THERAPEUTIC WRITING_Tese Doutor_UsC_2012_279p

USING THERAPEUTIC WRITING TO DECONSTRUCT RECOVERY FROM
POSTTRAUMATIC STRESS DISORDER (PTSD)
by
Pamela Phillips
Bachelor of Science in Nursing

Winston-Salem State University, 2002
Master of Science in Nursing

University of North Carolina at Greensboro, 2005
_______________________________________________
Submitted in Partial Fulfillment of the Requirements
For the Degree of Doctor of Philosophy in
Nursing Science
College of Nursing
University of South Carolina
2012
Accepted by:
Kathleen Scharer, Major Professor
Mary Boyd, Committee Member
Beverly Baliko, Committee Member
Laura Hein, Committee Member
Emily Wright, Committee Member
Lacy Ford, Vice Provost and Dean of Graduate Studies

UMI Number: 3523132
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ii
DEDICATION
This dissertation is dedicated to my father, Eugene Phillips, who has always
thought that girls were smart, and to my late mother, Dorothy Vaughn Phillips, who
always believed that women needed a career. Without their encouragement and support
over my lifetime, I would never have developed the confidence and work ethic to tackle a
project as large as this research study and complete it.
iii
ACKNOWLEDGEMENTS
To paraphrase Hillary Clinton, it takes a rather large village to raise a doctorally
prepared nurse. The leaders of my village were my dissertation chair, the very patient and
knowledgeable Dr. Kathleen Scharer, and my committee members: Dr. Mary Boyd (who
shares my enthusiasm for new technological trinkets), Dr. Beverly Baliko, and Dr. Laura
Hein, all of the University of South Carolina College of Nursing, and Dr. Emily Wright,
formerly of the USC School of Criminology and Criminal Justice and now of the
University of Nebraska at Omaha. My committee members tirelessly navigated me
through the maze of research and the subsequent dissertation, somehow sensing when I
needed a word of encouragement. Thank you all for helping me to become a scholar.
A pundit once said that working on a doctorate was like having someone come into
your brain and rearrange all the furniture. Some excellent furniture-arrangers in the
College of Nursing spent a great deal of time redecorating my brain. Among these were
Dr. DeAnne Messias, who made incomprehensible philosophical concepts concrete, and
Dr. Joanne Herman, who taught me how theoretical models worked. Dr. Mary Boyd
showed me the ins and outs of contemporary research projects and critiqued some of my
truly haywire research proposals with a straight face. Dr. Abbas Tavakoli unraveled
complicated statistical concepts for me and made them relevant to nursing. I appreciate
all of the faculty’s efforts on my behalf.
iv
The Nurse Educators of Tomorrow program of the North Carolina State Education
Assistance Authority provided primary funding for my graduate studies. Without this
funding, I would never have been able to obtain this degree. I also want to express my
gratitude to Ms. Edna Swartzbeck, whose USC College of Nursing scholarship aided me
as well. Most of all, I appreciate Ms. Edna’s friendship and encouragement. She sent me
many personal messages and greeting cards with cheery messages and treated me to
several lunches in order to keep me on track.
Outside of Columbia, I must thank a small band of supporters who provided
encouragement. Robin Estrada, a fellow graduate student, provided sorely needed
psychological first aid when I felt overwhelmed or defeated. My sister Alison Phillips
and dear friends Vivian Roberti and Margaret Kennard distracted me with entertainment
and encouraged me to persevere when I despaired of ever completing this project. My 92-
year-old father, E.J., listened sympathetically when I complained of overwork and then
kicked me in the pants and told me get back at it again. I also want to thank my very kind
boss Rita Conner, who willingly accommodated my studies, and my community college
colleagues Helen Martin, Linda Stirk, Stephanie Denison, Deb Henry, and Flo
Bissonnette for listening to me drone on endlessly about subjects in which they held little
interest. Finally, I appreciate the help of Alice Crisp, who helped me solve many
technological challenges. I am obliged to all of you. Outside of academia, Michele
Rosenthal’s help was invaluable in sending possible study participants my way.
Finally, I owe my largest debt of gratitude to my research participants who
generously shared their time and stories so I could understand what their post-trauma
lives were like. You tried very hard to make me understand how posttraumatic stress
v
disorder wreaked havoc on your lives and how you came out on the other side through
your own efforts. You are all very skilled wordsmiths and very giving people.
vi
ABSTRACT
Exposure to physical and psychological trauma has produced a post-millennial
epoch of posttraumatic stress disorder (PTSD), a debilitating anxiety disorder that occurs
after exposure to an extreme stressor or prolonged victimization. After an extensive
review of treatment protocols in 2008, the Institute of Medicine (IOM) exhorted
clinicians to focus on defining the concept of recovery, concentrating on symptom
reduction, removal of the PTSD diagnosis, and end-state function. Although the IOM
report mobilized large-scale efforts to quantify treatments and standardize delivery of
treatment protocols, PTSD recovery remains a concept that has been largely unexplored.
The primary aim of this study was to answer the following question: What is the basic
psychosocial process that men and women undergo in recovering from PTSD? The study
also fulfilled some secondary aims: (a) identifying which, if any, elements of traditional
therapy contributed to recovery and (b) establishing a realistic timeline for recovery.
Charmaz’s method of narrative analysis and grounded theory construction was used
to generate the PTSD Recovery Model. The model was nonlinear and included six
universal stages that occurred during PTSD recovery: Experiencing Trauma, Dominating
Diagnosis, Seeking Solace, Surviving Symptoms, Marking Time, and Navigating
Recovery. Support for the model came from research participants and experts.
Participants (N=41) were predominantly white, female, and had earned college or
graduate degrees. Almost half of the participants (47.5%) reported that it required five
vii
years or more for them to feel better or attain some degree of recovery after exposure to
trauma. Intimate partner violence and child sexual and/or physical abuse were the most
commonly reported traumatic events that had caused PTSD. Although participants stated
that experienced mental health clinicians were the most helpful persons or treatment in
seeking recovery, they also reported that recovery typically involved a combination of
traditional and alternative therapies, often used simultaneously. Most participants who
reported recovery were actively engaged in seeking beneficial therapies and saw
themselves as architects of the healing process.
viii
TABLE OF CONTENTS
COPYRIGHT .................................................................................................................. II
DEDICATION ............................................................................................................... III
ACKNOWLEDGEMENTS ............................................................................................IV
ABSTRACT ..................................................................................................................VII
LIST OF TABLES ........................................................................................................ XV
LIST OF FIGURES ..................................................................................................... XVI
CHAPTER I: INTRODUCTION ........................................................................................... 1
PURPOSE OF THE STUDY .......................................................................................... 4
SUMMARY ..................................................................................................... 7
CHAPTER II: BACKGROUND AND SIGNIFICANCE ............................................................. 8
TRAUMA, VICTIMIZATION, AND POSTTRAUMATIC STRESS DISORDER ....................... 8
PROPOSED DIAGNOSTIC DIFFERENCES IN DSM-5.......................................... 11
DELAY AND ABANDONMENT OF LIFE ROLES................................................. 20
ECONOMIC EFFECTS OF PTSD...................................................................... 23
ETIOLOGIES OF VICTIMIZATION AND PTSD............................................................ 25
TRAUMATIC EVENTS .................................................................................... 27
RISK FACTORS FOR INTIMATE PARTNER VIOLENCE (IPV) AND PTSD ..................... 28
TREATMENTS FOR PTSD ....................................................................................... 32
PAST-FOCUSED THERAPIES .......................................................................... 33
ix
PRESENT-FOCUSED THERAPIES .................................................................... 37
SUMMARY OF PTSD ETIOLOGY, RISK FACTORS, AND TREATMENT................ 40
RECOVERY: MENTAL ILLNESS AND PTSD.............................................................. 40
POLICY PERSPECTIVE ON RECOVERY FROM MENTAL ILLNESS ....................... 42
CONSUMER CONCEPTUALIZATION OF THE PROCESS OR RECOVERY................ 43
CORE THEMES OF RECOVERY FROM MENTAL ILLNESS .................................. 46
CONCEPTUAL MODELS OF RECOVERY FROM MENTAL ILLNESS ..................... 49
SUMMARY OF MENTAL HEALTH CONCEPTUAL MODELS ...................... 57
RECOVERY FROM PTSD ............................................................................... 62
SUMMARY OF PTSD RECOVERY ......................................................... 64
THE HEROIC JOURNEY: THERAPEUTIC WRITING, SOCIAL NETWORKING,
AND NARRATIVE THERAPY.................................................................................... 64
THE HEROIC JOURNEY ................................................................................. 65
THE VALUE OF THERAPEUTIC WRITING ........................................................ 67
WRITING AS A LITERARY ENDEAVOR ........................................................... 74
WEB 2.0, ONLINE COMMUNITIES, AND SOCIAL MEDIA .................................. 76
QUALITATIVE RESEARCH ...................................................................................... 78
QUALITATIVE METHODS .............................................................................. 81
GROUNDED THEORY .................................................................................... 83
BACKGROUND OF GROUNDED THEORY RESEARCH ....................................... 84
SECOND-GENERATION CONSTRUCTIVIST GROUNDED THEORY ...................... 87
GROUNDED THEORY METHODOLOGY ........................................................... 90
LITERATURE REVIEW: SUMMARY ................................................................. 95
x
CHAPTER III: METHODOLOGY .............................................................................. 101
OVERVIEW ................................................................................................ 101
RESEARCH QUESTIONS............................................................................... 102
SAMPLE SELECTION AND RECRUITMENT EFFORTS ...................................... 102
METHODS .................................................................................................. 106
DATA CODING ........................................................................................... 110
TRUSTWORTHINESS ................................................................................... 112
CREDIBILITY .................................................................................... 113
DEPENDABILITY ............................................................................... 116
DATA ANALYSIS ........................................................................................ 119
BUDGET AND TIME FRAME......................................................................... 119
POTENTIAL LIMITATIONS ........................................................................... 120
PROTECTION OF HUMAN SUBJECTS ...................................................................... 120
REPORT OF ADVERSE EVENTS .................................................................... 121
CLIENT CONFIDENTIALITY ......................................................................... 122
SUMMARY OF DATA HANDLING AND MONITORING..................................... 123
CHAPTER IV: RESULTS ........................................................................................... 125
DATA SAMPLE AND SAMPLE CHARACTERISTICS................................................... 125
PERSONAL AND DEMOGRAPHIC FINDINGS................................................... 125
FINDINGS ON TRAUMA EXPOSURE AND RESULTANT PTSD ......................... 130
xi
PARTICIPANT NARRATIVES AND THE RESULTING PTSD RECOVERY MODEL ......... 139
EXPERIENCING TRAUMA............................................................................. 143
PERMANENTLY CHANGED LIVES ....................................................... 147
TRAUMA SUMMARY ......................................................................... 149
DOMINATING DIAGNOSIS: PTSD ................................................................ 151
SURVIVING SYMPTOMS .............................................................................. 152
SEEKING SOLACE ....................................................................................... 156
LOOKING FOR INFORMED ALLIES ...................................................... 157
TRYING AND DISCARDING INEFFECTIVE REMEDIES ............................ 158
MEDICATION—PROS AND CONS ....................................................... 160
EFFECTIVE CONSUMER-SELECTED COMBINATION TREATMENTS ........ 161
SEEKING SOLACE SUMMARY............................................................. 165
MARKING TIME................................................................................................... 166
YEARS OF ANGST....................................................................................... 166
NAVIGATING RECOVERY ..................................................................................... 167
THE TURNING POINT.................................................................................. 168
MAKING INTENTIONAL CHANGES ............................................................... 171
DELIBERATELY MOVING ON ...................................................................... 172
SUMMARY OF TRAUMA RECOVERY NARRATIVES ................................................ 174
CHAPTER V: DISCUSSION ...................................................................................... 178
DEMOGRAPHIC FINDINGS OF THE SURVEY .................................................. 178
SURVEY FINDINGS RELATED TO TRAUMA AND TRAUMA SEQUELAE ............ 183
INCIDENCE OF PTSD......................................................................... 185
xii
FREQUENCY AND LENGTH OF TRAUMA EXPOSURE ............................ 186
EXPERIENCING PTSD SYMPTOMS ..................................................... 187
SUBSTANCE ABUSE AND OTHER COPING MECHANISMS ..................... 190
SUMMARY OF TRAUMA AND TRAUMA SEQUELAE FINDINGS ........................ 191
COMPARISON OF PTSD RECOVERY MODEL TO EXISTING
THEORETICAL MODELS .............................................................................. 193
TRANSACTIONAL MODEL OF STRESS AND COPING ...................................... 197
COMPARISON WITH OTHER STUDIES ON PSYCHOLOGICAL TRAUMA............. 200
IMPLICATIONS FOR CLINICAL PRACTICE AND FUTURE RESEARCH ......................... 202
TRAINED CLINICIANS ................................................................................. 202
CONTROL OF INTRUSIVE SYMPTOMS........................................................... 204
INTEGRATING PSYCHOLOGICAL THERAPIES WITH MEDICATION
FOR SYMPTOM CONTROL ........................................................................... 205
REFRAMING PTSD RECOVERY ................................................................... 207
RESEARCH QUESTIONS RAISED BY FINDINGS .............................................. 208
COMMENTS ABOUT METHODOLOGY .......................................................... 210
SUMMARY ................................................................................................. 210
REFERENCES........................................................................................................... 212
APPENDICES ............................................................................................................ 238
A. LOG OF EMAIL CONTACT WITH STUDY PARTICIPANTS AND OTHERS........ 239
B. RECRUITMENT LETTER/EMAIL/NEWS RELEASE ...................................... 242
C. POSTTRAUMATIC STRESS DISORDER (PTSD) RECOVERY STUDY
DEMOGRAPHIC INFORMATION FORM .......................................................... 243
xiii
D. REVISED POSTTRAUMATIC STRESS DISORDER (PTSD) RECOVERY STUDY
PARTICIPANT INFORMATION....................................................................... 250
E. PRELIMINARY, INTERMEDIATE, AND FINAL CODING CATEGORIES ........... 258
F. RESEARCH PROJECT INFORMATION AND INFORMED CONSENT ................. 261
xiv
LIST OF TABLES
Table 2.1. Proposed Changes in the 309.81 Posttraumatic Stress Disorder (PTSD)
Diagnosis in the DSM-5 ....................................................................................... 14
Table 2.2. Core Themes of Recovery from Mental Illness ............................................. 50
Table 2.3. Conceptual Models of Recovery from Mental Illness .................................... 58
Table 4.1. Frequency Distributions of Demographic Characteristics ............................ 126
Table 4.2. Frequency Distributions of Questions on Marital Status and Family
Characteristics.................................................................................................... 127
Table 4.3. Frequency Distributions of Questions on Work and Financial
Status ................................................................................................................. 129
Table 4.4. Frequency Distribution of Type of Traumatic Exposure .............................. 131
Table 4.5. Frequency Distributions on Frequency/Length of Trauma Exposure,
Persistence of PTSD Symptoms, and Symptoms Experienced ............................ 132
Table 4.6. Consequences and Abuse/Risk-Taking Behaviors Associated
with PTSD Symptoms ........................................................................................ 134
Table 4.7. Symptom Persistence, Treatment, and Recovery Factors of PTSD .............. 136
Table 4.8. Clustering Coding into Final Categories ...................................................... 139
Table 5.1. PTSD Symptom Occurrence: PTSD Recovery Study vs.
CPES Database .................................................................................................. 188
xv
LIST OF FIGURES
Figure 4.1. PTSD Recovery Model .............................................................................. 142
Figure 4.2. Nodes Clustered by Word Similarity.......................................................... 143
xvi
CHAPTER I
INTRODUCTION
Exposure to physical and psychological trauma has produced a post-millennial
epoch of posttraumatic stress disorder (PTSD), a debilitating anxiety disorder that occurs
after exposure to an extreme stressor or prolonged victimization. For example, war and
genocide have been significant stressors in sub-Saharan Africa, with up to 25% of the
population reporting symptoms that meet the criteria for PTSD (Njenga, Nguithi, &
Kang'ethe, 2006). In the United States, PTSD has become a burgeoning public health
problem for military combatants, starting with the initiation of the second Gulf War in
2003 (Keen & Soriano, 2003).
As of June 2009, some 25% of the veterans who served in Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF), the conflicts in Afghanistan and
Iraq respectively, who have obtained VA health care have been diagnosed with possible
posttraumatic stress disorder (U.S. Department of Veterans Affairs, 2010). This number
represented approximately 120,000 OEF and OIF veterans. Less recent combat-related
stressors have also been a significant source of PTSD. Medical experts have stated that
PTSD occurred in about 30% of Vietnam veterans and in as many as 10% of the first
Gulf War (Desert Storm) veterans (National Center for Postraumatic Stress Disorder
[NCPTSD)], 2010).
1
Although public awareness has been heightened by persistent news reports
highlighting the mental and emotional issues of returning veterans, natural and manmade
disasters have changed the world’s psychological landscape. Catastrophes such as the
World Trade Center attack in 2001, Hurricane Katrina in 2005 (Weems et al., 2007), and
the 2004 Indian Ocean and 2011 Japanese earthquakes and tsunamis have also produced
long lasting psychological turmoil in their victims. Survivors of these mass trauma and
casualty events have frequently experienced unresolved PTSD from exposure to
unimaginable trauma.
Less newsworthy, individual trauma also has caused chronic PTSD. Victimization,
especially intimate partner violence (IPV) against women, is pervasive, with nearly 25%
of all women in the United States reporting that they have been raped and/or physically
assaulted in their lifetime (North Carolina Coalition Against Domestic Violence, 2010).
Of these women, almost 8% will report development of PTSD. Aside from sexual assault
and exposure to combat and natural disasters, other categories of victimization, including
homicide, violence, and child abuse, have resulted in persistent PTSD.
One therapeutic byproduct of media depiction of traumatic events has been that
PTSD has increasingly become part of the national lexicon, with growing public
awareness of the condition and greater recognition of the need for effective treatment
(Karlin et al., 2010). PTSD evokes feelings of intense fear, helplessness, and horror in
victims and prohibits them from assuming usual life roles (American Psychological
Association [APA], 2000). For adults, life roles missed by many victims of PTSD have
included developing satisfying relationships with family and friends and rearing children;
engaging in lifelong learning, career development, and work; pursuing hobbies and
2
leisure activities; and preparing for and taking pleasure in retirement (Knowles, 1975;
Knowles, Holton, & Swanson, 2005; Super, 1990). Victims of PTSD often have had their
work roles delineated by the illness and do not develop satisfying work lives, which has
tremendous impact on them personally and financially.
Moreover, missed life roles such as being a child, student, citizen, worker, spouse,
homemaker, parent, and retiree can prevent the individual from developing several
important subjective frames of reference such as his or her basic place in the world and
society (Brott, 2005; Shulman & Mosak, 1988). A victim of PTSD may not develop
social skills such as relating to others and becoming intimate with partners and friends,
making a contribution to society, being happy with one’s life, and developing satisfying
spiritual connections (Mosak & Dreikurs, 1967). These absent adult life dimensions in
the respective life roles of relationships, work, family, self, and spirituality can be
directly related to significant symptoms of chronic PTSD (Shulman & Mosak, 1988).
Victims may also miss developmental milestones across the life span because of
chronic PTSD. Erikson (1963) and Havighurst (1972) both described developmental
stages crossing the entire life span from infancy to late adulthood. Each stage featured
essential tasks that had to be mastered for the individual to progress to the next stage.
Child and adult victims of PTSD may experience symptoms emanating from PTSD that
prevent them not only from assuming expected life roles but also from meeting expected
developmental milestones. More discussion on the array of life roles and developmental
milestones that can be missed by victims of PTSD and resulting consequences has been
presented later on in the literature review.
3
Aside from personal difficulties suffered by the individual, victimization and PTSD
have inflicted an enormous economic burden on society. Societal associated expenses
have included uninsured medical care, mental health services, and lost productivity in
time away from work. Approximately $6 billion was spent in 2004 in the United States
for mental and physical health services to treat PTSD, which ranks as the anxiety disorder
with the highest annual per person health care expenditure (Greenburg et al., 1999;
Tyson, 2008).
In summary, victimization and resultant PTSD have continually caused human
beings to be sidelined from their lives and unable to fulfill their potential. Physical and
emotional injuries and associated PTSD symptoms—e.g., persistent frightening thoughts
and memories of the ordeal, emotional numbing, disassociation, nightmares, sleep
problems, flashbacks, agitated or disorganized behavior, hopelessness, shame, or despair,
and hyperarousal—have isolated victims and prevented them from working, engaging in
productive personal relationships, and performing daily activities (American Psychiatric
Association, 2000; National Center for Injury Prevention and Control, 2003; National
Center for Posttraumatic Stress Disorder, 2009; Tjaden & Thoennes, 2000)
Purpose of the Study
Despite heightened attention to PTSD and improvement in treatment during the last
decade, many fundamental issues concerning the etiology, maintenance, treatment, and
realistic treatment goals of the disorder have been largely unresolved (Clark & Beck,
2010). Because of varied consumer expectations and inconsistent empirical data on
treatment outcomes, the Committee on Treatment of Posttraumatic Stress Disorder of the
Institute of Medicine (2008) encouraged mental health clinicians to examine the efficacy
4
of treatments and goals. When the Institute of Medicine (IOM) committee examined
2,771 studies of PTSD treatments, the committee discovered that only 90 studies met
strict criteria for evidence-based medicine standards. The committee concluded that
studies conducted over the almost 30 years during which PTSD has been accepted as a
valid psychological diagnosis and defined as a mental illness “do not form a cohesive
body of evidence about what works and what does not” (p. 10). The committee
particularly encouraged clinicians to focus on defining the concept of recovery,
concentrating on symptom reduction, removal of the PTSD diagnosis, and end-state
function.
In response to this charge, the PTSD Treatment Guidelines Task Force of the
International Society for Traumatic Stress Studies issued its practice guidelines for the
treatment of PTSD (Foa, Keane, Friedman, & Cohen, 2009). This book has been labeled
the definitive best-practice reference for mental health clinicians. Yet, out of 642 pages,
only four pages dealt with the concept of recovery, situating it in the public health realm
of psychosocial rehabilitation. The referenced recovery concept was itself borrowed from
President’s New Freedom Commission on Mental Health (2003) regarding recovery from
debilitating chronic mental health disorders such schizophrenia.
The task force did produce an additional eight pages on treatment goals, stating that
most clinicians believed that the patient’s needs, abilities, and preferences should help
define treatment goals (Foa et al., 2009). For example, many patients would consider
reduction of PTSD symptoms as the major focus of treatment. For others, stabilization
and prevention of relapse may have motivated treatment. For some, concurrent
comorbidities such as substance and alcohol abuse may have driven treatment decisions.
5
Other treatment goals may be to escape stressful life events or adverse life conditions
(Foa et al., 2009). However, these goals did not adequately describe real-world
functioning after recovery from a serious psychiatric illness such as PTSD.
In 2010, the U.S. Department of Veterans Affairs (VA) started nationally
disseminating two evidence-based psychotherapies for PTSD throughout the VA health
care system (Karlin et al., 2010). Moreover, the VA has developed “top down” national
initiatives to train mental health staff in the delivery of Cognitive Processing Therapy
(CPT) and Prolonged Exposure therapy (PE) for combat PTSD and has implemented a
variety of strategies to promote local implementation. Early data confirmed anecdotal
reports from clinicians in the field that these therapies have yielded gains they had
infrequently seen in the past with patients with PTSD (Karlin et al., 2010). The VA
initiative has focused on abatement of symptoms and eventual removal of the PTSD
diagnosis.
Although the IOM report has mobilized large-scale efforts to quantify treatments
and standardize delivery of treatment protocols, PTSD recovery, particularly the
individual’s struggle to attain acceptable end-state function, remains a concept that has
been largely unexplored. The IOM committee (2008) found that no generally accepted
and used definition existed which adequately defined the concept of “recovery” in PTSD.
It is quite possible that actions or events regarded as therapeutic by PTSD victims may be
lacking in current mental health treatment protocols. It is also possible that some
treatment protocols and therapies may actually hinder recovery. Thus, the specific aim of
this study was to answer the following question: What is the basic psychosocial process
that men and women undergo in recovering from PTSD?
6
Summary
In this chapter, I have discussed the environmental and psychological conditions
that create posttraumatic stress disorder, also known by its acronym as PTSD. PTSD is an
anxiety disorder that has had enormous influence on trauma victims’ lives, producing
persistent symptoms that inhibit role performance in adults and children. Victims of
PTSD have had difficulty establishing and maintaining satisfying emotional relationships.
Adult victims also have suffered economically, since symptoms often have inhibited
career development.
In addition to the personal toll it has extracted, PTSD has inflicted a large financial
burden on society because of the lost productivity of victims and the enormous cost of
treatment. Faced with an influx of veterans with PTSD who have strained the Veterans
Administration health care system, the Institute of Medicine has established a committee
to examine existing treatment methods. Their initial report stated that there was
significant lack of information about effective treatment strategies and global aspects of
recovery. Thus, this study has been designed to provide more information from the
perspective of the trauma victim on the PTSD recovery process.
7
CHAPTER II
BACKGROUND AND SIGNIFICANCE
Chapter II contains a synthesis of the literature, divided into several sections
covering the background and significance of trauma, victimization, and posttraumatic
stress disorder (PTSD), stress and coping mechanisms, and the concept of recovery as it
relates to mental disorders. The review of literature also has examined some themes
interwoven into the qualitative research process, such as the heroic journey, therapeutic
writing, and social networking.
Trauma, Victimization, and Posttraumatic Stress Disorder
Trauma is a life-threatening or terrifying event that an individual has seen or
experienced (National Center for Posttraumatic Stress Disorder, 2010). Victimization is a
broader term used to define an injurious act to an individual or community; the act may
or may not have included physical injury or violence. According to U.S. Bureau of
Justice Statistics (2009), victimization can include physical and sexual injury as well as
damage to property.
The anxiety disorder posttraumatic stress disorder (PTSD) occurs at the farthest,
most damaging end of the victimization continuum. PTSD occurs in persons who have
been exposed to an extreme stressor or prolonged victimization that evokes feelings of
intense fear, helplessness, and horror (American Psychological Association [APA],
2000). Acute stress disorder is said to have occurred when distressing symptoms have
8
lasted less than three months. If symptoms have lasted longer than three months, the
disorder is labeled as PTSD. Lingering PTSD is said to be chronic. There is also a
“delayed” variant that occurs months after exposure to trauma (APA, 2000). The
reworked criteria for PTSD in the proposed DSM-5 would collapse all prior categories
into one (APA, 2010). Regardless of their trauma history, individuals with PTSD have
similar symptoms and treatments and a common prognosis; the disorder represents the
unresolved aftermath of trauma and victimization.
The cross-cultural dimensions of PTSD are complex. The DSM-IV-TR (APA,
2000) stated that it is imperative that clinicians take into account an individual’s ethnic
and cultural context in the evaluation of any DSM diagnosis. Related to trauma exposure,
clinicians have identified some universal dimensions of human experience (Stamm &
Friedman, 2000). Researchers in human evolutionary biology have argued that all
cultures have a similar capacity to experience fundamental human emotions such as joy,
fear, anger, sadness, disgust, shame and guilt. However, researchers have disagreed over
the universality of expression of emotions. Some researchers have argued that
expressions of these emotions are cultural constructs. From these discussions, Matsumoto
(1989, 1990) has convincingly built a case that fear is the only emotion that is expressed
and received universally. Extrapolating from Matsumoto’s position, Stamm and
Friedman (2000) suggested, “… all humans have the capacity to experience and express
fear, helplessness, or horror when exposed to traumatic stress” (p. 70). Thus, victims of
trauma universally meet the response criterion of the PTSD diagnosis.
According to the Diagnostic and Statistical Manual of Mental Disorders IV, Text
Revision [DSM-IV-TR] (APA, 2000) and the National Institute for Mental Health
9
[NIMH] (2008), traumatic events that may trigger PTSD have included situations that are
experienced or witnessed directly, such military combat, violent personal assault (sexual
assault, physical attack, robbery, mugging), being kidnapped, being taken hostage,
terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp,
natural or manmade disasters, severe automobile accidents, or being diagnosed with a
life-threatening illness. PTSD can also occur at the community, national, and
international level, resulting in groups of traumatized people.
During the traumatic event, the person feels that his or her life, the lives of loved
ones, or others’ lives are in danger (APA, 2000). The individual reports being afraid and
feeling that he or she had no control over what happened. According to the National
Comorbidity Survey Replication, about 75% of the American men and women surveyed
reported lifetime exposure to at least one trauma with no resulting diagnosis of PTSD
(Sledjeski, Spiesman, & Dierker, 2008). However, another 6.7 to 7.8% reported at least
one lifetime trauma with resulting PTSD.
After the traumatizing event, victims feel scared, confused, or angry. People with
PTSD have persistent frightening thoughts and memories of their ordeal and feel
emotionally numb, especially with people with whom they were once close (NIMH,
2008). Victims may experience sleep problems, feel detached or disassociated from
reality, exhibit agitated or disorganized behavior, and be easily startled. If these feelings
have noted not abated in a short time—less than three months, according to the DSM
IV—or if they become worse, the victim may have chronic PTSD.
In summary, this section described the current criteria for a PTSD diagnosis;
however, the APA is currently revising the DSM-IV-TR, which is a complicated multi-
10
year project. While the gist of the PTSD criteria has remained the same, there have been a
few major changes in the text. Many of the proposed revisions were relatively subtle and
should contribute to a more precise diagnosis. The next section describes the changes
proposed in the DSM-5.
Proposed Diagnostic Differences in DSM-5
The current operational definitions of PTSD have been in place since 2000 when
the DSM-IV-TR was published. However, the definition of the disorder may be changed
and revised criteria may be in place by 2013 with the publication of the new DSM-5. The
draft diagnostic criteria for PTSD in the DSM-5 contained some noteworthy changes
(APA, 2010; Cloyd, 2010). In general, the DSM-5 PTSD diagnosis expanded from three
to four symptom clusters, removed the A2 criterion, and added negative mood states and
cognitions (McNamara, 2009). These proposed modifications are discussed in more detail
below.
In the proposed DSM-5, which is currently being trialed, the former three-cluster
criteria for diagnosis of PTSD have been expanded into four clusters: re-experiencing,
avoidance, numbing, and arousal (APA, 2010). Criterion A (prior exposure to traumatic
events) has been more specifically stated in the proposed revision. Evaluation of an
individual’s emotional response at the time (current Criterion A2) has been dropped.
Thus, the single Criterion A1 (exposure to a traumatic event) would be sufficient for
diagnosis of PTSD in the DSM-5. The proposed Criterion A for the DSM-5 has included
a footnote that witnessing or exposure to aversive details does not include events that are
witnessed only in electronic media, television, movies or pictures, unless this has
occurred as part of a person’s vocational role. Exposure to aversive details of death will
11
apply only to unnatural death. However, the proposed revisions do consider repeated or
extreme exposure to aversive details of the event or events (e.g., first responders
collecting body parts or police officers repeatedly exposed to details of child abuse) to be
all bona fide traumatic stressors (APA, 2010; McNamara, 2009).
Several items in Criterion B (intrusion symptoms) have been rewritten to add or
augment certain distinctions now considered important. Special consideration has been
given to developmentally appropriate criteria for use with children and adolescents,
which was lacking in the DSM-IV-TR (McNamara, 2009). These revisions were
especially evident in the restated Criterion B – intrusion symptoms. However,
development of age-specific criteria for diagnosis of PTSD has been an ongoing process
(APA, 2010; McNamara, 2009).
Criterion C (avoidance and numbing) has been split into “C” and “D” clusters since
psychiatrists participating on the revision panel decided that avoidance and numbing
were actually two distinct clusters of symptoms (McNamara, 2009). The proposed
Criterion C would focus solely on avoidance of behaviors or physical or temporal
reminders of the traumatic experience(s). What were formerly two symptoms would
become three because of these slight changes in the descriptions (APA, 2010).
The proposed Criterion D focused on negative alterations in cognition and mood
associated with the traumatic event(s), and contained two new symptoms, one expanded
symptom, and four largely unchanged symptoms specified in the previous criteria
(McNamara, 2009). These changes were proposed since people with PTSD can also
experience negative mood states, negative appraisals/cognitions, aggressive behavior, and
reckless behavior (Cloyd, 2010; McNamara, 2009). Other proposed changes included
12
persistent negative expectations about one’s self and others or one’s future, persistent
distorted blame of self or others about the cause or consequences of the traumatic event
(a new symptom), pervasive negative emotional state, feeling detached or estranged from
others, and persistent inability to experience positive emotions (APA, 2010).
The proposed Criterion E (formerly “D”) focused on increased arousal and
reactivity, and contained one slightly revised, one entirely new, and four unchanged
symptoms (McNamara, 2009). Addition of reactivity was the major proposed change to
Criterion E. Proposed phrasing for the DSM-5 was as follows: “… alterations in arousal
and reactivity that are associated with the traumatic event (that began or worsened after
the traumatic event) with three symptoms needed: irritable, angry, or aggressive
behavior; reckless or self-destructive behavior” (APA, 2010). The rest of the E criteria,
such as hypervigilance, exaggerated startle response, and problems in concentration,
remained largely the same, except for an updated definition of sleep disturbances
(McNamara, 2009). These changes are summarized in Table 2:1.
Other small changes included relabeling of criteria: Criterion F (formerly “E”)
would still require duration of symptoms to have been at least one month and Criterion G
(formerly “F”) stipulated that symptoms would impact the client (“disturbance”) in the
same way as before. The “acute” vs. “delayed” distinction for onset of the disorder would
be dropped in the DSM-5; the “delayed” specifier would be considered appropriate if
clinical symptom onset is no sooner than 6 months after the traumatic event or events
(APA, 2010). Research did not support the prior distinction of the two PTSD categories
used in the DSM-IV-TR (McNamara, 2009). Inclusion of a developmental trauma
disorder was still under discussion at the time of the draft publication (APA, 2010).
13
Table 2:1
Proposed Changes in the 309.81 Posttraumatic Stress Disorder (PTSD) Diagnosis in the DSM-5
DSM IV-TR Proposed DSM-5 Rationale for Change

Criterion A. The person has been exposed to a
Criterion A. The person was exposed to one or more of
traumatic event in which both of the following were
the following event(s): death or threatened death, actual
present:
or threatened serious injury, or actual or threatened
sexual violation, in one or more of the following ways:
**
1. The person experienced, witnessed, or was 1. Experiencing the event(s) him/herself Criterion A1. The new definition tightens up
confronted with an event or events that involved the A1 criterion to make a better distinction
actual or threatened death or serious injury, or a between “traumatic” and events that are
threat to the physical integrity of self or others distressing but which do not exceed the
“traumatic” threshold
2. The person's response involved intense fear, 2. Witnessing, in person, the event(s) as they occurred Criterion A2. Has no utility.
14
helplessness, or horror. Note: In children, this may to others

be expressed instead by disorganized or agitated
behavior
3. Learning that the event(s) occurred to a close relative
or close friend; in such cases, the actual or threatened
death must have been violent or accidental
4. Experiencing repeated or extreme exposure to
aversive details of the event(s) (e.g., first responders
collecting body parts; police officers repeatedly exposed
to details of child abuse); this does not apply to
exposure through electronic media, television, movies,
or pictures, unless this exposure is work related.
Table 2:1
Proposed Changes in the Posttraumatic Stress Disorder (PTSD) Diagnosis in the DSM-5 (continued)
Criterion B. The traumatic event is persistently Criterion B. Intrusion symptoms that are associated with
reexperienced in one (or more) of the following the traumatic event(s) (that began after the traumatic
ways: event(s), as evidenced by 1 or more of the following:
1. Recurrent and intrusive distressing recollections 1. Spontaneous or cued recurrent, involuntary, and Criterion B1 now distinguishes PTSD
of the event, including images, thoughts, or intrusive distressing memories of the traumatic event(s). spontaneous or triggered recurrent,
perceptions. Note: In young children, repetitive play Note: In children, repetitive play may occur in which involuntary, distressing memories from
may occur in which themes or aspects of the trauma themes or aspects of the traumatic event(s) are depressive ruminations
are expressed. expressed.
2. Recurrent distressing dreams of the event. Note: 2. Recurrent distressing dreams in which the content Criterion B2. Slight changes make the
In children, there may be frightening dreams without and/or affect of the dream is related to the event(s). criterion more applicable across cultures
recognizable content. Note: In children, there may be frightening dreams
15
without recognizable content. ***

3. Acting or feeling as if the traumatic event were 3. Dissociative reactions (e.g., flashbacks) in which the Criterion B3. Clarifies that flashbacks are
recurring (includes a sense of reliving the individual feels or acts as if the traumatic event(s) were dissociative experiences
experience, illusions, hallucinations, and dissociative recurring (Such reactions may occur on a continuum,
flashback episodes, including those that occur on with the most extreme expression being a complete loss
awakening or when intoxicated). Note: In young of awareness of present surroundings.) Note: In
children, trauma-specific reenactment may occur. children, trauma-specific reenactment may occur in
play.
4. Intense psychological distress at exposure to 4. Intense or prolonged psychological distress at Criterion B4. Unchanged
internal or external cues that symbolize or resemble exposure to internal or external cues that symbolize or
an aspect of the traumatic event. resemble an aspect of the traumatic event(s)
5. Physiological reactivity on exposure to internal or 5. Marked physiological reactions to reminders of the Criterion B5. Minor changes
external cues that symbolize or resemble an aspect of traumatic event(s)
the traumatic event.
Table 2:1
Criterion C. Persistent avoidance of stimuli Criterion C. Persistent avoidance of stimuli associated

associated with the trauma and numbing of general with the traumatic event(s) (that began after the
responsiveness (not present before the trauma), as traumatic event(s)), as evidenced by efforts to avoid 1 or
indicated by three (or more) of the following: more of the following:
1. Efforts to avoid thoughts, feelings, or 1. Avoids internal reminders (thoughts, feelings, or Criterion C1. Mostly unchanged. Exclusive
conversations associated with the trauma physical sensations) that arouse recollections of the focus on avoidance of subjective reactions
traumatic event(s)
2. Efforts to avoid activities, places, or people that 2. Avoids external reminders (people, places, Criterion C2. Mostly unchanged. Exclusive
arouse recollections of the trauma conversations, activities, objects, situations) that arouse focus on avoidance of behaviors or physical
recollections of the traumatic event(s). or temporal reminders
16
3. Inability to recall an important aspect of the Criterion C3. Mostly an extrapolation from
trauma C1 & C2 that focuses on avoidance of
interpersonal reminders
4. Markedly diminished interest or participation in
significant activities
5. Feeling of detachment or estrangement from
others
6. Restricted range of affect (e.g., unable to have
loving feelings)
7. Sense of a foreshortened future (e.g., does not
expect to have a career, marriage, children, or a
normal life span)
Table 2:1
Criterion D. Persistent symptoms of increased Criterion D. Negative alterations in cognitions and Criterion D. New Diagnostic cluster dividing
arousal (not present before the trauma), as indicated mood that are associated with the traumatic C criterion based on confirmatory factor
by two (or more) of the following: event(s) (that began or worsened after the traumatic analytic studies.
event(s), as evidenced by 3 or more of the following:
Note: In children, as evidenced by 2 or more of the
following:****
1. Difficulty falling or staying asleep 1. Inability to remember an important aspect of the Criterion D1. very minor change-more
traumatic event(s) (typically dissociative amnesia; not specific formulation of psychogenic amnesia
due to head injury, alcohol, or drugs).
2. Irritability or outbursts of anger 2. Persistent and exaggerated negative expectations Criterion D2. Expanded reformulation of fore-
about one’s self, others, or the world (e.g., “I am bad,” shortened future as negative expectations
“no one can be trusted,” “I’ve lost my soul forever,” about one’s self, others and one’s future.
17
“my whole nervous system is permanently ruined,” "the Additions pertaining to the nervous system
world is completely dangerous"). and soul makes the criterion more applicable
across cultures
3. Difficulty concentrating 3. Persistent distorted blame of self or others about the Criterion D3. New criterion-Emphasizes self-
cause or consequences of the traumatic event(s) blame regarding traumatic event
4. Hypervigilance 4. Pervasive negative emotional state -- for example: Criterion D4. New criterion-Emphasizes wide
fear, horror, anger, guilt, or shame variety of negative emotional states besides
fear, helplessness & horror
5. Exaggerated startle response 5. Markedly diminished interest or participation in Criterion D5. Unchanged
significant activities.
6. Feeling of detachment or estrangement from others. Criterion D6. Unchanged
7. Persistent inability to experience positive emotions Criterion D7. Unchanged
(e.g., unable to have loving feelings, psychic numbing)
Table 2:1
Criterion E. Duration of the disturbance (symptoms Criterion E. Alterations in arousal and reactivity that are
in Criteria B, C, and D) is more than 1 month. associated with the traumatic event(s) (that began or
worsened after the traumatic event(s), as evidenced by 3
or more of the following: Note: In children, as
evidenced by 2 or more of the following:****
1. Irritable or aggressive behavior Criterion E1. changes the focus from angry
feelings (retained in D4) to aggressive
behavior
2. Reckless or self-destructive behavior Criterion E2. New criterion-Focus on reckless
18
and self-destructive behavior

3. Hypervigilance Criterion E3. Unchanged
4. Exaggerated startle response Criterion E4. Unchanged
5. Problems with concentration Criterion E5. Unchanged
6. Sleep disturbance -- for example, difficulty falling or Criterion E6. Unchanged
staying asleep, or restless sleep.
Criterion F. The disturbance causes clinically Criterion F. Duration of the disturbance (symptoms in Criterion F. Unchanged
significant distress or impairment in social, Criteria B, C, D and E) is more than one month.
occupational, or other important areas of
functioning.
Criterion G. The disturbance causes clinically Criterion G. The disturbance causes clinically Criterion G. Unchanged
significant distress or impairment in social, significant distress or impairment in social,
occupational, or other important areas of occupational, or other important areas of functioning.
functioning.
Table 2:1
Criterion H. The disturbance is not due to the direct Criterion H. The disturbance is not due to the direct Criterion H. Unchanged
physiological effects of a substance (e.g., medication physiological effects of a substance (e.g., medication or
or alcohol) or a general medical condition (e.g., alcohol) or a general medical condition (e.g., traumatic
traumatic brain injury, coma brain injury, coma).
Specify if: Specify if: Acute vs. Chronic deleted because of lack of
evidence supporting such distinctions
Acute: if duration of symptoms is less than 3 months With Delayed Onset: if diagnostic threshold is not
exceeded until 6 months or more after the event(s) Delayed onset clarified
Chronic: if duration of symptoms is 3 months or
(although onset of some symptoms may occur sooner
more
than this).
With Delayed Onset: if onset of symptoms is at least
19
6 months after the stressor
Note. * Developmental manifestations of PTSD are still being developed. The term “developmental manifestation” in the DSM-5 refers to age-specific
expressions of one or more criteria that are used to make a diagnosis across age groups. ** For children, inclusion of loss of a parent or other attachment figure is
being considered. *** An alternative is to retain the DSM-IV criterion. **** The optimal number of required symptoms for both adults and children will be
further examined with empirical data. Adapted from “Considering PTSD for DSM-5” by M. Friedman et al. (2011), Depression & Anxiety, 28(9), 750-769, and
“The Cross-Cultural Validity of Posttraumatic Stress Disorder: Implications for DSM-5” by D.E. Hinton and R. Lewis-Fernandez (2011), Depression & Anxiety,
28(9), 783-801. Copyright 2011 by John Wiley & Sons. Used by permission.
Prior to the DSM-5 revision, some psychiatrists advocated that PTSD that
developed in the absence of a high-magnitude traumatic event be included in the DSM-5
(McNamara, 2007). This change was suggested because clinicians noted that PTSD could
arise following subthreshold events such as divorce, bereavement, or the end of a
romantic relationship. However, the DSM-5 retained the traumatic stressor as the major
criteria for diagnosis of the disorder. For children, inclusion of loss of a parent or other
attachment figure is currently being considered as a traumatic stressor (APA, 2010).
All of the distressing and persistent symptoms described in this section may disrupt
the life of an individual with PTSD, making it hard for the victim to continue with daily
activities (NCPTSD, 2010). One of the most significant effects of chronic PTSD and the
resulting symptoms has been that it prohibits the victim from participating in and fully
enjoying his or her life. The importance of life roles, meaningful work, and other
activities is discussed in the following section.
Delay and Abandonment of Life Roles
Posttraumatic stress disorder (PTSD) has evoked feelings of intense fear,
helplessness, and horror in victims and often prohibited them from assuming life roles
(APA, 2000), severely impacting quality of life. The most concrete theories regarding
adult life roles have centered on learning and career development. For adults with PTSD,
these unassumed roles and competencies have included life-long learning, holding a
sense of self or unique self-identity, being a friend, citizen, family member, or worker,
and enjoying leisure pursuits (Knowles, 1975; Knowles et al., 2005).
One alternate viewpoint was offered by Super (1990), who created a five-stage
model spanning the years from age 14 to 65-plus. Super’s model examined the cycling
20
and recycling of developmental tasks throughout the life span relating especially to career
development. Super’s stages were decline, maintenance, establishment, exploration, and
growth, during which an adult left behind adolescent roles of hobbies and leisure
pursuits, selected an occupation, established him- or herself in the field, explored related
opportunities and chances for career growth, and then segued into retirement. During that
time, the worker’s self task changed from developing a realistic self-identity in the teen
years to valuing work roles and the work identity in middle adulthood. By retirement age,
the individual wound up developing and valuing nonoccupational roles.
Super also delineated life roles in the following fashion: child, student, leisurite,
citizen, worker, spouse, homemaker, parent, and pensioner (Brott, 2005). The four
theaters in which life roles were performed are the home, school, community, and
workplace. Super’s conceptual model was unique in that it allowed career development
therapists to see that individuals are involved in several interwoven roles. Because
victims of PTSD often have their work roles delineated by their illness, they may not
develop satisfying work lives.
In addition to Super’s overview of work and the development of life roles, there
have been a number of other adult life role theories based on broader theoretical
perspectives. One was the lifestyle assessment based on the work of psychologist Alfred
Adler (1931). The assessment explored the client’s subjective frame of reference from
three perspectives: (a) the individual’s basic orientation to life; (b) the individual’s social
interest that began in childhood and involved finding a place in society and acquiring a
sense of belonging and of contributing; and (c) the individual as understood from a social
context. Mosak and Dreikurs (1967) presented five life tasks that included relating to
21
others, making a contribution, achieving intimacy, getting along with oneself, and
developing one’s spiritual dimension. All of these life tasks can be related to the
respective life roles of relationships, work, family, self, and spirituality.
Yet another perspective was based on choice theory (Glasser, 2000). This theory
stated that human beings are born with the genetically encoded needs of survival, love
and belonging, power, freedom, and fun. An individual’s quality of life is determined by
how well these needs are met. Various life roles, including work, relationships, and
leisure, can help to meet these needs. By contrast, existentialist philosophy, which
examined significance in life, included stages such as striving for identity, relationships
with others, and an individual’s search for meaning (May & Yalom, 1995; Yalom, 1980).
Humans have found meaningfulness by engaging in life through the activities of creating,
loving, working, and building. These tasks may be seen as the life roles of family,
relationships, work, and actualization.
Attainment of developmental tasks also has served as the basis for life role theories
for ages across the life span. Erikson (1963) described eight developmental stages
crossing the entire life span from infancy to late adulthood. For each stage he described
essential tasks that had to be mastered before the individual could progress to the next
stage. Failure to attain these life tasks mired the individual at a lesser developmental
stage. Erikson's basic philosophy may be said to rest on two major themes: (1) the world
gets bigger and more complex as life progresses, and (2) failure becomes cumulative
when developmental milestones are unmet (Harder, 2009).
Another well-known developmental theorist was Havighurst (1972). Like Erikson,
Havighurst’s developmental model covered the entire human life span, from birth to old
22
age. Havighurst’s model included six developmental stages. Each stage had tasks that
emanated from one of three sources: physical maturation, e.g., learning to walk and talk;
personal values, e.g., selecting work or developing an outlook on life; and societal
pressures, e.g., learning to read or assuming roles as a responsible citizen. Havighurst’s
theories, like those of Knowles, were largely applied to education.
In summary, child and adult victims of PTSD may experience symptoms emanating
from the disorder that prevent them from assuming expected life roles. While supportive
therapies can help the child and adult victim to become “unstuck” from a lower
developmental level and to negotiate later developmental milestones (Young & Ensing,
1999), considerable difficulties, such as failure to form bonds with others, take pleasure
from work, and become economically independent, can result. Aside from the financial
hardships suffered by the individual with chronic PTSD, who has been unable to assume
the life role of wage earner, society itself has experienced negative economic
consequences from the disorder. In the following section, I discuss the macroeconomic
effects of PTSD.
Economic Effects of PTSD
Together victimization and PTSD have had an immense impact on health care
costs. The cost of intimate partner violence (IPV) against women, a significant cause of
PTSD, was an estimated $5.8 billion in 1995; updated to 2003 dollars, the cost amounted
to more than $8.3 billion, including medical care, mental health services, and lost
productivity in time away from work (Max, Rice, Finkelstein, & Leadbetter, 2004). In
terms of dollars spent annually, PTSD has accrued more mental and physical health
expenses than any other anxiety disorder (Greenburg et al., 1999; Tyson, 2008). In
23
addition, some 54% of the total expenditures have been credited to nonpsychiatric health
care costs, such as primary care, emergency department visits, somatic complaints such
as chronic pain, back problems and general physical ailments, and substance use
disorders (Andreasen, 2004; Dienemann et al., 2000; D. G. Dutton, Starsomski, & Ryan,
1996; M. A. Dutton et al., 2006; Greenburg et al., 1999; D. W. King, King, Foy, Keane,
& Fairbank, 1999; Kulka et al., 1990; Najavits, Weiss, & Shaw, 1997; Price, 2006;
Walker, Logan, Jordan, & Campbell, 2004).
For combat-related PTSD, Tanielian and Jaycox (2008) projected two-year costs,
e.g., costs incurred within the first two years after service members return home, to be
approximately $5,904 to $10,298 per case. Two-year costs associated with major
depression were estimated to be approximately $15,461 to $25,757 per case. Costs
associated with co-morbid PTSD and major depression were approximately $12,427 to
$16,884 per case. According to Tanielian and Jaycox (2008), one-year costs for service
members who have accessed the health care system and received a diagnosis of traumatic
brain injury were even higher, ranging from $25,572 to $30,730 in 2005 for mild cases
($27,259 to $32,759 in 2007 dollars), and from $252,251 to $383,221 for moderate or
severe cases ($268,902 to $408,519 in 2007 dollars).
Furthermore, the findings of the National Comorbidity Study Revised supported an
already robust research base that had strongly suggested that multiple traumas have a
cumulative effect on physical health (Sledjeski et al., 2008; Tjaden & Thoennes, 2000).
In the recent past, research has typically focused on the etiology and epidemiology of
PTSD, treatments believed to be efficacious, and stress and coping variables associated
with development and progression of the illness. These topics have been discussed in
24
some detail in the following sections of this dissertation. However, despite the fact that
PTSD has been a disorder that can cause crippling and unremitting dysfunction in many
of its victims, no consensus has been reached among clinicians about recovery criteria
and proven treatment protocols. By necessity, that section is more limited.
Etiologies of Victimization and PTSD
The etiologies of victimization are varied. Intimate partner violence (IPV) against
women has been a significant source of victimization. One out of four women in the
United States has been physically or sexually abused by a husband or boyfriend at some
point in their lives (North Carolina Coalition Against Domestic Violence, 2010). IPV has
consistently been a significant health concern, since long-term abuse can cause serious
physical injuries, disabilities, death, and emotional problems for the victims (North
Carolina Coalition Against Domestic Violence, 2010). The National Violence Against
Women Survey (Tjaden & Thoennes, 2000) found that IPV has been pervasive, with
nearly 25 percent of surveyed women reporting that they were raped and/or physically
assaulted by a current or former spouse, cohabiting partner, or date at some time in their
lifetime. Approximately 1.5 million women have been raped and/or physically assaulted
by an intimate partner annually in the United States; because many victims were
victimized more than once, the number of victimizations exceeded a total 4.8 million
intimate partner rapes and physical assaults. Stalking by intimate partners also has been
very prevalent, with 5% of women reporting being stalked by a significant other or date
at some time in their lifetime (Tjaden & Thoennes, 2000). Thus, IPV has been a serious
criminal justice and public health concern.
25
Like IPV, military combat has been a significant cause of PTSD, with specific
implications for veterans of recent U.S. wars. Medical experts have stated that PTSD has
occurred in about 30% of Vietnam veterans and in as many as 10% of Gulf War (Desert
Storm) veterans (National Center for Posttraumatic Stress Disorder, 2010). In Operation
Enduring Freedom (OEF), some 6% to 11% of veterans of the Afghanistan war
experienced PTSD; by contrast, 12% to 20% of veterans of Operation Iraqi Freedom
(OIF) in Iraq have developed PTSD. Another cause of PTSD in the military can be
military sexual trauma, which has been defined as sexual harassment or sexual assault
that has occurred during military service. Military sexual trauma has affected both men
and women and can occur during peacetime, training, or war. Among veterans using
Veterans Administration (VA) health care, 23% reported sexual assault in the military;
55% of the female respondents and 38% of male veterans reported that they experienced
sexual harassment in the military (National Center for Posttraumatic Stress Disorder,
2010).
Of equal concern has been alcohol abuse, technically known as substance use
disorder (SUD), among returning veterans afflicted with PTSD. Among OIF/OEF
veterans who received VA care, the Survey of Health Experiences of Patients (2005)
reflected the high prevalence of alcohol misuse (Calhoun, Najavits, Kosten, & Kivlahan,
2007; Meis, Erbes, Polusny, & Compton, 2010). The survey showed that 18% of
responding OIF/OEF veterans screened positive for moderate to severe alcohol misuse
with an additional 22% screening positive for mild to moderate misuse. SUD has also
been a concern among IPV victims because of low self-esteem and poor coping skills
(Boyd, 2000); moreover, women who have abuse histories as children or adults are more
26
likely to turn to substance abuse as a coping method (Boyd & Mackey, 2000a). Without
effective treatment for both PTSD and concurrent substance abuse, the prognosis has
been poor for victims, who often “stay stuck” in the painful trauma-causing events
(Najavits, 2002b).
In summary, IPV and military combat exposure have been significant predictors for
the formation of PTSD. Researchers have agreed that the most significant variable for
development of PTSD is exposure to a traumatic stressor or cumulative stressors. In
addition, there are some risk factors that predispose some individuals to developing
PTSD. Traumatic events and associated risk factors have been interwoven in the
causation and progression of PTSD. The effect of traumatic events and risk factors that
cause an individual to be more vulnerable to developing chronic PTSD have been
discussed in the following two sections.
Traumatic Events
The occurrence of and contextual factors surrounding exposure to a traumatic
stressor are the key factors triggering development of PTSD. Variables associated with
PTSD formation have included the extent of devastation and destruction, injuries, deaths,
and permanent disruption to life resulting from the traumatic event, particularly response
to a mass-casualty incident (Raphael & Dobson, 2002; Raphael, Wilson, Meldrum, &
McFarlane, 1996; Raphael & Wilson, 1993). Women who have experienced sexual
assault reported that the nature of and violence of the attack, relationship and race of the
assailant, and institutional (e.g., police or law enforcement) response to the event were all
salient factors in developing post-rape PTSD (Burgess & Holmstrom, 1979).
27
War-zone stressors discovered to affect PTSD formation included traditional
combat events, subjective or perceived threat from the enemy, exposure to atrocities and
abusive violence, unremitting malevolent environment, and exposure to cumulative
stressors (D. W. King et al., 1999; D. W. King, King, Gudanowski, & Vreven, 1995;
Vogt, Pless, King, & King, 2005). Other military factors included lack of social support
at the time of deployment, the presence of psychiatric comorbidities such as depression
and anxiety, and military sexual trauma (Street et al., 2005; Vogt et al., 2005). With both
civilian and military traumatic events, media and cultural representations of crime and
disaster also influenced development and severity of PTSD (Quist & Wiegand, 2002).
In summary, traumatic exposure, victimization and cumulative and/or repetitive
trauma, and the context in which the trauma occurred have been significant influences on
the development of PTSD. In addition to traumatic events and salient contextual
stressors, there have been certain pre-trauma and post-trauma risk factors that
predisposed an individual to develop PTSD. These risk factors are discussed in the
following section.
Risk Factors for IPV and PTSD
Male/female relationship variables such as an education mismatch (e.g., the woman
having a higher education level than the man), presence of the woman’s children by a
previous partner in the home, pregnancy, history and frequency of past marital violence,
past victimization, male controlling behaviors, unemployment and financial strain, and
physical separation have all been implicated as risk factors in IPV (Boyd, 2003;
Kaukinen, 2004; Koziol-McLean et al., 2006; National Center for Injury Prevention and
Control, 2003; North Carolina Coalition Against Domestic Violence, 2010; Tjaden &
28
Thoennes, 2000). For men, factors predictive for perpetuating IPV have included
depression, anger, and hostility; antisocial and borderline personality traits; a prior
history of being physically abusive; a belief in strict gender roles (e.g., male dominance
and aggression in relationships); a desire for power and control in relationships; and
engaging in psychological aggression (Centers for Disease Control and Prevention:
National Center for Injury Prevention and Control, 2010a; Nicolaidis et al., 2003). The
Centers for Disease Control and Prevention [CDC] (2010a) also cited risk factors for
male abuse and battering such as low self-esteem, low income, low academic
achievement, young age, and aggressive or delinquent behavior as a youth. Synthesis of
all research has shown that the most significant variables predicting female IPV have
been the act of separation and controlling behaviors by the man (Nicolaidis et al., 2003;
Walker et al., 2004).
Both or either partner in an abusive relationship may have a history of having
experienced poor parenting as a child and a history of having been physically disciplined
as a child (Boyd & Mackey, 2000a; CDC, 2010a) As children, partners in an abusive
relationship may have been exposed to parental marital conflict and fights, marital
instability such as divorce or separation, dominance and control of the relationship by one
parent over the other, economic stressors, and unhealthy family relationships and
interactions (CDC, 2010b; Koziol-McLain et al., 2006). Seeing or being a victim of
violence as a child has been consistently one of the strongest predictors of IPV
perpetration (North Carolina Coalition Against Domestic Violence, 2010).
Community factors that have contributed to the occurrence of IPV include
poverty and associated factors such as overcrowding; low social capital such as lack of
29
institutions, relationships, and norms that shape a community’s social interactions; and
weak community sanctions and unenthusiastic support from law enforcement agencies
against IPV, e.g., unwillingness of neighbors to intervene in situations where they witness
violence (J. C. Campbell, Moracco, & Saltzman, 2000; CDC, 2010b; Humphreys, Sharps,
& Campbell, 2005; Rodriquez, McLoughlin, Nah, & Campbell, 2001). Societal factors
have also influenced IPV, including traditional gender norms such as ideas that women
should stay at home, not enter the workforce and be submissive, and that men support the
family and make the family’s decisions (CDC, 2010a). In summary, certain risk factors
have predisposed susceptible individuals to the occurrence of IPV and subsequent
development of PTSD.
In addition to IPV, there have been other risk factors that have helped trigger
development of PTSD. Childhood risk factors have also been strongly associated with the
later development of PTSD in both children and adults. Significant among these were
negative events such as childhood physical abuse and trauma, parental neglect, and
childhood sexual assault (Boyd & Mackey, 2000a, 2000b; Nishith, Mechanic, & Resick,
2000) as well as lack of or low childhood social support from maternal, paternal, and peer
sources (D. W. King et al., 1999; Kulka et al., 1990; Lauterbach, Koch, & Porter, 2007).
It has been believed that these negative life events presaged disorganized attachment and
later development of psychopathology (D. W. King et al., 1999; Kulka et al., 1990).
Sociocultural variables that have predicted PTSD included a rigid or conservative
religious background for the family, parents’ educational level, father’s occupation, and
family instability, such as health and mental health problems among family members (D.
W. King et al., 1999; Kulka et al., 1990). Childhood antisocial and delinquent behaviors
30
and adolescent mental health problems also predisposed children and adults to the
development of PTSD (D. W. King et al., 1999; Kulka et al., 1990; Sledjeski et al., 2008)
Exposure to and involvement in severe car accidents, criminal violence, homicide, and
witnessing severe injury or death negatively have impacted future mental health and later
role performance (Street et al., 2005).
Risk variables that have placed an adult at risk for PTSD formation include the
existence of interpersonal trauma, such as IPV (Jankowski, Lietenberg, Henning, &
Coffey, 2002; Lautherbach et al., 2007); early trauma history (Fontana & Rosenheck,
2005; Price, 2006); and cumulative childhood and adult victimization stressors (Cattaneo,
Bell, Goodman, & Dutton, 2007; Gill, Page, Sharps, & Campbell, 2008; Raghavan &
Kingston, 2006; Solomon, Zur-Noah, Horesh, Zerach, & Keinan, 2008; Wolfe,
Sharkansky, Dawson, Martin, & Ouimette, 1998). Gender (Turner, Turse, &
Dohrenwend, 2007) and ethnicity (Dohrenwend et al., 2006; Dohrenwend, Turner, Turse,
Lewis-Fernandez, & Yager, 2008; Lewis-Fernandez et al., 2008; Norris, 2004; Price,
2006; Ritchie, Watson, & Friedman, 2006) also have played a role in PTSD development.
Concurrent psychiatric issues and comorbidities (Calhoun, Bosworth, Stechuchak,
Strauss, & Butterfield, 2006; Dienemann et al., 2000; Gill et al., 2008) and alcohol and
substance abuse (Boyd & Mackey, 2000b; Harned, Najavits, & Weiss, 2006; Najavits,
2004a, 2004b; Najavits et al., 2003; O'Hare, Sherrer, & Shen, 2006) have also been
significant risk factors in the development and severity of PTSD.
Socioeconomic and ecological factors including poverty, urban residency, and
exposure to a persistent malevolent environment have increased an individual’s
likelihood of exposure to a traumatic event (Gill et al., 2008; D. W. King et al., 1999; L.
31
A. King, King, Keane, Fairbank, & Adams, 1998; Norris, 2004; Ritchie et al., 2006).
Obviously, the misfortune of experiencing a horrific manmade or natural disaster has
elevated an individual’s chances of developing PTSD (Galea, Vlahov, & Resnick, 2003;
Peleg & Shalev, 2005; Raphael & Dobson, 2002; Silver, Holman, McIntosh, Poulin, &
Gil-Rivas, 2002). The most poorly understood and researched risk factors were
neurobiologic risks and genetics that predispose individuals to the development of
chronic PTSD (Friedman & Pitman, 2007; Koenen, 2007).
In summary, risk factors for development of PTSD can be broadly categorized as
those which set up disorganized attachment or psychopathology in childhood; those that
inhibited the formation of effective coping strategies and/or a network of coping alliances
in adulthood; sociocultural and socioeconomic factors that overwhelmed existing adult
coping resources and strategies; and victimization and exposure to traumatic events. The
most significant risk factors for formation of PTSD were a history of victimization and
exposure to a traumatic stressor. The next section details treatment options for PTSD.
Treatments for PTSD
There are a number of treatments for PTSD of varying efficacy. A convenient way
of categorizing PTSD therapy has been by labeling the approach as either past-focused,
where the clinician and client explore the traumatic stressor and its context during
therapy, or present-focused, where the clinician avoids discussion of the trauma, electing
instead to focus on coping strategies to reduce distressing symptoms. Critics of past-
focused treatments have stated that this approach may destabilize certain fragile patients
by repeated exposure to terrifying traumatic events (Najavits, 2007). Detractors of past-
focused therapy also maintain that a high rate of patients do not complete treatment
32
because they want to avoid further exposure to their traumatic stressor (Cahill et al.,
2006) and drop out of lengthy treatment for time or cost reasons (Najavits, 2006; 2007).
Najavits (2002a) found that many therapists preferred to use present-focused therapies
because they were easier for clinicians to master and less likely to cause client
destabilization. Individual PTSD therapies are discussed below.
Past-Focused Therapies
Past-focused treatments for PTSD commonly have included graduated in vivo
(real-life) and imaginal exposures to trauma-relevant cues to promote emotional
processing and insight in the victim (Foa & Kozak, 1986; Keane and Kaloupek, 1996).
While in vivo exposure therapy is possible, such as using a live snake to treat a person
with herpetophobia, the mechanics of the process have been unwieldy and have the
potential to overwhelm the client (Davies & Janosik, 1991). Thus, the most used of the
past-focused psychotherapies has been imaginal exposure therapy (Foa & Kozak, 1986;
Substance Abuse and Mental Health Services Administration, 2003) and prolonged
exposure or flooding (S.P. Cahill et al., 2006; Foa, Hembree, & Rothbaum, 2007; van
Minnen & Foa, 2006). The initial objective of exposure therapy has been to identify the
client’s internal and external cues that elicit high anxiety; then anxiety resulting from
therapeutic exposure can be extinguished by saturation through prolonged exposure to the
feared stimulus situation or its substitute (Bremner & Marmar, 1998). Flooding is a more
intense variant of exposure therapy, developed after some researchers concluded that
more intense exposure to the feared object or traumatic scenario was needed for greater
success (Bremner & Marmar, 1998).
33
In 2010, the Veterans Administration nationally disseminated two evidence-based
psychotherapies for PTSD throughout the VA health care system (Karlin et al., 2010).
The two therapies were cognitive processing therapy, an information processing theory of
PTSD developed for victims of sexual assault that included education, exposure, and
cognitive components, as well as prolonged exposure therapy (Foa, Hembree, and
Rothbaum, 2007; Resick & Schnicke, 1992). These two therapies, which both contain
past-focused features, are now considered to be first-line treatment protocols for victims
of combat PTSD. Preliminary evaluation for initiation of the two therapies indicated
significant positive effects on patient outcomes as a result of implementation of the
therapy (Karlin et al., 2010). Initial evaluation data revealed an overall average decline of
approximately 30% (or 20 points) in PTSD Checklist (Weathers, Litz, Herman, Huska, &
Keane, 1993) scores among treatment completers, with similar results for cognitive
processing therapy (28%; N = 93) and prolonged exposure therapy (33%; N = 381).
Systematic desensitization, another type of therapy, has combined exposure to a
traumatic stressor with behavioral therapy to treat maladaptive anxiety in response to a
stimulus (Davies & Janosik, 1991; Dewey, 2007; Wolpe, 1958, 1962). The process of
extinction, in which a client faces a stimulus without feared consequences, has been used
to weaken and eventually extinguish an anxiety response (Wolpe, 1958). Although the
extinction method has been found to work for patients with low to moderate levels of
anxiety, clients with high levels of anxiety have been unwilling to expose themselves to
the stimulus long enough for extinction to occur (Davies & Janosik, 1991).
Systematic desensitization became more successful when the processes of
counterconditioning and deep muscle relaxation were added (Davies & Janosik, 1991;
34
Davis & Palladino, 1997; Dewey, 2007; Wolpe, 1958, 1962). Counterconditioning has
helped the client associate a new antagonist response to replace the anxiety response; it
was based on the principle of reciprocal inhibition (Wolpe, 1958). Unlike desensitization,
counterconditioning did not provoke a client’s avoidance behaviors, facilitated the
patient’s likelihood to interact with feared objects, and accelerated the extinction process
(Davies & Janosik, 1991). Wolpe (1958) also incorporated deep muscle relaxation
procedure because he believed that the relaxation response did not support concurrent
anxiety (Davis & Palladino, 1997). By directing the client to methodically tighten and
loosen various muscle groups in the body, the therapist could achieve physiological, and
subsequently, psychological relaxation (Davies & Janosik, 1991).
A variant of exposure therapy is eye movement desensitization and reprocessing
[EMDR], an integrative dual-stimulus psychotherapy approach during which the client
reprocesses disturbing past experiences and traumatic memories (Cahill, Carrigan, &
Frueh, 1999; EMDR Institute, 2009; Lee, Gavriel, Drummond, Richards, & Greenwald,
2002; Rothbaum, Astin, & Marsteller, 2005; Shapiro, 1995). During dual stimulation, the
therapist uses bilateral eye movements, tones, or taps as an external stimulus while the
client summons and dwells on past memories, present triggers, or anticipated future
experiences. The external stimulus during the reprocessing treatment has been reported to
aid the client in experiencing insight, changes in memories, or aid formation of new,
more pleasant associations (Devilly & Spence, 1999; EMDR Institute, 2009; Shapiro,
1995).
The most recently used past-focused therapy has been virtual reality (VR)
technology, in which computer graphics, sound, and sensory input such as haptics (touch)
35
have been integrated to create interactional computer-generated environments (Gregg &
Tarrier, 2007; Rothbaum, Hodges, & Kooper, 1997; Rothbaum, Hodges, Watson,
Kessler, & Opdyke, 1996). Through lifelike imagery, VR therapy resembles in vivo
exposure therapy, by immersing the client in a virtual world (Bricken, 1991).
Psychotherapists have found VR to be a valuable alternative to imaginal exposure in
situations where a client has had difficulty relying on internal imagery or visualization
(Gregg & Tarrier, 2007). In addition, VR has been used to treat PTSD since it can
recreate situations that cannot be re-experienced in vivo, such as combat situations or
terrorist attacks. As with phobic patients, VR-based exposure therapy may be useful for
patients with PTSD for whom avoidance and failure to engage with therapy may hinder
progress (Gregg & Tarrier, 2007).
A promising past-focused therapy involving the use of the beta blocker propranolol
has been recently supported in a randomized, double-blind trial. The drug, given within
hours of a psychologically traumatic event, has been shown to reduce physiologic
responses during subsequent mental imagery of the event (Brunet et al., 2008).
Physiologic responses were significantly smaller in the subjects who had received post-
reactivation propranolol a week earlier.
In summary, past-focused techniques have been successfully used to treat the
distressing signs and symptoms of anxiety related to PTSD. The drawbacks of exposure
therapies have typically included the reluctance of patients to expose themselves to a
traumatic stressor and subsequent treatment compliance (Cahill et al., 2006) and the
lengthy amount of time required for exposure therapy to succeed, often a year or more of
intensive treatment (Bremner & Marmar, 1998; Wolpe, 1958, 1962). Although exposure
36
therapy can be beneficial, it has not been frequently used by many psychotherapists
because of inadequate training in the method and concerns that fragile patients will
decompensate (Cahill et al., 2006). Lately this belief has been challenged. Evaluation of
the new VA treatment protocols indicated that clinician fears of retraumatization among
exposure therapy participants were not realized during therapy (Karlin et al., 2010). Of all
past- and present-focused therapies, exposure therapy has been found to be the most
efficacious in treatment of anxiety, phobias, and PTSD (Committee of Treatment of
Posttraumatic Stress Disorder of the Institute of Medicine, 2008; Foa et al., 1999).
Present-Focused Therapies
In present-focused therapy models for PTSD, the client learns coping skills to
improve functioning (e.g., social skills, relaxation, grounding, and cognitive
restructuring) and ultimately obtain symptom relief from the distressing anxiety
associated with PTSD (Najavits, 2006). Foremost among present-focused treatment
modalities has been cognitive-behavior therapy (CBT), a psychotherapeutic approach to
change dysfunctional emotions, behaviors, and cognitions through a goal-oriented,
systematic procedure (Green, Oades, & Grant, 2006; Leichsenring, Hiller, Weissberg, &
Leibing, 2006; Mohr, 2005). CBT is often brief and solution focused, with the patient
providing insight and self-direction (Najavits, 2006; Rachman, 1997).
Another method used has been rational emotive behavior therapy, an action-
oriented psychotherapy that teaches individuals to examine their own thoughts, beliefs
and actions and replace those that are self-defeating with more life-enhancing alternatives
(Albert Ellis Institute, 2009; Weinrach, 2006; Weinrach et al., 2006). For clients with a
co-occurring diagnosis of borderline personality disorder and an associated risk of
37
suicide, dialectical behavior therapy may be used (Lynch, Chapman, Rosenthal, Kuo, &
Linehan, 2006). Dialectical behavior therapy combines traditional cognitive behavior
techniques for emotion regulation and reality testing with the concepts of mindful
awareness, distress tolerance, and acceptance (Linehan, Heard, & Armstrong, 1993).
Other present-focused therapies that may be employed include stress inoculation
therapy, where patients prepare themselves in advance to handle stressful events. Stress
inoculation therapy was based on the concept that a therapist “inoculates” a patient to
become resistant to the effects of stressors in a manner similar to a vaccination used to
ward off disease (Jaycox, Foa, & Morral, 1998; Meichenbaum, 1996; O'Donohue, Fisher,
& Hayes, 2003). Also gaining favor in PTSD communities where patients are likely to
carry a dual-diagnosis of alcohol or substance abuse has been Seeking Safety, a program
combining grounding therapy and extensive case management (Najavits, 2004b). Seeking
Safety has been said to reduce the cognitive rigidity common to PTSD and substance
abuse (Najavits, 2002b). Seeking Safety has the following primary components: safety as
the client overarching goal; integrated treatment of both PTSD and substance abuse; a
focus on ideals to counteract the loss of ideals in both PTSD and substance abuse; four
content areas: cognitive, behavioral, interpersonal, case management; and attention to
clinician processes such as countertransference and self-care (Najavits, 2004b).
Another present-focused therapy that has been proved useful for the client inertia
associated with the depression that often accompanies chronic PTSD is behavioral
activation. An outgrowth of both cognitive and behavioral therapies, behavioral
activation is a brief, structured, highly individualized treatment for depression that aims
to reactivate clients in specific ways that will increase rewarding experiences in their
38
lives (Martell, Dimidjian, & Herman-Dunn, 2010). Behavioral activation’s specific goals
are to increase the patient’s activation and engagement in his or her own life. Behavioral
activation focuses on processes that inhibit activation, such as escape and avoidance
behaviors.
Of the present-based therapies, treatments containing cognitive-behavioral
therapies as a significant component may most help traumatized individuals understand
and manage the anxiety and fear associated with trauma-related stimuli (Bonanno, 2004;
Resick, 2001). However, the Committee on Treatment of Posttraumatic Stress of the
Institute of Medicine [IOM] (2008) contradicted this opinion. The IOM Committee stated
in its review of PTSD treatments that only exposure therapy, which is a past-focused
treatment, was found to be efficacious using strict evidence-based practice criteria. No
present-focused treatments or combination therapies met IOM criteria for
recommendation, primarily because of irregularities in research methodology. The
committee recommended that researchers identify and employ methods that will improve
the internal validity of the research, with particular attention to standardization of
treatment and outcome measures, follow up of individuals dropping out of clinical trials,
and handling of missing data. The IOM also noted that studies on PTSD interventions
have not “systematically and comprehensively” addressed the needs of veterans with
respect to efficacy of treatment and the comparative effectiveness treatments in clinical
use (p. 3). However, integrated treatment combining prolonged exposure therapy,
cognitive-behavior therapy, couples/family therapy, and pharmacotherapy have been
showing promise and will likely be employed in the future (Cukor, Olden, Lee, & Difede,
2010).
39
Summary of PTSD etiology, risk factors, and treatments. The development of
PTSD has been related not only to risk factors but also to events that occurred during and
after exposure to trauma; failure to recover from PTSD has been related primarily to
factors that occurred during and after the traumatic event (D. W. King et al., 1999; L. A.
King et al., 1998; Schnurr, Lunney, & Sengupta, 2004; Schnurr, Lunney, Sengupta, &
Waelde, 2003). Of all associated variables, the single most influential variable for PTSD
has been the traumatic event itself. D. W. King et al. (1999) theorized that the underlying
mechanism by which pretrauma factors related to PTSD symptomology reflected the
victim’s depletion of available resources to deal with subsequent stressors in the post-
trauma and recovery periods. In summary, pretrauma risk factors were not as salient
predictors of PTSD as were the trauma stressors, which were the most potent variables,
followed by availability of structural and functional social support (D. W. King et al.,
1999; L. A. King et al., 1998).
The following sections will examine the concept of recovery, its relationship to
PTSD, and relevant mental health literature detailing recovery from chronic mental
illness. The discussion has included both individual and institutional conceptualizations
of recovery. Mental health models depicting the recovery process will also be described.
Recovery: Mental Illness and PTSD
The meaning of the concept of recovery as it is used in health care has varied
greatly depending on context. Two widely accepted medical definitions stated that
recovery is “the act of retaining or returning toward a normal or healthy state” (Merriam-
Webster, 2010) and “gradual healing after sickness or injury” (Princeton University,
2010). Medical definitions commonly have denoted that recovery represents the act of
40
regaining or preserving a state of physical health that has been endangered. However,
physical illnesses have not been the only ailments afflicting human health. With
psychological disorders, it has been more difficult to determine whether a former state of
health has been recovered, especially since there were frequently no visible signs of
healing.
Because so little has been written describing recovery from PTSD, I decided to
examine a particularly strong body of literature that described recovery from serious
mental illness to search for recovery themes. This topic was selected because it seemed to
be roughly analogous to PTSD regarding chronicity of symptoms and degree of difficulty
in recovery. Professionals in the field of psychiatric rehabilitation, where practitioners
concentrate on the treatment and stabilization of persons with chronic mental illnesses,
have engaged in a spirited debate during the past decade on the concept of recovery as it
applies to their discipline and clients.
It is interesting to note that the greatest impetus for change within the mental health
system of the United States came from mental health consumers themselves. Starting in
the 1980s, consumers/survivors who had serious mental health illnesses such as
schizophrenia started publishing accounts of their individual pathways to recovery
(Andresen, Oades, & Caputi, 2003; Onken, Craig, Ridgway, Ralph, & Cook, 2007). Prior
to that time, the diagnosis of a severe mental illness doomed the patient to an unsatisfying
and unproductive life. Since then, consumers, aided by sympathetic therapists, family
members, and supportive peers have campaigned to remove the perception that a severe
mental illness predicts a long-term course of deterioration (Andresen et al., 2003;
41
Anthony, 1993). As discussed below, the consumer movement changed health policy
regarding chronic mental illness.
Policy Perspective on Recovery from Mental Illness
The discussion over mental illness and the emergence of a recovery vision for
chronic mental illness arose during the late 1980s and early 1990s. Seminal influences
were the de-institutionalization of the mentally ill, the physical disability movement,
resultant laws on disability rights and anti-discrimination, and the civil rights movements
of the 1960s and 1970s (Bonney & Stickley, 2008). In 2004, the Substance Abuse and
Mental Health Services Administration (SAMHSA) convened six federal agencies and
110 expert panelists, including mental health professionals and consumer stakeholders, to
craft a definition of mental health recovery. The resulting definition stated:
Mental health recovery is a journey of healing and transformation enabling a person
with a mental health problem to live a meaningful life in a community of his or her
choice while striving to achieve his or her full potential. (SAMSHA, 2005, p. 2)
The panel also agreed upon ten fundamental components of mental health recovery:
self-direction, individualized and person-centered; empowerment; holistic; non-linear;
strengths-based; peer support; respect; responsibility; and hope. Thus, recovery became a
term referring to proactively taking charge of one’s life and illness, in moving beyond the
chronicity of debilitating mental illness (McLean, 2003). Recovery also signified change
enacted through empowering efforts to become self-reliant and satisfied in personal
relationships and productive activities.
There were some countervailing efforts to ignore the consumer-driven movement.
These attempts primarily came from biomedically centered psychiatrists, family
42
advocates, and the pharmaceutical industry, which had been operating from a “deficiency
orientation” (Onken et al., 2007). Despite these negative influences, in accordance with
the President’s New Freedom Commission on Mental Health of 2003, the national mental
health system became revamped to create access and integration of services oriented to
recovery and consumer and family preferences (McLean, 2003; SAMHSA, 2005)
Later in 2005, the American Psychiatric Association endorsed and “strongly
affirmed” the SAMSHA panel’s work (APA, 2005). The APA statement noted:
The concept of recovery emphasizes a person’s capacity to have hope and lead a
meaningful life and suggests that treatment can be guided by attention to life goals
and ambitions…. The concept of recovery has a long history in medicine and its
principles are important in the management of all chronic disorders. (p. 1)
The policy statement also pointed out that the concept of recovery enriched and
supported traditional medical and rehabilitation models. In addition to the shifting
viewpoint of public perception, the consumer vision of the recovery process changed
dramatically, as discussed in the next section.
Consumer Conceptualization of the Process of Recovery
Consumer-driven discussion generated a new ecological paradigm of recovery that
contained distinct values, beliefs, practices, and terminology (Onken et al., 2007). The
definitions of recovery that resulted came from philosophical perspectives, grounded
theory, lived experience, and qualitative and quantitative research. Definitions were
shaped by converging viewpoints (i.e., recovery as a vision, outcome, or process).
One definition of recovery advanced by consumers has been psychological
recovery from the consequences of the illness, such as schizophrenia (Andresen et al.,
43
2003). Frequently, recovery has not been seen as an outcome or end state, but rather as a
process, distinct from a cure (Roberts, 2008; Roe, Rudnick, & Gill, 2007). However,
recovery has not always resulted in the person’s return to a prior state of functioning
(Beeble & Salem, 2009; Spaniol, Wewiorkski, Gagne, & Anthony, 2002). As Craig
(2008) noted, the concept of recovery has been redefined from the narrow perspective of
the absence of symptoms to a broader focus on the retention and development of
function. More specifically, contemporary consumer and psychiatric rehabilitation
literature has not maintained that either symptom remission or a client’s return to
premorbid functioning has been necessary for recovery to occur (Farkas, 2007).
Many researchers have situated recovery as a response by an individual to the
disorder. Anthony (1993) described recovery as ‘‘a deeply personal, unique process of
changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a
satisfying, hopeful, and contributing life even with limitations caused by illness” (p. 15).
Today’s definition of recovery also signified a change in professional responses to
chronic mental illness. According to Craig (2008), the treatment emphasis for therapists
has changed to “collaboration and choice rather than coercion, the positive reinforcement
of success rather than the punishment of failure, and a shared involvement with
professionals in how the service is provided” (p. 126). Davidson and White (2007)
expanded the mental illness recovery concept to include addictions. Their definition was
that recovery referred to the ways in which persons with or impacted by a mental illness
and/or addiction can experience and actively manage the disorders and their residual
effects in the process of reclaiming full, meaningful lives in the community.
44
Much discussion has also occurred concerning the provider role in mental health
recovery. Davidson, O'Connell, and Tondora (2006) addressed physician and provider
concerns that traditional cures have not been developed for mental illness by pointing out
the following:
When the illness is most severe, people who have disabling disorders have no
choice but to live in the face of them. This is the reality that takes priority in
recovery-oriented care…. In the past we have been immobilized by our lack of a
cure, and we have conveyed a message of hopelessness to our clients and
segregated people in artificial settings, expecting them to be cured before rejoining
community life. This contradiction has led to demoralization, despair, and
dependency. (p. 1510)
Davidson and White (2007) further delineated recovery-oriented care as comprising
the services psychiatric, addiction, and rehabilitation practitioners offer in support of the
client’s and family’s own long-term recovery efforts. The authors viewed recovery and
recovery-oriented care as complementary concepts, rather than as being mutually
exclusive. Despite some concurrence on the recovery and provision of recovery-oriented
care, the concept of recovery in mental illness has been criticized by some. In particular,
the concept of recovery has been disparaged for not being sufficiently evidence based
(Remington & Shammi, 2005), lacking a shared operational definition based on empirical
research (Liberman & Kopelowicz, 2005), and setting unrealistic expectations for some
consumers (Masland, 2006).
Through qualitative inquiry with patients with severe mental illness, researchers
have been able to parse out some of the reoccurring themes of recovery as viewed by the
45
consumer and validated by health care providers. Having discovered these themes and
their meaning and relevance to consumers, researchers have assembled conceptual
theories of the recovery process for chronic mental illness. Both the core themes and
resulting theories have been discussed in the following sections.
Core Themes of Recovery from Mental Illness
When recovery has been framed as an ongoing process rather than a medical
outcome, certain patterns of beliefs, behaviors, sequenced tasks, and relationships have
emerged. Andresen et al. (2003) identified four key processes of recovery relating to
patient locus of control: finding hope, re-establishment of identity, finding meaning in
life, and taking responsibility for recovery (pp. 589-590). Davidson and White (2007)
listed nine common elements of mental health and addiction recovery pertaining to client
management of the disorder and interaction with his or her support persons: (1) becoming
an empowered and contributing citizen of one’s community; (2) addressing and
overcoming stigma, promoting positive views of recovery; (3) assuming increasing
responsibility over one’s life; (4) incorporating illness, and maintaining recovery,
including managing symptoms and triggers; (5) understanding, redefining and accepting
self, including accepting the central role of others; (6) discovering or re-inhabiting a
valued niche or social role among family, friends, and peers; (7) renewing hope,
confidence, and commitment; (8) beginning of a sense of responsibility for and/or
determination in initiating recovery; and (9) feeling cared for, accepted, and supported by
trusting and trustworthy others (p. 115). Davidson and White noted that that some aspects
of recovery coincided or coexisted with other factors, whereas other aspects occurred
alone.
46
Onken et al. (2007) developed a dimensional analysis of the recovery literature and
characterized the recovery environment and process as multidimensional, fluid,
nonsequential, and complex. The authors noted that recovery permeated the life context
of the individual, with some elements linked primarily to the individual and others to the
community to provide resources and opportunities to individuals. According to Onken et
al., community-centered elements of recovery have occurred when an environment
provided the individual with opportunities and resources for new or resumed social roles,
engagement in relationships with others, and meaningful integration in the larger society.
Some core community themes in the recovery literature included social connectedness
and relationships; social circumstances and opportunities; integration into the
community; and realizing recovery.
After reviewing the British literature on mental health recovery, Bonney and
Stickley (2008) discovered six dominant themes comprising both internal and public
roles of the mentally ill individuals. From reviewing the literature, Nosieux et al. (2009)
discovered seven empirical interpersonal conditions or indicators in the recovery process.
Brown, Rempfer, and Hamera (2008) used the self reports of individuals experiencing
mental illness in a phenomenological study that also used psychometric instruments to
measure recovery. Brown et al. (2008) looked at both the “insider” (emic) perspective
and used objective measurements with clinicians and researchers to obtain the “outsider”
(etic) perspective. The purpose of this study was to examine the relations among insider
(hope and empowerment) and outsider (symptoms and cognition) variables of recovery.
The results suggested that there were relationships between the two conceptualizations in
47
that symptoms and cognition were associated with some aspects of hope and
empowerment.
Although qualitative research with its rich description of client experience has been
the predominant research method used to discover factors related to recovery from mental
illness, efforts have also been directed at quantitative measures. The Recovery
Assessment Scale (RAS), a widely used self-report scale of the mental illness recovery
process, has also been used in various recovery-oriented interventional studies and cross-
sectional analyses (Chiba, Miyamoto, & Kawakami, 2010). The RAS asks the client to
self-rate five personal characteristics on each item. The 24-item RAS scale and the 41-
item version, have proved to have high internal consistency reliability and validity with a
Cronbach’s alpha coefficient of 0.89 for the overall RAS. Intraclass correlation
coefficient and weighted kappa indicated good test–retest reliability, as measured by
positive and significant correlations with recovery concepts such as hope, empowerment,
and quality of life (Chiba et al., 2010; Corrigan, Salzer, Ralph, Sangster, & Keck, 2004).
Herman (1997)was one researcher who examined the experiences and recovery of
rape victims suffering PTSD. She discovered a number of psychological themes
mentioned by rape victims that paralleled the DSM-IV-TR diagnostic criteria for PTSD.
These themes included terror, hyperarousal, and intrusion among others.
In summary, the core themes of recovery from mental illness can be viewed from
two perspectives: the individual and society. For the individual, chronic mental illness
has contained such themes as despair and depression, grappling with the diagnosis,
finding appropriate support, discovery of a new self, and eventual emergence as a
functional person able to cope with the disease and its demands. Societal issues often
48
examined unequal power between the client and provider, access to resources, connection
with the community, and availability of social support. The core themes of recovery are
depicted in detail in Table 2.2.
In addition to discovering universal themes of recovery in mental illness, some
researchers have detected patterns in their analyses and have constructed explanatory
models of recovery from mental illness. Many of these models attempted to establish a
chronological order of recovery from mental illness. These conceptual models have been
discussed in the following section.
Conceptual Models of Recovery from Mental Illness
There are a number of models that attempt to describe the process of recovery from
mental illness. Davidson and Strauss (1992) built a four-stage conceptual model of
recovery. The focus of the model was reconstruction of the sense of self during the
recovery process. Heavily influenced by conceptual models of loss, Baxter and Diehl
(1998) developed a three-stage model of mental illness recovery focusing on an
individual moving forward from a crisis state. The final stage culminated in awakening to
a restructured “personhood” and building health interdependence with others.
Pettie and Triolo (1999) proposed a two-step process in reconstructing personal
identity. The first step of the process was answering the question, “Why me?” This step
was closely followed by a quest to determine the meaning of the illness to the person.
The second step was answering the question, “What now?” In this stage, the person
developed a new identify and more positive sense of self.
From their qualitative study, Young and Ensing (1999) discovered a three-stage
interpersonal model of recovery from psychiatric illness. The first of the three main
49
Table 2:2
Core Themes of Recovery from Mental Illness
References Research Sample Core Themes of Recovery
Andresen, Oades, & Caputi (2003) Analyzed 89 articles from Medline, PsycInfo, and Finding hope
Cinahl databases for keywords/ combinations: Re-establishment of identity
recovery; schizophrenia/mental illness/disorder; Finding meaning in life
psychiatric/psychosis/psychotic; consumer/first Taking responsibility for recovery
person/experiential; subjective or personal.
Davidson and White (2007) Extensive review of the recovery literature Becoming an empowered and contributing
citizen of one’s community
Addressing and overcoming stigma,
promoting positive views of recovery
Assuming increasing responsibility over
50
one’s life
Incorporating illness, and maintaining
recovery, including managing symptoms and
triggers
Understanding, redefining and accepting
self, including accepting the central role of others
Discovering or re-inhabiting a valued niche
or social role among family, friends, and peers
Renewing hope, confidence, and
commitment
Beginning of a sense of responsibility for
and/or determination in initiating recovery
Feeling cared for, accepted, and supported
by trusting and trustworthy others.
Table 2:2
Core Themes of Recovery from Mental Illness (continued)
Onken, Craig, Ridgway, Ralph & Cook (2007) Extensive review of the recovery literature Hope or the expectation of better
circumstances
A sense of agency
Self-determination
Meaning and purpose
Awareness and potentiality
Re-authoring elements of recovery
Coping
Healing
51
Wellness
Thriving
Social functioning and social roles
Power
Choice among meaningful options
Social connectedness and relationships
Social circumstances and opportunities
Integration into the community
Realizing recovery
Bonney and Stickley (2008) Review of more than 170 articles in British Identity
literature Service provision agenda
Social domain
Power and control
Hope and optimism
Risk and responsibility
Table 2:2
Nosieux, Tribble, Leclerc, Ricard, Corin, Interviews with schizophrenics, family members, Experience of schizophrenia
Morissette, & Lambert (2009) and care providers Descent into hell
Igniting a spark of hope
Process of introspection
Activating the instinct to fight back
Discovering keys to well-being
Capacity to manage the unequal interplay
between internal and external forces
Seeing light at the end of the tunnel
52
Brown, Rempfer, and Hamera (2008) Self reports of individuals experiencing mental Insider:
illness in a phenomenological study Hope
Empowerment
Outsider:
Symptoms
Cognition.
Chiba, Miyamoto, & Kawakami, 2010 Self-report scale of the recovery process for people Personal confidence and hope
with mental illness; has been used in various Willingness to ask for help
recovery-oriented interventional studies and cross- Goal and success orientation
sectional analyses Reliance on others
Lack of domination by symptoms
Table 2:2
Rape recovery:
Herman (1997) Experiences and recovery accounts of victims Terror

suffering posttraumatic stress from rape Hyperarousal
Intrusion
Constriction
Disconnection
Vulnerability
Social support
53
Captivity
Total surrender
Child abuse
Healing relationship
Reconnection
Commonality
stages was initiating recovery, which involved acceptance of the illness and finding hope
and the desire to change. The second stage was regaining what was lost and moving
forward, which included the tasks of taking responsibility, redefining self, and returning
to basic functioning. The final stage was improving quality of life, which encompassed
an overall sense of well-being and quest for new potential. Their analysis of numerous
accounts by consumers who described themselves as “being in recovery” suggested a
number of key conditions in the process. In the model, the word recovery referred both to
internal conditions, such as the attitudes, experiences, and processes of change of
individuals who were recovering, and external conditions (e.g., the circumstances, events,
policies, and practices that facilitated recovery). Together, internal and external
conditions produced the process called recovery.
After conducting a longitudinal qualitative study with clients with schizophrenia,
Spaniol, Wewiorkski, Gagne, and Anthony (2002) constructed a four-phase conceptual
model of recovery. Phase one occurred when the person was confused and overwhelmed
by the disability. During the second phase, the person struggled with the disability. In the
third phase, the client began to live with the disability. The fourth and final phase was
labeled as living beyond the disability where the person developed a sense of contributing
to a life unrestricted by the disability. In this final stage, the client had developed a sense
of meaning and purpose to his or her life.
Drawing from clinical observations, consumer groups, and consumer-professional
interactions, Noordsy et al. (2002) constructed a three-part model describing recovery.
The three components consisted of hope; taking personal responsibility for illness
management, and wellness; and “getting on with life” beyond illness. The authors stated
54
that their definition of recovery was structured into three core concepts or criteria that can
be operationalized and measured. Noordsy et al. also noted that while consumers made
changes in each of these areas as part of their process of recovery, the changes did not
necessarily occur in a sequential order. Behavioral, developmental, and interpersonal
aspects of recovery included active involvement in treatment, pursuit of a healthy
lifestyle, developing relationships, and work.
After conducting a phenomenological study of narratives of schizophrenia,
Davidson (2003) constructed a model that emphasized self-efficacy, belonging, and
reciprocity/social agency. Davidson found that better social functioning was protective
against the negative effects of depression in serious mental illness. He suggested that
services targeting social functioning and social support could be beneficial in restoring
function to clients. After an extensive review of consumer-written accounts of recovery
from schizophrenia, Andresen, Oades, and Caputi (2003) constructed a five-stage model
which ended in personal growth as an adaptive response. In the final stage, the person
may not have been totally symptom free but considered him- or herself responsible for
managing the illness and taking control of life.
Using data from a large, systematic study of schizophrenia, Resnick, Fontana,
Lehman, and Rosenheck (2005) identified items reflecting recovery themes and
measuring aspects of subjective experience, and used principle components and
confirmatory factor analyses to develop an empirical conceptualization of the recovery
orientation. Resnick et al. suggested that there was a bidirectional relationship between
recovery attitudes and the positive clinical outcomes that are the goals of evidence-based
practice. In a qualitative study, using narrative phenomenological methods, Borg and
55
Davidson (2008) explored the nature of recovery as a social process situated in everyday
life. The authors attempted to capture both the simplicity as well as the complexity of the
daily life experiences of people in recovery from serious mental illnesses. The resulting
model identified four areas of everyday life experiences in recovery.
Through their research with members of the mutual self-help group Schizophrenics
Anonymous, Beeble and Salem (2009) developed a four-stage model describing the
phases of recovery. The authors also sought to understand group mechanisms by
measuring the contributions of referent and expert power to group work. Referent power
was defined as social influence based on one’s sense of identification with and attraction
to another person or group and willingness to identify with and adopt the values and
norms of the individual or a group. Expert power was determined to be assistance
received from professionals. Beeble and Salem discovered that participants varied in their
experiences of expert power, referent power, and recovery; the phases of the recovery
process were differentially predicted by expert and referent power; and these
relationships differed by the member’s role within the group.
Finally, there was one model that was more connected with post-trauma recovery
than the other mental health models. Herman (1997), a psychiatrist who has treated rape
survivors, constructed a three-stage process of recovery from sexual assault derived from
accounts given by students, colleagues, patients, and research subjects. Herman cautioned
that the stages of her model were not to be taken too literally: “They are an attempt to
impose simplicity and order upon a process that is inherently turbulent and complex….
No single course of recovery follows these stages through a straightforward linear
sequence” (p. 155). Herman stated that one therapist described the progression through
56
the stages of recovery as a spiral, in which earlier issues “are continually revisited on a
higher level of integration” (p. 155). The various models of recovery from serious mental
illness and their component stages described in this section are summarized in Table 2:3.
Summary of mental health conceptual models. The core themes of recovery
from serious mental illness—despair and depression over the diagnosis, the struggle to
regain health while locating structural and functional social support, difficulty regaining
balance in one’s life, and ultimately developing a new post-illness self-concept—were
strongly echoed in the theoretical models. Likewise, the models considered the insider
(individual) and outsider (societal or institutional) points of view regarding power
inequalities between client and provider, resource allocation, and community support.
The models differed, however, as to the progression of recovery. Several models
conceptualized recovery as a linear process, while other models viewed the path to
recovery as a circular process where the patient periodically revisited past stages on the
way to recovery.
While the diagnosis of a chronic mental illness such as schizophrenia differed
significantly from that of PTSD, there were likely some common recovery elements. Like
schizophrenia, PTSD is a chronic mental health disorder, whose symptoms often persist
for many years; the severity of PTSD symptoms can be extreme, with many patients
reporting significant and/or permanent disruption in their lives; and the struggle to
negotiate therapies that yield an acceptable quality of life for both disorders can be
difficult. Finally, as with PTSD, individuals with chronic mental illness have their lives
changed permanently. PTSD recovery elements will be discussed in the next section.
57
Table 2:3
Conceptual Models of Recovery from Mental Illness
References Research Sample Conceptual Model Components
Davidson & Strauss (1992) Qualitative analysis of consumer accounts. 1.Discovering the possibility of a more active sense of
self.
2.Taking stock of one’s strengths and limitations.
3.Putting aspects of the self into action.
4.Using the enhanced sense of self as a recovery resource.
Baxter & Diehl (1998) This model was constructed using a two-step 1.Crisis, followed by recuperation accompanied by denial,
method. First, a questionnaire was developed confusion, and despair.
based on constructs in the recovery literature. 2.The decision to get going, which included rebuilding
life roles, suffering setbacks, and developing a more
A convenience sample of 40 consumers was
integrated sense of self.
interviewed face-to-face. Using content analysis,
3.Awakening to a restructured “personhood” and building
responses were condensed into a suggested
58
health interdependence with others.

model involving three psychological “events,”
each followed by a stage.
Pettie & Triolo (1999) Examination of brief case studies and patient 1.Answering the question, “Why me?” followed closely
profiles for common themes. by a quest to determine the meaning of the illness.
2.Answering the question, “What now?” and then
developing a new identify and more positive sense of self.
Young & Ensing (1999) Eighteen people with psychiatric disabilities 1.Initiating recovery, which involved acceptance of the
participated in individual interviews or focus illness and finding hope and the desire to change.
group discussions. A semi-structured qualitative 2.Regaining what was lost and moving forward, which
interview guide of eight primary questions to includes the tasks of taking responsibility, redefining self,
explore the recovery construct from the and returning to basic functioning.
consumers' perspective was used. 3.Improving quality of life, which encompassed an overall
sense of well-being and quest for new potential.
Table 2:3
Conceptual Models of Recovery from Mental Illness (continued)
Jacobson & Greenley (2001) An analysis of numerous accounts by consumers 1.Hope

of mental health services who describe 2.Empowerment
themselves as “being in recovery” or “on a 3.Healing
journey of recovery”. 4.Connection
Spaniol, Wewiorkski, Gagne, & A qualitative, longitudinal analysis to identify 1.Confusion and being overwhelmed by the disability; out
Anthony (2002) themes associated with improvement in of control, lacking confidence, and feeling disconnected
functioning and subjective experience. Twelve from others.
individuals with a diagnosis of schizophrenia or 2.Struggling with the disability. Finding an explanation
schizoaffective disorder were randomly selected for the disorder, learning to cope, fearing failure, and
and followed for four years. Every four to eight building strengths.
months each person participated in a semi- 3.Beginning to live with the disability. Managing,
59
structured, audiotaped interview about his or her developing a stronger sense of self, finding meaningful
current life experiences. Tapes were evaluated roles, and building a satisfying life within the limitations
independently by three assessors for themes and of the illness.
phases that emerged from these life experiences. 4.Living beyond the disability and contributing to a life
unrestricted by the disability. Developing sense of
meaning and purpose to life.
Noordsy, Torrey, Mueser, Mead, Define recovery from severe mental illness: 1.Hope
O'Keefe, & Fox (2002) hope, self-responsibility and “getting on with 2.Taking personal responsibility for illness management,
life” beyond illness. Each criterion can be and wellness
measured at the intrapsychic-subjective, inter- 3.“Getting on with life” beyond illness
personal- behavioral, and environmental levels.
Criteria were measured using Beck Hopeless-
ness Scale, Locus of Control Questionnaire,
instrumental and social role functioning scales,
and subjective ratings of quality of life.
Table 2:3
Davidson (2003) Qualitative, phenomenological study of 1.Self-efficacy

schizophrenic consumers; from the research 2.Belonging
viewpoint of Husserl 3.Reciprocity/social agency
Andresen, Oades, & Caputi Analyzed 89 articles from Medline, PsycInfo, 1.Moratorium, a state characterized by denial, confusion,
(2003) and Cinahl databases for keywords/ hopelessness, identify confusion, and self-protective
combinations: recovery; schizophrenia/mental withdrawal.
illness/disorder; psychiatric/psychosis/psychotic; 2.Awareness, where the client began to hope that life
consumer/first person/experiential; subjective or would become better and recovery was attainable.
personal. Used themes to develop model faithful 3.Preparation, where the client resolves to start work on
to consumer recovery experiences. recovery.
60
4.Rebuilding, a difficult stage where the client set and

worked toward valued goals.
5.Growth, the outcome of the process where the person
may not be totally symptom free but considers him- or
herself responsible for managing the illness and taking
control of life.
Resnick, Fontana, Lehman, & Data for the current study were derived from a 1.Empowerment
Rosenheck (2005) random sample of people with schizophrenia in 2.Hope
Ohio, Georgia, and a VA hospital for a total 3.Optimism,
sample of 1076 participants. Authors identified 4.Knowledge
items reflecting recovery themes and measuring 5.Life satisfaction
aspects of subjective experience, and used
principle components and confirmatory factor
analyses to develop an empirical conceptual-
ization of the recovery orientation.
Table 2:3
Borg & Davidson (2008) Qualitative study, using narrative 1.Having a normal life (e.g., spending time in ordinary
phenomenological methods, based on interviews environments with ordinary people).
with individuals in recovery. A total of seven 2.Just doing it (e.g., doing something concrete to improve
women and six men were interviewed about the current situation)
their everyday lives and experiences. 3.Making life easier (e.g., engaging in social situations,
seeing other people, and using coping strategies that were
experienced as helpful in the recovery process);
4.Being good to yourself (e.g., employing situations that
created good feelings, gave the person peace, or evoked
pleasant memories for comfort).
61
Beeble & Salem (2009) Forty-six semistructured, open-ended interviews 1.Mourning and grief
in which consumers were invited to tell the story 2.Awareness and recognition
of their recovery followed by quantitative 3.Redefinition and transformation
analysis for themes. 4.Enhanced well-being and quality of life
Rape recovery:
1.Establishment of safety
Herman (1997) Qualitative model derived from accounts given
2.Remembrance and mourning
by students, colleagues, patients, and research
3.Reconnection with ordinary life
subjects
Recovery from PTSD
The concept of recovery from PTSD has been poorly conceptualized and explicated
in the literature. Two significant combat PTSD research articles (D. W. King et al., 1999;
L. A. King et al., 1998) and the official 322-page federal report about PTSD and Vietnam
veterans (Kulka et al., 1990) all purported to examine recovery factors. However, there
was no definition of the concept and no criteria set forth for a clinical diagnosis of
recovery in any of the publications. By implication, the authors of all these studies
considered recovery to be the client’s departure from treatment for PTSD, which could be
related to frustration with treatment rather than a cure. Noting this lack, the IOM
committee members (2008) concurred that they found no generally accepted and used
definition for recovery in PTSD. The committee further recommended that clinicians
identify appropriate outcomes for PTSD research by working toward common outcome
measures in three general domains related to recovery: loss of the PTSD DSM–defined
diagnosis, PTSD symptom improvement, and end-state functioning.
In several descriptive articles, a few authors have offered their conceptualizations
of recovery from PTSD as a time of adaptation and/or personal growth. Park and
Folkman (1997) depicted recovery as a basic human adaptation process, proposing that
meaning-making is the ultimate outcome of coping. The meaning-making process
occurred when individuals achieved reconciliation either by changing the appraised
meaning of the situation to assimilate it into preexisting global meaning or by changing
their beliefs or goals to accommodate the event. Through this process, the individual
maintained coherence and consistency between his or her worldview and the traumatic
experience.
62
Tedeschi and Calhoun (2004) believed that PTSD recovery represented positive
transformational change. This process specifically entailed an increased appreciation for
life in general, more meaningful personal relationships, an increased sense of personal
strength, changed priorities, and a richer spiritual and existential life, all of which resulted
from painful and highly challenging life crises. To Tedeschi and Calhoun, posttraumatic
growth presented an iterative process or conscious rumination, as the individual sought to
find emotional relief and cognitive clarity.
Friedman, Keane, and Resick (2007) conceptualized recovery from major traumatic
events as an existential process where effective and complementary trauma-focused and
resiliency-focused interventions resulted in changes in learning and adaptation for
victims. In many cases, a return to previous functioning was unachievable and
undesirable since trauma had altered the victim’s worldview. From this perspective, a
return to baseline or a former state was unrealistic. Thus, Friedman et al. proposed that
research should explore such recovery elements as acceptance of loss, positive adaptation
to enduring or ongoing change, “reasonably good” survival, and posttraumatic growth (p.
515).
Tedeschi and Calhoun (Calhoun et al., 2006; Tedeschi & Calhoun, 1996, 2004)
have been the most active researchers attempting to quantify posttraumatic growth. They
have devised and expanded the Posttraumatic Growth Inventory (Tedeschi & Calhoun,
1996), a 21-item scale that assesses positive outcomes reported by individuals who had
experienced traumatic events. This instrument has been used to report posttraumatic
growth for survivors of breast and other types of cancer and individuals who have lived
through war and genocide.
63
Summary of PTSD recovery. The chronic mental illness literature has offered a
robust discussion on recovery from serious disorders such as schizophrenia. As
mentioned in the mental illness recovery summary, the themes discussed have included
individual attributes, spiritual dimensions (e.g., acceptance and hope for a better future),
coping strategies, social support, and community and organizational support for those
with mental health disorders. Considering that more than 30 years of study on PTSD have
passed, it is somewhat surprisingly that only hypotheses exist regarding the PTSD
recovery process. Still there have been no general guidelines to identify best practice
protocols and appropriate outcomes for PTSD recovery research (Committee on
Treatment of Posttraumatic Stress Disorder of the Institute of Medicine, 2008).
Since that initial report, the committee has continued to meet periodically. In 2010,
the Institute of Medicine convened a committee to conduct a study of ongoing efforts in
the treatment of PTSD (Board on the Health of Select Populations, 2010). The study,
funded by the Department of Defense, was designed to be conducted in two phases. The
focus in Phase 1 was to be on data gathering and to result in the initial study while the
focus in phase 2 was to be on the analysis of data and result in the updated study. Phase 1
was to be completed in late 2012, with Phase 2 to be completed in 2014.
In the next section, therapeutic writing and qualitative research, both of which are
research methods used in this study, will be discussed.
The Heroic Journey:
Therapeutic Writing, Social Networking, and Narrative Therapy
This study had some underlying narrative themes woven throughout the research.
The following themes were the foremost research threads:
64
the “heroic journey” as used in psychotherapy, since many PTSD victims regarded
their recovery as both an exploration and an odyssey;
therapeutic writing, since respondents composed written accounts of their recovery
and conveyed personal significance to their finished work;
and online social networking, since the study recruited participants using social
media and research was conducted in a secure online community created for
individuals who have recovered from PTSD.
These topics and their relevance to the study were explored in more detail throughout the
following sections.
The Heroic Journey
Many accounts of recovery from the literature have framed the individual’s pursuit
of happiness and wellness as a journey. The concept of the heroic journey has been a
familiar literary device throughout history. A common thread running through many
stories and legends, the hero’s journey has featured the protagonist successfully facing
many challenges during a long and arduous journey. Joseph Campbell (2008), in his
book, The Hero with a Thousand Faces, examined ancient hero myths, which he equated
with man’s eternal struggle for identity. He asserted that while the individual’s life
journey is always a solitary one, the trip is taken in the company of others: not only loved
ones and acquaintances, but also in the company of heroes and heroines who undertook
similar past journeys. In the case of PTSD recovery, this journey took place with the help
of physicians, therapists, family members, and peers.
Campbell (2008) used the term “monomyth” to describe the hero’s journey into a
region of supernatural wonder where the individual encountered fantastical forces and
65
ultimately won a decisive victory. Storytellers such as Buddha, Moses, and Christ have
relied on the monomyth in constructing their narratives, hence the resonant familiarity
that such stories have conveyed. Campbell identified 17 sequential stages in the
monomyth, starting with departure, then initiation into the travails of the journey, and
winding up with the return.
Many therapists have believed that Campbell was heavily influenced by the
psychoanalytic theorists of his day and have successfully appropriated the monomyth as a
counseling method. Clinicians have translated Campbell’s heroic journey into a
conceptual metaphor—a counseling technique to make an abstract concept, such as
travails from posttraumatic stress disorder (PTSD), more accessible to a client—to
represent the dynamic process of human development and change (Lawson, 2005).
Therapists have used the heroic journey metaphor to motivate clients and reframe
daunting challenges (Wickman, Daniels, White, & Fesmire, 1999). By recasting the
victim of trauma as a hero whose difficulties have been shared by others taking the same
journey, the victim can achieve hope that the journey will someday end and he or she will
live the life they desire (Jurich, 2008). In essence, the monomyth has served as a template
for change.
There have been several therapeutic benefits to the client’s activation of a heroic
archetype. First, it allowed an individual who had experienced trauma to recast him- or
herself as a hero rather than a victim; from that empowered perspective, the client felt
better equipped to face challenges by successfully drawing on internal resources
(Lawson, 2005; Pearson, 1986). Second, the client’s transformation into the hero role
reframed the therapist as a guide or companion on the epic journey rather than as an
66
interventionist (Halsted, 2000). The heroic metaphor has augmented therapist-client
communication and supported change (Wickman et al., 1999).
In summary, the conceptual metaphor of the heroic journey both normalized and
celebrated a trauma victim’s process of reclaiming his or her life from PTSD. The
process itself has been transformative; the journey did not lead the victim back to the
starting point, but rather to a new, more complex world viewed from a different
perspective. The therapist had functioned as companion and guide on this co-constructed
journey.
The Value of Therapeutic Writing
Often therapists have advanced goals through the use of bibliotherapy to assess the
patient’s progress and to provide meaning to the client’s struggle (Myers, 1998).
Bibliotherapy has typically involved using films, television shows, plays, and books to
draw parallels between the protagonist and the client to help the client reframe the
traumatic experience. Narrative approaches, in which the client writes his or her own
story, have been considered to be a variant of bibliotherapy.
Journaling and writing have long been regarded as beneficial endeavors for clients
with emotional and mental health problems and for individuals who have suffered
traumas such as rape, health care crises such as cancer, or who have experienced painful
life experiences such as grief (Celeste, 2005). Onken et al. (2007) summed up the
therapeutic significance of an oral or written project to its creator: “Dialogical action—
telling one’s narrative, uncovering the strengths and assets embedded within it,
untangling and externalizing the negative dominant discourses—results in a
transformative re-authoring of one’s experience, triggering new meanings and personal
67
and political growth” (p. 13). Onken et al. also noted that re-authoring was a pivotal task
in the recovery process, perhaps the primary mechanism of personal growth. Growth
itself has been conceptualized as a nonlinear process, since regression may occur
throughout the endeavor of contextualizing one’s experiences.
The ultimate goal, of course, in any therapeutic endeavor has been healing.
Therapeutic writing has been one therapy with the potential to achieve that goal in that
the re-authoring process has incorporated the elements of coping, healing, wellness, and
thriving.
According to Onken et al. (2007), the dual acts of taking hold of one’s history and
of conducting self-reflexivity have promoted recovery, as signified in the following
passage:
For people with psychiatric disabilities, the act of telling one’s narrative can
facilitate a healing process that increases coping ability as one integrates the trauma
experienced in conjunction with symptoms and stigmatization into a sense of self
broadened rather than limited by experience. (p. 13)
Delaney (2010) has noted that Onken et al.’s concepts about self and narrative have
closely aligned with the ideas of Peplau (1952), who believed that psychiatric nursing
was fundamentally about the nurse forming a relationship, or shared experience, by
exploring a person’s system of meanings. Peplau believed that it was important for the
nurse to understand how the person defined illness and healing. Peplau (1952) also
trained psychiatric nurses in the importance of helping the patient remember current
happenings and past events so that experiences can be integrated.
68
Pennebaker (1997) noted that bibliotherapy shared a fundamental process common
with all psychotherapies: labeling a problem and discussing its causes and consequences.
Participation in therapy presupposed that an individual acknowledged the existence of a
problem and openly discussed it with another person. Using a writing experiment in
which one group of participants wrote about superficial topics and the second group
wrote about deepest emotions and thoughts for up to 30 minutes a day, 3-5 days in a row,
Pennebaker received a remarkable array of submissions from his second group, as
evidenced by the following passage:
The writing paradigm is exceptionally powerful. Participants—from children to the
elderly, from honor students to maximum-security prisoners—disclose a
remarkable range and depth of traumatic experiences. Lost loves, deaths, incidents
of sexual and physical abuse, and tragic failures are common themes in all of the
studies. If nothing else, the paradigm demonstrates that when individuals are given
the opportunity to disclose deeply personal aspects of their lives, they readily do so.
(p. 162)
Pennebaker (1997) noted that even though a large number of participants who wrote
about painful episodes in their lives reported crying or being deeply upset by the
experience, the overwhelming majority reported that the writing experience was valuable
and meaningful in their lives.
In a study involving Holocaust survivors, Pennebaker, Barger, and Tiebout (1989)
discovered that degree of disclosure during an interview was positively correlated with
long-term health after the interview. High disclosers were significantly less likely than
low disclosers to visit a physician in the months following the interview, t (30) = -2.27, p
69
= 0.03. A later meta-analysis conducted by Pennebaker (1997) in conjunction with his
writing experiment supported this assertion. Participants in bibliotherapy research
reported a reduction in physician visits; showed improved physiological markers such as
increases in immune and other serum measures; improved behavioral markers (e.g., better
school grades and reduced absenteeism); and better self reports concerning physical
symptoms and distress, negative affect, and/or depression. Deters and Range (2003) have
replicated Pennebaker’s study with students who self-reported traumatic experiences and
found that both the control group and trauma writing groups reported fewer symptoms of
PTSD after the project.
Pennebaker (1997) concluded that the mere act of disclosure was a powerful
therapeutic agent that caused changes in basic cognitive and linguistic processes.
Drawing from research that did not include a therapeutic writing component, Mueller,
Moergeli, and Maercker (2008) and Littleton, Axsom, and Grills-Taquechel (2009)
supported Pennebaker’s claim that the act of disclosure itself was therapeutic. Both
studies had predicted a better recovery prognosis for crime victims who disclosed the
traumatic experience and received positive social acknowledgement.
The writing format most frequently used in therapeutic work has been the letter
(Moules, 2009a). The first contemporary report of therapeutic letter writing occurred
when Ellis (1965) noticed that written communication had a different influence on clients
than other forms of communication. Wagner, Weeks, and L’Abate (1980) later
discovered that written messages had a greater effect on recipients than similar verbal
communications. Noted psychotherapist Yalom has incorporated written summaries as an
adjunct therapy with his group work for more than 30 years (Yalom & Leszcz, 2005).
70
White and Epston (1990) formalized the practice of letter writing in clinical family
therapy and coined the phrase “therapeutic letter”; the clinicians composed letters and
mailed them to the family between sessions as an extension of their clinical work.
Epston (1994) noted that purposes of letters have been varied and included summarizing
clinical work with clients; creating opportunities for future reflection and discussion;
salvage of unproductive sessions; acknowledgment of clinician mistakes; clarification of
confusion; creation of possibilities for both client/clinician reflection; and as vehicles to
communicate difficult ideas that the client might digest more easily in private. From these
origins, clinicians extended the use of therapeutic letters to include the following
objectives: to engage clients in therapy; to promote client/clinician cooperation; to
discuss solutions to client problems; to engage nonparticipating family members such as
estranged spouses in therapy; to increase the effect of therapy and serve as a record; and
to offer teaching, education, information, and normalizing to clients (Bell, Moules, &
Wright, 2009).
Yalom has noted that his summaries of individual group work revivified prior
therapeutic efforts and encouraged continuity of work between meetings; helped clients
re-experience and understand important events that occurred during a meeting; helped
reinforce and shape group norms; and provided therapeutic leverage by reinforcing risk
taking and focusing clients on primary tasks (Yalom & Leszcz, 2005). Through written
group summaries, Yalom had provided understanding of the events of the session, taking
note of both productive and resistive sessions; commented on client gains; predicted and
prevented undesirable developments; brought in silent members; increased cohesiveness;
invited new behaviors and interactions; provided interpretations; and instilled hope.
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Yalom had theorized that written summaries were most valuable when they were
honest and straightforward about therapy, demystifying the process (Yalom & Leszcz,
2005). Indeed, Yalom agreed with Pennebaker that the writing process itself was very
therapeutic. Yalom recounted an experiment that he conducted in which he and a client
exchanged a letter after each weekly session for a year; he and his client had vastly
different perspectives of the shared hours. “All my marvelous interpretations?” Yalom
wrote, “She had never even heard them. Instead, [she] heard and valued very different
parts of the therapy hour; the deeply human exchanges; the fleeting supportive accepting
glances; the brief moments of real intimacy” (p. 458).
Despite varying perspectives on the healing mechanisms of therapeutic writing,
most anecdotal evidence has indicated that both writer and recipient regarded the letters
as significan (Epston, 1994; Wojcik & Iverson, 1989; Wood & Uhl, 1998). Families and
clinicians both indicated in outcome studies and clinical in-session comments that there
had been added value to the letter, with each letter representing the equivalent of 3 to 10
face-to-face clinical sessions (Freedman & Combs, 1996; White, 1995; Wright, Watson,
& Bell, 1996).
Therapeutic letters have represented many intents and purposes in psychotherapy,
but the fundamental aim of all written communication has been to help alleviate the
suffering of families and individuals. Moules (2009b) examined a 22-year family systems
nursing project where clinicians used therapeutic letters to communicate with families
experiencing illness and suffering. She concluded that letters had an influence related to
the tone of the individuals and the relationship created, the balancing of questions,
commendations, and artful writing, memory and remembrance, measures and markers of
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change, and the obligation of meeting people experiencing illness at the point of their
suffering.
One benefit of therapeutic writing has been that the practice challenged traditional
therapist-client boundaries, where the therapist held perceived power and controlled the
therapeutic relationship (Rodgers, 2009). Through the recursive process of therapeutic
writing, the professional therapist had created a more intimate connection between the
clinician and client. Therapeutic writing also had allowed a therapist to sample the
client’s experience while allowing the client to remain in the safety and security of his or
her customary setting.
Furthermore, letter writing and journaling have crossed the temporary and spatial
boundaries of the therapeutic relationship, by allowing clients to participate in therapy
outside of usual office hours (Rodgers, 2009). Therapeutic letters have represented a
generative process and produced relational responsivity, a relationship in which client
and clinician coordinate a language of mutuality (Pyle, 2009). Letters also have supported
reflexivity: One study of students who composed therapeutic letters to clients
demonstrated that the students became stronger clinicians since the reflective process
forced a more thorough assessment of both client weaknesses and strengths (Erlingsson,
2009). Journaling and letter writing—by challenging, extending, and redefining
traditional therapeutic boundaries—has enabled closer, more intimate counselor-client
connections to occur.
The therapist Epston (2009) revisited his original concept of therapeutic writing
and suggested that the written word consistently offered two therapeutic advantages: (1)
written works, through the act of creation, take on an existence of their own and (2)
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writing can be a solidifying and creative group activity that shares and negotiates
progress. Both Moules (2009a) and Epston have noted that the practice of email has been
causing an inevitable change in human communication. However, Epston has expressed
hope that the historical and cultural legacy of therapeutic letter writing would be
represented in the newer medium, that “good conversation” and “healing words” would
always be maintained regardless of the medium (p. 4).
In summary, therapeutic writing has been shown to be beneficial for many patients
and has been a valuable adjunct to traditional psychotherapy. Writing has provided a
means for self-disclosure, an act that itself can be liberating for many victims of
traumatic events. The therapist who has received the disclosure offered positive social
acknowledgment that can help victims to heal. Often, individuals have received
therapeutic insights from their writing, even from solitary efforts undisclosed to
therapists. However, skilled therapists have helped to accelerate the process and to coach
efficacious coping efforts. In addition to its psychological benefits, bibliotherapy has
provided the writer with great satisfaction and a sense of personal accomplishment, as
Writing as a Literary Endeavor
Writers of note have long considered letter writing and journaling to be integral
activities to their literary careers. Throughout history, diarists such as Samuel Pepys
(Tomalin, 2002), Mary Boykin Chesnut (Woodward, 1981), and Louisa May Alcott
(Stern, 1950) have found emotional release and gained insight from periodically
recording events in their lives. Furthermore, letter writing has been regarded as a daily
“limbering up” exercise by serious writers such as Samuel Clemens (Mark Twain),
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Ernest Hemingway, and Flannery O’Connor, who often wrote letters before turning to
their more lengthy literary compositions (Brockenbrough, 2009).
The literature supported my belief that writing about PSTD and the journey to
recovery could offer psychological benefits to study participants. As mentioned
previously, Onken et al. (2007) noted the therapeutic value of crafting and telling a
personal story as a healing process. Davidson and White (2007) also have validated the
value of writing for persons who suffered severe mental illness, noting that first-person
accounts have described recovery as both a transformational process and an incremental
process, celebrating change. Within these stories, people in recovery have been active
agents of change in their lives and not passive recipients of care. The stories have
contained many references to new perspectives and insights, important decisions, critical
actions taken, and discovery of healing resources within and beyond the self. Moreover,
as Davidson and White stated, first-person narratives of recovery also have revealed the
individualized nature of recovery processes and the existence of diverse religious,
spiritual, and secular frameworks of recovery initiation and maintenance. Finally, the
recovery writings have confirmed the role of family and peer support in making a
difference in their recovery.
In summary, the literature review supported the idea that a research participant in
this project could not only obtain therapeutic benefit from the act of creating a written
work of significance detailing his or her recovery from PTSD but also derive satisfaction
from crafting a creative literary effort. Finally, the literature demonstrated that research
participants could experience a satisfying sense of belonging to a virtual online
community of peers who constructed similar stories about traumatic stressors and
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recovery. The concept of a collective virtual community has been discussed more
thoroughly in the next section.
Web 2.0, Online Communities, and Social Media
This project used social media for recruiting and communicating with study
participants as well as a closed website for data gathering. Research participants
interacted within the closed website. The technology used in this research project has
been briefly described in this section.
The term Web 2.0 has been associated with web applications that have facilitated
interactive systemic biases, interoperability, user-centered design, and expansion of the
World Wide Web (Prashant, 2008). Web 2.0 sites have allowed users to interact and
collaborate with each other in a social media dialogue in a virtual community, in contrast
to older websites where users had been limited to retrieval of information and interactive
viewing of content only if they created and controlled it. Examples of Web 2.0 have
included social networking sites, blogs, wikis, video sharing sites, hosted services, web
applications, mashups and folksonomies (Prashant, 2008).
In addition to Web 2.0 applications, social media have enabled interactive and
interpersonal therapeutic connections, which previously only occurred face to face in real
time. Internet and social networking sites have helped victims isolated by symptomology
or geography to connect with peers. A recent Google search of “victims’ networks”
turned up 5.8 million listings; “victim support groups” returned 9.4 million hits; and
“victim blogs” retrieved 13.9 million potential sites. The social networking site Facebook
has more than 500 group sites each for veterans, rape, and trauma. As an example, seven
veterans’ groups and 20 rape groups had existed on Facebook specifically for peer
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support. Online communities have represented both collective intelligence (Vieweg,
Palen, Liu, Hughes, & Sutton, 2008) for gathering and disseminating information and
socially convergent online behavior (Hughes, Palen, Sutton, Liu, & Vieweg, 2008) for
normalizing group mores and behaviors. Online groups have provided structural social
support during disasters to coordinate relief efforts, offer financial assistance, coordinate
housing arrangements, and reconnect separated family members (Sutton, Palen, &
Shlovski, 2008; Vieweg et al., 2008).
Given widespread acceptance and use of the technology and social media software,
the internet has become a platform for health care research. The practice has been termed
as infodemiology, the science of distribution and determinants of information in an
electronic medium, specifically the Internet, or in a population, with the ultimate aim to
inform public health and public policy (Eysenbach, 2009). Social media have been useful
in research because data can be collected and analyzed in near real time. Examples of
infodemiology applications have included the analysis of queries from Internet search
engines to predict disease outbreaks (e.g., influenza); monitoring of individuals’ status
updates on microblogs such as Twitter for syndrome surveillance; detecting and
quantifying disparities in health information availability; identifying and monitoring of
public health relevant publications on the Internet (e.g., anti-vaccination sites, breaking
news articles, and outbreak reports); automated tools to measure information diffusion
and knowledge translation; and tracking the effectiveness of health marketing campaigns
(Eysenbach, 2009).
In addition, analysis of how people search and navigate the Internet for health-
related information, as well as how they communicate and share this information, has
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provided valuable insights into health-related behavior of populations (Eysenbach, 2009).
However, there have been ethical issues related to privacy and informed consent in the
unrestricted use of social media for data gathering (Koziatek, 2011). Aside from consent
and confidentiality issues, other potential problems have included restricting access to
data, encryption of electronic data during transmission and storage, and coding of client
names (Koziatek, 2011).
In summary, my review of literature offered support that the internet and social
media were convenient and accessible methods of recruiting study participants and
interacting with recovered PTSD victims. From the literature review, I concluded that I
could collect data online and use it to generate a grounded theory on the PTSD recovery
process. The literature also indicated that grounded theory would be the best qualitative
research method for data analysis. The background of qualitative research, its
methodologies, grounded theory, and second-generation grounded theory have been
Qualitative Research
Qualitative research, also known as naturalistic inquiry, has been derived from a
long tradition in people-focused disciplines such anthropology, sociology, clinical
psychology, and applied health fields (Merriam, 2002). At the center of all qualitative
research has been the idea that all meaning is socially constructed by individuals in their
interaction with the world. In this paradigm, the world is not a fixed, single, measurable
phenomenon as it is in positivist, quantitative research, but rather a reality that is in flux
and which changes over time (Merriam, 2002). Lincoln and Guba (1985) have expressed
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this concept in the following manner: “The inquirer and the ‘object’ of inquiry interact to
influence on another; knower and known are inseparable” (p. 37).
Qualitative research has been especially influenced by the era and context in which
data have been collected. This characteristic of naturalistic inquiry has been known as
“situated context,” which reflected where people were in their lives and represented them
at that snapshot in time. As Munhall (2007) noted:
Taking into consideration the situated context of participants in a study is
imperative. Who they are is taken very seriously. More than just demographics,
they are people who differ because of their subjective perspective, which evolved
from their experiences. Considering the situated context demonstrates respect for
these individuals by acknowledging their uniqueness and taking into consideration
their personal narratives of their lives. (p. 6)
All qualitative research has several key characteristics in common. First, qualitative
researchers have attempted to understand the meaning individuals have constructed about
their world and their experiences (Merriam, 2002). The focus of qualitative research has
been on subjectivity and intersubjectivity (Munhall, 2007). As Stolorow and Atwood
(2002) wrote: “… the subjective world of the individual as its central theoretical concept,
envisioning the world as evolving organically from the person’s encounter with critical
experiences that constitute his unique life history … the perspective toward being” (p. 2).
According to Munhall (2007), common characteristics of qualitative research have been
multiplicity, simultaneity, perspectivity, polyvocality, multiple realities, and individual
and cultural social construction of reality.
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Another characteristic of qualitative research has been that the researcher is the
primary instrument for data collection and analysis (Merriam, 2002). Human
interpretation can be an advantage since the researcher can assess nonverbal as well as
verbal responses. Guba and Lincoln (1981) noted that there are a number of
characteristics that uniquely qualify the human as the “instrument of choice” for
naturalistic inquiry. Among these characteristics have been responsiveness, adaptability,
holistic emphasis, desire for knowledge base expansion, processual immediacy, and
opportunities for clarification and summarization and to explore atypical or idiosyncratic
responses (Guba & Lincoln, 1981; Merriam, 2002).
Lincoln and Guba (1985) have written that because of the researcher’s interjection
into data collection, reality might have existed at any of four levels. The first of these
levels was objective reality, also known as naïve realism or hypothetical realism, a
tangible reality where experience with it can result in full knowing. The second level was
perceived reality, an ontological position from it can be asserted that there is a reality, but
one cannot know it. The third level has been constructed reality where reality exists as a
construction in the minds of individuals; no amount of this inquiry can produce
convergence, but consensus, at times, can be gained. The fourth and final level has been
created reality, which is that there is no reality at all; this is a position derived from
quantum physics. Lincoln and Guba stated that they have embraced constructed reality as
the most useful definition since it assumes that reality does not exist until it is constructed
and interpreted by an individual.
The drawbacks of qualitative research have been that the researcher may introduce
biases, prejudices, or false assumptions into the interpretation. The credibility of
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qualitative methods has greatly relied on the skills, competence, and rigor of the
researcher performing the fieldwork (Patton, 2002). For this reason, there have been
checks and balances in each qualitative analysis system, which if carefully followed, have
helped to ensure untainted analysis. These have been discussed throughout this section.
A final characteristic of qualitative research has been that it has produced rich
description (Merriam, 2002). This description may have covered the context of the
interview in various ways. The analysis may have contained thick description of the
participants, their interests, and daily lives; and observations by the researcher him- or
herself in the form of transcribed narrative and other documents; field notes; audio- or
videotapes, photographs, and other electronic communications; and other findings
(Merriam, 2002).
Qualitative Methods
There have been numerous types (also known as methods, approaches, or
traditions) of qualitative research. All of the methodologies have shared certain
epistemological and ontological characteristics (Rolfe, 2006). Some of the methods have
been briefly discussed below:
Basic interpretive qualitative study, used to develop broad, description of a
phenomenon;
Naturalistic inquiry, which has studied real world situations as they unfold;
Phenomenology, which has explored the essence or structure of an experience;
Heuristic inquiry, which has focused on the personal experience and insights
of the researcher;
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Grounded theory, which has used data to generate an inductively derived
theory “grounded” in the data;
Case study, which has been an intensive description and analysis of a social
unit or phenomenon;
Ethnography, which has presented a sociocultural interpretation of data;
Narrative analysis, stories and first-person accounts which have been used to
describe experiences;
Hermeneutics, a theoretical framework that has interpreted and understood
meaning with special attention to context and original purpose;
Critical qualitative research, which has uncovered, examined, and critiqued
social, cultural, and psychological assumptions that have structured and limited
humans (Creswell, 2007; Merriam, 2002; Munhall, 2007; Patton, 2002)
Numerous variants of these research methods have been devised. I collected and
analyzed narratives, e.g., first-person accounts, of recovery from PTSD to generate a
grounded theory of the recovery process. The actual analytic process will be discussed in
more detail in the “Grounded Theory” section later in this chapter.
Data used to generate grounded theory have been usually derived from interviews,
observations, and documents and have been written, oral, or visual (Merriam, 2002). The
products of qualitative research have included themes, categories, typologies, concepts,
tentative hypotheses, and substantive theory (Merriam, 2002). “Negotiated outcomes”
have been the results of naturalistic inquiry and have included both facts and
interpretation (Lincoln & Guba, 1985).
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Inquiry often has yielded an idiographic body in the form of working hypotheses
that have described the individual case being examined, which may have had meaning
only within the context of that time (Lincoln & Guba, 1985). Subsequent inquiry may
have produced different results, yet idiographic interpretation also has implied
understanding in a very holistic way (Lincoln & Guba, 1985). Moreover, qualitative and
quantitative research have increasingly been combined in the same study to yield a fully
dimensional view of a phenomenon; these studies have used mixed methods (Patton,
2002).
Generally, researchers have undertaken qualitative research because there has been
no extant theory or an existing theory failed to explain a phenomenon (Merriam, 2002).
In the case of this research project, recovery from PTSD has been an underexplored
phenomenon. Since qualitative research is inductive, researchers have used data to build
concepts, hypotheses, and theories rather than deductively testing postulates or
hypotheses as in positivist research (Merriam, 2002). The integral elements of the
grounded theory research method have been discussed in the following section.
Grounded Theory
Grounded theory has been a research approach that resulted in the development of
middle range theory at substantive or formal level; the theory-developing capacity of the
grounded theory method has distinguished it from other qualitative methods (Munhall,
2007). A grounded theory approach has demanded that the researcher move beyond
description of the domain of study toward a theoretical rendering that has identified key
explanatory concepts and the relationships among them. Data have formed the foundation
of the theory and analysis of the data has generated the constructed concepts (Charmaz,
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2006). Grounded theory has been especially powerful since it has emerged from the
researcher’s observations and interviews out in the “real world” rather than in the
laboratory or the academy (Patton, 2002).
Grounded theories have been useful within the field of nursing because they have
explained human behavior within a social context (Munhall, 2007). Grounded theory
methodology has emphasized steps and procedures for connecting induction and
deduction through constant comparative analysis and refinement of questions in
subsequent interviews, comparison of differences between research sites, theoretical
sampling, and testing emergent concepts with additional fieldwork (Patton, 2002).
Grounded theory methodology has been used to develop theories about human behavior
and society. It has also been used to describe various human processes that have been
minimally researched in the past, such as the topic of PTSD recovery in this study.
Background of Grounded Theory Research
Sociologists Glaser and Strauss (1967) have been credited with forming the
grounded theory research method when they were researching the process of death and
dying in the hospital setting. Glazer and Strauss conducted explicit analysis of the data
and produced theoretical analyses of the social organization and sequence of dying
(Charmaz, 2006). Grounded theory differed from conventional inquiry in that the theory
followed from data rather than preceding the data collection process. The naturalistic
paradigm has posited that multiple realities exist; thus, the transferability of a research
study will be dependent on the context. Wuest (2007) described the aspects of grounded
theory that differed from other avenues of naturalistic inquiry:
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The explicit goal of theory development makes grounded theory unique among
qualitative methods. A grounded theory approach demands that the researcher
move beyond description of the domain of study toward a theoretical rendering that
identifies key explanatory concepts and the relationships among them….Grounded
theories are useful for directing nursing practice because they are explanatory
theories of human behavior within social context. (p. 240)
In creating grounded theory, Glaser and Strauss married two contrasting
philosophical and methodological traditions: Columbia University positivism and
University of Chicago pragmatism (Charmaz, 2009). Wuest (2007) also has
acknowledged that a key philosophical underpinning of grounded theory was
pragmatism. Pragmatism has been defined as a philosophical worldview which holds that
the outcomes of research, its actions, situations, and the consequences of inquiry, are
more important than the antecedent conditions, an attitude characteristic of
postpositivism (Creswell, 2007). Patton (2002) described how pragmatic research can be
conducted in real-life applications:
Such pragmatism means judging the quality of a study by its intended purposes,
available resources, procedures followed, and results obtained, all within a
particular context and for a specific audience…. I reiterate: Being pragmatic allows
one to eschew methodological orthodoxy in favor of methodological
appropriateness as the primary criterion for judging methodological quality,
recognizing that different methods are appropriate for different situations.
Situational responsiveness means designing a study that is appropriate for a specific
situation or interest. (pp. 71-72)
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Grounded theory has contained several key premises. Strauss (1987) noted two
basic assumptions: (1) change is a feature of social life that can be observed through
attention to social interactions and process and (2) interaction, process, and social change
can best be understood by studying the participant’s point of view. Glaser (1992) wrote
that the key assumption of grounded theory has been that people actively shape their
worlds and human lives are characterized by variability, complexity, change, and process.
Glaser and Strauss (1967) have been credited with actually coining the term “grounded
theory” and establishing criteria for the methodology. According to them, a grounded
theory will:
… fit the situation being researched, and work when put into use. By “fit” we mean
that the categories must be readily (not forcibly) applicable to and indicated by the
data under study; by “work” we mean that they must be meaningfully relevant to
and be able to explain the behavior under study. (p. 3)
When establishing this process, the Glaser and Strauss developed systematic
methodological strategies that other social scientists could adopt and transfer to other
research areas. Their 1967 book outlined these strategies and encouraged the
development of theories from research rooted in data; this was in direct contrast of the
empiric method of deducing testable hypotheses from existing theories (Charmaz, 2006).
From their early writings, Glaser and Strauss’s approaches to grounded theory gradually
evolved, with Strauss later partnering with Juliet Corbin to propose a more prescriptive
approach to analysis (Wuest, 2007).
Today, most grounded theorists identify themselves as being either of the
Strauss/Corbin or Glaser orientation to the method. The theorist used to guide my
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interpretive analyses was Kathy Charmaz, a professor of sociology at Sonoma State
University. She studied under both Glaser and Strauss; the latter was her dissertation
chair at the University of California–San Francisco (Charmaz, 2006). Charmaz has
referred to her research orientation and methodology as “Second Generation
Constructivist Grounded Theory,” incorporating some of the assumptions and directions
of classic grounded theory from both Glaser and Strauss. Charmaz’s revised approach to
grounded theory has been discussed in the following section.
Second-Generation Constructivist Grounded Theory
Charmaz (2006, 2009) noted that the ontological and epistemological grounds of
grounded theory have shifted in the forty years since its original conception. The
constructivist approach is a contemporary revision of Glaser and Strauss’s (Glaser, 1992;
Glaser & Strauss, 1967) classic grounded theory in that it assumes a relativist
epistemology, sees knowledge as socially produced, and acknowledges multiple
standpoints of both the research participants and the theorist. Constructivist grounded
theory takes a reflexive stance toward examining the actions of the researcher, situations,
and participants in the field setting as well as analytic constructions of these factors.
Charmaz (2009) delineated the characteristics and boundaries of second-generation
research assumptions in the following passage:
Constructivist grounded theory assumes that we produce knowledge by grappling
with empirical problems. Knowledge rests on social constructions. We construct
research processes and products, but these constructions occur under preexisting
structural conditions, arise in emergent situations, and are influenced by the
researcher’s perspectives, privileges, positions, interactions, and geographical
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locations. All these conditions inhere [sic] in the research situation but in most
studies remain unmentioned or are completely ignored. Which observations we
made, how we make them, and the views that we form of them reflect these
conditions as do our subsequent grounded theories. Constructivists realize that
conducting and writing research are not neutral acts. ( p. 130)
Charmaz (2009) noted that constructivists enter participants’ “liminal world of
meaning and action” in ways that classic grounded theorists do not. Charmaz wrote: “We
try to get it right in the sense of trying to understand our research participants’ beliefs,
their purposes, the actions they take, and reasons for their actions and inactions from their
perspectives” (p. 131). Constructivists have tried to locate participants’ meanings and
actions in larger social structures and discourses of which they may be unaware, trying to
show connections between micro and macro levels of analysis.
Constructivists have viewed data as constructed rather than discovered; analyses
have been interpretive renderings rather than objective reports or the only point of view
on a topic (Charmaz, 2009). Because knowledge has been created through the interpretive
analyses of both the relative and empirical world, constructivists must take a reflexive
stand through the research and writing processes. Many constructivists have used
reflexive statements to disclose beliefs, insider knowledge, and professional expertise.
According to Charmaz (2009), the two primary differences between constructivist
and traditional grounded theory are that constructivist grounded theory takes reflexivity
into “explicit and continuous account” and first-generation grounded theory embraced
social constructionism that viewed research participants’ actions as constructed, but not
the actions of situations or researchers. However, Charmaz has rejected the methodology
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of researchers who subscribe to “radical subjectivism” with explanations shaped by the
“individual consciousness” rather than by social locations, cultural traditions, and
interactional and situational contingencies. Charmaz wrote: “In contrast, constructivist
grounded theory aims to position the research relative to the social circumstances
impinging on it” (p. 134).
Since data collection methods flow from the research question, particular data
collection methods or analytic strategies cannot drive the research question (Charmaz,
2006). Because of this truism, some grounded theory purists have viewed the interview
study as the preferred method of data collection; however, Charmaz has embraced
methodological eclecticism, having named written narratives (as was the case in this
study), documents, and ethnography, as acceptable techniques as well. “Clearly,
successively shaping and controlling the data works best,” she wrote, “but documents
may be the only data that researchers can obtain. Grounded theorists … have excelled in
using documents as their major source of data” (p. 134).
In summary, second-generation grounded theory has been a useful method of
studying process for years. In contrast to traditional grounded theory, constructivist
grounded theory has challenged the assumption of creating general abstract theories and
has led to situated knowledge. Constructivist grounded theory has moved the traditional
method further into an interpretive social science (Charmaz, 2006, 2009). I selected
Charmaz’s approach to grounded theory to guide me because I was forced to be as
interactive in interpreting these narratives as my participants have been in struggling with
PTSD. Thus, Charmaz’s interactive approach for the researcher was in line with my point
of view.
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Grounded Theory Methodology
Glaser and Strauss (1967) countered the positivist, quantitative research approaches
of the space-age 1960s by contesting notions of methodological consensus and offering
systematic strategies for qualitative research. The two proposed that systematic grounded
theory research had its own logic and could generate theory (Charmaz, 2006). Glaser and
Strauss identified seven key components essential to grounded theory research:
Simultaneous involvement in data collection and analysis.
Constructing analytic codes and categories from data, not from preconceived
logically deduced hypotheses.
Using the constant comparative method, which involves making comparisons
during each stage of the analysis.
Advancing theory development during each step of data collection and
analysis.
Memo-writing to elaborate categories, specify their properties, define
relationships between categories, and identify gaps.
Sampling aimed toward theory construction, not for population
representativeness.
Conducting the literature review after developing an independent analysis
(Charmaz, 2006; Glaser & Strauss, 1967).
The practices listed above were designed to help the researcher control the research
process and increased the analytic power of the study (Charmaz, 2006).
Researchers who have used grounded theory methods have studied the early data
and separated, sorted, and synthesized data through qualitative coding (Charmaz, 2006).
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Coding has attached labels to segments to depict the meaning of that segment. Coding
has helped the researcher to distill and sort data and permitted comparison with other
data. Making and coding numerous comparisons have allowed analysis to take place;
analytic memos have been kept containing codes and comparisons. By studying and
comparing data and writing memos, researchers have defined ideas that best fit the data
and interpreted the data as preliminary analytic categories (Charmaz, 2006).
When questions and gaps have appeared in the categories, the grounded theorist
returned to the data seeking answers (Charmaz, 2006). As more research participants
contributed, more data were gathered and analytic categories were strengthened. As the
process continued and data were interpreted and reinterpreted, the categories became
more theoretical from successive levels of analysis. From the analytic categories and
relationships, the grounded theorist built levels of abstraction and refined emerging
analytic categories (Charmaz, 2006). Diesing (2008) depicted models of explanation
emerging from “connecting themes in a network or pattern … discovered empirically
rather than inferred logically” (pp. 155-156). The work culminated in a grounded theory,
an abstract theoretical understanding of the studied experience (Charmaz, 2006).
The specific techniques and their sequence for conducting grounded theory
research using Charmaz’s approach follow:
1) Sensitizing concepts and general disciplinary perspectives.
2) Defining a research problem and opening research questions.
3) Initial coding and data collection; earlier data may also be re-examined.
4) Initial memos raising codes to tentative categories.
5) Data collection and focused coding.
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6) Advanced memos refining conceptual categories.
7) Theoretical sampling seeking specific new data.
8) Theoretical memo writing and adopting certain categories as theoretical
concepts.
9) Sorting memos.
10) Integrating memos and diagramming concepts.
11) Writing the first draft (Charmaz, 2006, p. 11).
After the first draft has been composed, the theorist may decide that further theoretical
sampling is needed.
Charmaz recommended two main types of grounded theory coding: (1) initial line-
by-line coding, a strategy that prompts the researcher to study data closely and to begin
conceptualizing ideas; and (2) focused coding, a process where the researcher separates,
sorts, analyzes, and synthesizes large amounts of data. Charmaz advocated writing
extended notes, or memos, on telling codes to help develop ideas. “Memos provide ways
to compare data, to explore ideas about the codes, and to direct further data-gathering,”
Charmaz (2006) wrote. “As you work with your data and codes, you become
progressively more analytic in how you treat them and thus you raise certain codes to
conceptual categories” (p. 12). Although gathering feedback from peers has not been a
step in Charmaz’s process, interdisciplinary research teams have conducted many
grounded research projects; thus, memos have likely been shared with and critiqued by
research team leaders and members. Furthermore, Charmaz (2006) noted that university
instructors “often have good reasons” for reviewing student memos: to evaluate quality of
work and to keep the student on track in a potentially unwieldy research process.
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After the researcher has collected data, selected focused codes, and written memos
about them, he or she may notice that the categories are workable but thin, with too much
assumed, unknown, or questionable (Charmaz, 2006). A workable strategy has been to
gather more data that focus on the category and its properties. Charmaz referred to this
strategy as theoretical sampling, a process of seeking and collecting pertinent data to
elaborate and refine categories in the emerging theory. Using Charmaz’s method, a
grounded theorist must conduct theoretical sampling until the properties of a category are
saturated, e.g., no new properties are emerging. “Thus, you saturate your categories with
data and subsequently sort and/or diagram them to integrate your emerging theory,”
Charmaz noted. “Conducting theoretical sampling can keep you from becoming stuck in
unfocused analyses” (pp. 97-98). For future ease, Charmaz recommended writing initial
proposals to include resampling of participants to accommodate theoretical sampling.
Charmaz (2006) stated that theoretical sampling is strategic, specific, and
systematic. The use of theoretical sampling will advance the researcher toward emergent
objectives such as delineating the properties of a category; checking hunches about
categories; saturating the properties of a category; distinguishing between categories;
clarifying relationships between emerging categories; and identifying variation in a
process (p. 104). Thus, theoretical sampling will help the researcher specify relevant
properties of the categories; increase the precision of the categories; provide substance to
move the material from description to analysis; make the analysis more abstract and
generalizable; ground conjectures in data; explicate the analytic links between or among
categories; and increase the parsimony of theoretical statements (Charmaz, 2006).
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After theoretical sorting, diagramming, and integrating have been done, the
researcher must construct the theory using well-developed analytic memos to create the
first draft. According to Charmaz (2006), a theory attempts to convince readers that
certain conclusions flow from a set of premises, presenting arguments about the world
and relationships within it. According to Glazer (1992), researchers must develop
“theoretical sensitivity” to construct theory. The process includes seeing possibilities and
establishing connections. Charmaz (2006) wrote: “The potential strength of grounded
theory lies in its analytic power to theorize how meanings, actions, and social structures
are constructed” (p. 151).
A controversial aspect of grounded theory has been conducting the literature review
after data collection and interpretation. Charmaz (2006) stated that this step has been long
disputed and misunderstood. The classic Glaser and Strauss texts advocated delay of the
literature review to avoid contamination of the data because of a priori ideas. This was a
valid concern because as Charmaz noted: “…scholars old and new may force their data
into pre-existing categories. The intended purpose of delaying the literature review is to
avoid importing preconceived ideas and imposing them on your work. Delaying the
review encourages you to articulate your ideas” (p. 165). Later writings by both Glaser
and Strauss indicated that they were well aware that contemporary scholars were very
likely to bring considerable professional and disciplinary knowledge to their research.
Charmaz has stipulated Henwood and Pidgeon’s (2003) suggestion of “theoretical
agnosticism”, where researchers take a critical stance to earlier theories, to be the most
useful approach throughout the research process. Charmaz also noted that the literature
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review must be thorough and sharply focused. Through this process, the theoretical
framework will emerge.
According to Charmaz (2006), the resulting study and theory will ultimately be
evaluated on four criteria: credibility, originality, resonance, and usefulness. Credible
research will obtain intimate familiarity with the setting or topic; cover a wide range of
empirical observations; and provide enough evidence for the reader to form an
independent assessment and agree with the researcher’s claims. Charmaz also noted that
original research is fresh, offers new insights, and offers a new conceptual rendering of
the data. She stated that research with resonance portrays the fullness of the studied
experience and will offer deeper insights to both the reader and research participant.
Useful research will suggest generic processes that individuals can use in everyday life
and contributes to knowledge. The value of conscientiously researched grounded theory
is immense. Charmaz (2006) wrote:
When born from reasoned reflections and principled convictions, a grounded theory
that conceptualizes and conveys what is meaningful about a substantive area can
make a valuable contribution. Add aesthetic merit and analytic impact, and then its
influence may spread to larger audiences. (p. 183)
Literature Review: Summary
This literature review has covered the background and significance of the stress
disorder PTSD, standard treatments, and applicable theoretical models on stress and
coping. The case was made for the need for a qualitative study on how individuals
recover from PTSD. The literature that was reviewed discussed such related concepts as
recovery and recovery from a chronic mental illness such as schizophrenia and examined
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core themes of recovery and related conceptual models. Finally, therapeutic writing, the
technique used to gather recovery narratives from individuals who had had traumatic
experiences, was examined. The therapeutic potential of social networking and a safe
online environment where study participants submitted private narratives was also
discussed. Before proceeding to the methodology chapter, I would like to reiterate and
summarize some key points from the literature review.
First, because of victimization, natural and manmade disasters, and combat
experiences, chronic PTSD is the most commonly diagnosed anxiety disorder today,
affecting some 8% of those individuals who experience significant traumatic events or
exposure to cumulative stressors (Greenburg et al., 1999; NCPTSD, 2008; Tjaden &
Thoennes, 2000; Tyson, 2008). The symptoms caused by chronic PTSD are very
intrusive and persistent, causing a victim to have persistent frightening thoughts and
memories of the ordeal; be numb or emotionally detached; experience sleep problems;
exhibit agitated or disorganized behavior; and display exaggerated startle responses
(APA, 2000; APA, 2010; NCPTSD, 2010). Many victims have turned to alcohol, drugs,
and use of illicit substances to mask symptoms and emotional pain (Boyd & Mackey,
2000a, 2000b; Calhoun et al., 2007; Najavits, 2000).
Because of intrusive and persistent symptoms and ineffective treatment, victims of
PTSD often have delayed and abandoned life roles, many of which center on learning and
career development (Knowles, 1975; Knowles et al., 2005; Super, 1990). The inability to
acquire marketable skills and to start and maintain a career has often negatively affected a
victim’s economic status. Equally important, because of disturbing and persistent
symptoms, victims of PTSD often have not had satisfying emotional lives; have not
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assumed rewarding personal roles, such as spouse and parent; have not enjoyed hobbies
and leisure pastimes; and may never feel comfortable being intimate with another person
(Glasser, 2000; Havighurst, 1972; May & Yalom, 1995; Mosak & Dreikurs, 1967;
Shulman & Mosak, 1988; Yalom, 1980). Many individuals with PTSD have stayed stuck
in their symptomology and role as a victim, unable to negotiate developmental milestones
and life challenges (Young & Ensing, 1999). In addition to personal difficulties, PTSD
has caused a significant economic impact on society, costing billions in health care
expenses every year (Andreasen, 2004; Dutton et al., 2006; Greenburg et al., 1999; Max
et al., 2004; Tyson, 2008).
Researchers have studied why some individuals develop chronic PTSD after
traumatic exposures and others do not. While exposure to a traumatic stressor has been
the most significant predictor for development of chronic PTSD (J. L. Herman, 1997; D.
W. King et al., 1999; Raphael & Dobson, 2002) there have been some other salient
factors that have predisposed trauma victims to development of PTSD. Among these
factors have been experiencing interpersonal trauma such as intimate partner violence
and sexual assault (Jankowski et al., 2004; Tjaden & Thoennes, 2000); military combat
(Kulka et al., 1990; NCPTSD, 2010); alcohol and substance use (Boyd, 2000; Calhoun et
al., 2007); childhood risk factors such as early trauma assault and physical/emotional
abuse (Fontana & Rosenheck, 2005; Price, 2006); an accumulation of traumatic events
(Cattaneo et al., 2007; Gill et al., 2008); and concurrent psychiatric comorbidities
(Dienemann et al., 2000; Gill et al., 2008).
Regardless of the etiology, treatment protocols for PTSD can be categorized as
belonging to one of two perspectives: past-focused and present-focused (Najavits, 2007).
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The primary past-focused treatment has commonly featured in vivo and imaginal
exposures to the traumatic event (Foa et al., 2009; Foa et al., 1986) to provide emotional
processing of the trauma and insight into the victim’s response. Present-focused therapies
have attempted to teach the victim cognitive-behavioral skills to negotiate anxiety more
successfully and gain symptom relief (Najavits, 2006). An Institute of Medicine (IOM)
panel (Committee on Treatment of Posttraumatic Stress Disorder of the Institute of
Medicine, 2008) reviewed all PTSD treatments and stated that the only treatment proven
to be efficacious in treating anxiety, phobias, and PTSD was exposure therapy. A 2010
paper detailing two evidence-based treatment protocols in the VA for combat PTSD
concurred that past-focused therapies were most efficacious (Karlin et al., 2010).
Proponents of present-focused therapies have objected to this finding, since they
have believed that exposure therapy can destabilize fragile individuals and promote early
departure from treatment (Cahill et al., 2006). Of particular relevance to this study, the
IOM committee (2008) stated in its findings that the concept of recovery from PTSD has
been poorly explicated in most treatment protocols, with little objective criteria
supporting the presence of a recovery state.
All of these complicated, interrelated factors have played into PTSD recovery. As a
broad health concept, recovery has implied regaining a normal state of functioning.
However, as the IOM panel (2008) noted in its report, there has been little information
available about the end state of PTSD recovery. Because of the scarcity of information, I
looked at a somewhat similar body of literature on recovery on chronic mental health
conditions, specifically schizophrenia. From this review of literature, core themes and
conceptual models of recovery emerged. Common threads included individual responses
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to the diagnosis, the struggle for wellness, and a return to an acceptable baseline. Some
models have also looked at community and institutional responses to the disorders. Two
large reviews of the mental health recovery literature (Bonney & Stickley, 2008; Onken
et al., 2007) explored many of these core themes and models of recovery. Findings from
the literature review were summarized in Tables 1 and 2.
Therapeutic writing, or bibliotherapy, has had a long history as a successful
treatment intervention for psychotherapy (Myers, 1998). Therapeutic writing can
facilitate healing and increase coping processes (Onken et al., 2007); help the victim form
a working alliance with a therapist (Peplau, 1952); perform valuable recordkeeping
functions, encourage reflexivity, and set the agenda for future client work (Moules,
2009b; Yalom & Leszcz, 2005); and demystify the illness and the therapy process
(Yalom & Leszcz, 2005). Both therapist and writer have regarded their works as
significant and believed that the process advanced therapeutic goals (Epston, 1994;
Freedman & Combs, 1996; Wood & Uhl, 1998). Pennebaker (1997), a psychologist who
has long studied the physiological and psychological effects of therapeutic writing, has
stated that the actual process of disclosure through writing speeds healing.
Changes in the internet and online technologies were also discussed. The onset of
Web 2.0 has allowed more interactivity and privacy for the development of secure, online
communities. These virtual communities have not only provided social connections for
individuals separated by geography, but also have advanced therapeutic goals. For
example, virtual communities have offered peer support, as in the case of veterans
groups, dispensed information about diseases or disorders, and provided structural social
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support during disasters. Virtual communities also have afforded convenient access to
individuals who have been willing to participate in online health care research.
Furthermore, I discussed the qualitative research, its origins, collection of personal
narratives, and the application of grounded theory methodology to analyze data. In
particular, I examined Charmaz’s (2006, 2009) second-generation constructivist
grounded theory, which was the method used for this study, and the evolution of
grounded theory generated by this method. Finally, the collection process of individual
recovery narratives and the application of grounded theory methodology to generate a
theory of PTSD recovery have been discussed in the next chapter.
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CHAPTER III
METHODOLOGY
This chapter describes the methodology that was used to conduct a qualitative
research study examining the recovery process from posttraumatic stress disorder
(PTSD). Data was collected as participant-submitted recovery narratives within a closed
website, which meant that only enrolled participants were able to access the website.
Social media sites such as Facebook and Twitter were used along with other methods for
recruiting study participants and updating them on recruitment. Grounded theory
methodology (Charmaz, 2006; Glaser & Strauss, 1967; Strauss, 1987; Strauss & Corbin,
1998) was used to explore the accounts of recovery from PTSD as self-reported by PTSD
victims, analyze the data, identify factors associated with recovery, generate theory, and
compile a timeline of recovery.
Overview
This research study was designed to address a deficiency in existing literature
regarding the process of PTSD recovery. The study used the qualitative research method
grounded theory. Individuals who regarded themselves as recovered or partially
recovered from PTSD were recruited and encouraged to write narratives of their recovery
processes. The study introduced the research participants to therapeutic writing as a
method by which they explored their personal PTSD recovery journey. The collected
narratives were then analyzed for common threads. The purpose of the study was to
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generate a grounded theory on the PTSD recovery process. Research questions, sampling,
and other topics related to the study are discussed in subsequent sections of this chapter.
Research Questions
The primary research question was: What is the basic psychosocial process that
men and women undergo in recovering from PTSD? Participants in the therapeutic
writing component of the study provided information that assisted in the formation of a
grounded theory describing the recovery process. In addition to expanding knowledge
about recovery process, the study fulfilled some secondary aims: (a) identifying which, if
any, elements of traditional therapy contributed to recovery and (b) establishing a
realistic timeline for recovery. The purpose of gathering and analyzing the data was to
expand knowledge regarding the sequence and length of PTSD recovery with the hope of
shaping efficacious treatments and interventions.
Sample Selection and Recruitment Efforts
To become research participants, potential enrollees had to consider themselves to
be currently functional in life roles (e.g., work and/or engaged in personal relationships).
Data was gathered from trauma survivors who have been given a psychiatric diagnosis of
PTSD and who reported at least partial recovery from the distressing symptoms of PTSD.
They may or may not have had formal treatment for PTSD. Since participants self-
enrolled in the study, this project was regarded as a convenience sample.
Participants who regarded themselves as recovered from PTSD were difficult to
find since they were active participants in their lives and were not visiting Veterans
Administration hospitals or community mental health clinics for treatment. Thus, a broad
internet-based effort was launched to locate study subjects.
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The social media used in this project included Facebook and Twitter. Facebook is a
free-access website that is the leading social networking site on the internet. It was used
to recruit participants for the study and provide updates on the study. Facebook users can
join networks organized by city, workplace, school, region, and common interests to
connect and interact with other people (Eldon, 2008). Within Facebook, users can add
friends and send them messages and update their personal profiles to notify friends about
themselves and their daily activities and current thoughts. Facebook currently has more
than 600 million users (Carlson, 2011).
Twitter offered social networking and microblogging, enabling its users to send and
read messages called “tweets” (@Biz, 2009). Tweets are text-based posts of up to 140
characters displayed on the user’s profile page. Users may subscribe to other users’
tweets, a practice known as following. Subscribers themselves are known as followers.
The first Twitter prototype was introduced in 2006 as an internal service for Odeo
podcasting employees (Arrington, 2006). Twitter has been estimated to have 190 million
users, generating 65 million tweets a day and handling over 800,000 search queries per
day (Quantcast, 2011). Twitter was also used for participant recruitment. Only one study
participant followed the study’s Twitter feed. For this reason, the Twitter feed contained
only three messages, all pertaining to continued recruitment of participants.
Moodle was the open source software used to structure the closed website. Moodle
is an open source course management system, also known as a learning management
system or a virtual learning environment. It has become very popular among educators
around the world as a tool for creating online dynamic web sites for their students
(Dougiamas, 2007; Dougiamas & Taylor, 2002). Open source software is computer
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software available in source code form for which the source code and certain other rights
normally reserved for copyright holders have been provided under a software license that
permitted users to study, change, improve and distribute the software at no cost
(Stallman, 2007).
Participants were solicited through a Facebook page about the project. The
Facebook page described the project and its aims and directed potential participants to the
closed website where they read instructions on how to enroll in the study. The Facebook
page was also used to update participants on study progress. Although Twitter was used
for recruitment, it did not prove useful in contacting participants. Most of the enrollees
learned about the project through direct solicitation of PTSD support groups. An email
account was set up specifically for this purpose. See Appendix A for details of email
communications for this study.
The informed consent, contained within the closed website, listed the inclusion
criteria for enrollment and described the project. Participants were excluded from the
project if they were under age 18 and had not received a diagnosis of PTSD. By self-
report, participants must have been recovered from PTSD for at least one year. No
participants seemed so emotionally fragile that they had to be encouraged to withdraw
from the project and to seek mental health services. There were no participants who were
not able to compose written English narratives, thus being excluded from the study.
At its end was a weblink where participants gave electronic consent, provided
demographic information, and provided trauma narratives. By submitting the informed
consent electronically, participants confirmed that they met the stated inclusion criteria.
The survey was constructed so that participants were not permitted to proceed unless they
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gave consent. While it was anticipated that each participant would submit only one
narrative, a few participants did submit addendums. These submissions were also
analyzed.
I also sent an emailed news release about the project to various local chapters of the
American Legion, Veterans of Foreign Wars (VFW), Wounded Warrior Project, and
similar organizations to inform them of the study and to encourage the organizations to
mention the study and its web address (i.e., uniform resource locator or URL) to
members in their newsletters and on their websites. In addition, I sent e-letters to various
domestic violence agencies to solicit victims of IPV. The intent of the mailing was to
“snowball” traffic to the website page. I also emailed writers forums looking for
participants. The recruitment news release is shown in Appendix B. A total of 113
agencies were contacted. National, rather than regional, participation was expected and
did occur, with several international submissions.
Within the closed website, the participant could participate in two different options:
(a) a written account of his or her personal recovery process submitted via email or (b)
free-texted narratives regarding recovery topics embedded within the electronic survey.
The online interface helped to provide an air of confidentiality and a layer of privacy to
shield participants who were disclosing painful events and dissecting their very personal
journeys of recovery for view by the researcher. The online forum originally intended for
group discussion was discontinued when participants preferred one-to-one
communication to protect privacy. I performed member-checking and theoretical
sampling using individual emails to participants. Information provided in the emails was
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used to triangulate data collected by written submission and to support a convergence of
analyzed evidence (Munhall, 2007).
Since it was impossible to compensate participants financially, I encouraged
participation by conceptualizing the written accounts of PTSD as significant literary and
research efforts. I regarded the participants writing PTSD recovery as authors rather than
research subjects and addressed them as research partners in communications. When
disinterest in group forums was shown, I discontinued efforts to persuade several well-
known published writers to conduct short writers’ forums in the discussion forum.
Finally, I decided not to offer study participants the opportunity to publish their recovery
accounts because of lack of interest and privacy concerns. In summary, the online
community served as a safe, supportive haven for the creation and discussion of trauma
and recovery narratives.
Methods
During the data collection phase, participants described their recovery journeys
through written submissions that were analyzed to produce a grounded theory of the
recovery process. Demographic information, including details of the victims’ treatment
history, and accounts of symptom abatement were also collected (see Appendix C).
Respondents voluntarily submitted a written reflection on their recovery process. The
replies were thorough and detailed; thus, I did not have to direct subsequent questions via
email to the participants to clarify certain points. Participants were asked to address the
following questions of interest:
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1) Please describe in your own words your personal journey in recovery from
PTSD. How long did it take you to recover? What effect did PTSD have
on your life and your family? How was your health affected?
2) Describe the event or events that led to your PTSD. What were your
symptoms of PTSD and what was their effect on daily life?
3) What, if any, professional treatments did you undergo to treat your PTSD?
How were they effective? Which treatments did you think were not
effective or were counterproductive?
4) What treatments did you devise yourself to help with your PTSD signs and
symptoms? Were they effective?
5) What role did spouses and significant others play in your recovery?
6) Outside of treatment professionals, who else played a significant role in
aiding your recovery? For example, did you use peer support groups and
find them helpful?
7) What drugs, including alcohol, did you use during your PTSD recovery?
8) Did any domestic violence occur? If so, describe.
9) When did you start the recovery process? Did you experience a turning
point or “snap moment” that you recall as beneficial?
10) Describe the timeline of your recovery. How long did it take for you to
realize that you were recovering? How did you know you were
recovering?
After the first six participants submitted the SurveyMonkey survey and composed
narratives, I noticed that 13 additional individuals had enrolled in the study but had not
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taken any action. I emailed them to see why they had not taken the survey. The replies
indicated that the idea of composing a narrative was too daunting or too time consuming.
I conferred with my dissertation chair, who suggested that I make the composed narrative
optional. Out of my ten original questions for narrative response, I eliminated seven,
which were already duplicated within the survey. I then incorporated three unduplicated
questions that could be answered by text entries within the survey. These questions are
numbers 37, 38, and 39 on the revised survey. Appendix C contains the original
demographic survey, while Appendix D shows the modified version.
From the first sampling, I also detected conflicting information on the efficacy of
medications for symptoms. With my dissertation chair’s guidance, I added three
questions to the survey to elicit more information about whether medications provided
symptoms relief and aided PTSD recovery. According to Charmaz, modifying the
interview as information emerges is an accepted technique in forming grounded theory.
Charmaz (2006) noted, “Like other skilled interviewers, grounded theory interviewers
must remain active in the interview and alert to interesting leads…. Interview questions
that allow the participant to reflect anew on phenomena elicit rich data” (pp. 32-33). The
additional questions are numbers 28, 29, and 30 contained in Appendix D.
Email contact information was provided for participants who had any questions
regarding the project in order to receive satisfactory answers before consenting. For
confidentiality, I assigned each participant an individual user name and password for
website access, which I used to enroll him or her in the study. As site administrator, I was
the only person able to access identifying information. Names and phone numbers were
not collected, and several participants used pseudonyms. Study enrollment instructions
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advised participants to use email addresses/names that masked their identity and to avoid
disclosing specific information in their narrative that would allow others to identify them.
As an added precaution, Moodle, the software used to develop the website, allowed
webmail addresses to be masked from all participants, which prevented study participants
from receiving unsolicited email from other enrollees.
Upon entering the website, participants could click on a link to an online consent
followed by demographic materials and survey questions on SurveyMonkey, an online
survey tool that enables researchers to create and post surveys. The demographic data
were collected in real-time and used to generate live graphs and charts. SurveyMonkey
permitted responses to be filtered, cross tabulated, and downloaded in multiple formats
(SurveyMonkey, 2009). SurveyMonkey also guaranteed the privacy of collected data.
The goal for the number of qualitative responses was concept saturation. Saturation
or redundancy can occur with fewer than 10 submissions or can require 30 submissions
or more (Munhall, 2007). As suggested by Charmaz (2006), I wrote my first draft when I
had received 31 submissions, before sampling ended. At that point, I conducted
theoretical sampling to attempt to saturate all categories.
One category of interest because of media attention was individuals who had been
exposed to combat PTSD. At 31 participants, I had only two respondents in that category.
After focusing solicitations to veterans groups, I was able to attract 3 more respondents,
for a total of five. I was also able to secure one participant who had experienced PTSD
from exposure to a manmade disaster. I was unable to secure a participant who had
experienced PTSD after being exposed to a natural disaster, the only category that had no
respondents. After reviewing the additional 10 interviews that came in after I had written
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my first draft, I saw that while the added information helped to strengthen my coding
categories, there were no new findings. Therefore, I stopped data collection after 41
submissions were received. After all data has been collected and analyzed and the
dissertation has been completed, participants will be asked in a follow up study to
provide feedback regarding the therapeutic writing component of the project.
Data Coding
Interviews were keyboarded and emailed to me by respondents. Participants who
had difficulty manipulating computer files were invited to submit written materials to a
post office box rented for this study; no participant used this method. No participants
were contacted regarding unclear or ambiguous submissions. They were all very
competent typists and wordsmiths. Written transcripts were analyzed using the constant
comparative method originally devised by Glaser and Strauss (1967) and reinterpreted by
Charmaz (2006). The coding process has been described in detail in the “Grounded
Theory Methodology” section in Chapter II. The transcripts were coded using NVivo, a
software program used to facilitate qualitative data analysis (QSR International, 2010).
By the constant comparison method, a full range of properties of the code were
developed and precise labeling emerged to describe those properties. Strict adherence to
constant comparison provided standardization and rigor to the analytical process (Patton,
2002; Strauss & Corbin, 1998).
Theoretical sensitivity was supported by my committee’s knowledge of extant
disciplinary theories and their relationship to the discovered, grounded categories (Glaser
& Strauss, 1967). Chair of the committee, Dr. Kathleen Scharer, has expertise in child
psychiatric and mental health issues, group therapy/support groups, web-based social
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support, and research of sensitive issues. These areas of research were directly applicable
to the web-based PTSD recovery study, which explores painful experiences via
therapeutic writing and Facebook. Dr. Mary Boyd and Dr. Beverly Baliko have research
interests in posttraumatic stress; substance use disorder; grief and trauma related to
violent death; domestic violence consequences of trauma and violence and mental health
interventions following traumatic loss or interpersonal violence; experiences of family
survivors of homicide; coping strategies of women survivors of life-threatening intimate
partner violence (IPV); intervention for survivors of traumatic loss; and women victims
of IPV-related homicide and suicide. Dr. Laura Hein has conducted research in lesbian,
gay, bisexual and transgender health disparities; youth homelessness; violence and
victimization; resilience; psychological empowerment; and internet sampling. All of the
previously mentioned committee members were from the College of Nursing. The final
committee member was Dr. Emily Wright, formerly of the Department of Criminology
and Criminal Justice at the University of South Carolina, who is currently at the
University of Nebraska. Dr. Wright’s research interests included intimate partner
violence, female offenders, and gender issues in theory and corrections.
Analysis was ongoing during the course of the study as each PTSD recovery
account was received. I was the primary coder for the project. All of my submissions
appeared to be genuine and consistent with the intents of the project. I did not flag any
suspicious or confusing entries for review by a second reviewer from my committee. I
found no individual accounts that were judged incongruent with other written accounts
(e.g., factitious submissions) and thus, no submissions were excluded from analysis.
Since trauma incidences cannot be corroborated, self report had to suffice. In summary,
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there were no submissions that did not seem to be authentic and I did not have to refer
any narratives to my committee for a second opinion regarding inconsistencies.
Trustworthiness
When the findings of qualitative research were first being assessed, the terms
objectivity and subjectivity were used to signify research that was conducted with rigor.
These terms were soon rejected as being not sufficiently precise. Lincoln and Guba
(1985) advanced a number of techniques or processes to be used in qualitative research to
make it more likely that credible findings and interpretations would be produced:
prolonged engagement, persistent observation, and triangulation; peer debriefing (to
provide an external check of the inquiry process); negative case analysis; referential
adequacy; and member checking with the direct sources of the data.
Lincoln and Guba (1985) asserted that worthwhile qualitative research had four
qualities: credibility, that the findings were a true representation of the data and processes
being examined; transferability or provision of the thick description necessary to enable
another researcher to make transferability judgments; dependability, based on whether
the findings are supported by the data; and confirmability, as supported by a rigorous
audit trail and by triangulation of data. Patton (2002) stated he preferred to use the terms
trustworthiness and authenticity to discuss credible findings induced by rigorous
methods. Rolfe (2006) agreed and used the terms, validity, trustworthiness, and rigor to
apply to quality research; he advocated that a qualitative researcher include a reflexive
research diary along with published findings. The following sections have examined
credibility and dependability as valid indicators of trustworthiness.
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Credibility. In the earliest days of naturalistic inquiry, qualitative research was
rejected as untrustworthy because it lacked the controls or randomization procedures
characteristic of quantitative research. Since that time, however, conscientious
researchers have successfully asserted that qualitative research can be conducted with
rigor and demonstrate “truth value.” Lincoln and Guba (1985) described the qualities of
rigorous naturalistic research as follows:
The naturalist must show that he or she has represented those multiple
constructions adequately … that [they] are credible to the constructors of the
original multiple realities. The operational word is credible. The implementation of
the credibility criterion—the naturalist’s substitute for the conventionalist’s internal
validity—becomes a two-fold task: first, to carry out the inquiry in such a way that
the probability that the findings will be found credible is enhanced and, second, to
demonstrate the credibility of the findings by having them approved by the
constructors of the multiple realities being studied. (p. 296)
In a similar vein, Lincoln and Guba (1985) suggested that transferability, or
similarity between two contexts, is the naturalistic equivalent of external validity, the
utility or applicability of findings beyond the cases studied. Qualitative researchers have
not been required to provide an index of transferability, but rather provided the database
that permitted the judgment of transferability by others. According to Lincoln and Guba,
the term dependability has been used instead of reliability to explain factors that are
associated with observed changes over time. Qualitative researchers have also substituted
the term confirmability—the degree to which the results could be confirmed or
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corroborated by others—for the quantitative term objectivity, which implied value-free
observations.
Lincoln and Guba (1985) offered naturalistic researchers several means for
operationalizing trustworthiness criteria. Activities that have made it more likely that
credible findings have been produced include prolonged engagement, persistent
observation, and triangulation. Prolonged engagement has meant investment of sufficient
time to learn the culture, test for misinformation, and build trust (Lincoln & Guba, 1985).
The PTSD study supported prolonged engagement, taking place over seven months using
a public interface. I had numerous opportunities to compare and contrast Facebook
message board discussion on PTSD sites with submitted peer accounts of recovery.
Through persistent observation, in this case, continual analysis of written accounts
and checking of trauma message boards and blogs, I identified and assessed salient
factors and crucial atypical events regarding the content and meaning of the written
accounts (Lincoln & Guba, 1985). This focus helped me to rule out irrelevancies and
tentatively identify important findings. Triangulation, or confirmation of findings with
multiple sources, resulted by comparing blog and message board postings to written
submissions, by comparing written accounts to news or literary accounts written during
the time of the trauma, by comparing collected demographic information with accounts in
the literature. I triangulated with multiple investigators by consulting my dissertation
committee. I also compared the narratives of participants who experienced certain types
of trauma with accounts from others who shared the same traumatic experience. Using all
of these procedures, I achieved contextual validation to reduce errors in my
interpretation.
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Peer debriefing was an activity that provided an external check on the inquiry
process (Lincoln & Guba, 1985). The purpose of peer debriefing was to explore aspects
of the inquiry that may be implicit in the researcher’s mind. Debriefing can help to keep
the researcher unbiased, clarify the basis of interpretations, test evolving working
hypotheses, develop and initially the test the next steps in the emerging theory process,
and provide the researcher with catharsis (Lincoln & Guba, 1985). Although Lincoln and
Guba recommended that dissertation committees not perform this function lest they
unduly influence the outcome, I believe that my committee performed this role with
integrity. The members of my committee amply met Lincoln and Guba’s admonition that
the debriefers be experts in the “substantive area” of the inquiry and in qualitative
methodology. Charmaz (2006, 2009) supported my opinion, pointing out that continuous
interdisciplinary review of data and findings is a respected contemporary research
technique. While in concord with all methods of external rigor, Morse et al. (2002)
exhorted investigators to assume the primary responsibility for trustworthiness
themselves.
Negative case analysis, the process of revisiting hypotheses, helped to refine
working hypotheses as more and more data were analyzed (Lincoln & Guba, 1985). The
object of negative case analysis is to refine a hypothesis until, as Lincoln and Guba
stated, it accounts for all known cases without exception. Negative case analysis requires
that the researcher look for disconfirming data in past and future observations; by this
process, outliers and exceptions are eliminated until the “fit” is perfect (Cressey, 1953).
A single negative case is enough to require the researcher to revise the hypothesis. I
received no submissions that differed substantively from the others. Moreover, my
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committee functioned in this role, pointing up flaws and inconsistencies in my
interpretations of data.
Finally, member checking can help provide a direct test of findings and
interpretations (Lincoln & Guba, 1985). In this process, research participants can review
analytic findings, interpretations, and conclusions and determine whether the
reconstructions are recognizable to them as authentic representations of reality. Lincoln
and Guba considered member checking to be the most crucial technique for establishing
credibility. Member checking offered research participants the chance to assess correct
errors, volunteer more information, affirm the correctness of interpretations, and rate the
overall adequacy of a construction.
As was mentioned in the “Grounded Theory Methodology” section previously, the
researcher should also conduct member checks, e.g., showing memos and asking for
feedback from research participants, during the sampling process to help validate findings
and interpretations. Charmaz (2006) has noted that member checks are an accepted and
expected practice; the researcher can successfully perform member checks
simultaneously along with theoretical sampling to saturate a category. I used member
checks and consulted with two PTSD experts to confirm the fit of the final PTSD
Recovery Model, as is discussed in Chapter IV.
Dependability. According to Lincoln and Guba (1985), credibility cannot exist
without dependability. Thus, Lincoln and Guba stated, the demonstration of credibility
has established the presence of the latter, i.e., the application of techniques to ensure
credibility and quality in a study obviate the need to implement additional dependability
checks. However, there are certain techniques such as overlap methods, stepwise
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replication, and the inquiry audit that have helped to validate dependability. The PTSD
study was small enough in scale and scope that overlapping methods and stepwise
replication by two teams of researchers were impractical. However, use of an audit trail
very much bolstered the dependability and confirmability of this study.
An audit trails examines two aspects of qualitative research, according to Lincoln
and Guba (1985) . First, an audit trail examines the process by which research is
conducted with the intent of identifying inaccurate or shoddy research practices. Second,
the audit trail examines the product of the research for accuracy of findings. Halpern
(1983) detailed the classes of raw records to be audited: raw data, data reduction and
analysis products, data reconstruction and synthesis products, process notes, materials
relating to intentions and dispositions, and instrument development information. Many
qualitative studies will not produce documents in all categories. Halpern also outlined
five stages of the audit process: preentry, determination of auditability, formal agreement,
determination of trustworthiness, and closure. According to Halpern, the audit trail must
be complete, comprehensible, useful, and linked to the methodological approaches.
The determination of trustworthiness by the auditor is the most detailed stage. From
the audit trail, the auditor must be able to reach a judgment about whether the findings
are grounded in the data as demonstrated by appropriate audit trail linkages (Halpern,
1983). Steps in this process include sampling findings to ensure that they can be linked
directly to interview notes, document entries, and other reference notes. The auditor will
also judge whether inferences based on the data are logical, assessing analytic techniques
used, appropriateness of category labels, and the possibility of likely alternative
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explanations. Other tasks of the auditor include examining the utility of the category
structure; its clarity and explanatory power; and its fit to the data (Halpern, 1983).
The auditor should examine the degree and incidence of inquirer bias;
overimposition of a priori theoretical concepts; and presence or absence of introspections
(Halpern, 1983). Finally, the auditor confirmed efforts such as triangulation used to
insure confirmability and the handling and accommodation of negative evidence.
Examination of the appropriateness of all inquiry decisions and processes will help the
auditor to make an overall decision on a study’s confirmability and dependability
(Halpern, 1983). In my PTSD study, my committee members, who are very familiar with
qualitative inquiry, served as auditors of my methodology and resulting decisions. In
addition, NVivo helped in maintaining an extensive audit trail of memos and coding
decisions.
To insure dependability, Lincoln and Guba (1985) recommended that the
naturalistic researcher maintain a reflexive journal, a diary in which information about
method and self is recorded regularly. This diary should contain a personal diary to
provide catharsis and reflection upon one’s own interests and values and a log of
methodological decisions and rationales. Charmaz (2006, 2009) seconded this suggestion,
advocating writing extended notes, or memos, on telling codes and interpretations
through the grounded theory process. In this project, I wrote detailed memos on the first
nine narratives. From that point on, my audit trail consisted of the line-by-line and
focused coding of 253 separate pieces of narrative in NVivo and detailed classification
and categorization in SurveyMonkey. Preliminary, intermediate, and final coding
categories are contained in Appendix E.
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Data Analysis
In addition to the coding and constant comparison methods of data analysis detailed
above, written submissions were compared to other online forum discussions for
consistency and discrepancies. Triangulation is a research strategy that combines
different research methods, data sources, theoretical perspectives, or other approaches
within a single study to validate findings (Munhall, 2007). Multiple measures are
employed in triangulation in an attempt to achieve convergence on a single concept
(Breitmayer, Ayres, & Knafl, 1993; M. E. Duffy, 1987; T. M. Duffy & Jonassen, 1992;
Hinshaw, Feetham, & Shaver, 1999). Triangulation has resulted in a more comprehensive
description of the topic being researched, confirmed data findings, affirmed completeness
of the data set, and increased trustworthiness in the findings (Breitmayer et al., 1993;
Hinshaw et al., 1999). In this study, within-methods triangulation was used, comparing
qualitative data obtained from written submissions to other written submissions and
postings in general public forums.
The collected demographic data were analyzed using descriptive statistics. Data
were stratified by age, type of traumatic event, and other criteria to determine sample
differences. Demographic findings have been presented in Chapter IV and discussed in
Chapter V.
Budget and Time Frame
The total budget was approximately $400 for website hosting and software costs
and miscellaneous expenses. I prepared a personal webpage, hosted on Google Sites,
explaining the project and containing useful links. The first draft of the project report was
written in three months and the project was completed in 12 months
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Potential Limitations
At the project’s start, I considered some of the following potential limitations
included in the study proposal. There could be limited interest in the project or lack of
feedback from PTSD victims, although I discovered that lags in participation were
successfully countered through periodic recruitment notices in social media and sent to
special interest groups. Written accounts of recovery could have varied so much that it
would impossible to find common threads to generate grounded theory. Fortunately, the
written accounts were remarkably consistent. Falsified accounts could have been
submitted in the written accounts. However, none were detected. Falsified demographic
measurements could have been received; however, no significant scoring differences
were identified during statistical analysis or during comparison with a comparable mental
health database. Participants did prove to be uninterested in the public writing forum or in
sharing their narratives with others than me, so that portion of the project was dropped.
Protection of Human Subjects
Subjects for this study had to be age 18 or older and able to consent of their own
free will, possessing no mental or physical disorder that would prevent informed consent
or understanding of study. Subjects had to be English-speaking and able to participate
physically in a computerized study. They all had a prior clinical diagnosis of PTSD,
considered themselves as at least partially recovered from the diagnosis, and were
capable of responding to questionnaires concerning their disorder.
The online consent, shown in Appendix F, contained the following information:
1. Voluntary nature of participation
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2. Instructions that participants were free to withdraw from the study at any
time.
3. A statement that there were no consequences for withdrawing from the
study.
4. Description of the study, its purpose and duration, procedures that were
followed, and their purposes
5. The exact nature of participation.
6. Description of any discomforts and risks.
7. Description of benefits.
8. An offer to answer any questions at any time with provided email address.
9. Criteria for removal from the study or ejection from the study.
10. Statement of confidentiality and exceptions to confidentiality.
11. Procedures for protection of confidentiality and security of data.
12. A place for the participant to sign and date.
13. A heading stating that it was an Informed Consent Form.
14. A statement that the participant could print a copy of the consent form.
15. A statement that since the consent was electronic, the participant waived a
witness.
The proposal was approved by the Institutional Review Board (IRB) at the University of
South Carolina on July 1, 2011. The dissertation was defended June 13, 2012.
Report of Adverse Events
Because of its noninvasive nature, it was not anticipated that this intervention
would cause any harm to participants. However, it was possible that adverse events or
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unanticipated problems resulting in social or psychological harm rather than physical
harm could occur among study participants or others. Although study participants might
regard themselves as recovered from PTSD, it was possible that participation in the
project could cause them to decompensate. Therefore, links to information concerning
recurrence of PTSD symptoms and suggestions as to where support could be found in the
local community were displayed prominently on the study website and my personal
website. There was also additional information concerning the project and its aims. No
participants showed any signs of distress throughout the study.
Since information was gathered confidentially, I did not collect names or phone
numbers. If I saw any possible instances of child or elder abuse or risk for suicide, I was
to email the participant and encourage them vigorously to contact mental health providers
or law enforcement. Should such an event be directly reported by a participant, as
required, I was to report the occurrence to my committee as soon as possible and to the
University of South Carolina Institutional Review Board within 10 days. No such events
occurred during data collection.
Client Confidentiality
Confidentiality was maintained by coding all submissions with an identification
number and replying to email on my password-protected home computer. Although
phone interviews were not planned, if required, they were to be conducted by me from a
private setting. No phone interviews were necessary. While it was possible for a
participant to submit a narrative using a pseudonym, some participants could be initially
identified by using their personal email accounts. I removed personal information from
these submissions and gave them a code number for identification prior to analysis. No
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names appeared on narratives shared with committee members. Names corresponding to
identification numbers were kept in a separate locked file at my home. Access to
individual data was available only to me, my dissertation chair, and members of my
committee. Identities were not disclosed to my committee.
At the completion of the study, names corresponding to the ID numbers were
destroyed. All data spreadsheets with potentially identifiable information were destroyed.
The Facebook page, Twitter account, study website, Gmail account, and SurveyMonkey
survey and account for the study were all terminated by June 15, 2012.
No transcripts were needed in this study. No audiotapes or videotapes were made in
this project. There were no violations of client confidentiality that required
communication to my dissertation chair or committee.
Summary of Data Handling and Monitoring Measures
To insure data quality and integrity, I was the only person interacting with
research participants and collecting data for them.
I followed all procedures for clarifying issues and reporting adverse events.
My dissertation committee supervised me to ensure consistent collection methods
and adherence to grounded theory protocol.
I cross-checked my data frequently for coding errors and inconsistencies.
I entered my coding system, memos, notes, and other pertinent materials into
NVivo, a manageable data management system. I made backup copies of all
analyses at frequent intervals.
SurveyMonkey software was also used for data management, analysis, and
reporting of descriptive statistics.
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All data was kept on a password-protected personal computer located in a home
office. I was the only person on premises using this computer. The computer had
a firewall to protect viruses. Viruses were screened for whenever the computer
was restarted with Avast antivirus software. All jump drives and external hard
drives were locked in a fireproof file at the residence.
Analyses were stored in a locked file and were accessible only upon request by
my committee members.
Dr. Abbas Tavakoli reviewed my demographic findings for accuracy and
completeness. After data entry, I placed all printed materials in locked storage.
Backup copies of all data files were created both on and off premises in a very
secure location. Additional copies were stored on a password protected external
drive and on a password protected flash drive (Tavikoli et al., 2006).
Findings from the study will be presented in Chapter IV. The findings will include
demographic data and findings concerning the participants’ trauma experiences.
Discussion of the demographic and narrative findings will be contained in Chapter V.
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CHAPTER IV
RESULTS
This chapter contains the findings of the quantitative demographic and trauma
recovery information. It also contains qualitative written responses and narratives
gathered from participants in this study. The participants represented a cross section of
trauma survivors who have negotiated varying degrees of recovery after their exposure to
trauma.
Data Sample and Sample Characteristics
Data collection started on July 15, 2011 and ended on December 7, 2011. During
that time, 113 agencies and websites that dealt with trauma victims were contacted. From
these solicitations, 61 individuals asked to be enrolled in the study and admitted to the
closed study website. Of these, 41 (67.2%) completed the study’s survey and answered
open-ended questions about their recovery experiences. The survey’s questions focused
primarily on three areas: demographic characteristics, dimensions of trauma, and
recovery factors. The demographic and trauma survey findings will be discussed first in
this chapter. The qualitative findings and subsequent grounded theory that resulted have
been discussed later in this chapter.
Personal and Demographic Findings
The personal and demographic findings of individuals participating in this study
showed that the group possessed many similarities, yet there were also a few noticeable.
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differences in several categories. Table 4.1 shows the demographic data for national
origin, sex, ethnicity, race and age. Although most were Americans (87%), participants
did enroll from across the world. There were several Australians and one person from
Wales who enrolled in the study. One respondent declined to specify gender. The
disparity in response rates to the gender question likely reflected gender differences in the
occurrence of posttraumatic stress disorder (PTSD) and has been discussed in Chapter V.
Table 4.1
Frequency Distributions of Demographic Attributes (N=41)
Characteristic n %
National Origin
United States 37 90.2
Australia 3 7.3
Wales 1 2.4
Gendera
Male 9 22.5
Female 31 77.5
Are you Hispanic or Latino?
No 38 92.7
Yes 3 7.3
Which of the following ethnic groups do you
consider yourself belong to?
Black or African American 2 4.9
White 38 92.7
Other 1 2.4
Age N Mean SD Range
41 44.2 12.38 27-70
a
One participant declined to specify gender.
Other demographic data showed some interesting results. One finding regarded the
number of individuals (35%) who lived alone. The educational attainment of the
participants was greater than normally expected, with 80.5% having graduated from
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college or attended graduate school. Detailed findings on marital status, family traits,
religion and educational attainment are displayed in Table 4.2.
Table 4.2
Frequency Distributions of Questions on Marital Status and Family Characteristics

(N =41)
Characteristic n %
Marital status
12 29.3
Single
15 36.6
Married
4 9.8
Living with Partner
2 4.9
Separated
6 14.6
Divorced
1 2.4
Widowed
1 2.4
Survivor of deceased partner
Current living situationa

Living alone 14 35.0
Living along with service dog 1 2.5
Living with spouse/partner 10 25.0
Living with spouse/partner and children 7 17.5
Living alone with children 4 10.0
Living with friends/family 3 7.5
Living with spouse, family, and children 1 2.5
Number of childrena
0 children 17 44.7
1 child 2 5.3
2 children 10 26.3
3 children 7 18.4
4 children 1 2.6
8 children 1 2.6
Number of children < 18 living at homea
0 child 26 68.4
1 children 4 10.5
2 children 6 15.8
3 children 1 2.6
4 children 1 2.6
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Table 4.2
Frequency Distributions of Questions on Marital Status and Family Characteristics

(N =41) (continued)
Characteristic n %
Number of adults living at home with youa, b
0 adults 14 35.9
1 adult 19 48.7
2 adults 3 7.7
3 adults 3 7.7
Are any of your dependents over 18? a
No 28 75.7
Yes 9 24.3
Highest educational levelc
High school graduate 8 19.5
College graduate 10 24.4
Graduate school and/or graduate degree 23 56.1
Religion
Christian 26 63.4
Muslim 1 2.4
Jewish 1 2.4
Buddhist 2 6.4
Mormon 1 2.4
“Spiritual” 1 2.4
No specific religion/not religious 9 22.0
a
Some respondents did not answer these questions.
b
Three respondents characterized adults who lived with them as “temporary” or
“intermittent.”
c
There were no respondents who did not finish high school.
Demographic data about employment and financial status are found in Table 4.3.
When asked whether they were working in the same job that they had when they
experienced their trauma, only two people (6.7%) were in the same position. Those who
had different jobs were asked whether they considered their current job to be worse or
better than the job held when they experienced trauma. Fifteen participants (83.3%)
reported that they were in better jobs.
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When asked about financial matters, 33 participants (82.5%) said that they had
enough money to meet their needs. In reply to the question whether they had enough
money to meet emergencies, 28 participants (68.3%) replied that they did have enough
money to cover emergencies. Twenty-six participants (63.4%) stated that they were not
receiving and had not applied for public assistance or welfare. Discussion regarding
personal and demographic findings will take place in Chapter V.
Table 4.3
Frequency Distributions of Questions on Work and Financial Status (N=41)
Characteristic n %
Do you have a paying job?

19 46.3
No
22 53.7
Yes
If you do have a paying job, how many hours a
week do you usually work?a
0-20 5 20.8
21-40 10 41.7
40+ 9 37.5
Are you working in the same job that you had
when you experienced trauma?a
No 28 93.3
Yes 2 6.7
If you are working in a different job, do you
consider it to be worse or better than the job
you had when you experienced trauma?a
Worse 3 16.7
Better 15 83.3
Are you the head of household?
No 13 31.7
Yes 28 68.3
Do you have enough money to meet your
needs? a
No 7 17.5
Yes 33 82.5
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Table 4.3
Frequency Distributions of Questions on Work and Financial Status (N=41) (continued)
Characteristic n %
Do you have enough money to meet
emergencies?
No 13 31.7
Yes 28 68.3
Type of public assistance or welfare received a,
b, c
General Assistance or welfare

Specific aid for childrend 1 3.4
Unemployment benefits 2 6.8
SSI (Supplemental Social Security Income) 3 10.3
SSD (Social Security Disability Insurance) 4 13.8
Food stamps 8 27.6
Veteran’s benefits 3 10.3
Social Security Retirement Benefits 5 17.2
Retirement benefits from a private 4 13.8
company, municipal/state government, or 3 10.3
other entity
a
b
Percentages do not add up to 100% because of multiple sources of income.
c
No participants reported receiving any workers compensation or WIC (Women, Infants,
Childrens’ Program) support.
d
One respondent received Medicare for a minor child, while another received child
support.
In the next section, findings regarding traumatic experiences will be discussed.
Findings on Trauma Exposure and Resultant PTSD
In this section of the survey, participants were asked to disclose details about
exposure to trauma, resultant PTSD symptoms, and other quantifiable dimensions of
recovery from PTSD. Participants first responded about the type of trauma to which they
were exposed. Twenty-one participants (51.2%) reported one type of trauma only, while
20 (48.8%) said their PTSD resulted from exposure to two or more types of trauma. Of
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the multiple trauma reports, eight participants had experienced childhood abuse
combined with at least one other type of abuse, yielding a total of 16 participants (39.0%)
in the study having experienced childhood sexual and/or physical abuse.
The other major category was sexual assault, rape, and/or violence with 5
participants (12.2%) reporting exposure to sexual assault as their sole traumatic events.
Of those experiencing multiple traumas, 13 participants (31.7%) reported the occurrence
of sexual violence and/or trauma in conjunction with another type of trauma. More details
on the trauma types and frequencies in contained in Table 4.4.
Table 4.4
Frequency Distribution of Type of Traumatic Exposure (N=41)
Category of Trauma n %a
Exposure to childhood abuse or sexual trauma with 16 39.0

delayed onset of PTSDb
Sexual assault or rape from a strangerc 3 7.3

Sexual assault, rape, or violence experienced in a 18 43.9
relationship with a spouse or intimate partner
Exposure to crime or violent personal assault on 3 7.3
yourselfd
Exposure to combat, war, or being stationed in a war 5 12.2
zone while in military service
Exposure to combat, war, or living in a war zone as 1 2.4
a civiliane
Exposure to a manmade disaster such as an 1 2.4
automobile or airplane accident, hostage event,
kidnapping, terrorist attack, mass shooting, etc.
Other
Chronic life triggers and events 1 2.4
Witnessing suicides/suicide attempts 2 4.8
Medical trauma 3 7.3
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a
Percentages do not add up to 100% because of the occurrence of multiple traumas.
There were 21 reported multiple traumas, primarily a combination of childhood and adult
physical/sexual abuse (or both) occurring with another trauma category.
b
Category was expanded to include childhood-onset PTSD.
c
Category also included known persons with whom the participant did not have an
intimate relationship.
d
Category included cyberstalking and workplace violence.
e
Category included one respondent who identified himself as a Lost Boy of Sudan.
Participants were then asked about frequency and length of traumatic exposure. The
longest reported interval was 42 years (or since 1969) for one Vietnam veteran now in his
seventies.
Regarding symptoms, respondents displayed all of the DSM-IV symptoms, with
many reporting multiple symptoms occurring simultaneously. The most frequently
reported symptom was emotional numbness, especially with people with whom the
participants were once close. Details regarding frequency and length of exposure to
trauma, persistence of PTSD symptoms, and symptoms experienced are in Table 4.5.
Table 4.5
Frequency Distributions on Frequency/Length of Trauma Exposure, Persistence of PTSD

Symptoms, and Symptoms Experienced (N=41)
Frequency of exposure to traumatic events a n %
Once 4 10.0
2-4 1 2.5
6-10 2 5.0
11-25 1 2.5
Repeatedly or daily for less than a year 7 17.5
Daily or repeated trauma occurring for greater than 18 45.0
one year
Othera 7 17.5
Length of time PTSD symptoms experienceda n %
3 months – 1 year 2 6.7

2 years 2 6.7
3 years 4 13.3
4 years 1 3.3
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Table 4.5
Frequency Distributions on Frequency/Length of Trauma Exposure, Persistence of PTSD

Symptoms, and Symptoms Experienced (N=41)(continued)
Length of time PTSD symptoms experienceda (continued) n %
5 years 5 16.7
Greater than 5 yearsb 16 53.3
Type of PTSD symptoms experienced n %
Emotional numbness, especially with people with 36 87.8

which you were once close
Sleep problems 34 82.9
Feeling detached or dissociated from reality 33 80.5
Anger 33 80.5
Prolonged depression or apathy 33 80.5
Was easily startled 31 75.6
Exhibited agitated or disorganized behavior 31 75.6
Confusion 28 68.3
a
b
Abuse time frames specifically cited by participants included 3, 7, 8, and 22 years.
c
Time frames specifically cited by participants who experienced symptoms included 6, 7,
8, 10, 13, 14, 15, 25, 35, and 42 years.
Participants were asked about the personal consequences of experiencing PTSD
symptoms. Thirty-six participants (an overwhelming 90.0%) reported experiencing
damage to self-image as a result of PTSD symptoms. Participants were queried regarding
abuse or use to excess of alcohol, drugs, or exhibition of risky behaviors while
experiencing PTSD symptoms. The two highest categories each contained 20 individuals
(50%). The first category was using food, including excess eating, deprivation, and
binging/purging and the second was using alcohol while experiencing PTSD symptoms.
Only five participants (12.5%) reported abusing or misusing prescription drugs, including
pain pills and antianxiety drugs. Details about specific categories on the consequences of
PTSD symptoms and substance abuse and risky behaviors are contained in Table 4.6.
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Table 4.6
Consequences and Behaviors Associated with PTSD Symptoms (N=41)
Consequences of PTSD symptomsa n %
Damage to self-image 36 90.0

Loss of former friends 29 72.5
Loss of hobbies and leisure pursuits 25 62.5
Family discord or strife 23 57.5
Job loss or inability to hold down permanent work 19 47.5
Self-injurious behavior or damage to physical health 18 45.0
Otherb 14 35.0
Financial problems, including bankruptcy 14 35.0
Alcohol abuse 14 35.0
Marital discord including separation and divorce 14 35.0
Impaired relationship with children 11 27.5
Disruption of education 11 27.5
Drug abuse, including marijuana use 9 22.5
Legal issues and/or arrests 6 15.0
Substance Abuse and Risky Behaviors related to n %

PTSD Symptomsa
Food, including excess eating, deprivation, and 20 50.0

binging/purging
Alcohol 20 50.0
Risk-taking behaviors such as driving your car or 14 35.0
motorcycle at excessive speed, going into dangerous
sections of town alone, etc.
Working excessively long hours by choice 13 32.5
10 25.0
Did not abuse alcohol or drugs or exhibit risky
behaviors
Out-of-control sexual behavior, including risky 10 25.0
behaviors and multiple affairs
Nicotine, including cigarettes and smokeless tobacco 9 22.5
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Table 4.6
Consequences and Behaviors Associated with PTSD Symptoms (N=41)

(continued)
Substance Abuse and Risky Behaviors related to PTSD n %

Symptomsa (continued)
Marijuana 6 15.0
Prescription drugs, including pain pills and antianxiety 5 12.5
drugs (please specify)c
Cocaine 2 5.0
Methamphetamine 2 5.0
a
b
Other responses included damage to family life, decreased quality of life, financial
difficulties, chronic health issues, difficulty fulfilling work and family roles, trust issues,
and guilt for actions. These are described later in this chapter.
c
Drugs specifically mentioned included Soma, trazodone, Ambien, Lorcet, Xanax, and
Lunesta; herbs misused included ephedrine; and one respondent reported huffing
compressed air.
Participants were asked how long it took to start feeling better after experiencing a
traumatic event. Nineteen participants (47.5%) reported that it took five years or longer
before they started feeling better. Participants were also asked when they felt the worst.
Eleven participants (27.5%) said that they felt the worst after five years or more, while 14
respondents (35%) said that they felt the worst between six months to two years.
Participants were also asked when they felt recovered from PTSD. More than
half—25 participants or 64.1%—reported that they felt recovered after five years or
more. When the three individuals (7.7%) who reported recovery during the four-year to
five-year interval were added in, it became apparent that PTSD is a long-lived disorder
with 71.8% of the participants taking four or more years to recover.
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When asked which person, group, or event was most helpful in their recovery
journey, participants reported that professional counselors such as psychiatrists,
psychiatric nurses, psychologists, or social workers were the most valuable resources.
The effect of symptoms, the time needed to feel better and recover from PTSD, and the
role of helpful healing allies and treatments are discussed in more detail in Table 4.7.
Table 4.7
Symptom Persistence, Treatment, and Recovery Factors of PTSD (N=41)
Length of time before feeling better post-traumaa n %
Greater than 3 months to six months 1 2.5

Greater than 6 months to 1 year 3 7.5
Greater than 1 year - 2 years 5 12.5
Greater than 2 years - 3 years 3 7.5
Greater than 4 years -5 years 5 12.5
Greater than 5 yearsb 19 47.5
When did you feel the worst?a n %

A few days to 3 months 6 15.0
Greater than 3 months to six months 1 2.5
c
Greater than 5 years 11 27.5
Length of time required to feel recovered from n %

PTSDa
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Table 4.7
Symptom Persistence, Treatment, and Recovery Factors of PTSD (N=41) (continued)
Length of time required to feel recovered from n %

PTSDa (continued)
d
Greater than 5 years 25 64.1
Person, group, or event most helpful in recovery n %

journeya
Professional counselors such as psychiatrist, 14 35.0

psychiatric nurse, psychologist, or social worker
Othere 11 27.5
The passage of time 4 10.0
No one; I recovered through my own efforts 4 10.0
Friends 3 7.5
Peer groups of other people who had undergone the 3 7.5
same trauma
Clergy, prayer groups, or other faith-based 1 2.5
counselors or groupsf
a
b
Participants detailed a lengthy period before feeling better post-trauma, with the longest
reported period being 32 years.
c
Participants detailed a lengthy period of experiencing symptoms with the longest
reported interval being 42 years.
d
Participants detailed a lengthy period of time before recovery, with the longest reported
interval being 25 years. Several responses dealt philosophically as to whether recovery is
a valid objective.
e
Eleven respondents wrote narrative answers to this question. Of these, eight combined
professional clinicians with other treatments.
f
The categories “spouse or significant other,” “your children,” and “kin, including
parents, siblings, cousins, etc.” received no responses.
In summary, this section involved questions that attempted to describe the
dimensions of the trauma experienced by individuals and resultant PTSD. Respondents
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were primarily American, White, and female with a mean age of 44.2 years. More than
one-third of them were married and living with a spouse. More than half of the
participants had children, with about 30% of the participants having children who lived at
home. Over 80% of the respondents had graduated from college and the majority had
attended graduate school or graduated with a graduate degree. Of the sample, 63.4% were
Christian. Around half of the sample had a paying job with the majority of those working
20-40+ hours a week. Almost 85% of those who responded said that they were in better
jobs than they held when they experienced their trauma.
Over 80% of the sample said that they had enough money to get by, and almost
70% said that they had enough money to meet emergencies. Over 60% of the sample had
not requested and were not receiving any form of public assistance or welfare. Over half
of the respondents had experienced a single source of trauma or abuse while the others
had been exposed to two or more types of abuse or trauma. The largest category of abuse
was child abuse. Over 60% of the participants had experienced daily or repeated trauma
for greater than one year. Seventy percent of the respondents experienced symptoms of
PTSD for five years or longer. They displayed the gamut of PTSD symptoms, with
emotional numbness, sleep problems, and flashbacks being the three most frequently
experienced symptoms.
Participants overwhelmingly reported experiencing damage to their self-image
because of PTSD symptoms. Many also lost former friends. About half of the sample
reported abusing food or alcohol in an attempt to cope. Almost 60% percent reported that
it took four years or longer to feel better after exposure to trauma; 64.4% said that they
felt recovered after five years or more. Participants named professional mental health
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clinicians as being their most useful helping ally. The passage of time and self-reliance
also played roles in recovery.
While this proportion of the survey attempted to quantify measurable dimensions of
the trauma experience and recovery, participants also answered subjective questions
about the impact that trauma had on their lives. Participants were asked probing questions
and produced trauma narratives and comments about recovery. These findings, which
resulted in a grounded theory model describing recovery, are discussed in the next
section.
Participant Narratives and the Resulting PTSD Recovery Model
From the narratives, I used Charmaz’s techniques to cluster the narrative categories
into ten initial classifications. Memos written within NVivo helped me to flesh out the
dimensions of various categories. The narratives were broken into 253 separate codes,
which were sorted into ten initial broad classifications. Using NVivo, I then collapsed the
ten categories into five final stable groupings. I also used SurveyMonkey’s word analysis
feature, which searches for and clusters related words, to help refine categories. Both of
these methods helped to define the categories and collapse themes into the final concepts.
The clustering of coding concepts that yielded the final categories is shown in Table 4.8.
Table 4.8.
Clustering Coding into Final Categories
First Set of Categories Final Category

Denying trauma
Dealing with abuser and abusers Experiencing Trauma
Feeling vulnerable
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Table 4.8.
Clustering Coding into Final Categories (continued)
First Set of Categories Final Category

Intruding symptoms and resultant losses Surviving Symptoms
Abusing drugs, alcohol, etc.
Receiving no help
Creating effective coping strategies Seeking Solace
Relying on self
Time factors Marking Time
Turning a corner Navigating Recovery
Never fully recovering
Constructing an abstract situational model from the five final clusters proved
initially difficult. Analytic methods from SurveyMonkey or NVivo produced inadequate
flowchart models that did not “feel” exactly like my participants’ narrative journey and
were too simplistic. Feeling certain that I had dissected the categories to their smallest
common denominators, I decided to employ a method developed by Joanne Herman,
PhD, RN of the University of South Carolina where the theorist “draws” the dynamic
action going on in a model and then fits in the concepts (Herman, 2008). When I did this,
I was finally able to portray the movement of the grounded theory process depicted in the
model.
The narrative analysis had produced five nodes, or broad concepts: Experiencing
Trauma, Surviving Symptoms, Seeking Solace, Marking Time, and Navigating Recovery.
The models’ elements came together when I surrounded the concepts of Surviving
Symptoms, Seeking Solace, and Marking Time with a circle representing the Dominating
Diagnosis. At that time, I reviewed my NVivo analysis and saw several narratives that
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specifically referred to the diagnosis dominating participants’ lives. To me, the diagnosis
circle enclosed the essence of the PTSD diagnosis: horrifying, persistent symptoms, an
arduous quest by victims for relief from these symptoms, and a surprisingly long period
of time required for the symptoms to abate. I then added that concept to my other five.
The finished model appears in Figure 4.1.
Support for the correctness of the model came from NVivo word analysis, which
linked nodes, or concepts, through analysis of the occurrence of similar language. Cluster
analysis was performed aggregating all five nodes to determine whether they were similar
in selected characteristics. The clusters were categorized by word similarity focusing on
the concept of time using Pearson coefficient correlation. I had been especially worried
whether the time continuum, which I conceived as an arrow traveling throughout the
entire disorder, would be supported in NVivo word analysis. I imagined the time
continuum as starting with the trauma event itself, evolving into the marking of time
where treatment was sought, and then finally signifying the occurrence of healing and
resultant loss of the PTSD diagnosis. I was reassured when the NVivo analysis showed
that the timeline was indeed interwoven throughout the narratives and linked all concepts
together. The node cluster word analysis is depicted in Figure 4.2.
Also, the concepts of Experiencing Trauma and Surviving Symptoms are linked
together as well as Seeking Solace and Navigating Recovery. These linkages symbolized
the process contained in the grounded theory and helped explain the recovery from the
disorder. This NVivo analysis reassured me that I was depicting the correct relationships
among my concepts. In the following sections, I will examine participant narratives and
discuss the dimensions of each stage of the process.
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Figure 4.1. PTSD Recovery Model
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Figure 4.2. Nodes Clustered by Word Similarity
Experiencing Trauma
Trauma is horrific, especially when it involves another human inflicting it on a
helpless individual. The accounts received were wrenching, even though the events may
have occurred many years before. The greatest number of narrative submissions came
from those who had suffered child abuse and intimate partner violence (IPV). I have
selected some passages that were representative of the shared experiences. One individual
who had suffered child abuse wrote an eloquent litany of the violence she had
experienced at the hands of her parents:
Continual events occurring from early childhood into adulthood led to diagnosed
PTSD. Memories of early childhood begin around four or five years old. I was
beaten with high heel shoes, men’s shoes, a handle from anything (broom, tool), a
rolling pin, meat tenderizer, and whipped with electric cords, belts, and switches
from lilac trees. I remember being slapped across my face, privately and many
times in public, by my mother’s hand, being choked by my mother and having her
try to kill me in the middle of the night, having blankets pulled off the bed, then
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beaten with an object for something I did or said earlier. I was hit on the head with
a hairbrush until it broke. I remember parental arguments and fights with lots of
screaming, cursing, swearing, glass breaking, holes in walls, wondering if one of
them would kill the other. I remember continual verbal assaults and threats, being
discounted, being scoffed at: “You’re not going to college; you are meeting a man
somewhere.”
On the way to grandmother’s house I remember being slapped across the face
and told to smile and be happy while there. I remember the police coming to our
house and demanding that my parents have all their five children line up so they
could count heads. I remember my sisters’ holding me down and spitting in my
mouth and shouting they hated me because I was smarter and prettier than them. I
remember my father trying to commit suicide by jumping off a bridge.
This individual’s torment did not abate as she aged out of childhood. She
reminisced: “At my college graduation ceremony as I came down the aisle with my
diploma, my mother pulled me aside, slapped me across the face, and said, ‘You think
you’re smarter than me now, don’t you?’ ” Another participant’s submission continued in
a similar vein:
I came from a large working-class family…. We lived on and off public assistance
to supplement my parents’ income from two or three jobs each. Both of my parents
were children of violent alcoholics. Neither of them ever drank to excess, but both
were emotionally absent and verbally abusive.
My mother only ever pointed out how stupid I was and everything I did
wrong. My father, a severe hoarder, had extremely mercurial mood swings. When
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he was enraged, he’d often strangle or choke us against the wall while our feet
dangled below. Or hold us to the ground by our throats while he beat us with his
belt buckle. He often laughed at us when we were hurt. He used to hang around
outside our bedroom door while us girls changed and look at us naked through the
crack in the door. In our 1,200-square-foot house, if you were not the one being
beaten, you were always close enough to hear or watch whoever was.
A female victim of child abuse wrote about abuse at the hands of her father and a
priest:
He [the father] had been sexually abusing me for years, but the rape stands out for
me. I was unable to comprehend what had happened to me. It was much too big for
my seven-year-old brain. My father and a family friend, a priest, sexually abused
me and my three younger brothers. While my mom was away … we were terribly
abused and made to do unspeakable things to each other. Again, at age eight to
nine, I could not understand what was happening. I knew that my life was in danger
and that I needed to escape.
Although the etiology of the abuse was different, victims of intimate partner
violence also experienced considerable emotional abuse and physical trauma. One victim
of domestic violence wrote about her ordeal with an abusive significant other, which
displayed the escalation of aggressive behaviors customarily experienced by many
abused women.
The first signs he showed of having anger issues were just yelling spells—
I actually sometimes thought they were funny, because he was being so
ridiculous—then some mean name calling came into play and I began to feel
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the effects of the verbal abuse. About two years into the relationship … was the
first time yelling turned into shoving me down. I wasn’t hurt but I was horrified
that he had physically attacked me. He worked out and was a very strong guy.
Gradually over the years, the verbal and physical abuse became more severe and
more often.
As if the domestic violence were not enough, this individual witnessed her abuser’s
suicide. She recounted:
The events of the evening are all jumbled in my memory…. Sometime in the night
I realized he still wasn’t in bed…. I checked out in the garage and saw that he was
sitting asleep on the floor and that he had blood on his forehead…. I walked out to
check on him and saw the gun on the ground. He had threatened to shoot himself
before—I even had to talk a gun out of his hand a few weeks before this. I thought
to myself in total shock, “Oh, he finally did it.” I felt his skin and called out his
name. He was cold. Then I called 911.
This individual further wrote that she had blocked from her memory that her
significant other had been playing with a gun in the next room earlier that evening. She
said
I heard ‘click, click, click’ and I knew he was playing Russian roulette without
even seeing him. I told myself, ‘He’s playing games, and if I just walk away, he'll
stop.’ I think I was actually protecting myself from witnessing what he was going
to do.
Trauma from combat likewise branded those who experienced it. One veteran
wrote about the context of his experience: “I served two tours with a Marine Recon Unit
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in Vietnam from 1967 to 1969. During this time I was transferred to the Phoenix
Program, a unit established to carry out assignations of enemy agents and Vietcong
insurgents embedded in the Vietnamese infrastructure. I was 18 and 19 years old.” Later
on after he had returned to the states, this veteran experienced a break from reality. “The
episode that led me to the VA happened in 2004,” he recounted. “My wife came home to
find me with an inner and outer perimeter set up in the living room. I had enemy in the
killing zone and I knew no one in the present. I was back in Vietnam in my present.”
Permanently changed lives. Experiencing horrific abuse changed these
participants permanently. One victim of child abuse wrote, “… Growing up with my
father has meant living with the consequences of feeling small, worthless, in danger, sad,
and not being able to trust others or myself.” Another former child victim noted that she
became an unwilling confederate in her abuse: “I was told I shouldn’t tell them about my
family. I should keep the family’s secrets. These secrets and my shame were heavy
burdens.” A few tried to disclose what was happening to them and got nowhere. One
victim wrote, “I told my mother what was happening, but she was unable to acknowledge
my truth.” One victim of child abuse noted that teachers and an aunt had looked out for
her, suspecting abuse. She said, “I was always good in school and I knew from their
encouragement—I never told anyone about my home life—and something inside told me
that education was my way out.”
Yet another victim of child abuse wrote a moving passage about all that she had
lost as a consequence of her experiences.
Because of trauma, I still don’t feel entirely safe and secure. I’m always scanning
for an attack, waiting for a disaster, wondering if today will be the day. I still startle
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extremely easily. I’m always bracing to be hit. Not sure any amount of therapy will
resolve that.
Because of trauma, I felt like I needed to be perfect at everything. I always
thought, if I could just do this or that better, my parents would love me, that my
father wouldn’t hit me, or yell at me for everything he thought I did wrong. If I
made my father laugh, he wouldn’t hurt my siblings or the dogs by slamming the
dogs’ heads in the door or punting them across the room. If I told a story, then
everyone was distracted and safe for a while. That was my role in the family: the
distracter.
Because of how hard my parents made me work—in vain—for just a glimpse
of love, most of my relationships have been lopsided, unreciprocated disasters.
Even now, I am the one who has to call, to fly, to reach out if I want connection
with my family.
Victims of domestic violence also suffered from their trauma. One victim wrote
about how difficult it was to leave an abuser: “I had a tough time leaving him—but I
finally managed to do it once after being with him for four years.” Another victim
affirmed this difficulty after she found herself in an abused role for the second time: “I
needed to leave again, but found I was so emotionally drained, I just couldn’t do it. And I
think pride made it hard for me to ask my parents for help again.” Being demeaned left its
mark, as one victim noted: “Because of trauma, I allowed myself to be treated like trash,
to be a target for some of the most disgusting men.”
While many who experienced child abuse and domestic violence expressed distaste
for the actions of others and dismay at the subsequent effects these assaults had on their
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lives, they did not seem to experience the pernicious self-castigation and guilt exhibited
by those who had combat PTSD. One veteran tried to explain his guilt in the following
passage:
The process of recovery with PTSD, especially which is derived from active up-
close and personal combat with an enemy of my country, has given me little
comfort…. To take another person’s life while watching them draw their last breath
goes against all I was taught as a child. My mother and father were far from
churchgoers, but they were very moral people and transferred that on to my sister
and myself…. I killed 56 people in the service of my country while serving…. I am
not looking forward to the next 20 or 30 years.
Trauma summary. In summary, the participants’ trauma accounts were unique to
each individual and conveyed the horror and disbelief experienced by each trauma
victim. The greatest number of narratives came from victims of physical, emotional,
and/or sexual abuse during childhood. The recurring theme from these submissions was
that the victim, even years after enduring the abuse, did not understand why they
experienced abuse. They also did not understand why their parents or trusted adults
violated societal and family taboos by abusing them. What was the point of it, they
wondered, and why me? Years of sifting through events and relentless self-examination
never provided clarity as to why their abusers singled them out for abuse. In the end,
recovery for these participants was a conscious decision to leave the past behind.
The second largest category was victims of intimate partner violence (IPV). While
all of the accounts that were collected in this study were male-to-female violence, female-
to-male and same-sex violence does occur. The accounts provided by IPV victims closely
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paralleled accounts in domestic violence literature: emotional and verbal abuse eventually
escalated into full-blown physical abuse, victims were either embarrassed and isolated
themselves from friends and family or the abusers isolated them, and escape from the
violence was difficult. If these participants exhibited any shame or guilt, it was self-
blame. They were disappointed in themselves for not recognizing telling signs in abusers
at the outset of relationships and were angry that they stayed in abusive relationships.
On the other hand, veterans with combat-induced PTSD exhibited a type of
persistent guilt that seemed rooted in having harmed or killed other humans. The veterans
in this study, especially those from the Vietnam era, seemed to have particularly severe
PTSD symptoms and difficulty achieving satisfactory symptom abatement. Many
reported that the fallout from the trauma and PTSD symptoms were so intrusive that
intimate relationships and family life had been severely affected.
Experiencing trauma also permanently changed victims of trauma. Several
participants who had experienced child abuse wrote about living smaller, constricted
lives, fearful of others. A few said that they were hypervigilant about possible attacks
even after the abuse had ended. Many had issues trusting new people. Others wrote of
keeping quiet about the abuse, especially as children, to avoid dragging the family secrets
into the open. A few victims of child abuse wrote about sympathetic adults who
suspected abuse and went out of their way to support and encourage the victims. Others
wrote about an overwhelming need for perfection, developed in childhood as a means to
appease critical, violent parents.
Victims of intimate partner violence also experienced long-lasting effects from
trauma. The most cited problem was that some women engaged in a series of abusive
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relationships, trying unsuccessfully to break the chain of violence. Having been
demeaned, they felt unworthy of a loving intimate relationship. In a similar manner,
combat veterans felt that since they had killed, they were unable to forgive themselves
ever. They remained mired in permanent self-castigation.
In summary, living through trauma often casts blight on the victim’s hopes for the
future. After trauma has pushed the victim into the full-blown PTSD diagnosis, it
becomes a difficult and lengthy journey to recover. The next section will demonstrate
how the diagnosis dominates victims’ lives.
Dominating Diagnosis: PTSD
If there is one message that came through the narratives it was the intrusiveness and
domination of the PTSD symptoms as a whole. Once the symptoms arrived, participants
said, everything else in life went out the window, including family, work, fulfilling
relationships, and even sleep. The symptoms began to take over the victim’s existence. In
fact, they became that individual’s life.
One veteran explained this phenomenon: “Combat PTSD, as I refer to my
diagnosed disorder from this time on (since military service) has affected all domains of
my very existence.” Another victim of domestic violence wrote about the pervasive
effects of PTSD and resultant symptoms on her life:
[I experienced] hypervigilence, nightmares, daymares, anxiety, unable to feel,
walking around in a cloud, had a weird attachment to my husband. I was irritable,
disorganized, avoiding anything that reminds me of anything or sometimes latching
on to a reminder or repeat until I feel something.
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One of the most significant signs of diagnosis’s domination was the isolation it
produced. One respondent wrote, “I felt like I lost all of our mutual friends, which made
things even worse. I think I isolated myself from the friends and family who actually
cared. I felt completely alone.” Another concurred, saying “I had no close friends and
very little support.”
One participant noted that the isolation clung to her even after she had started to
rebuild her post-trauma life. She wrote:
I went to a private university many hours by car away from my family. I was in a
large city with people from all over the world. What better place to create a life,
right? Wrong. As soon as I left, I realized how alone I had always felt.
Even after recovery, some still preferred isolation to intimacy. One respondent
wrote, “I’m 28 and unmarried—I’d like to marry, but I don’t know if that will ever
happen.” Yet another mused in a similar vein, “Finally, I find myself able to be
reasonably relaxed around strangers and have permitted a couple of men to kiss me on
the first date. When I started dating my ex, we did not kiss until our third date and did not
have sex until we’d been together nearly six months.”
Finally, one participant summed up life after she had had received the formal
diagnosis: “It hit me hard.” Another said that during her isolation, “I was nobody.” The
next section will discuss the specific effects that symptoms had on participants’ lives.
Surviving Symptoms
Study participants reported that PTSD symptoms have a tremendous impact of
daily living. Participants used the following words to describe themselves when
experiencing symptoms: numb, empty, frozen in fear, and stuck. Many of the responses
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indicated that PTSD symptoms had a global effect on their lives and caused inability to
perform life roles. “I felt like I couldn’t manage my responsibilities, but somehow
managed to keep up with them,” wrote one participant.
Job instability was also reported by several participants. One person wrote, “PTSD
has had a dramatic impact on my life, particularly my career.” Another stated, “I didn't
quite lose my job, but I almost did. I confided to my boss about my situation and was
bullied as a result.”
The symptoms themselves caused major distress. One participant wrote, “I found
myself disorganized, irritated, unable to pay attention, tired.” Another person recounted,
“My symptoms of PTSD ran the gamut; but my major and most crippling symptoms were
severe anxiety and hypervigilance. I’m hypervigilant to this day. My small circle of
friends became smaller and tighter.” Another individual commented about the intensity
and frequency of symptoms, saying, “I endured a solid two years of daily flashbacks,
memories, and nightmares.”
Several mentioned dissociation from self as an issue. One individual wrote, “I got
really anxious about going to therapy, which told me I needed to go—I was still having
some issues with drinking too much and I think I didn’t want to confront it. I still
couldn’t do the EMDR (eye movement desensitization and reprocessing)—I numbed up
and dissociated every time we talked about sensitive matters.” A victim of sexual assault
wrote, “But deep down I was sad a lot. I did not trust men, I did not date. I could not go
places by myself. I jumped often. I had no attachment to my body.” A veteran also
mentioned this symptom, musing, “When did I stop feeling and dissociate myself from
the killing? I wish I had the answer to that. The subconscious is a mystery at best.”
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Many participants discovered that random stressors would trigger PTSD symptoms.
One victim who had been stalked wrote, “Sometimes, a simple drive to the store would
cause me to break out in hives.” A victim of sexual abuse noted that she had an
exaggerated startle reflex. “Even noises others barely noticed would make me jump. This
has decreased through time, but my ex-boyfriend used to make a game of poking me at
unsuspecting times because I would literally jump,” she said. “He thought it was funny,
and I tried to laugh about it, but it served as a reminder that I was still not completely
well.” Moreover, anniversaries of trauma were difficult for victims. A victim of domestic
violence wrote, “At points of stress or anniversaries of trauma, these issues affect my
ability to care for my family more.”
Chronic health issues were also attributed to PTSD. “[I’ve experienced] a decrease
in quality of life, lack of access to quality care, several medical financial burdens, and
physical health decline due to stress and chronic pain and comorbid conditions,” wrote
one respondent. “[I’ve had] severe physical problems including much muscle pain,”
stated another participant. Yet another wrote, “My physical health was also affected by
PTSD. Following the abuse, I had difficulty sleeping, developed back spasms, and was
diagnosed with acid reflux and an ulcer.” Another respondent complained of migraines
post-trauma.
Difficulty with interpersonal relationships and loss of trust were other issues cited
related to PTSD. “It’s been hard on the kids,” wrote one participant. “They know about
the rape and molestation, but I think it’s hard watching me go through the anger, tears,
etc.” Another participant said, “I am suspicious and have a lack of trust of others’
motives; I live in isolation and run away from anticipated danger.” Subsequent poor
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relationship choices were also cited as an issue. As one individual wrote, “I got involved
with someone that didn’t make me happy—part of the problem was him—but my PTSD
symptoms were definitely a factor in our relationship problems and finally our breakup
… the unhealthy relationship was definitely a large factor in my inability to recover and
actually made my PTSD symptoms worse.”
One participant summed up damaged interpersonal issues, saying, “I’ve had
difficulty forming relationships and trusting others.” A victim of sexual abuse wrote, “I
have a fear of sex and am unable to make friends.” Yet another discussed the difficulty
that significant others have in maintaining a relationship after trauma, writing:
When I started seeing my current therapist—who specializes in trauma and
PTSD—a year ago, my husband was very supportive. I don’t think I would have
made such progress in therapy without his support. Before my most recent therapy,
he would get frustrated with my inability to be open about myself with our
friends—not expecting me to share all, however. Being married to me has been an
education for him.
Some turned to alcohol and drugs for relief. One victim of abuse wrote, “I was a
risk taker. In college, I started to drink a lot. I loved the release of stress I felt. I felt alive
and free. I drank for a long time and I drank a lot.” Another who was a victim of sexual
abuse by a professor wrote, “While I was being abused, I’d bring wine in juice bottles to
the university with me and would drink it in the bathroom before going into my lessons.
This helped me get through the abuse, but was probably one of the worst self-treatments I
tried.” Another victim of abuse wrote, “I was determined to pull myself together and
continued to do the things I needed to do to move forward, but I was still drinking too
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much. I did take control of my drinking because I made myself confront the problem and
my guilt about it.”
Combat PTSD added a different dimension to residual feelings. One respondent
from the Vietnam era reported lingering guilt over causing death. This veteran wrote:
My biggest problem has been guilt: I served in the Phoenix Program in Vietnam.
We were an assignation unit used to disrupt VC (Viet Cong) infrastructure.
Civilians and military targets were eliminated. So much of the horrors of war
stayed hidden there until several years ago. Since then, the flood gates have opened.
I know when one of the hallucinations is standing beside my bed.
Finally, PTSD symptoms place victims at risk for suicide. As one participant noted,
“I’ve had four suicide attempts in the past 33 years.” The efforts made by trauma victims
to manage symptoms are described in the next section.
Seeking Solace
The individuals who volunteered for this study reported actively searching for
support and treatments and doggedly following suggested therapies as a part of their
recovery journey. They wrote about seeking healing alliances and looking for therapies
that had the power to give them solace. Many wrote that they tried a number of therapies
and cobbled together a combination of therapies to overcome symptoms and find peace.
Respondents also criticized healers and therapies they did not find helpful. It became
apparent during analysis of the narratives that healing was an individualized process, and
therapies that worked for some did not perform as well for others. The major threads
were looking for allies, the struggle to find relief, and ineffective treatments and support,
all of which are discussed in the following section.
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Looking for informed allies. Participants in this survey overwhelmingly cited
clinicians such as psychiatrists, psychiatric nurses, psychologists, and social workers—or
“the pros” as one participant termed them—as the most beneficial persons to help them.
In addition to professional counselors, counseling techniques such as cognitive-behavior
therapy and holistic providers who also treated somatic problems were also listed as
being helpful. Despite their appreciation of mental health clinicians, many participants
considered them to be best used as part of a broad-based effort to achieve recovery.
One participant who advocated a broad-based approach to recovery took issue with
the survey question’s format, which allowed respondents to select only one answer. This
individual wrote, “This question should allow you to rank or select several. Recovering
requires a strong 360-degree support structure. Professional counselors are Number 1.”
Others concurred. One respondent wrote, “It took a combination of modalities: self-
driven personal development, relaxation breathing techniques, holistic providers, faith-
based study, and prayers.” Yet another participant noted that recovery demanded “a
combination of kids, family, counselor, lifestyle changes, and time.”
Aside from professional counselors, many participants relied most on themselves
for healing or recovered as time passed. One participant wrote, “I educated myself via
books and internet sites regarding workplace harassment. It was my main source of
validation.” Another wrote, “I got help from mental health professionals, Chinese
medicine, and my own sheer will.” Help also came from unusual sources. One individual
wrote, “My lawyer, of all people, helped me.” Some found help from participating in
support groups. One participant recounted:
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I joined the PTSD support group and life opened up. For the first time I felt that I
was in the right group. The group was very goal oriented. During the times I was
overwhelmed and couldn’t see my own process, I would witness other group
members moving forward in their own recovery. This has become a force of faith
in my life. I have strong faith that PTSD is not my end story, but only part of my
story.
As individuals were embracing workable therapies, they were also moving on from
therapeutic techniques that did not help. Some of the participants’ insights about
unhelpful treatments are discussed in the following section.
Trying and Discarding Ineffective Remedies. When asked if there were any
treatments that were not helpful, participants frequently mentioned poorly trained or inept
clinicians. “I spent two years in talk therapy with a counselor who knew nothing about
trauma,” said one participant. “She rarely even spoke. It was only helpful in that I really
needed to unload what happened to me with someone who would not betray my trust. I
didn’t get any tips or tools for dealing with my symptoms.” Another concurred saying,
I found that many professional counselors were not qualified or prepared to help
me. They didn’t seem to understand the effects of trauma, and tried to force me to
focus my energy more narrowly than was helpful. I found that a lot of professionals
were either afraid to engage with my trauma, or wanted to only deal with the
symptoms, the depression and anxiety, for example, and not the root problem.
Others disliked therapeutic or counseling techniques. One participant noted,
“Counseling was not helpful. The method did not seem to help, but only made me
angrier.” Several participants objected to a basic issue often cited about exposure therapy:
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lack of enthusiasm for discussing prior trauma. As one respondent stated, “I feel that
talking to a psychologist didn’t help. I didn’t enjoy talking about things.” In a similar
vein, another participant wrote, “Just talking never worked well, it made me feel dizzy.”
Another participant wrote about exposure therapy, “I felt that talking anymore in therapy
was setting me back and making me move backwards instead of forward. I felt that I was
retraumatizing myself.” Finally, a victim of childhood abuse also noted, “Talk therapy
was ultimately not helpful, since trauma is usually pre-verbal and definitely was in my
case.”
Other participants found no relief from specific therapeutic methods. One
respondent wrote, “I don’t think EMDR helped me much when I went to therapy. I think
my case was too complex since there wasn’t one trauma that occurred but rather many,
many different traumas.” Another found emotional freedom techniques not to be helpful.
Moreover, spouses, significant others, and family members were not frequently
cited as being helpful in recovery. These omissions were likely because the long life of
PTSD has a tendency to wear out family members and lessen emotional support as they
withdraw. For example, one combat veteran reported being currently married to his fifth
wife. The specialized needs of an individual with PTSD are also a problem for family and
friends. One participant recalled, “My family was generous, but ill-equipped to deal with
a daughter who had worse flashbacks than her Daddy did after Guadalcanal.”
Despite some participants’ positive experiences with support groups, peer groups
and clergy and faith-based groups were considered relatively unhelpful in this survey.
One participant stated, “I received suggestions from people in AA (Alcoholics
Anonymous) who had never experienced such trauma,” this participant recalled. “I was
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told often by many, many people, ‘Just forget about it, forgive and let it go.’ That didn’t
work. It made it worse because I was then dealing with all of the memories and feelings
on my own for awhile.” Another participant found support groups lacking, saying “I did
not find support groups for sexually abused adults to be helpful. I found that since they
were not goal-oriented, they made me feel worse and stuck.”
Finally, in this survey of articulate, computer-literate, highly educated participants,
one respondent acknowledged that a surfeit of information was an issue. This individual
wrote, “Because I am a researcher, I was able to do my own research. In some ways it
was helpful, in others it was not. I know too much, and that can make the therapy process
more difficult.”
Medications—Pros and Cons: After data about medication use was initially
collected on about a third of the sample, it became evident that findings were
inconclusive on the efficacy of medication for treating symptoms. At that time, two more
focused questions about medication use were added to the survey. The first one was
whether PTSD symptoms such as anxiety, disturbed sleep, nightmares, etc. were treated
with medications. Some 16 participants (69.6%) said that they did receive medications.
Seven participants (30.4%) did not receive medications. Of those who received
medications for the distressing symptoms of PTSD, 12 participants (71%) rated the drugs
as somewhat helpful. Five participants (29%) did not feel medications were effective in
treating PTSD symptoms.
Participants were also asked whether recovery would have occurred more quickly if
the distressing signs and symptoms of PTSD had been better controlled with medications.
Out of the 18 replies, six participants (30%) said they believed recovery would have been
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faster with effective medication and eight (45%) disagreed that medication would have
helped. Four participants (22%) were not sure whether or not the medications helped to
speed up recovery.
Overmedication and ineffective prescribed medications were also cited as
unhelpful. One participant wrote: “Antipsychotics didn’t work for me because they just
made me numb inside and out.” Another replied, “Xanax and hypnotherapy didn’t seem
to have any positive impact for me.” Yet another wrote that the following medication
issues occurred: “Lithium and Seroquel, a combination of meds over a six-week time
frame, overmedication, adverse reactions, and recent retaliations within my community,
clinic, hospital, HIPAA laws, noncompliance, and politics all were problems. The list
goes on and on.”
Another participant also noted that self-medication was a concern. “I would
overmedicate to numb the feelings; only to have them erupt later when I was
unmedicated.” One participant specifically cited antidepressants as a class of drug that
impaired function, stating, “They made it harder to figure out what was going on with
myself and figure out how to fix it.” Finally, one veteran dryly noted, “The hallucinations
are far less intrusive than the antipsychotic medications.”
Effective Consumer-Selected Combination Treatments: Regarding helpful
treatments, many participants said that they devised a combination of therapies that
helped them. The replies demonstrated that these PTSD victims were active seekers,
finding and trying a number of different therapies to find ones that worked for them.
Foremost was finding a clinician specializing in PTSD who fit their needs. Among the
traditional mental health therapies they found useful were desensitization, cognitive-
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behavior therapy, eye movement desensitization and reprocessing, dialectical behavioral
therapy, and developmental needs meeting strategy therapy.
One participant said, “Eye movement desensitization and reprocessing helped me
because I was able to reprocess the trauma that was torturing me daily.” One participant
wrote about an alternative therapy, saying, “The psycho-drama approach to defining
lifetime trauma has helped me; identifying crucial trauma defining moments; going back
there; and re-enacting it.” The Veterans Administration’s emphasis on a revamped
cognitive processing therapy process for treating combat PTSD has received some
positive reviews from veterans. One participant wrote, “Much of the Veterans
Administration has switched to the cognitive processing therapy model of recovery for
the vets; cognitive stimulation through rigorous self-discipline has helped the most.”
One respondent said that dietary changes such as avoiding sugar and caffeine were
helpful. Another participant concurred, saying, “I've always loved to cook/bake, but I
learned to make healthier choices and to feed my body, instead of just stuffing myself
with emotional eating.” Another wrote that vitamins and herbal teas gave relief while
another respondent said that she had adopted a vegan lifestyle to better deal with
symptoms.
A number of participants deemed exercise as helpful. Three individuals wrote about
using martial arts as a way to relieve stress. One respondent wrote about working out and
performing fighting sports such as mixed martial arts, and boxing. Another wrote, “I
began learning martial arts, and while it can trigger flashbacks and panic, it can also help
my symptoms decrease.” Another participant had taken up kick boxing. Other physical
activities mentioned included yoga, biking, walking, and weight training. Alternative
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therapies used included Tai Chi, breathing exercises, music, creativity, poetry writing,
playing instruments, kinesiology, reiki, biofeedback, dream analysis, massage, somatic
awareness, meditation, and medical Qi Gong (energy medicine).
Participants also turned to online sources of assistance, including support groups.
Trauma survivor Michele Rosenthal’s Heal My PTSD website (http://healmyptsd.com/)
was mentioned by a number of participants. A follower wrote, “The groups were very
goal oriented, and other members of the group were insightful and had the same goal of
becoming PTSD-free.” A combat veteran said that he found the social networking site
Facebook more useful for social support than the Veterans of Foreign Wars (VFW) post.
“I don’t like sitting around telling war stories,” he said. Another respondent cited Al-
Anon and the group’s literature as being helpful in recovery. Another individual said that
Incest Survivors Anonymous group meetings were useful.
Two authors were mentioned in the narratives. One was Louise Hayes who wrote
You Can Heal Yourself and Shakti Gawain, whose book, Creative Visualization, was
specifically mentioned. A number of participants embraced writing themselves. One
respondent wrote, “Writing has been very important to my recovery.” Another wrote that
recovery has required “lots of writing.” Several others mentioned that they kept daily
journals.
Two participants mentioned that their faith helped them recover. One participant
wrote finding “a renewed interest and practice of Christianity” post-trauma. Two others
mentioned that prayer and meditation helped center them. Another wrote that “positive
thinking, faith-based study, and helping others” helped recovery. Staying positive
personally and taking good care of oneself were useful activities, too. A participant said,
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“I do positive affirmations, choose to be around positive people and avoid negative
people, address problems in my life one at a time, learned to manage my stress, and find
things I enjoy doing and do them.”
Participants also challenged themselves to get better and often stretched their
previous boundaries. One respondent wrote, “I forced myself to enter situations which I
knew were safe, but still upset me.” Another participant agreed, saying, “I also forced
myself to face fears: public speaking in college and grad school, joining the Army,
traveling, living alone in a bad neighborhood, making friends—I would put myself out
there even when I felt severe anxiety.” One respondent said that she “made an effort to
make new friends outside of the workplace.” Another participant rearranged her life post-
trauma: “I joined the U.S. Army Reserve to provide structure and to be in an environment
with clearly defined expectations. The structure was very comforting. I also developed
confidence and self-defense skills. I became a fighter, not just for myself but for those
who need help.”
Several participants said that obtaining knowledge about the disorder became a
quest. One participant wrote, “I wanted to know what was wrong with me. I had taken a
concentration of psychopathology courses in my Masters, which is in Criminal Justice, so
I decided to work on a PhD in general psychology.” Another participant wrote, “Through
therapy I was able to understand boundaries and self care. I was able to learn parenting
skills.” Another found out that she had PTSD when she finally consulted a psychiatrist
after 35 years of anguish. She said, “I had only heard PTSD associated with war
veterans…. I felt like someone had reached into my soul and started to pull me out. I felt
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that I might possibly fit into the world. I also felt scared and overwhelmed, but a lot less
ashamed. At this point, I started to educate myself about PTSD and trauma.”
Another way in which participants healed is by seeking out highly compatible
significant others. One participant wrote, “What sealed the deal on my recovery was
marrying a man who is my best friend, and who helped me create a safe, stable home
environment.” However, not all respondents found recovery by reaching out for support.
One participant chose to look inward: “I now spend the majority of my time alone and
usually in silence. Probably not ideal, but I can find some peace that way.”
Seeking Solace summary. In summary, participants found that finding an
informed clinician experienced with treating PTSD was a vital first step toward recovery.
Many reported idiosyncratic responses to medication. They either found it effective in
promoting sleep and abating anxiety or ineffective if the medication sedated them to the
point where they were unable to participate in therapy. Most respondents tried and
discovered a number of therapies until they assembled a mixed bag of therapies that
combined traditional counseling techniques and New Age treatments that worked for
them.
Several reported that self-reliance was a factor in their recovery. One participant
said, “I did it mostly on my own. I live by myself.” Several individuals wrote that they
had discovered that they were worthy of a better life. One victim of childhood abuse
wrote, “I learned, on my own, that I matter, and that I deserve love: the real kind, not the
kind where something is expected in return, not the kind that sits in the spaces between
empty words, not the kind that strangles and hits.”
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Finally, the passage of time was frequently cited as a key component in recovery.
The concept of needing time to heal was interwoven throughout many narratives. This
part of the recovery process will be discussed in the following section.
Marking Time
A recurrent theme in these narratives was the length of time required to feel better,
frequently five years or more. Some participants mused that the passage of time did seem
to help with healing, but the disorder was still distressingly refractory to treatment. Still
others reported that symptoms still occurred and they were still having trouble
functioning decades after the initial trauma.
Years of angst. In this survey, respondents reported that PTSD is a remarkably
long-lived disorder, with almost 65% reporting that it took five years or longer to
experience any improvement whatsoever. “I still don’t feel better” wrote one respondent.
“Who knows?” replied another. “From four years old until I was at least 36: numb.” One
respondent defined the disorder as “short periods of wellness. Repeated life situations and
chronic stressors hinder my full recovery to this day, whereas my triggers relate to
everyday situations.” Another participant was able to attach a specific time frame to
recovery. “Almost 15 years passed between the end of my traumatic events and when I
started having symptoms and memory recovery,” this individual wrote. “It was probably
between two and three years before I started feeling better.”
A number of participants reported that engaging in active therapy improved their
lives. One participant wrote, “I did not get treatment until 20 years after the abuse began.
I felt some relief as soon as I was diagnosed and had therapeutic support.” Yet another
replied that it took “ten years with counseling and intense self-work” to feel better.
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When asked when they felt the worst, over half replied that they had felt the worst
in the period immediately after the trauma until two years had passed. Yet, greater than
25% reported that they still felt very bad even five years after experiencing trauma. As
one participant put it, “It can feel as bad at times as it did initially.” Another wrote, “The
symptoms got increasingly worse as I got older.” One individual felt that alcohol abuse
delayed the onset of symptoms: “I drank alcohol for about eight years and used a lot of
different drugs. I think I felt worse consciously about two years after I was sober because
that is when the memories starting consciously surfacing.”
The longest period of symptoms was reported by a Vietnam veteran. He wrote:
After the big crash as I call it, I discovered in my PhD journey that I had exhibited
the symptoms of combat PTSD even before I left Vietnam. I still am not feeling as
I did before I served in combat. That was 42 years ago, from 1967 to 1969.
If time has passed and the proper treatments have occurred, victims of PTSD may
experience some degree of healing and break free of the PTSD diagnosis. The Institute of
Medicine (2008) questioned what end-state function was like for victims of PTSD who
did eventually recover. Participants in this survey almost universally reported that
recovery did not occur as a discrete new stage in their lives, but rather a slow realization
that they did not hurt as bad as they used to. The concept of recovery from PTSD is
Navigating Recovery
Almost 65% felt that it took longer than four years to be recovered from PTSD.
Although the inclusion criteria for the study specified that participants had to consider
themselves recovered from PTSD for at least one year, some felt that the term “recovery”
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was a misnomer and argued that a more precise criterion would have been whether they
felt better now than they did immediately post-trauma. One individual wrote, “I still don't
feel recovered”. Another wrote in a similar vein, “I am not there yet....” Another
participant replied, “I do not feel recovered. I do not think ‘recovery’ is possible—just
periods where symptoms are decreased. I have been in good treatment for five years and I
am still struggling.” One participant stated, “I’m not recovered yet, but some things are
better.” Yet another stated, “Through study and first person experience, I sincerely
believe this disorder is treatable, but never cured.”
Several noted that recovery was a semi-permanent state, which was affected by
new trauma. One participant noted, “I was feeling recovered about three years ago but
extensive life events, parents’ death, several moves, a child’s illness, disability, self
advocating, business politics, school, clinic, medical, etc. just keep adding to my PTSD
triggers or symptoms and chronic conditions.” Another said, “I am not recovered due to
recent re-trauma.” Another participant stated, “I am not recovered from PTSD. I still
actively flash back and hallucinate.”
The Turning Point: At the end of the survey 91.7% (33 respondents) wrote about
when they knew they were going to recover or were getting better. Rather than a snap
moment or epiphany, many reported a dawning realization that life was improving. As
one participant wrote, “That turning point occurred within the last 12-18 months. It
wasn’t a single point in time, but a gradual realization that I was growing stronger,
feeling better, and had significantly fewer symptoms.” Another respondent concurred:
“Here was a day where I felt a sense of hope that I MIGHT just have 45+ years of life
AHEAD OF ME; where previously I had always just felt like I was hanging on the edge
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of ‘the end’.” Another wrote, “I know I will recover. I’m not there yet. I feel better than I
did a couple years in so I know it will either get better with time or the therapy.” One
participant reframed the question about recovery:
I don’t think there was a turning point so much as a fierce determination to get
better. Failure has never been an option for me, in any area of my life, so it’s not an
option with regard to recovery, either. I’m not sure I’ve fully arrived at recovery
yet, but I won’t quit until I get there.
Another participant wrote in the same vein: “I will recover because, very simply, I am
determined to.”
Others attributed recovery as an outcome of treatment. One participant said, “After
my third session I had tremendous progress and most of my symptoms disappeared, only
to re-appear two weeks later. But then I knew what freedom felt like. I knew then it will
be possible to get my life back.” Another wrote that she knew she would recover “once
I’d had eye movement desensitization and reprocessing (EMDR) and my flashbacks had
not returned for over 12 months. I’d gotten to the point where I was sick to death of
feeling so terrible, and I think that was important in being able to recover.” She
continued: “There was still plenty of work to do after that point, but realizing that
effective therapy was available and being determined to do the work was when I was sure
I'd get better one day.” Yet another wrote of getting better upon hearing that PTSD was
treatable:
I felt that I wanted to heal, but very few practitioners have this outlook. Once I
heard that it (PTSD) could be healed, I started to look for others who believed this,
too. I also started to realize that traditional therapy was not the only way to being
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PTSD-free. Traditional therapy was helpful for me to process the trauma initially. I
received resistance when wanting to move forward onto other therapies. It was
difficult to find support and there seemed to be a lack of knowledge about PTSD
recovery. [It was helpful] once I was able to connect with others through the PTSD
support group and hear that they, too, were experiencing a lack of knowledge about
PTSD recovery. It was extremely helpful to have goals, to see that I was moving
forward, to use mediation, affirmations, and imagery to bring me into the present
moment. Ultimately, creating a life in present moment helped me to become
unstuck.
Another participant who used eye movement desensitization and reprocessing
(EMDR) wrote, “I had a snap moment when I began being able to cry and feel feelings. I
realized EMDR was working.” Another respondent also gained some relief from EMDR.
She wrote, “I started to recover probably after a year’s worth of EMDR. The symptoms
were less and I was able to function and feel real feelings. Things are not as surreal and
more gets done.”
With treatment also came clarity for participants about how trauma and PTSD
symptoms have affected their lives. One respondent wrote, “Once you understand the
series of mini/moderate and major traumas that occurred throughout your lifetime, you
can begin to understand why you are the way you are; why you were vulnerable to
subsequent traumas; and how to protect yourself in the future from traumatic events and
some can’t be prevented or understood.” Another respondent wrote about a renewed
appreciation of natural beauty that presaged recovery. “I actually started to notice and
truly appreciate the joy I feel from nature,” this individual wrote.
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Relief from somatic symptoms also helped with recovery. One participant wrote
that she knew she was recovering “when I was able to fall asleep at night without
sleeping pills or being physically exhausted.” Another participant felt recovered when
muscle pain finally started to subside.
Making intentional changes. Some participants reported recovery when they took
control of their lives and made helpful changes. “I knew I would recover after I moved to
a new state and started over. I landed a full time job and have been successful at it so far.
Knowing that I could be employed and away from that location with all the bad
memories helped a lot,” a victim of domestic violence said. “I have visited the trauma
location a couple times, and it was hard but I was okay. I also knew that I would recover
when I stopped being so hypervigilant over door knocks.” Another participant agreed,
saying, “I feel the turning point was leaving the area/state. It took a while to adjust to the
new environment but not seeing the same places and faces everyday really made a
change.” A victim of child abuse put emotional and physical distance between herself and
her abuser. She wrote:
The last time my father attacked me, I was 21. I decided to visit during my winter
break from college. I had already been trained by the Army and had taken Tai
Kwon Do for a couple of years. But I didn’t see him coming. I swore that I would
never let him or any other man catch me off guard again. I even got a tattoo that
symbolizes “recovery”…. After I told him how much he hurt me, he didn’t
apologize or take responsibility for his actions. I knew then that my life was in my
hands. I told him: “I promise you that it won’t happen again.” He has interacted
with [me] on my terms for about 15 years now. I see him and the rest of my family
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only rarely. I live 3,000 miles away from them, where I can guarantee my safety.
The best thing I ever did for myself was leave them behind.
Another victim of abuse felt better after she discontinued all contact with her
family. She had discovered that family members had kept a letter from her that was
written more than a decade earlier before her mother had died. She said, “I still don’t
know why they kept it (the letter) from me, but I have decided to just move on with my
life by starting a new family of friends, church members, and my boyfriend's family.”
Another victim of abuse felt somewhat recovered when she accepted a new job. She
wrote, “My current boss physically resembles my abuser. When I was able to
successfully interview with him and accept the position without feeling sick to my
stomach, I realized how much progress I’d made.”
Deliberately moving on. Other means of recovery were letting go of anger,
forgiving abusers, and finding spiritual comfort. One participant wrote, “My turning point
was when I realized I no longer woke up feeling angry and was automatically able to
think of things other than my years of abuse.” Another participant said that recovery
came because “my cultural traditions encourage a spirit of bravery when one is subjected
to life challenges; also my Christian spiritual belief played … the most significant role in
my life journeys.” Another wrote, “I firmly believe that my Christian beliefs, faith, and
grace have been the primary source of healing from the inside out.”
In a similar tone, one respondent felt better after placing her trauma in perspective
as a life-changing force. She said, “I am trying to recover from 20 years of accumulated
responses [symptoms] that were responses to 10 years of abuse. I think recovery is going
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to be a lifelong process for me. I have been changed by my trauma, and recovery to me
means learning to accept those changes with compassion.”
Another participant found healing in advocacy. She wrote that she felt better “when
I took an active role in advocating for myself, my child, and my family members
following my mother’s death in 2009. [I developed] a self-driven determination to be an
active participant in overall health and recovery by speaking up, asking questions, and
focusing on the positive things, thoughts, and actions to change my perceptions or
reactions.” A PTSD advocate spurred the recovery of one participant. “I believe I became
most determined when I had met someone else on-line who had recovered,” she wrote.
“The more success stories I heard, the more determined I became. I felt things really
turning around maybe 2-3 years ago: two steps forward, one step back—but always
moving forward.”
Some participants were openly hopeful for the future. One respondent wrote, “My
attitude is better and I have a more optimistic perspective on life—good things are in
store for the future.” A victim of child abuse noted how her trauma journey has changed
the course of her life. She wrote, “My life as it is today began when I chose a different
life, when I chose to believe a better life was possible.”
Finally, a few participants despaired of ever achieving recovery. “I am still waiting
for [a] turning point, though I am working on that now,” one participant said. Another
concurred, saying, “I still haven’t recovered from it yet and am just starting on it.”
Another respondent wrote, “I am not yet recovered, but hopefully the passage of time will
help.” Finally, one individual wrote, “I do not know whether recovery is possible.”
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Summary of Trauma Recovery Narratives
From analyzing participant narratives using NVivo software, I constructed a six-
stage model depicting the process of PTSD recovery. The stages were Experiencing
Trauma, Dominating Diagnosis, Surviving Symptoms, Seeking Solace, Marking Time,
and Navigating Recovery. Although a victim of PTSD would experience all of these
stages at some time during PTSD recovery, the individual did not necessarily experience
the stages in any particular order. The process is nonlinear, almost as if a person falls into
a pit or well (i.e., the Dominating Diagnosis) after experiencing trauma. Many victims of
PTSD spend a long time struggling with symptoms and seeking solace, looking for
traditional and nontraditional therapies to find symptom relief. The passage of time, i.e.,
Marking Time, is required as well as intense individual labor to obtain relief and navigate
recovery.
The narratives recounting trauma that the participants experienced are especially
moving. Some narratives, such as those from individuals who experienced domestic
violence, demonstrated that years of reflection had provided some clarity. However,
victims of child abuse had obtained little, if any, insight into the motivations and actions
of those who abused them. That someone who was supposed to be their protector and was
to look out for them had beaten or violated them still mystified them after many years.
Many found that they were unable to associate with their abusers at all. One participant
summarized the feelings of many victims of child abuse when she wrote:
I vowed if I ever had kids, they would never, ever grow up in a bar like I did. I
would never expose them to parties where people were drunk and inappropriate. I
will put my hand on any God’s Bible and swear that I will take a life before
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someone hurts one of my kids. The thing that I don’t understand: Why didn’t my
parents vow to protect me like that? Because, excuse my language, my head is so
f***** up with nightmares, flashbacks—I call them “day mares”—where I just
drift off and I’m back there. I can feel them, their touch, their smell … I see them.
Victims of combat trauma seemed to experience a pernicious variant of PTSD that
was laced with guilt because of actions they took and people that they had hurt or killed.
Some have experienced long-lasting moral conflict from these actions, especially when
they were compelled to act against their own moral code. Veterans may or may not be
able to externalize any of the “blame” for the events that they have experienced. The
PTSD that resulted from combat also seemed to be especially refractory to treatment. The
literature contained many accounts of Vietnam veterans who still have not recovered
from their PTSD of 30+ years.
Once acquired from experiencing trauma, PTSD was a dominating diagnosis that
took over an individual’s life. The disorder was long-lived and difficult to treat. The
intrusive, distressing symptoms were at the heart of the disorder and had a tremendous
negative impact on daily living. The world of a person with PTSD shrank. Family and
friends departed as the disorder lingered on, and it became difficult to establish new
intimate relationships. Life roles such as work and parenting were abandoned until the
patient obtained symptom relief. Many turned to food, alcohol, or other escapes to find
symptom relief.
It was difficult for individuals to ameliorate the symptoms that accompanied PTSD,
and it frequently took many years to feel better or recovered. The most crucial step in
seeking symptom relief and eventual recovery was to locate and employ a skilled mental
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health clinician, versed in PTSD therapies. Most participants wrote that no single therapy
helped them, but rather they found that a shotgun approach combining traditional
psychological therapies with newer holistic approaches yielded the best results. Opinions
were divided regarding support groups and medications, with some participants finding
both approaches very beneficial, while others did not. Many regarded medication as
useful for symptom relief, but commented that overmedication prevent them from being
fully engaged in the therapies they needed to heal. A surprising number of people found
relief in physically active therapies such as yoga and martial arts, which likely dispersed
anxiety. It became evident from participant narratives that those respondents who had
experienced some degree of healing were active searchers, always seeking out, trying,
and sometimes discarding prospective healing therapies. They were actively involved in
designing and shaping their recovery and functioned as their own agents for change.
Years often passed before survey participants found signs of recovery. For some,
the struggle with symptoms lasted several decades. Often the therapy itself required
intensive periods of time. Even when participants began to feel better, they were not
entirely symptom free.
Recovery frequently took five years or longer to achieve. Most of the respondents
reported a gradual dawning of well-being rather than the distinct arrival of relief. Many
reported that recovery was accompanied by relapses and that staying recovered required
active engagement on their part. Many continued with the therapies that had brought
them relief from PTSD symptoms.
Finally, not all participants reported full recovery. Several despaired of ever
achieving that state, while a few stated that they were not sure that they could ever
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recover from their trauma. Experiencing PTSD changed the lives and world view of
participants permanently, but many expressed satisfaction with their attained recovery
status.
In Chapter V, the survey findings and narrative analysis will be discussed. Findings
will also be compared with current literature. Conclusions have been drawn regarding
study findings, and suggestions made for clinical practice and future research.
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CHAPTER V
DISCUSSION
In this chapter, findings from the survey and from analysis of narratives submitted
by study participants have been discussed and compared with related literature. The
PTSD model will also be discussed in more detail. Implications for further research and
nursing practice will also be considered.
Demographic Findings of the Survey
In general, the demographic findings of this survey were roughly analogous to
those expected for a population that had experienced PTSD. However, there were some
notable variances, which will be highlighted in this section. First, more females than
males voluntarily enrolled in the study. While males have been demonstrated to
experience traumatic events more often than females, PTSD occurs twice as often in
females than males, because of societal pressures and neuroanatomic, neuroendocrine,
and immune-related causes (Brady, 2001; Kimerling, Ouimette, & Wolfe, 2002; National
Comorbidity Survey, 2005).
While participants in this study were overwhelmingly White (92.7%), prior
research has demonstrated that there are some ethnic differences in individuals who
developed PTSD. Several studies have shown that lifetime prevalence of PTSD has been
highest among Blacks, intermediate among Hispanics and Whites, and lowest among
Asians (Perilla, Norris, & Lavizzo, 2002; Roberts, Gilman, Breaslau, & Koenen, 2010).
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Thus, the ethnic composition of this study varied significantly from the norm. There was
no apparent reason for this finding unless it was related to study recruitment using the
internet.
The statistics regarding marriage and living situation were not surprising, with
29.3% of the participants reporting that they were single. If the categories of separated,
divorced, and widowed participants were added together with singles, 51.2% of the
respondents were not currently married. These reports are in line with government data
that shows that increasing numbers of individuals live by themselves or cohabit without
marriage (Krieder & Ellis, 2011). The 2008 Community Survey showed that the share of
married Americans is shrinking, with 52% of males and 48% of females over age 15
being married (Cohn, 2009). By comparison, the 2010 U.S. Census found that 34% of all
males and 27% of females aged 15+ years had never been married (U.S. Census Bureau,
2010a).
Almost 45% of the participants in this survey reported having no children. This is
in line with U.S. Census (2010c) findings, which stated that slightly more than half of all
American families have no children under age 18 living at home. For couples with
children, the census found that married couples had a mean average of 1.97 children in
the householder under age 18 (U.S. Census Bureau, 2010c). Male and female
householders had a mean average of 1.60-1.85 children in their households. Regarding
dependents over age 18, 76% (28 participants) reported having no dependents over age
18. Some 24% (9 participants) had dependents over age 18. While this survey did not ask
for the age of the dependents, it is likely that many of these dependents were age 65 and
older. The national old-age dependency ratio in 2010 was 20.7 older dependents to 100
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working-age people (Howden & Meyer, 2010). Thus, one out of every five households in
the U.S. has at least one older dependent resident.
Another significant variance was that this survey drew an unusually large number
of individuals (80.5%) with higher education. Of the participants, 24.4% were college
graduates and 56.1% had graduate degrees, possibly due to the survey requiring computer
skills for participation. By way of contrast, in 2008, 85% of adults in the United States
over age 25 had at least a high school diploma, and 27.7% had a bachelor’s degree or
higher. In addition, 10.2 percent of people aged 25 and over have obtained advanced
degrees (Julian & Kominski, 2011). In 2010, some 71.1% of all households in the U.S.
had internet access (National Telecommunications and Information Administration,
2011) . Among internet users, 89.2% of individuals with a bachelors degree or higher had
internet service.
The religious affiliations expressed by the participants also were not surprising.
The findings were similar to recorded public statistics. In the United States in 2011,
78.4% of adults over 18 reported that they were Christian, with 51.3% stating that they
were Protestant (Pew Forum on Religion and Public Life, 2011). In this study, 63.4% said
they were Christian.
The unemployment and underemployment rates given by this sample probably
reflected the nation’s bleak unemployment rate of 9.1% in August 2011, a month after
this survey started (Bureau of Labor Statistics, 2011b). In September 2011, the broad
unemployment rate, which not only included the officially unemployed who have looked
for work in the last four weeks but also discouraged workers (who have looked for work
in the past year) and underemployed workers, hit 16.2%, down from a high of 17.5% in
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2009 (Bureau of Labor Statistics, 2011a). In contrast, 46.3% of the sample (19
individuals) taking this survey reported not having a paying job. Moreover, inability to
work can be a sequela of victimization and exposure to violence (National Center for
Injury Prevention and Control, 2003; Tjaden & Thoennes, 2000). Distressing resultant
PTSD symptoms also contribute to unemployment and underemployment (Tanielian &
Jaycox, 2008; U.S. Department of Labor, 2011).
Among the 53.7% in this survey (22 individuals) who were working, 20.8% were
working less than 20 hours a week and 41.7% were working 21-40 hours a week. A
sizable number (37.5%) were working 40+ hours a week. Other survey questions
regarding employment were also probably related as much to the unstable national
unemployment environment as they were to PTSD and its long-lasting effects. Of the
respondents, 93.3% said that they were working in a different job than they were when
they experienced trauma. Of these, 16.7% considered their current job to be a worse
position, while 83.3% considered it to be a better position. Considering that the majority
of the participants had obtained graduate degrees, satisfactory work status may have been
closely related to the high degree of educational attainment in this sample.
When asked whether the participant was head of household, 68.3% (28 individuals)
responded that they were. According to the U.S. Census Bureau (2010b), 49% of all
Americans were householders, the term used by that agency to replace head of
household. In response to the question “Do you have enough money to meet your
needs?”, 82.5% (33 individuals) responded affirmatively that they did have enough
money to meet their needs. When asked about having enough money to met emergencies,
68.3% (28 individuals) responded that they had enough money to meet emergencies. This
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survey did not ask for specific financial information regarding household income. By
way of contrast, across the U.S. real median household income declined and the poverty
rate increased between 2009 and 2010 (DeNavas-Walt, Proctor, & Smith, 2011). Again,
it is possible that this particular sample, because of its high educational attainment,
weathered the recession in better shape than less educated participants would have.
When asked about receipt or request for public assistance or welfare, including
social security, 63.4% (26 individuals) said they were not receiving and had not applied
for government assistance. The remaining participants said that they were receiving
assistance (34.1%) or had applied for assistance (2.4%), yielding a total of 36.5%
currently receiving or having applied for government assistance. The percentages
reported in this sample are akin to national statistics that show that government payouts,
including Social Security, Medicare, and unemployment insurance, currently make up
more than a third of total wages and salaries in the U.S. (Melloy, 2011). Regarding
specific type of assistance, eight participants (30.8%) reported receiving social security
disability insurance, the highest assistance category. The next highest categories were
social security retirement benefits and supplemental social security income, which each
13.7% (four individuals) received.
In summary, the demographic information reported by participants in this survey
closely paralleled that of typical Americans in employment, financial concerns, and
family structure. The most significant variances in the sample were that participants were
predominantly White and college-educated, with many having attended graduate school.
Since PTSD occurs across all strata of society, this variance likely occurred because data
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were collected through the internet for this study. The following section will review
findings of the survey relating directing to trauma exposure causing PTSD.
Survey Findings Related to Trauma and Trauma Sequelae
Although the concept of PTSD was referenced in ancient Greek and Roman
literature, the development and refinement of PTSD as a valid psychological diagnosis
took place in the latter half of the 20th century. The American Psychiatric Association
added PTSD as a diagnosis denoting a psychological disorder stemming from exposure to
an extraordinary traumatic event to its Diagnostic Manual of Mental Disorders (DSM-III)
in 1980 (Beall, 1997). In 1990, 20 years after American troops left Vietnam, the report
from the National Vietnam Veterans Readjustment Study was published, detailing the
extensive postwar psychological problems experienced by veterans of that prolonged
engagement (Kulka et al., 1990).
Concurrently with the National Vietnam Veterans Readjustment Study, the first
National Comorbidity Study (NCS) took place, fielded from 1990-1992. The NCS was
the first nationally representative mental health survey in the U.S. to use a fully structured
research diagnostic interview to assess the prevalence and correlates of DSM-III-R
disorders (Harvard School of Medicine, 2011). NCS respondents were re-interviewed in
2001-02 in a study referred to as the NCS-2. The NCS-2 studied patterns and predictors
of the course of mental and substance use disorders and evaluated the effects of primary
mental disorders in predicting the onset and course of secondary substance disorders
(Harvard School of Medicine, 2011).
In conjunction with the NCS-2, the National Comorbidity Survey Replication
(NCS-R) was also conducted from 2001-2003. A new national sample of 10,000
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respondents were surveyed to study trends in a wide range of variables assessed in the
baseline NCS and to obtain more information about a number of topics not covered in the
baseline or not covered extensively (Kessler & Merikangas, 2004). Thus, the NCS-R
became the foundation document that outlined the etiology and epidemiology of PTSD in
the United States.
Furthermore, a survey of 10,000 adolescents, the National Comorbidity Survey of
Adolescents (NCS-A) was conducted along with the NCS-R and NCS-2 surveys
(Harvard School of Medicine, 2011). The goal of NCS-A was to produce nationally
representative data on the prevalence and correlates of mental disorders among youth.
However, among children and adolescents, no broad-based epidemiological study has
surveyed the prevalence of PTSD alone (Gradus, 2011). By 2004, the Collaborative
Psychiatric Epidemiology Surveys (CPES), with support from the National Institute of
Mental Health, were initiated to compile comprehensive epidemiological data on the
distributions, correlates, and risk factors of mental disorders among the general
population with special emphasis on minority groups (Alegria, Jackson, Kessler, &
Takeuchi, 2003).
The primary objective of the CPES was to collect data about the prevalence of
mental disorders, impairments associated with these disorders, and their treatment
patterns from representative samples of majority and minority adult populations in the
United States. Secondary goals included obtaining information about language use and
ethnic disparities, support systems, discrimination, and assimilation, in order to examine
whether and how closely various mental health disorders are linked to social and cultural
issues (Alegria et al., 2003). The CPES joined three nationally representative surveys: the
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National Comorbidity Survey Replication (NCS-R), the National Survey of American
Life (NSAL), and the National Latino and Asian American Study (NLAAS). Since it is
the most comprehensive repository of data on mental health disorders, I used CPES
findings from questions relating to PTSD to compare with relevant questions in this
survey. Between 300 and 3,000 respondents answered each question in the various
databases concerning PTSD.
Incidence of PTSD. Using DSM-IV criteria for PTSD, the NCS-R estimated that
the lifetime prevalence of PTSD among adult Americans was 6.8% (Kessler et al., 2005).
The lifetime prevalence of PTSD among men was 3.6% and among women 9.7%
(National Comorbidity Survey, 2005). These findings were in line with the first National
Comorbidity Survey from 1990-1992, which found that lifetime prevalence among men
was 5.0% and among women 10.4% (Kessler, Sonnega, Bromet, Hughes, & Nelson,
1995). Lifetime prevalence in the general population established during that survey was
7.8%.
The findings of this study also reinforced the broad exposure that individuals have
to multiple types of trauma. The two largest categories of trauma exposure were child
abuse (39%) and sexual abuse and violence (51.2%). Mirroring national statistics that
women are more likely to experience PTSD, 78% of the respondents were women.
Moreover, over half of all participants reported exposure to multiple traumas, with a
strong link between child abuse and subsequent adult abuse. CPES data confirmed the
occurrence of multiple trauma, with 47% of the participants reporting two or three
different types of trauma (Alegria et al., 2003). For those experiencing multiple trauma, a
mean 3.62 trauma event types, standard deviation 2.70, was recorded.
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Studies involved high-risk children exposed to abuse or natural disaster have shown
that children who experience traumatic events may have a higher prevalence of PTSD
than the general adult population. Child protective services annually have reported that
some 3.3 million referrals involving 6 million children concern abuse (Hamblen &
Barnett, 2011). Of these 22.2 are substantiated cases of abuse; however, it has been
estimated that about two-thirds of all child/adolescent maltreatment cases have been
unreported (U.S. Department of Health and Human Services, 2009). In 2009,
professionals such as teachers, law enforcement and legal personnel, and social services
personnel submitted more than 60% of all abuse reports. The most common types of
abuse have included neglect (78.3%), physical abuse (17.8%), sexual abuse (9.5%), and
psychological maltreatment (7.6%). An estimated 1,770 children died in 2009 from abuse
and neglect (U.S. Department of Health and Human Services, 2009).
Frequency and Length of Trauma Exposure. Both this survey and the CPES
composite surveys distinguished between single episode occurrence and multiple
occurrences of trauma. The CPES data showed that 15.7% of those exposed to trauma
experienced it only once (Alegria et al., 2003). The remainder (84.3%) experienced a
recurrent single type of trauma or recurrent multiple traumas. CPES data also showed that
participants reported experiencing a mean 79.2 event occurrences. The CPES also
reported that 64% of its participants reported being exposed to trauma for years, with a
mean of 18.5 years. According to CPES data, trauma first occurred when respondents
were a mean age of 22.1 years (SD: 14.06). The age when the “worst event” occurred in
CPES data was 24.1 years (SD: 14.42)
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Experiencing PTSD Symptoms. When PTSD symptoms are now considered,
researchers generally cluster them according to a four-stage model with the overall
categories of avoidance, numbing, reexperiencing, and hyperousal (L. A. King et al.,
1998). The model was expanded from the prior three-stage model, which combined
avoidance and numbing symptoms, reflecting clinicians’ most recent decision that the
categories were discrete and should be separated (McNamara, 2009). According to CPES
data, the mean for length of continuation of PTSD symptoms was 8.97 years (SD 16.62),
with 58.9% reporting that the duration of continued reactions to the trauma occurred over
years.
Regarding type of trauma experienced, the CPES data showed that the rate of
respondents experiencing PTSD symptoms lasting longer than 30 days increased with the
number of traumatic exposures (Alegria et al., 2003). When exposed to a single traumatic
event, 26.7% of the participants reported that they had experienced PTSD reactions. With
two traumatic experiences, 35.5% of the participants reported PTSD symptoms. With 2-3
traumatic exposures, the rate of PTSD symptoms increased to 45.4% of all respondents in
that category. With exposure to 3+ traumatic exposures, 61.7% endorsed the presence of
PTSD symptoms.
This study and the CPES surveys asked a number of similar questions regarding
type of symptom experienced. Table 11 compares the questions and response percentages
for “worst event during past year” reports which corresponded closely with results from
this survey (“random event” statistics were lower for most categories). Great variation in
percentages existed between the two samples as well as among the composite CPES
surveys, e.g., adolescents cannot report as great a length of trauma exposure related to
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their younger age. Despite differences in recorded statistics for both surveys, the majority
of respondents reported experiencing a wide variety of customary PTSD symptoms.
Table 5:1
PTSD Symptom Occurrence: PTSD Recovery Study vs. CPES Database
PTSD Recovery Study n % Corresponding CPES n %

Questions Questions
Which of the following During the worst event did
symptoms of PTSD did you feel:
you experience?
Emotional numbness, 32 91.4 Emotional numbness 288 15.1
especially with people
with which you were once
close
Emotionally distant or cut- 3143 47.4
off from other people
Persistent frightening 28 80.0 Had repeated unwanted 2713 66.1

thoughts and memories of memories of the worst
the ordeal (flashbacks) event, remembering even
when you didn’t want to
Flashbacks 2713 51.7
Sleep problems 28 80.0 Repeated unpleasant 2713 49.7
dreams
Falling asleep or staying 2298 72.9
asleep
Anger 27 77.1 Upset when reminded of 2713 60.9
the event
2298 51.7
More irritable or short-
tempered
Feeling detached or 27 77.1 Trouble feeling normal 3143 41.6
dissociated from reality feelings like love,
happiness, or warmth
toward other people
Purposely stayed away 3143 50.2
from places, people, or
activities that reminded
you of the experience
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Table 5:1
PTSD Symptom Occurrence: PTSD Recovery Study vs. CPES Database (continued)
PTSD Recovery Study n % Corresponding CPES n %

Questions Questions
Was easily startled 27 77.1 Jumpy or more easily 2298 56.9
startled by ordinary noises
Physical reactions such as 2713 41.7
sweating, heart racing, or
feeling shaky
More alert or watchful, 2298 71.1
even when there was no
real need to be
Prolonged depression or 27 77.1 Lost interest in doing 3143 43.1
apathy things previously enjoyed
No future plans because 3143 21.7
you felt future would be
cut short
Exhibited agitated or 26 74.3 Terrified or very 3143 70.1
disorganized behavior frightened
Helpless 963 51.8
Confusion 24 68.6 Tried not to think of worst 3143 70.7
event
Unable to remember 3143 29.8
details of worst event
Trouble concentrating or 2298 64.1
keeping your mind on
what you were doing
Adapted from “Post-traumatic stress disorder” by M. Alegria, J.S. Jackson, R.C. Kessler,
and D. Takeuchi, 2003, Collaborative Psychiatric Epidemiology Surveys (CPES) 2001-
2003 [United States], ICPSR20240-v6. Copyright by the Inter-university Consortium for
Political and Social Research.
In this study, emotional numbness was the most frequently reported category with
87.8% reporting this symptom. Numbness is rated rather low in the CPES data at 15.1%.
This discrepancy is likely due to the wording of the CPES question, which referred only
to “numbness” rather than “emotional numbness.” In the CPES study, the highest
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category was sleep difficulties, e.g., falling asleep or staying asleep at 72.9%.
Respondents in this study rated sleep difficulties and flashbacks the same in second place,
with 87.8% experiencing the symptoms. The lowest category in the PTSD recovery study
was confusion, which ranked at 68.3%; this compared with 64.1% for the most similar
CPES symptom category (Alegria et al., 2003).
Substance abuse and other coping mechanisms: Survey participants reported
that their two most used coping mechanisms were food, including excess eating,
deprivation, and binging and purging, and overuse of alcohol. According to Mayo Clinic
staff (2011), emotional eating is used to suppress or soothe negative emotions, such as
stress, anger, fear, boredom, sadness and loneliness. Major life events and the hassles of
daily life trigger negative emotions that lead to emotional eating. While some people
actually eat less in the face of strong feelings or emotions, many eat impulsively or binge.
Anorexia nervosa and bulimia do co-occur with PTSD, and traumatic events tend to
occur before the onset of these diseases (Reyes-Rodriguez et al., 2011).
Researchers examining National Comorbidity Survey Replication data have also
discovered that there is evidence that PTSD mediates the relationship between the
number of distinct traumatic event exposures and substance use behaviors (Del Gaizo,
Elhai, & Weaver, 2011). Another study examining data from the National
Epidemiological Survey of Alcohol and Related Conditions (N=34,160) found significant
positive odds ratios among individuals meeting criteria for PTSD and having experienced
a childhood trauma (OR = 1.40 [95% CI: 1.08-1.83], P<.01) or assaultive violence (OR =
1.41 [95% CI: 1.13-1.77], P<.01) for predicting alcohol use disorders (AUD) (Fetzner,
McMillan, Sareen, & Asmundson, 2011). Also, among individuals without PTSD,
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childhood trauma (OR = 1.32 [95% CI: 1.23-1.41], P<.001), assaultive violence (OR =
1.42 [95% CI: 1.13-1.74 P<.001), unexpected death (OR = 1.19 [95% CI: 1.12-1.28],
P<.001), and learning of trauma (OR = 1.22 [95% CI: 1.13-1.30], P<.001) positively
predicted the presence of alcohol use disorders (Fetzner at al., 2011).
One interesting finding from this survey was that 34.3% reported working
excessively long hours by choice. Being a workaholic or working long hours as a coping
mechanism may trigger more symptoms in a person after he or she cuts back on work or
retires (Friedman et al., 2007). In a meta-analysis of 12 studies in involving holocaust
survivors, Dasberg (2003) found that delayed, postponed, or late-onset PTSD at an
advanced age occurred in Holocaust survivors. However, Dasberg noted that
traumatization did not preclude good or even excellent social and vocational functioning
over the course of decades.
Only 11.4% of the participants in this study also reported abusing prescription
drugs. Those who reported specific drugs stated that antianxiety drugs, specifically
Xanax, pain medicine (Lorcet), Soma (used as a muscle relaxant), and sleeping
medications were the categories most abused. Despite the number of participants
reporting substance abuse and risky behaviors, it must be noted that 28.6% of the
participants reported that they did not abuse drugs or exhibit risky behaviors.
Summary of Trauma and Trauma Sequelae Findings
In this chapter, the survey’s demographic findings were discussed and compared
with information on the population at large and other samples diagnosed with PTSD. It
should be noted that this survey sample was collected because of the participants’
willingness to compose narrative answers to questions about PTSD. No attempts were
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made to compile a sample representative of the general population diagnosed with PTSD.
Thus, there were some significant differences in the demographic characteristics of this
sample as compared with the population in general. However, despite demographic
differences between this sample and the general population, many similarities in trauma
experiences and PTSD symptoms existed.
More females than males enrolled in this study. This was not unusual given that
more females than males have been diagnosed with PTSD. More Whites volunteered to
participate in this study, which is not representative of the general population where
lifetime prevalence of PTSD is considered to be highest among Blacks, intermediate
among Hispanics and Whites, and lowest among Asians (Perilla et al., 2002; Roberts et
al., 2010).
Questions that attempted to quantify PTSD symptoms and to explore the
dimensions of the experience were compared with the Collaborative Psychiatric
Epidemiology Surveys (CPES) database, a compilation of information from three
national surveys regarding mental health disorders. In this survey, roughly half of the
participants experienced trauma from a single source, while the other half experienced
trauma from multiple sources. Almost 63% experienced daily or repeated trauma for
greater than one year. When asked how long they experienced the symptoms of PTSD,
70% said that their PTSD symptoms had persisted for five years or greater. Participants
displayed all of the DSM-IV symptoms, with many reporting multiple symptoms
occurring simultaneously. The global report of symptoms is likely a testament to the
precision of the DSM-IV-TR diagnosis. The most frequently reported symptom was
emotional numbness, especially with people with which the participants were once close,
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with 97.8% reporting that problem. The second most-reported symptoms were sleep
problems and flashbacks, reported by 83%.
Regarding other trauma categories, many findings were in line with the CPES
categories, but others varied significantly because of differences in how the samples were
drawn. Different trauma findings between this survey and the CPES data set were
highlighted in Table 5.1. In summary, PTSD is a mental health disorder causing an array
of distressing symptoms that have a global negative effect on daily life. Despite different
trauma etiologies and different samples, participants reported very consistent responses
and reactions to PTSD symptoms. The next sections will discuss how the PTSD
Recovery Model compares with related theoretical models.
Comparison of PTSD Recovery Model to Existing Theoretical Models
There are a number of multifactorial cognitive theories and models that have
explained the phenomenon of PTSD and associated symptomology, yet have not
addressed recovery. As discussed in the literature review, these cognitive models
generally examined pretrauma, trauma, and post-trauma factors, including the nature of
the trauma experience, post-trauma cognitions, and appraisal and emotional responses.
The purposes of these models have been to demonstrate which variables predicted or
were associated with poor client outcomes. One drawback of many extant trauma models
has been that they considered PTSD from the point of view of the mental health provider
rather than the client.
Dalgleish (2004) discussed the evolution of and critiqued five PTSD models. Of
these, he concluded that two models, the integrated model of PTSD (Foa, Steketee, &
Rothbaum, 1989) and Dalgleish’s own schematic, propositional, analog and associative
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representational systems (SPAARS) model came closest to describing the interaction of
various cognitive components in the process of PTSD. There were three core components
in Foa et al.’s integrated model of PTSD. Two were types of mental representation:
memory records of the trauma and other pre- and post-trauma events and schemas. The
third consisted of the range of posttraumatic reactions of self and others. The nature of
the components and the interaction between them determined the type and extent of post-
trauma symptomology.
Foa et al. (1989) extended the theory twice. The first extension emphasized the
disorganized nature of memories concerning traumatic experiences (Foa and Riggs,
1993). A second elaboration centered on the relative numbers of stimulus, response, and
meaning elements and their combinations in the representation of the trauma. From
treating rape victims, Foa and Rothbaum (1998) also proposed that large numbers of
stimulus-danger associations often characterize trauma memories. They noted that
because of large amounts of ambient stimuli in contemporary life, only tangentially
related stimuli become associated with danger.
The SPAARS model (Dalgleish, 2004) comprised four explicit levels/formats of
mental representation. The schematic representation, similar in concept to schemas,
represented abstracted, generic knowledge. Propositional representations symbolized
referential meaning in verbal form. The analogical system stored information and
memories and coded nonverbal information. Finally, associative representations were
similar to fear networks and represented the connection to information presented in other
ways. The different components in the SPAARS model dealt with both cognitive
representation and process.
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In his discussion, Dagleish (2004) pointed out that acceptable theories of PTSD
should offer an account of the symptoms of the disorder and treatment, have utility as a
tool for developing treatments and explaining treatment failures, and be easy to explain to
patients as a rationale for treatment. By Dalgleish’s measurement, contemporary
cognitive theories of PTSD have been “generally keeping abreast (and may even be
slightly ahead) of market demands…. In a sense then, current cognitive theories of PTSD
are well evolved for the clinical/clinical research environment in which they are
predominantly utilized” (p. 52).
The PTSD Recovery Model (Fig. 4.1) meets all of Dalgliesh’s criteria for
operationalizing a model of PTSD. The model adequately depicts the symptoms of PTSD
and the struggle to find effective treatments for the disorder. It defines the diagnosis as
permeating all areas of a victim’s life for a significant length of time. It defines treatment
as a lengthy journey, a quest for solace. Finally, it resonates with clients as representative
of the entire experience.
However, even though the PTSD Recovery Model focuses on the client
perspective, clinicians should be cautious about blaming treatment failure on the patient.
Clinicians may want to remember that the primary reason the client has the disorder is
exposure to trauma. Furthermore, failure of the patient to engage fully in treatment
should not be viewed as noncompliance. Rather, the clinician may want to assess reasons
for treatment failures such as the client’s symptoms being too intrusive for active
participation or client/treatment mismatch, e.g., the client dislikes the therapy or finds it
ineffective.
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The PTSD Recovery Model also can be situated into the current national mental
health recovery model promulgated by the Substance Abuse and Mental Health Services
Administration, also known as SAMHSA. The agency has fully embraced its message
that recovery is a possibility for individuals who have mental health and substance use
disorders (Substance Abuse and Mental Health Services Administration, 2011). In fact,
recovery support is one of the agency’s eight strategic initiatives for 2011-2014. This
recovery initiative reads as follows:
[SAMSHA will be] partnering with people in recovery from mental and substance
use disorders and family members to guide the behavioral health system and
promote individual-, program-, and system-level approaches that foster health and
resilience; increase permanent housing, employment, education, and other
necessary supports; and reduce discriminatory barriers. (p. 3)
Among its public efforts, SAMHSA has designated September as Recovery Month
2012. According to SAMHSA (2012a), the event “promotes the societal benefits of
treatment for substance use and mental disorders, celebrates people in recovery, lauds the
contributions of treatment and service providers, and promotes the message that recovery
in all its forms is possible.” The project’s goals include “spreading the positive message
that behavioral health is essential to overall health, that prevention works, treatment is
effective and people can and do recover” (2012a).
Furthermore, SAMSHA (2012b) has launched Voices for Recovery, a website
where people in recovery can “celebrate their successes and share them with others in an
effort to educate the public about treatment, how it works, for whom, and why.” States
such as North Carolina have also embraced the sharing of recovery narratives. The NC
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Division of Mental Health, Developmental Disabilities & Substance Abuse Services has
initiated RecoveryNC.com to collect recovery stories, has sponsored recovery events, and
has sought support for recovery projects in the state (NC Division of Mental Health &
Developmental Disabilities & Substance Abuse Services, 2011).
In summary, the PTSD Recovery Model integrates the cognitive interaction of
traditional PTSD models with the contemporary concept of recovery. As the narratives of
study participants have shown, people can get better after experiencing PTSD. Through
engagement with skilled therapists and other individualized therapies, trauma victims can
achieve some state of recovery and move forward in their lives. The PTSD Recovery
Model encompasses all of these dynamics.
Aside from cognitive and recovery components, PTSD can be viewed as a response
to a stimulus (trauma). Attempts to deal with symptoms and to negotiate treatment may
be seen as coping efforts. Thus, the PTSD Recovery Model can also be situated among
stress and coping theories. The next section examines similarities between the PTSD
Recovery Model and Lazarus and Folkman’s transactional model of stress and coping.
Transactional Model of Stress and Coping
When I first started researching posttraumatic stress disorder (PTSD), an extant
theory that initially seemed to be applicable to this research project was Lazarus and
Folkman’s (1984) transactional model of stress and coping. This comparison has held up
through analysis of the recovery narratives. Like the final PTSD Recovery Model, this
model is not a stage model, but rather examines an individual’s stress and coping
responses over a period of time. Lazarus and Folkman viewed stress as a product of an
imbalance between demands and resources that occurs when pressure exceeds an
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individual’s perceived ability to cope. Thus, stress can be managed if an individual is able
to strengthen his or her abilities and resources to address the problem or source of stress.
This theory seemed particularly applicable to recovery and PTSD for several
reasons. First, the theory focused on stress. Lazarus (1966) suggested that stress be used
as an organizing concept, or rubric containing many variables and processes, for
understanding a wide range of phenomena that affect human and animal adaptation.
Second, the theory can be extended to encompass the related concept of anxiety, a
persistent undercurrent in PTSD symptoms. Lazarus and Cohen (1977) defined three
types of stress stimuli: major changes or cataclysms, often affecting great numbers of
people, major changes affecting one or a few persons, and daily hassles, less dramatic
stressors that arise from daily living. Obviously, PTSD results from cataclysmic events,
which are universally stressful and outside of human control. Cataclysms and major
change may be singly occurring or prolonged events, with physical and psychological
consequences that can last a long time (Lazarus and Folkman, 1984). PTSD meets all of
these criteria.
Furthermore, although extreme environmental conditions almost always result in
stress for all exposed to them, there has typically been great variation in human response
to the same stressors. Lazarus and Folkman (1984) summarized response variation in this
way: “Psychological stress is a particular relationship between the person and
environment that is appraised by the person as taxing or exceeding his or her resources
and endangering his or her well-being” (p. 19).
Third, the theory is a transactional theory in which an individual negotiates, or
transacts, ways to mediate stress (Lazarus & Cohen, 1977). This give-and-take between
198
the individual and his or her environment seemed to suit the gain-an-inch, give-an-inch
recovery trajectory reported in many mental health recovery narratives. Of particular
significance to the individual experiencing stress are two person-environment mediators,
cognitive appraisal and coping. Cognitive appraisal is an evaluative process where an
individual determines why and to what extent a particular transaction of series of
transaction between the person and environment are stressful (Lazarus & Folkman,
1984). Cognitive appraisal strategies that minimize the occurrence of trauma and its
effects may be part of the difference why some people get PTSD and others do not.
Burgess and Holmstrom (1979) stated that some women who have been raped used
minimization to reduce the anxiety of trauma to a smaller, more manageable context.
Victims who employ minimization do so by comparing the trauma to their perception of
what the trauma should be like, their current situation, the outcomes of other victims, or
to a prior experience.
Coping is the process through which an individual manages the demands of the
person-environment, e.g., the stress and emotions it generates (Lazarus and Folkman,
1984). Lazarus and Folkman (1984) advocated separating outcomes from the concept of
coping, noting that coping should be viewed as efforts to manage stressful demands
regardless of outcomes. Therefore, no coping strategy including those commonly thought
to be ineffective, e.g., denial or avoidance, should be considered inherently better or
worse than another. Judgments regarding adaptiveness of a strategy must be made in
relation to context. Finally, coping should not be equated with mastery over the
environment, since some sources of stress may not be mastered, e.g., horrendous trauma
or abuse. In this vein, Lazarus and Folkman (1984) said, “Effective coping under these
199
conditions is that which allows the person to tolerate, minimize, accept, or ignore what
cannot be mastered” (p. 140).
When compared with Lazarus & Folkman’s model, PTSD may be thought as the
most extreme form of stress and coping, representing the trauma victims’ frantic and
persistent efforts (coping) to deal with cataclysmic events (stress). Creative and dogged
determination has permitted the participants in this study to tolerate, minimize, ignore, or
otherwise transact the intrusive symptoms of this disorder. Finally, the participants in this
survey also seemed to agree that PTSD recovery can never be mastered and that there is
no one treatment or pathway to recovery that leads to recovery.
Comparison with Other Studies on Psychological Trauma
Support for some findings from this study came from two other researchers who
have examined psychological trauma such as loss and grief. Baliko (2005) studied the
lived experience of life after homicide. Regarding recovery, she noted that research
participants viewed their experience of lessening symptoms as “healing”, which
supported my contention that recovery from PTSD equates with symptom relief. Baliko
(personal communication, May 19, 2012) noted:
The way they [family of homicide victims] lived in the world had changed and they
were adapting to that fact to a greater or lesser degree, but they had no expectation
of ever feeling or being the same as they were before the trauma…. the experience
was nonlinear, and other triggers, traumatic or otherwise, could affect how they felt
from day to day. (p. 1)
Baliko (2005) as well as Bonanno (2004, 2009), who has extensively studied
bereavement, both agreed that there is no one-size-fits all plan of coping or treatment for
200
clients who have experienced psychological trauma. Baliko (2005) termed coping efforts
as the individual’s attempt of “staying afloat.” Baliko (personal communication, May 19,
2012) noted:
There is no one treatment that is effective for everyone, because people respond
differently and have different preferences, which may change over time. The one
thing that does seem to be universally helpful is acknowledgement of the trauma
and letting people know they’re not “crazy”. (p. 1)
Bonanno (2004, 2009) coined the term “coping ugly” for survival behaviors
employed by his research subjects in order to carry on their lives. Bonnano (2009) noted:
The phrase [coping ugly] captures the kind of “whatever it takes” approach that we
might use to deal with the unexpected adversities in our lives. Another phase might
be “pragmatic coping”…. When bad things happen, people often find the strength
to do whatever is necessary to get back on track. (p. 79)
Both Baliko (2005) and Bonnano (2009) supported this study’s finding that victims
of psychological trauma often needed years to feel better. Bonanno (2009) found that his
bereavement study participants who experienced uncomplicated grief started putting their
lives back together in about two years. Baliko (2005) also detailed her participants’ two-
to three-year search for relief and eventual personal transformation after suffering from
the homicide of a loved one.
Finally, given the similarities of the accounts of all individuals who have
experienced some sort of psychological trauma, are the recovery experiences not the
same? Could they all be part of the same psychological trauma spectrum where response
to a human loss or shock, regardless of etiology, results in similar responses of varying
201
intensity? Could an uncomplicated grief response be at the other end of the spectrum
from full-blown PTSD? The recovery journeys of individuals who have lost a family
member to homicide, others who have been bereaved and victims of PTSD all exhibit
marked overlap. Perhaps, all diagnostic categories will someday be collapsed into a
single, all-encompassing psychological trauma diagnosis.
Implications for Clinical Practice and Future Research
In the following section, I have discussed implications for clinical practice and
future research. Both practice and research will be intertwined in the future as the
Veterans Administration (VA) has scrambled to treat an unprecedented number of
veterans who have combined physical trauma, traumatic brain injuries, and unresolved, or
complex, PTSD. As with prior wars, advances in medicine have been spurred by
necessity. In the future, expert clinicians trained in PTSD therapies will be absolutely
mandatory for recovery and symptom control will be paramount for patients to progress.
In response to the Institute of Medicine rejoinder concerning imprecise criteria outlining
PTSD recovery, I maintain that symptom abatement that results in the loss of the PTSD
diagnosis should be the primary criteria for determining recovery.
Trained Clinicians
The participants in this survey cited experienced, trained mental health clinicians as
the most helpful component of their recovery journeys. Some participants expressed
scorn for clinicians who took an overly simplistic view of the disorder. Others were
unhappy with clinicians who were uncomfortable treating the disorder or who lacked
viable or workable therapies.
202
The best model for addressing this need for combat veterans has been developed by
the VA. The VA has not only developed protocols for the delivery of their chosen
evidence-based psychological therapies, exposure therapy (ET) and cognitive processing
therapy (CPT), but also large scale training programs for clinicians (Karlin et al., 2010).
The VA realized early on that carefully selected therapies would be ineffective unless all
clinicians were thoroughly trained to implement the therapies.
The VA has spent an inordinate amount of time and money investing in the training
necessary to deliver a comprehensive continuum of specialized mental health services,
covering inpatient, residential, and outpatient care (Karlin et al., 2010). These counseling
initiatives included national programs to provide intensive, competency-based training to
VA mental health providers in the delivery of these therapies. As of May 31, 2010, the
VA had provided training to over 2,700 VA mental health staff in the delivery of CPT or
ET, with some staff trained to delivery both therapies.
In addition to providing specialized training, the VA has developed a number of
top-down and bottom-up approaches to promote dissemination and implementation
(Karlin et al., 2010). This included development of the PTSD national mentoring
program to promote regional and national communication between PTSD clinic managers
and sharing of best practices to clinic design and care processes. In addition, a local
evidence-based psychotherapy coordinator has been appointed at each medical center to
champion evidence-based psychotherapies at the local level and to promote local
implementation of evidence-based psychotherapies. According to the VA, the PTSD
mentors and local evidence-based psychotherapy coordinators have been key in
203
developing local clinical infrastructures necessary for the delivery of evidence-based
psychotherapies (Karlin et al., 2010).
Although the VA’s project has been ambitious, its overriding principles—
development of evidence-base treatment protocols, meticulous training of invested
clinicians, and continued monitoring for adherence to the treatment protocol—can be
emulated by smaller clinics and agencies. To obtain progress, it is imperative that well-
trained clinicians treat individuals with PTSD. As in the VA system, it is imperative with
non-combat patients to be allowed to participate in the treatment selection process for
therapies to be successful.
Control of Intrusive Symptoms
Aside from illnesses and disorders that cause crippling chronic pain, PTSD has an
almost unparalleled ability to disrupt daily life. According to CPES data (Alegria et al.,
2003), 45.6% (n=319) of respondents experienced intense reactions occurring greater
than 10 times per month caused by exposure to trauma. Thirty-three percent (n=235)
experienced intense PTSD-related actions 3-10 times a month. When asked to rate the
severity of the distress caused by these reactions, 34.3% (n=231) rated their distress as
moderate, 32.8% (n=221) rated their distress as severe, and 20.9% (n-141) rated their
distress as very severe. Thus, an astounding 88% rated their distress related to this disease
as moderate to very severe.
Furthermore, interviewees were asked to rate whether their PTSD-related reactions
interfered with daily life, using a five-point Likert scale ranging from 1 for “no
interference” with daily life to 5 for “extreme interference” with daily life (Alegria et al.,
2003). In response to this question, 26.2% (n=176) said that PTSD reactions interfered
204
“some”, 28.4% (n=191) said that PTSD symptoms interfered “a lot”, and 18.1% (n=122)
said that PTSD symptoms interfered “extremely” with daily life. Thus, 72.7% of the
respondents said that PTSD reactions affected their daily living to a substantial degree.
Finally, CPES data showed that individuals were unable to work or carry out
normal activities a mean 49.5 days (n=322; SD = 104.3) annually because of reactions to
PTSD symptoms (Alegria et al., 2003). Because of its global intrusiveness into daily life
and its disruption of normal daily and work activities, PTSD symptoms must be
effectively controlled in order to offer any relief or hope of recovery to trauma survivors.
In the next section, a significant change in alcohol rehabilitation treatment that could be
potentially applied to PTSD treatment has been discussed.
Integrating Psychological Therapies with Medication for Symptom Control
Harmon (2011) has explained that many neuroscientists have become frustrated
because traditional alcohol rehabilitation using self-help methods has been so ineffective.
Data have suggested that these programs have not offered recovery rates that have
exceeded spontaneous rates of recovery from alcoholism, e.g., an estimated 25% of all
alcoholics have recovered on their own. Because of that dismal statistic, psychotherapists
have been currently studying whether combination therapies (in which traditional
psychological therapies are combined with medications) should become the first-line
treatment for addictions.
In a similar vein, some researchers have been investigating the efficacy of
medications administered at the outset of the PTSD diagnosis and throughout the
progression of chronic complex PTSD. Friedman, Davidson, and Stein (2009) compiled a
literature review looking at 34 randomized clinical trials focusing primarily on selective
205
serotonin reuptake inhibitors (SSRIs: sertraline, paroxetine, and fluoxetine) and one
serotonin-norepinephrine reuptake inhibitor (SNRI: venlafaxine extended release).
Because of successful trials with sertraline and paroxetine, the U.S. Food and Drug
Administration approved both SSRIs for use in treatment. The two SSRIs were relatively
well tolerated, promoted global clinical improvement, and ameliorated associated
symptoms such as impulsive, suicidal, and aggressive behavior (Friedman et al., 2009).
Although not as widely trialed as SSRIs, there are some other drugs that may have
a place in PTSD treatment (Friedman et al., 2009). These include other serotonergic
agents such as Trazodone and cyproheptadine, which may be efficacious against
traumatic nightmares and flashbacks. Buspirone may be prescribed as an anxiolytic
agent. Newer antidepressants such as mirtazapine (for traumatic nightmares) and
buproprion have had success in limited trials. Antiadrenergic agents such as prazosin,
propranolol, clonidine, and guanfacine all have helped with adrenergic dysregulation.
Monoamine oxidase inhibitors have been shown to produce moderate-to-good global
improvements in patients due to reduction in reexperiencing symptoms. The tricyclic
antidepressants imipramine and amitriptyline have had modest results in reducing
reexperiencing symptoms. However, the evidence has not supported the use of
benzodiazepines, which have potential for abuse and addiction, as an appropriate
treatment for PTSD.
While research on anticonvulsants has been initiated because of the class’s
antikindling properties, randomized clinical trials have been inconclusive on therapeutic
results with PTSD victims (Friedman et al., 2009). According to Friedman et al.,
randomized clinical trials have shown that atypical antipsychotics may have a “unique
206
niche as adjunctive agents for not only chronic, treatment-refractory patients but also
PTSD patients who exhibit extreme hypervigilance/paranoia, physical aggression, social
isolation, and trauma-related hallucinations” (p. 263).
The cognitive enhancer D-cycloserine (Seromycin) has shown potential to facilitate
extinction learning (Cukor et al., 2010). Originally developed as an antituberculosis
antibiotic, Seromycin acts as a partial agonist for the N-methyl-daspartate glutamate
receptor, which has a crucial role in learning and memory functions. Seromycin has been
shown to facilitate extinction learning in animal models of conditioned fear and in some
human trials of other types of learning. Existing research has shown that Seromycin may
help facilitate fear extinction and reduce post-treatment relapse (Cukor et al., 2010).
In summary, according to Friedman et al. (2009), medications have offered three
potential benefits for patients with PTSD. These benefits have included (1) amelioration
of PTSD symptoms, (2) treatment of comorbid disorders, and (3) reduction of associated
symptoms that interfere with psychotherapy and/or daily function. Because of these
potential benefits, successful treatment programs will likely offer pharmacotherapy in
conjunction with psychological treatments.
Reframing PTSD Recovery
When the Committee on Treatment of Posttraumatic Stress Disorder of the Institute
of Medicine (2008) encouraged mental health clinicians to examine the efficacy of
treatments and goals for PTSD, the committee also exhorted clinicians to focus on
defining the concept of recovery, concentrating on symptom reduction, removal of the
PTSD diagnosis, and end-state function. After conducting this research, I believe that the
heart of recovery is symptom abatement with the resulting loss of the PTSD diagnosis
207
and that therapies should be aimed at that target. After analyzing the responses received
in this survey, I think that defining an acceptable baseline function is almost impossible.
Recovery is an idiosyncratic process, and each individual will take a different pathway to
recovery. What matters to most individuals is that they are relatively content when they
reach their recovery destination.
Research Questions Raised by This Study’s Findings
Although this study had been intended only to discover the psychosocial process
that men and women undergo while recovering from posttraumatic stress disorder,
analysis of the data yielded some other areas for future inquiry. One finding was the
reliance that many participants had on complementary and alternative medicine and
nontraditional remedies. Also, many respondents mentioned that prescribed medications
either helped them cope or were completely ineffective against the symptoms of PTSD.
Indeed, the Institute of Medicine’s two-phase research project has corroborated these
findings. Two aims of that ongoing study have been to discover effective pharmaceuticals
and alternative therapies that help in PTSD recovery (Board on the Health of Select
Populations, 2010).
While drug and alternative therapies research has been already started, the
narratives seem to suggest that other lower-tech therapies may be viable treatments.
There are also concerns about the role alcohol and drug use play in recovery. Study
questions might include the following:
How did the therapies mentioned as beneficial by participants in this study
actually aid recovery?
Does sleep normalization and good sleep hygiene help reduce PTSD symptoms?
208
What role can the psychotherapy behavioral activation play in reducing symptoms
of depression in clients with PTSD?
Is exercise effective in PTSD symptom abatement? How much exercise is needed
to reduce anxiety significantly? Are some forms of exercise more effective than
others?
Which meditative or Eastern therapies offer significant anxiety reduction and
symptom relief to clients with PTSD?
What role do online communities and blogs such as www.healthmyPTSD.com
and online support groups play in recovery from PTSD symptoms?
Does concurrent diagnosis of a substance use disorder lengthen PTSD recovery?
Another possible area of inquiry would be to locate individuals who have never
sought help for PTSD. These individuals may not be aware of why they are experiencing
PTSD symptoms and have not linked them to prior traumatic experiences. There may be
some particular interventions that could yield success with this group. Also, individuals
who have PTSD and who have few resources or support systems could experience real
benefit from internet-based interventions. Isolated or individuals who prefer to control
disclosure in private would likely find web-based interventions more appealing than
traditional individual or group therapy. However, reaching lower-literacy victims of
PTSD will remain a challenge.
Finally, being a nurse, I noticed one tantalizing outlier in the data that merits
further consideration. Three out of 41 participants stated that medical trauma caused their
PTSD. This suggested a promising avenue of research, likely situated within emergency
departments or intensive care units, looking to see which medical events have caused
209
PTSD, whether medical practices or treatments exacerbated the trauma, and developing
subsequent interventions to ameliorate medically related trauma.
Comments about Methodology
The online components of this research project worked much as anticipated in the
proposal. Only two of the participants had initial difficulty accessing the closed website,
but were able to log in with additional coaching. SurveyMonkey worked well to capture
participant responses and added useful analysis. Initially, I anticipated that Facebook and
other social networking sites would yield the most participants, but more than half of the
participants read about the survey in the Heal My PTSD online blog. On reflection, I
believe that people with PTSD are always looking for answers, and the internet is a
convenient way for them to cover a wide variety of topics and catch up on medical news
quickly. Yet, individuals who were willing to engage in a study such as this one had to be
more actively engaged in seeking new information about the disorder and its treatments
than just internet surfing. Thus, motivated participants were more like to be found on
serious specialty blogs than on social networking sites. Without the internet, I could not
have reached my research participants and completed this study.
Summary
The resounding finding elucidated by these study participants is that hard work and
commitment are required to struggle successfully with PTSD. It is a lengthy multi-year
quest for help: locating understanding clinicians, finding effective treatments and
symptom relief, and, finally, recognizing a slowly dawning sense of well-being. PTSD is
sui generis among the anxiety disorders: it arrives on the heels of cataclysmic trauma and
210
then firmly entrenches itself in its victims. PTSD is stubbornly refractory to treatment and
so long lived that it attains a life of its own.
I hope sincerely that I have given appropriate voice to my fellow researchers, the
participants in this study who navigated their own recoveries from PTSD. I also hope that
I have interpreted their poignant narratives of recovery in a way that conveys the all-
encompassing dimensions of this disorder and its devastating effects on human lives.
Finally, I hope that all of the research on PTSD taking place today yields quicker, more
effective therapies and treatments to shorten the course of this disabling disorder.
211
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APPENDICES
Appendix A ........................................................................................................... 239
Appendix B ........................................................................................................... 242
Appendix C ........................................................................................................... 243
Appendix D ........................................................................................................... 250
Appendix E ........................................................................................................... 258
Appendix F ........................................................................................................... 261
238
APPENDIX A
Log of Email Contact with Study Participants and Others
Date To From Message Content

7/12/11 PP* Help for Adult Organization agreed to place notice of study in
Victims of Child forums
Abuse
(HAVOCA)
7/17/11 PP Morris Center Study notice was passed along to newsletter editor
for Healing from for inclusion.
Child Abuse
7/18/11 PP Amnesty Organization not able to help with study participants
International
USA
7/20/11 PP Wounded Forwarding message to newsletter editor
Warrior Project
8/4/11 PP The Survivors Included in newsletter;
Club
http://www.thesurvivorsclub.org/health/mental/ptsd-
research-study-usc-pamela-phillips
8/11- PN** PP Several emails to me regarding progress on narrative;
10/31/11 0102 invited to comment on PTSD model and did
8/11/11 PP Michele Invitation to PP to write a guest column in the
Rosenthal www.healmyPSTD.com blog; published 9/19/11:
http://healmyptsd.com/2011/09/ptsd-thoughts-
study.html
9/11/11 PN 0100 PP Email noting that participant had not taken survey;
stated that composed narrative was now optional; no
reply
9/11/11 PP PN0126 Email noting that participant had not taken survey;
stated that composed narrative was now optional;
participated
9/12 & PP PN 0123 Three updates on additional thoughts she wanted to
add to her submission
10/31/11
239
APPENDIX A (CONTINUED)

9/13/11 Michelle PP Request for mention on www.healmyPTSD.com that
study is still recruiting; received additional mention
in column: http://healmyptsd.com/2011/09/ptsd-
thoughts-study.html
9/19/11 PP PN 0110 Questions re enrollment criteria; participant informed
that “50%” recovery was sufficient; participated
19-9/22 PP PN 0133 Needed assistance to log onto website; two emails
from PP giving more explicit instructions regard case
and numeric sensitivity; participated
9/20/11 PP NC Victim Study notice was passed along to board of directors
Assistance for consideration; no further contact from
Alliance organization
9/20/11 PP PN 0136 Questions re enrollment criteria; participant informed
that partial recovery was sufficient; participated
9/20/11 PN 0132 PP Email to participant after receipt of narrative,
assuring that it was very useful and appropriate; did
not respond to 10/31/11 email from PP inviting
critique of PTSD model
9/21/11 PP Michele Forwarded email from potential participant who
Rosenthal wanted to enroll in study
9/26 & PN 0149 PP Two emails; one acknowledging receipt of narrative;
10/31/11 second asking for feedback on PTSD model; no reply
10/1/11 PN 0150 PP Email to let me know participant had completed
survey
survey
-11/8 survey; attached written narrative; sent three emails
with web links regarding PTSD; invited to comment
on PTSD model and did
10/18/11 ASCA PP Requested more info regarding study; no further
contact
10/31/11 PP PN 0123 Participated in study; invited to give feedback on
PTSD model; no reply
10/31/11 PN 0149 PP Participated in study; invited to give feedback on
PTSD model; no reply
240
APPENDIX A (CONTINUED)

12/6 – Spouse of PP Former Vietnam vet who declined to do survey but
12/7/11 PN 0105 recruited participant from circle of friends; several
emails regarding study enrollment and participant
contact information
1/30/12 PP Michele Invited to comment on PTSD model and did
Rosenthal
1/30/12 PP Hope4PTSD Had not participated; reinvited to participate in study;
Vets two emails from director of organization with
questions regarding study enrollment
* PP = Pamela Phillips, doctoral candidate

** PN = Participant Number
241
APPENDIX B
Recruitment Letter/Email/News Release
I am doing a research study at the University of South Carolina (USC), College of

Nursing to examine the basic psychosocial process that men and women undergo in
recovering from posttraumatic stress disorder (PTSD). PTSD is a debilitating anxiety
disorder that occurs after exposure to an extreme stressor or prolonged victimization. It
has been estimated that some 8% of all individuals exposed to a traumatic stressor such
as sexual assault or rape, military combat, child abuse, manmade and natural disasters,
accidents, and the like will develop PTSD. PTSD evokes feelings of intense fear,
helplessness, and horror in victims and prohibits them from assuming life roles.
Since little is known about how people recover from exposure to traumatic events,
I am seeking recovered victims of PTSD who are willing to participate in a survey
describing their recovery journey. The findings may help to refine traditional mental
health therapies and shape new practices. Some participants may find the process to be
painful, reminding them of old memories. However, many people who participate in
projects such as this one often consider the experience therapeutic and gain clarity about
former events.
All research will be conducted on a closed website at

http://www.PTSDrecoverystudy.com. All submissions will be confidential. The result
will be a grounded theory describing the recovery process from PTSD. More information
about the project is contained at the website.
Participants must be at least 18 years of age, English speaking, and capable of

using the internet. More information about other enrollment criteria is provided at the
study website. There is no payment for participation, but all contributions will be highly
valued and will help contribute to mental health knowledge.
Contact Information
You can contact me, Pamela Phillips, RN, MSN, PhD Candidate, at any time at
PTSDrecovery@gmail.com for any questions or concerns about this study. Thank you for
your support of this important research.
242
APPENDIX C
Posttraumatic Stress Disorder (PTSD) Recovery Study Demographic Information
DIRECTIONS:
All information received through this survey will be kept confidential.

Please try to answer as completely as possible.
DEMOGRAPHIC DATA FORM:
1)What is your year of birth:

__________________________________________________
2)What is your zip code? _______________________
3) Are you Hispanic or Latino?

0. No
1. Yes
If you answered no to the above question, which of the following ethnic groups
do you consider yourself belonging to? (Choose one)
1. American Indian or Alaskan native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Other _____________________
4)What is your gender?

0. Male
1. Female
5)What is your current marital status? (Choose One)

1. Single
2. Married
3. Living with partner
4. Separated
243
5. Divorced
6. Widowed
7. Other______________________
6)Which of the following best describes your current living situation? (Choose One)
1. Living alone
2. Living with spouse/partner
3. Living with spouse/partner and children
4. Living alone with children
5. Living with friends/family
6. Other______________________________________
7)How many children do you have? ____________________
8)How many children (under the age of 18) live in your house with you?
_____________
9)How many adults live with you?___________

Are any of your dependents over 18?
0.No
1.Yes
10)Which of the following best describes your educational level? (Choose One)
1. Did not graduate from high school
2. High school graduate
3. College graduate
4. Graduate school and/or graduate degree
11)What is your religion? (Choose One)

1. Christian
2. Muslim
3. Jewish
4. Other ______________________
5. No specific religion/not religious
12) Do you have a paying job?

0. No
1. Yes
13) If you do have a paying job, how many hours a week do you usually work?
1. 0-20
2. 21-40
3. 0+
14) Are you working in the same job that you had when you experienced trauma?
0. No
244
1. Yes
15) If you are working in a different job, do you consider it to be worse or better than
the job you had when you experienced trauma?
0. Worse
1. Better
16) Are you the head of household?

0.No
1.Yes
17) Do you have enough money to meet your needs?

0.No
1.Yes
Do you have enough money to meet emergencies?

0.No
1.Yes
18) Are you receiving or have you applied for any form of public assistance or
welfare, including social security? (Choose One)
0. No, and have not applied for
1. Yes, and currently receiving
2. Applied for, not yet receiving
19) If you answered yes to Question S, do you or another member of your household
receive any of the following? (Select Yes from the dropdown menu for any that
apply)
1. General Assistance or welfare 0. No 1. Yes
2. Workers Compensation 0. No 1. Yes
3. Unemployment benefits 0. No 1. Yes
4. WIC (Women, Infants, Children Program) 0. No 1. Yes
5. Support for families with dependent children 0. No 1. Yes
6. SSI (Supplemental Social Security Income) 0. No 1. Yes
7. SSD (Social Security Disability Insurance) 0. No 1. Yes
8. Food Stamps 0. No 1. Yes
9. Veteran's benefits 0. No 1. Yes
10.Social Security Retirement benefits 0. No 1. Yes
11.Retirement benefits from a private company, municipal/state government, or
other entity 0. No 1. Yes
12.Other (Please specify)____________________________________________
245
Now I want to ask you about the traumatic event(s) that led to your developing
posttraumatic stress disorder (PTSD).
20) How would you categorize the trauma you were exposed to?
1. Sexual assault or rape from a stranger
2. Sexual assault, rape, or violence experienced in a relationship with a spouse or
intimate partner
3. Exposure to crime or violent personal assault on yourself
4. Exposure to crime or violent personal assault on someone else
5. Exposure to combat, war, or being stationed in a war zone while in military
service
6. Exposure to combat, war, or living in a war zone as a civilian
7. Exposure to childhood abuse or sexual trauma with delayed onset of PTSD
8. Exposure to a natural disaster such as a hurricane, tsunami, tornado, or other
unpredictable natural event
9. Exposure to a manmade disaster such as an automobile or airplane accident,
hostage event, kidnapping, terrorist attack, mass shooting, etc.
10.Other event (please describe):_______________________________________
21) How long were you exposed to the traumatic event(s)?

1. Once
2. 2-5 times
3. 6-10 times
4. 11-25 times
5. Repeatedly or daily for less than a year
6. Daily or repeated trauma occurring for Greater than one year
7. Other (please describe):_______________________________________
22)How long did you experience the symptoms of PTSD?

1. 3 months – 1 year
2. 2 years
3. 3 years
4. 4 years
5. 5 years
6. Greater than 5 years (please list)_______________________________
23)Which of the following symptoms of PTSD did you experience? (Check all that
apply.)
1. Confusion
2. Anger
3. Persistent frightening thoughts and memories of the ordeal (flashbacks)
4. Emotional numbness, especially with people with which you were once close
5. Sleep problems
246
6. Feeling detached or dissociated from reality
7. Exhibited agitated or disorganized behavior
8. Was easily startled
9. Prolonged depression or apathy
24) Did you experience any of the following results from experiencing PTSD
symptoms? (Check all that apply.)
1. Job loss or inability to hold down permanent work
2. Disruption of education
3. Marital discord including separation and divorce
4. Family discord or strife
5. Impaired relationship with children
6. Loss of former friends
7. Financial problems, including bankruptcy
8. Alcohol abuse
9. Drug abuse, including marijuana use
10. Legal issues and/or arrests
11. Loss of hobbies and leisure pursuits
12. Damage to self-image
13. Self-injurious behavior
14. Other (please describe):________________________________________
If you developed a dependency on alcohol and other drug, please answer the
following question. Otherwise skip to Question Z:
25)Which of the following substances or behaviors did you abuse or use to excess
while experiencing PTSD symptoms? (Check all that apply.)
1. Alcohol
2. Marijuana
3. Cocaine
4. Methamphetamine
5. Heroin
6. Nicotine, including cigarettes and smokeless tobacco
7. Food, including excess eating, deprivation, and binging/purging
8. Prescription drugs, including pain pills and antianxiety drugs
(please describe):___________________________________
9. Out-of-control sexual behavior, including risky behaviors and multiple affairs
10. Risk-taking behaviors such as driving your car or motorcycle at excessive
speed, going into dangerous sections of town alone, etc.
11. Working excessively long hours by choice
26)How long do you think it took for you to get start feeling better after experiencing
a traumatic event?
1. A few days to 3 months
2. Greater than 3 months to six months
3. Greater than 6 months to 1year
247
4. Greater than 1 year - 2 years
5. Greater than 2 years - 3 years
7. Greater than 4 years -5 years
8. Greater than5 years (please specify):___________________________
27)When did you feel the worst?

8. Greater than 5 years (please specify):_________________
28)How long did it take you to feel recovered from PTSD?

8. Greater than 5 years (please specify):__________________
29)Which person, group, or event was most helpful in your recovery journey? (Select
only one.)
1. Spouse or significant other
2. Your children
3. Kin, including parents, siblings, cousins, etc. (please
specify):_______________________________________________
4. Friends
5. Clergy, prayer groups, or other faith-based counselors or groups
6. Peer groups of other people who had undergone the same trauma
7. Professional counselors such as psychiatrist, psychiatric nurse, psychologist, or
social worker
8. The passage of time
9. No one; I recovered through my own efforts
10. Other (please specify):____________________________________
248
Finally, can you define a turning point at which you knew you would recover? Please
describe this. ____________________________________________________
Thank you for your time.
249
APPENDIX D
Posttraumatic Stress Disorder (PTSD) Recovery Study Participant Information (Revised)
250
PTSD Recovery Study Participant Information
PTSD Recovery Study Informed Consent
On this page you must enter the mail address that you will be using for this research
project.
You also must sign an electronic consent that affirms that you meet the criteria listed on
the website for participating in this PTSD research project.
1.Please supply the following information which will be used to identify you in
this study.
ZIP: __________________________________________________________
Email Address:____________________________________________
2. I meet all of the criteria listed on the website for participating in the PTSD
Recovery Study. I voluntarily give my consent to participate in this study.
o Yes
o No
All information received through this survey will be kept confidential. Please try to
answer as completely as possible.
The first questions deal with personal information. Later on, the survey will ask about
your experience with trauma and posttraumatic stress disorder.
3. What is your birth year? _______________________________
4. Are you Hispanic or Latino?

o Yes
o No
5. Which of the following ethnic groups do you consider yourself belonging to?
o American Indian or Alaskan native
o Asian
o Black or African American
o Native Hawaiian or Other Pacific Islander
o White
o Other (please specify)__________________________
251
6. What is your gender?
o Male
o Female
7. What is your marital status? (Choose One)

o Single
o Married
o Living with partner
o Separated
o Divorced
o Widowed
o Other (please specify) _______________________
8. Which of the following best describes your current living situation?

(Choose One)
o Living alone
o Living with spouse/partner
o Living with spouse/partner and children
o Living alone with children
o Living with friends/family
o Other (please specify)________________________
9. How many children do you have? __________
10. How many children (under the age of 18) live in your house with you?______
11. How many adults live with you?_______________

12. Are any of your dependents over 18?
o No
o Yes
13. Which of the following best describes your educational level?

(Choose One)
o Did not graduate from high school
o High school graduate
o College graduate
o Graduate school and/or graduate degree
14. What is your religion? (Choose One)

o Christian
o Muslim
o Jewish
o No specific religion/not religious
o Other (please specify)_______________________
252
15. Do you have a paying job?
o No
o Yes
16. If you do have a paying job, how many hours a week do you usually work?
o 0-20
o 21-40
o 40+
17. Are you working in the same job that you had when you experienced
trauma?
o No
o Yes
18. If you are working in a different job, do you consider it to be worse or better
than the job you had when you experienced trauma?
o Worse
o Better
19. Are you the head of household?

o No
o Yes
20. Do you have enough money to meet your needs?

o No
o Yes
21. Do you have enough money to meet emergencies?

o No
o Yes
22. Are you receiving or have you applied for any form of public assistance
or welfare, including social security? (Choose One)
o No, and have not applied for
o Yes, and currently receiving
o Applied for, not yet receiving
253
23. If you answered yes to Question 21, do you or another member of your
household receive any of the following? (Select Yes from the menu for any that
apply)
General Assistance or welfare o No o Yes
Workers Compensation o No o Yes
Unemployment benefits o No o Yes
WIC (Women, Infants, Children’s Program) o No o Yes
Support for families with dependent children o No o Yes
SSI (Supplemental Social Security Income) o No o Yes
SSD (Social Security Disability Insurance) o No o Yes
Food Stamps o No o Yes
Veteran's Benefits o No o Yes
Social Security Retirement Benefits o No o Yes
Retirement benefits from a private company, o No o Yes
municipal/state government, or other entity
Other (please specify) ___________________ o No o Yes
Now I want to ask you about the traumatic event(s) that led to your developing
posttraumatic stress disorder (PTSD).
24. How would you categorize the trauma you were exposed to?
o Sexual assault or rape from a stranger
o Sexual assault, rape, or violence experienced in a relationship with a spouse or
intimate partner
o Exposure to crime or violent personal assault on yourself
o Exposure to crime or violent personal assault on someone else
o Exposure to combat, war, or being stationed in a war zone while in military service
o Exposure to combat, war, or living in a war zone as a civilian
o Exposure to childhood abuse or sexual trauma with delayed onset of PTSD
o Exposure to a natural disaster such as a hurricane, tsunami, tornado, or other
unpredictable natural event
o Exposure to a manmade disaster such as an automobile or airplane accident,
hostage event, kidnapping, terrorist attack, mass shooting, etc.
o Other (please specify)_______________________________________________
25. How long were you exposed to the traumatic event(s)?

o Once
o 2-5 times
o 6-10 times
o 11-25 times
o Repeatedly or daily for less than a year
o Daily or repeated trauma occurring for greater than one year
o Other (please specify)
254
26. How long did you experience the symptoms of PTSD?
o 3 months – 1 year
o 2 years
o 3 years
o 4 years
o 5 years
o Greater than 5 years (please list)
27. Which of the following symptoms of PTSD did you experience?

(Check all that apply.)
o Confusion
o Anger
o Persistent frightening thoughts and memories of the ordeal (flashbacks)
o Emotional numbness, especially with people with which you were once close
o Sleep problems
o Feeling detached or dissociated from realityExhibited agitated or disorganized
behavior
o Was easily startled
o Prolonged depression or apathy
28. Some earlier participants in this survey have talked about the disturbing
signs and symptoms of PTSD. Were your symptoms treated with medications
for anxiety, sleeping pills, nightmares, etc.?
o No
o Yes
29. If you received medications, what drugs were you given? Did you find
them to be effective? ______________________________________________________
30. If the distressing signs and symptoms of PTSD had been better controlled
with medications, do you think you would have recovered more quickly? Why?
_____________________________________________________________________
255
31. Did you experience any of the following results from experiencing PTSD
symptoms? (Check all that apply.)
o Job loss or inability to hold down permanent work
o Disruption of education
o Marital discord including separation and divorce
o Family discord or strife
o Impaired relationship with children
o Loss of former friends
o Financial problems, including bankruptcy
o Alcohol abuse
o Drug abuse, including marijuana use
o Legal issues and/or arrests
o Loss of hobbies and leisure pursuits
o Damage to self-image
o Self-injurious behavior or damage to physical health
o Other (please specify)___________________________________________
32. Did you abuse or use to excess alcohol or drugs or exhibit risky behaviors
while you were experiencing PTSD symptoms? (Check all that apply.)
o Did not abuse alcohol or drugs or exhibit risky behaviors
o Alcohol
o Marijuana
o Cocaine
o Methamphetamine
o Heroin
o Nicotine, including cigarettes and smokeless tobacco
o Food, including excess eating, deprivation, and binging/purging
o Out-of-control sexual behavior, including risky behaviors and multiple affairs
o Risk-taking behaviors such as driving your car or motorcycle at excessive
speed, going into dangerous sections of town alone, etc.
o Working excessively long hours by choice
o Prescription drugs, including pain pills and antianxiety drugs
(please specify)_________________________________________
This page contains the final questions about the traumatic event(s) that led to your
developing posttraumatic stress disorder (PTSD).
33. How long do you think it took for you to start feeling better after
experiencing a traumatic event?
o A few days to 3 months
o Greater than 3 months to six months
o Greater than 6 months to 1 year
o Greater than 1 year - 2 years
o Greater than 2 years - 3 years
o Greater than 4 years -5 years
o Greater than 5 years (please specify)__________________________________
256
34. When did you feel the worst?
o Greater than 5 years (please specify)_____________________________
PTSD
35. How long did it take you to feel recovered from PTSD?
o Greater than 5 years (please specify)________________________________
36. Which person, group, or event was most helpful in your recovery journey?
(Select only one.)
o Spouse or significant other
o Your children
o Friends
o Clergy, prayer groups, or other faith-based counselors or groups
o Peer groups of other people who had undergone the same trauma
o Professional counselors such as psychiatrist, psychiatric nurse,
psychologist, or social worker
o The passage of time
o No one; I recovered through my own efforts
o Kin, including parents, siblings, cousins, etc.
o Other (please specify)
37. Did you find any treatments that were not helpful? Why? __________________
38. Did you devise or discover any treatments that you found to be especially
helpful? ____________________________________________________________________
39. Finally, can you define a turning point at which you knew you would
recover? Please describe this. __________________________________________
Thank you very much for taking the time to answer these questions.
257
APPENDIX E
Preliminary, Intermediate, and Final Coding Categories
Initial Coding Categories Intermediate Coding Final Coding Category

Categories
Disbelief Denying trauma Experiencing Trauma

Memory blocking
Significant other experiencing abuse Dealing with abuse and Experiencing Trauma
Allowing others to abuse me abusers
Difficulty leaving abuser
Rreturning to an abuser
Disclosing abuse
People thinking they knew me Feeling vulnerable Experiencing Trauma
Being in a hostile environment
Not controlling the power
Being in a minority
Factors increasing abuse
Being invisible
Targeting the vulnerable
Feeling isolated
Being different after abuse
Preferring isolation to intimacy
Keeping secret
Having poor boundaries
Putting others needs above my own
Bargaining for love
Looking for escape
Trauma becoming a prison
Being numb and empty Intruding symptoms and Surviving Symptoms
Acting out resultant losses
Demanding attention
Dissociating from self
Dwindling resources
PTSD triggers
258
APPENDIX E
Preliminary, Intermediate, and Final Coding Categories (continued)

Categories
Confronting the bad Intruding symptoms and Surviving Symptoms

Mistrust of allies resultant losses
Losing fear
Felt the worst
Abusing drugs, alcohol, etc. Intruding symptoms and Surviving Symptoms
resultant losses
Being diagnosed with PTSD Dominating Diagnosis
Reeling from the diagnosis
Losing work related to PTSD
diagnosis
Affects all domains of my existence
Receiving no help Creating effective Seeking Solace
Receiving advice from others coping strategies
Becoming educated
Relying on self Seeking Solace
Gradual process Marking Time
Moving on
Long-term therapy
Short periods of wellness
Still in recovery
Not 100% yet
Intense self-work
Being visible Turning a corner Navigating Recovery
Being invincible
Speaking out
Being called to action
Standing firm
Knowing one’s true self
Taking back life
Sharing the truth
Standing tall
Feeling good about recovery
259
APPENDIX E
Preliminary, Intermediate, and Final Coding Categories (continued)

Categories
Knowing I would be all right Resuming life Navigating Recovery

Being reborn
Finding satisfaction with life post-
recovery
Living a smaller life post-recovery Never fully recovering Navigating Recovery
Regretting combat actions
Experiencing moral conflict
Worrying about other victims
Going backward in healing
Post-recovery frustration
Loss of the past Being unstuck in time Navigating Recovery

Nightmares Experiencing post- Navigating Recovery
Flashbacks recovery symptoms
Anxiety
Hypervigilance
Having only mild symptoms
260
APPENDIX F
RESEARCH PROJECT INFORMATION AND INFORMED CONSENT

Here is some information about this research study. At the end of this section,
there is a link where you can give consent for participation and provide
information about yourself.
About PTSD
PTSD is caused by trauma. Some common causes of trauma are
victimization such as rape, physical assault, or child abuse, natural and
manmade disasters, and combat experiences. Chronic PTSD is the most
commonly diagnosed anxiety disorder today, affecting some 8% of those
individuals who experience significant traumatic events or exposure to
cumulative stressors. The symptoms caused by chronic PTSD are very
intrusive and persistent, causing a victim to have persistent frightening
thoughts and memories of the ordeal; be numb or emotionally detached;
experience sleep problems; exhibit agitated or disorganized behavior; and
display exaggerated startle responses. Many victims have turned to
alcohol, drugs, and use of illicit substances to mask symptoms and
psychological pain.
Inclusion and Exclusion Criteria for Participation

Data will be gathered from PTSD survivors who have been given a
psychiatric diagnosis of PTSD and who report that they have recovered
and resumed life roles successfully for at least one year. You may or may
not have had formal treatment for PTSD.
Individuals who choose to participate in this project must be computer

literate, English speaking, age 18 or over, and capable of participating in a
writing project. You must provide informed consent before the written
recovery narrative will be accepted. You also must provide informed
consent to participate in the discussion forum only.
261
What about confidentiality?
You are allowed to participate in this project and remain confidential. You
do not have to provide your name or phone number. You must provide a
working email address. If you write a narrative and/or participate in the
discussion forum, you must fill out a consent form and submit some
demographic data. Your responses are kept strictly confidential.
To protect your confidentiality when participating in forums, you should

choose a user name that obscures your identity. Also, if your do not want
any study email to go to your regular email address, you can use a public
domain email such as one created in Hotmail, Google, Yahoo, etc.
Despite these measures, keep in mind that you may accidentally reveal
your identity if you disclose too specific information about yourself. For
that reason, please be guarded in responses that allow a reader to
pinpoint your identity or other personal information. Also, be sure not to
fill in profile information, post any pictures, or post any public narratives
that identify you.
Risks and Benefits

Some participants may find the writing process to be painful, reminding
you of old memories. While this project does not offer any mental health
services, many people who participate in writing projects such as this one
consider the experience therapeutic and gain clarity about former events.
Your participation will be highly valued and will help contribute to mental
health knowledge since little is known about how people recover from
exposure to traumatic events and PTSD. You may withdraw from the
study at any time without penalty.
Required Forms for Submission of Your Recovery Narrative

You must provide consent (permission) for your narrative to be used. If
you want to participate in the discussion forum only, you must provide
consent. Also, it is necessary for me to collect demographic data to
describe the participants in this research. You can give consent
electronically through the link below. No witness will be required. The
informed consent/demographic link will take you to a secure site where
you can reply to some questions online.
CLICK THIS LINK TO GO TO THE CONSENT AND SURVEY
(URL: https://www.surveymonkey.com/s/GLBV22X)
262

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USING THERAPEUTIC WRITING TO DECONSTRUCT RECOVERY FROM

POSTTRAUMATIC STRESS DISORDER (PTSD)

Bachelor of Science in Nursing

Master of Science in Nursing

Submitted in Partial Fulfillment of the Requirements

For the Degree of Doctor of Philosophy in

University of South Carolina

Kathleen Scharer, Major Professor

Mary Boyd, Committee Member

Beverly Baliko, Committee Member

Laura Hein, Committee Member

Emily Wright, Committee Member

Lacy Ford, Vice Provost and Dean of Graduate Studies

All rights reserved

INFORMATION TO ALL USERS

This dissertation is dedicated to my father, Eugene Phillips, who has always

project as large as this research study and complete it.

To paraphrase Hillary Clinton, it takes a rather large village to raise a doctorally

University of Nebraska at Omaha. My committee members tirelessly navigated me

all of the faculty’s efforts on my behalf.

several lunches in order to keep me on track.

Outside of Columbia, I must thank a small band of supporters who provided

encouragement. Robin Estrada, a fellow graduate student, provided sorely needed

technological challenges. I am obliged to all of you. Outside of academia, Michele

Rosenthal’s help was invaluable in sending possible study participants my way.

Finally, I owe my largest debt of gratitude to my research participants who

Exposure to physical and psychological trauma has produced a post-millennial

after exposure to an extreme stressor or prolonged victimization. After an extensive

review of treatment protocols in 2008, the Institute of Medicine (IOM) exhorted

clinicians to focus on defining the concept of recovery, concentrating on symptom

report mobilized large-scale efforts to quantify treatments and standardize delivery of

Diagnosis, Seeking Solace, Surviving Symptoms, Marking Time, and Navigating

themselves as architects of the healing process.

DEDICATION ............................................................................................................... III

LIST OF TABLES ........................................................................................................ XV

LIST OF FIGURES ..................................................................................................... XVI

CHAPTER I: INTRODUCTION ........................................................................................... 1

PURPOSE OF THE STUDY .......................................................................................... 4

CHAPTER II: BACKGROUND AND SIGNIFICANCE ............................................................. 8

TRAUMA, VICTIMIZATION, AND POSTTRAUMATIC STRESS DISORDER ....................... 8

PROPOSED DIAGNOSTIC DIFFERENCES IN DSM-5.......................................... 11

DELAY AND ABANDONMENT OF LIFE ROLES................................................. 20

ECONOMIC EFFECTS OF PTSD...................................................................... 23

ETIOLOGIES OF VICTIMIZATION AND PTSD............................................................ 25

TRAUMATIC EVENTS .................................................................................... 27

TREATMENTS FOR PTSD ....................................................................................... 32

PAST-FOCUSED THERAPIES .......................................................................... 33

SUMMARY OF PTSD ETIOLOGY, RISK FACTORS, AND TREATMENT................ 40

RECOVERY: MENTAL ILLNESS AND PTSD.............................................................. 40

POLICY PERSPECTIVE ON RECOVERY FROM MENTAL ILLNESS ....................... 42

CONSUMER CONCEPTUALIZATION OF THE PROCESS OR RECOVERY................ 43

CORE THEMES OF RECOVERY FROM MENTAL ILLNESS .................................. 46

CONCEPTUAL MODELS OF RECOVERY FROM MENTAL ILLNESS ..................... 49

SUMMARY OF MENTAL HEALTH CONCEPTUAL MODELS ...................... 57

RECOVERY FROM PTSD ............................................................................... 62

SUMMARY OF PTSD RECOVERY ......................................................... 64

THE HEROIC JOURNEY: THERAPEUTIC WRITING, SOCIAL NETWORKING,

AND NARRATIVE THERAPY.................................................................................... 64

THE HEROIC JOURNEY ................................................................................. 65

THE VALUE OF THERAPEUTIC WRITING ........................................................ 67

WRITING AS A LITERARY ENDEAVOR ........................................................... 74

WEB 2.0, ONLINE COMMUNITIES, AND SOCIAL MEDIA .................................. 76

QUALITATIVE RESEARCH ...................................................................................... 78

QUALITATIVE METHODS .............................................................................. 81