Jennifer Drake dissertation

1 Institute for Clinical Social Work

The Self Rendered: AI-Generated Art as a Tool for Exploring Identity After Traumatic Brain Injury

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By

Jennifer Lorraine Drake Chicago, Illinois January 10, 2026

2 Abstract Traumatic brain injury (TBI) often disrupts continuity of identity, emotional regulation, and social connection. This qualitative study examined how adults with TBI engage with Artificial Intelligence (AI)-generated art to express and explore their sense of self. Five adults aged 30–60 participated in several semistructured interviews and an image-creation process using Midjourney, an AI tool that generates visual art from text prompts. Participants provided words and symbolic descriptions representing aspects of their inner experience; the resulting images were reviewed, selected, and reflected on after receiving a physical copy. Data were analyzed using a constructivist and psychodynamic framework. The AI chatbot ChatGPT (OpenAI, GPT5) was used only as a preliminary organizational aid to identify recurring patterns within deidentified excerpts. At the same time, I reached all the interpretive decisions and thematic conclusions independently. Five themes emerged: identity disruption, invisible cognitive and sensory burden, adaptive agency, isolation and connection, and systemic barriers to healing.

Findings suggested that AI-generated imagery may offer a meaningful reflective tool for articulating complex emotional and identity-related experiences after TBI. This study contributed to emerging literature on creative, technology-assisted approaches to post-TBI self-exploration.

Keywords: traumatic brain injury, identity disruption, AI-generated art, sense of self, qualitative research, psychodynamic framework

3 Dedication For my love, Eric, the best partner and companion on this swirling rock, and always knowing when to offer a cliffhanger grab.

4 Acknowledgements Thank you to my dissertation chair, Jacquelyn Vincson, PhD, for encouraging creativity and exploring new avenues, to my supportive committee members, Denise Duval Tsioles, PhD, Gina Shropshire, PhD, and Karen Baker, MSW. I would especially like to thank each participant for the vulnerability, authenticity, and the ability to dive into the deep end—thank you for trusting me with your story.

5 Table of Contents Abstract ........................................................................................................................................... 2 Dedication ....................................................................................................................................... 3 Acknowledgements ......................................................................................................................... 4 List of Figures ............................................................................................................................... 11 Chapter 1: Introduction ................................................................................................................. 12 General Statement of Purpose ................................................................................................. 12 Significance of the Study for Clinical Social Work................................................................ 12 Statement of the Problem and Specific Objectives to Be Achieved ....................................... 13 Research Question Explored ............................................................................................. 15 Theoretical and Operational Definitions of Major Concepts ............................................ 15 Statement of Assumptions ...................................................................................................... 16 Chapter 2: Literature Review ........................................................................................................ 19 Approach to the Literature Review ................................................................................... 21 Organization of the Chapter .............................................................................................. 22 Theoretical Foundations for Identity Exploration............................................................. 22 Freud’s Mourning and Melancholia............................................................................ 22 Kohut’s Self Psychology............................................................................................. 25 Restoration of Selfobject Functions. ..................................................................... 26 The Role of Optimal Frustration. .......................................................................... 26 Selfobject Recovery in Practice. ........................................................................... 27 Right-Brain Healing: Affect Regulation and Self-Development in TBI Recovery. .................................................................................................................... 27 Rediscovering Authenticity: Winnicott’s True Self and False Self in TBI Recovery ..................................................................................................................... 29

6 From Safety to Selfhood: Polyvagal Theory and Identity Reconstruction ................. 30 Creative Therapies and Social Belonging in TBI Recovery ............................................. 32 Art Therapy and Emotional Healing ........................................................................... 32 The Neuroscience of Art Therapy: Brain-Based Healing in TBI Recovery ............... 33 Virtual Art Therapy..................................................................................................... 35 Theoretical Foundations of AI-Generated Art in Identity Reconstruction ................. 36 Neuroplasticity and the Role of Bottom-Up Processing in Recovery ........................ 37 Narrative Reconstruction Through Creative Modalities ............................................. 40 The Role of Creative Therapies in Emotional Healing ............................................... 43 Exploring Sense of Self in TBI Recovery......................................................................... 45 The Role of Narrative and Identity ............................................................................. 45 Integrating Technology and Self-Exploration in TBI ................................................. 46 Integrating AI and Creative Therapies in TBI Recovery .................................................. 48 Artificial Intelligence in Cognitive and Emotional Recovery .................................... 48 Enhancing Accessibility Through AI.......................................................................... 49 Future Implications for AI in Creative Therapies ....................................................... 49 Ethical and Relational Considerations .............................................................................. 50 Conclusion ........................................................................................................................ 51 Chapter 3: Methods ....................................................................................................................... 54 Rationale for Qualitative Research ......................................................................................... 55 Rationale for the Case Study Method ..................................................................................... 55 Research Sample ..................................................................................................................... 56 Research Plan or Process ........................................................................................................ 56 Data Collection ....................................................................................................................... 60 Plan for Data Analysis ...................................................................................................... 61

7 Use of ChatGPT for Data Analysis ................................................................................... 63 Ethical Considerations ............................................................................................................ 64 Informed Consent.............................................................................................................. 65 Confidentiality and Privacy .............................................................................................. 65 Addressing Potential Risks and Ethical Approval ............................................................ 65 Trustworthiness ................................................................................................................. 66 Limitations and Delimitations........................................................................................... 68 Limitations .................................................................................................................. 68 Delimitations ............................................................................................................... 69 Role and Background of the Researcher ........................................................................... 70 Chapter 4: Results ......................................................................................................................... 71 The Impact of Traumatic Brain Injury on Research Participation .......................................... 71 Participant Profile: Rhuadh (49 Years-Old) ..................................................................... 72 Neurological and Medical Journey ............................................................................. 73 Psychosocial and Emotional Impact ........................................................................... 73 Symbolic and Artistic Expression............................................................................... 74 Rationale for Chosen Image........................................................................................ 77 Image Integration and Ongoing Reflection................................................................. 77 Identity and Remarkable Growth. ......................................................................... 77 Profound Isolation and the Desire for Connection. .............................................. 78 The Weight of the Experience. ............................................................................. 79 Participant Profile: AZYogi (43 Years-Old)..................................................................... 79 Neurological and Medical Journey ............................................................................. 79 Psychosocial and Emotional Impact ........................................................................... 80 Symbolic and Artistic Expression............................................................................... 81

8 Rationale for Chosen Image........................................................................................ 84 Image Integration and Ongoing Reflection........................................................... 84 Resilience and Shifting Identity. ........................................................................... 85 Acceptance and the Nonverbal Path. .................................................................... 85 Proposed Revision. ............................................................................................... 85 Participant Profile: Anunnaki (32 Years-Old) .................................................................. 86 Neurological and Medical Journey ............................................................................. 86 Psychosocial and Emotional Impact ........................................................................... 87 Symbolic and Artistic Expression............................................................................... 87 Rationale for Chosen Image.............................................................................................. 92 Image Integration and Ongoing Reflection........................................................... 92 Multifaceted Identity After TBI. ........................................................................... 93 Thoughtfulness and Desire to Connect. ................................................................ 93 Proposed Revision. ............................................................................................... 93 Participant Profile: Mechelle (58 Years-Old) ................................................................... 94 Neurological and Medical Journey ............................................................................. 94 Psychosocial and Emotional Impact ........................................................................... 95 Symbolic and Artistic Expression............................................................................... 96 Rationale for Chosen Image........................................................................................ 98 Image Integration and Ongoing Reflection................................................................. 99 Sustained Meaning and Symbolism. ..................................................................... 99 Impact on Healing and Identity............................................................................. 99 Therapeutic Value of the Process. ........................................................................ 99 Proposed Revision. ............................................................................................. 100 Participant Profile: Brain (39 Years-Old) ....................................................................... 100

9 Neurological and Medical Journey ........................................................................... 101 Psychosocial and Emotional Impact ......................................................................... 101 Symbolic and Artistic Expression............................................................................. 102 Rationale for Chosen Image...................................................................................... 105 Image Integration and Ongoing Reflection......................................................... 105 Sustained Meaning and Symbolism. ................................................................... 105 Profound Influence on Self-Perception. .............................................................. 106 Connection to Others. ......................................................................................... 106 Proposed Revision. ............................................................................................. 106 Major Themes of TBI Recovery ........................................................................................... 107 Identity Disruption and the Loss of the “Former Self” ................................................... 107 The Invisible Cognitive and Sensory Burden ................................................................. 108 Reclaiming Agency and Purpose Through Adaptation .................................................. 109 Isolation Versus the Craving for Connection.................................................................. 110 Institutional and Systemic Barriers to Healing ............................................................... 111 Chapter 5: Discussion ................................................................................................................. 113 Psychodynamic Interpretation of Findings ..................................................................... 114 Freud’s Loss .............................................................................................................. 114 Mirroring With AI Art .............................................................................................. 115 Winnicott’s True Self, Play, and the Holding Environment ..................................... 116 Schore’s Theory of Affect Regulation and its Application to TBI Identity Recovery ................................................................................................................... 117 Implications........................................................................................................................... 120 Use of AI-Generated Art in TBI Work ........................................................................... 120 Future Research Directions ............................................................................................. 121 Appendix A: Recruitment ........................................................................................................... 123

10 Appendix B: Screening Questionnaire........................................................................................ 124 Appendix C: First Interview and AI Image Creation Process .................................................... 125 Appendix D: Second Interview – Reflection on AI Image and Identity..................................... 128 Appendix E: Curriculum Vitae (CV) .......................................................................................... 130 References ................................................................................................................................... 134

11 List of Figures Figure 1. Rhuadh’s Runner-Up Image .......................................................................................... 75 Figure 2. Rhuadh’s Chosen Image ................................................................................................ 76 Figure 3. AZYogi’s Runner-Up Image ......................................................................................... 82 Figure 4. AZYogi’s Chosen Image ............................................................................................... 83 Figure 5. Anunnaki’s Runner-Up Image 1 ................................................................................... 88 Figure 6. Anunnaki’s Runner-Up Image 2 ................................................................................... 90 Figure 7. Anunnaki’s Chosen Image ............................................................................................ 91 Figure 8. Mechelle’s Runner-Up Image ....................................................................................... 96 Figure 9. Mechelle’s Chosen Image ............................................................................................. 97 Figure 10. Brain’s Runner-Up Image ......................................................................................... 103 Figure 11. Brain’s Chosen Image ............................................................................................... 104

12 Chapter 1: Introduction General Statement of Purpose The purpose of this case study was to explore how engaging with Artificial Intelligence (AI)-generated art could facilitate self-exploration in adults recovering from traumatic brain injuries (TBI) in a virtual setting. This study examined AI-generated art as a reflective tool that study participants used to explore and express their sense of self, particularly as they navigated shifts in self-perception, social relationships, and emotional experiences following injury. For the purposes of this study, engaging with AI art was defined as the use of AI-generated creative tools that allowed TBI survivors to explore and give visual form to their inner experience.

Significance of the Study for Clinical Social Work In this case study, I investigated whether AI-generated art might serve as a creative tool for self-exploration among individuals recovering from TBI. Rather than offering a therapeutic intervention, this study examined how AI-generated art may support individuals in exploring aspects of their identity, including experiences that may be difficult to access through verbal expression. Historically, clinicians and researchers have relied on traditional verbal methods, such as interviews, to explore a person’s internal world. Artificial Intelligence-generated art may offer an additional way to represent and explore inner experiences, including unconscious material that may otherwise remain inaccessible.

Artificial Intelligence-generated art may offer a way to express aspects of self that are difficult to articulate verbally. These developments may be valuable in a field where understanding each person’s unique internal experience is essential, and where traditional methods may not fully capture the complexity of psychological effects. This research introduced

13 a potential new tool that reflects the ongoing integration of technology in healthcare and may contribute to more nuanced and reflective practices in supporting individuals with TBI. Nevertheless, further research is needed to explore the integration of AI, art, and identity exploration. As AI technology advances, it becomes increasingly important to consider how such innovations can be thoughtfully incorporated within reflective, psychodynamic frameworks to support ethical and appropriate use in personal exploration. The rapid evolution of AI highlights the need for careful attention to developing ethical guidelines that address patient privacy, informed consent, data protection, transparency in AI-generated outputs, and ensuring that AI tools complement, rather than replace, human connection (Fulmer, 2019). The integration of AI into reflective and creative processes must prioritize the well-being of individuals above all else (Fulmer, 2019).

There are numerous unexplored possibilities for harnessing AI’s technological benefits within creative, reflective spaces, since AI tools may offer greater accessibility and personalization to meet individuals’ diverse needs and abilities. Additionally, since the COVID19 pandemic, reflective and supportive conversations have shifted from in-person to virtual spaces, making it timely to explore how AI might be integrated into evolving virtual environments for identity exploration.

Statement of the Problem and Specific Objectives to Be Achieved Recent advancements in AI technology have introduced tools that can generate images, videos, and texts with remarkable speed and complexity. These developments present both opportunities and challenges across several fields of research, including mental health and selfexploration. As AI becomes more sophisticated, there is growing interest in understanding how such technologies might be used as tools to support creative and reflective processes. Some

14 scholars and professionals are exploring ways in which AI might complement meaning-making processes, while others express concern about potential risks and limitations. Regardless of perspective, exploring how AI aligns with ethical and professional standards remains an important area of inquiry—especially as AI-generated art emerges as a possible tool for selfexploration.

Visual narrative techniques, such as photo-elicitation, have long been used in qualitative research to help individuals reflect on and make sense of their experiences (Burton et al., 2017; Coussens et al., 2020; Sibeoni et al., 2017; Zhang & Hennebry‐Leung, 2023). Like photoelicitation, AI-generated art may offer a creative and reflective process that helps individuals express internal experiences that are difficult to articulate verbally (Sibeoni et al., 2017; Zhang & Hennebry‐Leung, 2023). However, the use of AI-generated art as a reflective tool remains largely unexplored.

Research on creativity support tools in human-computer interaction has shown that AI can assist creative processes, including divergent and convergent thinking (Zhang et al., 2022).

This may be particularly relevant for individuals with TBI, whose cognitive and emotional experiences are often complex and difficult to communicate. Previous research suggested that creative tools, such as art therapy, can help TBI survivors engage in self-reflection, though AIgenerated art represents a new frontier that requires further exploration (Di Vita et al., 2020; Zhang et al., 2022). Emerging AI systems have been used to support creative storytelling and visual narrative development, particularly in supporting emotional expression and meaningmaking (Du et al., 2024; Lawton et al., 2023). Although AI tools are becoming more accessible, their potential role in reflective processes for adults with TBI has not been studied in depth.

15 While AI-generated art may hold promise as a creative tool for identity exploration, its use should be approached thoughtfully and ethically. Recent examples of harmful AI-human interactions emphasized the importance of ethical safeguards (Webb, 2023). Psychodynamic and reflective frameworks may offer important guidance for ensuring AI-generated tools are used in ways that prioritize human experience (Webb, 2023). This study explored whether AI-generated art may serve as a creative tool for identity exploration for individuals recovering from TBI, with attention to how these tools might be accessible and meaningful for individuals’ unique experiences. Although AI-generated art may offer a new resource for reflection, much still remains unknown about its role in this context (Batool & Yosuf, 2023; Cooney & Menezes, 2018; Pataranutaporn et al., 2021).

Research Question Explored This case study explored the research question: “How might engaging with AI-generated art support TBI survivors in exploring their sense of self?” In this study, I examined whether AIgenerated art may serve as a creative tool to assist individuals in reflecting on and expressing aspects of their identity. The study aimed to explore how AI-generated art may contribute to processes of self-exploration and emotional reflection, including how it may help bring unconscious experiences into conscious awareness. While drawing on psychodynamic concepts to inform the research framework, I focused in this study on understanding AI-generated art as a possible means of self-exploration, not as a replacement for clinical intervention.

Theoretical and Operational Definitions of Major Concepts The following are operational definitions of the most used and theoretically significant terms in this study:

16 Artificial Intelligence: systems or machines that mimic human intelligence to perform tasks and can iteratively improve themselves based on the information they collect (Fulmer, 2019).

Art Therapy: a form of psychotherapy that enriches the patient through a creative and active art-making process rooted in psychological theory (American Art Therapy Association, 2022).

Self-Exploration: the process of becoming aware of one’s inner experiences, including thoughts, feelings, and parts of the self that may feel hidden or disconnected (Bromberg, 2011).

Sense of Self: an individual’s internal experience of identity and coherence, shaped by relational and affective experiences (Kohut, 1984; Stern, 1985).

Traumatic Brain Injury: An impairment in brain function caused by an external force, characterized by symptoms that may include loss of consciousness, headache, confusion, dizziness, and cognitive, emotional, or sleep disturbances (Centers for Disease Control and Prevention [CDC], 2022) Unconscious: Thoughts, feelings, and experiences that exist outside conscious awareness but influence feelings, thoughts, and behaviors (Bromberg, 2011; Freud, 1915).

Virtual Therapy: Delivery of psychotherapeutic services through digital platforms that allows for therapeutic engagement outside traditional face-to-face settings.

Statement of Assumptions Four primary assumptions were made regarding the present study based on my experience as a Licensed Clinical Professional Counselor (LCPC) and having experienced a TBI. 1. The study presumed that individuals with TBI can engage meaningfully with AIgenerated art as a tool for identity exploration and self-reflection.

17 2. Individuals who have experienced a TBI may have a disjointed or disrupted sense of self and may benefit from opportunities to explore, express, and reflect on their identity in creative ways.

3. Psychodynamic concepts may offer a valuable lens for understanding how individuals make sense of loss and internal experiences, especially when paired with visual creative processes, such as AI-generated art, that allow for nonverbal expression.

4. Artificial Intelligence-generated art brings both opportunities and challenges, and it is important for psychodynamic researchers and clinicians to consider how this emerging technology intersects with questions of identity, self-expression, and clinical understanding.

Foregrounding I approached this study with biases and the lived experience of suffering a TBI when I was 11 years-old. I cannot bracket this experience because I viscerally know the devastating and life-altering impact of a TBI. The effects of the TBI were not well understood at the time of my accident, which caused significant confusion, angst, loneliness, and, at times, despair. I still feel it in my body after all these years. This suffering has shaped me into the person and clinician I am today.

A TBI can strike like a thief in the night; an intruder that one does not expect to encounter, which can rob one’s sense of self. The world and one’s body become a strange land filled with distortions and fragmented pieces, and it can be challenging to find the words to express what has occurred. For much of my adult life, I have endured intense occupational, physical, and vision therapies, hoping to find a way to piece myself back together. Words can escape, but visual representations can be grounding and healing.

18 The idea for this study came from an unexpectedly painful class assignment, in which I had to write an in-depth paper about my experience of grief from personal losses due to the COVID-19 pandemic. This was due to my role as a bereavement coordinator in an extensive hospital program that was overwhelmed by an increase in deaths and a lack of community resources during the pandemic. Revisiting that time was a painful process. I found it confusing to recount the traumas and felt disconnected from the world and myself, an experience that felt akin to my recovery phase from TBI. At that time, I decided to create a visually appealing PowerPoint presentation and began to experiment with AI art generative programs. Through an iterative process, I cocreated images with AI to represent COVID-19, mourning, loss, community, therapeutic alliance, and more. Over the following weeks, I revisited some images in my mind’s eye. Instead of fragmented pain and suffering, I created a more precise picture representing hope.

I noticed a shift within my body at that time. The seeds of healing were planted, as well as the spark of an idea; if this was helpful for me, could it be helpful for others?

19 Chapter 2: Literature Review Traumatic brain injury is often referred to as a “silent epidemic” because its effects are mostly invisible yet can be utterly and continuously life-altering. A TBI occurs when a sudden bump, blow, or jolt to the head disrupts normal brain function (CDC, 2022). These injuries can range from mild to severe and affect an estimated 69 million people worldwide each year (Dewan et al., 2018). In the United States alone, TBIs have been responsible for more than one million deaths over the last two decades (CDC, n.d.). Although TBIs are more common among certain groups—such as athletes, military personnel, victims of domestic violence, the elderly, and incarcerated individuals—they can affect anyone, regardless of age or background (World Health Organization [WHO], 2006). Survivors in regions with limited healthcare access face additional challenges, often lacking the specialized rehabilitation services that are critical to recovery (WHO, 2006).

Many TBI survivors face social stigma, which can interfere with their emotional wellbeing and ability to reintegrate into daily life. Individuals recovering from TBI often report feelings of isolation and diminished self-esteem, particularly when their experiences are not well understood by family, friends, or even healthcare professionals (Levack et al., 2010). Financial constraints can make it challenging to access specialized medical interventions, leading to poorer recovery outcomes (Dewan et al., 2018). In rural and underserved areas, limited healthcare resources further compound these challenges, restricting access to essential treatments and prolonging recovery (CDC, n.d.). Given these social and emotional difficulties, many survivors may also struggle to make sense of their shifting identities and sense of self, underscoring the need to explore tools that could support personal reflection and self-understanding.

20 For survivors, TBI can lead to short- or long-term issues that affect nearly every aspect of their life, including the ability to work, form relationships, and navigate daily living. Physically, TBIs can result in profound changes in gait, voice, and body composition, often making survivors unrecognizable to themselves and others (Villa et al., 2020). Beyond the immediate physical repercussions, TBI significantly impairs cognitive functioning, emotional regulation, and the survivor’s sense of self (D’Cruz et al., 2019; Levack et al., 2010; Villa et al., 2020). As a result, recovery often involves navigating fragmented self-narratives, disrupted autobiographical memory, and diminished social belonging (D’Cruz et al., 2019; Levack et al., 2010; Villa et al., 2020).

Recent research has highlighted the potential of combining creative therapies with emerging technologies, such as AI, to support individuals in reflecting on their experiences of TBI (Guay, 2018; Reynolds, 2012; Webb, 2023). Creative modalities offer nonverbal avenues for emotional expression and identity exploration, allowing survivors to reflect on and express aspects of their experience that may be difficult to articulate verbally (Guay, 2018; Reynolds, 2012). Community-focused initiatives, such as the LoveYourBrain Retreat, demonstrate how group-based engagement can help foster a sense of belonging and shared understanding among individuals with TBI (Donnelly et al., 2024). This study explored whether AI-generated art may serve as one possible tool for supporting such self-exploration, including the potential to bring unconscious experiences into conscious awareness. Rather than offering a therapeutic intervention, this research focused on examining AI-generated art as a means of supporting personal reflection and sense-making in the context of living with TBI. This chapter charted the process of identity exploration in individuals recovering from TBI, integrating perspectives from psychodynamic theory, neuroscience, and social dynamics. It

21 examined how creative and somatic approaches, including polyvagal-informed techniques and AI-generated art, may support individuals in reflecting on and expressing their sense of self. A key focus is on understanding whether AI-generated art can serve as a tool for self-exploration, including the possibility of bringing unconscious experiences into conscious awareness. While traditional rehabilitation often emphasizes physical and cognitive recovery, the psychological and emotional aspects of recovery—including a person’s evolving sense of self—are equally important. Drawing from psychodynamic and creative theories, this chapter highlighted how AIgenerated art might support identity exploration and emotional reflection, offering insights that could inform future clinical practices. This chapter did not explore AI as a therapeutic intervention but instead considered how AI-generated art may serve as a tool for individuals to engage in personal reflection.

Approach to the Literature Review I conducted this literature review to explore the theoretical foundations, relevant research, and interventions related to identity exploration in TBI survivors. The goal was to identify gaps in current rehabilitation practices, particularly those addressing emotional and psychological recovery. Databases such as PubMed, PsycINFO, PEP-web, and Google Scholar were searched using keywords including ‘TBI recovery,’ ‘identity,’ ‘self-exploration,’ ‘creative therapies,’ ‘psychodynamic approaches,’ and ‘AI in rehabilitation.’ Articles published within the last 15 years were prioritized, although seminal works were included for their relevance to the theoretical foundation of identity exploration.

The inclusion criteria for reviewed literature focused on peer-reviewed studies, metaanalyses, and systematic reviews that examined psychological, social, or creative approaches to TBI recovery. Exclusion criteria eliminated works solely addressing acute medical treatment or

22 unrelated neurological conditions. Selected studies were grouped into categories for analysis: foundational theoretical works, research broadly relevant to identity exploration, studies closer to the specific focus of this dissertation, and works directly aligning with the integration of creative therapies and AI in TBI recovery.

Organization of the Chapter This chapter explored foundational theories that shape our understanding of identity exploration. It begins with key psychodynamic concepts, including Freud’s (1917/1957) theories of melancholia and mourning, and examines how they relate to shifts in self-perception. Creative therapies are discussed as important avenues for expression and meaning-making in trauma recovery. The chapter then reviews studies on TBI recovery, focusing on narrative-based therapy and other creative approaches that may help survivors explore and make sense of their experiences. Additionally, this chapter examines emerging research on integrating AI into creative processes for individuals with TBI, including innovative uses of AI-generated art and ethical considerations. These findings are combined to offer a framework for understanding and supporting identity exploration and self-reflection in the context of TBI recovery.

Theoretical Foundations for Identity Exploration Freud’s Mourning and Melancholia Freud’s (1917/1957) concepts of mourning and melancholia offer a distinctive and informative lens for understanding the emotional challenges that TBI survivors face. According to Freud (1917/1957), mourning involves the ego gradually withdrawing libidinal energy from a lost object. Through this process, the ego eventually regains the capacity to invest in new relationships and roles. While this process can be painful, it is adaptive and healing, as it allows individuals to acknowledge the absence of the loss while making new connections and living

23 their lives in the here and now. For TBI survivors, mourning might include grieving the loss of preinjury abilities, relationships, or roles that once defined their identity. The gradual acceptance of these changes can facilitate emotional resilience, enabling survivors to reinvest in new forms of identity and purpose.

In contrast, melancholia represents an inability to withdraw libidinal energy from the lost object, resulting in internalized grief, diminished self-worth, and persistent despair. Unlike mourning, melancholia is characterized by an unconscious identification with the lost object, where the ego incorporates aspects of the object into itself (Freud, 1917/1957). Freud (1917/1957) described this dynamic when he wrote, “the shadow of the object fell upon the ego, and the latter could henceforth be judged by a special agency, as though it were an object, the forsaken object” (p. 249). Freud observed that this internalization often leads to harsh selfcondemnation, with the individual experiencing feelings of worthlessness and failure. For TBI survivors, melancholia might manifest as pervasive self-criticism, where the loss of physical or cognitive abilities is internalized as a reflection of personal inadequacy (Ogden, 2002). Nochi (1998) identified similar themes in the narratives of TBI survivors, noting how many described a profound “loss of self,” reflecting the fragmented identity that emerges when preinjury abilities are perceived as irretrievable.

This state can create a cycle of despair, where the survivor becomes trapped in the pain of the loss, unable to reconcile their pre- and postinjury selves. Levack et al. (2014) highlighted the importance of understanding survivors’ mourning as they reconstruct their identity. Mourning provides pathways for growth and redefinition, whereas melancholia can hinder recovery (Freud, 1917/1957). By identifying the dynamics of these processes, clinicians can better support survivors in articulating their losses and moving toward emotional reintegration. Gracey and

24 Ownsworth (2012) underscored the pivotal role of social contexts in the neurorehabilitation process. They stated that reestablishing connections with supportive networks can alleviate grieving preinjury identity roles and promote the development of a redefined self-concept.

Ogden (2002) emphasized that the hallmark distinction between mourning and melancholia is the disturbance of self-esteem. While mourning externalizes loss as belonging to the world, melancholia internalizes it, resulting in a sense of the ego itself becoming ‘worthless’ or ‘incapable.’ For TBI survivors, mourning may involve consciously grieving the loss of preinjury abilities, roles, or autonomy. Conversely, melancholia may manifest as a more profound emotional challenge, with survivors unconsciously internalizing these losses and experiencing profound self-reproach (Ogden, 2002). Walsh et al. (2020) discussed how uncertainty in the lived experiences of TBI survivors contributes to the erosion of self-cohesion and amplified internalized grief, which is characteristic of melancholia. Often, survivors experience uncertainty that exacerbates reconciling their pre- and postinjury selves, which mirrors Freud’s (1917/1957) observations about the unconscious dimensions of melancholia.

For example, a survivor may consciously acknowledge the loss of their career and, through therapeutic support, reinvest their emotional energy into building new skills, thereby redefining their purpose. However, melancholia may lead survivors to view their ego as fundamentally diminished, with pervasive self-criticism that prevents recovery. Ogden (2002) further noted that melancholics may not fully recognize “what they have lost” or may even be unaware of how the loss has altered their internal self. This unconscious dimension complicates the grieving process for TBI survivors who may feel trapped, stuck, or frozen.

Freud’s distinction between mourning and melancholia emphasizes the importance of therapeutic support in helping survivors externalize their losses and reconstruct their self-image.

25 Therapeutic interventions can aid in addressing unconscious losses while offering survivors a pathway from despair to adaptation and healing (Ogden, 2002).

Understanding these Freudian processes of mourning and melancholia provides a valuable lens for examining how TBI survivors may struggle with identity reconstruction and internalized loss. This study sought to investigate how AI-assisted art therapy might offer new ways to externalize and work through such experiences of loss, offering an innovative pathway to healing.

Kohut’s Self Psychology While Freud’s theories focused on the internal struggles of loss, Kohut expanded this understanding by exploring how external relationships and supports sustain identity and selfcohesion. Kohut’s Self Psychology highlights the critical role of selfobjects. In Self Psychology, selfobjects are not separate individuals but rather the functions provided by others that sustain a person’s sense of self. These selfobject functions—such as mirroring, idealization, and twinship—are essential for maintaining self-cohesion and emotional stability (Kohut, 1984).

Selfobjects are experienced as part of the self and serve to stabilize and organize the self’s structure, especially during times of stress or loss. For individuals recovering from TBI, disruptions in selfobject experiences can create profound feelings of fragmentation and disconnection from one’s identity. When there is a loss, it can often leave survivors feeling fragmented, disconnected, and emotionally adrift. For example, a survivor who once relied on their career to provide a sense of competence may feel directionless when that role suddenly vanishes. Additionally, the loss of physical abilities can erode self-cohesion, possibly leading to feelings of hopelessness and despair.

26 Restoration of Selfobject Functions. Self-Psychology highlights the importance of restoring selfobject functions through empathic and supportive environments that help individuals feel understood and validated. Kohut (1982) emphasized that empathy is not merely a therapeutic tool but a fundamental mode of observation essential for understanding the inner life of individuals. Supportive relationships can bolster survivors’ feelings of safety and stability through empathetic attunement. For example, trusted others can help meet essential selfobject needs by offering reassurance and creating space for individuals to reflect on their experiences.

This attunement and feelings of safety and stability ultimately enable them to begin rebuilding their fragmented selves.

Beyond the therapeutic relationship, there are other expressive pathways for survivors to meet selfobject needs, including art therapy, journaling, or storytelling. What is so powerful about these tools is that they can help survivors externalize their inner experiences and even transform feelings of loss into representations, such as visual art, written narratives, or physical movement. A survivor might use visual art to depict their fragmented sense of self, which could lead to an emotional catharsis and self-cohesion. Creative modalities and empathic attunement allow survivors to rebuild their sense of agency and connection, aligning with Kohut’s (1982) framework of the self as an evolving and dynamic structure.

The Role of Optimal Frustration. Kohut (1984) observed how setbacks and frustration could lead to growth and coined the term ‘optimal frustration,’ which refers to the experience of manageable disruptions in selfobject needs that promote psychological growth and resilience.

According to Kohut (1984), when selfobject functions are imperfectly but tolerably provided, individuals internalize these functions themselves, fostering autonomy and self-cohesion. In the context of TBI recovery, optimal frustration may be relevant as individuals engage with

27 incremental, achievable challenges that gently test their limits. For example, individuals might work on small artistic projects, participate in support groups, or gradually reengage with social or occupational roles. While each step of the process may encounter its own set of challenges, the hope is that these are manageable frustrations that help rebuild a sense of agency and confidence.

The ultimate goal is to transform dependency on external support into internalized strength and self-reliance.

Selfobject Recovery in Practice. Like all recoveries in life, there is no straightforward path for healing. Recovery often involves setbacks that can trigger feelings of fragmentation, and TBI survivors may struggle with accepting their limitations and may even regress. Kohut (1984) emphasized the influential role of empathy and external support in meeting selfobject needs, which helps to strengthen the self and allows survivors to gradually internalize these stabilizing functions. With that in mind, therapeutic relationships and creative modalities play a necessary role as they offer both structure and validation when survivors feel stuck or defeated.

Right-Brain Healing: Affect Regulation and Self-Development in TBI Recovery.

Schore (2012) built upon Kohut’s Self Psychology by emphasizing the role of early relational experiences and affect regulation in shaping identity formation and emotional resilience. Schore’s research highlighted the dominance of the brain’s right hemisphere in processing emotions, nonverbal communication, and relational experiences, and how a breakdown or disruption in the right hemisphere can result in dysregulation and lack of selfcohesion (Schore, 2003). This perspective is particularly relevant to TBI, where survivors often struggle with a fragmented sense of self due to neurological and psychological disruptions.

In relation to TBI, Schore (2019) underscored the importance of right-brain-focused processes, including nonverbal, relational, and creative experiences, as they engage the brain’s

28 affective and adaptive capacities. His work aligned with research on neuroplasticity, demonstrating that structured art-based experiences can promote self-reflection and emotional processing by facilitating new neural connections (Schore, 1994). Additionally, Schore (2003) emphasized the role of optimal frustration—small, manageable challenges that may promote resilience and emotional growth.

This concept suggests that structured creative experiences, such as narrative-based processes, expressive arts, and relational engagement, may offer individuals living with TBI ways to explore loss, engage with their sense of self, and reflect on their experiences (Schore, 2012). Schore’s research highlighted how intentionally engaging right-brain mechanisms— through relational and creative processes—may support individuals in navigating affective and relational experiences connected to shifts in sense of self following TBI. The potential of integrating AI into creative processes may expand these possibilities by offering TBI survivors innovative ways to explore self-expression and meaning-making while supporting the neurobiological processes involved in self-reflection and affect regulation (Schore, 2019). Ultimately, Schore’s work reinforced the importance of relational attunement, affect regulation, and creative engagement in supporting identity exploration and resilience in individuals with TBI. Schore’s emphasis on nonverbal, relationally attuned processes aligned closely with this study’s examination of AI-assisted art as one possible way for individuals with TBI to access right-brain pathways of emotional processing and identity exploration. In this way, AI-assisted art may serve as a nonverbal, emotionally attuned medium that supports right-brain processes, offering individuals with TBI a pathway to express and explore fragmented aspects of their identity.

29 Rediscovering Authenticity: Winnicott’s True Self and False Self in TBI Recovery Winnicott’s (1960) theory of True Self and False Self provides a lens to frame the experience of TBI survivors. The True Self represents an individual’s authentic, spontaneous self that is free to experience and express a range of human emotions (Winnicott, 1960). In contrast, the False Self is a defensive adaptation that protects individuals by masking vulnerabilities and conforming with societal norms (Winnicott, 1960). As Taipale (2023) showed, the development of these different selves reflects an individual’s capacity for authentic self-expression (True Self) and a protective mechanism that can isolate individuals from their emotional core (False Self).

The False Self is a protective mechanism that can emerge for TBI survivors as they navigate negative societal stigma and face new interpersonal challenges. They might attempt to suppress their struggles and attempt to present as ‘normal’ to avoid judgment or even pity from others (Nochi, 1998). This reaction is protective initially; however, if the False Self is overutilized, it can result in a more profound sense of isolation and a disconnect from one’s True Self. Walsh et al. (2020) highlighted the uncertainty many survivors face in their postinjury identities, which often reinforces their reliance on the False Self as a way of managing external pressures. Rediscovering the True Self is critical for emotional well-being, enabling survivors to engage with their vulnerabilities and form genuine connections.

A supportive relational space allows an individual the possibility to rediscover or strengthen their True Self. A “holding environment” is essential in this reflective process, as it provides a relational space where one can feel safe to explore emotions without fear or threat of judgment (Winnicott, 1960). Ideally, this environment mirrors early caregiving relationships, which are essential for developing the capacity to reconcile fragmented parts of the self (Taipale, 2023). Individuals living with TBI may benefit from a ‘holding environment’ as they let go of an

30 over-reliance on their False Self, moving toward a more flexible engagement with their True Self. Creative processes such as visual arts and storytelling can offer opportunities to reflect on and explore inner experiences and reclaim a sense of agency (Gracey & Ownsworth, 2012).

Narrative exploration may help individuals integrate fragmented aspects of self (Nochi, 1998). Engaging in storytelling or visual art can create a space for reflecting on identity and exploring experiences that may feel disjointed following traumatic brain injury. When the individual’s awareness is brought into the here and now while acknowledging their past internal struggle, it can foster authenticity and emotional resilience.

Winnicott’s (1960) framework highlights the importance of authenticity and emotional vulnerability in the recovery process, offering key insights into how survivors can rebuild their identities after TBI. These ideas offer a conceptual framework for understanding how authenticity and relational experiences may support identity exploration when considered alongside Kohut’s focus on selfobject functions. Additionally, these frameworks align with the person-centered rehabilitation process that many professionals advocate as it addresses the internal and social needs of the patient as they recover (Levack et al., 2014). Winnicott’s concepts are central to this study’s inquiry of whether AI-assisted art can function as a holding environment for TBI survivors, enabling them to explore and express their authentic selves in a creative and supportive way. By offering a contained yet creative space for self-exploration, AIassisted art may help individuals with TBI reconnect with their authentic selves, providing a digital holding environment that supports emotional integration and identity exploration.

From Safety to Selfhood: Polyvagal Theory and Identity Reconstruction Polyvagal Theory introduces the role of neuroception—the nervous system’s unconscious ability to detect cues of safety or threat (Porges, 2022). Neuroception plays a critical role in how

31 TBI survivors experience identity shifts. When neuroception is dysregulated, TBI survivors may misinterpret neutral or supportive interactions as threatening (Porges, 2022). Social reintegration and identity reconstruction are more challenging if the survivor experiences dysregulation, as it can lead to a persistent state of defensiveness, which can manifest as hypervigilance, dissociation, or a diminished sense of self. All of this reinforces feelings of alienation.

To recalibrate neuroception and restore a sense of physiological safety, survivors benefit from body-based interventions such as somatic therapy, breathwork, and creative expression (Payne et al., 2015). These modalities engage the autonomic nervous system in regulating emotional responses (Payne et al., 2015). These approaches support survivors in shifting from chronic states of fear and withdrawal toward a more integrated and connected self-experience.

Polyvagal Theory provides a neuroscientific framework for understanding how TBI survivors experience autonomic dysregulation and identity disruption following trauma.

According to Porges (2022), the autonomic nervous system functions hierarchically, cycling through three states in response to safety or threat: the ventral vagal system (social engagement, which is sometimes referred to as ‘rest-and-digest’), the sympathetic system (‘fight-or-flight’), and the dorsal vagal system (‘freeze/shutdown’). All TBI survivors are confronted with the loss of their sense of safety; some may become trapped in prolonged states of hyperarousal (anxiety, agitation) or hypoarousal (emotional numbness, disconnection), whereas others can reengage with their ventral vagal system for regulation (Porges, 2022). Restoring autonomic balance is essential for survivors for reengaging in identity reconstruction, emotional processing, and social connection. Porges (2011) suggested that social engagement and creative expression play a vital role in regulating autonomic function, enabling survivors to transition from hypervigilance to states of connection and safety. Polyvagal Theory highlights the critical role of safety in self-

32 expression and identity reconstruction, supporting this study’s exploration of whether AI-assisted art can foster a sense of physiological and emotional safety in TBI survivors. By creating an emotionally safe and visually expressive space, AI-assisted art may enable TBI survivors to engage in identity work that would otherwise feel overwhelming, offering a new pathway for healing that integrates both emotional and physiological regulation.

Creative Therapies and Social Belonging in TBI Recovery Art Therapy and Emotional Healing Trauma can leave survivors in a prolonged state of physiological shutdown, making emotional engagement and identity reconstruction challenging (Payne et al., 2015). Animals can instinctively recover from the freeze response, but humans, unfortunately, tend to remain stuck in trauma, which leads to unhealthy avoidance behaviors and emotional withdrawal (Payne et al., 2015). Creative therapies, such as art therapy, can bypass cognitive barriers by engaging the body’s sensory and autonomic systems and facilitating nonverbal emotional processing—a concept supported by research in neurobiology and psychotherapy (Levine, 2010; Porges, 2011; Schore, 2012).

Haeyen (2024) showed that creative arts therapies can regulate autonomic arousal by activating the ventral vagal, which is responsible for social engagement and emotional connection. Engagement in art-making, movement, and expressive therapies has been shown to reduce cortisol levels, lower stress, and enhance self-regulation (Haeyen, 2024). These findings align with the Polyvagal Theory’s emphasis on body-based healing, demonstrating that art therapy provides a structured yet fluid approach to emotional integration for trauma survivors.

Art therapy creates a safe and transformative space for survivors of TBI to process trauma and rediscover a sense of self. When an individual begins a creative process, it allows

33 them to externalize their internal conflict, and the fragmented aspects of their identity begin to come into focus. Art-making fosters both exploration and integration of their fragmented parts, all while gaining insight into their experience (Sagan, 2012). Reengagement in meaningful activities through art can restore one’s occupational identity by providing a renewed sense of competence and purpose (Cotton, 2012). Collaborative projects reinforce shared commitment to healing and community. These findings on creative therapies and neuroscience offer a foundation for this study’s exploration of AI-assisted art as a potential tool for self-exploration in TBI survivors, expanding established art therapy principles into the realm of emerging technology.

Schouten et al. (2014) further described art-making as a nonverbal means to express and process trauma, providing survivors with opportunities to foster coherence in their emotional and cognitive experiences. Creative expression supports both neuroplasticity and bottom-up processing by activating neural pathways linked to emotional regulation and memory integration.

Neuroplasticity—the brain’s capacity to form new connections—is crucial for adapting to trauma (Doidge, 2007). Similarly, bottom-up processing engages sensory and emotional regions of the brain, integrating fragmented memories into cohesive narratives (Porges, 2011; van der Kolk, 2014). Creative approaches, such as art-making, may be most effective when combined with other reflective or therapeutic practices, offering a holistic way to address the multifaceted challenges that TBI survivors face.

The Neuroscience of Art Therapy: Brain-Based Healing in TBI Recovery Magsamen and Ross (2023) presented neuroscientific evidence showing that creative activities play a key role in stimulating neuroplasticity, improving cognitive flexibility, and supporting emotional regulation. Art therapy engages neural networks linked to memory,

34 emotion, and executive function—critical areas for long-term psychological recovery in TBI survivors. By highlighting the brain’s response to artistic expression, their work further supports the inclusion of creative therapies in neurorehabilitation.

Art is not merely a form of self-expression but a biological necessity that fosters brain growth and rewiring (Magsamen & Ross, 2023). Contrary to early scientific beliefs that the brain becomes static and declines with age, neuroscientists now recognize that enriched environments, including artistic engagement, stimulate neural adaptation and plasticity (Magsamen & Ross, 2023). The brain continuously rewires itself in response to sensory, emotional, and environmental stimuli (Magsamen & Ross, 2023). Creative therapies are essential for restoring cognitive and emotional resilience for TBI survivors, which aligns with research on the “aesthetic triad”—a neurological model in which art engages three core systems: sensorimotor processing, the reward system, and meaning-making functions (Magsamen & Ross, 2023).

By incorporating creative therapies into rehabilitation, survivors gain access to an environment that supports neural regeneration while also providing a meaningful outlet for processing trauma, rebuilding identity, and reconnecting with the world. These therapies highlight the value of nonverbal interventions, as artistic expression can engage healing processes that traditional cognitive or talk therapy may not fully address. Furthermore, engaging in creative expression fosters neuroplasticity and activates multiple neural networks related to emotional regulation, memory, and meaning-making (Magsamen & Ross, 2023). These brainbased approaches provide survivors with opportunities to reconnect fragmented parts of the self while developing new pathways for emotional healing. These findings on creative therapies and neuroscience offered a foundation for this study’s exploration of AI-assisted art as a possible tool

35 for self-exploration in TBI survivors, building on established art therapy principles with emerging technology.

Virtual Art Therapy Telehealth and other digital platforms are rapidly integrating into mental healthcare, providing opportunities for participants in shared meaning-making and collective emotional processing. Virtual settings create spaces for individuals to connect and support one another, even when physical distance separates them. Dunn-Snow and McNutt (2009) found that virtual art therapy groups reduce isolation and create a shared space where participants can connect while engaging in the creative process. Their case studies illustrated the value of these groups, where members exchange insights, receive validation, and ultimately foster a sense of belonging (Dunn-Snow & McNutt, 2009).

The combination of AI-generated art platforms and virtual reality (VR) technologies creates exciting new avenues for creative expression. The digital tools enable users to experiment with visual storytelling, imagery, and an externalization of emotions that are not always possible with traditional art materials. Virtual environments facilitate symbolic expression and emotional processing, creating immersive opportunities for therapeutic exploration beyond the constraints of physical media (Shamri-Zeevi, 2021). Additionally, AI-assisted art bridges verbal and nonverbal communication, offering individuals recovering from traumatic brain injuries multiple avenues for expressing their internal experiences (Milasan, 2024; Shojaei et al., 2024).

Despite the many advantages, incorporating AI tools present unique challenges for virtual art therapy groups. Mental health practitioners must consider the possibility of technological accessibility issues, confidentiality concerns, and the potential loss of sensory engagement with physical materials. Additionally, the use of AI in therapeutic settings requires thoughtful

36 facilitation to ensure that digital tools support—rather than replace—the depth of psychodynamic exploration. However, research suggested that with structured facilitation, interactive digital tools, and an emphasis on interpersonal connection, AI-assisted virtual art experiences can offer a meaningful space for self-exploration, creative expression, and reflection on one’s sense of self (Dunn-Snow & McNutt, 2009; Milasan, 2024; Shojaei et al., 2024; Shamri-Zeevi, 2021).

Theoretical Foundations of AI-Generated Art in Identity Reconstruction Understanding the reflective potential of AI-generated art requires examining its theoretical foundations. Psychodynamic and constructivist approaches provide complementary perspectives on how creative expression fosters self-exploration, particularly in the aftermath of trauma. Psychodynamic theory emphasizes the role of intrapsychic processes, with creative media offering a means to access and integrate unconscious material that may be difficult to verbalize (Di Vita et al., 2022). Constructivist perspectives, in contrast, view identity as an evolving narrative shaped by experience and social context, where self-expression through creative engagement allows individuals to explore and reshape their self-concept and reclaim agency (D’Cruz et al., 2019; Candlish et al., 2023).

Case studies illustrated how art therapy enables individuals to externalize emotions and process trauma when verbal expression is insufficient (Dunn-Snow & McNutt, 2009). For instance, an adult with cerebral palsy struggled with emotional restriction and suicidal thoughts despite extensive medical treatment. Through art therapy, she could express long-suppressed emotions, accessing psychological material that had remained inaccessible through verbal means (Dunn-Snow & McNutt, 2009, p. 148). Similarly, a cancer patient undergoing treatment painted a self-portrait with morning glories to explore her evolving identity beyond illness, reconnecting with hope and deepening her relationships. These cases underscore how artistic expression

37 fosters emotional resilience and reflection on one’s sense of self, particularly when verbal therapy alone is limiting.

For TBI survivors, the challenges of articulating shifts in their sense of self and emotional experiences can be profound. AI-generated art offers a novel extension of these established creative principles, providing new ways to engage with fragmented self-narratives and explore evolving experiences in a dynamic, interactive format. Unlike traditional art-making, AI-assisted creative modalities allow for rapid iteration, sometimes unexpected visual outputs, and digital transformations of self-representation, giving individuals an opportunity to experiment with different facets of their sense of self in ways that might not be possible through conventional artistic methods. As research into the psychological benefits of AI-generated art continues, it holds potential as a reflective tool for self-exploration and emotional expression in TBI recovery.

Neuroplasticity and the Role of Bottom-Up Processing in Recovery Neuroplasticity plays a pivotal role in the brain’s ability to adapt following trauma, particularly for survivors of TBI. Neuroplasticity is the brain’s capacity to reorganize itself by forming new neural connections, which is essential for rebuilding disrupted pathways and adjusting to the profound changes that TBI brings (Doidge, 2007; Kolb & Whishaw, 1998). This process helps survivors regain cognitive and emotional capacities, allowing them to reconnect with their daily lives. Without neuroplasticity, the brain would struggle to adapt to injury, leaving survivors with persistent challenges. Because of this, approaches that actively promote neuroplasticity are crucial for supporting individuals in navigating life after TBI. Magsamen and Ross (2023) emphasized that the brain is not a static organ but a constantly evolving system, shaped by one’s environment. Early neuroscience suggested that the brain’s structure and function declined with age, but modern research demonstrates that enriched

38 environments can stimulate new neural growth and improve cognitive flexibility (Magsamen & Ross, 2023). Exposure to art, music, nature, and other sensory-rich experiences enhances neural connectivity, highlighting the dynamic relationship between perception and the physical environment. For TBI survivors, creative practices provide a crucial enriched environment that fosters neuroplasticity, offering structured yet flexible ways to promote brain adaptation, emotional resilience, and self-reflection.

Art-based processes engage multiple brain networks simultaneously, activating sensorimotor pathways, the reward system, and meaning-making circuits, all of which contribute to cognitive and emotional processing (Magsamen & Ross, 2023). By immersing survivors in sensory experiences, creative engagement can bypass cognitive barriers, offering individuals alternative ways to reflect on and express difficult experiences. This perspective aligns with research on bottom-up processing, which emphasizes that sensory and motor engagement can precede conscious cognitive reorganization (Levine, 2010; Porges, 2011). By integrating art, movement, and expressive practices into supportive environments, individuals may find new ways to explore their experiences, supporting brain plasticity and emotional processing.

Bottom-up processing supports neuroplasticity by engaging sensory and emotional brain regions, helping survivors reconnect fragmented memories and emotional experiences (Porges, 2011; van der Kolk, 2014). Unlike top-down approaches that rely primarily on cognitive reasoning, bottom-up methods tap into the body’s natural capacity to process and integrate trauma (Levine, 2010; Payne et al., 2015). Van der Kolk (2014) and Porges (2011) emphasized that sensory-based approaches, such as art-making and somatic practices, stimulate these pathways, enabling survivors to form a more cohesive and regulated emotional narrative.

Through tactile, movement-based, and expressive modalities, individuals may engage in a

39 deeper, body-centered integration of traumatic experiences (Levine, 2010; van der Kolk, 2014).

By addressing preconscious bodily responses, bottom-up processes can play a vital role in helping survivors cultivate emotional stability and self-regulation after TBI (Payne et al., 2015; Porges, 2011).

Ogden et al. (2006) further highlighted the role of sensorimotor and somatic practices in addressing deeply rooted trauma through physical and sensory engagement. These methods recognize that trauma is not only stored in explicit memory but also within the nervous system, where it can manifest as physiological dysregulation. Breathwork, guided movement, and somatic tracking may help survivors regulate their autonomous nervous system, alleviating symptoms such as dissociation, anxiety, and hypervigilance (Porges, 2011; van der Kolk, 2014).

These sensorimotor approaches integrate mind-body experiences that promote more adaptive responses to stress, supporting long-term neurobiological integration (Levine, 2010; Payne et al., 2015).

Creative processes utilize both neuroplasticity and bottom-up processing by engaging survivors in activities that activate neural pathways related to emotional regulation, memory integration, and sensory engagement. Craig (2002) underscored how interoception—the sense of the body’s internal state—plays a critical role in emotional awareness and self-regulation, aligning with bottom-up approaches. Art-making, music, and expressive writing offer survivors alternative avenues to explore and express emotions when verbal communication may be limited (van der Kolk, 2014). These creative outlets provide a balance of structure and flexibility, giving individuals space to explore and make meaning of their experiences in a natural and personal way. Through multisensory engagement, TBI survivors can strengthen neural pathways while reflecting on and reshaping their sense of self and agency (Levine, 2010; Porges, 2011).

40 Emerging research supported the value of neuroplasticity-informed and bottom-up approaches in enhancing emotional regulation and coherence in individuals’ narratives of self, following TBI (Cramer et al., 2011; Schore, 2012). Studies showed that engagement in creative and somatic processes supports functional improvements in brain connectivity, leading to greater self-awareness, emotional resilience, and adaptive coping (Di Vita et al., 2022). Tapping into the brain’s capacity for adaptation, these processes may foster meaningful opportunities for individuals to reconnect with themselves and their experiences following TBI (D’Cruz et al., 2019). As research continues to evolve, integrating evidence-informed neuroplasticity and bottom-up methods will remain essential for supporting reflective and adaptive processes in TBI survivors (Candlish et al., 2023; Webb, 2023).

Narrative Reconstruction Through Creative Modalities Dunn-Snow and McNutt (2024) explained how survivors use visual storytelling to process trauma, explore their self-concept, and reclaim agency over their narratives. Through this process, individuals externalize internal struggles and reframe their experiences to foster selfawareness and emotional growth. Similarly, D’Cruz et al. (2019) showed that personal narrative approaches help survivors make sense of their experiences by reconnecting their pre- and postinjury identities. Through storytelling, survivors can piece together fragmented selfperceptions, creating a more cohesive and adaptive understanding of their journey.

One powerful example of narrative exploration in trauma recovery is mask-making, a practice dating back over 9,000 years, which continues to be used today (Magsamen & Ross, 2023). By creating masks, individuals can externalize emotions in a nonjudgmental space, offering a tangible representation of their internal experiences. This process is particularly valuable for those who struggle with verbal expression, as it provides an alternative means of

41 communication when words are inaccessible. Through mask-making, survivors can symbolize their emotional experiences, fostering deeper self-awareness and reflection.

Magsamen and Ross (2023) highlighted the work of Melissa Walker, an art therapist specializing in trauma recovery for veterans and individuals with posttraumatic stress disorder (PTSD) and TBI. Walker developed a mask-making program to help survivors explore their experiences through visual storytelling. Many of her patients, who previously struggled to articulate their trauma, found that masks allowed them to express their experiences symbolically.

One veteran shared that before engaging in art-making, he was unable to describe what it felt like to live with PTSD and TBI—yet after creating his mask, he no longer struggled to communicate his emotions (Magsamen & Ross, 2023). This process bridges the gap between unspoken pain and emotional expression, offering survivors a sense of control over their narratives.

This finding aligned with research on metaphor and symbolism in trauma healing, reinforcing that creative expression provides a safe way to externalize overwhelming experiences (Reynolds, 2012). The primary goal of mask-making in this context is to help individuals channel emotions, memories, and shifts in self-experience into a visible, tangible form (Magsamen & Ross, 2023). More than just artistic objects, masks serve as tools for selfunderstanding, personal storytelling, and emotional reflection. By shaping an external representation of their internal world, survivors can explore fragmented aspects of self in a way that feels both authentic and empowering.

This approach also connects to Winnicott’s (1960) theory of the True and False Self, as many survivors feel pressure to project a ‘normal’ exterior while concealing their inner struggles.

Mask-making provides a way for individuals to explore both their external and internal worlds in

42 a safe and supportive setting. This process allows survivors to reconnect with parts of themselves that may feel disjointed or lost, especially when held within a containing environment.

Mask-making and other forms of visual storytelling provide TBI survivors with a meaningful way to explore their sense of self. Creative approaches such as these enable individuals to reflect on identity shifts and emotional challenges in ways that do not rely solely on verbal communication. Magsamen and Ross (2023) suggested that engaging in creative processes plays an active role in supporting self-exploration and emotional resilience, rather than serving only as a coping tool. Creative expression supports reflection, resilience, and personal meaning-making, helping survivors make sense of their experiences in a structured yet deeply personal way.

Blending psychodynamic principles with creative processes provides survivors with a way to explore trauma and make sense of disrupted memories. Van der Kolk (2014) explained that sensory-based approaches support trauma integration by engaging the body in processing difficult experiences, while psychodynamic perspectives highlight how unconscious conflicts and relational dynamics influence self-experience. Ogden et al. (2006) highlighted the value of integrating somatic and psychodynamic approaches to work through deeply rooted trauma.

Schore (2012) and D’Cruz et al. (2019) expanded on this idea, showing how these methods help survivors process painful experiences in ways that foster self-reflection, emotional expression, and an evolving sense of self. Together, these frameworks provide survivors with tools to cultivate coherence and resilience, which are critical for meaningful adaptation following trauma.

43 The Role of Creative Therapies in Emotional Healing When words fall short or fail us, creative processes offer TBI survivors an alternative way to process emotions and explore their sense of self. Many individuals with traumatic brain injuries struggle to articulate their emotions due to cognitive impairments, making practices such as art-making, storytelling, and journaling particularly valuable (Reynolds, 2012). These approaches offer both structure and flexibility, allowing survivors to express emotions, reflect on their experiences, and explore their evolving sense of self. For instance, a TBI survivor who struggled with verbal communication may discover that painting provides an outlet for emotions they had been unable to articulate. Engaging in the creative process deepens self-awareness and fosters connection with others.

Trauma can fundamentally alter brain function, making it difficult—if not impossible— for survivors to put their experiences into words. Magsamen and Ross (2023) highlighted that when individuals relive trauma, the brain’s Broca’s area—the region responsible for speech and language—shuts down. fMRI scans reveal that when trauma survivors, such as individuals with PTSD or TBI, attempt to recall distressing events, Broca’s area becomes inactive, mirroring the effects seen in stroke patients (Magsamen & Ross, 2023). This neurological suppression explains why many survivors struggle to verbalize their emotions—their language centers are offline, preventing them from forming a coherent narrative of their experiences.

Van der Kolk’s (2014) research further supported this, showing that trauma survivors experiencing flashbacks display a significant decrease in Broca’s activity, confirming that the effects of trauma can resemble the neurological impact of physical brain lesions (Magsamen & Ross, 2023). One patient who had survived a major car accident was asked to recall as much as possible about the event. As soon as a flashback was triggered, their Broca’s area “went offline,”

44 making it impossible for them to put their emotions into words (Magsamen & Ross, 2023).

These findings underscored why traditional talk therapy is often insufficient for trauma survivors—their brains simply cannot access language in moments of distress.

Creative processes provide a vital alternative by bypassing the brain’s impaired verbal processing centers, instead activating intact sensory, motor, and emotional networks (Magsamen & Ross, 2023). Art-making, movement-based practices, and expressive storytelling allow survivors to externalize their experiences without relying on speech. This offers a pathway to meaning-making and self-exploration.

Beyond offering an outlet for emotional expression, creative engagement also fosters a sense of agency by helping survivors reflect on their experiences and explore different facets of their identity. Through such activities as visual art, written narratives, and symbolic representation, survivors can engage with trauma in a tangible way, moving beyond cognitive constraints that might limit verbal articulation (Reynolds, 2012; van der Kolk, 2014). By transforming their experiences into creative expression, individuals may reconnect with parts of themselves that feel fragmented or lost after injury, fostering a renewed sense of continuity and self-awareness.

Additionally, creative processes significantly stimulate neuroplasticity—the brain’s ability to reorganize and form new neural pathways—while supporting emotional regulation and psychological resilience (Doidge, 2007; Porges, 2011). Through structured creative engagement, TBI survivors can reconnect with their emotions while simultaneously reshaping neural pathways, improving cognitive flexibility, and reinforcing the connections between memory, emotion, and sensory processing (Doidge, 2007; Porges, 2011). Neuroscientific research supports the idea that engaging in these practices facilitates long-term psychological adaptation,

45 offering survivors a means of both self-expression and neurological integration (Sivertsen & Normann, 2015).

Exploring Sense of Self in TBI Recovery The Role of Narrative and Identity Memory loss disrupts the continuity of one’s self-narrative, significantly impacting individuals’ ability to bridge the gap between their pre- and postinjury identities (Salmond & Sahakian, 2005; Villa et al., 2020). Without a stable autobiographical memory, TBI survivors may struggle to integrate their past experiences into a coherent sense of self, leaving them feeling disoriented and fragmented. After experiencing a TBI, memory impairments disrupt one’s ability to construct a meaningful life story; a personal self-narrative is an essential element in developing a sense of identity (Salmond & Sahakian, 2005). The lasting impacts of memory disruption can deepen feelings of disconnection, distress, and emotional dysregulation.

Fortunately, narrative approaches offer structured ways to organize life experiences and help survivors foster a sense of continuity and meaning as they explore evolving aspects of identity (D’Cruz et al., 2019). By shaping their experiences into a coherent storyline, survivors may reclaim agency over their narratives, reframing their past and present to cultivate selfunderstanding.

Creative processes, such as art-making, enhance this narrative exploration by offering survivors ways to visually represent and reimagine their experiences (Reynolds, 2012). When verbal articulation is impaired, visual and symbolic expression provide alternative pathways for processing emotions and making sense of disrupted memories. Artistic engagement helps survivors externalize their inner worlds, supporting emotional regulation and self-reflection (Reynolds, 2012). Through art, survivors can create tangible representations of their shifting

46 sense of self, integrating fragmented aspects of experience into a more cohesive and meaningful whole. Creative expression fosters self-awareness and may offer opportunities for personal insight (Reynolds, 2012).

Beyond cognitive and verbal expression, reconnecting with the physical self is essential in supporting emotional and psychological adaptation (Sivertsen & Normann, 2015). Many survivors experience a stark dissonance between their pre- and postinjury identities, making it challenging to reconcile changes in cognitive, emotional, and physical states. The VR-assisted practices can help survivors explore and reshape self-perception, enhance emotional processing, and reconnect with aspects of self that feel lost or fragmented (Sivertsen & Normann, 2015). By incorporating sensory and narrative elements, these approaches offer a more holistic and adaptive pathway for exploring identity and supporting integration.

Integrating Technology and Self-Exploration in TBI Cognitive impairments following a TBI present significant challenges, as survivors grapple with disrupted autobiographical memory, emotional regulation difficulties, and a fragmented sense of self-narrative (Reynolds, 2012). Due to motor and cognitive limitations, traditional psychotherapeutic approaches may be inaccessible, creating a need for technological tools that facilitate self-expression and support reflection on one’s evolving sense of self (Du et al., 2024). Advancements in digital tools, such as AI-enabled storytelling platforms and VRbased environments, offer new possibilities for helping survivors externalize emotions, explore agency, and engage with their personal narratives in creative and flexible ways (Manivannan et al., 2019).

The AI-driven applications, including automated storytelling programs and digital art tools, allow survivors to engage in narrative and creative expression even when traditional verbal

47 communication is challenging (Du et al., 2024). With customizable and responsive features, these tools offer survivors opportunities to externalize fragmented memories and reflect on their shifting sense of identity (Du et al., 2024). Unlike fully automated AI-generated content, interactive AI-assisted storytelling and art platforms foster active participation, ensuring that survivors retain control over their narratives and expressions (Du et al., 2024).

The DeepThInk system, for example, was designed to assist rather than replace human creativity, allowing users to guide AI-driven artistic modifications while preserving their original intent and emotional expression (Du et al., 2024). The AI tools also offer greater accessibility, enabling participants to engage remotely—an important benefit for individuals facing mobility challenges or geographic barriers (Reynolds, 2012). Online platforms provide structured yet flexible spaces for creative engagement at individualized paces, reducing the pressure of inperson interactions while maintaining opportunities for self-expression and reflection (Du et al., 2024).

Integrating VR into supportive practices offers innovative pathways for individuals recovering from TBI. Virtual Reality-based environments create immersive, controlled spaces that can support cognitive and motor engagement. Studies have demonstrated that VR applications address neurocognitive challenges—particularly in memory, executive function, and attention—by providing adaptable settings for targeted cognitive and motor tasks (Moulaei et al., 2024). Moreover, VR-based cognitive engagement has shown promise in enhancing cognitive function in older adults with mild cognitive impairment, offering ecological and flexible alternatives to traditional methods (Tortora et al., 2024). Similarly, VR environments have been shown to enhance neurocognitive functioning in individuals recovering from TBI, suggesting

48 their potential value as tools for supporting cognitive processes in accessible and adaptive ways (Manivannan et al., 2019).

Integrating AI and Creative Therapies in TBI Recovery Artificial Intelligence in Cognitive and Emotional Recovery The integration of AI into reflective and creative practices is reshaping how TBI survivors may explore their experiences, offering innovative ways to engage with the complex challenges of TBI. Artificial Intelligence-driven VR environments create immersive spaces where survivors can engage in activities that reflect aspects of their preinjury roles and daily routines (Akbar et al., 2024). By simulating realistic, adaptive scenarios, these technologies support cognitive engagement by strengthening executive functioning, attention, and memory, while also promoting neuroplasticity and offering supportive environments for practice (Beard et al., 2024).

Beyond cognitive engagement, AI-supported creative tools provide new pathways for emotional processing and self-exploration. Artificial Intelligence-generated art platforms help survivors externalize emotions, fostering self-expression and opportunities for reflection (Say et al., 2022). Robotic art-making systems extend this further, acting as dynamic creative partners that respond to survivors’ evolving emotional states with real-time feedback and personalized creative input (Rajaei et al., 2023). For those with cognitive impairments that limit verbal communication, these technologies offer alternative ways to explore and express evolving aspects of self and personal narratives (Akbar et al., 2024). By complementing more traditional reflective practices, AI-assisted creative tools expand opportunities for self-exploration and emotional expression beyond the limits of verbal communication.

49 Enhancing Accessibility Through AI A significant advantage of AI-integrated creative tools is their ability to enhance accessibility, particularly for TBI survivors who face mobility restrictions or geographic barriers.

Artificial Intelligence-enabled telehealth platforms, VR-based art-making applications, and digital storytelling tools provide remote access to narrative-based and creative experiences, ensuring that survivors in rural or underserved areas can engage in reflective practices from home (Beard et al., 2024). These AI-driven platforms can dynamically adjust creative tasks, track user engagement, and offer adaptive feedback, creating personalized experiences that evolve with the survivor’s cognitive and emotional needs (Kim et al., 2024). By reducing logistical challenges, AI expands access to creative and narrative processes, ensuring that these opportunities remain available to a broader and more diverse population.

In addition to increasing accessibility, AI-supported creative tools promote engagement by allowing survivors to interact with these processes at their own pace. Digital platforms offer real-time modifications to tasks based on individual responses, ensuring that creative activities remain stimulating and manageable (Say et al., 2022). By integrating biometric feedback and machine learning, AI systems help optimize the balance between challenge and skill level, encouraging long-term participation and meaningful engagement (Akbar et al., 2024). These adaptive capabilities help ensure that creative processes remain relevant as survivors progress through different stages of their personal exploration, making AI-enhanced tools a flexible and sustainable option for supporting ongoing reflection and self-expression.

Future Implications for AI in Creative Therapies As AI technology continues to evolve, its ability to adapt in real-time and incorporate biometric feedback could make TBI rehabilitation even more personalized and effective.

50 Researchers have begun to explore how AI-driven neurofeedback and physiological monitoring in VR-based therapy might deepen both cognitive and emotional recovery (Beard et al., 2024).

Moving forward, it will be essential to study the long-term effects of AI-driven art therapy— mainly how these interventions support identity reconstruction and resilience in meaningful and lasting ways (Kim et al., 2024).

At the same time, AI works best when paired with human connection. Hybrid models that integrate AI-assisted therapy with clinician-guided interventions could strike a balance, combining the precision of AI-driven personalization with the depth and nuance of therapeutic relationships (Rajaei et al., 2023). By bridging the gap between self-guided and therapistsupported care, these approaches ensure that survivors receive both customized feedback and the relational support essential for emotional healing (Akbar et al., 2024). As these technologies continue to develop, embedding AI-driven creative therapies into broader neurorehabilitation frameworks could make recovery more accessible, scalable, and impactful.

Ethical and Relational Considerations The use of AI in trauma rehabilitation and creative therapies brings both exciting possibilities and critical ethical considerations. One of the most pressing concerns is data privacy—AI systems process vast amounts of sensitive patient information, making security, informed consent, and patient autonomy critical issues (Kim et al., 2024). There is a need for strong security measures and clear data governance policies to prevent misuse (Beard et al., 2024). It is also essential that AI-generated therapeutic recommendations remain transparent and interpretable so that both clinicians and patients understand how these conclusions are reached (Rajaei et al., 2023).

51 Beyond the technical safeguards, integrating AI into TBI therapy raises questions about the balance between automation and human connection. While AI can expand access to care and tailor interventions to individual needs, it cannot replace the depth of human empathy, intuition, and relational understanding that are central to healing (Cooney & Menezes, 2018). Therapists provide essential skills—reading emotional cues, building trust, and exercising nuanced clinical judgment—that AI cannot replicate (Akbar et al., 2024). Some researchers cautioned that overreliance on AI-assisted therapy could weaken the human connection that many TBI survivors depend on for emotional recovery (Beard et al., 2024). To avoid this, AI should serve as a complement to human therapy, not a replacement.

Artificial Intelligence can support therapy by providing adaptive interventions, predictive analytics, and real-time biometric feedback, while human therapists offer the emotional attunement, ethical discernment, and relational depth that technology alone cannot replicate (Say et al., 2022). This integration upholds the principles of patient-centered care, ensuring that AI enhances—rather than undermines—the therapeutic relationship (Kim et al., 2024). As the field progresses, it is imperative that future research focus on the establishment of clear guidelines for AI and human collaboration so that there is complete transparency and ethical use of machine learning in trauma rehabilitation (Beard et al., 2024).

Conclusion This chapter explored the theoretical, creative, and technological advancements that may support identity exploration for individuals recovering from TBI. The discussion highlighted the multifaceted nature of TBI recovery, emphasizing the psychological, neurological, and social factors that shape post-injury identity and sense of self. The literature reviewed demonstrated that while traditional rehabilitation models primarily address physical and cognitive aspects of

52 recovery, the emotional and psychosocial challenges of TBI often receive less attention and remain inadequately addressed (Levack et al., 2010; Villa et al., 2020). Supporting identity exploration in TBI survivors requires a more integrated and reflective approach that includes creative processes, community-based support, and emerging technologies.

Creative processes offer nonverbal avenues for self-expression, supporting survivors in processing emotions, exploring fragmented aspects of identity, and fostering a sense of agency (Guay, 2018; Reynolds, 2012). These approaches enhance emotional regulation and contribute to social belonging, especially when integrated with community-focused programs that provide peer validation and shared understanding (D’Cruz et al., 2019; Donnelly et al., 2024). Because survivors often experience profound isolation, these programs offer critical spaces for reflection, recognition, and relational connection as they navigate evolving self-narratives.

Emerging AI and digital technologies introduce new possibilities for accessible and adaptive tools that support creative self-exploration. Artificial Intelligence-assisted platforms, such as VR environments, AI-generated art applications, and interactive storytelling tools, offer survivors novel ways to engage in reflective processes that may otherwise be difficult due to cognitive or physical impairments (Akbar et al., 2024; Kim et al., 2024). These technologies support both cognitive and emotional processes, helping individuals engage with memory, attention, and executive functioning, while also fostering creative and symbolic representations of their inner experiences (Beard et al., 2024). However, while AI tools hold transformative potential, important concerns around data privacy, AI bias, and the limitations of automated processes highlight the need for responsible, transparent, and ethically guided implementation (Rajaei et al., 2023).

53 A hybrid model that combines AI-supported creative tools, clinician-guided processes, and peer-based relational support offers a promising framework for supporting identity exploration in TBI survivors. By integrating AI’s adaptability with human relational depth, these models can provide more holistic and individualized care (Say et al., 2022). Future research should investigate the long-term impact of AI-assisted creative tools, with attention to how these technologies can promote cognitive engagement, emotional resilience, and meaningful social reintegration for individuals living with TBI (Kim et al., 2024).

As the field of neurorehabilitation continues to evolve, integrating AI-enhanced creative tools with traditional rehabilitation approaches may expand possibilities for supporting survivors’ emotional and relational needs. The insights from this chapter contributed to the growing body of interdisciplinary research on reflective, creative, and technology-assisted practices. By addressing the diverse and complex needs of TBI survivors, future approaches to rehabilitation can move beyond symptom management to support deeper processes of selfexploration, foster agency, and improve overall well-being.

54 Chapter 3: Methods The purpose of this case study was to explore how AI-generated art may facilitate selfexploration for adults recovering from TBI. This study examined how AI-generated art tools can support individuals in reflecting on and expressing their sense of self within a virtual environment. Artificial Intelligence-generated art refers to computer-based programs that create visual images in response to words, phrases, or ideas provided by participants. These tools offer an alternative means of expression that may help individuals explore complex thoughts and emotions that are difficult to articulate through language alone.

The primary focus of this case study was to explore how adults recovering from TBI may use AI-generated art to support self-exploration. This study considered AI-generated art as a creative and reflective tool that helps individuals explore and express their sense of self following TBI. Artificial Intelligence tools are systems that mimic human intelligence to perform tasks and can adjust and evolve based on the information they receive (Fulmer, 2019). The use of AI-generated art for identity exploration is new and underexplored, particularly for individuals with TBI; too little is currently known about how such tools can assist recovering individuals to engage with complex internal experiences, including emotions and aspects of identity that may be difficult to express. The central research question guiding this inquiry is: “How might engaging with AI-generated art support TBI survivors in exploring their sense of self?” This chapter outlines the research methodology for exploring AI-generated art as a creative tool for self-exploration in adults with TBI. It details the research design, rationale, and methods for investigating this innovative approach.

55 Rationale for Qualitative Research A qualitative research design was chosen for its ability to provide an in-depth understanding of participants’ experiences and perceptions. Qualitative methods are particularly suited for exploring complex, context-dependent phenomena, making them ideal for this study.

This approach aligned with a constructivist epistemology, which posits that knowledge is constructed through social interactions and experiences (Creswell & Creswell, 2023).

Constructivist epistemology emphasizes the cocreation of meaning between the researcher and participants, acknowledging that reality is subjective and shaped by individual perspectives. Participants in this study met the inclusion criteria of having a TBI; however, there were diverse experiences among participants. The focus was on the participants’ subjective experiences; therefore, the chosen study design is qualitative.

Rationale for the Case Study Method This study employed a case study methodology to explore AI-generated art as a tool for self-exploration in individuals recovering from TBI. Case studies enable a detailed examination of individual experiences, providing rich, contextual insights. Literature emphasizing the value of case studies in understanding complex processes within real-life contexts supported this method (Hyett et al., 2014). Specifically, this methodology enabled an in-depth investigation of how AI-generated art tools are used for self-exploration and how individuals use them to reflect on their sense of self. The study delved deeply into the nuances of each participant’s experience, capturing the multifaceted nature of AI-generated art as a reflective process. This approach was particularly valuable for uncovering the personal and emotional processes of engaging with AIgenerated art and identifying potential benefits and challenges. Additionally, case studies facilitate the collection of various data sources, including interviews, observations, and the AI-

56 generated images themselves. Through this comprehensive exploration, the research aimed to contribute to broader discussions on the use of AI-generated art as a tool for self-exploration, especially for individuals living with TBI. Research Sample The study included five adult participants who have experienced a TBI. Inclusion criteria specified individuals between the ages of 30–60, who were diagnosed with TBI at least two years prior to the start of the study, and who sustained the injury during adulthood. Exclusion criteria included individuals with severe cognitive impairments that would prevent meaningful participation in interviews or engagement with the image-based components of the study.

Participants were selected using criterion sampling, a type of purposive sampling, to ensure they met these criteria and could provide rich, detailed data. This sampling method was designed to identify individuals who could offer valuable insights into the research questions (Etikan et al., 2016). By focusing on this targeted group, the study aimed to gather in-depth information on the subjective experiences and outcomes related to AI-assisted therapeutic interventions.

Research Plan or Process The research process involved several steps: 1. Recruitment of Participants: Participants were recruited through established clinical networks and community organizations. Recruitment targeted local resources, such as the Brain Injury Association of Illinois and Shirley Ryan AbilityLab, as well as community organizations on Facebook, including the “Traumatic Brain Injury Support Group” and “The Ghost In My Brain—Traumatic Brain Injury (TBI) Support Group.” This multipronged approach ensured access to a diverse pool of individuals who have experienced TBI. While there is no financial compensation for participation, participants

57 received a $30 gift card as a token of appreciation for their time and contribution, even if they did not complete the interviews. During the recruitment process, several individuals responded to the study invitation but were identified as ineligible due to inconsistencies in their responses or indications of fraudulent intent as they were overly interested in the $30 gift card. Additional screening measures were implemented to ensure that only verified participants who met the inclusion criteria were enrolled in the study. The recruitment script is provided in Appendix A. 2. Initial Screening: I conducted an initial screening process to confirm that participants met the inclusion criteria. The initial screening script is provided in Appendix B. •

Eligible participants were adults aged 30–60 who have been diagnosed with a TBI. This age range was selected to focus on individuals who are likely to have developed a more established sense of identity, allowing for deeper exploration of how identity is impacted and potentially reconstructed following a TBI.

•

Additional details, such as the type of TBI (e.g., mild, moderate, or severe) and time since injury (minimum of two years) was recorded to support accurate differentiation from other cognitive or neurodevelopmental condition.

3. Exclusion Criterion—Severe Cognitive Impairments: participants with severe cognitive impairments were excluded from the study. For the purposes of this research, severe cognitive impairments are defined as deficits that significantly hinder an individual’s ability to understand, process, or communicate information. Examples of such impairments include: •

Significant memory deficits, such as difficulty recalling recent or past events, which may affect the reliability of self-reported experiences.

58 •

Impaired attention and concentration, resulting in an inability to sustain focus during tasks or conversations, thereby limiting meaningful participation.

•

Severe language or communication difficulties, such as profound aphasia, which interfere with understanding questions or expressing thoughts.

•

Marked limitations in executive functioning, including difficulty planning, organizing, or effectively carrying out tasks.

•

Overall reduced comprehension: difficulty in understanding instructions or consent forms.

These impairments were identified via the screening questionnaire.

4. In-depth Interviews and AI Tool Usage Sessions: I conducted several in-depth interviews to gather comprehensive insights into participants’ experiences of identity and selfexploration following TBI. To meet the participants’ needs, interviews were spread out and interviewees were offered breaks and the ability to stop interviews and resume another day. All participants utilized breaks or shortened interviews to meet their needs.

These interviews focused on: •

How participants perceived and explored their sense of self post-TBI.

•

Reflections on identity, including changes in self-perception, emotional experiences, and future self-concept.

•

The impact of engaging with AI-generated art on their narratives and selfunderstanding.

In addition to the interviews, participants engaged in AI art creation sessions as a reflective and creative process. The AI tool Midjourney, which generates visual art from natural language prompts, was used to create images based on participants’ descriptions of their

59 thoughts, feelings, and sense of self. Participants were asked to provide words, phrases, or ideas that represent aspects of their inner experience. I entered these prompts into Midjourney to produce AI-generated images that give visual form to their self-exploration. This process unfolded in two stages: 1. Initial Interviews and AI Image Creation Session: Participants engaged in in-depth conversations about their sense of self and experiences following TBI. During this session, they shared details for me to create several AI-generated image that served as a self-portrait reflecting their internal experiences, identity, or emotional states. Initial reactions to the images were gathered through open-ended discussion, allowing participants to share their immediate thoughts and feelings about how the image related to their sense of self. A semistructured interview guide was used to facilitate this conversation (see Appendix C).

2. Subsequent Follow-Up Interviews (Reflection on AI Art): Conducted approximately one week after participants received a physical copy of their AI generated self-portrait, this follow-up interview gave participants time to reflect on their AI-generated images. This interview focused on how participants interpreted and related to the images, and whether the images helped them explore aspects of their identity that might be difficult to express verbally (see Appendix D).

The AI art process served as a creative and reflective space where participants could explore aspects of their identity by generating and discussing AI-created images. This process aimed to: •

Offer participants a way to visually express and explore their sense of self using AIgenerated art.

60 •

Encourage reflection on personal experiences and identity through interaction with AIgenerated images.

•

Gather participant reflections and observations on how engaging with AI-generated art relates to their thoughts and feelings about themselves.

Detailed protocols were documented to ensure consistency and clarity throughout the

study. These protocols outlined how participants are introduced to the AI-generated art process, how prompts for image creation are collaboratively developed, and how reflections on the images are facilitated through guided conversation. Full protocols and interview guides are provided in Appendix C and Appendix D. Data Collection Data were collected from the interviews and AI sessions, then analyzed using qualitative methods to uncover patterns, themes, and insights. This involved coding the data, categorizing it, and interpreting the results to understand the impact and effectiveness of AI in therapeutic settings. By following these steps, the study aimed to provide a detailed examination of how AIgenerated art may support identity exploration in individuals with TBI. Further Data were collected using a combination of demographic information, semistructured interview guides, and participant observations.

1. Demographic Information: Basic background information was collected from each participant, including age, gender, time since TBI diagnosis, and other relevant personal or medical history. These details helped contextualize the findings and provide a fuller understanding of each participant’s lived experience.

2. Semistructured Interview Guides: The interviews were conducted to explore participants’ experiences with AI-generated art as a reflective tool for identity exploration. This

61 approach enabled a flexible, yet systematic exploration of key themes related to participants’ experiences using AI-generated art to express aspects of their identity and sense of self. Interview questions covered various topics, including participants’ perceptions of the AI-generated art process, their experiences creating and reflecting on AI-generated images, and their reflections on the challenges and insights that emerged.

The semistructured format enabled participants to share their stories in their own words while ensuring that the core research questions were addressed. Semistructured interviews are particularly effective for qualitative research, as they balance guided inquiry with the freedom to explore emergent topics in depth (Ruslin et al., 2022).

3. Participant Observations: I recorded observational data in the form of field notes, which I documented in a personal research journal throughout the study. These notes captured nonverbal cues, emotional tone, participant reactions during interviews, and any contextual factors that may inform the interpretation of the data. Keeping detailed field notes supported reflexivity and provided a richer understanding of the participants’ experiences beyond verbal responses.

By using these diverse data-collection methods, the study aimed to gather rich, detailed information that contributed to a nuanced understanding of how AI-generated art may support identity exploration in individuals with TBI. This comprehensive approach facilitated an in-depth analysis of participants’ subjective experiences and the ways AI-generated art may serve as a creative tool for reflecting on and expressing aspects of self.

Plan for Data Analysis Data analysis involved coding and categorizing the collected data to identify emerging themes and patterns related to identity, self-exploration, and the use of AI-generated art.

62 Following the guidelines outlined by Creswell and Creswell (2023), the analysis process included several detailed steps to ensure a systematic and rigorous approach: 1. Organizing and Preparing the Data for Analysis: The first step involved transcribing interviews, organizing AI-generated images, and compiling participant notes and demographic data. All data were sorted and arranged by type (e.g., interview transcripts, AI images, reflective notes) to ensure accessibility and readiness for analysis.

2. Reading Through the Data for Familiarization: Once organized, I conducted a comprehensive read-through to develop an overall sense of the content. This step afforded me to immerse in the data and to identify initial impressions, key ideas, and possible areas for deeper exploration.

3. Coding the Data: The data were analyzed through open and thematic coding. This involved breaking down interview transcripts, participant reflections, and descriptions of AI-generated art into meaningful segments. I labeled each segment with descriptive codes that captured essential ideas. Coding was an iterative process, with multiple rounds of refinement.

4. Identifying Themes: After coding, I grouped related codes to form broader themes that reflected key patterns in participants’ experiences. Themes included, for example, identity reconstruction, emotional expression, and meaning-making through AI-generated art. The process involved analyzing relationships among codes to identify how participants engage with AI-generated images and how these images relate to their sense of self.

5. Developing a Narrative Interpretation: Once themes were identified, a narrative account was developed to connect and interpret these themes. This process involves creating a

63 coherent storyline that reflects participants’ experiences of using AI-generated art for self-exploration. The narrative highlighted how participants made meaning of the images, how the process influenced their reflections on identity, and what insights emerged through this creative engagement.

6. Applying an Analytic Framework for Deeper Interpretation: To further analyze the data, an analytic framework grounded in psychodynamic and constructivist theories was applied. This framework guided the interpretation of how AI-generated art facilitates access to unconscious material, symbolic representation, and identity exploration.

Applying this lens enabled deeper insight into the emotional and reflective processes that participants engage in through AI-generated art.

7. Representing and Interpreting the Data: The final step involved representing the findings in a way that communicated participants’ experiences clearly and meaningfully. This included detailed narratives, visual representations (e.g., selected AI-generated images, thematic diagrams), and participant quotes to illustrate key points. Interpretation connected findings to existing literature on identity, self-exploration, and creative tools in recovery from TBI, while considering broader implications for clinical practice and future research.

Use of ChatGPT for Data Analysis While qualitative analysis software such as ATLAS.ti is often used for thematic analysis, in this study I employed ChatGPT (OpenAI, GPT-5) as a digital tool to assist with organizing and synthesizing data. After manually transcribing each interview, I entered deidentified excerpts into ChatGPT to find recurring words, metaphors, and emotional patterns related to identity, selfperception, and meaning-making. These outputs served only as preliminary guides to support

64 theme development. I independently reviewed all suggestions, verified the relevance of each theme, and refined the coding framework through iterative, reflexive engagement with the transcripts and field notes. In keeping with a constructivist and psychodynamic approach, final themes were derived through my interpretive analysis rather than through automated processes.

The ChatGPT software was used strictly as an analytic assistant to enhance organization and efficiency; all interpretive decisions, thematic categorizations, and theoretical integrations were my own, and were made to ensure rigor, reflexivity, and alignment with the study’s conceptual framework. ChatGPT (OpenAI, GPT-5) was used to assist with data organization and preliminary thematic synthesis. No identifiable data were entered into the program, and all content was deidentified prior to use to protect participant privacy.

By systematically following these steps, I aimed to provide a rich and nuanced analysis of how AI-generated art may support identity exploration in individuals living with TBI. This approach ensured that findings are credible, reflective of participants’ lived experiences, and contribute to understanding creative, reflective tools in post-TBI self-exploration.

Ethical Considerations In researching the use of AI-generated art to explore identity after TBI, several ethical considerations were addressed to ensure the protection and respect of participants. To acknowledge participants’ time and effort, participants received a $30 gift card. This was not considered payment but rather a small token of appreciation. I informed participants that their participation is voluntary and that they may withdraw at any time without penalty or loss of this gift card, should they choose to discontinue.

65 Informed Consent Prior to participation, informed consent was obtained. This process included clearly explaining the study’s purpose, procedures, potential risks, and benefits. Participants were informed of their right to withdraw from the study at any time without consequence. Consent forms were written in plain language and provided in accessible formats for individuals with cognitive impairments associated with TBI. This approach aligned with the ethical principles Keller and Lee (2003) outlined, emphasizing that participants must fully understand the study to agree to participate.

Confidentiality and Privacy All participant data were securely stored and anonymized to protect identities.

Pseudonyms were used in all publications and presentations. Only the research team had access to the data, and all electronic files were encrypted and stored on secure servers; physical documents were kept in locked storage. As Keller and Lee (2003) highlighted, safeguarding confidentiality is especially important in online research settings where risks of breaches are heightened. Participants were fully informed about how their data would be used. While final results were not automatically shared, participants requested a summary of general findings if they were interested. Debriefing was offered to allow participants to reflect on their experience of participating in the study.

Addressing Potential Risks and Ethical Approval Engaging with AI-generated art to explore identity may evoke emotional responses, especially when reflecting on personal experiences post-TBI. To mitigate these risks, participants were informed that they could pause or stop participation at any time. Psychological support resources were available, and I monitored participant responses throughout the process. The AI

66 tools were tested to ensure they are user-friendly and nonintrusive. As noted by Keller and Lee (2003), minimizing potential harm includes offering appropriate support when needed.

Approval was sought from the Institute for Clinical Social Work’s Institutional Review Board (IRB) prior to beginning the study. The IRB reviewed the research design to ensure compliance with ethical standards, and any modifications to the study will be promptly reported for reevaluation. While deception was not anticipated in this study, any potential use was minimal, fully justified, and subject to IRB approval. If used, participants were fully debriefed to explain the nature and rationale for any deception and to address any concerns. Debriefing focused on participants’ experiences of the AI art and interview process and provide an opportunity to reflect on their participation. As noted by Keller and Lee (2003), debriefing is critical in online environments where participants may disengage before fully understanding the study procedures.

By adhering to these ethical considerations, I aimed the study to respect and protect participants while contributing meaningful insights into how AI-generated art may support identity exploration in individuals living with TBI. The commitment to ethical research practices ensured that the study upheld the dignity, privacy, and rights of all participants involved.

Trustworthiness To ensure the study’s trustworthiness, the following criteria were addressed: 1. Credibility involves establishing that the results of qualitative research are believable and accurate from the participants’ perspectives. To enhance credibility, the study employed triangulation of data sources and member checking. Triangulation involved using multiple forms of data, including interviews, AI-generated images, and participant reflections, to cross-verify emerging themes and patterns (Shenton, 2004). Member

67 checking invited participants to review and provide feedback on my interpretations, ensuring that their perspectives are accurately represented.

2. Dependability refers to the consistency and reliability of the research process over time.

An audit trail was maintained to document research decisions, methodological adjustments, and the overall process of data collection and analysis (Shenton, 2004).

Additionally, I kept reflective journals to provide transparency regarding my thought processes, biases, and decision-making (Ortlipp, 2008). These journals helped to critically engage with and monitor personal assumptions, thereby enhancing the study’s rigor.

3. Transferability concerns the extent to which study findings may be applicable to other contexts or groups. To support transferability, detailed descriptions of the research context, participant demographics, and data-collection procedures were provided. These “thick descriptions” enable readers to determine whether the findings may be relevant to similar populations or settings (Shenton, 2004).

4. Reflexivity involves critically reflecting on the researcher’s role and influence within the study. Given my personal experience of living with TBI, bracketing was used to acknowledge and set aside personal biases and assumptions during data collection and analysis (Tufford & Newman, 2010). Reflective journaling was employed throughout the study to monitor and examine the researcher’s evolving thoughts and emotional responses, helping ensure that participants’ experiences remain the central focus. This reflexive process enhanced the credibility and trustworthiness of the findings.

5. Ethical rigor supports the overall trustworthiness of qualitative research. Ensuring informed consent, participant confidentiality, and attention to potential risks reflects a

68 commitment to ethical research practices. Approval from the IRB was obtained prior to data collection. Adhering to these ethical guidelines help to ensure that the research was conducted with respect, care, and transparency.

By addressing these criteria, I ensured the trustworthiness and rigor of the research findings, contributing valuable insights into the role of AI art in understanding identity following TBI. Limitations and Delimitations Limitations I acknowledged several limitations in this study that may influenced the interpretation and applicability of the findings: 1. Small Sample Size: As a case study with a small number of participants, the findings may not be broadly generalizable. A larger sample could provide a more robust data set and potentially offer broader insights into how AI-generated art may support identity exploration for individuals with TBI. 2. Researcher Bias: Despite efforts to mitigate bias through such techniques as bracketing and maintaining a reflective journal, there remained an inherent potential for researcher bias. My personal experiences, values, and assumptions may have influenced data collection, interpretation, and analysis. As Tufford and Newman (2010) noted, acknowledging and addressing these biases is essential to enhancing the rigor of qualitative research.

3. Subjectivity in Interpretation: Qualitative research is inherently subjective, and interpretations may vary based on my perspective. Although such strategies as member

69 checking and triangulation will be employed to strengthen credibility, the subjective nature of qualitative analysis remains a limitation.

4. Limited Transferability: This study’s focus on individuals with TBI engaging with AIgenerated art as a reflective tool may have limited the transferability of findings to other populations or contexts. The unique experiences of this specific group may not reflect the experiences of individuals outside of this context.

Delimitations Delimitations define the scope and boundaries of this study, providing clarity on what is included and excluded.

1. Focus on AI Art: This study specifically focused on the use of AI-generated art as a tool for exploring identity following TBI. Other forms of art-making, creative media, or therapeutic interventions were outside the scope of this research.

2. Participant Criteria: Participants were limited to individuals who have experienced a TBI and were willing to engage in the AI art creation process. This focus excluded individuals without TBI or those not interested in participating in AI art creation.

3. Contextual Boundaries: The research was conducted within a specific context, which may have limited the applicability of findings to other settings or populations. However, detailed descriptions of the research context, participants, and procedures were provided to support the transferability of findings to similar settings (Shenton, 2004).

4. Temporal Scope: I conducted the study within a defined timeframe, which may have influenced the results. A longitudinal study might offer additional insights into the longer-term effects of using AI-generated art for identity exploration post-TBI.

70 By clearly outlining these delimitations, I aimed to provide transparency regarding this study’s scope and potential influences on the findings. Such transparency was essential for understanding the research’s context and for assessing the relevance of the findings to other settings.

Role and Background of the Researcher This study was informed by my background as a LCPC and as an individual with lived experience of TBI. This positionality offered unique insights into the emotional and psychological complexities of living with TBI. However, it also required continuous reflexivity to manage potential biases and maintain a rigorous, participant-centered approach throughout the research process.

71 Chapter 4: Results The purpose of this research was to gauge the potential use of AI-generated art as a tool for exploring identity in individuals who experienced a TBI. The study investigated how AIgenerated art might support adults recovering from TBI in reflecting on their sense of self. The central research question guiding this work is: “How does engaging with AI art enable TBI survivors to explore their sense of self?” Rather than offering a clinical intervention, this study used a psychodynamic-informed framework to investigate self-expression and symbolic meaning-making.

This chapter presents the findings from this qualitative case study exploring how engaging with AI-generated art supports TBI survivors in exploring their sense of self. The chapter begins with an overview of each participant’s experience, including their AI-generated artwork and accompanying reflections, followed by a cross-case analysis highlighting the major themes that emerged. Data were thematically analyzed using a combination of manual coding and AI-assisted synthesis via ChatGPT. This hybrid process supported the identification of core patterns and themes, which were then refined through reflexive analysis and theoretical integration.

The Impact of Traumatic Brain Injury on Research Participation A key theme that emerged during the data-collection process was the presence of unforeseen significant logistical challenges. Participants would sometimes forget meetings, not respond to emails for days or weeks, or need to reschedule due to flare-ups of their medical conditions. Additionally, it became evident during the screening interviews that the research process would need to be broken up into mini-interviews to accommodate the participants’

72 needs, as lengthy interviews were problematic on both a physical and emotional level due to having endured a TBI. It was essential for me to monitor participants’ mental and physical states during the interview through mini check-ins, which allowed them to choose whether to continue, take a break, or end the interview for the day. There were several instances when a participant needed to pause for the day due to fatigue, vision issues, difficulty with word recall, or just feeling “crummy.” To accommodate participants’ needs, they were given the option to turn their cameras off and sit wherever they felt most comfortable during the Zoom interviews. All participants elected to have their camera on, but several chose to close their eyes at times.

Several participants chose to spend time outdoors while sharing their thoughts during the interviews. These struggles were not a reflection of a lack of commitment on the part of participants but a direct consequence of their injuries. Each participant was committed to the process, even though it was sometimes taxing for them. The logistical challenges of the research process highlighted the immense mental and physical effort required to complete tasks that were once effortless, before experiencing the TBI. Participant Profile: Rhuadh (49 Years-Old) Rhuadh is a 49-year-old woman whose life underwent a profound transformation following two TBIs. Before her injury, she identified as a “helper,” a voracious reader, and a gifted musician who played the cello daily as a form of journaling. As a child, a teacher once remarked that she might end up with four part-time jobs, not due to limitation, but because her wide-ranging interests could lead her in many directions. Now, she navigates the complexities of her new life with the ongoing support of her family and finds a new way to be the “helper” through her involvement in community work at a local garden. In this green space, she is

73 cultivating not just plants, but a sense of purpose. She is slowly discovering that being a “helper” is not about having all the answers, but about being present and tending to what needs to grow.

Neurological and Medical Journey Rhuadh’s first TBI occurred in April 2000 during a severe car accident where she lost consciousness. Her heart stopped, causing a period of oxygen deprivation. The TBI left her with a significant loss of English vocabulary and an inability to comprehend her own college papers that she had written just weeks prior. Seven years later, in 2007, she suffered a second TBI in Uganda when a van she was traveling in with no working seatbelts rolled over. This second injury was too much and caused her body to “shut down.” She described in detail how she became sensitive to all stimuli as she could not read, listen to music, or watch TV without feeling “seasick.” Rhuadh shared that her words would sometimes become jumbled, and others told her she sounded ‘like Yoda,’ not because of wisdom, but because her grammar and word order were off. Today, she endures approximately 15–20 migraine days a month, which are triggered by a range of factors, including weather, stress, hormones, and food.

Psychosocial and Emotional Impact After her first injury in 2000, Rhuadh abandoned her plans for graduate school and instead worked in a “simpler job” until 2006. When her second TBI occurred in 2007, her body could no longer keep up, and she has not been able to return to work since. These changes forced her to narrow her life in ways she had never anticipated. She lost the identity she had built as a “helper,” describing that loss as “a punch in the gut,” as she questioned who she was if she was not the “helper.” She grappled with the feeling of being “a big old waste of space” and constantly struggles with the “weight of the difference” between her past and present selves. This pain of

74 comparison is so profound that she and others in her support group have sometimes wished they could not remember life before their injuries.

Rhuadh feels misunderstood by strangers, who often interact with her as if she were a “fifth grader” because of the physical “armor” she wears, such as a hat, sunglasses, and headphones. She worries that her need to cancel plans unexpectedly makes her seem “unreliable.” Nevertheless, she holds on to her sense of worth, anchored by her father’s consistent message to her that she is “precious” even if she were just “a brain on a pillow.”

Symbolic and Artistic Expression Rhuadh often turns to metaphor to make sense of her inner world, which she describes as “layered” and difficult to reconcile. At times she imagines herself as a “geode, plain on the outside but containing unexpected facets within,” while at other times she likens herself to a Hindu statue with “a thousand heads, or eyes, or hands.” These images reflected her sense of holding many different roles and perspectives at once. She also distinguishes between two versions of herself, the “real me,” who is proactive and engaged, and the “pain Rhuadh,” who is more constrained in their ability to navigate the world. To convey the divide between her mind and body, she drew on the image of the Hulk, showing how her intentions often exceed her body’s capabilities. She further described herself as a “duck, calm on the surface but frantically paddling underneath,” a metaphor that conveyed the constant hidden effort required to get through the day. Living with these contradictions, she said, could feel like being “painted in a corner.”

Art provides an outlet. In guided meditations, Rhuadh regularly returned to a recurring landscape of meadow, river, lake, and mountains that offered her a sense of peace. She connected the “crackled surface” of the Indonesian art form Batik to the idea of repair,

75 suggesting that damage and restoration are intertwined. She also resonated with what she called the “Sisterhood vibes” in Lizzie Sykes’s work. In reflecting on these experiences, she described her identity as less singular and more like a kind of “mosaic.” The pieces may not all match, yet together they form something that holds (see Figures 1 and 2).

Figure 1 Rhuadh’s Runner-Up Image

Note. An AI-generated image created for participant Rhuadh. The image was generated using the text prompt: “An emotional fine art abstract landscape in batik style, infused with Van Gogh swirls, Hildegard von Bingen’s luminous medieval motifs, and mosaic artistry. A central mosaiclike female figure with flowing brown hair, seen from behind, gazes out over a sloping meadow with a river flowing toward a shimmering lake. Her form, with multiple faint overlapping silhouettes like a gentle Hindu deity, expresses her many selves: helper, rest, resilience, creativity. Around her, swirling chaotic patterns hold pain, trauma, and expectations at the edges,

76 while her center glows with golden serenity. Kintsugi-like gold cracks weave through her and the land, symbolizing healing and resilience. Rich blues, purples, greens, and golds blend with waxresistant crackles, creating a scene that feels spiritual, compassionate, and timeless. In the style of batik, mosaic fine art, sacred illumination, and sisterhood-inspired symbolic portraiture.”

Figure 2 Rhuadh’s Chosen Image

Note. An AI-generated image created for participant Rhuadh. The image was generated using the text prompt: “An emotional fine art abstract landscape in batik style, infused with Van Gogh swirls, Hildegard von Bingen’s luminous medieval motifs, and mosaic artistry. A central mosaiclike female figure composed of colorful facets rises from a sloping meadow with a river flowing toward a shimmering lake. Her form has multiple serene faces, like a gentle Hindu deity, each expressing a different self: helper, rest, resilience, creativity. Around her, swirling chaotic

77 patterns hold pain, trauma, and expectations at the edges, while her center glows with golden serenity. Kintsugi-like gold cracks weave through her and the land, symbolizing healing and resilience. Rich blues, purples, greens, and golds blend with wax-resistant crackles, creating a scene that feels spiritual, compassionate, and timeless. In the style of batik, mosaic fine art, sacred illumination, and sisterhood-inspired symbolic portraiture.”

Rationale for Chosen Image Rhuadh chose the image because it provided a reflection of her inner world, which she often visits during guided meditations. She repeatedly felt this image, which contained a central tree/person figure, was “winning all the time” and had a profound “impact somehow.” The abstract style was crucial because it resonated with the nonliteral, symbolic landscape of her meditation, a place with “mountains, and a meadow, and a lake, and a river, and a garden and a forest” that is “not any real place.” Ultimately, she preferred the abstract images as they allowed her to mentally “put yourself in it” more easily than the realistic portraits.

Image Integration and Ongoing Reflection Rhuadh’s reflections after engaging with the image for a week center on the themes of personal transformation, powerful growth, and challenging isolation in the context of her life following two TBIs. The image, a large metal print of an AI-generated figure she calls the “tree lady,” served as a dynamic mirror for her inner world.

Identity and Remarkable Growth. Rhuadh interpreted the image as a representation of her complicated but powerful survival and ongoing development. She saw the image as “growth emerging from a heavy, slightly dark palette.” This directly mirrored her identity as someone

78 who has been “broken apart and reassembled multiple times” due to severe injuries, but is “freaking lucky at how much” she has recovered.

The figure, the “tree lady,” resonated with her sense of self as an entity that blends seemingly separate parts. She playfully questioned, “Is it a tree, or is it a lady,” but concluded that it “somehow all makes a thing” that feels “powerful.” Engaging with the image confirmed her reality, allowing her to realize, “Yes, I am a miracle,” and that the progress she had made was genuine, reminding her to “keep it up.”

The image also helped her acknowledge and affirm her emerging role as a “transformation shaman.” This identity grew from her ability to be a voice for others. She shared that when she sought treatment at a pain clinic, the medical team often turned to her to describe what the treatments felt like, as she became a voice for patients who had lost the ability to communicate. Additionally, she used her experiences to “be helpful” to friends and neighbors navigating various life challenges.

Profound Isolation and the Desire for Connection. Despite the feelings of power and growth, the image also brought her deep-seated feelings of separation into sharp focus. The fact that the figure in the image is alone magnifies her feeling of being on the “fringe.” Her isolation was also connected to the “things I can’t do,” such as attending a music concert or spontaneously driving to help her best friends or sisters. These limitations restricted her ability to interact with people and fulfill her core identity as a helper. She also noted that the perfect landscape she had described in the past did not include people, which she found significant.

79 The Weight of the Experience. Rhuadh also used the reflection to articulate the hidden difficulty of her life. She described the reality of her life as “heavy.” She wished she could have a supplementary image that showed an “iota of the hard, freaky, unstable part” that she does not believe people have any clue about. At the same time, she acknowledged the intellectual curiosity of the process, noting the “weird academic, fascinating thing” of an almost “randomly generated AI image” that she, as a human, kept noticing details in and “ascribing meaning to it.”

To better reflect her desire for community, Rhuadh suggested revising the image by adding a “little path that was going into the village” so that the figure would not be “on my own planet totally by myself.”

Participant Profile: AZYogi (43 Years-Old) AZYogi’s has been an ongoing battle with her own body for her adult life. She is a former competitive equestrian who exuded grace, power, and precise control while working with her horse. However, a series of TBIs shattered that world and plunged her into a new world where she felt like a foreigner in her own body. She has developed a form of intractable epilepsy as a result of TBIs, and her life is full of daily challenges. She shared a story about how identity can be reshaped by physical trauma, but that purpose can still be found.

Neurological and Medical Journey AZYogi’s initial TBI occurred in February 2000, at age 17, when she was “kicked in the head by a horse” and was rendered unconscious for several days. Despite being advised by doctors to undergo a follow-up TBI scan three months later, her mother, a registered nurse, did not facilitate this recommended medical care. A more severe neurological event occurred in February 2003, when she sustained two additional TBIs after falling twice while riding in a work-student program. She was told to “get back on the horse” and was refused access to

80 medical care. Within two months of these injuries, she began experiencing déjà vu sensations, and by May 2003, a neurologist diagnosed her with epilepsy. The seizures, primarily focal impaired awareness seizures, originate in her temporal lobe, the same area impacted by her TBIs. Her epilepsy is intractable, meaning it does not respond to standard treatments. She has gone through four episodes of status epilepticus, when seizures would not stop without emergency intervention, and she nearly died twice. Her treatment has also included brain surgery and the placement of a vagus nerve stimulator. One of the most challenging experiences came when she was admitted to a psychiatric unit, where staff misunderstood her postictal state following the epileptic seizure, and labeled it as bipolar disorder and schizophrenia.

Psychosocial and Emotional Impact These experiences posed significant challenges for AZYogi. She reported persistent difficulties with short-term memory and word recall, impairments directly associated with temporal lobe damage and recurrent seizures. AZYogi perceived her illness as a “filter” as she has lost many relationships, leaving her feeling lonely and abandoned. She noted the strained relationships with her mother and brothers. She described a neglectful mother and physically abusive brothers, which led to trauma and intense feelings of vulnerability. There are “only a few who have chosen to stay” by her side. However, this “filter” has also allowed her to feel a deep sense of gratitude for those who have chosen to stay.

AZYogi demonstrated remarkable resilience. She identified her long-term partner as a consistent source of courage and stability. Drawing from her lived experience, she has transformed suffering into purpose by teaching yoga to children with epilepsy, encouraging them to connect with their bodies and discover inner strength. She also advocated for the prevention of

81 traumatic brain injury within equestrian sports, actively promoting helmet use as a means of protecting others from harm.

Symbolic and Artistic Expression AZYogi often turns to imagery to describe her journey (see Figures 3 and 4). In her words, it feels like ”a lonely path,” narrow and unsteady, with cliffs on either side. She noted that “someone could walk alongside” her, but it would be difficult, as it is an arduous route with rough terrain. To capture her resilience, she likened herself to a broken porcelain plate mended with gold, referencing the Japanese art of kintsugi. For her, the cracks are not a mark of weakness but of meaning, reminders that she is “stronger because of the journey.” She often returns to the image of a butterfly circling in search of a field of flowers. For her, this picture carries the ache of wanting a community that feels safe and welcoming. In contrast, yoga provides her with steadiness. It gives her peace and, as she puts it, a “connection to the ground again.” Above all, she wanted to “keep lighting up the room,” using her own strength to guide others as they navigate their paths.

82 Figure 3 AZYogi’s Runner-Up Image

Note. An AI-generated image created for participant AZYogi. The image was generated using the text prompt: “A mystical symbolist painting in the style of Gustav Klimt and Agnes Pelton, glowing gold accents, dreamlike surrealism, and soft textured brushwork. A petite woman with sandy blonde shoulder-length hair and blue eyes, seen from behind, walking a narrow kintsugirepaired path between towering cliffs adorned with ancient markings, radiant sun breaking through violet and cobalt storm clouds, subtle lightning glimmers, glowing butterfly floating beside her, distant black bird near the light, luminous purple field in the distance, garden below glistening with dew; a mood of sacred solitude, transformation, and emerging light.”

83 Figure 4 AZYogi’s Chosen Image

Note. An AI-generated image created for participant AZYogi. The image was generated using the text prompt: “A mystical symbolist painting in the style of Gustav Klimt and Agnes Pelton, glowing gold accents, dreamlike surrealism, soft textured brushwork. A petite woman with sandy blonde shoulder-length hair and blue eyes, seen from behind, walking a narrow kintsugi-repaired path between towering cliffs adorned with ancient markings, radiant sun breaking through violet and cobalt storm clouds, subtle lightning glimmers, glowing butterfly floating beside her, distant black bird near the light, luminous purple field in the distance, garden below glistening with dew; a mood of sacred solitude, transformation, and emerging light.”

84 Rationale for Chosen Image AZYogi reflected on the two images by saying, One is more peaceful and represents the emotions that I feel when I wake up and feel throughout my life. The other feels more like how my journey has been since dealing with the TBI and everything that has happened because of it.

After giving this some thought, she explained, The chosen image would be the one for optimistic meditation and reflection. The runnerup image would be more suitable for reflection and might evoke negative thoughts. While it is more representative of what I have gone through, it isn’t what I want my life to continue to be … The chosen image feels more aligned with how I want to live moving forward—it brings me a sense of peace and optimism that I can carry into meditation and daily life. The runner-up image captures my struggles and pain, but that’s not the space I want to stay in. While my seizures will continue throughout my life, I have worked hard not to fear them. With that said, I would choose the chosen image.

Image Integration and Ongoing Reflection. AZYogi keeps her cocreated image prominently displayed, using it as part of her meditation and yin yoga practice. The image depicts a path divided into two sides. The right side, filled with what she interprets as lavender, represents a “gentle path” of relaxation and calm. The left side, by contrast, is “more rocky and steep,” symbolizing the inherent peril of her epilepsy.

The central figure in the image functions as a self-representation. AZ Yogi identified strongly with this figure, stating she could “easily see myself as this person.” A striking golden seam appears where the path had been broken and repaired. She described it as “forged” and

85 “fixed,” suggesting the road might be stronger now, a metaphor for her own resilience and new, more durable existence shaped through rupture and repair.

Resilience and Shifting Identity. The butterfly that accompanies the figure became a central and evolving symbol. Initially, AZYogi understood the butterfly as expressing her “search for a supportive community.” Over time, its meaning shifted inward. She came to see it as a representation of her own resilience, a “strong little friend” who, though delicate, is “really pretty amazing.” This shift underscored her commitment to ”moving on forward” with a gentle path, a deliberate choice in the face of epilepsy’s ”violent” reality. The butterfly, like her path, reflects both fragility and strength.

Acceptance and the Nonverbal Path. With over two decades of experience navigating her diagnosis, AZYogi has developed a strong capacity to verbalize her medical history. Thus, the image did not serve to articulate something inaccessible. Instead, she emphasized its potential benefit for others earlier in their diagnosis, particularly those struggling emotionally or resisting acceptance. She described the image as a ”gentler way” of confronting the diagnosis, contrasting it with the abruptness of simply being handed a pill. As she noted, ”Words and art are different, art taps into a different part of the brain,” and can open a softer, more embodied path to understanding.

Proposed Revision. When selecting her final image, AZYogi chose an optimistic one that conveyed movement forward, deliberately setting aside a darker image that had captured her feelings of “sadness and isolation.” She declined revisions, explaining that each image had its own “narrative” tied to a particular moment, and she preferred to “complete the story” with the chosen one. Notably, I reminded her that she was permitted to treat the image as entirely her

86 own, including the freedom to discard it should it ever become a source of stagnation or discomfort.

Participant Profile: Anunnaki (32 Years-Old) Anunnaki sustained a severe TBI at age 23. His childhood was marked by instability in the foster care system, where he was exposed to painful isolation and violence. He described himself as having been a timid child who preferred to remain alone, though he noted he would defend himself if provoked. Anunnaki reported that he has never lived in one place for more than three years. Today, he travels the country in his RV with his two dogs, identifying himself with pride as a “puppy dad.”

Neurological and Medical Journey On Memorial Day in 2016, Anunnaki was struck by a sedan while walking on a curb. He recalled that the side mirror struck his elbow, fracturing it so that the bone protruded. He was then dragged along the street, his body twisted and his head caught beneath the front tire, before the driver slammed on the brakes. The sudden stop threw him onto the windshield, which cracked on impact, forming a spiderweb pattern. He sustained multiple injuries, including a compound fracture, fractured ribs, and a collapsed lung, and he still bears tire tread marks on his torso. He lost consciousness for an unspecified length of time, choked on his own blood, and was later placed in an induced coma. Anunnaki reported being told that his frontal lobes were “crushed.” Nearly nine years later, he continues to live with severe migraines, which remind him of the feeling of having his head “back underneath the tires.” Despite the seriousness of the accident, he never received formal rehabilitation services and instead developed his own strategies for coping. He has done everything in his power to “not become a statistic.”

87 Psychosocial and Emotional Impact Anunnaki described his recovery as a profound change in identity. He believes that he “died” during the accident and that a “different version” of himself returned. He recounted a near-death experience in which he became a “star,” traveled through space, and met with a “powerful being in multiple dimensions.” He also recalled seeing a “city full of stars like New York City.” Waking from this experience, he remembers feeling angry at being brought back to a life he believed had little purpose.

Impulse control has been one of Anunnaki’s most difficult challenges postinjury. He acknowledged “close calls with law enforcement” in the early years when his speech and behavior were less restrained. However, over time, he has become calmer and more tactful, using humor to navigate social situations. Humor, often self-deprecating or playful, serves as a coping mechanism, while spirituality has become another source of meaning. Anunnaki now believes that “the universe is alive and speaks to me,” a conviction that has helped him move away from self-destructive behaviors. He connected this outlook to both his near-death experience and his earlier struggles in foster care, which shaped his empathy for “those that have already been forgotten.”

Symbolic and Artistic Expression Anunnaki’s symbolic world drew heavily on contrast. For about seven years after his TBI, he experienced recurring hallucinations of “shadow people.” At one point, he recalled seeing a shadow figure react with horror upon realizing that he could see it. He joked that the shadow people may have “sent out a memo,” because after that encounter, the figures stopped appearing. His near-death imagery continued to influence him, and he envisioned a multiverse

88 divided between two opposing sides: a star-filled New York-like city populated by shadow figures, and a sanctuary of lush greenery and puppies.

Anunnaki also brought childhood symbols into his imagery. He remembered “tree stars” from The Land Before Time and the “daddy longlegs” spiders he once considered his closest companions when living alone in a dark, damp basement as a child. These symbols, though simple, carry deep emotional significance. In terms of aesthetics, Anunnaki prefers shades of green and metallic teal, which he described as “uplifting” and “heartening.” He also emphasized the importance of smooth textures, which he associated with self-soothing practices developed during childhood (see Figures 5, 6, and 7).

Figure 5 Anunnaki’s Runner-Up Image 1

89 Note. An AI-generated image created for participant Anunnaki. The image was generated using the text prompt: “Cinematic photorealistic self-portrait, surreal symbolism, the scene split exactly 50/50 with a sharp vertical boundary down the center. Left half: cosmic New York City at night, every brick glowing like stardust, skyline under a radiant star-filled sky, streets lit in deep purples, electric blues, and shimmering gold. Graceful shadow people in tall hazy silhouettes walk under glowing streetlamps, outlined with soft silver light. Right half: lush daytime sanctuary, vibrant jade, emerald, and lime foliage, smooth black volcanic soil, playful puppies in warm golden sunlight, air glowing with pink, coral, and amber. Center: a tall man with short dark brown hair stands straddling the boundary, left foot planted in the glowing starry city among shadow people, right foot firmly in the vivid green sanctuary, calm yet searching.

Details: luminous Tree Star leaves (The Land Before Time) floating across the divide, sparkling in the light; tiny Daddy Long Legs spiders glistening in the sanctuary grass; subtle Gohan reference (Dragon Ball Z) hidden in the scene. Smooth textures, bold contrasting color palettes, high-contrast cinematic lighting, dreamlike realism, polished fine art photography, two worlds clearly separated yet joined by the central figure.”

90 Figure 6 Anunnaki’s Runner-Up Image 2

Note. An AI-generated image created for participant Anunnaki. The image was generated using the text prompt: “Cinematic photorealistic self-portrait, surreal symbolism, the world split in two left side: cosmic New York City, every brick glowing like stardust, skyline under a radiant starfilled sky, streets bathed in deep purples, electric blues, and shimmering gold light, shadow people in tall hazy silhouettes walking under glowing streetlamps, mysterious and captivating.

91 Right side: lush green sanctuary bursting with life, vibrant jade, emerald, and lime foliage, smooth black volcanic soil, puppies playing in warm golden sunlight, air glowing with hints of pink, coral, and amber. At the center: tall man with short dark brown hair, one foot stepping into the glowing starry city streets among shadow people, the other grounded in the vivid green sanctuary, calm yet searching. Hidden symbols: luminous Tree Star leaf (The Land Before Time), subtle Gohan reference (Dragon Ball Z), small Daddy Long Legs spider glistening in the grass.

Smooth textures, radiant color palette, high-contrast cinematic lighting, dreamlike realism, polished fine art photography, emotionally charged and visually stunning.”

Figure 7 Anunnaki’s Chosen Image

Note. An AI-generated image created for participant Anunnaki. The image was generated using the text prompt: “Hyperrealistic cinematic split-screen diptych, vibrant sun-drenched forest sanctuary on the left, lush foliage in seafoam, jade, and sage green, volcanic black soil, golden

92 sunlight filtering through tall trees, dogs and puppies playing in soft grass, glowing Tree Star leaf, Daddy Long Legs spider catching sunlight, clear blue sky with no stars, warm natural lighting, grounded and alive; on the right, surreal stardust New York City, glowing skyscrapers made of gold, teal, lavender, and cosmic white particles, night sky filled with crystal stars and a heroic-shaped constellation, ghostlike shadow people in slow motion, cold ethereal lighting, magical and distant atmosphere; in the center, tall man with short dark brown hair, seen from behind, mid-stride, walking away from forest into stardust city, one foot in fertile soil, one foot on glowing pavement, bittersweet emotion, cinematic mood, emotional transformation.”

Rationale for Chosen Image Anunnaki chose the final image because it powerfully captured his sense of self, following his TBI. He felt the image represented the simultaneous existence of his “bad world” and “good world” and his struggle to integrate them to form his “best me.” The image’s core appeal was that the “shadow/star” worlds existing in parallel could be interpreted as him, or as “a different version” of himself from “a different universe.” He particularly liked the inclusion of stars and their perception as multidimensional, which directly resonated with his feeling of having “belonged somewhere else since TBI.” Image Integration and Ongoing Reflection. Anunnaki’s personalized image, which he considered setting as his phone wallpaper, features a “Spirit Walker” and a bear set against a backdrop of stars and a city skyline. He found the image to be an impactful, daily reminder to “be positive.” He saw the bear as “scrappy looking,” sometimes reflecting a readiness in himself to fight. The Spirit Walker, the bear, and the stars were deemed the most “vital” elements for telling his story.

93 Multifaceted Identity After TBI. The core theme captured by the image is the manifestation of Anunnaki’s multiple selves and “different facets” following his TBI. He explained that the image reflects how he feels much of the time, noting a sense of being composed of “different beings” and sometimes feeling as though he does not “belong here.” The stars, for instance, represent a part of him that is sometimes “just hanging out.” The image effectively conveyed the difficulty of describing his “multiple versions” to others without them thinking, “Oh my God, he’s got three different people living inside.” He clarified that these different aspects are merely differing views, not separate personalities. This transformation stood in contrast to his pre-TBI self, whom he characterized as “more timid.”

Thoughtfulness and Desire to Connect. Engagement with the image prompted Anunnaki to reflect more deeply on his place in the world, noting that it made him “definitely more thoughtful.” He described a growing openness to connection and a newfound motivation to “try to help others.” The image further functioned as a reference point for articulating his life story, encouraging him to share it more readily with others. He emphasized the nonlinear nature of this narrative, shaped by his survival of a near-death experience and subsequent significant transformations. He identified the visual art as a valuable tool for communicating such complexity.

Proposed Revision. Anunnaki did not want to fundamentally alter the image but instead sought refinements to strengthen its personal significance. He requested that the skyline be revised to depict the pre-9/11 New York City skyline on the right side, noting that the current rendering was inaccurate. He also suggested an aesthetic adjustment, preferring fewer stars on the left to reduce visual clutter. At the same time, he emphasized that minor elements, such as the

94 grass and the existing skyline were not vital to the narrative, whereas the Spirit Walker, bear, and stars remained central to the image’s symbolic power.

Participant Profile: Mechelle (58 Years-Old) Mechelle sustained a series of TBIs that profoundly reshaped both her personal and professional trajectory. At the time of her last injury, she was serving as director of a residential treatment facility. In that position, she demonstrated considerable skill in balancing the competing demands of patients, staff, and institutional systems. The injury, however, dismantled her professional identity and left her contending with significant cognitive and emotional impairments. No longer the decision-maker, she was thrust into the role of patient, a reversal that underscores both the magnitude of her losses and the difficulty of reconstructing a sense of stability and purpose in the aftermath of trauma.

Neurological and Medical Journey Mechelle slipped on the ice and sustained her fourth and most consequential TBI in January 2025. Although she was initially cleared to return to work after her first emergency room visit, her symptoms quickly worsened and required a second evaluation. During that visit, the physician cautioned her that she might never fully recover from the most recent TBI. Systemic and financial barriers further complicated Mechelle’s recovery. When her workers’ compensation claim was denied, she lost immediate access to her scheduled vestibular, speech, and occupational therapies. Soon afterward, she was dismissed from her job without explanation. When she lost her job, she also lost her health insurance and affordable medical care. To advocate for herself, Mechelle sought legal counsel, but was told that her former employer’s Native American sovereignty status prevented attorneys from taking her case. With

95 no legal avenue available, she was left to bear the financial and emotional weight of managing her TBI on her own.

Psychosocial and Emotional Impact Before her TBI, Mechelle described herself as “vivacious, gregarious, intelligent, and highly empathetic.” The TBI transformed her into a “rageful, angry person” who struggled with basic, sequential tasks such as “walking through a door, pumping gas, or managing household chores.” This rage was intensified by the frustration of seeking help from a healthcare system that she found to be “uncompassionate and bureaucratic.” She also reported that her TBI and associated PTSD “triggered memories of past traumas,” including rape, abuse, and domestic violence, compounding her emotional distress. She described her mind as a “messy, chaotic” entity, a stark contrast to her once-functional self.

A turning point in her recovery occurred when she discovered a study she believed showed that 81% of TBI patients consider self-harm in the first six months following the injury.

This study led her to realize that her feelings of despair and suicidal ideation were a normal part of the injury, not a personal failure. This realization provided a sense of relief and empowered her to take control of her recovery.

She found solace and a sense of purpose by applying her professional knowledge of healing programs to her own life, focusing on mindfulness, exercise, and connecting with something larger than herself. She also found community in an online support group for TBI survivors, though she acknowledged the need to carefully regulate her empathetic responses to others’ suffering to prevent becoming emotionally overwhelmed.

96 Symbolic and Artistic Expression Mechelle envisioned her inner world as a chaotic, dynamic entity, a “long strand of DNA” from head to toe, symbolizing her genetic makeup and inherited trauma. She described this strand as “messy and constantly moving,” with “jagged rocks” representing the barriers and oppression she has faced. She resonated with the abstract style of Jackson Pollock as she felt it captured the frenetic energy and chaos of her mind. Mechelle described the use of a fire ritual where she would write down painful memories and then burn them as a therapeutic and symbolic release of pain (see Figures 8 and 9).

Figure 8 Mechelle’s Runner-Up Image

97 Note. An AI-generated image created for participant Mechelle. The image was generated using the text prompt: “A long vertical strand of DNA, swirling chaotically, painted in the explosive, splattered style of Jackson Pollock. The DNA represents inherited information—messy, kinetic, uncontrollable. It is tangled in motion, surrounded by smoke, fire, and jagged rocks. A golden sun rises behind the chaos, barely visible through layers of color. Every color is present, symbolizing the emotional spectrum.”

Figure 9 Mechelle’s Chosen Image

98 Note. An AI-generated image created for participant Mechelle. The image was generated using the text prompt: “A vertical strand of DNA spiraling upward through a chaotic field of vibrant color, painted in the expressive, splattered style of Jackson Pollock. The DNA is tangled and alive, with some strands unraveling and burning into rising smoke. Every color is present—bold, jagged strokes that symbolize emotion, identity, and inherited history. Around the DNA, sharp rocks float and begin to crumble, representing oppression and past trauma. In the distance, a large golden sun rises, casting warm light across the textured scene. The sky is filled with cosmic threads and layered paint, suggesting motion, release, and transformation. The image is abstract, emotionally raw, richly symbolic, and full of kinetic energy.”

Rationale for Chosen Image Mechelle chose her final image because it successfully provided a dynamic and soothing representation of her internal world, striking the right balance for ongoing reflection. While the initial image evoked a deep emotional response that captured “everything” she had discussed, she ultimately found it “too intense,” and it was emotionally laden because it reminded her of a prior painting she had done. She preferred the chosen image’s energetic quality, which was described as having a “calming essence” rather than the pure “intensity” of the initial image. The chosen image’s abstract, “Jackson Pollocky” style appealed to her because its “frenetic nature” resonated with the complexity of her experience, and it incorporated all the core elements she had requested without recalling her previous artwork. She also explicitly disliked other images that were too dark, too realistic, or had a “fantasy” feel, which the chosen image avoided.

99 Image Integration and Ongoing Reflection When engaging with her image, Mechelle immediately experienced a blend of positivity and chaos. She described the visual as an “accurate self-torture” that mirrored her current identity. Despite the turmoil, she emphasized that the image remains “beautiful” and “aesthetically pleasing,” suggesting that disorder can coexist with resilience and grace.

A central meaning emerged when Mechelle recognized the strand originally conceptualized as DNA as resembling “steps.” These steps appeared to ascend from the ground toward the sun, symbolizing emergence and transition in her life. She identified the image as “dynamic” and “not something static,” which for her embodied a sense of growth and change.

Sustained Meaning and Symbolism. Over the week of engagement, the image’s meaning deepened while remaining consistent. The composition continued to provide a “sense of strength” and served as a positive reminder in the context of her new professional role. The yellow sphere, representing the sun, became particularly significant as a reminder that light inevitably returns after cloudy days.

Impact on Healing and Identity. Mechelle reported that the process of engaging with the image enhanced her sense of connectedness to herself and shifted her perspective on her relationships and place in the world. She stated that the process allowed her to “find myself more,” including different aspects of her “selves,” and described herself as “definitely more thoughtful” about her role in the broader world.

Therapeutic Value of the Process. Expressing deep gratitude for the experience, Mechelle emphasized that cocreating and reflecting on the image was “more advantageous therapeutic healing” than anything she had previously encountered. In comparing this process to her experiences with the healthcare system, she noted that while she waited four months for her

100 Medicaid case manager to make contact, the image-based process allowed her to “gain so much” in her healing journey at a time when “no one was available” to provide guidance or support.

Proposed Revision. When asked about potential revisions, Mechelle suggested adding a metallic element to the composition. She envisioned “a shininess, or, a reflection” that would resonate with her lived experience of traumatic brain injury. She explained that such an addition would mirror the heightened reflectivity that often follows brain injury, where one becomes “ensconced in this metacognitive experience.”

Participant Profile: Brain (39 Years-Old) Brain, a 39-year-old, experienced a life-altering TBI at age 37. This participant chose his pseudonym both as a reference to his brain injury and a play on his given name, which people have often misspelled as “Brain” throughout his life. Before the accident, he saw himself as a highly independent, creative, and patient individual. He worked as an international teacher for nearly 15 years, including 10 years abroad. Brain jokingly referred to his preinjury self as a, quote, “damn robot” due to his exceptional memory and ability to manage a busy schedule without needing reminders. His sense of self-worth was closely tied to his career, independence, and role as a nurturing provider for others.

Brain is also a father to two children. His TBI recovery required him to return to his hometown, which has significantly influenced his ability to see his children. If not for the TBI, he would be near them and more involved in their day-to-day lives. He currently has periodic inperson visits (four per year) and two one-hour phone calls a week with them. Losing the daily presence of his children has been the most hurtful and difficult thing to deal with during his recovery.

101 Neurological and Medical Journey In December 2023, Brain suffered a serious TBI while riding his motorcycle late at night in Ghana. He was not wearing a helmet and sustained broken ribs and required a craniotomy to relieve pressure. He reports being conscious and responsive at the time of the accident, but he has no memory of the events from the accident until early February 2024. Just three days after the injury, he was flown to New York City on a private medical flight, which cost over $200,000 and was staffed by doctors.

The stroke resulted in permanent vision loss known as homonymous hemianopia. Brain’s eyes are physically healthy. However, the stroke in his right occipital lobe damaged the visual processing area, meaning his brain can no longer process anything on the left side of his visual field. He also has double vision, which he manages with prism lenses. These visual challenges contributed to extreme fatigue. Brain notes that reading a single word is “like reading a sentence” because he can only process a few letters at a time. His short-term memory is also affected, leading him to rely on multiple alarms to help with daily tasks.

Psychosocial and Emotional Impact Brain feels in his own way that part of him did die that day and that his former self “doesn’t exist anymore”. Early in his recovery, he experienced emotional dysregulation, which manifested as an uncharacteristic outburst of anger towards his mother “over a bag of carrots.”

Much of this was based on his children being relocated across the country against his will and control. Brain experienced shame and embarrassment due to his loss of independence in the early stages of his recovery. The once self-sufficient “robot” felt embarrassed for needing support with simple tasks, like getting a ride, and felt like he was being cared for like a child.

102 As of late, Brain has become more accepting of his challenges and no longer feels deep embarrassment, but instead focuses on finding new, adaptive ways to navigate life. He is now back to a point of being able to do things for other people, such as cooking dinner for his mother.

These small acts of kindness remind him that the old him is still there. His self-worth remains a source of struggle, as it was previously tied to his identity as a supportive and creative teacher.

He noted that he is a step down from what he used to be. While others perceive him as “normal in conversation,” he feels a sense of “sputtering” and less connection because of the immense mental effort required. Brain is actively working to balance his innate drive with the vital need for rest, which he describes as a “tricky balance.”

Symbolic and Artistic Expression Brain uses several metaphors and images to describe his internal world and recovery process. He visualizes his experience as a landscape with a river and a large maple tree. A small part of this landscape is described as “scorched earth,” with dead plants and shrubs, representing the damage he has endured. The image also holds a sense of hope for regrowth, even if some of the changes are permanent. He also identifies with the concept of a phoenix, viewing his journey as a “rebirth-type situation,” where he is figuring out a new direction for his life.

A significant image he considers for a tattoo is a light bulb with a pull chain. Originally a symbol of heartbreak, it now represents both his heart and his brain. He described the light as “currently being dimmed and flickering, rather than at full power,” symbolizing his ongoing recovery. He felt he was waiting for the “right little tug of that chain” for his brain to return somewhere close to its full capacity. The texture of how his life feels now like a heaviness or a muckiness, as if he’s moving through quicksand or stuck in the mud without a clear path forward but “trying his best to trudge” through it as best he can (see Figures 10 and 11).

103 Figure 10 Brain’s Runner-Up Image

Note. An AI-generated image created for participant Brain. The image was generated using the text prompt: “A symbolic self-portrait landscape with a gentle contrast of perception. The right side is vibrant and colorful, the grass greener, the details clearer. The left side is softer, muted, with a bluish-grey haze. A calm river flows with many rocks jutting out, a small sandy entrance slopes into a divot at the water’s edge. A large maple tree on a hill fuller and brighter on the right, softer and subdued on the left. A small patch of scorched earth with dead shrubs rests among green renewal. A simple bald white man sits cross-legged in meditation, head tilted slightly right, facing the muted side of the landscape. A subtle vintage lightbulb with a pull chain glows faintly, inside it a heart and brain. Painted in the style of Tonalist oil painting, atmospheric haze, muted tones, soft transitions of light and shadow, moody and poetic.”

104 Figure 11 Brain’s Chosen Image

Note. An AI-generated image, created for participant Brain. The image was generated using the text prompt: “A symbolic self-portrait landscape with a gentle contrast of perception. The right side is more vibrant and colorful, the grass greener, the details clearer. The left side is softer, muted, with a faint bluish haze. A calm river flows with rocks jutting out, a small sandy entrance drops into a divot at the water’s edge. A large maple tree stands on a hill bright and full on the right, subdued on the left. A small patch of scorched earth contrasts with the green renewal. A simple bald white man sits cross-legged in meditation, head tilted slightly right, facing the muted side. A subtle vintage lightbulb with a pull chain glows faintly, holding a heart and brain. Painted in the style of Hudson River School oil painting, luminous golden light, detailed natural landscape, radiant and expansive.”

105 Rationale for Chosen Image Brain chose his final image because it serves as a deeply meaningful visual tool for processing his recovery. The image’s fogginess on the left side is a powerful metaphor, directly mimicking both his physical vision loss (hemianopia) and the “fogginess in my brain” concerning the many unknowns about his future and how he handles daily life.

Image Integration and Ongoing Reflection. Brain described the image as a “guided reflection” tool, noting that it helped him access thoughts he would not otherwise have. He referred to the image as having an “AI reflection therapist.” Originally, he had set an alarm to go off as a reminder to look at the image, but he found himself looking at the image “way more than just once a day.” He frequently moved his image between his bedroom, living room, and kitchen so that it remained a constant presence throughout his day.

A central metaphor emerged through the fogginess on the left side of the image. This represented both his permanent physical vision loss (homonymous hemianopia) and the “fogginess in my brain of, like, a lot of unknowns” regarding how he now manages daily life.

Simply looking at this side of the image often evoked deep emotion, making him feel “wateryeyed” without deliberate thought, as if the latent “sadness” was “leaching out of my system, rather than keeping it all bottled up.”

Sustained Meaning and Symbolism. The image also helped Brain connect specific life skills to his evolving identity. The meditative figure in the composition became a significant symbol of his current self, representing his transition into meditation and breathwork practices following his TBI. These practices provide him with tools to “navigate stuff” such as relationship difficulties by achieving a “calmer, more relaxing … state of mind.”

106 The image also carried forward a sense of hope. Brain imagined that on the foggy side, “there could be a little boat there that’s going to have a fisherman in it,” symbolizing an “unexpected” and positive “new experience that I wasn’t expecting to happen.” Overall, he felt the image served as an “active reminder” that he is “not through the … full process” of acceptance and healing, and that he still requires “more time, more healing, more processing.”.

Profound Influence on Self-Perception. Brain asserted that the image elicitation process has “abso-freaking-lutely” influenced his thinking about identity and healing. He explained that having visual access to a representation of what he has been through, what he is currently experiencing, and what he anticipated in the future has been far more powerful than reflection through thought alone. The image also enabled him to appreciate life in ways his vision loss now limited.

Connection to Others. Brain also emphasized the relational value of the image.

Explaining the composition to others provided alternative ways of understanding his experiences from an “outside perspective,” which helped him “better understand what the hell it is that I go through.” This communicative process reinforced his healing by offering a different mode of processing and sharing his journey.

Proposed Revision. Although Brain described the image as already “beautiful,” he expressed a desire to refine its clarity. Specifically, he suggested fine-tuning the right side to achieve a deeper level of detail, explaining that this would elevate the image’s quality. He noted that this adjustment would reduce the overall “level of muteness” present on both sides of the composition.

107 Major Themes of TBI Recovery During this process, all participants struggled to choose just one image. Each expressed a desire to have two representations; one that captured the true nature of their struggle and reality, and another that reflected the hope and healing emerging in their lives. The participants were intentional and reflective in their selections. They were provided with 18–24 images to choose from and were mindful that the image they selected would remain with them in tangible form for at least one week. It is particularly interesting that each participant wrestled with the decision between portraying the harshness of their reality and the growth and renewal they had cultivated through their healing process.

Identity Disruption and the Loss of the “Former Self” This theme centered on the devastating fragmentation in self-perception following injury, where the capable preinjury self is mourned, rejected, or perceived as permanently lost.

Participants described the loss of their former identities, imbued in such roles as international teacher, voracious reader, gifted musician, or student. Each participant had to endure the painful realization that those versions of themselves no longer existed. Brain reflected that his preinjury self “doesn’t exist anymore,” expressing grief over the absence of the person he once was.

Similarly, Rhuadh reported that she continually struggled with the “weight of the difference” between her past and present selves, a burden that left her questioning her worth and usefulness.

Anunnaki’s narrative provided a profound representation of this theme through his near-death experience. He described the individual who was run over as “no more” and believed that a “different version” of himself returned. This belief shaped both his self-concept and his artmaking, where he gravitated toward imagery that symbolized a split multiverse. For him,

108 identity disruption was not simply a matter of diminished capacity but of existential rupture, as he mourned the loss of his former self and an ersatz self that replaced it.

Mechelle also experienced this disruption through the sudden collapse of her professional identity. Losing her job after her TBI left her without the role that had once defined her sense of competence, stability, and self-worth. For her, the contrast between her capable preinjury self and her current reality intensified grief and disorientation. AZYogi echoed this theme, describing how her injury not only stripped her of athleticism and independence but also left her mourning the “former self” who had once felt invincible. She described her preinjury identity as permanently out of reach, forcing her to reconstruct who she could be in light of lasting limitations. Collectively, these narratives illustrated how TBI destabilizes identity, leaving participants grieving for the former self while struggling to integrate a changed and constrained present self.

The Invisible Cognitive and Sensory Burden Another pervasive theme concerned the hidden mental effort required to manage daily life with neurological impairments. Participants frequently described difficulties with language, concentration, and sensory processing, often compounded by chronic conditions, such as epilepsy or migraines. Tasks that were once automatic, such as reading, following conversations, or tolerating background noise, now demanded extraordinary effort and constant self-monitoring.

Outwardly, individuals often appeared composed, but internally, they must be perseverant from having to use so much energy to exertion, in order to function. This ongoing strain resulted in profound fatigue and reinforced the sense of carrying an unseen yet constant burden.

Anunnaki’s account provided particularly raw evidence of this hidden toll, given the severity of his frontal lobe damage. In the early years of recovery, he struggled with impulse

109 control and emotional dysregulation, which not only undermined his daily functioning but also strained his relationships. Severe migraines added to the weight of this burden, which he vividly described as feeling like his head was “back underneath the tires.” For seven years, he also endured recurring hallucinations of “shadow people,” an intense sensory disruption that reinforced the relentless and intrusive nature of his symptoms.

For Rhuadh, sensory disruption meant becoming so sensitive after her second TBI that she could not read or listen to music without feeling seasick. Brain relied on multiple alarms to compensate for memory loss, and his visual deficits made reading even a single word feel as laborious as a sentence. Rhuadh compared herself to a duck “calm on the surface but paddling frantically underneath,” while Brain compared his daily life to “moving through quicksand.”

Mechelle described a different cognitive burden: the constant hyperreflection that left her feeling “ensconced in a metacognitive experience.” For her, even simple tasks demanded heightened awareness and self-monitoring, an exhausting process that others often could not see.

AZYogi added another layer with her postictal states, which left her disoriented and vulnerable.

Although she often appeared fine outwardly, she described the invisible labor required to mask confusion and maintain composure.

Reclaiming Agency and Purpose Through Adaptation This theme highlighted the active, resilient effort participants made to rebuild self-worth and meaning by forging new paths and adopting adaptive practices. Anunnaki’s path demonstrated a particularly strong example of agency through his transition from rage-infused and nihilistic behaviors to ones defined by disciplined emotional control and social purpose. In the years immediately following his TBI, he struggled with uncontrollable anger and despair, but over time he cultivated the ability to manage his emotions “way more tactfully.” His current

110 purpose has been rooted in empathy for “those that have already been forgotten,” a stance that tied directly to his own childhood trauma and fueled his commitment to advocating for marginalized others.

Rhuadh reengaged her identity as a “helper” through community work in a local garden, finding new meaning in service even within her limitations. AZYogi transformed her suffering into purpose by teaching yoga to children who have epilepsy and advocating for helmet safety in equestrian sports, directly reframing her loss into prevention and healing for others. Brain emphasized mindfulness, exercise, and technological supports to stabilize his environment, cultivating calm and structure where chaos once dominated. He described his trajectory as a “phoenix-like rebirth,” signaling forward momentum. Mechelle found her sense of agency through the reflective art-making process itself. Cocreating and engaging with her image allowed her to reclaim self-connection and offered her what she described as “more advantageous therapeutic healing” than anything the healthcare system provided. Collectively, these accounts illustrated the ways participants reclaimed agency by reframing limitations, embracing symbolic narratives, and finding purpose in adaptive practices that integrate loss with resilience.

Isolation Versus the Craving for Connection This theme captured the tension between the functional limitations that contributed to social isolation and the enduring need for connection and understanding. For Rhuadh, profound isolation followed when her limitations restricted her ability to interact with others and fulfill her identity as a helper. She noted that strangers often treated her dismissively, interacting with her as if she were a child because of the protective “armor” she wore, such as dark glasses and a hat to shield herself from sensory overload.

111 Brain highlighted the pain of losing daily presence with his children, describing this as one of the most difficult consequences of his injury. His image reminded him that he was “not through the … full process” of acceptance, reinforcing both his isolation and his longing for deeper connection. Anunnaki described social alienation shaped not only by his TBI but also by his history in foster care. These early ruptures in belonging left him mistrustful of others, and his postinjury struggles with impulse control further strained relationships. Yet, over time, he worked to rebuild connections through more tactful communication, demonstrating how the craving for connection persisted even when isolation dominated his daily life.

Mechelle emphasized that the reflective process of engaging with her image made her feel “more connected to [her]self,” which in turn reshaped how she related to others. This increased thoughtfulness about her place in the world alleviated some of the isolation she had felt when medical systems left her unsupported. AZYogi navigated the tension between isolation and community by creating new relational spaces. Her work teaching yoga to children and building advocacy networks helped counteract the social disconnection that came with injury, giving her meaningful ways to connect. Together, these accounts underscore how participants simultaneously struggled with isolation while continuing to long for connection, understanding, and community.

Institutional and Systemic Barriers to Healing This theme highlighted the external systems that acted as obstacles, magnifying personal trauma and financial stress. Mechelle experienced financial devastation when her workers’ compensation claim was denied, and she was subsequently dismissed from her job without explanation. The termination also resulted in the loss of her health insurance, and due to her employer’s legal status, she had no avenue to pursue justice or financial relief.

112 Anunnaki’s narrative further underscored the destructive role of systemic neglect, which spanned from his childhood through the post-TBI period. Growing up in foster care left him without a consistent support system, and following his injury, he encountered a striking absence of institutional care. He described having to learn most lessons “the hard way” because no formal rehabilitation was ever offered. For nine years after his traumatic brain injury, he received what he described as a “no brainer here,” a complete absence of structured services or rehabilitation support. His experience illustrates how systemic abandonment not only denies individuals access to healing but also forces them to bear the weight of recovery on their own.

AZYogi also highlighted institutional failure through medical misunderstanding. She was misdiagnosed when psychiatric staff interpreted her postictal state as a psychiatric disorder, a mistake that delayed proper care. Mechelle described her broader encounters with the healthcare system as uncompassionate and bureaucratic, with rigid processes that disregarded her lived experience. Brain similarly encountered systemic obstacles through delays in accessing care and difficulty navigating benefits systems, which compounded his emotional stress.

Even the research process itself reflected these systemic challenges: participants required shorter “mini interviews” to manage fatigue, rescheduled frequently due to symptom flare-ups, and needed regular check-ins to assess whether they could continue. The immense mental and physical energy demanded for these basic research tasks mirrored the effort required for everyday living with TBI. Collectively, these accounts underscored how institutional failures not only obstruct recovery but also amplify the trauma and burden participants already face.

113 Chapter 5: Discussion The purpose of this study was to explore how engaging with AI-generated art may support adults recovering from TBI in exploring their sense of self. In this chapter I offer a psychodynamic interpretation of the findings, research, and participant dynamics, along with clinical and practical implications, potential broader implications for AI use, and future research directions.

Several themes emerged from the data analysis. Participants struggled with portraying both the suffering and the healing that characterized their recovery. This theme showed the complicated tension between loss and growth. Participants wanted to express their pain while also affirming their resilience and transformation. Another theme centered around identity disruption and the loss of the former self. Participants mourned who they once were while struggling to integrate who they are now, a struggle that, for some, resulted in a fragmentation of self. The study also highlighted the invisible cognitive and sensory burden of living with neurological impairments. This theme captured the discrepancy between appearance and the internal struggle. Despite the devastating losses, participants were able to reclaim agency and purpose. Another theme is the social disconnection and craving for connection. While they would sometimes withdraw, they also sought out connection. The study highlighted the impact of institutions and systemic barriers to healing and how navigating a broken system added to trauma and heartbreak. Across all the themes, there was a unifying threat concerning the transformation through engagement. Either through image selection, storytelling, or community involvement, participants employed creative processes to bridge the gap between loss and renewal, thereby aiding in meaning-making

114 Psychodynamic Interpretation of Findings Freud’s Loss I used Freud’s concepts of mourning and melancholia as an interpretive lens interpreting the results. Mourning is an adaptive grief in which the ego releases the lost object, whereas melancholia involves internalizing the loss and the ego identifying with the lost object (Freud, 1917/1957). The heart of the participant interviews showed how these two processes unfolded during their recovery, with participants oscillating, to varying degrees, between mourning and melancholia.

Brain shared that his former self “doesn’t exist anymore,” which represented the conscious mourning of the preinjury identity, a painful confrontation, but also a key part of acceptance. Rhudha shared how she struggled with the “weight of the difference” between her past and present selves, which highlighted the ongoing negotiation between grief and adaptation.

Anunnaki captured the mourning of a vanished self and the emergence of a new identity when he shared that a “different version” of himself returned. AZYogi described her preinjury identity as “permanently out of reach”; she grieved for what she could not find but was also aware of the formation of her new role as an advocate. These snippets from participant interviews exemplified the early stages of mourning: awareness of loss, working through the pain, and the slow process of learning to know and redefine oneself. Their words echoed Freud’s concept of mourning as it takes time and energy to free oneself from the lost object and reinvest it elsewhere.

In contrast, other comments represented a melancholic experience in which the loss was internalized and turned inward. Brain felt like living life was like “moving through quicksand.”

Rhuadha stated that she felt “calm on the surface but paddling frantically underneath,” and Anunnaki recounted that there were times when he felt his head was “back underneath the tires.”

115 These statements reflected Freud’s concept of melancholia as an inward collapse of energy; the grief was trapped in the psyche.

For several participants, engaging with AI-generated art created an avenue to externalize and transform their grief. Brain’s “little boat” idea served as an “active reminder” of his healing; Rhuadh’s “broken apart and reassembled” reflection; the acknowledgement of “Yes, I am a miracle”; and AZYogi’s “forged” and “fixed” golden seam represented repair leading to resilience. Through symbolic creation, mourning could take shape and shift in a new way. What was once stuck and trapped as melancholia could now be expressed, seen, and reworked into meaning.

Mirroring With AI Art Kohut’s (1977, 1984) Self Psychology introduced the vital concept that the self requires empathetic selfobject functions, including mirroring (being seen), idealizing (drawing strength from others), and twinship (feeling a sense of belonging). As trauma can fragment the sense of self, everyone needs selfobject functions and empathic attunement to maintain cohesion (Kohut, 1977, 1984). Participants’ experiences reflected the selfobject needs, specifically mirroring, which were addressed through the process of AI-generated art and empathic engagement.

Artificial Intelligence-generated art reflected the participants’ inner emotional states, acting as a symbolic mirror of their inner psychic life. Brain described this process as “absofreaking-lutely” influential when he thought about his “identity and healing” as he saw his inner world represented visually, which enabled him to feel seen and validated. Rhuadh spoke about being broken apart and reassembled multiple times. Rhuadh’s art reflected her fragmented yet resilient self, reinforcing self-worth and wholeness. The visual reflection created a symbolic

116 piece that words alone could not fully grasp. Mechelle shared that her image captured something she “could never put into words,” reflecting the symbolic mirroring of unarticulated emotion.

Participants found strength and reassurance within the creative process, as the images served as idealized symbols of resilience, and art and the relational process as a whole acted as stabilizing selfobjects. These experiences reflected Kohut’s (1984) idealizing selfobject function, which helps stabilize the self. Twinship emerged in the reconstruction of shared experience between myself and the participants. The mutual understanding provided a sense of belonging.

Participants engaged in the research process with openness and connection, allowing empathic relating and symbolic creativity, which served as a process of repair and reestablishing cohesion within a fractured self. Kohut (1982, 1984) believed that empathy and relational attunement are curative forces that help restore vitality and wholeness. The findings in this study aligned with the notion that empathy and connection hold significant power.

Winnicott’s True Self, Play, and the Holding Environment Winnicot’s (1960) theories of True Self, play, and the holding environment provided a framework for understanding how creativity and safety supported participants’ emotional recovery from TBI. The True Self can only emerge when an individual feels safe and is securely held in an environment that promotes spontaneous and authentic expression (Winnicott, 1960, 1971). Both the relational process and creation of art offer a space that invites participants to explore and reconnect with aspects of self that may have been constrained or lost following their TBI experience.

The holding environment offers safety, trust, and containment. Mechelle shared that she felt “safe to share” and that she did not have many other environments to explore her experiences. Anunnaki expressed trust in the process as he shared his innermost thoughts about

117 his “different version” of self. A holding environment that can contain anxiety, foster safety, and enable emotional interaction depicts Winnicott’s concept of emotional holding (Winnicott, 1965).

Potential space serves as a transitional area between the internal and external worlds, where play and imagination foster new meanings to emerge (Winnicott, 1971). Brain’s image of a “little boat” with a “fisherman in it” demonstrates playfulness and openness to new experiences. Rhuadh’s “tree lady” bridged her inner transformation with an outward representation. The AI art created a Winnicottian space of play, serving as an imaginative and transitional space that facilitates exploration, meaning-making, and healing.

The True Self can only emerge when individuals feel safe enough to express themselves spontaneously, without fear, judgment, or collapse (Winnicott, 1960). All participants had playful moments that allowed for genuine self-expression. The participants were authentic and shared parts of themselves that were difficult to share, including their pain and suffering, as well as their growth and healing. Brain, Rhuadh, Michelle, Anunnaki, and AZYogi each expressed renewal through the creative process, illustrating how the holding environment and potential space foster authenticity and emotional repair.

Schore’s Theory of Affect Regulation and its Application to TBI Identity Recovery Schore (2012, 2019) emphasized that right-brain-focused interventions are crucial for trauma recovery, including art-based therapies, narrative-based symbolic work, movement and sensory approaches, and relationally attuned psychotherapy. Creative work engages surviving right-brain functions even when verbal centers are impaired (Schore, 2012, 2019). Creative processes stimulate neural connections that promote self-repair after trauma, and structured art-

118 based interventions can facilitate the formation of new neural pathways that support emotional integration, improved regulation, and a renewed sense of agency (Schore, 1994, 2012, 2019).

Artificial Intelligence art can act as a right-brain activator as the images function as symbolic and nonverbal representations of emotional life. Artificial Intelligence art can help participants articulate experiences that were not easily expressed verbally due to TBI-related cognitive or expressive limitations. Mechelle stated that the creation of the AI art “captured something I could never put into words,” and Brain noted that the imagery helped him understand “identity and healing.” Artificial Intelligence art is a medium for nonverbal emotional processing through ‘bottom-up engagement’ via sensory, then emotional, and finally cognitive processing (Schore, 2012, 2019).

Healing occurs in affectively attuned relationships through right-brain-to-right-brain communication. As the researcher, I intentionally focused on empathetic dialogue, curiosity, and continuity. The coconstruction of meaning around the images offered mirroring, emotional validation, and containment. The relationship between myself and the participants amplified the healing effects of the imagery.

Transference and Countertransference Dynamics As previously noted, my role as the researcher placed me in a unique position within this study’s sample population. I have survived a TBI myself and know intimately the pain, fear, disorientation, and identity disruption that many participants described. While I did not initially plan to disclose my TBI history, early in the research process, it became clear that thoughtful self-disclosure created a sense of kinship. Participants frequently expressed that it mattered to them that “I get it” and several reflected that my lived experience made them feel safer, more understood, and less alone. This dynamic inevitably shaped the relational field and influenced

119 how participants approached the interviews, the imagery, and the meaning they drew from the process.

Transference emerged as participants positioned me in various ways, sometimes as someone who could understand them in ways that others in their lives could not, sometimes as a witness to their suffering, and at other times as a companion on the journey of meaning-making.

For some, I was a validating presence; for others, I functioned as a reflective container for emotions they had not been able to articulate elsewhere. These transferential positions appeared to facilitate openness, emotional depth, and trust, enabling participants to engage with both the imagery and the interview process with greater vulnerability.

My countertransference responses were equally complex. I entered the research with a genuine desire to help participants find the language and imagery for experiences that often felt invisible or invalidated. However, I was also surprised by the emotional intensity that arose within me, including moments of identification, sadness, protectiveness, admiration, and, at times, a felt sense of responsibility for their healing. I noticed that I resonated deeply with their frustration, grief, and desire to reclaim a sense of self. At times, I felt pulled to comfort, reassure, or interpret too quickly; at other times, I felt a profound stillness and respect for the weight of their stories.

These countertransference reactions served as essential data. They alerted me to shared vulnerabilities in the space, reminded me to maintain boundaries, and helped me remain attuned without becoming overidentified. They also illuminated how AI-generated imagery functioned not simply as a tool but as a shared symbolic object that held meaning for both participants and researcher. In several interviews, the image became a third presence, a mediating space where emotions, projections, and reflections could unfold safely.

120 From a psychodynamic perspective, these relational dynamics enriched the depth of the findings. The intersubjective field shaped how images were created, how narratives were formed, and how participants connected with parts of themselves that had been disavowed or fragmented following their TBI. Acknowledging the transferential and countertransferential processes did not compromise the rigor of the study; rather, it clarified the emotional and relational context through which meaning was coconstructed.

Implications Survivors of TBI struggle with the loss of their former self and the challenge of making sense of their new identity. Clinicians must be able to attend to the grief while also cultivating and highlighting their clients’ emerging strength and budding resilience. It is vital for TBI survivors to feel understood by their therapist. Traditional psychotherapy is not always sufficient, as it does not readily offer a creative and symbolic space to access what is often hidden. TBI patients experience an internal chaos despite appearing outwardly stable.

Those closest to a TBI survivor need to recognize that their loved one struggles with an “invisible illness.” Many TBI survivors report feeling misunderstood; for example, one might view their emotional challenges as “moodiness” or “laziness.” Loved ones must balance a delicate dance between giving the survivor space to grieve, grow, and redefine themselves.

Images can help families understand the survivor’s internal world that they cannot easily put into words. These images can foster empathy and connection.

Use of AI-Generated Art in TBI Work Artificial Intelligence art allows individuals to communicate what they feel but cannot express neatly in words. Seeing a visual metaphor provides a way to explore painful material safely. Images become anchors for meaning-making. Creating multiple versions of their

121 described images enabled individuals to explore various dimensions and possibilities of self, while choosing one image enabled them to focus on what was most salient to them in the here and now. Artificial Intelligence is a tool that can enhance relational work, but it is not a substitute for the therapeutic experience.

There is a possibility of creating a hybrid model combining AI-generated images with therapist-guided reflection. This would be especially impactful for individuals who are unable to create art due to physical limitations. There is also potential for group-based interventions in which participants could share images and stories. This would build community, shared understanding, and a sense of belonging. Additionally, this could be used as a psychoeducation tool where survivors can communicate their internal experience to providers and family.

Specifically, it involves assessing and understanding how one’s identity shifts and changes during the recovery process. This type of intervention could be used in outpatient and inpatient settings. It is also vital to ensure privacy, consent, and emotional safety when using AI. Artificial Intelligence can support agency for clients who feel powerless after injury through creativity, but training would be needed for therapists to safely and effectively integrate these tools.

Future Research Directions Future research could include larger, more diverse participant samples drawn from broader age ranges, cultural backgrounds, and socioeconomic groups. There could also be a more focused study comparing different types of brain injuries, such as stroke, concussion, anoxic injuries, childhood TBI, or even long COVID-19 neurological impacts. There could be comparative studies exploring AI-assisted art reflection versus traditional art therapy, or AIassisted art reflection versus talk therapy alone. There could be a longitudinal study exploring how identity shifts and evolves over months or years. A clinical protocol could be developed that

122 would provide structured guidelines for using AI imagery with TBI clients. Lastly, future studies could explore using AI art with other populations: chronic illness, PTSD, depression, autism, Amyotrophic Lateral Sclerosis (ALS), and adolescents struggling with their identity.

Understanding identity after traumatic brain injury requires recognizing that survivors are navigating both the loss of who they once were and the uncertain emergence of who they are becoming. When clinicians, families, and innovative tools work in concert, they create a network of support that enables survivors to reclaim a sense of continuity, connection, and purpose as they rebuild their lives.

123 Appendix A: Recruitment

124 Appendix B: Screening Questionnaire Please answer the following questions to determine your eligibility for participation in the research study: 1. What is your age?

2. Have you been diagnosed with a TBI? 3. When did your TBI occur, and how old were you at the time?

4. Where were you when the injury happened (e.g., at home, work, in a vehicle)?

5. Are you comfortable describing your thoughts and feelings in language that can be used to generate AI-created images?

6. Are you able and willing to commit to participating in two virtual interviews?

7. Can you sit for a 90-minute interview with a 10-minute break?

Thank you for your interest in this study. Your responses will help determine your eligibility for participation.

125 Appendix C: First Interview and AI Image Creation Process Overview of Interview Process and AI Image Creation This interview includes both open-ended discussion and a creative component involving AI-generated imagery. The process unfolds in the following stages: 1. Rapport Building and Framing the Interview: The interviewer welcomes the participant, establishes comfort, and introduces the purpose of the conversation.

2. Exploration of Identity Post-TBI: Through flexible, open-ended questions, the participant reflects on their sense of self, both past and present.

3. AI Image Creation: Participants are invited to describe their inner experience using imagery, symbols, feelings, or metaphors. These responses are used to generate an AI image representing a symbolic self-portrait. The researcher inputs the participant’s words into the image-generation tool (e.g., Midjourney).

4. Image Reflection and Meaning-Making: Participants are guided through reflective questions to explore how the image resonates with them. This step invites interpretation, emotional response, and exploration of congruence or dissonance.

5. Optional Image Revisions: Based on the participant’s feedback, the image may be revised using new descriptive input. A second or third version may be created collaboratively.

6. Closing Reflection: The interview ends with questions that encourage the participant to reflect on the process and any new insights gained about themselves through this visual medium.

Introduction and Interview Overview This first interview is designed to explore your experience of self after a traumatic brain injury and guide you through the process of creating a personalized AI-generated image based on

126 your reflections. The image will be shaped using descriptive words, emotions, and symbols you identify. You’ll also have the opportunity to revise the image if you’d like to see a second or third version.

Opening Script and Rapport Building Thank you for joining me today. Before we begin, I want to remind you that there are no right or wrong answers — I’m here to listen to your story and experiences. Please take your time, and let me know if you need a break or would like to skip any questions. Do you have any questions before we begin?

Exploring Identity and Sense of Self •

Can you tell me a little about yourself and what life has been like since your brain injury?

•

How would you describe yourself now compared to before your injury?

•

Are there parts of yourself that feel hard to explain or share with others?

•

How do you think others perceive you? How is that similar or different from how you see yourself?

•

If you were to describe your inner world — your thoughts, feelings, or identity — what kinds of words, images, or metaphors would you use?

AI Image Creation Using the participant’s responses, the researcher and participant collaboratively select descriptive words and phrases to input into Midjourney in order to generate a symbolic image.

Initial Reactions to the Image (After generating the first AI image) •

What’s the first thing that comes to mind when you see this image?

•

In what ways does this image reflect something about you?

127 •

Are there parts of it that feel accurate or resonate with you?

•

Are there elements that don’t feel quite right?

•

If you could revise this image, what would you change to make it feel more like you?

•

What would you add or take away?

•

If you were to create a new version, what would be different?

•

How do you feel looking at this image? Did it bring up anything unexpected?

•

If this image could evolve or change, what would that look like?

Optional Revision and Reflection (If the participant wants to revise the image) •

What new ideas or feelings would you like to include in a second version?

•

Would you want to change colors, mood, or visual elements?

•

Is there something missing from the first image that you’d like to represent?

•

What would an image of your “best self” or “how you want to be seen” look like?

•

If this image told a story about you, what would that story be? Would you want to change that story?

Wrap-Up Reflection •

How was this process of creating and revising an image of yourself?

•

Did anything surprise you about what you created or how you responded to it?

•

Has this process changed how you see or understand yourself in any way?

128 Appendix D: Second Interview – Reflection on AI Image and Identity This follow-up interview is designed to give participants space to reflect more deeply on the symbolic image they helped create and how it connects to their evolving sense of identity and self-understanding post-TBI. Questions are grounded in core concepts such as continuity of self, identity transformation, emotional expression, and narrative meaning-making.

Suggested Open-Ended Questions: •

Now that you’ve had time to reflect, what thoughts or feelings arise when you look at the image we created together?

•

Has the image taken on new meaning for you over time? If so, how?

•

Are there parts of the image that feel more or less important to you now than when you first saw it?

•

How do you see your current identity reflected in this image? Has that changed since our last conversation?

•

Does the image capture anything about your sense of self that’s hard to express in words?

What aspects of your identity feel visible here?

•

Has engaging with this image helped you feel more connected to any particular part of yourself? If so, how?

•

Does the image reflect changes in how you relate to others or see your place in the world?

•

If this image were telling the story of your post-injury journey, what chapter would it represent?

•

Is there anything missing from this image that you feel matters to your identity or your inner world?

129 •

If you could revise this image today, what would you change and why?

•

Overall, how has this process influenced the way you think about your identity, your sense of self, or your healing journey?

130 Appendix E: Curriculum Vitae (CV) Jennifer L. Drake, MA, LCPC, NCC

Credentials LICENSED CLINICAL PROFESSIONAL COUNSELOR (LCPC), ILLINOIS License No. 180015284 LICENSED MENTAL HEALTH COUNSELOR (LMHC), INDIANA License No. 39004984A NATIONAL CERTIFIED COUNSELOR (NCC) National Board for Certified Counselors Education INSTITUTE OF CLINICAL SOCIAL WORK, CHICAGO, ILLINOIS PH.D. Candidate in CLINICAL SOCIAL WORK – August 2021 – Present NORTHWESTERN UNIVERSITY, EVANSTON, ILLINOIS M.A. COUNSELING December 2018 to September 2020 – 4.0 GPA PURDUE UNIVERSITY, WEST LAFAYETTE, INDIANA B.A. POLITICAL SCIENCE –August 2001 to May 2005 Experience MONARCH INSIGHT THERAPY PLLC, ILLINOIS OWNER AND PSYCHOTHERAPIST NOVEMBER 2023 – PRESENT • Provide compassionate, evidence-based psychotherapy for adults, addressing anxiety, depression, grief, ADHD, and major life transitions.

• Offer tailored mental health support, using specialized techniques to help clients manage complex emotions and improve overall well-being.

• Licensed and nationally certified, combining advanced clinical knowledge with a warm, client-centered approach to foster growth and healing.

UNBROKEN FAMILY COUNSELING – EVANSTON, ILLINOIS PSYCHOTHERAPIST JANUARY 2020 – DECEMBER 2023

131 • • • •

Provided empathetic individual counseling within a psychodynamic framework.

Utilized mindfulness techniques within client sessions.

Offered targeted counseling for children, young adults, adults, and geriatrics with a range of presenting issues.

Create, organize, and implement grief mindfulness support groups via Zoom.

RESIDENTIAL HOSPICE BEREAVEMENT SERVICES COORDINATOR FEBRUARY 2022 – APRIL 2023 • Provided support to bereaved individuals • Made condolences calls • Created and organized grief support groups for bereaved children NORTHSHORE UNIVERSITY HEALTHSYSTEM HOSPICE – SKOKIE, ILLINOIS BEREAVEMENT SERVICES COORDINATOR JANUARY 2021 – FEBRUARY 2022 • Create, organize and implement Northshore’s pilot grief mindfulness support group via telehealth • Offer individual counseling sessions for those that have experienced a loss of a loved one • Review and edit Northshore Hospice articles • Assist in creating PowerPoint presentations • Present informational sessions to the bereaved NorthShore Hospice individuals and the community at large • Responsible for connecting with identified vulnerable patients to provide informational resources and perform intake sessions NORTHSHORE UNIVERSITY HEALTHSYSTEM HOSPICE – SKOKIE, ILLINOIS CLINICAL INTERN MARCH 2019 – SEPTEMBER 2020 • Counseled individuals who have experienced the death of a loved one within the last year.

• Reached out to family members to assess needs and inform of services available.

• Assisted and cofacilitated bereavement support groups, informational sessions, and social support groups.

• Created detailed and accurate notations of academic works that serve as educational supplementation for staff.

HOT CAKES BAKERY – NORTHBROOK, ILLINOIS

132 BUSINESS MANAGER January 2011 –August 2018 Initiatives • Spearheaded redesign of a marketing campaign, including new website, logo, and product labels.

• Organized company meetings to review company policy and procedures with employees.

• Reformatted all internal and external documentation and set up a new filing system for the entire company which catalogs all prior documentation.

Responsibilities • Processed accounts receivable for $1.5 million annual revenue and manage accounts payable for multiple vendors.

• Established accounts for new customers and ensuring a smooth transition while also facilitating all customer inquiries in a professional manner.

• Accountable for all human resource needs for the company ranging from new hire documentation, payroll, managing employee schedules, interfacing with full time and temporary employees. Prepared operational reports for specific products, ingredient usage, and profit margin.

DOLCE PAPERIE – OMAHA, NEBRASKA AND CHICAGO, ILLINOIS OWNER 2009 – 2012 • Established all aspects of new business by finding appropriate vendors and marketing products.

• Handled all finances from invoicing clients to banking procedures .

• Provided exceptional detailed orientated assistance to all clientele during their planning process.

THE GROWTH COACH – OMAHA, NEBRASKA EXECUTIVE ADMINISTRATIVE ASSISTANT 2008 – 2009 • Organized seminars from start to finish, which included negotiating contracts with numerous outside vendors.

• Created new policies and forms to keep track of scholarship participants.

• Designed and implemented a new filling system.

HUB INTERNATIONAL – GLENVIEW, ILLINOIS ACCOUNT ASSISTANT 2006 – 2007

133 • • •

Interfaced with executives and employees from different offices to acquire the knowledge necessary to complete essential job functions.

Prepared client-specific reports; such as periodic premium and claim information, utilization reports, and coverage summaries Assisted the team and executives in processing paperwork for consulting invoices, new business, renewals, and cancellations.

GUARANTEE TRUST LIFE – GLENVIEW, ILLINOIS ADMINISTRATIVE ASSISTANT 2005 – 2006 • Established procedures for new insurance agents and assisted in their orientation.

• Created and implemented new business transmittal, which limited the number of errors to ensure timely application approval.

• Developed strong customer service skills in helping customers with concerns or questions regarding their policies.

Volunteer Experience • JOURNEYCARE, (FORMERLY MIDWEST PALLIATIVE AND HOSPICE CARE CENTER) Professional Organization Membership • AMERICAN COUNSELING ASSOCIATION (ACA) • ILLINOIS MENTAL HEALTH COUNSELORS ASSOCIATION (IMHCA) • AMBASSADOR – VESTIBULAR DISORDER ASSOCIATION (VEDA)

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