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UNIVERSITY OF CALGARY Living With Military-Related Posttraumatic Stress Disorder (PTSD) - A Hermeneutic Phenomenological Study by Rachel Kroch A THESIS SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY DIVISION OF APPLIED PSYCHOLOGY CALGARY, ALBERTA JUNE, 2009 © Rachel Kroch 2009 Library and Archives Bibliotheque et 1*1 Canada Archives Canada Published Heritage Direction du Branch Patrimoine de I'edition 395 Wellington Street 395, rue Wellington Ottawa ON K1A 0N4 Ottawa ON K1A 0N4 Canada Canada Your file Votre reference ISBN: 978-0-494-54472-3 Our Hie Notre r6f6rence ISBN: 978-0-494-54472-3 NOTICE: AVIS: The author has granted a non L'auteur a accorde une licence non exclusive exclusive license allowing Library and permettant a la Bibliotheque et Archives Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par telecommunication ou par I'lnternet, preter, telecommunication or on the Internet, distribuer et vendre des theses partout dans le loan, distribute and sell theses monde, a des fins commerciales ou autres, sur worldwide, for commercial or non support microforme, papier, electronique et/ou commercial purposes, in microform, autres formats. paper, electronic and/or any other formats. The author retains copyright L'auteur conserve la propriete du droit d'auteur ownership and moral rights in this et des droits moraux qui protege cette these. Ni thesis. Neither the thesis nor la these ni des extraits substantiels de celle-ci substantial extracts from it may be ne doivent etre imprimes ou autrement printed or otherwise reproduced reproduits sans son autorisation. without the author's permission. In compliance with the Canadian Conformement a la loi canadienne sur la Privacy Act some supporting forms protection de la vie privee, quelques may have been removed from this formulaires secondaires ont ete enleves de thesis. cette these. While these forms may be included Bien que ces formulaires aient inclus dans in the document page count, their la pagination, il n'y aura aucun contenu removal does not represent any loss manquant. of content from the thesis. 1+1 Canada Abstract The present study explored the phenomenon of living with military-related (M-R) Posttraumatic Stress Disorder (PTSD). What it is like and what it means for the (M-R) traumatized person to live with PTSD in everyday living was the research question. The study follows the hermeneutic phenomenological methodology as developed by Max van Manen (1997). The study was conducted both in Canada and in Israel: Thirteen male military veterans, five Canadian former peacekeepers in Bosnia or Somalia (six to twelve years after traumas) and eight Israeli veterans who took part in Israel's wars and/or military operations (six to thirty six years after the traumas), participated in the study. Hermeneutic phenomenological interviewing was the study's main method for collecting lived-experience descriptions. With each of the Canadian participants, a two hour interview was conducted, and with each of the Israelis - one to seven hour interviewing, in one to three meetings. The interviews were taped, transcribed, and translated (if necessary). Phenomenological thematic reflection as a way to uncover the meaning- dimensions of the phenomenon was done by researcher, sometimes in collaboration with the participants. Etymological reflection was another method used to disclose the meaning of the phenomenon. A line-by-line thematic analysis of the lived experience descriptions was done, as well as a wholistic approach. Four major themes emerged from the inquiry: trauma remembering, the encounter with death, being hypervigilant in an unsafe world, and being another to oneself and others. It is hoped that the research will contribute to mental health care of (M-R) traumatized persons, as well as to a better understanding of the phenomenon in society at large. ii Acknowledgements First of all, my deepest thanks to the veterans who agreed to participate in the study: I know that it was not easy for them, but the urge to let the scream of war and human atrocities be heard has been stronger. I thank the Psychiatric Services in Tel-Aviv Sourasky Medical Center, the Unit for Veterans with PTSD in particular, for providing me access to the Israeli participants. A warm thank you goes to Dr. Miri Robson, a senior psychologist in Edmonton Garrison Mental Health Services, who opened up the door for me, introducing me to the world of traumatized peacekeepers, helping to access the Canadian participants, being there for me throughout the research journey, and becoming a close friend. I thank Dr. Alice Mohr, the head psychologist of Edmonton Garrison Mental Health Services, for letting me get to know the lifeworld of the spouses of traumatized soldiers and veterans. I profoundly thank my supervisory committee: Dr. Anne Hughson, my supervisor, who has been there for me in an unequivocal way. Anne has been very open and attentive to my needs from the start, respecting my wish to be exposed to diverse areas of learning, and thereafter,throught the research endeavor: always ready to listen and engage in thoughtful conversations with me, very warm, supportive, and respectful, providing me space to have my own understandings and way of writing the phenomenological text. I thank Dr. Max van Manen who introduced me to the world of phenomenology in his research seminar on Phenomenological Inquiry and Writing: Participating in his class was a once-in-a-life-time-experience, both learning and personal. I have been very fortunate to be accompanied by Max along my study from the start, reading and re- iii reading my drafts, always with a critical eye, sharing with me his profound scholarship and wisdom, always questioning, striving for depth of thought, precision of details, and completeness, encouraging me not to compromise on less than the best of my ability. Max's sensitive and humane way of guidance has been for me an example of what supervision can mean in the life of a student. I thank Dr. Nancy Dudley for her thoughtful insights, warm support, and appreciation for precision of details, a quality I share, though needed help. Thanks to my examining committee members, Dr. Jo-Anne Willment and Dr. Marvin Westwood, for their insightful feedback which turned my Defence into a source of learning in a non-threatening and respectful atmosphere. The passion for education, reading, and broadening my intellectual horizons I acquired from my parents: My father Aharon who died when I was 17, guided me to search for the spiritual, not the material, and was a scholar in Jewish as well as wide- world literature. I thank my loving mother Miriam who always has believed in my intellectual abilities, teaching and guiding me not to compromise on less than the best. The curiosity to learn I can see in my sons. I thank Amit and Yakir for being and loving, believing in me, encouraging and proud of their mother who became a student again at a late phase of her life. Last but not least, I thank Uri: Uri and I went, jointly and separately, along the Ph.D. journey, both of us learning with Dr. Max van Manen the phenomenological research approach which guided our studies, a fact that provided me lots of support in not being alone. Uri's love, warm support, faith in my abilities, and patience in times of doubt and difficulties have been of utmost importance for me. Thank you!! iv Dedication I dedicate this study to the Canadian and Israeli veterans who shared with me their traumatic and post-traumatic concrete lived experiences and suffering, giving a voice and a face to what living with military-related PTSD is like and what it means. I also dedicate the study to their families who share the suffering of post traumatic day-to-day living, often being a supportive and protective shield for the traumatized person in the world. v TABLE OF CONTENTS Abstract ii Acknowledgements hi Dedication v Table of Contents vi List of Symbols xi CHAPTER ONE: INTRODUCTION 1 Preface 1 Research Question and Rationale 5 Personal and Professional Contexts of Study 9 Psychiatric Diagnosis of PTSD 15 Social Context of Military-Related PTSD 16 Overview of the Following Chapters 22 CHAPTER TWO: LITERATURE REVIEW 24 Historical Review on Response to Trauma 24 Organic or Psychological? 25 Intra-Psychic or World-Related? 28 Genuine or Simulated? 29 Denial and Recognition of the Response to Trauma 31 DSM Views of PTSD 35 Current Psychiatric Diagnosis of PTSD 37 Broader Psycho-Socio-Biological Model of PTSD 39 Empirical Findings of PTSD 43 Memory and Dissociation 43 Cognitive-Affective 45 Coping Strategies 47 Psychological Theories of PTSD 48 Stress Response Theory 48 Theory of Shattered Assumptions 50 Conditioning Theory 52 Information-Processing Theories 53 Anxious Apprehension Theory 55 Emotional Processing Theory 56 vi Dual Representation Theory 57 Ehlers and Clark's Cognitive Model 63 Socio-Cultural Model of Response to Trauma 66 A Phenomenological Approach to (M-R) PTSD 72 CHAPTER THREE: HERMENEUTIC PHENOMENOLOGICAL METHODOLOGY 79 Rooted in Philosophy 79 Intentionality and Being-in-the-World 81 Horizon and Hermeneutic Circle.. 84 Starting From Concrete Lived Experience 87 Phenomenological Reduction and Bracketing 88 Description or Interpretation? 89 Uncovering Meaning Dimensions 90 Generalizability 91 Research Leading to Practice 92 Language-Oriented