, and treatment of

mild TBI (Polito et al., 2010).

Summary

This literature review also focused on the efficacy of individual and group

practice and the financial aspects of TCC as a therapeutic intervention for mild TBI. The

argument that TCC practices in a group setting show promise is well documented. But

research must understand the sustainability of TCC practice in an individual setting. The

largest proportion of evidence supports the observation that participants will practice

TCC in an individual setting. Finally, there is no data to compare the efficacy of group

and individual practice. The growing acceptance of TCC will offer opportunities to

examine the benefits of in-group and home settings. Gaps in this literature warrant

additional research on TCC as an evidence-based exercise intervention to mitigate

cognitive degradation, cognitive recovery, and strengthen psychosocial interaction.

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CHAPTER THREE: METHODOLOGY

Research Design

The research method for this study is a qualitative descriptive phenomenological

analysis and method (Creswell, 2009; Moustakas, 1994). Phenomenological research has

its roots in the disciplines of psychology and philosophy. Qualitative methodology

describes a lived condition or experience. Phenomenological methods seek to understand

the application and efficacy of TCC as an intervention and treatment for mTBI. In

addition, both methodologies will ascertain the value of TCC in the psychosocial

reintegration of veterans with mild traumatic brain injury (Groenewald, 2004).

Creswell (2009), Groenewald (2004), and Moustakas’ (1994) qualitative

descriptive phenomenology is the appropriate methodology to ascertain the experiences

of veterans participating in TCC intervention. By using this methodology, a clear,

comprehensive baseline of the interest in using TCC as a therapeutic intervention to treat

mild traumatic brain injury can be ascertained and studied. Qualitative methodology,

phenomenology is the best fit in describing the experiences of veterans while engaging

in the TCC intervention. By using this methodology, a better understanding of the

interest in this intervention and any difficulties with practice, adherence, and any

perceived benefits could be ascertained. This information can tailor a larger qualitative

study geared towards uncovering improvements in psychosocial symptoms associated

with mild Traumatic Brain Injury (mTBI; Creswell, 2009; Moustakas, 1994).

Subjects

The researcher selected veteran participants for a qualitative descriptive

phenomenological analysis. Case studies are descriptive studies. They typically use one

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or two instances of an event to show or delineate a given a situation. Case studies

purpose is to make the unfamiliar familiar. This approach gives a reader a common

language about this research topic (Creswell, 2009; Moustakas, 1994).

The researcher selected veteran participants for this qualitative descriptive

phenomenological analysis through purposeful sampling. Purposeful sampling allowed

the selection of individuals and the location for this study. The veteran participants and

the site will improve the researcher's understanding of the research and similar

phenomenon within this research study (Creswell, 2009; Moustakas, 1994).

The research determined what factors were significant that affected veteran's

decision to engage in TCC as an alternative holistic augmented treatment for mTBI.

There were nine veteran participants from Vietnam, Operation Iraqi Freedom (OIF) and

Operational Enduring Freedom OEF). The veterans were recruited from veteran

organizations, Buckley Airforce Base, and referrals in the Denver Metropolitan area. The

Defense and Veterans Brain Injury Center were used as a resource for follow through

referral upon request. The DVBIC-Colorado Springs is one of nine civilian facilities (R.

Harris, personal communication, October 24, 20167).

This is part of the vast military and veteran network of care providers dedicated to

the treatment of brain injury. The DVBIC-Colorado Springs provides a community-

integrated brain injury rehabilitation program with a comprehensive evaluation,

outpatient therapy, vocational training, and innovative community re-entry services for

veterans (and civilians to a lesser extent) with acquired or traumatic brain injuries. All

components of the rehabilitation program are directed towards rebuilding life and work

skills as a foundation for restoring independence, fostering community participation, and

49

work re-entry. Veterans receiving treatment through DVBIC-Colorado Springs will live

in family-style houses or commute to the rehabilitation facility (R. Harris, personal

communication, October 24, 2016).

Veteran participants met six criterions. First was the veteran participant must

have experienced mTBI during active military service. Second, the veteran participant

applied or is receiving outpatient treatment for mTBI. Third, the veteran participants

were 18 years of age or older. Fourth, the veteran participant had a history of social

isolation from their social support system. Fifth, veteran participants should have had a

pending diagnosis of mTBI. Sixth, veteran participants should speak and understand

English and a willingness to discuss to veteran participants in the research study.

Instruments

The purpose of a qualitative descriptive phenomenological analysis is to gather,

conceptualize, understand, and interpret factors of veterans practicing TCC. The Brief

Traumatic Brain Injury Screen (BTBIS), questionnaire, interviews, and observations are

the instruments will fulfill the purpose of the study. The data collected in this process

were from nine veteran participants to achieve saturation, the researcher and questions,

and data collection procedures. Research questions were answered and conclusion

analysis based upon the purpose of this research.

The first instrument was the demographic questionnaire. The questionnaire is

nine open-ended questions to open a dialogue with the researcher. The questions are

framed to ascertain branch of service, veteran status, theater of operation, type of brain

injury, injury date, psychosocial impact, marital status, and gender identification.

50

The second question was the Readiness to Participant questionnaire. The

questionnaire ascertained background of the veteran participant's willingness to

participate in a non-polypharmacy treatment modality using TCC. The question queries

knowledge of traumatic brain injury, understanding of mild traumatic brain injury,

biopsychosocial awareness, self-efficacy, motivation, and level of engagement on a scale

of 1 to 10. The questionnaire was utilized as a screening tools determine if the veteran

participant wished to be part of the research study.

Third was the BTBIS. The BTBIS is a three question open ended self-report

screening tool. Each question had seven to eight response A through H available to the

veteran participant. Upon completion of the screening, the researcher determined the

severity of the brain injury. Also, the veteran and researcher determined if the additional

services were needed during the TCC Group Therapy.

Fourth was the interview process delineated in three separate interrelated

questionnaires on a rating scale from 1 to 10.

(1) The pre-interview phase that occurs before the veteran participant with the

TCC Group.

(2) The progress phase is an interview during the observation phase in the fourth

and fifth session.

(3) The post-interview phase is when the researcher interviews the veteran

participant and ascertain the benefits of the TCC therapy.

Although separate, these three phases are related. This meant the researcher developed

impressions that may have affected how they viewed the person in a later phase.

51

Fifth was the final questionnaire called the Tai Chi Chuan Psychosocial

Reintegration Model. The purpose of the TCCPRM was to determine the efficacy of the

model. The questions solicited feelings about TCC intervention, group interaction, social

interaction, connecting with social support systems, and willingness to connect with other

people.

The researcher knew of biases that may have manifested in confirmation, cultural,

question-order, leading questions, and halo effect biases. The researcher was cognizant

of researcher bias and was vigilant on how research bias manifests throughout the

research study. This was accomplished by asking questions at the right time, being

cognizant of the source of bias, and maintaining the standards of qualitative research

(Sarniak, 2015).

The researcher considered the respondent biases upon the researcher a product of

the Hawthorne Effect. The Hawthorne effect or observer effect is a type of reactivity in

which veteran participants adjust their behavior in response to their awareness of being

observed. This is challenging to control in a study. The biases presented itself as an

inability or unwillingness to response. The purpose is to influence the study for an

individual benefit (McCambridge, Witton, & Elbourne, 2014). The benefits to the

participants are social desirability and social acceptance.

This question was important due to the previous military officer status of the

researcher. Veteran participants will experience a power differential if they know of the

rank. The researcher addressed the biases by reflexivity throughout the research process.

This permitted the focus on the human elements of the research process driven from the

respondent and the researcher. Having an awareness of how the researcher’s previous

52

military status may have affected respondents. The potential impact that bias had on

qualitative research was managed.

Reflexivity assumes the researcher should be aware of his/her own contribution to

constructing meaning in the research process. It was a process that occurred throughout

the research and allowed the researcher to reflect on how bias may occur. The researcher

can acknowledge their background and beliefs can influence the way the research is

conducted (Mann, 2016).

According to Mann (2016), there are two reflexivities: personal and

epistemological reflexivity. Personal reflexivity involves reflecting on how factors such

as the researcher’s values, beliefs, interests, experiences, and political commitment have

influenced the research. It involves thinking about how the research has affected the

researcher. Epistemological reflexivity is thinking in how knowledge has been generated

in the study (Mann, 2016).

The interview was an important qualitative research tool in this research study. It

provided a means to ascertain traditional and alternative treatment for mTBI. The

interview allowed each veteran participant to reflect and provide information that

produced insight into the reasons veteran participants chose TCC as a treatment option.

The format of the interview was based on 28 questions that serviced a guide for

each veteran participant. This provided a forum to express their experience and thoughts

regarding the positive aspects of why they chose TCC. The 28 questions in three separate

interview were based on common themes found in a literature search regarding TCC and

traumatic brain injury (Zhu, Guan, & Yang, 2010). The themes included psychosocial

and culture variables. Although the research questions were pre-defined, additional

53

questions develop as the researcher and veteran participant's progress through the

interview process (Blake & Batson, 2009; Worth, 2016).

The second instrument was the researcher's observation of veteran participants

practicing TCC. Observation in context to the research question was unstructured. The

observation was purposeful to record physical and behaviors. Observations schedules

were predetermined using taxonomies developed from known theory. The observation

was based on the interpretive and constructivist paradigm that acknowledged the value of

context and construction of knowledge between the researcher and the veteran

participant. Observations included the training location, external and internal

accommodations such as parking, security access, and lavatories facilities.

Methodological Assumptions, Limitations, and Delimitations

Assumptions

Assumptions of this study included (a) all veteran participants provided honest

and accurate responses to the interview questions, and (b) the use of interviews and

observations were adequate forms of data collection to solicit information required to

analyze the perception and experiences of participants practicing TCC. Threats to

validity that pose a challenge in this study included descriptive and interpretive validity

threats (Creswell, 2009; Moustakas, 1994).

The researcher’s status as a former officer presented may have been another

unique challenge. Many participants were former enlisted members of the military. A

reasonable assumption was whether the researcher's former status, if known, would

influence the relationship between interviewer and interviewee. The researcher wanted to

guard against the participants feeling obligated to participate in the study.

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The researcher assumed that participants were open and honest about both

positive and negative life experiences. Participants should do not have felt threatened

about direct responses. Finally, the main assumption was that veterans who received

positive therapeutic outcomes from TCC underwent a holistic realization of cognitive,

emotional, and physical capacities to actively engage and manage their mild traumatic

brain symptoms.

Limitations

Limitations of this study included the researcher was familiar with TCC and had a

favorable bias. The study was a qualitative study from which the findings were not

generalized beyond this sample population of veterans with mTBI. The profundity of

understanding and insight as this research proceeded provided clinicians with a baseline

of differentiated experiences of participants who agreed to learn TCC as a therapeutic

intervention to treat mTBI.

The scope of this research was limited to a qualitative study using data from

participants from Operation Iraqi Freedom, Operation Enduring Freedom, and veterans

support groups in the Denver metropolitan area. Veterans also were recruited from

Buckley Airforce Base. There were three sets of data collected: pre and post interviews,

depth interviews, and observations (two sessions observed at the beginning, week four,

and week eight).

The researcher was a graduate student qualitative researcher, not a trained expert

with years of experience. The researcher’s status as a former veteran was a potential

limitation because of the occurrence that the research participants may have been former

enlisted members. The human element of narrative accounts offered a compelling

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opportunity to verify and triangulate personal stories of participants without access to

psychosocial and cultural historical records.

Limitations of this study included the researcher was familiar with TCC and had a

favorable bias. The study was a qualitative study from which the findings were not

generalized beyond this sample population of service members and veterans with mTBI.

The profundity of understanding and insight as this research proceeded, provided the

clinician with a baseline of differentiated experiences of participants who agreed to learn

TCC as a therapeutic intervention to treat mTBI.

The scope of this research was limited to a qualitative study using data from

participants from Operation TBI Freedom, Traumatic Brain Injury Trust, and the VA

Health Care System within the Denver Metropolitan area. There were three sets of data

collected: pre and post interviews depth interviews, observations (two sessions observed

at the beginning, and six weeks), and case studies. Upon conclusion of the eight weeks

therapeutic session, veteran participant's initial screening were compared and contrasted

to ascertain their willing to consider re-integrations into their social systems.

Delimitations

The delimitation that narrows the scope of this study was the realization that TCC

can be practiced by any participant, anywhere and anytime. This study was limited to

service members and veterans of Operation TBI Freedom, Traumatic Brain Injury Trust,

and the VA Health Care System within the Denver Metropolitan area. Also, TCC, as

mentioned in this study, can be used by anyone with neurotrauma. In this study, the

research was delimited to six veterans with mTBI. The practice of TCC can be used in

any therapeutic setting.

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Data Processing and Analysis

Process

The researcher conducted this qualitative descriptive phenomenological analysis

and data collection using standardized methods for qualitative research analysis

(Creswell, 2009; Smith & Firth, 2011). Interviews were recorded utilizing a digital

recorder. Observations of veteran participants practicing TCC were recorded on field

notes. Information ascertains during the document review were transcribed into a journal

for future data analysis. The interview and observations were reviewed to uncover

patterns and themes of veteran participants.

The researcher followed the guidelines outlined in the Argosy Student

Dissertation Guide 2012 and sought IRB approval and obtained approval, certification,

paperwork, and signatures as prescribed by the Argosy Student Dissertation Guide 2012.

Upon approval of the research application, the researcher contacted DVBIC Colorado

Springs, VA Medical Center Denver, VA Medical Center Kansas City, KS, and requested

approval to conduct research at their facilities. Each agency received progress reports as

defined by the researcher and the agency's representative.

The researcher secured documentation in the mission statement, clinician job

descriptions, and treatment guides for mTBI from DVBIC Colorado Springs and

participating VA Medical Centers. The DVBIC and VA Medical Center websites were

reviewed to ascertain information about traumatic brain injury and treatment modalities.

The researcher communicated with representatives of each facility to ensure there was

fidelity in the research process.

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After distributing questionnaires and interviews, the researcher provided a letter

to each candidate allowing them to participate in the study. The letter delineated the

purpose of the study, volunteer participation, time for interviews, confidentiality

statement, study design, and consent agrees during the interview. Veteran participants

had an opportunity during the study to ask clarifying questions to enhance their

engagement in the group.

The researcher scheduled an hour for the interview for each candidate. A room

and a second room to conduct interviews were scheduled in advance. This ensured

confidentiality of the researcher and veteran participants was protected, and the interview

proceeded unencumbered by unforeseen events. The researcher used public facilities

such as the library or mall if DVBIC and VA Medical Center could not conduct an

interview.

At the beginning of each interview, the researcher ensured (a) the interview

environment was comfortable, (b) pointed out the location of lavatory facilities, (c)

attended to veteran participant's disability accommodations as needed, (d) explained the

research study, (e) explained and provided the consent form, (f) the researcher asked the

veteran participant if there were questions, and (g) offered bottled water refreshment

prior to the start of the interview.

The researcher explained that the two Saveeck Digital Voice Recorder, Model

GS-R06 were used during the interview. Two recorders ensured the interviews were

recorded and saved the researcher and veteran participant time if one recorder became

inoperable. The researcher also used pen and paper to elucidate any points during the

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interview. Each veteran participant was informed that the researcher used pseudonyms to

protect their identity.

The researcher observed TCC practice of veteran participants in one-hour

segments at Week-2, Week-4, Week-6, and Week 8. The researcher observed veteran

participant's practice sessions to include movement, social interaction, attitude, and

motivation in the class. These observations were transcribed by using field notes.

Data Analysis

The first step of analysis involved reading all the interview data to get a sense

of the whole. This step provided familiarization and a platform for understanding the

general experiences of the veteran participant. The researcher followed the qualitative

process delineated by Smith and Firth (2011) of transcribing, content analysis,

summarizing, and preparing of reports.

The second analysis was from observations of veteran participants in the TCC

class. The researcher's observations were one hour in duration over an eight-week

period. The data were comprised detailed observational notes made during the session.

The observations contained information about the session and the researcher

interpretation of the veteran participant's reflection on their experience.

The third step comprised the researcher transcribing the interview, write, and edit

the interviews from the digital recorder and field notes following each interview. The

next step was to separate the data into meaning units that represented key elements,

terms, attitudes, or experiences (Creswell, 2009; Moustakas, 1994). NVivo 11 software

identified the key elements of the veteran participant's experiences.

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All the data collected were managed and secured using True Crypt. True Crypt is

an open source encryption software available to the public. Also, the research data were

transferred to a secure encrypted USB flash drive call Iron Key. Iron key uses 128 key

encryption algorithms. The flash drive has a strong, metallic outer casing to protect

against physical damage, and the internal components are sealed with an epoxy-based

potting compound to protect against tampering. The flash drive is waterproof. If

someone other than the researcher attempted to access the flash drive, Iron Key would

have sensed a change in the access code and would have self-destructed the next time

power is applied. The researcher routinely backed up data on two Iron Key flash drives

(http://www.ironprotector.com).

Summary

In summary, other approaches such as focus group, case study, grounded theory,

and ethnography methods of data collection do not serve the purpose of this research.

Instead, the unstructured interview was the best method with which to proceed with this

research. One important benefit of using a qualitative method is the ability to perform

inductive reasoning. This was an essential benefit because different veteran participants

experience a given phenomenon in the same way.

This researcher chose to use the qualitative phenomenological method for this

study. This chapter discussed the method chosen to perform this study. The details for

collecting, analyzing, coding, and storing the data needed for this study were also

described in this chapter. Also, this chapter discussed the reliability and validity of the

study.

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This researcher argued that the purpose of this study can be achieved with the

use of the phenomenological method and interviews. Data triangulation was used to

establish reliability, and bracketing was used to establish validity for this study.

Purposive sampling and convenience sampling were used to identify nine individuals

who met the sample criteria.

Coding of data facilitated understanding and retrieval of information for the

study. The researcher identified and tentatively named conceptual categories into which

the observed phenomena groups. Qualitative research reports were developed using the

quotes that illustrate the themes emerging from the veteran participants’ responses.

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CHAPTER FOUR: FINDINGS

Introduction

This chapter introduces the findings through the lens of the methodological

triangulation process, which included the issuance and collection of questionnaires,

observations, and in-person and telephonic interviews of participants. Triangulation is

unraveling information through the process of data collection using the instruments

mentioned in the sentence above (Roulson, 2018). Chapter Four explores emergent

themes and the impact of the data on the central research question thorough

examination of the interviews. This chapter also provides information on the study

participants; types of instrumentation used, and the results of data from the

questionnaires and interviews. Data collected as part of this qualitative research will be

presented. Chapter Four of this qualitative case study introduces the veterans with a

brain injury who participated in this research. It presents their experiences in their

points of view. The chapter concludes with a summary of findings of all collected data.

Purpose of Study

This study will determine the efficacy of Yang Style Tai Chi Chuan (TCC)

practice as a holistic augmented therapeutic intervention to veterans with mild traumatic

brain injury (mTBI). Previous neuroscience research proves that Movement Therapy

facilitates neuroplasticity and development of neuropathways in the brain (Hawkes,

2012). The practice of TCC stimulates neuronal development in the prefrontal cortex and

contributes to a relaxation response in the limbic system (Hawkes, 2012).

The goal of this research is to inform future non-pharmacologic research in brain

injury. The specific aims are (a) find the perceptions of veteran's experiences living with

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mild TBI, (b) analyze veteran's learning and practicing Tai Chi Chuan as a treatment for

mild TBI, and (c) chronicle the experience during the intervention period regarding the

efficacy of TCC on psychosocial reintegration of the veteran.

Research Question

The researcher admits the existence of a bias in this study resulting in the

researcher’s own prior military service and being a student of TCC. This researcher’s

observations of the veterans at the VA Medical Center in Denver, CO consider the

research idea. Theories of psychosocial development, social identity, social integration,

besides multiple conversations with veterans solidified the research topic. The research

question or questions that investigates the experiences of veterans diagnosed with mild

traumatic brain injury.

This study explored life experiences and challenges derived from veterans’

personal stories. The central research question was designed to capture qualitative data to

evaluate the overall impact of the life experiences of veterans with mTBI. Therefore, this

research question with subquestions was formulated as the guiding focus of the study.

The research question for this dissertation focuses on the perception of a veteran's

understanding and efficacy of TCC. The purpose of the study was to identify the specific

variables investigated from the research question.

Organization of the Chapter

This chapter is divided into eight sections. Section one presents the researcher’s

reflection and precautions. Section two delineates Veteran Participant Identification and

Demographics. Section three contains the Clinician Identification and Demographics.

Section four is the interview questions and summary. Section five reflects the data

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presentation. Section six contains the data analysis. Section seven holds the Theme

Summary. Section eight displays of the research question.

Researcher’s Proclivities Prevention

The researcher’s required action to identify, minimize, and eliminate

preconceptions.

Removing Bias with Research Design

Data were collected using different methods in the study. The study included the

use of a screening instrument, four questionnaires, eight observations, and a final

interview. During this process, the researcher took precautions to eliminate bias. The

researcher asked the same questions to ensure consistency. The researcher kept the

questions neutral, quantitative, and excluded leading questions. Four clinicians from the

psychological community reviewed the research screening instrument and the questions

to identify any bias and ambiguous writing that existed in the instrument. Based on their

response, five questions were revised for greater clarity and precision to reduce the

potential for participant confusion further.

Removing Bias from Veteran Participant Selection

Veteran participant (VP) selection procedures were carefully reviewed for

potential bias, particularly in the potential elimination process. Potential veteran

participants were given the Brief Traumatic Brain Injury Screen (BTBIS). The BTBIS is

a three-question self-report screening tool produced by the Defense Veteran Brain Injury

Center. The screening tool was used during the interviews to ascertain VPs eligibility to

engage in the research study. The researcher used “keywords” as “mild traumatic brain

injury,” “family connection,” and “isolation” to further facilitate the screening process.

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Ethnic identification and sexual orientation were not factors in the study.

Therefore, no such data were collected. The VPs were asked about their knowledge of

traumatic brain injury and the impact of TBI on their life. The last question asked if the

interviewee wanted to be included in the study eliminating unwarranted negativity from

reluctant respondents. Sixteen veterans “self-selected” to participate by volunteering to

engage in the Tai Chi Chuan study. To overcome sample bias, the researcher employed

random selection to identify 10 veteran participants from the 16 respondents who

qualified and agreed to participate in this study.

Removing Interview Bias

The researcher conducted digital voice recording interviews with the ten

randomly selected veteran participants. Interviews were in person to observe the

participant’s body language to permit the researcher to know of his body language, facial

expressions, dress, tone, and style. The researcher is a licensed professional counselor

and understands the importance of both physical and verbal communication in

establishing rapport with veteran participants. Physical and verbal communication was

not part of the data examined in this study.

Removing Researcher’s Belief System Bias through Supervision

To remain mindful, aware, and nonjudgmental to build rapport throughout the

research process, the researcher examined his belief systems. A belief system develops

from lived experiences through people in relationships, dealing with the interactions of

groups. Belief systems can produce accurate and unbiased observations. Belief systems

and the words used to express them can also create biased observations and perspectives

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while raising questions. The researcher engaged in supervision with a psychologist each

week to ensure the interpretation of data was based on content and not on his own beliefs.

The final effort to reduce bias was to critically review the themes and supporting

narratives utilizing Weaver and Goldberg’s (2011) “What’s Wrong Here?” The

researcher pondered of the 39 questions at length regarding his own biases to add validity

and reliability to this research. The researcher can state that the study results are valid

and reliable with the utmost confidence.

Data Presentation

The researcher attained quantitative responses from each veteran participant that

directly pertained to the TCC Therapy sessions. Answers were rated on a 10-point

interval rating scale know as Likert Response Scale. The Likert Response Scale is used

when employing questionnaires to capture attitudes, beliefs, pattern, and perceptions.

Based upon the research question of “How does Tai Chi Chuan facilitate Psychosocial

Reintegration?” the Likert Response Scale was chosen to eliminate contradicting data

and promoted active engagement during each category of the interview process.

The answer from the veteran participants determined the emergent themes and

voices reveal during the study. The researcher validated response with the recorded

transcripts and created individual textural descriptions of each veteran participant’s

experience. The researcher composed the original data collected from in-depth semi-

structured interview questions, observations, and dialogue. The structures of the

experiences were described based on the researcher’s interpretation of the participants’

description (Moustakas, 1994).

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There are five categories of question totaling 33 that were presented to the

veteran participants: (a) Readiness to Participate Interview, (b) Pre-Intervention

Interview, (c) In-Progress Intervention Interview, (d) Post Intervention Interview, and

(e) TCCPRM Reintegration Interview. The researcher designed the Likert Response

Scale to ascertain the intensity and strength of the veteran participant’s response to the

questionnaire. The answer is operating on a continuum with two options: strongly agree

to disagree strongly and highly unlikely to highly likely. Normally, the Likert Response

Scale is designed with an uneven number to designate a neutral answer. The researcher

designed was informed by the research goal, knowledge of veteran participants,

research design, instrumentation, and eliminating force choice answers during in-depth

structured interviews. Self-disclosure of personal information is a sensorial topic for

individuals with a brain injury.

Research Interview Questions

In this section, the researcher will define each interview question. The purpose

was to facilitate veteran participants’ understanding of the questions and terms used

during the interview process. The outcome of explaining the questions contextualized

the interview experience for each veteran participant in the study. This interview

approach created an atmosphere of cooperation, respect, validation, and commonality

with the researcher. There were five questions presented to veteran participants.

1. What is your knowledge of mild traumatic brain injury?

2. What is your understanding of mild traumatic brain injury?

3. What is your level of biopsychosocial awareness?

4. What is your understanding of self-efficacy?

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5. What is your motivation level?

Readiness to Participate

Table 2 presents the results of the Question 1: What is your knowledge of mild

traumatic brain injury? Thirty percent answered; “I do not have any specific

knowledge;” 40% answered they had some knowledge of mBTI; 20% had little

knowledge of mBTI, and 10% had only average knowledge of mBTI.

Table 2

Question 1: What is Your Knowledge of Mild Traumatic Brain Injury? Veteran Participant (VP) Response VP1 1: I have no specific knowledge VP2 1: I have no specific knowledge VP3 1: I have no specific knowledge VP4 3: Some VP5 3: Some VP6 3: Some VP7 3: Some VP8 6: Average VP9 2: Little VP10 2: Little

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having expert knowledge

Table 3 presents the results of the Question 2: What is your understanding of

mild traumatic brain injury? Thirty percent answered; “I do not have any specific

knowledge;” 40% answered they had some knowledge of mBTI; 20% had little

knowledge of mBTI, and 10% had only average knowledge of mBTI.

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Table 3

Question 2: What is Your Understanding of Mild Traumatic Brain Injury? Veteran Participant (VP) Response VP1 1: I have no specific knowledge VP2 1: I have no specific knowledge VP3 3: Some VP4 3: Some VP5 3: Some VP6 3: Some VP7 6: Average VP8 2: Little VP9 2; Little VP10 1: I have no specific knowledge

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having expert knowledge.

Table 4 presents the results of the Question 3: What is the level of

biopsychosocial awareness? Thirty percent answered; “I do not have any specific

knowledge;” 40% answered they had some knowledge of mBTI; and 30% did not have

any specific knowledge of mBTI.

Table 4

Question 3: What is the Level of Biopsychosocial Awareness? Veteran Participant (VP) Response VP1 1: I have no specific knowledge VP2 1: I have no specific knowledge VP3 3: Some VP4 3: Some VP5 3: Some VP6 3: Some VP7 2: Little VP8 2: Little VP9 2; Little VP10 1: I have no specific knowledge

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having expert knowledge.

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Table 5 presents the results of the Question 4: What is your understanding of self-

efficacy? One hundred percent answered, “I have an average knowledge of self-

efficacy.”

Table 5

Question 4: What is Your Understanding of Self-Efficacy? Veteran Participant (VP) Response VP1 5: Average VP2 5: Average VP3 5: Average VP4 5: Average VP5 5: Average VP6 5: Average VP7 5: Average VP8 5: Average VP9 5: Average VP10 5: Average

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having a high level of self-efficacy.

Table 6 presents the results of the Question 5: What is your level of motivation?

One hundred percent answered, “I have an average level of motivation.”

Table 6

Question 5: What is Your Level of Motivation? Veteran Participant (VP) Response VP1 5: Average VP2 5: Average VP3 5: Average VP4 5: Average VP5 5: Average VP6 5: Average VP7 5: Average VP8 5: Average VP9 5: Average VP10 5: Average

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having a high level of motivation.

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Table 7 presents the results of the Question 6: What is your level of engagement

to participate in therapy? One hundred percent answered I have an average level of

engagement to participate.

Table 7

Question 6: What is Your Level of Engagement to Participate in Therapy? Veteran Participant (VP) Response VP1 5: Average VP2 5: Average VP3 5: Average VP4 5: Average VP5 5: Average VP6 5: Average VP7 5: Average VP8 5: Average VP9 5: Average VP10 5: Average

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being highly motivated to participate in therapy. Table 8 presents the mean scores of the six Readiness to Participate questions.

Veteran participants answered the all the questions. Surveyed Veterans Participant’s

Readiness to Participate Results (N=10).

Table 8

Surveyed Veteran Participant’s Readiness to Participate Results Question Mean

Score Decline to

Answer What is your knowledge of mild traumatic brain injury?

2.2 0

What is your understanding of mild traumatic brain injury?

2.4 0

What is your level of biopsychosocial awareness? 2.1 0 What is your level of self-efficacy? 5.0 0 What is your motivation level? 5.0 0 What is a level of engagement to participate in therapy?

5.0 0

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The researcher determined the mean by adding the scores and dividing by the

total score which is depicted in Table 8. The meaning of the score suggests the level of

potential engagement by the veteran participant who considered being involved in the

research study. Three of the questions reveal an absence of information and

understanding mild traumatic brain injury and how to access treatment.

Veteran Participant’s Pre-intervention Questions

The pre-intervention questions were given to determine the veteran participant’s

knowledge of Tai Chi Chuan. In addition, the researcher wanted information on potential

barriers, health concerns, motivations, and reasons for considering TCC Therapy as a

treatment modality. The questionnaire helped the researcher access the risk and

protective factors of the veteran participants. There were six questions in this section

presented to veteran participants.

1. What is your level of knowledge of Tai Chi Chuan meaning having an

acquaintance with information on the topic of Tai Chi Chuan?

2. Do you have factors that brought you to consider Tai Chi Chuan relates to the

individual who is considering a non-poly pharmacological approach to

treating their mild traumatic brain injury?

3. What is your motivation level to consider Tai Chi Chuan as a treatment for

mTBI as an alternative therapeutic approach to the treatment of their

condition?

4. Do you have barriers that would prevent Tai Chi Chuan practice means are the

conditions and reasons that would prevent the veteran participant from

participating in the study?

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5. Do you have any symptoms you now notice or experience addressing any

medical or physical conditions that may be of concern to the veteran

participant in the beginning of the study?

6. Do you have conditions that will affect your ability to perform Tai Chi Chuan

means are there any disabilities the Veteran Participant wish to disclosure

before the beginning of the study?

Veteran Participant’s Pre-intervention Questions

Table 9 presents the results of the Question 7: What is your knowledge of Tai Chi

Chuan? Forty percent answered, “I do not know Tai Chi Chuan;” 40% answered they

had “very little knowledge of Tai Chi Chuan;” and 10% “little knowledge of Tai Chi

Chuan.”

Table 9

Question 7: What is Your Level of Knowledge of Tai Chi Chuan? Veteran Participant (VP) Response VP1 1 VP2 3 VP3 2 VP4 1 VP5 2 VP6 2 VP7 1 VP8 2 VP9 2 VP10 1

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having expert knowledge. Table 10 presents the results of the Question 8: Do you have factors that brought

you to consider Tai Chi Chuan? Ten percent answered; “I have average reasons for

considering Tai Chi Chuan;” 20% answered they had “I have above average reasons for

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considering Tai Chi Chuan;” 10% answered “I have good reasons for considering Tai Chi

Chuan;” and 50% answered “I have many reasons for considering Tai Chi Chuan.”

Table 10

Question 8: Do You have Factors that brought You to Consider Tai Chi Chuan? Veteran Participant (VP) Response VP1 5 VP2 6 VP3 6 VP4 10 VP5 10 VP6 7 VP7 10 VP8 10 VP9 10 VP10 10

Note. The question was scored on a Likert scale of 1-10 with 1 being no specific knowledge and 10 being having expert knowledge. Table 11 presents the results of the Question 9: What is your motivation level to

consider Tai Chi Chuan as a treatment for mTBI? Forty percent answered; “I am above

average when to being motivated to consider Tai Chi Chuan as a treatment for mTBI;”

30% answered “I am highly motivated to consider Tai Chi Chuan as a treatment for

mTBI;” and 30% totally motivated to consider Tai Chi Chuan as a treatment for mTBI.

Table 11

Question 9: What is Your Motivation Level to Consider Tai Chi Chuan as a Treatment for mTBI? Veteran Participant (VP) Response VP1 7 VP2 8 VP3 7 VP4 10 VP5 8 VP6 7 VP7 7 VP8 8 VP9 10 VP10 10

Note. The question was scored on a Likert scale of 1-10 with 1 being low motivation to motivated.

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Table 12 presents the results of the Question 10: Do you have barriers what would

prevent Tai Chi Chuan practice? Thirty percent answered; “I have one barrier to prevent

Tai Chi Chuan practice;” 10 answered “I have a couple of barriers to prevent Tai Chi

Chuan practice;” and 60% answered, “I have no barriers that would prevent me from Tai

Chi Chuan practice.”

Table 12

Question 10: Do You have Barriers that would Prevent Tai Chi Chuan Practice?

Veteran Participant (VP) Response VP1 2 VP2 3 VP3 1 VP4 1 VP5 1 VP6 1 VP7 2 VP8 2 VP9 1 VP10 1

Note. The question was scored on a Likert scale of 1-10 with 1 being no barriers and 10 being barriers would prevent Tai Chi Chuan practice. Table 13 presents the results of the Question 11: Do you have any symptoms you

now notice and experience? Twenty percent answered; “I have some symptoms that are

noticeable;” 10% answered, “I have below average and manageable symptoms that are

noticeable;” 10% answered, “I have average but manageable symptoms; 10% answered,

“I have above average and manageable symptoms;” 20% answered, “I have symptoms

but can regulate my condition;” and 20% answered, “I am symptomatic but take

medication to manage the condition.”

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Table 13

Question 11: Do You have hny Symptoms You now Notice and Experience?

Veteran Participant (VP) Response VP1 5 VP2 6 VP3 4 VP4 10 VP5 7 VP6 3 VP7 7 VP8 4 VP9 3 VP10 10

Note. The question was scored on a Likert scale of 1-10 with 1 being no symptoms to 10 being symptomatic conditions being experienced. Table 14 presents the results of the Question 12: Do you have conditions that will

affect your ability to perform Tai Chi Chuan? One hundred percent answered, “No

impact of condition would affect their ability to perform Tai Chi Chuan.”

Table 14

Question 12: Do You have Conditions that will Affect Your Ability to Perform Tai Chi Chuan?

Veteran Participant (VP) Response VP1 1 VP2 1 VP3 1 VP4 1 VP5 1 VP6 1 VP7 1 VP8 1 VP9 1 VP10 1

Note. The question was scored on a Likert scale of 1-10 with 1 being no effects from condition to 10 being condition prevent the ability to perform Tai Chi Chuan.

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Table 15 presents the mean scores of the six Readiness to Participate questions.

Veteran participants answered all the questions. Surveyed Veterans Participant’s

Readiness to Participate Results (N=10).

Table 15

Surveyed Veteran Participant’s Six Pre-intervention Questions Readiness to Participate Results

Question Mean Score Decline to Answer

Q7. What is your level of knowledge of Tai Chi Chuan?

1.7 0

Q8. Do you have factors that brought you to consider Tai Chi Chuan?

8.4 0

Q9. What is your motivation level to consider Tai Chi Chuan as a treatment for mTBI?

8.2 0

Q10. Do you have barriers that would prevent Tai Chi Chuan practice?

1.5 0

Q11. Do you think Tai Chi Chuan affects your rehabilitation process?

5.5 0

Q12. Do you have conditions that will affect your ability to perform Tai Chi Chuan?

1.0 0

The researcher determined the mean by adding the scores and dividing by the

total amount of score which is depicted in Table 15. The meaning of the score suggests

the level of potential engagement by the veteran participant who considered being

involved in the research study. Three of the questions reveal an absence of information

and understanding mild traumatic brain injury and how to access treatment.

Veteran Participant’s Progress-intervention Questions

The progress -intervention questions were given to veteran participants the fourth

TCC Therapy Session. The researcher wanted information on how the veteran

participant was progressing in the fourth session of the research study. The information

extracted from this interview revealed the current level of motivation, barriers in

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communications, symptomology, and overall attitude towards Tai Chi Chuan. The

progress questionnaire helped the researcher to continue accessing the risk and protective

factors of the veteran participants. There were ten questions in this section presented to

veteran participants.

1. What was your motivation level since your participation in the Tai Chi Chuan

group?

2. Veteran participant (VP) related to the individual’s reason who is starting the

study and willingness to continue?

3. Do you continue to experience barriers in communicating with your social

support system means have group participation in the Tai Chi Therapy Group

help with a willingness to communicate outside the Tai Chi Therapy group?

4. What types of symptoms do you now notice, and experience relates to an

update of the individual’s reported symptoms before the therapy session?

5. Has any of your symptoms affected your ability to perform Tai Chi Chuan is

an opportunity to provide feedback on changes which may have occurred

during therapy?

6. Do you think Tai Chi Chuan affects your rehabilitation process is ascertain the

individual’s perception of their individual experience in the Tai Chi Chuan

Therapy group?

7. Explain precisely what symptoms were affected by Tai Chi Chuan practice

relates to the individual’s perception of how the therapy has impacted reported

symptoms?

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8. What do you enjoy about Tai Chi Chuan practice is the level of positive

interaction with the group and personal well-being?

9. Would you recommend this therapy or do it again if you had the chance is the

individual opinion of how they ascertain Tai chi Chuan Therapy as an

effective therapeutic approach for managing their mild traumatic brain injury

condition?

10. What changes have you experienced since you started with the Tai Chi Chuan

group and the personal experience of change that occurred with themselves?

Progress-intervention Questions

Table 16 presents the results of the Question 14: What was your motivation level

since your participation in the Tai Chi Chuan group? Ten percent answered, “I am really

motivated since participating in the Tai Chi Chuan group;” 50% answered, “very

motivated since participating in the Tai Chi Chuan group;” 10% answered, “I am highly

motivated since participating in the Tai Chi Chuan group;” and 30% answered, “I am

totally motivated since participating in the Tai Chi Chuan group.”

Table 16

Question 14: What was Your Motivation Level since Your Participation in the Tai Chi Chuan Group? Veteran Participant (VP) Response VP1 8 VP2 8 VP3 7 VP4 10 VP5 8 VP6 8 VP7 8 VP8 9 VP9 10 VP10 10

Note. The question was scored on a Likert scale of 1-10 with 1 being low motivation to motivated.

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Table 17 presents the results of the Question 15: Do you continue to experience

barriers in communicating with your social support system? One hundred percent

answered, “There are not experiencing barriers in communicating with their social

support system.”

Table 17

Question 15: Do You Continue to Experience Barriers in Communicating with Your Social Support System? Veteran Participant (VP) Response VP1 1 VP2 1 VP3 1 VP4 1 VP5 1 VP6 1 VP7 1 VP8 1 VP9 1 VP10 1

Note. The question was scored on a Likert scale of 1-10 with 1 being low motivation to 10 being unable to communicate.

Table 18 presents the results of the Question 16: What was your motivation level

since your participation in the Tai Chi Chuan group? Ten percent answered, “I am really

motivated since participating in the Tai Chi Chuan group;” 50% answered, “very

motivated since participating in the Tai Chi Chuan group;” 10% answered, “I am highly

motivated since participating in the Tai Chi Chuan group;” and 30% answered, “I am

totally motivated since participating in the Tai Chi Chuan group.”

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Table 18

Question 16: What Types of Symptoms do You Now Notice and Experience? Veteran Participant (VP) Response VP1 5 VP2 6 VP3 4 VP4 10 VP5 7 VP6 4 VP7 5 VP8 3 VP9 3 VP10 3

Note. The question was scored on a Likert scale of 1-10 with 1 being no symptoms to 10 being symptomatic.

Table 19 presents the results of the Question 17: Has any of your symptoms affect

your ability to perform Tai Chi Chuan? One hundred percent answered, “I have no

symptoms that affect the ability to perform Tai Chi Chuan.”

Table 19

Question 17: Have any of Your Symptoms Affected Your Ability to Perform Tai Chi Chuan? Veteran Participant (VP) Response VP1 1 VP2 1 VP3 1 VP4 1 VP5 1 VP6 1 VP7 1 VP8 1 VP9 1 VP10 1

Note. The question was scored on a Likert scale of 1-10 with 1 being no affect to 10 being unable to perform.

Table 20 presents the results of the Question 18: Do you think Tai Chi Chuan

affects your rehabilitation process? Thirty percent answered, “Tai Chi Chuan had a

favorable effect in the rehabilitation process;” 20% answered, “Tai Chi Chuan has a more

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than average effect in the rehabilitation process;” and 40% answered, “Tai Chi Chuan

was highly effective in the rehabilitation process.”

Table 20

Question 18: Do You Think Tai Chi Chuan Affects Your Rehabilitation Process? Veteran Participant (VP) Response VP1 8 VP2 8 VP3 9 VP4 10 VP5 8 VP6 9 VP7 9 VP8 10 VP9 10 VP10 10

Note. The question was scored on a Likert scale of 1-10 with 1 being no affect to 10 being highly effective.

Table 21 presents the results of the Question 18: Do you think Tai Chi Chuan

affects your rehabilitation process? Sixty percent answered, “Tai Chi Chuan had a

favorable effect in managing anxiety during Tai Chi Chuan Practice;” 20% answered,

“Tai Chi Chuan had a favorable effect in managing pain during Tai Chi Chuan Practice;”

and 20% answered, “Tai Chi Chuan had a favorable effect in improving balance during

Tai Chi Chuan Practice.”

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Table 21

Question 19: Explain precisely What Symptoms Were Affected by Tai Chi Chuan Practice? Veteran Participant (VP) Response 1=Anxiety, 2=Balance, 3=Pain VP1 Anxiety VP2 Pain VP3 Anxiety VP4 Anxiety VP5 Anxiety VP6 Pain VP7 Balance VP8 Anxiety VP9 Anxiety VP10 Balance

Note. The question was scored on a Likert scale of 1-3 with 1 being Anxiety, 2 being Balance, and 3 being Pain.

Table 22 presents the results of the Question 20: What did you enjoy about Tai

Chi Chuan practices? One hundred percent answered, “Tai Chi Chuan practice was an

enjoyable experience.”

Table 22

Question 20: What did You Enjoy about Tai Chi Chuan Practice? Veteran Participant (VP) Response 1=Group, 2=Other VP1 Group practice VP2 Group practice VP3 Group practice VP4 Group practice VP5 Group practice VP6 Group practice VP7 Group practice VP8 Group practice VP9 Group practice VP10 Group practice

Note. The question was scored on a two-point scale of 1 being Group and 2 being Other.

Table 23 presents the results of the Question 21: Would you recommend this

therapy or do it again if you had the chance? One hundred percent answered, “I would

recommend Tai Chi Chuan as a therapeutic treatment for my condition.”

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Table 23

Question 21: Would You Recommend This Therapy or do it Again if You had the Chance? Veteran Participant (VP) Response: 1=Yes, 2=No VP1 Yes VP2 Yes VP3 Yes VP4 Yes VP5 Yes VP6 Yes VP7 Yes VP8 Yes VP9 Yes VP10 Yes

Note. The question was scored on a two-point Likert Scale with 1 being Yes and 2 being No.

Table 24 presents the results of the Question 22: What changes have your

experienced since you started with the Tai Chi Chuan group? One hundred percent

answered, “Improvement in my condition.”

Table 24

Question 22: Would You Recommend this Therapy or do it again if You had the Chance? Veteran Participant (VP) Response 1= Improvement, 2= No Improvement VP1 Improvement VP2 Improvement VP3 Improvement VP4 Improvement VP5 Improvement VP6 Improvement VP7 Improvement VP8 Improvement VP9 Improvement VP10 Improvement

Note. The question was scored on a two-point Likert Scale with 1 being Improvement and 2 being No improvement.

The researcher determined the mean by adding the scores and dividing by the

total amount of score which is depicted in Table 25. The meaning of the score suggests

the level of potential engagement by the veteran participant who considered being

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involved in the research study. Three of the questions reveal an absence of information

and understanding mild traumatic brain injury and how to access treatment.

Surveyed Veterans Participant’s Progress Interview

The researcher determined the mean by adding the scores and dividing by the

total amount of score which is depicted in Table 25. The meaning of the score suggests

the level of potential engagement related to motivation, barriers, symptomology, and

attitudes to TCC. This session indicated the veteran participants were becoming a

homogenous group that indicated an active willing to connect with others in the group.

Table 25

Surveyed Veterans Participant’s Progress Interview Results (N=10) Question Mean Score Decline to

Answer Q1. What was your motivation level since your participation in the Tai Chi Chuan group?

9.6 0.0

Q2. Do you continue to experience barriers in communicating with your social support system?

1.0 0.0

Q3. What types of symptoms do you now notice and experience?

5.5 0.0

Q4. Has any of your symptoms affected your ability to perform Tai Chi Chuan?

1.0 0.0

Q5. Do you think Tai Chi Chuan affects your rehabilitation process?

9.1 0.0

Q6. Explain precisely what symptoms were affected by Tai Chi Chuan practice?

6.0, 2.0, 2.0 0.0

Q7. What do you enjoy about Tai Chi Chuan practice?

1.0 (10) 0.0

Q8. Would you recommend this therapy or do it again if you had the chance?

1.0 (10)

0.0

Q9. What changes have you experienced since you started with the Tai Chi Chuan group?

1.0 (10) 0.0

The data depicted indicates the veteran participants begin to experience a change

in their behavior presentations. The mean scores indicate the efficacy of TCCPRM to

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help with social reintegration. Furthermore, veteran participants began to engage with

other social support systems per their self-report socially.

Post-Intervention Interview Questions

The post interview was a culmination of the eight-week TCC Therapy sessions.

The veteran participants demonstrated a connection of mutual admiration and respect for

each other. They were elated to be part of the research study and wanted

psychoeducation on the topic of mild traumatic. There were eight questions in this

section presented to veteran participants.

1. What is your motivation level upon completion of the Tai Chi Chuan therapy

group relates to the level of change in their reasons for participating in the

therapy group?

2. What barriers to you experience means has the reported barriers changed in

relation to the first interview?

3. Do you think Tai Chi Chuan affects your rehabilitation process is a progress

report on the individual perception of the effectiveness of therapy as it relates

to the veteran participants individual mild traumatic brain injury?

4. Do you think you will continue to practice Tai Chi Chuan relates to the

veteran participant’s willingness to participate in a Tai Chi program to

manage their quality of life?

5. What do you enjoy about Tai Chi Chuan practice and what did you not enjoy

is an individual assessment of the benefit of Tai Chi Chuan therapy group?

6. Do you think you will continue to practice Tai Chi Chuan means that the

veteran participant has found value in the Tai Chi Chuan therapy group?

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7. Would you recommend this therapy or do it again if you had the chance

means how satisfied is the individual with the Tai Chi Chuan therapy group?

8. How has your first impression of Tai Chi Chuan practice change during the

past eight sessions is the change the veteran participant’s perspective since the

start of the study?

Post-Intervention Interview Questions

Table 26 represents the results of Question 23. One hundred percent answered, “I

enjoyed the group practice.”

Table 26

Question 23: What is Your Motivation Level Upon Completion of the Tai Chi Chuan Therapy Group?

Veteran Participant (VP) Response VP1 10: Enjoyed group practice VP2 10: Enjoyed group practice VP3 10: Enjoyed group practice VP4 10: Enjoyed group practice VP5 10: Enjoyed group practice VP6 10: Enjoyed group practice VP7 10: Enjoyed group practice VP8 10: Enjoyed group practice VP9 10: Enjoyed group practice VP10 10: Enjoyed group practice

Note. The question was scored on a 10-point Likert Scale with 1 being Dislike to 10 being Enjoyed.

Table 27 represents the results of Question 24. One hundred percent answered,

“None, not experiencing as barriers.”

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Table 27

Question 24: What Barriers do You Experience?

Veteran Participant (VP) Response VP1 1: None VP2 1: None VP3 1: None VP4 1: None VP5 1: None VP6 1: None VP7 1: None VP8 1: None VP9 1: None VP10 1: None

Note. The question was scored on a 10-point Likert Scale with 1 being None and 10 is significant. Table 28 represents the results of Question 25. One hundred percent answered,

“Yes that Tai Chi Chuan affected their rehabilitation process.”

Table 28

Question 25: Do You Think Tai Chi Chuan Affected Your Rehabilitation Process?

Veteran Participant (VP) Response VP1 10: Yes VP2 10: Yes VP3 10: Yes VP4 10: Yes VP5 10: Yes VP6 10: Yes VP7 10: Yes VP8 10: Yes VP9 10: Yes VP10 10: Yes

Note. The question was scored on a 10-point Likert Scale with 1 being No and 10 being Yes.

Table 29 represents the results of Question 26. One hundred percent answered,

“The instructor was patience and understanding. I enjoyed the Tai Chi Chuan practice

during the eight-week study.”

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Table 29

Question 26: What did You Enjoy about the Tai Chi Chuan Practice? What did You Not Enjoy?

Veteran Participant (VP) Response VP1 10: Instructor was patience and understanding VP2 10: Instructor was patience and understanding VP3 10: Instructor was patience and understanding VP4 10: Instructor was patience and understanding VP5 10: Instructor was patience and understanding VP6 10: Instructor was patience and understanding VP7 10: Instructor was patience and understanding VP8 10: Instructor was patience and understanding VP9 10: Instructor was patience and understanding VP10 10: Instructor was patience and understanding

Note. The question was scored on a 10-point Likert Scale with 1 being disliked to 10 being patience and understanding.

Table 30 represents the results of Question 27. Ninety answered, “Yes, if I have

the time, money, and a good instructor,” and 10% answered, “If I had the time.”

Table 30

Question 27: Do You Think You will Continue to Practice Tai Chi Chuan?

Veteran Participant (VP) Response VP1 10: Yes, if I have the time and money VP2 9: Yes, if I have the time VP3 10: Yes, if I have the time and money VP4 10: Yes, if I have the time and money VP5 10: Yes, if I have the time and money VP6 10: Yes, if I have the time and money VP7 10: Yes, if I have the time and money VP8 10: Yes, if I have the time and money VP9 10: Yes, if I have the time and money VP10 10: Yes, if I have the time and money

Note. The question was scored on a 10-point Likert Scale with 1 being No and 10 being Yes. Table 31 represents the results of Question 28. One hundred percent answered,

“Yes, I would recommend Tai Chi Chuan to everyone.”

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Table 31

Question 28: Would You Recommend this Therapy or do it again if You had the Chance?

Veteran Participant (VP) Response VP1 10: Yes VP2 10: Yes VP3 10: Yes VP4 10: Yes VP5 10: Yes VP6 10: Yes VP7 10: Yes VP8 10: Yes VP9 10: Yes VP10 10: Yes

Note. The question was scored on a 10-point Likert Scale with 1 being No and 10 being Yes.

Table 32 represents the results of Question 29. Sixty percent answered, “Tai Chi

Chuan was a positive experience;” 30% answered, “Tai Chi Chuan was a favorable

experience;” and 10% answered, “The same; I a positive experience with Tai Chi in the

past.”

Table 32

Question 29: How has Your First Impression of Tai Chi Chuan Practice Changed during the past Eight Sessions?

Veteran Participant (VP) Response VP1 10: Positive experience VP2 8: Favorable VP3 8: Favorable VP4 8: Favorable VP5 8: Positive experience VP6 9: The same VP7 10: Positive experience VP8 10: Positive experience VP9 10: Positive experience VP10 10: Positive experience

Note. The question was scored on a 10-point Likert Scale being 1 is a negative experience and 10 being a positive experience.

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TCCRM Reintegration Questions

The Tai Chi Chuan Reintegration Model questions related directly to the research

question of “How does Tai Chi Chuan facilitate reintegration?” There were five

questions that queries the Veteran Participant TCC Therapy experience. The responses

indicated that TCC Therapy was an empowering, engaging, exciting, interesting, and

motivational events. Below are the answers to the questionnaire. There were five

questions in this section presented to veteran participants.

1. How do you feel about the Tai Chi Chuan Exercise intervention is the veteran

participant’s perspective on their quality of life?

2. How do you feel about the group interaction during therapy mean the value of

the therapy as it relates to reintegration in the veteran participant’s

psychosocial system?

3. Are you comfortable in a social setting relates to the research question and the

reduction of isolation behavioral presentations when connection with

psychosocial systems?

4. How prepared are you to connect with your social support system means the

individual is ready to reintegrate into their families?

5. Would continuing practice help with connecting with people relations to the

study and the positive outcomes that contributed to their willingness to relate

to family, friends, and social systems?

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TCC Reintegration Questions

Table 33 presents the results of the Question 30: How do you feel about Tai Chi

Chuan as an exercise intervention? One hundred percent answered, “Tai Chi Chuan is a

great intervention for their condition.”

Table 33

Question 30: How do You Feel about Tai Chi Chuan as an Exercise Intervention?

Veteran Participant (VP) Response VP1 10 VP2 10 VP3 10 VP4 10 VP5 10 VP6 10 VP7 10 VP8 10 VP9 10 VP10 10

Note. The question was scored on a 1-point Likert Scale with 1 being no impact and 10 being positive.

Table 33 presents the results of the Question 31: How do you feel about group

interaction during therapy? Twenty percent answered, “They felt favorable about the

group interaction during therapy;” 30% answered, “They felt highly favorable about the

group interaction during therapy;” and 50% answered, “They felt positive about the

group interaction during therapy.”

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Table 34

Question 31: How do You Feel about Group Interaction during Therapy?

Veteran Participant (VP) Response VP1 9 VP2 8 VP3 9 VP4 10 VP5 8 VP6 9 VP7 10 VP8 10 VP9 10 VP10 10

Note. The question was scored on a 1-point Likert Scale with 1 being no impact and 10 being positive.

Table 35 presents the results of the Question 32: Are you comfortable in a social

setting? Ten percent answered, “I above average comfortable in a social setting;” 10%

answered, “I am more comfortable in a social setting;” 20% answered, “They feel highly

comfortable in a social setting;” and 50% answered, “They positively comfortable in a

social setting.”

Table 35

Question 32: Are You Comfortable in a Social Setting?

Veteran Participant (VP) Response VP1 7 VP2 10 VP3 9 VP4 8 VP5 9 VP6 10 VP7 10 VP8 10 VP9 10 VP10 10

Note. The question was scored on a Likert Scale being 1 is uncomfortable and 10 being positively comfortable.

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Table 36 presents the results of the Question 33: How prepared are you to

connect with your social support system? Ten percent answered, “They feel comfortable

connecting with their social support system;” 10% percent answered, “They are highly

comfortable connecting with their social support system;” and 80% answered, “positively

comfortable connecting with their social support system.”

Table 36

Question 33: How Prepared are You to Connect with Your Social Support System?

Veteran Participant (VP) Response VP1 8 VP2 10 VP3 10 VP4 10 VP5 10 VP6 10 VP7 10 VP8 9 VP9 10 VP10 10

Note. The question was scored on a Likert Scale being 1 is uncomfortable and 10 being positively comfortable.

Table 37 presents the results of the Question 34: Would you continue the practice

to help with connecting with people? One hundred percent answered, “Yes, they would

continue to practice to help with connecting with people.”

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Table 37

Question 34: Are You Comfortable in a Social Setting?

Veteran Participant (VP) Response 1=Yes, 2=No VP1 Yes VP2 Yes VP3 Yes VP4 Yes VP5 Yes VP6 Yes VP7 Yes VP8 Yes VP9 Yes VP10 Yes

Note. The question was scored on a 2-point Likert Scale with 1 being Yes and 2 being No. Surveyed Veterans Participant’s TCC Reintegration Interview Summary

The mean score reflects the veteran participant’s attitude and perceptions of the

TCC Therapy. The veteran participants started as newcomers to Tai Chi. The fourth

session indicated a growing connection with each other. The final interview revealed a

willingness to understand the value of social connection with the group and with family.

The Tai Chi Instruction informed the researcher that the veteran participants

comment that the researcher was professional and comfortable for them. The interviews

were trustworthy, honest, and non-threatening. Cultivating a manner of professional

confidence, the sense from the Tai Chi Instructor felt the veteran participants had nothing

to worry about because the researcher knew what he was doing.

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Table 38

Surveyed Veterans Participant’s TCC Reintegration Interview Summary (N=10)

Question Mean Score

Decline to Answer

Q1. How do you feel about the Tai Chi Chuan Exercise intervention?

10.0 0.0

Q2. How do you feel about the group interaction during therapy?

9.2 0.0

Q3. Are you comfortable in a social setting? 9.3 0.0 Q4. How prepared are you to connect with your social support system?

9.8 0.0

Q5. Would continuing practice help with connecting with people?

1.0 (10) 0.0

Table 37 shows the mean score of the five questions relating to the Tai Chi Chuan

Psychosocial Reintegration Model and the efficacy of TCC Therapy. The collective

opinion of all veteran participants of Tai Chi Chuan was positive and empowering in

context of the research question. For example, the willingness to connect with their

familial and social support systems demonstrated a significant shift in perception as it

relates to their personal identity. The data show growth in five of the six theories of

TCCPRM. The researcher posits a relationship between the TCCPRM and psychosocial

reintegration.

The researcher conducted interviews with clinicians who have a history of

treating clients and patients with external and internal traumatic brain injuries. Their

responses support the research study with empirical evidence from actual clinician

experience. The average clinical experience of the clinician is 30 years as clinical

psychologists. The Somatic Therapists have been in Movement Therapy the average of

10 years. Their inputs provide a richness to the anecdotal interviews with the veteran

participants.

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1. What is the relationship between an individual’s social support system and the

mental health relates to that people of social beings and need interaction with

others to survive, strive and succeed?

2. Does a social support system improve an individual’s well-being and why

means as social beings people have an opportunity to reflect their feelings,

ideas, and with others in their social systems?

3. What is the relationship between an individual’s social support system and

their personal identity means that the people with define themselves as with

the confines of their social frame of reference?

4. What is the relationship between an individual social support system and their

ability to connect with others is the willingness to consider other perspectives

outcome their social biases and social inheritance (e.g., individualism and

collectivism)?

5. What is the importance of social connection relating to the value of people

feeling valued in their interaction with self and others?

Clinician Reflection Questions

Table 39 presents the results of Question 35. One hundred percent answered, “An

individual support system is important to mental health.”

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Table 39

Question 35: What is the Relationship between an Individual’s Social Support System and Mental Health?

Clinician Reflection (CR)

Response

CR 1 Mental health is extremely important, you know. No person is an island and even though some people believe that they are alone, and they can do things alone, nobody, nobody can be mentally healthy. By themselves, a human being needs to touch. Encounter.

CR 2 That relationship is one that I would identify as being Paramount social support system as far as I'm concerned, It can literally make the difference between whether a person evolves in a normal, healthy, a fashion of mental health or even in a situation where a person does display, uh, some indication or some sign of having a mental health issues. The social support system makes a tremendous difference regarding whether or not they get treatment and how successful they are in the treatment. Um, because of the, um, the very large amount of influence that individuals who are in our lives have upon, um, how we see ourselves, how we define ourselves, what we do, what we don't do, and what our, um, knowledge and information is and how we value thing is influenced by the social support system. So, I see that as being a, have a very key part of, of a person's mental health.

CR 3 We are only healthy, uh, and well in our community. So, um, after the, uh, after [inaudible] I am because we are because we are, therefore, I am so far people are essential that we have that community connectedness, that support system. Otherwise, it's really impossible to have optimal, um, mental health because our wellness actually in relationship to all community. It's not an individualistic, uh, endeavor has in a euro-centric, Umm, our creativity or psychology.

CR 4 I have seen anecdotally as well as the clinical settings and consistent with the research as well is that social systems in various strong variable in predicting the mental health, in being correlated with mental health. There is a very strong variable.

CR 5 It is very important for a strong social support system that understands the person and understand what they've gone through or as willing to understand what they have gone through. More important just to have people that support them for positive support to support them mentally, spiritually, physically, emotionally in any way possible.

CR 6 Some cultures, of course have a more communal basis, so the social connections would be extremely important in terms of the person's mental health as well as some of the basic issues like their identity and sense of self. Other cultures value individualism, individuation, self-reliance, and independence, so, they social relationships would be less

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significant and that type of culture, but still important. The culture's definition of mental health itself is important. In some cultures, if you hear voices you put on track to be a somatic practitioner. Just speak for the culture and other cultures, if you're hearing voices, they will give drugs. So, the definition of mental health would vary from one culture to another. In some cultures, when you are going to consider mental illness is attributed to demonic possession. Cultural rituals to deal with healing as opposed to say some other approaches that are a more middle class European based. Does that make sense?

CR 7 Very complicated for you in doing the peer support, mental health work and my own transition out of the military is without social systems, without social connection, we better for veterans. Is there anybody else we've seen distantly that a pure programs and community support on one of the main three elements that help people get better and readjust and I don't think that I could do my work as a mental health professional without my clients having the goal to better connect with someone or community.

CR 8 I don't think you can separate them. People are able to maintain the mental health. Yeah. People were made to be a sociable person and it's one of the three things that people need is companionship, is one of them. Well, they must be focused on.

CR 9 In considering the question, I think there is a direct relationship between an individual's social support simply in going over the use of those individuals I've met who's seeing this involved, meaning they had no specific support system and how they seem to be fairing in life and they seemed not to be doing well.

CR 10 In my opinion, it hinges on the nature of effectiveness of their ability to acquire and make use of social support. When we will begin with the premise that we are social beings, that our identity and our world. Looking for identity is an integration of what we learn, the knowledge that we have, our experiences, reflected appraisals that we take in from other people, and their reactions. That other people in their reactions too was in there. People manner of engaging us, give us information about who we are, about our identity becomes an integral in that interaction with other people. Those social interaction become a foundational component of our mental health.

Note. The question was measured by the experience of the clinician interviewed.

Table 40 presents the results of Question 36. One hundred percent answered, “An

individual support system is important to an individual’s well-being.”

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Table 40

Question 36: Does a Social Support System Improve an Individual’s Well-Being? Why?

Clinician Response

CR 1 Well, since you said that well-being a subjective evaluation, there are people who has been an imbalance; other people you need them. You need a social system where you can communicate. This might sound primary but loved is important.

CR 2 Yes, the support system can have a very influential role in improving a person's well-being for a couple of reasons. Number one, depending on, um, the, the physician that individuals in the support system take, if they understand the importance of good mental health, then they can be a key factor in helping that person to stay healthy as they can provide them with a positive information about themselves, positive information about the importance of having a support for their mental health and also, um, help to keep that individual in a realistic, uh, and, and I'm functioning re reality relationship was the world around them. So, I hope I'm making sense with that.

CR 3 Oh, absolutely. Particularly if it's a healthy support system, we do know that, um, in our community, there are some, some clinical support systems which toxic mess because of are the nature of the people who are involved with it support systems. So, we're using a support system with the, uh, qualification that the support system has to be healthy and well in order for the individual to be healthier and well until a pain, an optimal, um, um, mental health. A wellness. Yeah. And um, yeah, that's all I'll say about that have to be a healthy one.

CR 4 Absolutely. I think in terms of outlook, a physical activity health, maintaining behavior, and just mood management across the, across the board. There is a variety of ways in which it helps individual’s well- being. Social support systems provides more energy, provides an intellectual stimulus, provides a positive reinforcement for positive behaviors in a variety of ways in which it demonstrates that we're very social animals, so it helps her well-being.

CR 5 Yes, it very much. We are very much driven by pretty much wanted to connect. So, to have a positive support system, um, is always beneficial to that.

CR 6 Well, again, culturally conditioned, but generally I would say yes. The research supports that there is a study that was done by a social worker in Washington state by the name of Clark and he attributed four primary factors to reducing recidivism on the part of a substance using clients that had a criminal justice background. The first one was 40 percent was the client's own motivation to change, of course, is always the primary factor. Fifteen percent to what he called a hope of the cognitive behavioral therapy. People call it hope, the motivational interview

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people call it confidence. The person who actually believe they are going to get better themselves. Thirteen percent are the counseling techniques and methods is used in working with the client. The 30 percent of the recidivism factors were attributed to healthy relationships. The research said that if someone is involved in an intimate partnership or marriage that encourages them to meet their treatment goals it reduces prevents recidivism. The research would support that on someone's social relationship are affecting not only in mental health but in an ability to complete a treatment and recovery.

CR 7 I think it's going to depend on the social support system. A healthy support system, absolutely. Um, but some of the data that's just come out indicates the people that come home off deployments into a family setting are actually at greater risk for suicide and self-harm. I think a well-informed, well- coordinated social support system is probably one of the best ways to get some food better. I think a poorly coordinated in a poorly informed social support system can do more damage than anything else.

CR 8 Otherwise they won't be an island unto themselves and then they cannot improve. There's just no way to have improvement. You have to be social.

CR 9 I believe so. As long as it is a positive support system, those children who are in negative environments can only copy what they see. Those children who are in strong positive environments, I do believe regardless of peer pressure, they will grow up at some point. It may be that they will venture away for a while, but I honestly believe that anchored in that growing up in that environment, that that will be their lifestyle that they choose to emulate.

CR 10 It does and does not. It does not inherently do that. The capability of doing that has the capacity to our social experiences, a capacity to enhance our sense of wellbeing or detract from my sense of wellbeing.

Note. The question was measured on the subjective experience of the clinician interviewed.

Table 41 presents the results of Question 37. One hundred percent answered, “An

individual support system is important to an individual’s well-being.”

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Table 41

Question 37: What is the relationship between an individual’s social support system and their personal identity?

Clinician Response CR 1 Lot of people identify with something. There are so social support

system on who they are usually surround themselves with like-minded people.

CR 2 That takes me back to that saying in the, you know, in, uh, the African tradition of who going to I am because we are and we are because I am. So, your social identity a is defined. I mean W, we see ourselves or perceive ourselves as being reflected up by those who are around us. And so, our identity often times is determined by the feedback and the information that we get from others, particularly key individuals that are in the family that are in the community, um, that are in various key social structures such as, um, the school, um, our, um, avenues for, for our religious or spiritual expression. Um, individuals who are in all of those key environments help us to, to know and understand who we are.

CR 3 Well, I'm very real census where people are personally. I do the three well ties into a connection, a correctness as well as our support system. Um, so we oftentimes have, that's a, it will be, I'm looking graph filth. We get along of feedback from our support system, but who we are and the value, the rehab to them, um, off of them some information about, um, uh, the, the surf rep still value that we have an individually.

CR 4 I always thought that was a very interesting question. Hippocrates 2000 years ago said that a man alone is not a man. And what he meant by that was if we need to see reflected in each other's feedback. Being alone, it's very difficult to maintain an accurate personal identity. So, having a support system not only provides new ideas and provide accurate feedback and inspiration to do more healthier activities.

CR 5 In a lot of cases, every flex fully we are a set that we become people that we surround ourselves with soul self, with negative people. We tend to think that way versus if we are able to surround herself with people that support us and love conditionally, um, we cannot help but track some of that energy and able to pretty much reflected out from ourselves and our work to other people.

CR 6 I would say strong. Unfortunately, that could be good or bad on the positive sense as there, a sense of self to meet her later determined and the environment is positive. Then again, it reinforces their mental health and ability to change and motivation to change and a positive sense. So however, if it's a negative peer group, then it reinforces a behavior. It can have negative consequences for the individual.

CR 7 I think our personal identity comes from being reflected in others. The emotions, guilt and shame are directly correlated to how we relate

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ourselves to groups and what we see in ourselves and how that's reflected in others.

CR 8 I think you'd have to have quite a bit of social going to have an identity I how you measure it.

CR 9 I possibly answered this question of the previous answer. CR 10 Because I said earlier, our identity are components of how people react

to us and how we respond to them. When people react to us, we get the reflective appraisals of ourselves that when people react positively, what they are saying to us is you're okay. When they react negatively to us, they're saying there's something about you or something about your behavior that I disapprove of, so you're not.

Note. The question was measured on the subjective experience of the clinician interviewed.

Table 42 presents the results of Question 38. One hundred percent answered, “An

individual support system improves an individual’s well-being.”

Table 42

Does a Social Support System Improve an Individual’s Well-Being/ Why?

Clinician Response CR 1 For your social support system connecting with other people it is a

fundamental primary skill. You can learn how to be your support system, tells you who you are. They do not pull punches. So, you do not have a group of people telling you yes, yes, yes, because that's what you want to hear. They do not lie to you.

CR 2 Their ability to connect with each other. We learn from individuals in our support system, how to be in relationship with other people. So, if we have people in our support system who, um, display healthy behaviors around being in relationships, we are likely to mimic that. And if they display unhealthy behaviors around being in relationships with others, we are oftentimes likely to mimic that as well. So, we repeat that behavior which we are exposed to. Um, so we are learning all the time, uh, just by being in the company of other people, um, how to be in a relationship. And I to be dominant, am I to be equal in this relationship? Am I, it should be a supportive or you know, whatever behaviors we see. We repeat that.

CR 3 Individual support system that really through social practice into our interactions with the health and have a healthy relationship with the wider community. Um, outside with off support system.

CR 4 That's an interesting question between the support system and their ability to connect with this. I am having a support system in place and mix us more opportunities to connect with others. I am having a support system implies some familiarities are recognition of a sense of belonging. I think all that improves the ability to connect.

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CR 5 If they don't have this, it's just like the nature versus nurture thing. We are taught by our, so routing either communicate or just to withhold if we don't have a support system that allowed, that tend to be more inclusive with our feelings. But if we have a system that allows us to be open and freely that we weren't able to able to express ourselves in a better way, which increases positive mental state and just be able to not hold in our feelings and our world.

CR 6 How we develop relationships and maintaining relationships is something that we've learned as part of the cultural socialization process. Relate to the same gender relate to another gender, how to relate to people that are liking how to relate to people that are not like you are all part of the socialization process in our culture for that matter. Any culture. How do I want to socialize to relate to others is a big component of a situation?

CR 7 It's going to depend on how broad their support system becomes. I think in the veteran community, ours can be quite limiting. I think a lot of times will self-isolate. When I was running a pure support programming on campus, we would have veterans that would not leave the veteran's office except to go to class and back. They never responded with any other social groups on campus. Um, I saw different families that were involved in churches doing outreach that we're much more broadly impactful on in a community rather than just a small subset.

CR 8 If they don't have a social support system and they can't connect without that connection. They're an island to themselves.

CR 9 I think it's vital. I think children who grow up in an isolated environment definitely have a problem in relating to others, the larger the social system and especially the positive social system, uh, and the more support that one receives, the more likely one is going to emulate that and then be a, an adult who can also give support to others if you have no idea what support is you're virtually incapable of sharing or giving to others.

CR 10 That's a complex relationship. It is a dynamic and diabetic. The communication, the interaction is by directional. When we explained this, when we are interacting in social relationships, we are building up or detracting from our sense of wellbeing. It's almost never neutral.

Note. The question was measured on the subjective experience of the clinician interviewed.

Table 43 presents the results of Question 38. What is the importance of social

connection? One hundred percent answered, “An individual support system improves an

individual’s well-being.”

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Table 43

Question 39: What is the Importance of Social Connection?

Clinician Response CR 1 It's primary. It's fundamental. As I said before, no person is an island.

Every person needs need some social needs, social skills, and you need to be in a position where you connect with other human beings because not like mine, but people who touch, feel. That's just human nature. You've got to have that. Otherwise you'd die.

CR 2 Well, how do I say that in a few words? What is the importance of social connections? Let me express it this way. Without social connection, I can't imagine how human beings would exist without social connection. Uh, we would not have a sense of ourselves. We would not have a sense of our place in the world around, us. You know, what's coming to mind for me right now is that one of the, uh, most stringent and, and punishments that a person might receive is to the, to a situation where they have no human contact, where they are literally in solitary confinement. That is, that is a method of punishment. And individuals who are placed in those types of situations usually come out of it. Um, I don't even know what the word is to express, ah, they come out of it in a stupor when they are taken out of solitary confinement because they don't have human interaction. And so, interaction with other human beings and the ability to see ourselves reflected, uh, with other human beings is, um, is paramount to us being able to survive a book, a mental, emotional, and even our physical survival because that's how, you know, we learn from, from being in a group, um, and we learn how to take care of ourselves and literally how to be in the world.

CR 3 Well, centric perspective is essential central r, d, this being um, um, Camille if very crucial that we have a social connection with others. In fact, that informs us of all of status, uh, and wellness, um, with our own, uh, a fear of personal fear. So, to be connected from an interaction with others is a very unhealthy state. We're not individualistic as people. Uh, even though some have been assimilated into your centric thinking to the 20 fifth, they would look answer, ability to be detached from their community as being one of the wellness when in reality it's a sign of their pathology and their illness.

CR 4 Again, as I have said above, we are not, we're not designed. Our neurology does not support as being isolated. The research shown that isolated individuals administrative segregation in the penal system to be very injurious to mental health. Some kind of social connection needs to be in place for optimal living.

CR 5 It is very important for a strong social support system that understands the person and understand what they've gone through or as willing to understand what they have gone through. More important just to have

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people that support them for positive support to support them mentally, spiritually, physically, emotionally in any way possible.

CR 6 Physical promoted, but positive social relationships want them along a, we belong to families. We belong to groups we belong to. Cultures are important though. Then what other people think of someone is what they think of themselves. Like my father used to say what people call you, what to answer to. So, learning what cohort group is most important to the individual himself or herself. Making assumptions. I think it's important in general, but it's certainly important for clinicians.

CR 7

I think the importance of social connection is paramount. I think there's a reason why it's considered torture to leave somebody in isolated confinement, um, for too long a time. I think that at the end of the day, we're primates and without some kind of social connection, we were on a vine and die.

CR 8 For me, I could care less, but at my age I've had plenty of sociability and as I've gotten older I've turned more inward. Now for a lot of people, especially the millennials, they will have a social connection there, like dead parents. You've seen that transition. Okay. That makes sense to me. Have to have your own identity at work. If you don't, then you can't progress, and management doesn't recognize you, so you're kind of forced in a way for that. As you build your connections or network, which helps you get your work done, do need to have questions about something or you can't figure it out, you call up part of that network and then they can help you with that. They all. That is also very fulfilling to the people you call because they feel like they're unnecessary part in your life.

CR 9 We are a social civilization, uh, to work your way through this oral. I definitely really believe you need to be able to not only socialize but to understand the levels of socialization where one, sometimes lift be reticent, that uh, not everybody likes a thoroughly outgoing connection that, uh, you must be aware enough of human behavior to be able to navigate the ins and outs and the variety of people that one will meet during this journey through life. So, I think it's very important.

CR 10 We require connections to other people. To other human beings and in order to establish both our identity and to maintain a psychological sense of will be a without those social connections we are, we're like slowly on.

Note. The question was measured on the subjective experience of the clinician interviewed.

There is a relationship between social connection and reintegration into

psychosocial systems. The researcher conducted interviews with Somatic Movement

Therapists who have a history of treating clients traumatic brain injuries. Their responses

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support the research study with empirical evidence from actual clinician experience. The

average experience of the therapist is 10 years in Movement Therapy. There inputs

provide a richness to the anecdotal interviews with the veteran participants. There were

five questions in this section presented to veteran participants.

1. What is the relationship between movement and mental health of an

individual means that the literature states there is a connection between

movement and behavioral presentations such as depression?

2. Does movement improve an individual well-being relates to the development

of new neuropathway when movement is part of an exercise program to

increase a sense of accomplishment?

3. What is the relationship between movement and mental health of an

individual personal identity relates to the level of self-efficacy and self-

agency?

4. What is the relationship between movement and connecting with others means

that individuals are engaged in social activity which increases an opportunity

to connect with others?

5. What is the importance of movement relate to a change in sedentary behavior

to active engagement in physical movement that improves health conditions?

Somatic Movement Therapist Questions

Table 44 presents the results of Question 40. What is the relationship between

movement and mental health of an individual? One hundred percent answered, “The

relationship between movement and mental health is vital to the individual’s well-being.”

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Table 44 Question 40: What is the Relationship between Movement and Mental Health of an Individual? Somatic Movement Therapist (SMT)

Response

SMT1 So, as I just mentioned, um, the body and mind isn't inseparable. They move as one unit and not a separate unit. So, any information that the brain receives a moose, it's the body receives it through all of our sensory, um, our senses. And then from there is integrated into the nervous system and then it gets cataloged pretty much into the brain. So, um, our environment can trigger mental health if we are already pre-disposed to it or it can also, um, cause whether you're abusing substance abuse, which can trigger a mental health as well. So, um, movement itself is the language for the body. And so, the body, um, move to, to be able to relate with this environment, to build attachment, um, as well as to regulate itself. Then in turn, um, the brain knows what to do and whether there is some level of disconnect, so concern in the processing of how one, um, social emotional development, then it enhances and, or create the brain, the ability to digest what's happening with movement and proved and individual's well- being.

SMT2 Movement/dance offers an awareness and connection between the mind and the body. Through this connection, individuals are able to express themselves through the use of body movements that might communicate ideas, beliefs, thoughts, feelings, or aspects of ones’ culture. Movement/dance also helps to decrease stress and increases individuals’ ability to manage their moods.

Note. The question was measured on the subjective experience of the clinician interviewed.

Table 45 presents the results of Question 41. Does movement improve an

individual’s well-being? One hundred percent answered, “Movement improves an

individual’s well-being.”

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Table 45

Question 41: What is the Relationship between Movement and Mental Health of an Individual?

Somatic Movement Therapist (SMT)

Response

SMT 1 And why, of course it does, of course it does lose me. Whether it's on a micro or macro level. Movement is always, um, we'll move you to well-being because again, that's the language of the body. And when the body can move, whether it's blinking, I am snapping your fingers, moving your arms, swinging your arms to jumping. Um, the body is able to take that energy and disperse it in it's correct place so that you're looking at supporting mental health to physical. So, number three, what is the relationship between movement and individual's personal identity, movement and the personal.

SMT2 Movement and dance improve physical, emotional, and psychological well-being. In terms of physical well-being, movement and dance increase flexibility, muscle strength and tone, endurance, balance, coordination, and cardiovascular conditioning. Movement/dance also offers a great way to burn calories and maintain weight. In terms of emotional well-being, movement/dance helps individuals to decrease or manage stress and to decrease symptoms of anxiety and depression, as it enables individuals to become more aware of their thoughts and feelings and to express them in a healthy way. In terms of psychological well-being, movement/dance helps individuals to feel a sense of contentment or satisfaction with life in general, as they achieve improved body image, increased self-esteem, and greater self-worth.

Note. The question measured on the subjective experience of the clinician interviewed.

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Table 46

Question 42: What is the Relations between Movement and Mental Health of an Individual’s Personal Identity? Somatic Movement Therapist (SMT)

Response

SMT1 Yes, it does. It does. What is the relationship between movement and connecting various, yeah, so and next and that attachment that I mentioned at the beginning of the first question, our ability to make attachment bond as it relates to others have to do with the bio chemical relationship that we have with each other. One can could get disconnected at, through development, trauma at birth, um, and that the connection between the parent and I'm the whole dean and making connection where the child is learning during those gestures on a biochemical level of how to attach, how to relate with one another. Um, and so, it's not movement itself, but it's the body. And I want you to remember that the movement is the language of the body. So, the body is what has to execute movement. Other than that, there is no movement from breath to blinking of the eyes from your digestive system, moving your part b to your arms, moving your legs moving and how you, how you're moving through the world. So, the connection is a, it's the through the body and the movement is the execution.

SMT2 The relationship between movement/dance and an individual’s personal identity can be viewed as the non-verbal expression of self that movement provides, as it offers a way for individuals to express their personality and to express their personal thoughts, feelings, ideas, beliefs, and/or aspects of their culture. Through non-verbal expression, movement allows individuals to express who they are as a person and enables them to feel a greater sense of self-worth.

Note. The question was measured on the subjective experience of the clinician interviewed.

Table 47 presents the results of Question 43. What is the relations between

movement and mental health of an individual’s personal identity? One hundred percent

answered, “There is a relationship between movement and personal identity.”

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Table 47

Question 43: What is the Relations between Movement and Mental Health of an Individual’s Personal Identity?

Somatic Movement Therapist (SMT)

Response

SMT1 Yes, it does. It does. What is the relationship between movement and connecting various, yeah, so and next and that attachment that I mentioned at the beginning of the first question, our ability to make attachment bond as it relates to others have to do with the bio chemical relationship that we have with each other. One can could get disconnected at, through development, trauma at birth, um, and that the connection between the parent and I'm the whole dean and making connection where the child is learning during those gestures on a biochemical level of how to attach, how to relate with one another. Um, and so it's not movement itself, but it's the body. And I want you to remember that the movement is the language of the body. So, the body is what has to execute movement. Other than that, there is no movement from breath to blinking of the eyes from your digestive system, moving your part b to your arms, moving your legs moving and how you, how you're moving through the world. So

SMT2 Movement/dance offers a way for individuals to connect with others, as it provides a means of non-verbal communication and direct expression of thoughts, feelings, and ideas through the use of body movement. It also improves individuals’ ability to cooperate with others and improves relationships through enhanced communication skills.

Note. The question was measured on the subjective experience of the clinician interviewed.

Table 48 presents the results of Question 44: What is the importance of

movement? One hundred percent answered, “Movement is important to an individual

development.”

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Table 48

Question 44: What is the Importance of Movement?

Somatic Movement Therapist (SMT)

Response

SMT1 All of that is language and language in a nonverbal, um, on a, on a non-verbal level. Um, because that's how the body, that's how the body communicates. The importance, I guess, to just wrap everything up that we just finished talking about, the importance of moved from there is the body's way to integrate all of the information that it has received from, from the eyes, ears, nose, taste, touch, the whole gamut. All of what the senses and received the movement helps integrate it so that the nervous system knows what to do with it as well as Senate.

SMT2 Movement/dance is important because it provides a connection between the mind and body; allows individuals to become more aware of the connection between their emotions and motions; offers a means of direct expression of individuals’ personality, thoughts, feelings, ideas, and beliefs; allows individuals to use their creative imagination; improves self-worth; improves communication skills; and promotes a general feeling of well-being through decreased stress and improved physical, emotional, and psychological well-being.

Note. The question was measured on the subjective experience of the clinician interviewed.

Demographics

The term demographics refers to characteristics of a population. The word is

derived from the Greek words for people and picture (Salkind, 2010). Examples of

demographic characteristics include age, race, gender, ethnicity, religion, income,

education, home ownership, sexual orientation, marital status, family size, health and

disability status, and psychiatric diagnosis. Demographic information provides data

regarding research participants and is necessary. Demographics determines whether the

individuals in a study are a representative sample of the target population for

generalization. Research participant characteristics are reported in the methods section of

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the research report and serve as independent variables in the research design.

Demographic variables are independent variables because they cannot be manipulated

(Salkind, 2010). The demographics of the veteran participants were African Americans

(AA), White Americans (WA), and Hispanic Americans (HA).

This table represents interviewed veteran’s participants considered for the

research study. There were 29 invitations to veterans to participate in the research study.

Fifteen of the veterans declined. Four volunteered and 10 were selected for the study.

The number accepted into the study would provide saturation for the study. Saturation is

defined as data satisfaction. It is when the researcher reaches a point where no new

information is obtained from further data (Leong & Austin, 2006). Ten participants were

the saturation point determined for this research study.

Table 49

Q45 - Interviewed Veteran Population (N=23)

Interviews Participants Declined 15 Volunteered 4 Selected 10 Totaled 23

This table presents data regarding the age of the veteran participants. Fifty

percent (50%) were in the age group 65-75. Forty percent (40%) were in the age group

of 55-64. One percent (1%) were in the 35 to 54 group. Interviewees in the 18 to 34

range declined to participate in the research.

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Table 50

Q46 - Age of Veteran Participants (N=10)

Age Range Percentage % 18-34 0% 35-44 10% 45-54 0% 55-64 40% 65-75 50% 10 100%

Table 51 represents the ethnicity of the veteran participants. The criteria for the

study was (a) you were veteran and (b) you had a brain injury. The ethnicity of the

veteran participants was not a factor in the study.

Table 51

Ethnicity of Veteran Population (N=10)

Age African Americans Hispanic Americans White Americans 18-34 0 0 0 35-44 0 1 0 45-54 0 0 0 55-64 5 0 0 65-75 0 0 4 Total 5 1 4

Data Analysis

The first step of analysis involved reading all the interview data. This step

provided familiarization and a platform for understanding the general experiences of

the veteran participant. The researcher will follow the qualitative process delineated by

Smith and Firth (2011) of transcribing, content analysis, summarizing, and preparing of

reports.

The second step was to observe the veteran participants in the Tai Chi Chuan

class. The researcher's observations were an hour in duration over an eight-session

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period. The data included detailed observational notes made during each session. The

observations contained information about the session and the researcher interpretation of

the veteran participant's reflection on their experience.

The third step, the researcher transcribed and edited the interviews from the

digital recorder from each interview. The data were separated into meaning units that

represented themes, terms, attitudes, or experiences (Creswell, 2009; Moustakas, 1994).

The researcher manual analysis was the primary method to find patterns and themes. In

addition, NVivo 11 Pro software was a secondary tool to identify patterns and theme.

Both the researcher’s and NVivo 11 Pro analysis produced comparable results of the

veteran participant's experiences.

Qualitative Interview Results

Delivery. A prominent issue in this study was the matter of delivery of the

questionnaire. This researcher concluded that for this study, the participants could submit

completed questionnaires to the researcher by email, by postal service, and or in person at

the time of the in-person interviews. The questionnaire was provided in written form and

presented during the oral interview. Questionnaire analysis and interviews were used to

collect large amounts of qualitative work for this study. The interviews followed a

systematic process.

Interview process. Qualitative interviews were the primary vehicle for data

collection with observation during the therapeutic intervention. Patton (2002) wrote

about three types of qualitative interviewing: (a) informal, conversational interviews, (b)

semi-structured interviews, and (c) standardized, open-ended interviews. The synthesis

of the three interviews were used in this study. This would allow phenomenological

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reduction, (a) delineating meaning, (b) themes formation, (c) extracting general and

unique themes, and (d) summarizing and validating each interview (Maher, 2007).

The researcher used NVivo 11 as the secondary tool in this qualitative research

study. Qualitative researchers use a small sample size because it is a rigorous and

systematic method (Moustakas, 1994). The researcher interviewed 10 veterans with a

history of mild traumatic brain injury and traumatic stress disorder. The researcher and

each participant agreed upon a time and place for the interview.

The interview location requested by the veteran participants included the TCC:

therapeutic intervention location at 2BFIT Injury Prevention and Specialty Fitness in the

Aurora Town Center Aurora, CO, and local telephone calls from the Denver

Metropolitan Area to the veteran participant. The researcher began the interview process

by having the veteran participant to sign through completion of the demographic form

included as Appendix E and asking the participant to sign the consent form included as

Appendix G. The process was informal and began with an informal conversation

between the researcher and veteran participant. The researcher then asked semi-

structured questions.

Then the researcher asked the veteran participants to describe their military

experiences that relate to this research study. A complete list of the questions asked of

each participant can be found in Appendix I. The interview continued until the 39

questions were exhausted in each individual interview with each veteran participant.

According to Sobell, Manor, Sobell, and Dum (2008), one strategy in good

interviewing is the use of Motivational Interviewing (MI) Strategies and Techniques.

The strategies of motivational interviewing are more persuasive, supportive, and

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efficacious than other techniques. This researcher engaged the veteran participant with

a strong sense of purpose, clear strategies, skills for pursuing that purpose, and a sense

of timing to intervene in particular ways at incisive moments. A summary of the

Motivational Interviewing Strategies and Technique: Rationales and Example are in

Appendix O.

This researcher used detail-oriented probes throughout the ten interviews.

Elaboration probes encourage the interviewee to tell the researcher more (Patton, 2002).

Clarification probes ask for clarification, communicating that it is the interviewer’s

difficulty in understanding the response and not the fault of the interviewee responding

(Patton, 2002). Examples of probes the researcher used to prompt participants for more

detailed answers include: (a) “please tell me more about that” and (b) “could you

provide examples?”

The taped interviews. According to Anyan (2013), the interview is the most

readily used tool to collect qualitative data. During the interviews, the researcher

developed a good rapport with the participants, used a superior interviewing technique,

and asked questions so the veteran participants felt capable of speaking freely. The

confidentiality of the participants and study data were protected by making sure the

veteran felt secure with the location and environment chosen for the interview.

Field notes were taken to document observations about the mood, manner, tone,

speech, and body language. This task was easier to carry out because different veterans

requested interviews in uncommon places: a local restaurant, meeting rooms, public

library, and by telephone via long distance. Research data from veteran participants

were collected, managed, and secured using True Crypt. True Crypt is an open

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source encryption software. In addition, the research data are secure using an

encrypted USB flash drive call Iron Key. Iron key uses 128 key Encryption Algorithm

to secure and encrypted data to ensure confidentiality.

To ensure confidentiality, any information that identified the participant or

anyone named in the interview by the participant was removed or replaced with a code

known only to the researcher. Any veteran participant who declined to continue

participating or ceased to participate withdrew from this study without consequence.

The veteran participant’s responses were not to be quoted or referenced in the research.

No veteran participant chose this option. A transcript for each participant interview was

prepared. The data from the recorded interviews were organized, analyzed, and

synthesized to form structural meaning and essence (Moustakas, 1994). The intent of

the study was to illuminate the findings derived from the participants’ descriptions of

those experiences.

Emergent Themes

Traumatic brain injury can change the way a survivor feels and express emotions.

A litany of emotions was experienced by the VPs. The researcher identified five

reoccurring emergent themes that VPs identified during the eight-week therapeutic

session of Tai Chi Chuan. The identified themes were: (a) Anger, (b) Fear, (c) Familial

Support, (d) Judgment, and (e) Social Isolation. The researcher has named the five

emotional variables as the Five Interactive-integrated Emotional Limits Decision-making

(FIELD).

Emergent theme anger. Anger can be an important clinical problem after any

traumatic brains injury. The VPs expressed during the interviews experiencing

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symptoms of irritability to outbursts. These emotional expressions were evidence after

the brain occurred. Anger does not self-remit after an expression of the emotion; it

becomes problematic irritability and has been linked to unfavorable social outcomes such

as family problems, social isolation, and loss of employment (Hart et al., 2017).

The research study focused on familial and social reintegration of VPs after a

brain injury. Based upon the research question, the relationship between a traumatic

brain injury and the FIELD was not entertained. The concerns about anger was not

related to the TBI. Fear is a mask to protect the individual from emotions their

presenting to others and themselves.

Emergent theme fear. Fear is part of the emotional cocktail experienced by the

VPs. The antecedent to fear is anxiety. Anxiety is a somatic first step to a brain injury

survivor fear. VPs share this statement, “I not sure why I feel this way.” The VPs are

having a normal physiological response to a traumatic brain injury. The VPs were

informed that non-poly-pharmacy therapies are available to treat their anger. TCC is one

approach to managing the emotional cocktail.

Reflection on fear. The VPS were comfortable sharing their experience with

other VPs. According to Salas (2016), “Sameness” is an important concept that unite

individuals from different backgrounds. The eight-week session created an environment

to communicate in a safe space. VPs requested counseling resources to educate

themselves on traumatic brain injury. A resource list was provided upon request to the

VPs.

Emergent theme familial support. Family and friends provide help for VPs

struggling with mild traumatic brain injury. VPs stated the value of their spouse’s

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acceptance, support and understanding. Their spouse’s acceptance, support, and

understanding provided validation, valuation, and voice for the VPs to begin the

reintegration with a social support system. The family reintegration therapy according to

Hinojosa and Hinojosa (2011), emphasizes that social support system is vital in recovery

from an injury. In addition, this theory is a part of the conceptual model for the Tai Chi

Chuan Psychosocial Reintegration Model (TCCPRM) that supports sustainability of

health outcomes results from TCC as a therapeutic intervention.

Reflection on familial support. The VPs communicated the importance of a

family and social support system in their lives. VPs were concerned that family and

friends did not understand their brain injury and co-occurring behavioral presentation of

post-traumatic stress disorder. The VPs admitted a lack of knowledge as evident in their

answers during the screening process. However, VPs were interested in psychoeducation

for themselves and their social support group. Social support group for this study are

families and close friends.

Emergent themes judgment. VPs who participated in the study reveal the

challenge of making timely judgments. There patterns of judgment were singular based

upon the events leading to a judgment. For example, a VP mentioned they made a family

judgment without consulting the family members. In the previous decisions, the VP

includes the entire family system. A brain injury can affect the prefrontal cortex or

executive decision-making process. According to Rowley (2017), individuals with a

traumatic brain injury can engage in counter-intuitive moral judgment. This often occurs

when there is a moral dilemma and the brain survivor makes a utilitarian judgement.

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Reflection on judgment. VPs were responsive during the interview process.

Disclosure of their concerns was encouraged and limited to the research question. The

TCC therapy help the VPs consider options to help themselves and manage the dynamic

of the FIELD. The VPs know of how the FIELD can affect the quality of the familial and

social support systems.

Emergent themes social isolation. Social isolation is a common theme as

reported by veteran participants with mild traumatic brain injury. The lack of clinical

information on physical, cognitive, and behavioral changes resulting from an injury

contributed to the veteran participants becoming less socially active. In addition, they

experienced a significate decrease in social interaction with family and friends. The

decision to engage in social isolation was not a volition choice. The veteran participants’

conscious and pre-conscious must protect themselves from the FIELD became a

challenge for family members and friends.

Reflection of social isolation. The social identity theory by Tajfel and Henry

(1979) utilized to develop the Tai Chi Chuan Psychosocial Reintegration Model,

addresses this concern. WPs explored the impact of their mTBI condition on family and

social groups. The goal of this research is to facilitate the veteran participants’ subjective

account of the challenges encountered in reintegrating and establishing family and

friendship connections. In addition, the TCC group could assist in (a) the veteran

participants gaining insight into their understanding of such difficulties and (b) facilitate

identity reconstruction.

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Summary

The results of the Brief Traumatic Brain Injury Screen (BTBIS) administrated to

all veteran participants. The BTBIS indicated a form of mild traumatic brain injury based

upon the self-report of the VP. The BTBIS, in-depth interview, a personal narrative is the

rationale for this researcher’s statement. The primary causes of TBIs in the veteran

participants were falls, motor vehicle accidents, being struck by an object, and assaults.

After the initial brain injury, 80% to 100% of the veteran participants experienced one or

more symptoms related to their injury (e.g., headache, dizziness, insomnia, impaired

memory, and/or lowered tolerance for noise and light). Usually an mTBI of the patient

returns to their previous level of function within three to six months.

However, the military culture does not lend itself to disclosure of personal injury.

Seeking medical and psychological treatment for traumatic brain injury is a career ending

decision. Veterans predispose themselves to the development chronic post-concussive

symptoms. These symptoms manifest as somatic, cognitive, and emotional presentations.

The following is a list of presentations experienced by veteran participants: headache,

tinnitus, insomnia, memory, attention and concentration difficulties and irritability,

depression, anxiety, and behavioral dysregulation. In addition, veteran participants who

have experienced mTBI during the military service are also at increased risk for

psychiatric disorders compared to the general population, including depression and

PTSD.

The primary causes of TBI in veterans of Iraq and Afghanistan are blasts, blast

plus motor vehicle accidents (MVAs), MVAs alone, and gunshot wounds. Exposure to

blasts is unlike other causes of mTBI and may produce different symptoms and natural

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history. For example, veterans seem to experience the post-concussive symptoms

described above for longer than the civilian population; some studies show most will still

have residual symptoms 18-24 months after the injury. In addition, many veterans have

multiple medical problems. The comorbidity of PTSD, history of mild TBI, chronic pain

and substance abuse is common and may complicate recovery from any single diagnosis.

Given these special considerations, it is especially important to research the hidden

injuries that occur from mild traumatic brain injury.

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CHAPTER FIVE: SUMMARY, FINDINGS, CONCLUSIONS, IMPLICATIONS,

AND RECOMMENDATIONS

Introduction

Chapter Five of this qualitative phenomenological research study includes a

summary of the research study, discussion of the findings, conclusions, implications,

recommendations, and summary drawn from the collected data. The findings provide an

overview of the study methodology and results. Implications for the field of study

include the application of Tai Chi Chuan Psychosocial Reintegration Model for use

veterans with mild traumatic brain injury. The Tai Chi Chuan Psychosocial

Reintegration Model, hereinafter, will be referred to as TCCPRM. The recommendation

section provides suggestions for future research in the field of study. Finally, the

summary discusses the findings, conclusions, implications, and recommendations of this

research study of Psychosocial Reintegration of Veterans with Mild Traumatic Brain

Injury.

Findings

This section discussed the findings of addressed the methodological triangulation

of utilizing questionnaires, observations, and in-depth interviews. Additionally, the

Defense Veterans Brain Injury Center Screening Instrument was the tool utilized to

identify service members with brain trauma (Baker et al., 2006), was used by this

researcher. The Brief Traumatic Brain Injury Screen (BTBIS) is a three question self-

report that indicated the researcher and the veteran participant an awareness of a potential

brain injury. The Brief Traumatic Brain Injury Screen, hereinafter will be referred to

BTBIS. The BTBIS is not a formal clinical instrument to detect, evaluate, and diagnose

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patients with traumatic brain injury. The researcher was able to utilize the BTBIS to

determine a veteran participant’s suitability for the research study.

Data collection and analysis were conducted to address the central research

question, and interview questions. The in-depth interviews or personal narrative

provided validation. Interviews included experiences that provide insight into the

research question as follows: “How does Tai Chi Chuan facilitate psychosocial

reintegration?” “How does the Tai Chi Chuan activities help with connecting with

people in your life?” The captured life experiences served as a Segway for individual

veteran participants’ reintegration into their social support systems. The Tai Chi Chuan

therapy sessions and observations were buttressed by the rich in-depth interview. Tai Chi

Chuan, hereinafter, will be referred to as TCC.

Questionnaires

The initial distribution of the screening instruments was targeted to veterans who

were being considered TCC Therapy Group. Sixteen screening instruments were

distributed and 10 were returned for a 65% participation rate. The study required 10

veterans to reach saturation and this goal was accomplished. Moreover, the BIBTIS and

five sets of questionnaires for a total of 33 questions were utilized during the eight-

sessions of TCC Therapy. The analyses of the questionnaires centered on the benefit of

TCC therapy with inquiries about life experiences and motivators toward psychosocial

support consideration. Specifically, the research inquired about social relationships with

other veteran participants and their social systems in the research study.

A finding from veteran participants was an acute recognition of their minimum

knowledge of mild traumatic brain injury. Another finding was the need veteran

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participant need for protection from being label and condemned as an individual with a

brain injury. Veteran Participant One declined to answer the BIBTIS. Veteran

Participant Two and Veteran Participant Three reported not being cognizant of their brain

injury. Veteran Participant Four was fully aware and expressed concern about the impact

of his military career. Veteran Participants Five, Veteran Participant Six, Veteran

Participant Seven, Veteran Participant Eight, Veteran Participant Nine, and Veteran

Participant Ten were interested in how TCCPRM could help them. After the fourth TCC

session, the 10 veteran participants became a homogenous TCC therapy Group. The six

veterans who opted out of the research expressed their brain injury could be treated with

medication and traditional therapeutic counseling such as Cognitive Behavioral Therapy.

In-depth Interviews

Veteran participants were open and forthcoming to during the interview process.

Veteran Participant One was initially resistance to the Demographic and Readiness to

Participate questionnaire. The resistance to the BTBIS screening may have encroach in

subsequent interviews. However, by the virtue of creation of a therapeutic rapport and

use of the motivational interviewing techniques, the research was successful in creating a

safe space for disclosure of veteran participant’s personal narrative. Veteran Participant

Two and Veteran Participant Three were comfortable after a brief explanation of

traumatic brain injury physiological and psychological impact of an injury. Veteran

Participant Four was fully engaged in the interview process and indicated a desire to learn

more about psychoeducation on the topic of traumatic brain injury. According to Veteran

Participant Four, this was due to the multiple traumatic brain injuries that was

126

experienced during military service. Veteran Participant Five through Ten indicated an

interest in continuing a TCC therapy after the eight-week session.

All veteran participants were honorable discharged from their branch of service.

Veteran Participant Four, Veteran Participant Five, and Veteran Participant Seven

completed 20 years or more of service before considering the adverse impact of their

mild traumatic injury. Additionally discussions revealed that veteran participants were

not cognizant of services to treat their condition, Veteran Participant Four refuses VA

Medical Center treatment. Veteran Participant Nine and Veteran Participant Ten are

considering seeking psychotherapy in additional to TCC at the VA Medical Center.

Other veteran participants opted to utilize their personal medical insurance for treatment

options.

Use of Tai Chi Chuan Psychosocial Reintegration Model and the determination to

reconnect with family and social support systems is a strong motivator for veteran

participants.Veteran Participants. The research that revealed veteran participants are

committed to reintegrating into social support systems and in managing their mild

traumatic brain injury. Other key motivators reflected personal ambitions such as strong

to a family commitment, better family life, fulfilling social connections, and productive

citizenry. Additionally, all veteran participants’ reflected on their service branch military

core values, philosophy of "not quitting," and "determination," as being central to their

ability to overcome individual health challenges. The service branches military core

value depicted in Table 1 in Chapter Three.

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Tai Chi Instructor

The Tai Chi Chuan instructor has 11 years of experience as a martial artist and

instructor in Tai Chi Chuan (internal martial art) and Chinese Kenpo (external martial

art). TCC is consider by practitioners as an internal martial arts. The interview revealed

that veteran participants began to connect to each other after the third session. Veteran

participants stated having physical balance concerns in addition to a traumatic brain

injury. Veteran participants were motivated, focused, and stated enjoying the interaction

with each other and the instructor. The instructor articulated the veteran participant’s

levels of stress, irritability, and anxiety were not evident during the TCC Therapy session.

The interview below captures the reflections of the instructor.

What was your impression of veterans’ motivation to take Tai Chi Chaun as therapy?

What was their motivation? Their motivation was, I believe curiosity had a d in the past, but a span lung is long enough in it or got out of this month time ago and I think their expectations was to review some of the things they already knew someone at to see if there was something that could help them with some of the issues that they had experience of being in the military. And uh, another part was of curiosity.

What's your perspective on their progress during the eight sessions?

I've always, their balance improves. Um, I, I love the fact that during the process of, of the, the days of the class is increasing for them. Uh, I did see improvement of Ah,

What do you think is [inaudible] as a treatment modality for veterans?

I think it's the actual movement. Uh, I think it should, it shouldn't even be, don't emphasize as an exercise. It should be part of everyone's daily activity, um, because it helps so many movements, national movements or um, anyone human who, who do things on a daily basis. And it's a powerful method, probably said more of a method that can teach the body how to

128

expand itself, um, defends itself, um, next week, durance and, and protect itself to, um, improve your mental state, your awareness of the mobility of it, the stability of it. And the flexibility is all one mechanical movement. It's natural for human, human beings. And I think the method is, is very powerful on introducing so many aspects of, of what the mechanics of a body is capable of doing to, um, that ability through your life. So it's, it's within us, without, as the president, um, um, being part of it is the very house.

Figure 4. Tai Chi Chuan Instruction Interview.

Conclusions

The research study highlighted the triangulation of observations, questionnaires,

and in-depth interviews. These instruments provided the collected data used to answer

the research question. The collected data further revealed veterans participant’ life

experiences that helped answer the research question. The majority of veteran

participants indicated overall the experience of learning in group environment with

individuals with similar background enhanced the therapeutic experience. Additionally,

veteran participants desire to have non-poly pharmalogical options to contribute a

positive quality of life outcomes (Hempel et al., 2014).

Implications

The implication of related to this study’s TCCPRM may help transform the lives

of its veteran participants. The collected data, documented interviews, and TCC Therapy

of veterans harvested quality of life outcomes, tangible, and mostly intangible rewards, as

a result of reintegration into family and social systems. In addition, the opportunity to

129

learn the implications of a traumatic brain injury and manage their mild traumatic brain

injury is vital to improving healthy behavioral outcomes.

A broader implication was that veterans with mild traumatic brain injury may

derived a psychological and sociological benefit derived from TCCPRM Theory. The

psychological benefits may manifest in an improvement in personal psychosocial

development and personal social identity. The sociological benefits are social

integration, family reintegration, and interpersonal and intergroup activity. Moreover, the

cost for considering TCCPRM as a therapeutic modality is negligible to the cost of poly

pharmacy. Additionally, implications for scholastic stakeholders include addition to

academic where such research does not currently exist.

Nationwide, political, and education leaders, and veteran stakeholders can also

draw implications from the collected data concerning veterans with mild traumatic brain

injury. The life experiences are critical data that provide lessons learned in the areas of

clinical treatment, family and social relationships, and overall specialized support

services for successful health outcomes (McClure, 2017). Collected data in this study

clearly indicated themes related to brain trauma and family hardships. Therefore, it is

possible that veterans may require clinical support in these areas to prevent reoccurrences

that could hamper recovery and healthy management of their condition. Establishing the

TCCPRM is a veteran friendly approach that contributes to improving a veteran’s quality

of life and wellness who has experience a traumatic brain injury and co-occurring

medical/psychological presentations (Zhou, Yin, Gao, & Yang, 2015).

130

Recommendations

As with many research paths, the findings from this study introduce many more

divergent areas of inquiry. This section describes some of the relevant issues for future

research regarding traumatic brain injury and co-occurring conditions. This study needs

to be repeated several times to address the diverse medical concerns for service members,

veterans, and family members.

The following recommendations are not listed in order of importance. They are

applied for stakeholders having direct impact on the future outcomes of the veterans with

mild traumatic brain injury. Recommendations are based upon supporting theories, and

collected data represented in this study.

Recommendation 1

Investigate the efficacy of utilizing Tai Chi Chuan as an augment therapeutic

treatment utilizing the Tai Chi Chuan Psychosocial Reintegration Model (TCCPRM) for

veterans with mild traumatic injury in active military and stakeholder organization such

as Wound Warriors, veteran service providers, and transition organization. Positive

outcomes of this type of therapy can be considered for moderate and severe brain injuries

upon stabilization of the veteran's condition.

Recommendation 2

Conduct a survey of service members with a traumatic brain injury and provide

mandatory transition briefing prior to leaving active duty. Determine the level of interest

in Tai Chi Chuan augmented treatment therapy. Research outcomes of this study can

outline the benefits of Tai Chi Chuan in facilitating reintegration into family and social

systems.

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Recommendation 3

Discuss with Veterans Administration Medical Center the Tai Chi Chuan

Psychosocial Reintegration Model as therapy rather than a recreational activity. This

would ensure active engagement by stakeholders in the rehabilitation process. TCCPRM

can aid in improving the veterans social identity and group participation.

Recommendation 4

Provide TCC at Veterans Administration Medical Facilities, Veteran Service

Centers, and Veterans Community Living Centers. This is a cost effective, slow motion,

low impact mind body, and brain exercise appropriate for all fitness levels. There are

VAMCs that offer Tai Chi Chuan to treat a myriad of medical conditions in Washington,

D.C, New Jersey, and Kansas.

Recommendation 5

Utilize the General Self-Efficacy (GSE) scale (English version) developed by

Schwarzer and Jerusalem (1995) to assess a general sense of perceived self-efficacy as an

indicator on how to adapt the Tai Chi Chuan Psychosocial Reintegration Model to

enhance outcome transitional success for veterans in the program.

Recommendation 6

Review the “Evidence Map of Tai Chi” and how this complementary alternative

medicine treatment modality can help veterans and service members with a myriad of

medical health concerns with current evidence-based practices.

Summary

This chapter summarized the findings, conclusions, implications, and

recommendations of this research study of Psychosocial Reintegration of Veterans with

132

Mild Traumatic Brain Injury. The research findings serve as a basis for conclusions and

recommendations for future implication of Tai Chi Chuan Psychosocial Reintegration

Model as a treatment modality choice. The veteran participants in this study wish a non-

pharmalogical approach to ameliorate the effect of a mild traumatic brain. This serves as

a starting point for future research and implementation. These results indicate additional

research is warranted to ascertain the relationship between Tai Chi Chuan and veteran’s

reintegration into their familial and social systems.

133

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APPENDICES

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APPENDIX A

Interview Checklist

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APPENDIX A

Interview Checklist

Prior to each interview the following will be performed: Participant Name: ________________________________ Assigned Pseudo Name:___________________________ Date of Interview: _______________________________________________________ Telephone #: ___________________________________________________________ Email Address: _________________________________________________________ Received the Signed Letter of Consent from participant: _____ Yes _____No If no, do not proceed with the interview. Contact participant and request the sign form. • Upon receiving the participant email address, send the Letter of Consent and times for

potential scheduling times for the interview, along with the preferred telephone number for the interview

• Log the participant’s email address and telephone number in the researcher’s folder for accessing the information prior to the interview

• Send a verification email reminding the participant of the interview date and time. This is a short email with time, date, and telephone number to be used. Also included will be the researcher’s contact name, telephone number, and email address

• Immediately prior to the interview, the researcher will: o Ensure the interview room (researcher’s) will be quiet, no interruptions o Check the voice recorder to ensure it is working, batteries are charged o Check the phone (iPhone 6 plus) is charged or plugged into the electrical

adapter o Test the recording to ensure the phone and recorder are in proper working

order o Have additional pens and a notebook for taking notes

• Call the participant at the designated time • Verify the participant’s name, and time allotted for the interview. An assigned pseudo

name will be used for identification • Remind the participant of the confidentiality of the interview, and inform he or she of

the recording that will begin when he or she is ready to start the interview. • Turn on the recorder • Again, remind the participant of the following:

o They may opt out (leave) the interview at any point o If the participant felt the need to speak to anyone due to an emotional trigger,

a list of resources would be provided (see Appendix ____). o All of the information will be kept confidential o All names will be changed o If the call is somehow disconnected, the researcher will immediately return

the call to start where the interview left off before the disconnect • Begin the interview

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• Post interview, thank the participant for her time and effort in the doctoral study. Inform her of the timing (approximately one week) of the transcription that will be emailed to her for accuracy of the interview information.

• Send the recording to the transcription service • Upon receiving the transcription, the researcher will check for accuracy, then attach

the document in an email requesting the review from the participant by a specific date • Follow up with an email by the specified date if the review has not been returned • Make changes if necessary based on the participant’s review • Ensure the interview is secured, backed-up data using security protocol. • Begin the data analysis

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APPENDIX B

Dissertation Background

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APPENDIX B

Dissertation Background

Research Title: Psychosocial Reintegration of Veterans with Mild Traumatic Brain

Injury Utilizing Tai Chi Chuan (TCC).

Study Site: The study will occur at the Aurora Mall, Filetta’s Couture Boutique Store,

Lower Level next to J.C. Penney 14200 E. Alameda Avenue, Aurora, CO. Contact Tai

Chi Instructor, Michelle Breckenridge of 2bfittraining.com at (720)-422-6784 (Cell) or

720-722-1647 (Office).

Name of Researcher(s) & University Affiliation: The name of the Researcher of this

study is James Pinkney III, a Doctoral Candidate at Argosy University-Denver Campus.

Participation and Withdrawal: You are being asked to participate in a research study

conducted by James Pinkney III from the College of Psychology and Behavioral Science

at Argosy University, Denver Campus. The study will contribute to a dissertation which

is the final requirement for the Doctor of Education in Counseling Psychology. Your

participation in this study is entirely voluntary. You may ask questions regarding the

research study and you can withdraw at any time.

Purpose of this Study Ascertain the efficacy of Yang Style Tai Chi Chuan practice as a

holistic augmented therapeutic intervention to treat service members with mild traumatic

brain injury (mTBI). Previous neuroscience research that Movement Therapy

demonstrated that Movement Therapy facilitates neuroplasticity and development of

neuropathways in the brain (Hawkes, 2012). The practice of TCC stimulates neuronal

development in the prefrontal cortex and contributes to a relaxation response in the

limbic system (Hawkes, 2012).

Risk: This study involves the following risks: None. There may also be other risks that

researcher cannot predict. Non-physical risks may include social, psychological, or

economic harm; risk of criminal or civil liability; or damage to financial standing,

employability, or reputation. None

Benefits: It is reasonable to expect the following benefits from this research: Alternative

and complimentary treatment for your health condition. However, the researcher cannot

guarantee that you will personally experience benefits from participating in this study.

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Other veterans may benefit in the future from the information found in this study:

Socialization and connection with veterans who experience a reduced quality of life

challenges resulting from military service.

Procedures: This will be a face to face introduction, participant’s sign-up, form, consent

form, and self-report questionnaires. The primary mode of data collection will be through

in-depth interviews, observation, and questionnaires. The total time required to complete

the interview is approximately one hour. There will be two follow-up interviews to

ascertain progress if agreed upon by you. As a participant, you will have minimal risk of

discomfort during this research study.

If you experience discomfort at any time and wish to terminate your participation. You

seek services available at the local U.S. Department of Veterans Affairs Medical Center

and the local U.S. Department of Veterans Affairs VET Center. In addition, veteran

support groups have community-based referral for service it needed. The contact

numbers for your local VET Center and your closest VA hospital will be made available

prior to the commencement of the interview. If you have questions regarding your rights

as a human subject, you may seek assistance from Argosy University Institutional

Review Board at 303-923-4110.

Anonymity and Confidentiality: The researcher will take the following steps to keep

information about you confidential, and to protect it from unauthorized disclosure,

tampering, or damage. Individuals and agencies who will have access to the data and

records, and how data will be described if published or shared with others. None. Will

you be using direct quotes which could be traced to an individual? No. Will you be

aggregating the data? Yes. Participant’s data files kept in locked cabinets, encrypted

data kept on a computer, and 256 AES password required for getting onto the system.

Participants will not write their names on any materials or questionnaires, other than the

Consent forms. Only the researcher will know participant’s names. The results of this

study will refer to the participants as an anonymous veteran participant (1), two (2), and

three (3). The coded subjects will not be publicly identifiable.

Ethical Considerations: For this study, guidelines for protecting the rights of human

subjects that are in operation and may be found on Argosy University website:

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http://www.Argosy.edu. Or you may contact the Argosy University Institutional Review

Board at 303-923-4110.

Identification of Researcher: If you have any questions about this research project,

please feel free to contact the researcher, James Pinkney III at 303-909-9952,

laft@gmx.com or you have the options to contact Dr. Michele Post, Committee

Chairperson at mpost@argosy.edu. For additional information regarding your rights as a

research participant, please feel free to contact the Argosy University Institutional

Review Board at 303-923-4110.

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APPENDIX C

Age Verification

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APPENDIX C

Age Verification

I am of age 18 or older and I agree to participate in this research study. Yes________ No_______ Please print your name here_____________________________________ Participant’s Signature _________________________________________ James Pinkney III Researcher’s Signature _________________________________________ Upon completion of this consent form, please sign and present to James Pinkney III. A copy will be provided for your files upon request.

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APPENDIX D

Permission to Record

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APPENDIX D

Permission to Record

Researcher’s Name: James Pinkney III

Research Title: Psychosocial reintegration of veterans with mild traumatic brain injury

utilizing Tai Chi Chuan.

James Pinkney III has permission to record (DVR or transcribe) this interview. This

recording will be used as part of a research project at Argosy University. I have provided

written consent to participate in this research during the time frame to complete the

research project. The recording will be destroyed six months after the study is submitted

to the Dissertation Committee. I have the option to withdraw or not having the interview

recorded. Upon request, the recording will no longer be used. The choice to withdrawal

will not affect my relationship with Argosy University.

Participant Name: ______________________________ Date ____________________

Signature: ____________________________________

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APPENDIX E

Demographic Form

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APPENDIX E

Demographic Form

This form provides this study with background information of the participation. The

purpose is to examine the data, compared the control group with the experimental group.

1. What is your branch of military service?

2. What is your veteran status?

3. What theater of operation did you serve?

4. What type of brain injury (e.g., mild, moderate, and severe, etc.)?

5. Who diagnosed you with the brain injury?

6. When did the injury occur?

7. Is there any personal and social impact of your brain injury?

8. What is your current marital status?

9. What is your gender identification?

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APPENDIX F

Interview Questions

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APPENDIX F

Interview Questions

My name is James Pinkney III. I am a doctoral candidate in the Counseling Psychology

Program at Argosy University in Denver. I am conducting interviews for a research topic

to identify a non-evasive treatment modality for veterans with mild traumatic brain

injury. The interview will be recorded, transcribed, and analyzed. You may remain

anonymous and will be identified as a Veteran Participant in this study. Upon

completion of the study, I compare the control group to the experimental group (you).

Thank you for agreeing to participate in this research project. I will now start the

interview starting with the demographic form. The demographic form provides the study

with background information on participant veteran.

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APPENDIX G

Demographic Form

158

APPENDIX G

Demographic Form

This form provides this study with background information of the participation. The

purpose is to examine the data, compared the control group with the experimental group.

What is your branch of military service? What is your veteran status? What theater of operation did you serve? What type of brain injury (e.g., mild, moderate, and severe, etc.)? Who diagnosed you with the brain injury? When did the injury occur? Is there any personal and social impact of your brain injury? What is your current marital status? What is your gender identification?

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APPENDIX H

GMX

160

APPENDIX H

GMX

161

APPENDIX I

Brief Traumatic Brain Injury Screen

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APPENDIX I

Brief Traumatic Brain Injury Screen

You may detail your response.

Did you have any injuries during your deployment from the following? (Highlight all that apply):

A. Fragment B. Bullet C. Vehicular (any vehicle) D. Fall E. Blast (Improvised Explosive Device, RPG, Landmine, Grenade, etc.) F. Other specify:

Did any injury received while you were deployed result in the following? (Highlight all that apply):

A. Being dazed, confused or “seeing stars” B. No remembering the injury C. Losing consciousness (knocked out) for less than a minute D. Losing consciousness for 1-20 minutes E. Losing consciousness for longer than 20 minutes F. Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.) G. Head Injury H. None of the above

Are you experiencing the following problems you think might be related to a possible head injury or concussion? (Highlight all that apply):

A. Headaches B. Dizziness C. Memory problems D. Balance problems E. Ringing in the ears F. Irritability G. Sleep problems H. Other: specify

Schwab, K. A., Baker, G., Ivins, B., Sluss-Tiller, M., Lux, W., & Warden, D. (2006). The Brief Traumatic Brain Injury Screen (BTBIS): Investigating the validity of a self-report instrument for detecting traumatic brain injury (TBI) in troops returning from deployment in Afghanistan and Iraq. Neurology, 66(5)(Supp. 2), A235.

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APPENDIX J

Readiness to Participate

164

APPENDIX J

Readiness to Participate

Score your response on a scale from 1 to 10. You may detail your response.

What is your knowledge of mild traumatic brain injury?

What is your understanding of mild traumatic brain injury?

What is your level of biopsychosocial awareness?

What is your level of self-efficacy?

What is your motivation level?

What is level of engagement to participate in therapy?

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APPENDIX K

Pre-intervention Interview Form

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APPENDIX K

Pre-intervention Interview Form

Score your response on a scale from 1 to 10. You may detail your response.

Level of knowledge of Tai Chi Chuan?

Do you have factors that brought you to consider Tai Chi Chuan?

What is your motivation level to consider Tai Chi Chuan as a treatment for mTBI?

Do you have barriers to prevent Tai Chi Chuan practice?

Do you have symptoms do you now notice and experience?

Do you have conditions that will affect your ability to perform Tai Chi Chuan?

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APPENDIX L

Progress Interview Form

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APPENDIX L

Progress Interview Form

Score your response on a scale from 1 to 10. You may detail your response.

1. What was your motivation level since your participation in the Tai Chi Chuan group?

2. Do you continue to experience barriers in communicating with your social support

system?

3. What types of symptoms do you now notice and experience?

4. Has any of your symptoms affected your ability to perform Tai Chi Chuan? (Describe)

5. Do you think Tai Chi Chuan affects your rehabilitation process?

6. Explain specifically what symptoms were affected by Tai Chi Chuan practice.

7. What do you enjoy about Tai Chi Chuan practice? What did you not enjoy?

8. Do you think you will continue with the Tai Chi Chuan group? (Explain why or why

not)

9. Would you recommend this therapy or do it again if you had the chance?

10. What changes have you experience since you started with the Tai Chi Chuan group?

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APPENDIX M

Post-Intervention Interview Form

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APPENDIX M

Post-Intervention Interview Form

Score your response on a scale from 1 to 10. You may detail your response.

What is your motivation level upon completion of the Tai Chi Chuan therapy group?

What barriers do you experience?

Do you think Tai Chi Chuan affects your rehabilitation process?

What do you enjoy about Tai Chi Chuan practice? What did you not enjoy?

Do you think you will continue to practice Tai Chi Chuan? (Explain why or why not)

Would you recommend this therapy or do it again if you had the chance?

How has your initial impression of Tai Chi Chuan practice change during the past 6-

weeks?

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APPENDIX N

TCCPRT Reintegration Questionnaire

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APPENDIX N

TCCPRT Reintegration Questionnaire

Score your response on a scale from 1 to 10. You may detail your response.

How do you feel about the Tai Chi Chuan Exercise intervention?

How do you feel about the group interaction during therapy?

Are you comfortable in a social setting?

How prepare are you to connect with your social support system?

Would continuing practice help with connecting with people?

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APPENDIX O

Conceptual Framework

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APPENDIX O

Conceptual Framework

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Diagram ___

Tai Chi Chuan Psychosocial Reintegration Theory Symbols Reintegration Indicator A (RI-A) Traumatic Brain Injury Henry (2006) Key Terms Theory of Mind Emotional Identification Executive Function Reintegration Indicator B (RI-B) Psychosocial Development Erickson (1959) Key Terms Ego Identity Identity Crisis Unfinished Business Reintegration Indicator C (RI-C) Social Identity Theory Tajfel and Turner (1979) Key Terms Categorization Social Identity Social Comparison

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Reintegration Indicator D (RI-D) Group Theory Yalom (1995) Key Terms Interpersonal Learning Cohesiveness Reintegration Indicator E (RI-E) Social Integration Blau (1977) Key Terms Social Position Social Status Reintegration Indicator F (RI-F) Family Reintegration Key Terms Emotional support Family reintegration Social support

Diagram

Tai Chi Chuan Psychosocial Reintegration Model (TCCPRM) Cycle Theoretical Cycle

Diagram Tai Chi Chuan Psychosocial Reintegration Model (TCCPRM) Cycle

Tai Chi Chuan Intervention

RI-A RI-C

RI-D RI-E

RI-F RI-B

RI-A RI-C

RI-D RI-E

RI-F RI-B

RI-D RI-A RI-C RI-B

RI-E

RI-F

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Diagram ____

TCCPRM Cycle

Diagram

Readiness to Participate Model

Perception of MBTI

Understand Effects of MTBI

Self-Motivation

Bio-Psycho-Social Awareness

Self-Efficacy

Engagement in Functional Therapy

Social Participation

Tai Chi Chuan Intervention

Self Reflection

Identity Consolidation

Psycho Social Reintegration

RI-A RI-C RI-D RI-E

RI-F RI-B

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APPENDIX P

Figure 5

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APPENDIX P

Figure 5

Note: Yang Style Tai Chi Chuan Basic Movements

http://2.bp.blogspot.com/_dbHrJohTfcY/RkOYuA2QCGI/AAAAAAAAAAM/xC-JTxNHHu0/s320/TaiChi24form.gif