A GROUNDED THEORY STUDY OF MEANING-MAKING COPING AND GROWTH IN COMBAT VETERANS By Brad Alan Larner A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Human Development and Family Studies – Doctor of Philosophy 2013 i ABSTRACT A GROUNDED THEORY STUDY OF MEANING-MAKING COPING AND GROWTH IN COMBAT VETERANS By Brad Alan Larner Meaning-making coping is an essential process for recovery from combat trauma. The meanings that combat veterans make after combat trauma, the meaningbased processes they utilize, and the social interactions they experience have not been compared across outcomes. This study was designed to shed light on this meaningmaking coping process with four main goals. The first was to ascertain what combat veterans believe about their experiences. The second was to find out what meaningmaking processes combat veterans utilize. The third was to understand how meaningmaking coping is related to the significant relationships combat veterans have. The final question to be answered was to understand how these beliefs, meaning-making processes, and relationship interactions vary between combat veterans experiencing very different outcomes. This study utilized semi-structured interviews with 15 male combat veterans from the post 9/11 wars in Iraq and Afghanistan. The sample consisted of 5 resilient combat veterans, 5 highly traumatized combat veterans, and 5 growthoriented combat veterans. A grounded theory of meaning-making coping was developed for each group and compared to the others. Results suggest global beliefs to be the driving force behind the success or failure of meaning-based coping during and after combat. The adequate global beliefs of the resilient combat veterans led to low discrepancy of meaning which enhanced the ability of that combat veteran to see the experience of combat as a challenge to be overcome by improved mental and ii emotional focus and internal control. After their deployment they reported improved relationships with significant others. The insufficient global beliefs of the highly traumatized group and the initial beliefs of the growth-oriented group, by contrast, led to high discrepancy of meaning which led to a sense of existential threat, physiological and emotional flooding, and high symptomology. They also reported difficulties with most significant relationships and increased closeness with other highly traumatized combat veterans. The growth-oriented group reported congruent experiences with the highly traumatized group until some point after their deployment when they recall a change in their global beliefs. At this point, they reported that their beliefs and meaning-based coping styles began to emulate those of the resilient group. Further, instead of dissociating from others they began to rebuild relationships with significant others and seek out more effective and supportive relationships. Though the sample is small, the tentative, but identifiable differences between-groups are compelling. What is believed before combat affects the perception of and response to combat itself which in turn leads to different levels of effectiveness and ability to successfully cope afterward. iii Copyright by BRAD ALAN LARNER 2013 iv DEDICATION This dissertation is dedicated to my God, who has given me all I have in spite of myself, and to my beautiful wife Michele who endured all, in order that this could happen. v ACKNOWLEDGMENTS Like a quarterback without a team or a general without an army, I could never have completed this dissertation without the help of several people in different capacities. I am grateful for the opportunity to thank them. Some are named and known and others preferred to remain nameless for various reasons, but to anyone and everyone that has helped in any way I am supremely thankful. The greatest sacrifice and burden was carried by my family. Too often I had to be physically present but mentally absent; immersed (or drowning) in data. Their patience was priceless. My wife Michele stood by me through every surprise and burden, and my children, Elizabeth, Allison, Andrew, and Adam all had to endure more than I ever thought they’d have to. My parents, Sharon and Ernest Larner, helped as they were able, as graduate studies took their toll. I would like to express my very deep appreciation and thanks to my advisor and committee chair, Dr. Adrian Blow. I am grateful for his patience with this long research process, social and human resources which proved to be priceless and willingness to just tell me straight up when I wrote something that just plain made no sense at all. At no time did I feel unsupported during this process and his guidance proved time and again to bring me back on track when I needed… even when he was nearly off-grid on another continent. Thanks for your continued contact especially when it was terribly inconvenient. I would also like to thank my other committee members, Drs. Barbara Ames, Robert Griffore, and Robyn Mace. Their different insights from a number of angles vi challenged me to look outside my tunnel-vision in ways that enhanced the final product considerably. They were always supportive when providing feedback which is a gift I know is not to be taken for granted. They helped me keep my early focus theoretical, and challenge the very fit of any given theory. My perspective changed early due to their consideration and I believe it was for the better. Though not on the committee, I would like to include my sincere appreciation to Dr. Jose Ruben Parra Cardona. Early in my graduate career he encouraged me to continue to pursue my research interest in spirituality and religiosity in families and to challenge me to address any bias head on by asking what the research indicated rather than avoid controversial topics like these. His support was a key factor when deciding on a dissertation topic that ran deep enough with me that I might actually want to finish it in spite of what seemed like an endless barrage of setbacks. Others include Dr. Louis Cohen, a professor from my undergraduate days, without whom I would never have been prepared to even apply to graduate school and my symbolic logic professor whose name eludes me, but was truly the first person to indicate to me that I had what it took to pursue a PhD in anything at all. I would like to thank Melissa Alex, the Family Readiness Coordinator with the Michigan National Guard. Without her assistance I might still be searching for participants at this very moment. Finally, I would like to extend my sincere appreciation to every combat veteran who participated in this study. Their willingness to be open about topics that are almost always off-limits to even their closest family and friends was priceless beyond measure. vii It was my honor to hear their stories and I have taken very seriously the obligation to portray their words as accurately as possible. viii TABLE OF CONTENTS LIST OF TABLES xv LIST OF FIGURES xvi CHAPTER ONE INTRODUCTION Background of the Problem Present State of the Literature Combat Trauma is Unique Purpose of the Study Research Questions Significance of the Study Overview of Theoretical Perspectives Coping and Growth in Combat Veterans Three Primary Outcomes Resilience High traumatization Growth-orientation Domains of Meaning Deployment context Overall meaning Self-meaning Family & friends Military meaning Societal meaning Taking another’s life and “the enemy” Spiritual & existential meaning Summary and Overview of the Dissertation 1 1 2 4 5 6 6 8 8 8 8 8 9 9 10 10 10 11 11 11 12 12 13 CHAPTER TWO LITERATURE REVIEW Introduction The Context of Combat Trauma Meaning-Making Coping A Guiding Framework Meaning-Making and Discrepancy Global Meanings Appraised Meanings Discrepancy Reappraisal Processes Rumination Social Support Therapeutic Processes 15 15 16 18 20 24 25 26 26 27 27 27 28 ix Trauma Outcomes Resilience to Wartime Trauma Negative Outcomes of Wartime Trauma Growth After Wartime Trauma Ecological View of Combat Related PTG Shattering of World Assumptions Posttraumatic Growth and Posttraumatic Stress Posttraumatic Growth and Resilience Dimensions of Posttraumatic Growth Ecological Framework Individual Factors of Combat Veterans Age Education Race / ethnicity Personality factors Cognitive factors Acceptance, rumination, and meaning-making Microsystem Factors Social Support Existential / Spiritual / Religious Killing, combat guilt, and growth Military Factors Mesosystem Factors Exosystem Factors Macrosystem Factors Chronosystem Factors Conclusion CHAPTER THREE RESEARCH DESIGN AND METHOD Introduction Overview of Methodology and Research Design Researcher as Instrument Sampling Access Sampling Strategy Sample Size Procedures Quantitative Instruments and Procedures Resilience scale (RS-14) Posttraumatic growth inventory – Short form (PTGI-SF) PTSD Checklist – Military version (PCL-M) Stratification procedure by instrument Overview of Qualitative Interviews Research Questions Compensation x 29 30 30 31 32 33 34 35 36 36 38 38 39 39 39 40 41 42 43 44 47 48 48 49 50 51 52 55 55 55 56 57 60 63 68 69 71 71 72 72 73 73 77 78 Confidentiality Coding and Data Analysis Coding Bias, Reliability, and Trustworthiness CHAPTER FOUR FINDINGS General Overview of Findings Emerging Themes and Annotations by Outcome Common Themes News Media Resilient view: Biased and detrimental Highly traumatized view: Propaganda Growth-oriented view: Biased and dangerous View of Society as Naïve Resilient view Highly traumatized view Growth-oriented view Summary Resilience Trajectory Difficult Experiences What do resilient combat veterans believe? (RQ1) Comprehensive world assumptions Prescriptive rumination Benevolent relationship with God Sustaining faith Military context Congruent appraised global meaning of war Congruent appraisal for their war Resilient enemy combatant appraisal Taking another’s life: Contextual Resolved personal mortality How do resilient combat veterans cope through meaning? (RQ2) Lower post-trauma symptomology Meaning-making during combat deployment Challenge appraisal Combat Normal: Professional, Calm Effective assimilation Meaning-Making After Combat Deployment Deliberate rumination Forgiveness and understanding Little to no therapy needed Lack of negative coping evident in narratives How do resilient combat veterans interact with others? (RQ3) Decreased tolerance for immaturity Keeping it private xi 79 79 81 83 85 85 87 88 88 88 90 91 93 93 93 94 96 97 97 98 99 103 105 107 108 108 111 115 117 120 121 121 125 125 127 130 131 131 132 134 136 137 137 139 Post-combat family interaction Families of origin: Shared meaning Intimate relationships: Less supportive Fewer, but stronger friendships Veteran friendships: Brotherhood Summary Deeply Traumatized Trajectory Difficult Experiences What do deeply traumatized combat veterans believe? (RQ1) Initially idealized world assumptions Shattering of world assumptions Intrapsychically defined world assumptions Judgmental world assumptions Spirituality incongruent with war Reactive / external locus of control Military context Congruent meaning of war Inconsistent appraisal for their war Military service as struggle Enemy: Dehumanize and judge Taking a life: Deeply personal Loss of buddies: Hatred and judgment How do deeply traumatized combat veterans cope? (RQ2) Deeply traumatized symptomology Meaning-making coping during deployment Threat appraisal Failed assimilation and accommodation Meaning-making coping after deployment Failed assimilation and accommodation Intrusive rumination / reliving Low self-awareness Dependency coping Unsuccessful therapy / suicide ideation Perseverance and grit How do deeply traumatized combat veterans interact? (RQ3) Social dissociation Disconnected from family Active culling of friend network Closest to veteran friends Summary Growth-Oriented Trajectory Difficult experiences What do growth-oriented combat veterans believe? (RQ1) Initial global beliefs: Naïve and idealistic Shattering of world assumptions Growth-oriented global assumptions xii 139 139 141 143 144 146 148 148 149 150 150 154 155 157 159 160 160 161 162 163 165 168 169 169 172 172 174 175 175 176 176 177 179 180 181 181 182 184 185 187 189 189 190 190 192 194 Growing relationship with God Increasing faith Forgiveness by God, self, others Military context Incongruent military factors Congruent global meaning of war Increasingly negative war appraisal Enemy: Positive redefinition Taking a life: From callous to contextual Personal mortality: Positive change How do growth-oriented combat veterans cope? (RQ2) Growth-oriented symptomology Meaning-making coping during deployment Threat appraisal and emotional reactivity Lack of peer support: Failure and shame Meaning-making after deployment Hyper-vigilance and threat appraisal Chemical dependency and avoidance coping Perseverance / grit Therapy and suicide ideation Initiation of posttraumatic growth From judgment to forgiveness Accessing emotions & deliberate rumination How do growth-oriented combat veterans interact? (RQ3) Pre-deployment judgment Less patience for selfishness Military family: Struggle and support Keeping it private Family relationships: Inconsistent growth Intimate relationships: Mixed responses Civilian friendships: Fewer, but closer Veteran friendships: Less significant Summary Group Comparisons (RQ4) Overall Impression Comparison of Beliefs Global belief systems / world assumptions Similarly appraised meanings Differentially appraised meanings Comparison of Meaning-Based Coping Comparison of coping during combat Comparison of coping after deployment Comparison of Social Interactions from an Ecological Perspective News media as macrosystem feedback Friendships Family relationships xiii 195 197 199 201 202 203 205 207 211 214 216 216 218 218 220 221 221 222 225 225 227 231 232 234 235 236 237 239 240 242 243 245 246 249 249 249 249 252 253 255 257 258 260 260 263 264 Intimate partners Veteran friendships Summary CHAPTER FIVE DISCUSSION AND CONCLUSIONS Revisiting the Purpose of the Study Revisiting the Research Questions Research Question 1: Beliefs Relevant to Combat Experience Discussion of resilient beliefs Discussion of highly traumatized beliefs Discussion of growth-oriented beliefs Synthesis Research Question 2: Meaning-Making Processes Utilized Discussion of resilient meaning-making coping Discussion of highly traumatized meaning-making coping Discussion of growth-oriented meaning-making coping Synthesis Research Question 3: Social Interactions and Meaning-Making Discussion of resilient social interactions Discussion of highly traumatized social interactions Discussion of growth-oriented social interactions Synthesis Implications for Theory Implications for Practitioners Limitations Future Directions Personal Reflections 266 267 268 APPENDICES Appendix A: Initial Screening Instrument (ISI) Appendix B: Informational Flyer Appendix C: Outcome Definition Handout Appendix D: Research Consent Authorization Form Appendix E: Demographic Information Sheet Appendix F: Resilience Scale (RS-14) Appendix G: Post-Traumatic Growth Inventory – Short Form (PTGI-SF) Appendix H: PTSD Checklist – Military Version (PCL-M) Appendix I: Interview Guide Appendix J: Contact Summary 311 312 313 314 315 317 318 319 320 322 326 REFERENCES 327 xiv 270 270 271 271 272 274 277 278 279 279 281 283 284 285 285 287 288 289 290 297 300 305 307 LIST OF TABLES Table 3.1: Demographic Summary of the Sample 61 Table 3.2: Stratification of the Sample 67 Table 3.3: Averaged Group Scores for Qualitative Measures 68 Table 3.4: Relationship of Research Questions and Interview Questions 78 Table 4.1: Comparison of Global Beliefs and Appraised Meanings 250 Table 4.2: Comparison of Meaning-Based Coping Themes 256 Table 4.3: Comparison of Social Interaction Themes 261 xv LIST OF FIGURES Figure 2.1: The Guiding Framework 21 Figure 2.2: Proposed Ecological Model of Posttraumatic Growth 37 Figure 3.1: Informants and Participants 64 Figure 4.1: Grounded Theory of Resilient Meaning-Making Coping 147 Figure 4.2: Grounded Theory of Highly Traumatic Meaning-Making Coping 188 Figure 4.3: Grounded Theory of Growth-Oriented Meaning-Making Coping 248 Figure 5.1: Revised Ecological Map 294 xvi CHAPTER ONE: INTRODUCTION Background of the Problem What do combat veterans believe about their wartime experiences, and how are these beliefs related to the different life outcomes that they may have after they return home? This study explores the differences between resilience, posttraumatic growth (PTG), and posttraumatic decline in a sample of war veterans to learn more about these issues. An exploration of recent scholarly literature of meaning-making coping in combat veterans reveals that in spite of anecdotal accounts we are still in the dark about how meaning-making coping processes are related to different outcomes (Larner & Blow, 2011). Over 1.6 million American military men and women have deployed to fight the Global War on Terror (Seal et al, 2010) since 9/11/2001, and since this time there has been an explosion of research focused on the negative mental health consequences of wartime trauma (Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004; Hoge, Terhakopian, Castro, Messer, & Engel, 2007; Tanielian & Jaycox, 2008). This research largely has focused on prevalence of diminished mental and behavioral health and access to adequate mental health care for troubled veterans returning from combat. In spite of this focus on mental health problems, most veterans report more positive than negative outcomes from their wartime experiences, and some who are initially distressed are even able to overcome these difficulties and go on to live improved lives (for a detailed review see Schok, Kleber, Elands, & Weerts, 2008). Indeed, because most trauma survivors adjust to life challenges in a manner that produces growth, it can be considered to be the normative response to stress and trauma. 1 Increasingly, meaning-making is viewed as a central component of growth that occurs after trauma (Larner & Blow, 2011; Park, 2005; Park, 2008). Unfortunately, research on the differential link between the meaning-making process and the possible range of outcomes after trauma is lacking. Combat trauma represents a unique subset of traumatic experiences that are particularly underrepresented in the literature in comparison to other types of trauma. In short, according to the literature we have a lot left to understand about how combat veterans make meaning of their wartime experiences (Larner & Blow, 2011). Present State of the Literature In the last decade there has been an increased focus on post-traumatic growth (PTG) and how individuals are able to reevaluate their difficult experiences and grow because of or in spite of a traumatic life experience. Surprisingly, veterans have been largely ignored in these studies (Rosner & Powell, 2006), and while some PTG research findings can be applied to trauma in general, other research has shown that the experience of trauma differs by factors such as type of trauma (Shakespeare-Finch, 2010) and population under study (Deering et al., 1996; Kleim & Ehlers, 2009), highlighting the importance of studying specific populations related to particular types of trauma. With an increasing number of combat veterans returning home, the need for focused research in this area continues to grow. Building on this, the focus of this study was on how veterans make meaning about their combat experiences and how these meanings help them to cope with their traumas with a particular focus on personal growth, or PTG, after the experience of combat. 2 Larner and Blow (2011) reviewed all articles in the last ten years focused on growth after trauma in military and non-military populations and used this review to develop a conceptual model to guide future research in this area. In our review, we could find only eight studies addressing PTG in veteran populations specifically, and of these eight articles, four focused on Prisoners Of War, leaving only four studies addressing a more representative sample of veterans. One of the four non-POW articles focused on veterans from the first Gulf War (Maguen et al. 2006), finding that social support was positively associated with PTG. Another (Lee, Luxton, Reger, & Gahm, 2010) evaluated the use of the Post-traumatic Growth Inventory (PTGI), finding the PTGI to be a reliable measure for use with veterans returning from the post 9/11 wars in Iraq and Afghanistan. Kaler, Erbes, Tedeschi, Arbisi, and Polusny (2011) validated the PTGI-SF (short form of the PTGI) with a sample of National Guard soldiers. Their findings showed satisfactory reliability and replicated the factor structure found in the original PTGI among Iraq War veterans. The final study (Pietrzak et al. 2010) found unit member support to be significantly and positively related to higher levels of PTG. Though these studies are useful, the lack of PTG research utilizing veteran populations overall is of note considering the massive media attention given to both the Iraq (Operation Iraqi Freedom; OIF) and Afghanistan (Operation Enduring Freedom; OEF) wars and the concern for the welfare of the men and women returning home after their combat deployments. The numbers of veterans returning home from recent wars with crises of conscience and meaning that is related to mental health decline calls for a renewed focus in this area. 3 Meaning-making is widely accepted as a core component of dealing with loss and other traumatic events. Though empirical testing of the underlying assumptions has been thin, recent efforts have been made to bridge the knowledge divide between meaning-making coping and PTG (Park, 2008). In one notable study, Lomsky-Feder (1995) completed a phenomenological analysis of the life stories of Jewish-Israeli combat veterans of the Yom Kippur War, providing insight into the interpretive mechanisms that combat veterans use to develop a sense of coherent meaning of their wartime experiences. This study found that Israeli soldiers from the war internalized and normalized their wartime experience rather than viewing it as traumatic, which is the overwhelming view in the literature. As a small country surrounded by enemies where every citizen must serve in the military, this contextual understanding makes sense. In spite of this one study, there is a lack of research of this nature exploring the meanings and processes of growth in combat veterans, especially from US veterans. More work needs to be done to gain a contextual understanding of the role of meaning-making in the PTG process of combat veterans. This study was undertaken to help fill this gap in our knowledge. Combat Trauma is Unique Veterans returning home from combat represent a group with unique trauma experiences that are ideally viewed contextually through a lens that is sensitive to the specifics of combat trauma and the unique characteristics of the veterans themselves. The psychological trauma of military combat is very different from other traumas such as being the victim of a natural disaster, a severe car accident, or a terminal illness. Being the victim of interpersonal violence such as rape or violent assault may be more 4 closely related to combat trauma due to the interpersonal nature of the events, but in these cases the trauma survivor is still considered solely as a victim rather than also a perpetrator of violence and trauma against others at the same time. Further, the pile-up of prolonged trauma and other stressors that come with the intensity of combat is not typical of traumas any other trauma group, with research often focusing on a single traumatic event. Current US combat veterans represent a self-selected population of individuals who willingly face traumatic experiences with foreknowledge and in the name of national security, rather than as victims of random events. What is not known is how these unique factors interrelate to the different outcomes veterans face as a result of their combat experience. In this research I used semi-structured interviews to explore the uniqueness of combat trauma, which allowed each participant’s experience to inform the research in a way that necessarily incorporated the rich context that is critical to increasing our understanding of how combat veterans cope with their experiences. Purpose of the Study The purpose of this study was to explore the process by which combat veterans deal with combat trauma with a specific focus on meaning-making processes and resultant meanings made. While we know that different veterans respond in different ways to combat, with some doing well and others not, little is known about the processes that these veterans go through in order to deal with these experiences and what the differences between groups may be. For each group of veterans (interviewed post war-time deployment), I asked them to describe their pre-combat beliefs, their meaning-making processes, and what they now believe. By comparing the differences 5 in pre-to-post meanings, and associated processes, I was able to learn what these process and outcome differences are for at least a modest group of combat veterans. Research Questions In order to gain a more thorough understanding of this process, these lines of research (decline, resilience, and PTG) need to continue to be brought together to discover how meaning is related to different outcomes after the traumatic experience of combat. Armed with this knowledge, this study set out to establish a theory of meaning grounded in the meaning laden narratives of 15 American combat veterans. Thus, the purpose of this study can be summed up in the following research questions: 1. What do combat veterans believe about their combat experience and their roles during and after their deployment? 2. What is the process used by combat veterans to overcome or make sense of combat trauma? 3. How is meaning-making coping related to the relationships veterans have with family members and other people who are significant in their lives? 4. How do the beliefs, meaning-based growth processes, and social interactions with significant others differ between those who achieve resilient, decline oriented, and PTG outcomes? Significance of the Study Quantitative research comparing PTG and post-traumatic stress has been inconsistent. Though attempts have been made to discern why, most explanations fall short. Kleim and Ehlers (2009) discovered a curvilinear relationship between PTG and PTSD scores, and they provide an informed speculation about the causes of this 6 curvilinear relationship. However, the search continues for more definitive and conclusive answers. Meaning-making coping research suggests that ascribing different meanings to different aspects of the combat deployment experience plays an important role in the outcome that veterans develop (Maddi, Khoshaba, Harvey, Fazel, & Resurreccion, 2011; Owens, Steger, Whitesell, & Herrera, 2009). This study allowed combat veterans to describe what their experiences meant in their own words so as to increase our understanding of how meaning-making coping is related to the different outcomes they experienced. This study is innovative for three reasons. First, very little traumatology research focuses on more than one type of trauma outcome, and this study addressed three major outcomes, each of which has a solid history of quantitative inquiry. Secondly, the qualitative nature of the study was designed to allow for the discovery of features of traumatology that are simply not available through quantitative investigation. Finally, qualitative research is both challenged and enhanced by the characteristics of the researcher. In the case of this study, the quality of data gathered stands to gain from the status of the researcher as both former active duty United States Marine, and as a veteran who had acquired a partial disability as a result of his military service. These factors provided insider status. Insider status has been shown to enable access to closed populations and enhance the richness of data when that access is gained compared to that of outsiders (Talbot, 1998-1999). It also raised considerations that needed to be addressed, such as bias and the potential for role confusion (Asselin, 2003). Taken together, these factors allowed me to gather a deep and rich dataset for analysis that is unique to the trauma literature. 7 Overview of Theoretical Perspectives Coping and Growth in Combat Veterans As a guiding theoretical framework, the model of meaning-making coping and growth developed by Larner and Blow (2011) provided a starting point for the study. Our model maps out a longitudinal trajectory that incorporates a cognitive base, which focuses primarily on level of discrepancy between global meanings and appraised meanings of traumatic events. According to the model, this process of meaning-making leads to primarily three distinct, but not mutually exclusive, outcomes. Meaning-making coping and the model we developed is discussed further in chapter two. Three Primary Outcomes Resilience. Resilience is the ability of someone to experience trauma without a shattering of world assumptions, which in turn, allows the individual to return to or surpass previous levels of functioning. Resilience is often characterized by positive self-esteem, optimism, and having some sense of control or coherence regarding life events by some (Agaibi & Wilson, 2005) and as the lack of PTSD by others (Levine, Laufer, Stein, Hamama-Raz, & Solomon, 2009). Growth through resilience is a result of application of existing resources that enable a person to remain stable, and/or grow as a result of a traumatic experience without undergoing a shattering of world assumptions. High traumatization. High traumatization, which also can be viewed as a negative or decline, occurs when an individual is not able to cope with the trauma and develops a pathological response, often resulting in a diagnosable mental health condition such as, but not limited to Posttraumatic Stress Disorder (PTSD), depression, or suicidality. This decline in functioning is indicative of a number of physiological 8 factors, but also is accompanied by a shattering of world assumptions with inadequate or failed attempts to cope. Growth-orientation. Having a growth-orientation, or undergoing posttraumatic growth, or PTG, is defined as interpersonal growth or positive change as a result of struggling with trauma, and growing in spite of it (Tedeschi & Calhoun, 2004). Though other conceptualizations exist, PTG is most often measured by total scores and individual subscale scores on the posttraumatic growth inventory (PTGI). Posttraumatic growth is preceded by an initial shattering of world assumptions, but followed by growth in some or all of the domains within the PTGI. Outcomes of PTG include changed priorities, a greater appreciation for the value of one’s own life, having a better understanding of spiritual matters or a stronger religious faith, and discovering previously unknown inner strength. Outcome research in traumatology needs to address each of these potential trajectories, and this research investigated the role of meaning in the post-trauma growth process. Domains of Meaning Combat veterans, through the course of their deployment experiences and afterward, must answer important questions regarding their beliefs and values. Though the list of potentially important meanings is long, some domains of meaning have been most prominent in the literature regarding combat trauma, or are of ubiquitous importance where military action is concerned. The next chapter outlines these meanings more thoroughly utilizing an ecological lens, but important domains of meaning are introduced below providing an introductory rationale for the primary interview questions. 9 Deployment context. The deployment context is different for every combat veteran. Context informs meaning. The first two interview questions allowed the participant to inform the interviewer of the events they were involved in. Did they see multiple close engagements? Did they get hit by multiple IEDs? Were they on foot patrols or did they have light trucks or Humvees? How many buddies did they lose during their deployment? This provided a sense of context for the deeper, more personal interview questions. Overall meaning. Along with the deployment context is the overall sense of meaning that combat veterans have about war in general and the war(s) they fought in. Combat veterans who believe deeply in the cause of the war they fought often respond very differently than those who do not believe in the cause for which they fight. The survey questions were designed to elicit global meanings, or world assumptions, by which context-specific appraised meanings will be compared. Self-meaning. Each combat veteran must answer questions central to his or her own identity, beliefs, and values. These individual factors play a central role in the PTG process and outcome for combat veterans. Personality variables, cognitive appraisal strategies like meaning-making coping, and the use of other coping styles are important to the PTG process (Armeli, Gunthert, & Cohen, 2001). Some veterans benefit from cognitive reappraisals like moving from thinking of themselves as a victim to becoming a survivor (Linley & Joseph, 2004; Helgeson, Reynolds, & Tomich, 2006). Having strong convictions has been found to be not only protective, but allows one to endure even greater adversity than those without such conviction (Basoglu, et al. 1997). 10 Family & friends. Social support from close friends and family is important (Robinaugh, 2011). Though rumination processes are intrapsychic, the reappraisal process overall is thought to be an inherently social one (Harvey, 1996) with survivors interacting with others, or refusing to do so, on a number of levels, and for a number of different reasons. They may discuss complex or deeply personal views with family and friends or they may choose to listen or separate themselves from the moment. The ability of family members to make sense of the traumatic experience is an important factor in family resilience and coping (Walsh, 2007). Families who fail to make meaningful sense of the combat trauma their veteran has experienced may be party to negative interactions detrimental to the veteran’s mental health and social functioning (Ehlers & Clark, 2000). Military meaning. Another important source of meaning for combat veterans is the military context. Feeling unsupported by other unit members or those in leadership has been correlated with greater loneliness and increased levels of combat stress response in Israeli combat veterans of the 1982 Israeli-Lebanon war (Solomon, Mikulincer, & Hobfol, 1986), while perceiving positive unit member support has been found to promote PTG in OEF and OIF veterans (Pietrzak, et al., 2010). The social support received by unit members and the perceived relationship one has with military peers and leaders plays an important role requiring further attention. Societal meaning. Society plays an important role in the self worth that trauma survivors feel (MacDonald, Saltzman, & Leary, 2003). When others in society are disapproving or disinterested, trauma survivors can experience higher rates of distress after trauma (Lepore, Ragan, & Jones, 2000). This effect of societal meaning has been 11 seared into American social consciousness through the treatment of returning Vietnam veterans. Cultural identity (Taylor & Usborne, 2010) also can be related to positive mental health. Finally, interpersonal components of religious coping such as forgiveness, spiritual support from others, and making spiritual connections also are important (Pargament, Smith, Koenig, & Perez, 1998; Ai, Peterson, & Huang, 2003). Taking another’s life and “the enemy”. The combat trauma survivor is not only survivor, but also agent of trauma for others. How service men and women find meaning and growth afterward is of great importance. The lack of research in this area (Grossman, 2008) does not diminish its importance. While there are those who see all killing as not just undesirable, but always wrong, others have noted and discussed a difference between just and unjust killing during wartime (Benbaji, 2007). Maguen and colleagues (2009) found that mental health outcomes for combat veterans were worse when they had killed civilians versus having killed other enemy combatants. Combat related guilt and shame is potentially one of the most consequential factors in predicting suicidal thoughts and behaviors in Vietnam veterans (Hendin & Hass, 1991). This study spoke to these areas as literally as research is able. Though a difficult topic for many veterans to discuss, the benefits of increasing our understanding of the personal meaning of killing during wartime were warranted, and their narratives did not disappoint. Spiritual & existential meaning. Spiritual, religious, or otherwise existential meanings are unique in that they are deeply personal (relating to the self-meaning category above), but also global in their role in the perception of how the world functions. Through their existential beliefs, veterans form their own understanding of 12 the meaning of life in general and the meaning of their own life in particular. Often, combat veterans experience a significant increase in their appreciation of life (Pietrzak, 2010). Unfortunately those that believe God has abandoned or is punishing them tend to report lower quality of life (Pargament, Smith, Koenig, & Perez, 1998), leading researchers to investigate the importance of the relationship trauma survivors have with existential beliefs in general or their belief in God in particular. The existential meanings that combat veterans hold are of great importance. Each of these meaning domains was investigated during the course of the semi-structured interviews. Summary and Overview of the Dissertation Meaning-making coping research has indicated that combat veterans and other trauma survivors who have primarily negative outcomes process the meanings of their experiences differently than those who experience primarily positive or resilient outcomes. Unfortunately, the range of specific and relevant meanings still remains relatively uninvestigated. This grounded theory study allowed 15 combat veterans to express what their combat experience meant to them and how they came to their conclusions. This qualitative study had five tightly related aims. The first was to gather these meanings from the narratives of male combat veterans who served in OIF and OEF. Veterans interviewed were identified as primarily having a resilient outcome, a negative outcome (decline), or a PTG outcome. The beliefs held by each of the five veterans were compared to each other with the same group to look for patterns of similar meanings and get at the essence of those meanings related to that outcome. Unique meanings that are not as central or shared among the group were investigated. 13 Secondly, the meaning-making coping processes used by each group were grouped and compared. Thirdly, the social interactions of the combat veterans from each group were investigated. Fourthly, the patterns of meaning, meaning-making coping, and social interactions from each group were compared to the patterns of other groups to look for similarities and differences based on outcome. Finally, a grounded theory of meaning-making coping after combat trauma was developed from these data. A discussion follows in chapter five, comparing this grounded theory with the Larner and Blow model, leading the way for future enhancements to be made to the earlier model based on this comparison. The line of questioning was supported by and grounded in a wide broad field of traumatology outcome research and coalesced in the model we developed (Larner & Blow, 2011). The current study produced a theory of meaning-making coping in combat veterans that was grounded in the narratives of the veterans themselves. 14 CHAPTER TWO: LITERATURE REVIEW Introduction Meaning-making coping is a critical component of dealing with threatening events (Frankl, 1992; Larner & Blow, 2011), and this is particularly true for combat veterans. Unfortunately, the meanings and the processes by which Veterans adjust remain largely undocumented. Meaning-making coping has been empirically validated with veteran populations reporting resilient outcomes (Pietrzak, et al., 2009), negative outcomes (Owens, Steger, Whitesell & Herrera, 2009), and posttraumatic growth (PTG) after exposure to traumatic experiences (Caserta, Lund, Utz, and deVries, 2009). Sadly, there is a lack of effective comparison between the coping processes across these three outcome types and existing comparisons have been inconsistent (Hobfoll, et al., 2009; Kleim & Ehlers, 2009; Tedeschi & Calhoun, 2004). This calls for a deeper investigation into meaning constructs that might more effectively and reliably explain trauma outcome differences. Quantitative instruments can only investigate those specific variables they are designed to measure, but it is possible that there are as yet unknown meaning related factors that are most readily understood through qualitative methods that explore the experiences of veterans in depth and which compare the responses to trauma between veteran narratives. What follows is a review of the literature relevant to this research. The first section will introduce the wartime deployment context. The next section provides an indepth review of meaning-making coping processes. Then the three most well researched outcomes of wartime trauma are detailed. In the final section, I provide an 15 in-depth review of PTG from an ecological perspective with a focus on those factors that relate to potential meaning constructs. The Context of Combat Trauma Trauma differs by type with interpersonal trauma being the most problematic for recovery. Interpersonal trauma, being the target of someone else’s aggression is unique and deeply personal, (Green et al., 2000). Compared to other types of trauma, those stemming from wartime experiences greatly differ from natural disasters, illnesses, automobile accidents, and others. Linley and Joseph (2004) identified at least four factors they differ on: helplessness, controllability, expectation, and threat to one’s life. Further, men and women in the military are not only allowed to, but are specifically expected to kill other people, destroy their property, take control of their territory, and break their will to fight. Combat trauma is specifically unique due to reciprocal aggression requiring each one who experiences this type of trauma to also become an agent of trauma for others. It is also important to note that questions of right and wrong or good and evil inevitably must be dealt with as warriors carry out their mission. Ultimately they will look back on their own decisions made during those times and reassess them. Lt. Col. Dave Grossman is a former army Ranger, paratrooper, and psychology instructor at West Point. Having written extensively on the topics of killing and combat, he wrote “The surest way to a dose of posttraumatic stress disorder is to commit an atrocity or a criminal act that violates your code of ethics” (2008, p. 358). To this end, killing civilians or prisoners of war has been linked to worse outcomes than for those who only had killed enemy combatants (Maguen et al., 2009). 16 Other factors play a role in how well combat veterans cope with their experiences. Many veterans from Iraq and Afghanistan have been on multiple deployments, which makes recovery from combat trauma more difficult. These multiple deployments also increase the likelihood that combat-related stressors will pile up over time (Kline et al., 2010; Seal et al., 2009). Individual soldier responses vary considerably, ranging from resilience to posttraumatic stress and other issues including socio-emotional problems and suicide (Sayers, Farrow, Ross, & Oslin, 2009). A number of factors may help to explain this wide variation, and this research study attempts to demonstrate the centrality of meaning-making coping processes and increase our understanding of how these processes may differ for each of the three general identified outcomes to those exposed to combat trauma. Even veterans who go through essentially the same experiences can have the full range of outcomes. It is likely then, that their responses to combat trauma have more to do with any number of individual characteristics such as personality, individually perceived unit cohesion, physiological stress tolerance (Grossman, 2008), and ultimately how each veteran creates meaning to cope with and understand the events (Park & Ai, 2006; Schok, Kleber, & LensveltMulders, 2010). Demographically, military men and women of the United States are a representative cross-section of society and are highly trained so that they possess a heightened ability to persevere under stress. Those who sign up for military duty during wartime put themselves at risk voluntarily and do so more knowingly than those during peacetime. Those who cannot pass basic training are sent home without fanfare, with the most resilient remaining. 17 Combat trauma also has other dimensions not common to many other types of trauma. Similar to natural disasters, It is a mass trauma with very many survivors. This is another understudied aspect of trauma. Combat is also a multi-trauma experience, or complex trauma, which is carried out over an extended period of time with alternating periods of extreme stress and boredom, poor health conditions, and many other factors that pile up. Finally, there is one aspect of combat trauma that is most unlike every other trauma experience. Combatants on the field of battle are duty-bound to perpetrate a great deal of trauma, death, and destruction on their enemies. This purposeful nature subjects combatants to decisions of conscience which cause them to question some of their most closely held global beliefs. In summary, combat trauma differs from other traumas in many important ways. Meaning-Making Coping Understanding the relationship between emotions and cognitions is important in the study of meaning in the face of trauma. Decety, Michalska, and Kinzler (2012) studied how emotion and cognition are related to moral sensitivity. Morals are a subset of beliefs that make up global meanings. Their findings support the view that negative emotions about events precede, and alert individuals to moral violations of meaning and that the process of moral judgment involves a complex integration of emotion and cognition. Meaning-making coping posits that cognitive processes are responsible for evaluation and reevaluation of events. Assigning meaning to events plays a critical role in determining the stressfulness of an event (Frankl, 1992). Based on this understanding, Frankl theorized that it is meaning that people strive for and it is meaning that helps one cope with stress and 18 trauma. Meanings combat veterans hold about themselves, their experiences, and their environment can at times be very traumatic. It is the transformation of these meanings that as a central focus that most or all therapies share (Brewin & Power, 1997; Sprenkle & Blow, 2004). Overall, people will have better outcomes if they are able to incorporate their traumatic experiences (appraised meanings) into their global meaning system with little to no discrepancy or if they are able to make changes to their global meaning system to accommodate the traumatic experience (Joseph & Linley, 2005). The decrease in meaning-discrepancy will correlate with a decrease in negative emotions. Although positive and congruent meaning-making will not guarantee a symptom-free outcome, evidence indicates that meaning-making is instrumental in helping to determine if a memory is traumatic or simply stressful (Park, 2005). Cognitively based theories generally hold that distress correlates with the level of discrepancy between appraised meanings of the event(s) and the person’s sense of global meaning. When there is discrepancy, distress follows until there is reconciliation between these two meanings. Recently, Linley and Joseph (2011) found that the presence of meaning (outcome) in life, which is an aspect of global meaning, was associated with greater PTG but that the search for meaning (process) was associated with higher levels of posttraumatic stress. This emotional hurdle is common among therapeutic interventions where clients cognitively may indicate agreement about the need for change, but that turning that understanding into action is met with internal resistance due to the stressfulness of initiating change. This has been the subject of much attention in cognitive-behavioral interventions (Greenberg & Safran, 1984; Leahy, 19 2001). This may help explain the inconsistent correlations between posttraumatic stress and PTG. A Guiding Framework Larner and Blow (2011) proposed a model of meaning-making coping and growth specific to combat veterans (figure 2.1) based on previous work regarding meaning making coping after trauma (Park & Folkman, 1997; Park, 2005; Park & Ai, 2006). Building on existing research relevant to veteran populations, their model provides specific context and integrates the research on three general categories of process and outcome: resilience, decline, and PTG. Linley and Joseph (2004) identified four important aspects of PTG literature needing attention, which are: investigating the associations between growth and distress, the need for more longitudinal research, links with psychosocial variables such as social support, spirituality, and religion, and the construction and testing of comprehensive theoretical models. The Larner and Blow (2011) model is amenable to all four of these dimensions and is specific to the trauma of combat deployments. The present research begins to answer the central question; what are those meanings that combat veterans have made of their experience? It is also designed to explore the premise that their model poses: that meaning-making and meanings made are associated differently according to each outcome type. The longitudinal nature of the Larner and Blow (2011) model is important for a number of reasons. Prior to deployment, future combat veterans hold beliefs and values (meanings) that have not yet been exposed to combat situations. It is these meanings that are tested during the combat deployment and consequently reappraised afterward. 20 A MODEL OF MEANING-MAKING COPING AND GROWTH IN COMBAT VETERANS Pre-deployment Deployment Post-deployment Outcome Reappraisal Processes Global Meanings High Discrepancy? Appraised Meanings No Crisis Low level of distressing memories and emotions Resilience Process No Facing Distressing Memories and Emotions Crisis Yes PTG Process Pathology Process Avoiding distressing memories and emotions Figure 2.1. The Guiding Framework. 21 Constructive, Coherent Meanings Made Destructive, Self-Critical Meanings Made During the initial reappraisal phase, meanings and meaning processes may change over time. Most research to date is cross-sectional, and as such, is not capable of incorporating this dimension properly. Interestingly, discussions regularly cite the possibility of change over time as a potential explanatory factor for confusing or unexpected results. Finally, the meanings that combat veterans hold post-deployment may be very different from those they once held. These new post-trauma / postreappraisal meanings tend to become fairly stable and may remain consistent even years or decades later. Many service members have had multiple deployments which have had a negative effect on their morale, combat readiness, and family lives (Reed & Segal, 2000). New deployments have appraised meanings that are affected by previous deployments and service members hold global meanings that have developed since the previous deployments. Each deployment is unique and represents a full cycle of the process represented by the model. Note again that a fundamental difference between the proposed model and existing models of trauma lies in the conceptualization of the traumatic experience as happening during a combat deployment timeframe rather than as a single event. In a study of civilians displaced by war, those who had become refugees outside their war torn country fared better than those who were internally displaced (Rosner & Powell, 2006), thus supporting the importance of reducing perceived threat through a change in context for the reappraisal process. Though tentative, for American service members, this may be akin to leaving the theater of combat and returning home to the United States where there is no current military conflict. Milliken, Auchteronie, and Hoge, (2007) found that veteran mental distress is 22 directly related to combat exposure, but that the distress itself manifests during the reintegration period. As a further complication for the veterans of the wars in Iraq and Afghanistan, this post-deployment reappraisal process is often cut short by multiple combat deployments. Veterans leave their families and other sources of social support behind, exacerbating recovery from previous trauma and creating new stressors and emotional crises as families scramble to cope yet again before the wounds of the previous deployment have healed. This important area deserves further inquiry. In this study, whenever a combat veteran experienced multiple deployments, attention was given to this during each interview (i.e. the reappraisal phase and the effect of multiple deployments whenever relevant). The final portion of the chronological arrow is the outcome. Although further growth and meaning making may continue years into the future, the meanings made are likely to become relatively stable over time. Chronologically, it is the reappraisal and outcome phases of the model that received primary attention in this study. The model developed by Larner and Blow (2011) was designed to bring together many important aspects of the study of combat trauma and to set up future comparison of different outcomes. This grounded theory study was designed using their model as a theoretical framework to investigate the meanings that combat veterans hold, the meaning-making coping processes they utilize, and the social interactions related to these processes. Meaning-Making and Discrepancy 23 All combat veterans must make meaning of their experiences. Although not the only relevant factor, assigning meaning to events plays a critical role in determining the stressfulness of those events (Frankl, 1992). Based on this understanding, Frankl theorized that it is meaning that people strive for, and it is meaning that helps one cope with emotional stress and trauma. One core component that most, if not all, psychological therapies share is the focus on the transformation of meanings that clients have about themselves, their experiences, which are often traumatic during wartime, and their environment (Brewin & Power, 1997; Sprenkle & Blow, 2004). Through this transformation of meaning, events that once evoked intense emotions can be dealt with and ultimately resolved. In a general sense, people will have a more positive outcome if they are able to somehow incorporate their traumatic experience into their existing global meaning system without discrepancy or alternatively make adequate changes to that system as a result of those experiences (Joseph & Linley, 2005). This is not to say that positive and congruent meaning-making will guarantee a symptom-free outcome, but rather that the evidence seems to indicate that meaning-making is instrumental in helping to determine if a memory is traumatic or simply stressful and if so, how deeply traumatic the event, action, or decision was and is. Park and Ai (2006) developed a model to help explain how growth may result from the meaning-making coping process. They based their model on theories of trauma that indicated that distress is caused by the violation of global meanings and goals by appraised meanings of traumatic events (Park 2005, 2008). Global meanings are those that people use to base their decisions upon and live 24 their lives by. Appraised meanings are those meanings related to the traumatic events, such as car accidents, terminal illness, or combat-related traumatic experiences. Cognitively based theories generally hold that if there is no discrepancy between the appraised meaning of the event(s) and the person’s sense of global meaning, distress is minimized. If, however, there is a discrepancy between the global meanings held by the person and the appraised meaning of the event, then distress follows until there is reconciliation between these two meanings. Park and Folkman (1997) found that the level of discrepancy between these two meanings is significantly correlated with the level of distress created by that event. This distress creates an emotional crisis that impairs intrapsychic and interpersonal functioning until it is dealt with. When there is a discrepancy, people work to reduce the distress through meaning-making coping processes so that the appraised meaning of the event is integrated and no longer violates the global meaning system (Klinger, 1998). Global Meanings Global meanings consist of three parts; general beliefs, major goals, and subjective feelings such as overall meaningfulness and purpose in life (Park, 2005; Park & Ai, 2006). For veterans about to deploy, important global meaning questions are posited about one’s purpose in life, how their deployment fits into their life purpose, and what actions are right and wrong for them to do when they finally see combat action. These questions will have tentative and untested answers. Their adequacy will be tested and those meanings will be related to either their resilience, their mental and emotional decline, or could initially be related to decline followed by the process and outcome of eventual growth. Owens et al., (2009), studied veterans from all of the major 25 American wars from WW-II to the current wars in Iraq and Afghanistan. They found overall meaning in life was related to lower levels of PTSD severity and depression in their sample. Appraised Meanings Appraised meanings are those that a person associates with a traumatic event (Park, 2005; Park & Ai, 2006). Combat related traumatic events can include, but are not limited to: killing someone under unusual circumstances, seeing a friend get killed in a particularly gruesome manner, losing control (going berserk) or breaking down under stress, and committing or being an observer of an atrocity that violates one’s own conscience. For the combat veteran, traumatic events may stack, overlap, or exacerbate other traumas. These multiple processes in turn increase the difficulty of sorting out these appraised meanings. Discrepancy After an event is appraised, it is compared with a person’s existing global meaning system. According to meaning-making coping theory, when appraised meanings of troubling events are highly discrepant with global meanings, distress results (Park, 2005; Park & Ai, 2006). This research aims to shed light on these meanings. It is believed that resilient warriors not only hold less discrepant meanings than those suffering the most after armed conflict, but also exhibit lower levels of distress. By interviewing combat veterans with differing outcomes this idea was put to the test. The narratives of the veterans not only demonstrated their discrepancy, but also the similarities and differences in several categories of meaning across outcome types. 26 Reappraisal Processes The goal of reappraisal is the reconciliation of appraised and global meanings. During this process, trauma survivors either face or avoid facing difficult memories and emotions. This process is also inherently social (Harvey, 1996) and intrapsychic (wrestled with internally). Affect figures prominently in this process and emotions can be either inhibitors to the process, motivators to cope, something to avoid, or outcomes of the coping process (Park, Aldwin, Fenster, & Snyder, 2008). Park et al (2008) studied just over a thousand U.S. adults about 6 weeks after the September 11 th terrorist attacks finding that positive coping and anger were associated with PTG while negative coping and depression were associated with PTSD. Rumination. Rumination has long been associated with PTSD (Michael, Halligan, Clark, & Ehlers, 2007) and depression (Cambron, & Acitelli, 2010), but recently rumination has been positively associated with PTG as well. Rumination is multidimensional. Utilization of deliberate and intrusive rumination tends to change over time with regard to PTG (Taku, Cann, Tedeschi, and Calhoun, 2009; Cann, Calhoun, Tedeschi, and Solomon (2010). Soon after the event, intrusive rumination (involuntary thinking) is positively related to PTG, but long after the event, deliberate rumination (purposeful reappraisal) most strongly predicts current PTG levels. This study was able to get at these processes and comparisons were made between combat veterans experiencing different outcomes. Social support. Recovery and growth after trauma have benefited from a long history of research on social support. Social support has often been correlated with decreased likelihood of developing PTSD (Taft, Stern, King, & King 1999). The 27 opportunity to process the events with others (Harvey, 1996; Orbuch, Harvey, Davis, & Merbach, 1994) is important, but being supportive of combat veterans is not always easy. Negative social behaviors associated with combat-related PTSD make it more difficult for others to offer their social support, especially if they are not veterans (Solomon, 1988). This may be self-protective as secondary traumatic stress has been reported by caregivers of combat veterans (Bride & Figley, 2009). Finally, disapproval and disinterest are related to higher rates of distress after trauma (Lepore, Ragan, & Jones, 2000) by creating constraining social environments which make it very difficult if not impossible to mention, much less process their trauma. This is as true with societies as it is in more intimate relationships. During WW-II, veterans were welcomed as heroes of the free world while Vietnam veterans ubiquitously experienced public scorn. Though social support is critical, the aforementioned research indicates that quality of social support is potentially more important for trauma survivors than the size of their social networks and should be included alongside of other measures. Therapeutic processes. Therapy has helped many people reconcile traumatic memories. Traumatic memories or formed in primitive ways, as dissociated sensory and affective elements (Van der Kolk and Fisler, 1995). Only during the reappraisal process are these elements molded into explicit personal narratives. Merely distressing memories, however, are formed with coherent and functioning narratives absent the dissociation and deep affect associated with traumatic memories. Is it that these elements have no adequate global meaning system to form them as they occur? This study set out to shed light on this question. In order for therapy with combat veterans to be effective, trauma reappraisal will successfully help the veteran rework these affect 28 laden memories into constructive narratives (Van der Kolk & Fisler, 1995). Unfortunately, many veterans avoid these intense feelings through dissociative or avoidant processes such as substance abuse, avoiding intimate contact with loved ones, or requesting redeployment. Successful psychotherapy interventions help these veterans to face these difficult emotion laden memories. Overall, the reappraisal process involves intrapsychic as well as social processes, which include social support, rumination, and for some it includes professional therapeutic relationships. Trauma Outcomes Three broad categories of traumatic outcomes have been researched. The following section presents a general summary of traumatic outcome research and meaning-making coping in veteran populations. Trauma research incorporating all three trajectories: resilience, PTG, and PTSD (representing decline) is virtually non-existent. Though their sample consisted of motor vehicle accident survivors Nishi, Matsuoka, and Kim, (2010) demonstrated the appropriateness of this inclusive approach. Interestingly, they found some PTG subscales to be associated with PTSD and others to be related to PTG. Their data also showed an inverse relationship between resilience and PTSD. Resilience to Wartime Trauma Resilient outcomes are characterized by a relative lack of decreased functioning or an effective and sustained return to adequate functioning soon after a traumatic event. It consists of self-esteem, optimism, and perceived control (Schok et al., 2010). There are three types of resilience according to Lepore and Revenson (2006): resistance, recovery, and reconfiguration. With resistance the survivor has a relative absence of negative symptoms. With recovery, there is a return to normal in a relatively 29 short period of time. Finally, survivors who undergo reconfiguration change for the better as they adapt their global meanings to their experiences. Military populations tend to be resilient due to the selection process and mental and physical training. The U.S. Army, realizing the need to increase the resilience of military men and women so that they may fare better after combat trauma, has developed what is called the Comprehensive Soldier Fitness (CSF) program (Casey, 2011; Seligman & Fowler, 2011). They did this in cooperation with the nation’s top behavioral health experts. Recently, a special issue of American Psychologist was dedicated to this endeavor (Anderson, 2011). The Master Resilience Trainer (MRT) course (Reivich, Seligman, & McBride, 2011) was designed to train non-commissioned officers in mastering resilience skills. They are then taught how to train others so that these resilience skills are passed down through their units. Davis, Wortman, Lehman, and Silver (2000) equated combat-related resilience with having no discrepancy between one’s global meaning system and the appraised meaning of their situation. Negative Outcomes of Wartime Trauma Many combat veterans are afflicted by negative outcomes that are marked by decreased functioning in many areas of their lives. Combat Stress Response, PTSD, Drug and Alcohol Addiction, Suicide, Depression, and other outcomes may occur (Van der Kolk & Fisler, 1995). One component common to each of these outcomes is avoidance and dissociation. Rape survivors tend to have more severe PTSD when they have more negative appraisals of their rape experience. Though it might seem obvious that one would have a negative appraisal of such a horrendous event, feeling that one has survived an event (positive appraisal) has more beneficial intrapsychic implications 30 compared to believing that one has been a helpless victim (negative appraisal). Blocking or minimizing these memories as continued dissociated elements correlates with higher levels of PTSD whereas integrating these experiences into one’s sense of global meaning is related to better outcomes (Boeschen, Koss, Figueredo, & Coan, 2001). Meaninglessness in life has been linked to more intense negative outcomes in Vietnam veterans (Dasberg, 1976). But meaninglessness is not the only meaning-based effect of combat for Vietnam veterans. Price, Risk, Haden, Lewis, and Spitznagel (2004) studied 641 Vietnam veterans. They discovered significantly higher suicidality in voluntary enlistees (23.7%) than those who were drafted (6.9%). The reasons for this are worthy of investigation, but personal ownership of voluntary enlistment during an unpopular conflict may be a factor. Meaning is not only important in the combat zone, Bragin (2010) and Shay, 2002) argue that while combat veterans’ worldview is necessarily changed because of their experiences in the war zone, the surrounding worldview of civilians they come into contact with is devoid of any adequate understanding of their experience of combat. Negative social construction and hindered reappraisal of meaning is related to the onset and maintenance of PTSD and other negative outcomes after combat trauma (Larner & Blow, 2011). Growth After Wartime Trauma Not all who suffer negative outcomes fail to grow and recover. The process of growth after trauma indicates a reaching toward resilience and one possible outcome of the meaning-making coping process according to empirical research is PTG (Park, 31 2008). Unfortunately, the study of PTG after combat trauma is still lacking (Larner & Blow, 2011; Rosner & Powell, 2006). Though the meaning-making coping process, PTG, and the utilization of combat veteran populations have been studied in pairs, what are completely missing from the literature are studies of the meaning-making coping process with combat veterans experiencing PTG. This research addressed this gap in the literature. The following section will explain what is currently known about the PTG process from an ecological perspective that includes the biopsychosocial and the spiritual components that have been previously researched. Ecological View of Combat Related PTG Veterans have been largely ignored in the bulk of studies of Posttraumatic Growth (PTG; Rosner & Powell, 2006). In one notable and recent exception to this, Pietrzak, et al. (2010) found that perhaps as many as three fourths of returning veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) report significant levels of PTG, highlighting the importance of understanding the context within which PTG develops and when it does not. Combat trauma is one form of adversarial trauma. Adversarial trauma, that is, trauma caused by aggression between people, is different than traumas such as natural disasters and terminal illness. It often carries with it increased negative sequelae, but also greater opportunities for PTG (Rosner & Powell, 2006) as being the target of another’s aggression raises interpersonal and existential questions that may not apply to other types of trauma. 32 In the case of combat trauma, service men and women are also agents of trauma for others, introducing an aspect of personal agency not present in survivors of rape or non-wartime assault. This personal agency as both survivor and progenitor of trauma brings with it the need to resolve aspects of conscience in order to produce growth. These differences call for a contextual understanding of combat trauma that sets it apart from other types of trauma. Shattering of World Assumptions An important prerequisite of PTG is the initial shattering of world assumptions, or global beliefs. People throughout history have sought to create a sense of coherent meaning in their lives, or world assumptions. Important examples of this can be found in the Torah (Judaism) over two millennia ago, followed by the Bible (Christianity), and more recently the Koran (Islam). Later, during the nineteenth century, this search for coherent understanding of life’s most basic of questions gave rise to such existential thinkers as Soren Kierkegaard (1983) and Friedrich Nietzsche (1955) who have explained suffering in terms of personal development. During the twentieth century, theorists, researchers, and therapists have continued to pursue a deeper understanding of human thinking. Victor Frankl rekindled the direct focus of meaning-making with a form of therapy based on what he called a will-to-meaning called Logotherapy and with his book Man’s Search for Meaning (4th Ed; Frankl, 1992). Nietzsche is credited with two relevant and oft used quotes: “That which does not kill us makes us stronger.” and “He who has a why to live can bear almost any how.” This would be true of the resilient survivor. But some survivors of trauma find that their personally held beliefs or assumptions about the world are inadequate for explaining 33 events (leaving them in a state of mental and emotional dissonance and distress). When this happens they are said to have undergone a shattering of world assumptions, a prerequisite for both mental health distress and PTG according to cognitive and meaning-making models (Larner & Blow, 2011; Park, 2008). This begs the question: Does trauma automatically create difficulties that must either be overcome or succumbed to or does it intensify latent beliefs and meanings because they become more real after a person has to act on them causing some to fall apart and others to thrive? This question was answered by this study. Posttraumatic Growth and Posttraumatic Stress The unique relationship between PTG and Posttraumatic Stress (PTSD) requires some attention. Posttraumatic Stress is a disorder caused by extreme mental and emotional trauma. It is characterized by recurrent distress, persistent avoidance of stimuli, and increased affective and physiological arousal at levels causing clinically significant impairment in social or occupational functioning (American Psychological Association, 2000). PTSD has been frequently correlated with PTG, as a shattering of world assumptions is a shared component of each. This correlation, however, has also been found to decrease over time (Davis, Nolen-Hoeksema, & Larson, 1998) as the PTG process continues. Meaning-making coping research may hold the key to understanding how the shattering of world assumptions remains problematic for some and how these assumptions come to be more congruent as time passes for others. Do the world assumptions change, do the appraised meanings evolve, or both? 34 Posttraumatic Growth and Resilience Posttraumatic Growth has a unique relationship with resilience as well. Factors that support resilience also support PTG. Optimism, for example – a commonly studied indicator of resilience – was measured in Vietnam prisoners of war who also exhibited PTG (Fedor et al., 2008), and yet those who are resilient tend to exhibit low levels or need for PTG (Levine, Laufer, Stein, Hamama-Raz, & Solomon, 2009; Westphal & Bonanno, 2007). One explanation for this could be the lack of shattered world assumptions in resilient individuals required to spur such traumatic growth. In other words, they may need to grow less because they are already resilient and their world assumptions have held up; their world assumptions are able to account for the meanings assessed of the traumatic experience (Westphal & Bonanno, 2007). This study may help us to understand if the meanings held at the conclusion of successful PTG processes begin to look more and more like resilience or if the PTG process produces meanings that are entirely different. Dimensions of Posttraumatic Growth The most common measure of PTG is the PGTI, providing a unified score as well as individual scores on five separate dimensions: (1) relating to others, (2) new possibilities, (3) personal strength, (4) spiritual change, and (5) appreciation of life (Cohen, Hettler, & Pane, 2008). Research supports validity of both total scores as well as subscale scores for this measure with a number of populations. A change in one’s world assumptions is important, though difficult to measure Janoff-Bulman (1992). Potentially this would require qualitative methods, as changes in one’s belief system are, almost by definition, more about how so than how much. 35 Becoming less naive about the world or having a more tempered optimism, for example are protective against future trauma and constitute a certain psychological preparedness borne of a change in world assumptions (Riolli, Savicki, & Cepani, 2006). Ecological Framework Context is important to meaning, which makes a bioecologcial view a natural theoretical choice. An ecological framework is able to incorporate the interpersonal with the intrapsychic aspects of trauma and PTG. “Human ecology is concerned with interaction and interdependence of humans (as individuals, groups, and societies) with the environment” (Bubolz & Sontag, 1993, p. 421). Posttraumatic growth is meaning intensive, but it is also an inherently social process. Figure 2 below depicts the ecological relationship between the environment and meaning-making coping in combat veterans that was initially predicted based on existing literature. Trauma survivors have an effect on and are affected by their families and others they come into direct or indirect contact with. Society also has a reciprocal relationship with trauma survivors based on social norms and expectations as evidenced by the mobilization of American citizens after the Japanese attack on Pearl Harbor, which brought the US into WW II and Al-Qaeda’s attack of the World Trade Center on 9/11/01, which provided the impetus for the wars in Afghanistan and Iraq. Human ecology includes a biopsychosocial view of the individual. This perspective described by Urie Bronfenbrenner (1979), is comprised of different systems nested within each other. Each person interfaces with his or her environment through biological, psychological, and social processes in ways that are (intended to be) mutually beneficial. 36 The microsystem (Bronfenbrenner, 1979) consists of the structures and people with which a Macrosystem Exosystem Mesosystem Deploy. Home Combat Veteran Posttraumatic Growth Microsystems Chronosystem _______________________________________________________________ Figure 2.2: Ecological Model of Posttraumatic Growth person has direct contact. According to Hook and Paolucci (1970), the family is a lifesupport system interfacing with both the natural environment and social processes in order to provide both quality and meaning to life. The microsystems of service men and women typically consist of family (home microsystem), friends, and others they have direct contact with while at home on base or at the home of their family of origin. While on deployment this may include close friends and other members of their military unit including authority elements such as platoon sergeants and platoon commanders (deployment microsystem), but also local people, enemy combatants, and others. The next structure, the mesosystem (Bronfenbrenner, 1979), is so called because it represents interactions between microsystems important to the person. For 37 service men and women these include the various support organizations that interface, for example, between the military and family systems. These systems are nested within the exosystem (Bronfenbrenner, 1979) of community and culture. The military has a sense of community and culture while each service member also brings with them their own sense of community and culture. The manner in which these systems interact can help to support or hinder PTG. Beyond this is the macrosystem (Bronfenbrenner, 1979), which includes the wider social and cultural context such as the nation one belongs to. National ideals have a bearing on individuals and each person is simultaneously a part of the whole. Beyond this, but also part of the macrosystem, is the rest of the world in a global age. Actions of individual service men and women have affected the entire world through international media. This same media has had a direct effect on service men and women in the theater of war and technology in the last few decades has allowed people all over the world to watch combat operations happen in real-time. Individual Factors of Combat Veterans Individual factors play a major role in process and outcome of PTG in combat veterans. Recent studies have identified patterns of PTG based on age, education, race/ethnicity, and other sociodemographic factors. Personality variables, cognitive appraisal strategies such as meaning-making coping, and the use of other coping styles and activities are also important to the PTG process (Armeli, Gunthert, & Cohen, 2001). Age. Most studies of combat related PTG either did not find or did not report significant differences in PTG based on age (Erbes et al., 2005; Fedor et al., 2008; 38 Solomon & Dekel, 2007). Others, however, Pietrzak, et al. (2010) found that younger age predicted PTG in OEF and OIF veterans. Education. Education was not found to be a significant factor in PTG scores for combat veterans in some studies (Solomon & Dekel, 2007 ) and again was not reported in others (Erbes et al., 2005; Pietrzak et al., 2010). This may be due to the educational homogeneity among military members as most enlisted men and women join soon after graduating high school and officers tend to be commissioned similarly after their college education. Race / ethnicity. Though many demographic variables appear to be nonsignificant with regard to PTG in Gulf War I veterans, in one study, minority status was found to be the only significant predictor of new possibilities, one of the five factors of the PTGI (Maguen et al., 2006). The authors speculate that this may be due to the increased opportunities offered as a result of military service compared to a relative lack of opportunities prior to service. Personality factors. Low self-worth is directly related to psychological distress and impairment (Currier, Holland, & Neimeyer, 2009). The importance of the social aspects of self-worth cannot be understated as some have indicated that it is a combination of not only personal judgment of the self, but also the perception of judgment of society (MacDonald, Saltzman, & Leary, 2003). This perception of judgment by the society they serve is destructive, but positive self-worth, protective against judgment by others, has been shown to be predictive of PTG in bereaved parents (Engelkemeyer & Marwit, 2008). 39 Pietrzak, et al. (2010) found 48.5% of OEF/OIF veterans to report significant levels of increased personal strength as a result of their combat experiences. The military experience is often said to grow people up, or give them a sense of responsibility and maturity through the rigor of training and high expectations of personal performance. Survivors of combat trauma, within that military service, have demonstrated even greater personal strength. Cognitive factors. Joseph & Linley (2005) discuss the role of assimilation and accommodation in trauma recovery. They point out that much of the trauma literature makes no explicit reference to them in spite of the central role these cognitive processes have in the meaning-making coping process. When new information is gained it is either assimilated into existing cognitive structures (world assumptions) or accommodation must occur (reappraisal) through cognitive and affective change processes (Hollon & Gerber, 1988; Payne, Joseph, & Tudway, 2007). Linley (2004) found three factors related to wisdom resulting from traumatic experiences. These factors are identified as both processes and outcome. They are: the recognition and management of uncertainty, the integration of affect and cognition, and the recognition and acceptance of human limitation. These may lead to more realistic reappraisals paving the way for growth. Optimism can lead to increased levels of PTG (Linley & Joseph, 2004) and is often considered to be a central component of resilience. Optimism helps survivors focus on future events with hope rather than hopelessness that can lead to other negative outcomes. 40 Acceptance, rumination, and meaning-making. Acceptance coping leads to increased levels of PTG (Linley & Joseph, 2004). Being the antithesis to magical thinking and other negative coping, acceptance coping allows for survivors to see life on life’s terms, which can be a strong basis for meaning-making coping. But not all survivors have come to a point of acceptance in the aftermath of their trauma. Long understood to be an indicator of PTSD, some have found rumination to be a multidimensional construct in that intrusive rumination soon after the event and deliberate rumination long after the event to be strongly predictive of current PTG levels in a US sample (Taku, Cann, Tedeschi, & Calhoun, 2009). Others have also found deliberate rumination to be associated with increased PTG (Linley & Joseph, 2004) as survivors work to find meaning both cognitively and emotionally. Victims become survivors and experience PTG through personally meaningful cognitive reappraisals (Helgeson, Reynolds, &Tomich, 2006, Taku et al., 2009). Frankl (1992) pointed out that assigning meaning to events plays a critical role in determining the stressfulness of an event. Owens, Steger, Whitesell, and Herrera, (2009) found meaning in life to be inversely predictive of PTSD symptoms in military veterans across service eras. With a mean age of 57 in their sample, these survivors are long into the growth process indicating the long-term importance of having or developing a sense of meaning in life. The present military force in The United States is voluntary. This personal agency component can have important implications for the returning combat veteran. Price and colleagues (Price, Risk, Haden, Lewis, & Spitznagel, 2004) reported that voluntary combat veterans participating in the Vietnam War reported significantly higher 41 rates of mental health distress compared to those that were drafted. With the war in Vietnam being so socially unpopular, taking personal agency put them at odds with society and potentially their own belief system upon reappraisal. But firm global meaning systems that help to explain events in a manner that do not violate one’s beliefs are related to better outcomes. Brune and colleagues (Brune et al., 2002) found that in traumatized refugees, firm philosophical and spiritual beliefs minimized PTSD symptoms and further helped in the recovery process. Among torture survivors, (Başoğlu et al., 1997) found that political activists with strong convictions receiving significantly higher levels of torture fared better than those who received less torture and had no activist political activity indicating that conviction allows one to endure significantly greater hardships. Though direct generalizations cannot be made, if this protective power of conviction holds for combat veterans, believing deeply in the reasons one goes to war are of central importance. Perhaps the firmness of ones beliefs intensifies the power of the experience whereas the discrepancy or congruency of meaning determines the presence of distress vs. conviction and reinforcement of held beliefs. Microsystem Factors The microsystem consists of face-to-face interactions and interrelations between an individual and other people and factors in their immediate setting (Bronfenbrenner, 1979). Most social support takes place within the microsystem and is discussed below. In their study of displaced refugees of the war in Sarajevo, Powell and colleagues (Powell, Rosner, Butollo, Tedeschi, & Calhoun, 2003) highlight the importance of the reappraisal context. Externally displaced refugees – those that could get out of the 42 country fraught with war – fared better than those who were displaced within the country still in fear of further trauma. For US service men and women the reappraisal context changes from deployment microsystem to home microsystem. Social support. Greater positive social support from those close to the survivors of trauma is important (Ehlers & Clark, 2000). Though trauma survivors reevaluate events on their own through rumination processes, the reappraisal process is an inherently social one (Harvey, 1996). MacDonald, Saltzman, and Leary (2003) point out that self-worth is not only a function of self-judgment, but also of perception of judgment by others. This perception of acceptance or judgment by others happens through relationships with members of ones microsystem such as family, friends, or buddies from ones unit. Positive unit member support was found to predict PTG in veterans of OEF/OIF (Pietrzak, et al., 2010) and the ability for a family to make sense of the traumatic experience is a critical factor in understanding family resilience and coping (Walsh, 2007). Social support helps to facilitate the meaning-making coping process through the opportunity to process the events with others (Harvey, 1996). In fact, (Maguen et al., 2006) found that social support was rated as the most predictive measure of PTG in Gulf War I veterans. Pietrzak et al. (2010) found that 52.2% of OEF/OIF veterans reported significant levels of changing priorities, which typically includes greater emphasis placed on personal relationships. Unfortunately, combat trauma is often difficult for survivors to talk about, and social environments indicated by disapproval or disinterest are related to higher rates of distress after trauma (Lepore, Ragan, & Jones, 2000). Ehlers and Clark (2000) point out that the failure ofsurvivors to share their “trauma story” with others in their support 43 network results in fragmented and disjointed (incoherent) understandings. Indeed much of the work in most therapy approaches surrounds breaking through these affect laden avoidance strategies such as dissociation related to unintegrated traumatic memories (van der Kolk & Fisler, 1995), while promoting healthy coping skills. When microsystems prove ineffective or unhelpful survivors sometimes reach out to professionals. Though no articles could be found for specific PTG interventions with veteran populations, it is not difficult to argue that the primary goal of therapy after trauma is to encourage growth and reinforce existing resilience. Antoni, Lehman, and Killbourn, 2001) found that formal support groups help to foster growth in women who are in early stage breast cancer and group based exposure therapy has been shown to produce lasting significant reductions in PTSD symptoms in combat veterans (Ready et al., 2008). Existential / spiritual / religious. One may experience a greater appreciation of life as a result of trauma. Pietrzak et al. (2010) found 51.1% of OEF/OIF veterans reported significant levels of increased appreciation of life, a positive consequence of existential struggle. The intersection of meaning-making, social support, and world assumptions often coincides with spiritual meaning systems. Spirituality can serve as a coping resource as well as a source of struggle (Pargament, Desai, & McConnell, 2006). People who believe that God has punished or abandoned them tend to have a lower quality of life (Pargament, Smith, Koenig, & Perez, 1998). They also identified a negative pattern of coping characterized by spiritual discontent, belief that God is bringing down punishing reprisals, interpersonal religious discontent, demonic reprisal, and reappraisal of God’s 44 power (i.e. how good can God be if…). Further, individuals with a spirituality that grows out of extrinsic (utilitarian) motivations such as security and social status report higher levels of psychological distress than those who are intrinsically religious, living out their faith as a means unto itself, providing life focus and meaning (Genia & Shaw, 1991). And intrinsic religiosity is positively correlated with PTG (Park, Cohen, & Herb, 1990). Though spiritual change scores have been associated with PTSD rather than resilience in some studies (Nishi, Matsuoka, & Kim, 2010), the overwhelming majority of the literature indicates a more positive relationship between PTG and religiosity (Helgeson, Reynolds, & Tomich, 2006). Religion can be seen as a meaning-making framework that has both personal and social aspects (Park, 2005). Those who utilized religious coping after a wide variety of traumatic experiences often report greater initial distress followed by better outcomes up to one or two years later (Ai & Park, 2005), which may indicate a more genuine grieving process encompassing positive meaningmaking and acceptance. One mechanism of religious coping is vicarious control (a belief that God is in control), a secondary control strategy often utilized by people experiencing overwhelming threats (Heckhausen & Schulz, 1995). Belief in a close, loving, approving, and forgiving God has been inversely related to many psychiatric symptoms (Bradshaw, Ellison, & Flannelly, 2008; Flannelly, Gelek, Ellison, & Koenig, 2010). People that believe that God is loving, caring, forgiving, and approving report greater life satisfaction (Kirkpatrick & Shaver, 1992), while attributing deaths of loved ones to a purposeful God have been correlated with higher levels of growth (Park & Cohen, 1993). 45 Attachment theory has been extended to an attachment to God construct. Kirkpatrick and Shaver (Kirkpatrick & Shaver, 1992) identified three styles of attachment to God that mirror parent-child attachment styles: secure, avoidant, and anxious/ambivalent attachment. Avoidant attachment to God has been correlated with lower levels of competence, life satisfaction, and religious well-being (Weinborn, 1999). Anxious attachment to God has been found to be a significant predictor of neuroticism, negative affect, and inversely predictive of doctrinal orthodoxy, intrinsic religiousness, positive affect, and a loving God image (Rowatt & Kirkpatrick, 2002). Finally, Secure attachment to God, similar to secure parent-child attachment, is characterized by feelings of warmth, support, and protection. Those who have a secure attachment to God believe that he is responsive to their needs, but that he also allows them to make their own mistakes. It has been associated with greater psychosocial competence, life satisfaction, and religious well-being. Mainstream clinicians have begun to realize how important the religious meaning systems of their clients are (Richards & Bergin, 2000), and the empirical studies above indicate the value of inclusion of these meaning systems in the therapeutic process whenever appropriate in order to foster growth after trauma. Killing, combat guilt, and growth. Combat is ubiquitous with the act of killing on a mass scale. Though an extensive search on killing in multiple databases turned up no articles related to killing and PTG or resilience, the following puts this topic into context. Others have also found a serious lack of empirical research regarding the taking of life during wartime (Grossman, 2008). To simply ignore this area would be like 46 failing to notice the invisible elephant in the room, and no ecological view of combat trauma would be complete without at least some treatment of the subject. This one responsibility further separates combat trauma from other traumas, making it even more appropriate for study with this population. The combat trauma survivor is not only survivor, but also agent of trauma for some and intentional death for others. How service men and women find meaning and growth afterward is of great importance. Benbaji (2007) discusses the bases of just vs. unjust killing during wartime. He takes on topics such as the difference between innocents vs. combatants and the idea of the moral equality of soldiers. These concepts form the basis of The Geneva Conventions of war followed by many, but not all contemporary nations or groups (e.g. Al Qaeda). In one of the very few empirical studies of killing during wartime, Maguen et al. (2009) found that though Vietnam veterans who had taken the life of an enemy combatant often suffer from mental heath problems such as depression and PTSD, scores were worse for those that had killed civilians and worse still for those that admitted to killing prisoners who had already surrendered. Exposure to combat and the taking of life during combat can lead to combat related guilt and shame (Marx et al., 2010) and combat related guilt is perhaps one of the most significant factors predicting suicide ideation, suicide attempts, and successful suicide in Vietnam veterans (Hendin & Hass, 1991). Though her sample was not combat veterans, Van Vliet (2008) utilized a grounded theory research design to explore how adults grow and rise above deep shame. She discovered how the 13 adults in her study did so through processes of self- 47 reconstruction that emerged with five subcategories of growth: Connecting, Refocusing, Accepting, Understanding, and Resisting. These categories are very similar to the five categories of PTG (Tedeschi & Calhoun, 2004) and are consistent with adversarial growth (Linley & Joseph, 2004) and resilience (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). Due to generalizability issues, this categorical assessment is exploratory and in need of further attention. It does, however, highlight the strength of allowing participant responses to provide a depth and richness to the data that is simply not available with quantitative research designs. Military factors. A number of studies have shown that prisoners of war exhibit PTG (Erbes et al. 2005); Solomon & Dekel, 2007) and at rates higher than their nonPOW peers (Solomon & Dekel, 2007). In fact, PTG has been studied in prisoners of war more than any other subgroup of veterans (Larner & Blow, 2011). In their study of Israeli soldiers who had fought in the 1982 Israeli-Lebenan war, Solomon, Mikulincer, and Hobfoll (1986) found that feeling unsupported by buddies as well as officers was related to greater loneliness and increased levels of combat stress response. Pietrzak et al. (2010) found perception of unit member support and perceptions of effort and perseverance to promote PTG in OEF and OIF veterans. Mesosystem Factors The mesosystem consists of the interactions of the different factors of the microsystem (Bronfenbrenner, 1979). Specifically for military families, these interactive mechanisms consist of structures such as rules, policies, and acceptable practices that govern the ways in which microsystem factors interact. For combat veterans, this would consist of the Constitution of the United States, the oath of enlistment to protect the 48 same, rules of communication to spouses and family members back home while in a warzone, the rules of engagement for their specific missions, and others. Unfortunately, research of mesosystem factors of PTG is effectively nonexistent. Hobfoll and a large group of trauma researchers (Hobfoll et al., 2007) present five essential elements of mass trauma interventions targeted for the immediate aftermath and mid-term post-trauma with the goal of promoting resilience and growth. As combat trauma is also a subset of mass trauma, their findings are relevant. Based on their collectively vast experience these important elements of mass trauma interventions are: to promote a sense of safety, calming behaviors, a sense of self and collective efficacy, a sense of connectedness, and hope. Exosystem Factors Much of the traumatic literature is focused on individual traumas. Although a mass trauma, most literature on combat trauma is also individually focused. The effects of mass trauma on groups are similar to those experienced at the individual level. After the attacks of September 11th 2001, acute myocardial infarctions, cardiac arrhythmias, and drug & alcohol abuse had all risen by more than 30% in the civilian population (Landau, Mittal, & Wieling, 2008). Conversely, PTG had also been found among Americans in the aftermath of the terrorist attacks of September 11th 2001 (Ai, Cascio, Santangelo, & Evans-Campbell, 2005). Macrosystem Factors Clarity of cultural identity is important to the promotion of positive mental health and well-being (Taylor & Usborne, 2010). Thombre, Sherman, & Simonton, (2010), found that family caregivers of cancer patients in India reported higher average levels of 49 PTG than family caregivers in North American studies where cultural identity can be less rigid. Tying resilience factors and PTG factors together, (Ai, Peterson & Huang, 2003) studied Muslim refugees from Kosovo and Bosnia. They found optimism to be related to positive religious coping, and hope to be positively correlated with education and negatively associated to negative religious coping (feeling abandoned or punished by God). Trauma survivors and their families are embedded within and interact with their culture and the larger society. Though each combat veteran has to go through their own meaning-making process, this larger context is also important. Being considered a minority is a label that necessarily compares the individual with the larger society in which they live (macrosystem). Maguen and colleagues (Maguen et al., 2006) found, in their study of Gulf War I veterans, that having minority status was the only significant predictor of new possibilities, one of the five factors of PTG. Spiritual coping is not confined to the microsystem, but spans the macrosystem and crosses spiritual meaning systems. Pargament and colleagues Pargament et al., 1998) identified positive mechanisms of religious coping found in Judeo-Christian believers. Others have reported similar findings in Islamic believers (Ai et al., 2003). These positive religious coping mechanisms consisted of: Forgiveness, seeking spiritual support, collaborative religious coping, and making spiritual connections. Powell et al. (2003) found lower scores overall in their sample of Sarajevo refugees than those typically found in United States populations. This could indicate that not all populations experience PTG equally around the world. 50 Society on the whole plays an important role in the self worth of survivors of trauma (MacDonald et al., 2003). As stated earlier, self-worth is partially comprised of perception of judgment by others. Society then, is able to effect this perception in a number of ways, and national and international media only increases the influence of the macrosystem in the lives of combat veterans and their families. Chronosystem Factors Larner and Blow’s (2011) contextual model (Figure 1) takes into account temporal factors (chronosystem): pre-deployment meanings, the deployment context where multiple traumas occur, and the reappraisal phase after veterans return home. Further, their model includes positive processes and outcomes (resilience), negative processes and outcomes (PTSD, depression, and suicidality for example), and growth outcomes characterized by initial distress followed by an extended period of PTG. Multiple deployments to Iraq or Afghanistan have been associated with physical and mental health that often declines after successive deployments (Kline et al., 2010). Measures of PTG over multiple deployments could not be found. However, the importance of efforts to support growth after the trauma of repeated deployments cannot be understated and are warranted in light of this finding. Though longitudinal research on PTG is decisively lacking, Davis, NolenHoeksema, and Larson (1998) carried out a prospective study with pre-loss measures followed by measures at 6 months post-loss and 13 months post-loss. They found that benefit finding was strongly associated with positive adjustment, which continued to grow stronger over time. 51 In a meta-analysis of benefit finding and growth after trauma, Helgeson et al. (2006) found that benefit finding was more strongly related to less depression and greater positive affect when the time since trauma was greater than 2 years. Also, they found that benefit finding was related to global distress when time since the traumatic event was 2 years or less. In their study of German child-soldiers of World War II later in life (mean age 78 years), Forstmeier, Kuwert, Spitzer, Freyberger, and Maercker (2009) found that social acknowledgment as a survivor, and meaningfulness in life were the only two remaining significant factors measured that predicted PTG, indicating that family and social recognition of wartime experiences as meaningful events that veterans should be proud of is an important factor for extremely long term maintenance of PTG. Conclusion The literature concerning combat trauma overall indicates that it is different than other traumas in a number of ways in need of targeted attention. Considering the dearth of PTG literature with combat veterans, and the still increasing numbers of veterans returning home that must make sense of their deployment experiences much more needs to be done. The literature concerning the meaning of combat trauma as it relates to the outcomes that veterans experience is also lacking. As a core mechanism of the PTG process, understanding the meanings that combat veterans make of their experiences will help guide future research. This study was designed to discover the patterns of meaning that veterans make after their combat deployments. 52 A number of trauma outcomes have been identified in the literature, but these tend to fall into three broad categories: resilience, decline, and posttraumatic growth. In order to better understand the role of meaning and meaning-making in the PTG process it is most appropriate to study and compare the meanings and the associated processes of each outcome category. This present study allowed thoughtful, thorough, and rich comparisons. The above ecological view of combat trauma showcases the range of meanings related to meaning-making coping and it elucidates particular domains of meaning that are worthy of further investigation. Demograpic variables appear to have little relationship to PTG in combat veterans (Erbes et al., 2005; Fedor et al., 2008; Solomon & Dekel, 2007). Though it is among other individual factors, meaning-making coping stands out as the central process by which people grow (Frankl, 1992; Park, 2005; Linley & Joseph, 2004; Helgeson et al., 2006; Owens et al., 2009). The incorporation of the Chronosystem is very important (Frazier et al., 2009) because the results of prepost designs differ from cross-sectional studies. The microsystem appears to facilitate PTG primarily through social support from family and friends (Maguen et al., 2006; Walsh, 2007), the professional community (Antoni et al., 2001; Ready et al., 2008), unit members and officers (Harvey, 1996; Maguen et al., 2006; Pietrzak et al., 2010) and through spiritual or religious meaning systems (Helgeson et al., 2006; Nishi et al., 2010; Park, 2005) that connect the individual to further spiritual-social supports (Harvey, 1996), positive religious coping strategies (Bradshaw et al., 2008; Flannelly et al., 2010), life meaning (Park, 2005), and often the belief in a relationship with a transcendent God that is able to take vicarious control (Heckhausen & Schulz, 1995) 53 and offer a relationship (e.g. attachment theory; Kirkpatrick & Shaver, 1992; Rowatt & Kirkpatrick, 2002; Weinborn, 1999) that is increasingly associated with positive mental health outcomes. These meanings, meaning systems, and processes of meaning reappraisal are central to the understanding of traumatology in general and PTG in particular. The next chapter lays out the method I used to gather and analyze the beliefs and meanings that combat veterans hold regarding their experiences. 54 CHAPTER THREE: RESEARCH DESIGN AND METHOD Introduction This grounded theory study utilized semi structured individual interviews as the primary method of data collection. This method maximized the advantage of researcher as instrument to gain reliable data for the development of a grounded theory of meaning-making coping and growth in combat veterans. Larner and Blow (2011) developed a model of meaning-making coping and growth based on past research, however, their model only provides a general guiding framework. The present research compared the narratives of three different outcome groups of combat veterans. Through these interviews, this research was able to highlight how each group differed in their pre-deployment beliefs and their post-deployment beliefs. The coping processes utilized by each group, and how they differed, also emerged. Finally, the relationship processes that these combat veterans had partaken in were discovered. Together, these findings take the research on meaning-making coping in combat veterans to a new, more detailed level. Though informed by their model and other past research, the theory developed for this research was grounded in the narratives of combat veterans themselves. It provided new insights based on the methods below. Overview of Methodology and Research Design This research is a qualitative grounded theory study that utilized face-to-face interviews of male combat veterans of OEF/OIF to garner a deeper understanding of the differences in meaning-making and beliefs held by combat veterans who report considerable differences in combat trauma outcomes. In other words, how do the beliefs 55 and meanings held by troubled combat veterans differ from those who exhibit primarily resilient outcomes and those who exhibit posttraumatic growth? Grounded theory research, developed by Glaser and Strauss, is a method of developing a theory that is based on (or grounded in) the data. It is an inductive method in which general explanations of an identified process are generated through careful analysis of data generated through participants who have experienced the process under inquiry (Strauss & Corbin, 1998). In this study, data were generated through semi-structured interviews, which were transcribed, coded, and analyzed for meaning and meaning-making processes. Researcher as Instrument The researcher, particularly the qualitative researcher, has a privileged position in the research process. Though quantitative researchers doing deductive research make serious attempts to remove any hint of subjectivity, the qualitative researcher doing inductive research must contend directly with subjectivity and bias. This is done by creating checks and balances which allow the researcher to be as dynamic as possible. The researcher can use his potential expertise to its fullest potential, while including research processes that create transparency such as journaling, and third party oversight (allowing for verifiability). Further, researchers are strongly encouraged, and are even assumed to take “a more self-conscious approach to authorship and audience”, (Coffey, 2003, p. 321) than they otherwise would in doing other research. I believe I have a unique perspective on combat trauma having served in the Marine Corps, I also have a service-connected disability; I understand the system and process of the Veterans Administration. Being a veteran helped participants feel a 56 sense of connection, allowing them to be more open and candid while some reported that the research flyer they saw was compelling enough for them to want to share their stories on their own. Being a service-disabled veteran enabled me to have higher credibility among these combat veterans and provided a second layer of insider status. This made acquisition of an appropriate sample easier, and allowed them to talk freely without fear that I would get lost in military jargon. This also was of great help to me as I was able to naturally move with the flow of interviews with a full understanding of these terms and their use. Also, to assist in the data analysis, I engaged in a process of memoing, and through this process I tracked my own responses as the research process unfolded. I completed interview contact summaries, and typed in a dated running journal, utilized a notebook to sort, brainstorm, and theorize. I created many notes throughout the transcripts themselves, and generally tracked my thoughts and reactions to interviews, how theory began to emerge from the data as it was collected, and the ideas that emerged during the process of open, axial, and selective coding. Sampling The sample for this study consisted of United States veterans with combat experience from the post 9/11 wars in Afghanistan and Iraq (OEF/OIF). To account for the variability of outcomes based on severity of combat experience, participants were screened to ensure that their level of combat exposure was somewhat homogenous. They all had to have experienced direct contact with the enemy through small arms fire in multiple engagements. This is indeed a subset of combat veterans as a fair number of those who inquired about participation were turned down, but thanked for their 57 interest. Reasons for exclusion included lacking small arms contact with the enemy, experiencing conflict other than post 9/11 Iraq or Afghanistan, or screening into a group that had already reached saturation. The enemies in both of these wars preferred to use indirect fire such as mortars or bombs that were either set up on roads and remotely detonated or were placed inside vehicles as VBEDs (Vehicle Borne Explosive Devices) and driven into crowded or high population areas. Many combat veterans had extensive experience being shelled by mortars or being hit by IEDs on their routes of travel. This line of questioning was asked in the initial screening instrument (ISI; See Appendix A) and proved helpful in acquiring this homogenous sample. Though these military conflicts have inevitably put women into direct combat situations, the literature indicates that the experiences of women in combat are quite different from those of men (Carney et al., 2003). Including women into a study with such a limited population and focus would have brought additional confounders based on gender. For this reason, only males were included in the study, though future studies with female combat veterans from these wars would be valuable. Combat veterans are a difficult to reach population for a number of reasons, which needed to be overcome in order to undertake this research. Initial access was made possible through my professional connections with combat veterans and veteran service organizations. Due to the sensitive nature of the research, rapport with these individuals was a key factor in their openness. I had initially thought that communicating an understanding of sensitivities surrounding the phenomenon of combat trauma would be critical, as potential participants would have to see and internalize a sense of value to themselves 58 and others in their participation. Interestingly, those who made contact with me seemed intrinsically motivated, but helped along by our shared military experience. This was further validated within the interviews by their general openness, but also some specific statements to this effect. As with other vulnerable populations, the need for sensitivity could also have been true of these combat veterans, many of whom have seen deep moral injustices with consequences far more graphic than most can imagine. Although many indicated how upset they had gotten with others who just didn’t understand, I believe my insider status was most helpful and at no time did any participant indicate that he felt uncomfortable sharing details with me. This was valuable and even held true for veterans who spoke right through their tears, or cleared their throats as affect welled up in them. There appeared to be an assumption that I would understand, which emerged in a general sense during the interviews. Also my ability to track meaning with them, which was indicated by the smooth responses, seemed to only validate this. I have previous experience in dialogue when a common understanding is not shared and this did not emerge at any point I could identify. Obtaining a complete sample of combat veterans was difficult, and once accessed the stories of veterans often required an understanding of military terminology and their way of life. This allowed them to speak naturally without also having to translate while recalling affect-laden experiences. This could have been further complicated since many veterans simply do not want to tell their story to someone they suspect will misunderstand or misrepresent their difficult and sensitive experiences. Some of the participants mentioned others who might participate, but in most cases the other person did not make contact. In two cases, the other person was their brother. I 59 was hopeful for this opportunity, but it did not materialize. In both cases, the participant said that his brother reported a very different outcome. Table 3.1 gives a summary of the demographics of the combat veterans who participated. Access After consulting with a number of combat veterans from Vietnam, Afghanistan, and Iraq, I had developed a strategy to address the difficulties in gaining access to veterans who fit the study criteria. The sample was gathered through various points of access into the community of veterans who had seen combat in either Iraq or Afghanistan. The most effective connection was through a state-wide Army National Guard family readiness coordinator who sent an internal email which generated about double the number of inquiries that were able to participate due to criteria. The second most helpful contact was through a local Vetcenter where veterans could go to get counseling in a community setting. The third most helpful contact was through the local university Veteran’s Organizations. Finally, one participant was referred directly by a mutual professional acquaintance. I posted flyers on informational boards in these locations with enough information about the research project for potential participants to make an informed decision to participate or not (see Appendix B). Initially I had difficulty obtaining an adequate sample in spite of my many contacts. The dissertation committee chair has worked for the last five years conducting research on military personnel and their families, and initial access to the readiness coordinator came through one of these contacts. 60 Table 3.1 Demographic Summary of the Sample Grp. Name Age 33 Ron 29 Jeremy 39 Matt Resilient John 31 Education Bachelor’s Degree Bachelor’s Degree Some College Bachelor’s Degree 31 Kevin Highly Traumatized Joseph 26 Steven 34 Wayne 43 Chris 36 Some College High School High School High School Some College Joshua 24 Some College Deploy. Marital Status Current Marital Status Ethnicity Single Divorcing Caucasian Christian Single Married Caucasian Lutheran Single Married Caucasian Protestant Single Single Caucasian Baptist Religious Affiliation Caucasian Catholic Hispanic / Latino Lutheran [Branch] Tour (months) Income combat? (yes/no) $50,000 - [NG] OIF (17)yes $60,000 [NG] OND (11)no $60,000 $70,000 [A] OIF (15)yes $70,000 - [NG] OIF (6)yes $80,000 [NG] OIF (12)yes [A] OIF (12)yes <$20,000 [NG] OIF (12)yes $30,000 - [A] OIF (12)yes $40,000 [NG] OIF (11)yes Single Married Single Single Single Separated Caucasian None Married Married Caucasian (left blank) <$20,000 $50,000 $60,000 $30,000 $40,000 Married Married Caucasian Christian Single Single Caucasian None 61 Rank at 1st Depl. E-3 2nd Lt (O-1) E-5 E-4 E-3 [NG] OIF (12)yes E-1 E-4 >$80,000 [NG] OIF (11.5)yes [NG] OIF (12)yes [NG] OIF (12)no [NG] OIF (15)yes [NG] OIF (12)yes >$80,000 [M] OIF (7)yes [M] OIF (7)yes E-4 E-5 E-2 Table 3.1 (cont’d) Growth-Orientated Anthony 34 Chuck 26 Some College High School Some College Some College Married Divorced Caucasian Single Single Caucasian Christian Fr. Catholic to Agnostic No Preference $20,000 $30,000 $30,000 $40,000 $50,000 $60,000 $50,000 $60,000 [A] OIF (14)yes E-3 [A] OIF (13)yes E-3 [NG] OEF (12)yes Kenneth 37 Married Married Caucasian [NG] OEF (12)yes E-6 [NG] OEF & OIF David 44 Single Married Caucasian Christian (13)yes E-5 [A] OIF (15)yes Some $50,000 - [NG] OIF (9)yes Dennis 34 College Single Married Caucasian Christian $60,000 [NG] OEF (9)yes E-5 Branch of service during deployment: [A] (Army Active Duty), [NG] (Army National Guard), M (Marines) Tour: OIF (Operation Iraqi Freedom), OEF (Operation Enduring Freedom), OND (Operation New Dawn) Length of Deployment: In parentheses with yes indicating combat action and no indicating no combat action during that deployment. 62 Sampling Strategy Snowball sampling (Goodman, 1961) is one form of purposive sampling, and has been one of the most commonly used methods for reaching hidden or difficult to reach populations (Magnani, Sabin, Saidel, & Heckathorn, 2005). Purposive sampling is a non-probability sampling technique (Holstein & Gubrium, 1997) that is an effective way to obtain a small sample size that represents a specifically targeted population (e.g. combat veterans). Snowball sampling was used to obtain the desired sample by initially recruiting those veterans with the desired experience and the variety of outcomes needed to make appropriate comparisons. These participants become the seed for the snowball sampling process. It is a preferred method for attaining difficult to reach populations (Magnani, Sabin, Saidel, & Heckathorn, 2005). Though one of the easier to implement sampling strategies, it is not without negative considerations. Snowball sampling is subject to selection bias. Due to the highly specific nature of the target population, I decided that the risk of selection bias was outweighed by the ability to reach participants who would otherwise be unavailable. The connection between informants and participants is presented in Figure 3.1. Initial participants or informants were identified through professional relationships as well as fliers left at strategic locations at veteran service organizations where potential participants were likely to be found. In the end, flyers were posed at an American Legion office, a Vetcenter office, and the offices of Veteran groups within three universities. Further, participants who successfully completed the interview process were asked to help recruit others by telling other potential participants and informants about the study. Only two participants were recruited in this manner. In order 63 Figure 3.1 Informants and Participants Vet Center Military Family Readiness Coordinator University Group Acquaintance of Coworker Informant / Source Participant 64 to have them recruit participants who fit criteria for the remaining unsaturated categories, they were given a sheet of definitions (see Appendix C) for each category (resilient, posttraumatic stress, and PTG) and informed regarding which outcomes still needed participants. This took into account social networks that are presumed to exist within hidden populations like combat veterans. Most veterans mentioned that they kept in touch with those with whom they experienced combat, validating the existence of such a network. This snowball sampling method continued until an adequate sample had been successfully recruited. When saturation occurred for any of the categories, participants were asked to recruit only those combat veterans they believed anecdotally fit into the remaining categories. At the conclusion of their own interview, the categories that still needed participants were explained, and they were handed the definition sheet mentioned above. Saturation is difficult, if not technically impossible, to achieve. Individuals will always have some new information to add. Interestingly enough, however, was that the core themes for each group were reached with three to four participants. Each group of veterans was quite homogenous compared to the other groups. This was helpful in the process of determining some meaningful level of saturation. Another factor that helped with saturation is that the questions related well enough that a missing factor often was found in the response to a different question. Stratification is the separation of participants into specific coherent groups based on some criteria (Patton, 1990) and was the most appropriate method of categorizing participants for this study. Participants were divided into three groups based on their overall well-being after the trauma of combat deployment. Each participant was 65 identified as having either a resilient, highly traumatized, or PTG outcome. This stratification provided for the widest possible variation with theoretical consistency and was in keeping with the model proposed by Larner and Blow (2011). Participants were initially screened by phone to ensure that their experiences exemplified the desired theoretical sample through the use of the ISI. This initial phone screening took less than 5 minutes every time. If the ISI indicated a good fit for the study and they still wished to participate, an interview was scheduled with them. Though initial stratification was done based on the ISI, as predicted, subjective participant responses typically matched quantitative measures, but at times were at variance with the results of these more rigorous quantitative instruments as can be seen in Table 3.2. The specific experience of stratifying this sample based on the ISI and the other quantitative measures is explained below. Utilizing these instruments helped to provide context to the data and verify participant stratification into the most appropriate of the three distinct outcome categories. The results of these instruments were not part of the primary data analysis. All eligible participants who responded to the phone screening participated, with one exception of a participant who could not schedule the interview at that time and then was unresponsive by email and unavailable by phone as his phone voice mail box was full. Also regarding stratification, scores from each instrument were compared relative to the scores of the other instruments. Highest resilience scores indicated placement into the resilience group and were correlated with the participant’s initial response from 66 Table 3.2 Stratification of the Sample Resilient RS-14 PCL-M PTGI-SF John 86 54 50 Resilient Resilient No shattering / Consistently spiritual and Religious Ron 91 22 44.5 Resilient Resilient No shattering / Consistently spiritual and Religious Jeremy 92 23 12 Resilient Resilient No shattering / Consistently spiritual and religious Matthew 93 26 32 Resilient Resilient No shattering / Consistently spiritual and religious Joseph 98 31 45 Resilient Resilient No shattering / Consistently spiritual and religious PTSD RS-14 PCL-M PTGI-SF Self-ID Assigned Belief System Notes From Interviews Kevin 52 64 29 PTSD PTSD Shattered Beliefs / High spiritual self-judgment Steven 59 46 28 PTG PTSD Shattered Beliefs / No religious affiliation Wayne 67 69 22 PTG PTSD Shattered Beliefs / Atheist Chris 69 61 27 PTSD PTSD Shattered Beliefs / Anti-religious Joshua 72 67 31 PTSD PTSD Shattered Beliefs / Deep active existential struggle RS-14 PCL-M PTGI-SF Self-ID Assigned Belief System Notes From Interviews Anthony 61 45 35 PTG PTG Chuck 75 47 37 Resilient PTG Shattered Beliefs / Spiritual & religious seeking Kenneth 76 50 34 PTG PTG Shattered Beliefs / Spiritual seeking David 84 28 45 PTG PTG Shattered Beliefs / Has become ordained minister PTG Self-ID Assigned Belief System Integrity / Notes From Interviews Shattered Beliefs / Spiritual seeking Dennis 89 56 45 PTG PTG Shattered Beliefs / Spiritual seeking RS-14 (Resilience Scale): Higher scores represent more subjective resilience on the part of the participant. PCL-M (PTSD Check-List, Military): Higher scores indicate greater symptomology (50 or more is clinically significant). PTGI-SF (Posttraumatic Growth Inventory-Short Form): Higher scores indicate more subjective growth. Belief System Integrity / Notes from Interviews: Was there shattering of global beliefs present? Existential Status of their global belief system overall as indicated during the interview. 67 the phone interview. Participants reporting highest PTSD scores were placed into the PTSD group. Participants with the highest PTG scores were placed into the PTG group. Previous research indicated that PTSD and PTG at times correlate; I had prepared to make efforts to select those participants with scores favoring one or the other measure, but this was hardly necessary. Beyond my own expectations, the average of those who had the highest scores for each particular group did not overlap. Results of this stratification process can be found in Table 3.3 and the procedure is explained in more detail below. Table 3.3 Averaged Group Scores for Quantitative Measures Instrument RS-14 (average) PCL-M (average) PTGI-SF (average) Resilient Participants 92 31.2 36.6 PTSD Participants PTG Participants 63.8 77 61.4 45.2 27.4 39.2 Sample Size Though sample size is a primary initial consideration for quantitative research, qualitative studies require more consideration near the completion of data collection as the investigator considers if the data have reached a point of saturation (Bowen, 2008). This point of saturation in qualitative research can be difficult to define. As a starting point for this research, saturation was identified when new cases failed to result in new open coding meaning categories and axial coding adequately informed the open coding meaning categories. Ideally, when new participants begin to provide an adequate degree of redundant data, data collection can stop. Open coding meaning categories were deemed consistent with no new categories emerging before or by the time five 68 participants had been interviewed for any of the three groups. Given the nature of this study, it was believed that an initial sample size of five participants in each group for a total of 15 would be sufficient and was considered the absolute minimum for this study. More interviews were not indicated by this process. Procedures Participants were pre-screened with the ISI over the phone asking how life has changed as a result of their deployment. The primary focus was to stratify potential participants into one of the three outcome categories before the interviews began to avoid having to complete interviews that would be considered redundant. Groups filled evenly up to three participants each and then filled one at a time. Saturation occurred in the resilient group at three interviews, with very similar responses overall. Data collection for that group stopped at the five participant minimum without generating new primary themes beyond those generated from the third participant. This was followed by saturation being reached in the deeply traumatized group at five interviews. The PTG group reached the minimum of five participants and saturation last as I had difficulty with scheduling for the last two interviewees. Questions screened for general levels of resilience, pathology, and PTG and to ensure that each combat veteran had met the criteria of multiple engagements in direct fire with their respective enemies. As long as participants were needed for the group into which the ISI indicated, an interview was scheduled. Interviews took place at my office in Saginaw, Michigan or at an office space near the participant location depending on which office was more convenient for the participant. The first task was for them to read and sign the consent form (see Appendix 69 D). The consent form fully explained the project and the rights of each participant. The consent form explicitly stated that participants could withdraw from the research at any time without any negative consequences and for any reason. They would have been asked why they did not wish to continue participation in case something about the study needed to be adjusted, but they would not have been required to give a reason. No participants who began the interviews withdrew. Each participant completed a set of questionnaires in person immediately prior to the individual face-to-face interview. These questionnaires consisted of demographic data, a resilience measure, a PTG measure, and a PTSD measure. These instruments were then used to provide context to the interview data and verify the stratification process. At first, participants were accepted as long as they fit minimum selection criteria. This was the case until the resilient group was filled and the other two groups had three participants each. After cross-case analyzed participant data in the resilient group reached saturation, only participants fitting the remaining categories, based on the results of the ISI, were scheduled for an interview. At the conclusion of data gathering the sample represented an even distribution of resilient, deeply traumatized, and high PTG individuals. Each group consisted of five participants. The constant comparative method (Strauss & Corbin, 1998) consists of comparing data as it is gathered with emerging categories of data that have already been analyzed. I utilized the constant comparative method which allowed the data to lead the research by indicating new categories or subcategories. This also meant that the point of saturation was a matter of collecting data until new categories and subcategories failed to emerge. 70 Quantitative Instruments and Procedures The instruments below represent the primary mental health outcomes associated with trauma. These instruments are consistent with the model developed by Larner and Blow (2011) and were selected in order to maintain relevance to existing theory and the overall program of research. They were used in conjunction with the narratives to stratify participants into the resilient, highly traumatized, and growth-oriented groups. The Initial Screening Instrument (ISI). This instrument consisted of questions that helped the researcher to identify the group to which the participant was most likely be stratified into based on the full instruments described below. The ISI (see Appendix A) contained a question relevant to each of the expected outcomes (resilience, PTG, and PTSD). Final stratification matched the placement indicated by the ISI in all but three cases. In each of these cases, final placement was made based on scores from the three instruments below. Importantly, this accuracy allowed for every interview to be used in the study and no potential participants had to be turned away because of a mismatch once they arrived at the interview location. The Demographic Information Sheet (DIS). This consisted of general questions to provide basic context to the data. The DIS (see Appendix E) asked questions such as age, race, socio-economic status, marital status, and military branch of service. Resilience Scale (RS-14). The fourteen question Resilience Scale (RS-14; Wagnild & Young, 1993) will be used to measure Resilience in participants. The RS-14 (see Appendix F) was chosen because of its reliability and brevity. With only 14 questions I was able to look it over quickly and potentially ask questions based on the 71 responses during the interview. Psychometric properties have not been found for this instrument. Posttraumatic Growth Inventory – Short form(PTGI-SF). Posttraumatic growth (PTG) was measured using the Posttraumatic Growth Inventory – Short Form (PTGI-SF; Cann, et al., 2010). This 10-item instrument (see Appendix G) is the new short form of the most commonly used instrument used to measure PTG (the PTGI) and has been validated as equivalent when compared to the full inventory for each domain as well as for total score. The long form was considered, but due to the equivalency of the two instruments, the short form is ideal because its function is to aid in stratification, and it will allow more time to be devoted to the semi-structured interview. The alpha coefficient of the PTGI-SF has been reported to be .90 with victims of intimate partner violence with an adjusted correlation between the PTGI full form (which has a considerable recent history of use) and the PTGI-SF of .90 as well (Cann et al., 2010). Questions based on responses were also asked during the interview. PTSD checklist – Military version (PCL-M). Post-traumatic Stress Disorder (PTSD) was measured utilizing the PTSD Check List – Military version (PCL-M; Weathers, Huska, & Keane, 1991). This 17-question instrument (see Appendix H) is frequently used with veterans and provided a standardized measure of PTSD symptoms to screen for one of the most commonly identified pathological outcomes and to assist in question formulation. The PCL-M has a reliability of .93 and a test-retest reliability of .96 (Evans, Cowlishaw, Forbes, Parslow, & Lewis, 2010). A score of 50 or more has been considered consistent with a diagnosis of PTSD and is the expected minimum score for stratification into the PTSD / decline group. All PTSD participants had scores 72 above 60 with one exception. This participant had a PTSD score of 46, but was placed in the PTSD category because he reported a shattering of world assumptions, while his PTGI-SF scores were considerably lower than the others from the PTSD group. Having a shattering of world assumptions and an RS-14 score 25 points below the average of the other Resilient participants precluded him from this group as well. Interestingly, he was the only participant who was not allowed to fire back at the enemy during fire-fights due to his occupational specialty. Questions based on responses to this instrument were also asked during the interview as appropriate. Stratification procedure by instrument. The category into which participants were tentatively placed was based on the ISI. Scores were then compared to other existing participant scores on the RS-14, PCL-M, and PTGI-SF. Results of the ISI and ultimate stratification can be found in Table 3.2. Participants were stratified into the resilient group based on each one having noticeably higher RS-14 scores than the other participants with one minor exception. One highest scoring growth-oriented combat veteran had an RS-14 score higher than the lowest scoring resilient combat veteran, but that growth-oriented participant was also tied for the highest score on the PTGI-SF making that a more appropriate selection for him. This placement was further validated by the absence of any shattering of world assumptions on the part of any of these participants. Participants were stratified into the highly traumatized group based on each one having the highest levels of PTSD symptomology compared to the others as measured by the PCL-M. All but one had a score indicating clinically significant symptom levels (61 and higher) with the final participant in this group having the most controversial 73 placement in the study. This final participant’s placement was not settled until after the interview was completed. His narrative indicated a shattering of world assumptions with very minimal growth. Further, he was the only participant in the study who had been in small-arms engagements with the enemy while his specialty did not allow for him to fire his weapon or maneuver against the enemy removing one element of personal agency related to the meaning of combat experience. Participants were stratified into the growth-oriented group based on the examination of three factors. The first prerequisite to be in the growth-oriented group is that they must have undergone a shattering of world assumptions. Among all who underwent this shattering of world assumptions, the division process was not difficult because of the divergence of the remaining two measures. The highly traumatized participants had the lowest PTGI-SF scores and the growth-oriented participants had the second lowest PCL-M scores. Further, the growth-oriented combat veterans in the study had similar PTGI-SF scores as those in the resilient group, though the average of all scores was still higher. A properly handled discussion of the similarity of these scores for both growth-oriented combat veterans and resilient combat veterans is needed, but is beyond the scope of this study with one exception. In order to have undergone posttraumatic growth one must have undergone the prerequisite shattering of world assumptions, making scores for resilient combat veterans technically irrelevant. Stratification of the sample using this method worked well and was validated by the interviews themselves. 74 Overview of Qualitative Interviews The unit of analysis for this study is meaning. Specifically, the meaning constructs of interest are those that relate to the combat deployment experiences of these male combat veterans. To obtain these meaning constructs, semi-structured qualitative interviews were employed. It was expected that many of the meanings of interest would be affect-laden, or highly related to emotional content. It was believed that directly asking questions about emotions would likely lead to shorter responses and a lack of context, so these were kept to a minimum. As it turns out, emotion was readily expressed during each interview. Some had momentary, almost unnoticeable lengths of silence when talking about buddies who did not come home, while others let their responses roll through tears, throat clearing, and other expressions of deep affect. I encouraged them to take their time, but each time they would continue, the interview becoming their mission of the moment. They knew the value of sharing their experiences. The primary method of data collection was through a two-hour long semistructured interview with each veteran. The longest interview took nearly three hours total, which was the first interview. The shortest interview took just over one and a half hours. An interview guide (see Appendix I) was used in order to ensure inclusion of interview questions which were informed by existing research to ensure that my line of questioning and the participant responses did not lose focus. Open-ended questions were asked in order to elicit rich responses regarding the specific meanings held about their combat experiences. The open-ended nature of questions ensured that participants had as much control over their own responses as 75 possible. In these interviews I utilized such techniques as empathic engagement, reflective listening, drill-down questioning, and circular questioning in order to elicit a deeper and more meaningful level of information (Boss, Dahl, & Kaplan, 1996). In order to connect with and build a relationship of trust with each participant, I introduced myself; provided a brief introduction highlighting my prior military experience, current disabled veteran status, and the importance of the research to other returning veterans. I then allowed them to ask questions about myself, the reason for the research, or any part of the research process itself. This opportunity to help fellow veterans, as predicted, was of great personal interest to these combat veterans. Some mentioned how they walked by the flyer for a time and then decided they needed to call. Others responded to an email providing contact information and short paragraphs explaining their experiences in brief to help me determine if they were a good fit for my research. As such, it went a long way in setting the stage of openness by enlisting the very sense of purposeful meaning that is the focus of the study. Interview data were initially recorded on a hand-held digital voice recorder, and redundantly recorded on a laptop microphone. The hand-held recorder proved insufficient and inefficient and thus was discontinued completely after the first interview. These interviews were then transcribed using an audio transcription program called F4 which allowed me to interface with an Infinity transcription foot pedal. Transcription was further enhanced and sped up by the use of Dragon Naturally Speaking 11 which increased the speed of transcription to nearly real-time depending on the interview. After interviews were transcribed in preparation for data analysis, meanings and beliefs were highlighted by hand. Choosing to do this by hand proved useful as I felt I 76 could move back and forth in the interview more naturally to check potential meanings with supporting context which were often found in different questions. Questions were formulated from a wide range of factors with previously demonstrated relevance to trauma outcomes. The first two questions generated a reallife context for the remainder of the interview. Remaining questions related to specific areas of meaning identified in the literature. The interview guide had the questions listed in a particular order with building significance. I anticipated the possibility that I might change the order of questions based on participant response, but this proved unnecessary. Notes about each interview were also recorded on a Contact Summary Form (see Appendix J). Research Questions The purpose of this study was to explore the effect of meaning on the outcome of combat trauma in wartime veterans with the understanding that families as social supports play a critical role. The research questions answered are: 5. What do combat veterans believe about their combat experience and their roles during and after their deployment? 6. What is the process used by combat veterans to overcome or make sense of combat trauma? 7. How is meaning-making coping related to the relationships veterans have with family members and other people who are significant in their lives? 8. How do the beliefs, meaning-based growth processes, and social interactions with significant others differ between those who achieve resilient, decline oriented, and PTG outcomes? 77 These four central questions guided the research in order to develop a grounded theory of meaning-making coping and growth in combat veterans. Based on existing literature on meaning-making and discrepancy as impetus to decline, I asked specific interview questions that were intended to elicit both global meanings and appraised meanings of the specific events experienced by each combat veteran. Table 3.4 shows the relationship between Research Questions and Interview Questions. For a list of the questions themselves, refer to the interview guide (Appendix I). Table 3.4 Relationship of Research Questions and Interview Questions RQ1: 1-3, 6-8, 11-16 RQ2: 4,5, 17a, 17b, 18 RQ 3: 9, 10 Question 19 could apply to any of the research questions. Compensation Participants were initially offered a $25 Visa gift card for participation in the interviews. After two months without making contact with potential participants, the compensation was increased to $50. This led to some initial interviews. Shortly after this, contact was made with a statewide family readiness coordinator through the state National Guard. This led to a fair volume of inquiries and several interviews. Interestingly, many of these had stated that they were more interested in helping other veterans through their participation than they were in accepting the compensation. This led me to believe that the lack of initial participants was more about access to this difficult to reach population than about motivation, reducing potential concerns about 78 coercion via generous compensation. Any participant that traveled an hour or longer to participate was reimbursed $20 for gas. Each participant was also given the opportunity to recruit other veterans. The process continued until the desired number of participants for each category was reached. Confidentiality The study was undertaken with approval from the Michigan State University Institutional Review Board (IRB). I was the only person able to identify participants other than the participant or the informant that recruited them. I am further bound by professional ethical standards of confidentiality, specifically those established by the American Association of Marriage and Family Therapy (AAMFT) and the Health Insurance Portability and Accountability Act (HIPAA). The identities of all participants will remain confidential. The real names of participants will not be recorded with the data, and any identifying information in their narratives was changed as necessary if it would potentially identify them. For purposes of the study, each participant was given a pseudonym. The interviews were recorded on and kept on the same passwordprotected laptop computer immediately following each interview. All audio data were stored on the password-protected laptop until transcribed and then deleted at the end of the study. All physical copies of data and information such as informed consent forms, transcribed interviews, and the quantitative instruments were kept in a locked filing cabinet inside a locked office. Coding and Data Analysis I interviewed and audio-recorded the session of each participant, which was transcribed and then coded for the meaning constructs that are relevant to the study of 79 meaning-making coping after combat trauma. These meanings were compared and contrasted to look for patterns, differences, and unique meaning structures. From these data a grounded theory of meaning making and coping after combat trauma was developed. Data were analyzed utilizing the constant comparative method where each interview was compared to the interviews already completed (Miles & Huberman, 1994). The interviews were analyzed and organized using Microsoft Word 2010, Microsoft Excel 2010. Manual methods were also used to help guard against loss of potential meanings due to the complexities of language that cannot be captured by word searches and electronic comparisons. Connections were made until each stratified data group reached saturation. The constant comparative method allowed me flexibility in adjusting future interviews based on information already analyzed. This in turn added a layer of protection to the groundedness of emerging narratives rather than insisting that narratives conform to the initial questions. It should be noted, however, that changes to the questions were relatively minor. One potential weakness in the questioning strategy was the number of questions. Twenty questions led to a broad spectrum of meaning constructs, but as helpful as this was in making sure no stone was left unturned, it also created a sense of submersion, rather than immersion in the data. The important nature of this study made this a preferred weakness compared to missing some important aspect of meaning. As interviews were completed, they were analyzed individually. The meanings and beliefs that each veteran held fell into one of two levels: global meanings and appraised meanings. Global meanings were compared to appraised meanings for 80 discrepancy or congruence. This level of analysis was compared to the quantitatively measured outcomes for theoretical consistency. The qualitative data proved to be in congruence and quite homogenous with the quantitative measures. Cross-case analysis was then used to compare participant responses within each category using the open, axial, and selective coding processes explained below. For instance, resilient participant data were compared with the previously analyzed resilient participant data until the cross-case data became saturated. This process was replicated for the deeply traumatized outcome participant group and the PTG participant group. A separate line of analysis was performed for each group. Finally, the three lines of analysis were compared across groups in order to identify similarities and differences between them and generate an overall grounded theory of meaning-making coping in combat veterans. This newly developed higherorder theory is intended to explain how meanings, meaning-making processes, and meaning-related social interactions differ by identified outcome. Coding One can evaluate the quality of a theory by the process by which it is constructed (Strauss & Corbin, 1998). The analysis for the research is based on the Strauss and Corbin systematic grounded theory approach and modified for comparison of a stratified sample. Though sentences or specific words are often used as the unit of analysis, the unit of analysis for this study was an idea, or a specific meaning construct about a specific aspect, quality, or event related to the combat veteran’s deployment experience. This particular form of segmentation is most appropriate because individual 81 words or sentences may not convey the appropriate or intended meaning conveyed by the participants. Although this method of parsing qualitative data is more ambiguous, it allowed for more flexibility while still maintaining a segmentation standard for the interviews. Sometimes the meaning was conveyed in one to two words. At other times it was found only in the context of a full contextual explanation. Open coding was done first to discover major categories of meaning contained within the transcribed interviews. These resulting meanings were divided between two levels of meaning: Global Meanings and Appraised Meanings. These meanings were compared for each individual for level of discrepancy or congruency. They were compared to others within the same group, looking for similarities and differences in meaning as well as levels of meaning discrepancy. These sets of global/appraised and pre to post combat meanings were then compared to those held by participants of the other two groups. After the major categories of meaning had been identified axial coding was used to build on each major category by going back to the data and looking for constructs or categories related to it (Strauss & Corbin, 1990). During this axial coding process, categories consisted of the causal conditions for the meaning construct, strategies utilized to respond to it, intervening conditions that influence it, and the consequences or outcomes of the particular meaning construct and its related processes. The final step was selective coding. From the data I developed propositions that explained key relationships between beliefs and outcomes that emerged and hypotheses that could be tested in later research (Creswell & Brown, 1992). These 82 relate to two hypothetical levels. One level focused on each outcome group. The second level focused on the differences between outcome groups. Bias, Reliability, and Trustworthiness Trustworthiness is particularly important in qualitative research and refers to the standards used to ensure that data are accurate and of good quality in spite of the inherent subjectivity, and even messiness, of qualitative research (Morrow, 2005.). Demonstrating the credibility of the researcher and the methods used is paramount (Lincoln & Guba, 1985). For this reason, an audit trail was produced, including interview questions and protocol, fully transcribed interviews, and a detailed account of the coding process. This makes the data available for re-analysis and demonstrates the study’s confirmability. Ultimately, the beliefs of combat veterans expressed in their own words were the capstone of trustworthiness in this study. I documented every step of the research process in a research journal to create an open record of the facts, impressions, struggles, and solutions related to the process. This provided a comprehensive audit of the research process to help account for bias and add credibility to analysis as it unfolded. If bias or leading questions were detected, subsequent interviews could be modified to improve objectivity. The self of the researcher is an important consideration regarding bias and trustworthiness in this process. While being a veteran was a very positive factor in eliciting meaningful responses from participants, it also presented potential bias that had to be addressed. One such concern was role ambiguity between licensed therapist and that of researcher. This was addressed through a focus on inquiry and understanding (researcher) rather than on problem solving or support (therapist). 83 Additionally, however, I am a therapist who works with veterans regularly adding another level of emotional safety for participants. I am equipped and indeed watched for and avoided potential safety issues that might have arisen by interviewees becoming traumatized during the interview. One interviewee admitted that although he is an Army instructor who teaches from his wartime experiences, the interview was the first time he had a chance to talk to someone about his own personal feelings and beliefs regarding his combat experience. I explicitly paced his interview based on this information, as he was surprised at his own level of affect during the first two contextual questions. Another admitted that he was going to go home and smoke weed after the interview to recenter himself emotionally. Concerned for his emotional state, I checked in with him about any negative thoughts, and he said he was okay and that the interview was no worse than his therapy sessions. This was just a matter of process for him. None of these combat veterans indicated a need to talk to a therapist in response to the interviews. The dissertation committee chairperson further ensured that my questions were asked from a focused researcher perspective, and was prepared to help to make corrections as necessary. He was consulted as needed throughout the process. Finally, the dissertation committee chair person, acting as professional gatekeeper with a vested interest in ensuring the quality of research, reviewed the data and codes in order to further help identify bias and individual assumptions that may have affected data collection and coding. The dissertation committee chairperson also looked at the text of the interviews to identify and correct any bias that may have influenced the way the co-constructed dialogue developed. 84 CHAPTER FOUR: FINDINGS General Overview of Findings This study explored what combat veterans believe about their combat deployment experiences, how they coped with these meanings, and how relationships with others have related to this process of meaning making. Anthony, a combat veteran who became at one point, in his own eyes, just like the very person he hated most, and then proceeded down the difficult journey that is post-traumatic growth, made the case for this very research in his interview: You could take two guys that were from the same exact unit and seen the same exact combat and they're gonna be affected in two completely different ways. One might show severe, severe signs of PTSD and having a really hard time, breaking a lot of rules, breaking a lot of laws, drinking... nightmares, flashbacks. But the other guy seems like he's got it together and is doing okay. He's not taking his wife across the house, kicking the dog across the house, not drinking his life away, shows up to PT on time, does everything he is supposed to do as if he did before he left. There might be a different stigma about him. There might be more of a coldness maybe, but what's the difference there. I'm very interested in that. I proposed that the meanings, coping strategies, and social interactions of combat veterans would differ based on the outcomes they reported. Fifteen combat veterans, stratified into groups by PTSD outcome, provided detailed and uncharacteristically open accounts of their personally held meanings, coping strategies, and social interactions. By examining what these fifteen combat veterans believe, I was able to arrive at conclusions that help us have a greater understanding of how meanings and beliefs are related to the outcomes of combat veterans. Amazingly, each point made by previous researchers within the literature review was validated in some way by their stories. But they had even more to say. The findings are presented according to the three outcomes discussed. The first 85 section, Common Themes, highlights themes they all had in common. This was difficult because even with the commonality there were thematic differences. They are represented here because the similarities highlight a common experience more than they help to explain the differences between each group. The Resilience Trajectory, displays the beliefs and meanings held by resilient combat veterans about their wartime experiences and how those experiences have affected them. This section is characterized by a coherent spiritual and religious belief system and related coping skills which prepared them for combat, supported them during war, and helped them cope after their combat experiences. It is also characterized by forgiveness, letting go, and moving forward with a renewed focus on meaningful relationships. This outcome is the hope for every warfighter, their family, and their nation. It stands in stark contrast with the outcomes experienced, indeed suffered by, deeply traumatized combat veterans. The second section, the Deeply Traumatized Trajectory, displays the beliefs and meanings held by highly traumatized combat veterans about their wartime experiences. It shows how those beliefs have interacted with their chosen meaningbased coping strategies, and influenced their interactions with others. This section is characterized by challenged and changed world assumptions, troubled and often contradictory beliefs, and judgmental assessments of self, God, and others. Their narratives tell of broken relationships, culled social networks, and dissociation. This outcome is all too common, and is the impetus for research such as this; that no combat veteran should have to suffer so great a loss of their inner-self in response to an already unimaginable and selfless sacrifice on behalf of others. The third section, the Traumatic Growth Trajectory, displays the beliefs and meanings held by combat veterans who 86 initially suffered a shattering of their world assumptions, but have been in the process of considerable growth. It sheds light on how their original beliefs were challenged and found unable to sufficiently explain their experiences in a manner that allowed them to thrive afterward. Light is then shed on the post-traumatic growth process as it relates to their emerging beliefs and changes in coping strategies utilized. This section is characterized by belief systems which are changing from those similar to the Deeply Traumatized Trajectory toward those in the Resilience Trajectory, from judgmentalism toward forgiveness, from idealism toward acceptance. This section elucidates the process of change from reduced social interactions toward rebuilding of relationships and discovering new ones. Though the outcome of traumatic growth is identifiable, this process of traumatic growth (which is also existentially traumatic) is the traumatized veteran’s path to inner peace and hope. Post-trauma growth is every therapist’s goal: to come alongside those who have been to hell and back and help them to move forward, not by burying or avoiding reminders of the horrors of war, but through reappraising their experiences more constructively. Emerging Themes and Annotations by Outcome Typically, results and discussion are separated. Due to the complex and comparative nature of the findings I found it necessary to expand slightly within each section, annotating findings as they are presented. The patterns found among the belief systems within each group represent distinct views of life and humanity. Failing to add this context would make group-wise comparisons more difficult. In the final section, a summarized comparison is given to highlight the most salient themes. 87 Common Themes Two common themes emerged from the data. First, every participant in the study was displeased with the news media portrayal of the wars in Afghanistan and Iraq to some extent. Some held harsh views. Though these themes are common throughout, they are separated out by outcome to highlight the differences that do exist. The second theme is that these combat veterans, regardless of outcome, believed the American people to be naïve about these wars. They attributed this to both individual complacency and the news media portrayals of the wars. News Media Resilient view: Biased and detrimental. The resilient combat veterans in the study held a negative view of the news media. For the most part, however, they would tune it out, turn it off, or otherwise ignore it. They felt that most of the news was inconsequential to their beliefs. John said, "In my experience, my personal beliefs… my views of it, would be that Fox News kinda gets it. Most other people don’t.” He then named nearly every household acronym related to news. Matthew said that the news did a disservice to the American people by hurting their ability to understand the war. He felt it was sensationalistic, and when I told him a different veteran said it was propaganda, he agreed: News in general is… they like to get viewers so they only do the dramatic. They like to get viewers so they only kind of, they focused on the bad aspects of, of well 15 soldiers died today, but they don't tell of the 20 or 30 soldiers that did a humanitarian mission and provided books and pencils and paper to 50 schoolchildren or provided security for Iraq elections. They don't do that… [also] there are thousands and thousands of soldiers getting out of the Army and they can't find a job. That's a hardship. And the news isn't really focusing on that. Matthew, full of controlled anger, spontaneously commented on Fahrenheit 9/11 a 88 popular documentary produced by Michael Moore: Fahrenheit 9/11. That's one of the most… that movie pissed me off to so much of a degree I can't really even explain it. It's… how do you do that? You find… Of course there are soldiers out there [with particular views], but I feel like he purposefully edited that movie to show what he wanted to show, which is fine for a movie. But that's not real, it wasn't real. They indicated that they believed there were two main reasons for what they reported was news and media bias, which were apathy and the agenda behind each news outlet. Apathy was discussed in that resilient veterans believed most people would rather watch television about what they considered pseudo-reality and accept the report from a news reporter rather than believe a veteran who had been there. Jeremy gave this account of a conversation he had with someone when he returned home: I get involved in political discussions and some of them were like even before I left theater, I started talking about how through my interactions with the Iraqi’s, I found out that they actually wanted President Bush to win the election, so these other guys were sitting here saying, “You need to stop listening to Rush Limbaugh.” I’m like, “No you don't understand. Rush Limbaugh is not on Armed Forces network. I'm talking to the Iraqis.” “You need to stop listening to Rush Limbaugh.” “I don't listen to Rush Limbaugh. I’m talking to Iraqi’s! I'm in Iraq!” And when I got back I had quite a few people, in roundabout ways, they will take what a reporter, who briefly was in Iraq wrote, rather than come to a guy who has been there like me. And I've been called a liar.” The gruesomeness of war is hard enough to endure, but agenda-driven news outlets did them no favors in their eyes. How can they talk about those experiences with those who would rather take the word of a reporter over those who were there carrying out missions? Still, these responses were not as dire as those of the highly traumatized group. Some interactions were even positive: 89 Jeremy appreciated consideration from others for the sensitivities caused by combat action, but specifically without sympathy. Empathy, on the other hand, he was able to appreciate: One of the most thoughtful things I've experienced since… I was in a larger store, it's like this woman was moving some boxes, and I was in uniform. She comes over and she goes, “I had just wanted to let you know that I’m going to drop these pallets down so it's gonna make a loud noise.” And that was it, so I'm like, “That’s pretty cool.” She didn't do it to anybody else, she did it to somebody… she recognized the fact that I might have an adverse reaction. She didn't say I was gonna get scared or something. She just wanted to say hey, I'm gonna do this and I just wanted to make you aware of that. That was something that was very important. Sympathy comes across to nearly all combat veterans as offensive, but empathy or even a genuine attempt at understanding or open curiosity is often welcomed. Highly traumatized view: Propaganda. Like the others, the highly traumatized group believed that the news and the media were wrong about the context within which they portrayed the wars in Iraq and Afghanistan, but their descriptions of the news media were more negative. This belief is important for a number of reasons. Primarily, their first-hand accounts, along with those of the other two groups of veterans, were in stark contrast with the news that was presented to over 300 million Americans. They believed that bias existed that was harmful to the cause overall. I asked Kevin if he thought the news portrayed the war accurately. “Naw. Certain people… some of it was right. A lot of it was wrong, but that's the media. I mean they ain't never going to get the whole story out there.” Wayne agreed: No (laughing like, not a chance). No (while laughing). No. It's all propaganda. It's facts, but you have to dig through so much of their spectacular bull shit. I mean the good things that we do over there every day? That wasn't on the news. None of that stuff is on the news. 90 Steven was equally upset: Yeah, they could have gotten… basically they should just pretty much stop reporting stuff. All they do is report the bad stuff; they don't report the good stuff that happens in Iraq. Wayne expressed a sentiment that ran through their narratives. He believed the reason for the inaccurate reporting was about ignorance and bias: It's based on propaganda and ignorance. I have no respect for their opinions, and even the embedded reporters. They don't see everything. They see whatever they planned on seeing before they ever left. They see whatever their network that they work for wanted them to see. Growth-Oriented View: Biased and Dangerous. The growth-oriented group, like the others, was very frustrated with the news and media. Anthony connected the bias in the news with the reason he believed the American people did not understand what was going on. Regarding the news media, he said: It disgusts me, because the civilian population as a whole had no frickin' idea what's going on over there; what the purpose is. (sarcastically) It's about oil, it's about money, it's about this, it's about that! Horse shit! “Because CNN told you it's about this or it's about that, and that means that's what it's about?" Chuck felt the same way. When I asked him how he felt about the portrayal of the war by the news media, he said: A lot of frustration, it really depends on which national news media outlet they're paying attention to. You have the people that are watching CNN. They learn one thing about the war. Then if they watch Fox news they get another perception. …I've stopped watching national media because they always have an agenda that they're negotiating. You can't trust them one way or another to report objectively. It's always, they are going for the shock and awe factor for the media. They're just trying to get their ratings up in numbers. He was specifically frustrated with the failure of the news to account for meaningful events like those he was a part of: 91 We walked into schools that combat engineers helped rebuild after we blew it up, and the kids all stood up and sang our national anthem, but all in Arabic, which is really weird sounding. You can tell what they're saying because of the melody they're trying to carry out. It was crazy cool. Like the others, this frustration with the news media pushed him to look for news elsewhere: I'm more into the alternative media now because I think you get more of an objective approach, where people can make their opinions, or a news piece without fear of shareholders or bosses or something like that. Similarly, Kenneth felt the view of the war was tainted by unbalanced reporting and a distasteful political bias: News? Bad news sells, which sucks. You don't always get the good news, and, and that ties… the news ties in the politics. And I never really realized this until post-deployment, how bad it ties into politics. While the news continued to report about the wars in Iraq and Afghanistan with bias, Kenneth pointed out that some news should not be broadcast for fear of consequences to the troops on the ground: Some of the news… there is too much news. Why the hell are they reporting this?!. What do you mean there's a leak?! A leak about what? You know you’ve heard many examples in the last year alone, this year. It’s just… oh my goodness, would… would somebody please shut up?! You're gonna get somebody hurt. David was also in agreement with the others. He had a few specific things to say regarding the reporting. He believed the news was either biased to the “left” or to the “right”, but was not objective. He felt that a lot of attention was given to the treatment of detainees and believed it to be politically motivated. The first was the failure to report the existence of weapons of mass destruction. He claimed to have seen them. When challenged by others. He said, “I… sat on one.” While he was laughing. “I personally sat on one. There weren’t many, but they were there.” The second reason was about the 92 outcry regarding waterboarding. He claimed that had been waterboarded and said it was not nearly so terrible as the media made it seem. This sentiment of politics and ratings injected into news being dangerous and likely to get people hurt or killed was common among participants in this sample. View of Society as Naïve Resilient view. Through interview question 13, I asked combat veterans how the civilian portrayal of the wars they fought in affected them with particular emphasis on the news and media. I considered these to be extensions of, and informers of public opinion; a Macrosystem feedback loop. Overwhelmingly, resilient combat veterans believe that most civilians are uninformed about the wars they fought in Iraq and Afghanistan. They reported nearly universally that this was a source of frustration, but since they could not control others, they just ignored them. Highly Traumatized View. So, what did they believe was the net effect on society of the bias reporting that they believed existed at the time? Wayne believed that the news led many people to misunderstand what the war was about, but he put the responsibility on the people who did not dig into the stories for what he believed was the truth. “They're spoon-fed the garbage that they get. They don't know reality.” He continued: You know, to people, and I hear them every day. People that have never been anywhere, never done anything. They sit back here and they have all these views on the world and what's going on, and their views are based on religious and political propaganda, not real experiences. That's why I say they’re sheep. They're spoon-fed information. They don't ever find anything out on their own. Kevin put it this way: If some people picket the war, “stop the war, bring the troops home”, and stuff like that. I see a lot of that stuff going on, and… you can't even pay it no 93 attention, because if so you are probably going to lose your life, or the person next to you is going to lose their life. His sentiment was that the broadcasting of such public negative sentiment about the war while troops were still in harm’s way actually put lives at risk, hurt morale, and emboldened the enemy. This belief was widely held by participants. Steven felt that the biased reporting undermined support for his own meaningmaking process: Yeah, they don't… when we were over there they were just saying all, “Everybody's losing troops; were losing troops!” It's not all about that, it's what we’re over there for! We're keeping them over there so they don't come over here! The emerging sentiment was that they were being undermined by the media for reasons that they had to tune out in order to do their job, rather than feeling supported by the public voice of the people back home that the news represented. Growth-oriented view. The emerging group narrative from the growth-oriented combat veterans was that the American society as a whole is naïve and that some of this naiveté is due to the news media bias. Kenneth talked about the effect of skewed news on society with two effects. First, he believed that the media bias made it difficult for people to get behind the war until it was finished. Second, he believed that the focus on political views kept people from understanding that the United States had a positive effect on the lives of every day citizens of Afghanistan where he was deployed: “Why are we even over there?” I get that asked, ‘Why are we even over there?’ I'm just like, “Because we had, you know, two airliners crash into two separate buildings, and then shortly after that the Pentagon got into it? Really?! Why are we there?! The USS Cole, we never did anything about?! Really? We never did anything about the Beirut bombings!” You know, it's not… in my personal opinion it's not… In the Cold War we had a clearly defined enemy. Heh, heh. And we don't anymore, and it's really hard you know. People say why. “Why do you love the Afghan people?” Because I had to learn to love them… The true Muslims are 94 very peaceful people. The true ones. The ones you meet out there, the country folk. And they're not corrupted by the money, the power; these are the ones scraping by making a living. They’re truly… They are peace-loving. They are tired of fighting, and they will tell you this. And that's it, and the [American] civilians don’t grasp that concept. When you say they're in the stone ages. They don't get that. He believed that the American presence was positive for the Afghan people until more recently. During the interview Anthony made an impassioned case for how pacifism leads to violence due to bottled up emotions and helplessness: I would say that our society has gotten to the point where we are actually fighting human nature. I believe that wholeheartedly… whether people realize it or not this world is getting more and more and more and more violent and there's a reason for it. But yet we keep trying to be more humanitarian. We tried to be pronon-violence, and ‘everybody should have a frickin puppy’ kind of mindset. So why is it getting worse? ...It makes no sense. But it does. Say you know the law about defending yourself in [this state]. You have the right to defend yourself. The hell if you do! If you get into a fight with somebody, whether they hit you first… if you hit them, your ass is going to jail... their meaning of self-defense is 'run and run and run and run until you're cornered, then you have no choice, but to hit somebody, and then it's still wrong. He continued on, noting that teaching people that it is never okay to fight and then sending them off to war is incongruent. This sentiment resonated with the other narratives, both resilient and highly traumatized: According to society "It's never okay to fight. Haven't you heard that before? It's never okay to fight. Never. (long and drawn out). I don't believe that. I don't believe that one bit. There is a time. If that was the case, it would never be okay to go to war. Right? If you raise me to believe that it's never okay to hit somebody, but then the day I turn 18 it's okay for me to go across the world and kill somebody because my country said it's okay? How does that make any flippin sense? It makes zero sense to me." At the time of writing this portion, schoolyard bulling remains a consistent topic in the news. He alluded to the stereotypical bully in the schoolyard and contrasted this with his appraisal of the role the United States plays in the world: 95 The bully in the schoolyard? He needs his ass kicked. Plain and simple. And I was the one in the schoolyard to have kicked his ass. I can't stand bullying. And I've seen… I see our culture, I see the way America is becoming a bully." This highlighted the discrepancy he felt regarding his combat deployment to Iraq. On the one hand, he believed that the United States did the world a favor by taking out a bully, Saddam Hussein, but on the other hand, he could see that the way that the United States tended to mess with the affairs of other nations. This lack of clarity in purpose during wartime was for him and others, a source of frustration and incongruence. Chuck felt the American people had a hard time supporting the wars after 9/11 because the reasons for war, aside from taking out the Taliban and searching for Osama Bin Laden, were not clear, “A lot of them still don't understand why we’re over there, for right or wrong.” Summary Ecologically, these combat veterans saw the news media as the feedback mechanism for the macrosystem so that American citizens could understand the wars they had sent young men and women to fight. Overall, they were displeased with the portrayal of these wars to the point where some believed harm had come to American warriors because the cause had been undermined and the enemy had been emboldened at times. They believed that this had a negative effect on the people overall and that this in turn was detrimental to some returning veterans wondering if they had fought a just war or not. Others believed that the news even bolstered the enemy at times, indirectly leading to lost lives. Though some persevered, the news media, rather than being a supportive structure for our armed forces, turned out to be a hindrance to be overcome. 96 Resilience Trajectory The resilience trajectory is characterized by a relatively stable outcome in spite of the existence of some PTSD symptomology due to physiological and psychological changes which become necessary for survival in a traumatic combat environment. The resilient group consisted of five male combat veterans reporting overall resilient outcomes. Each of them reported being resilient at the time of the initial phone screening and each of them scored higher than all other participants in the study on the RS-14 scale. See Table 3.2 for a comparison of this measure. Several themes emerged related to resilient outcomes. These themes provide the foundation for the conclusions, comparison to other outcomes, and discussion in Chapter 5. Difficult Experiences If debilitating trauma outcomes were merely about physiological overload, one could assume that resilient combat veterans simply did not experience the horrors of “real” combat. John’s account shed light on one of his experiences: My first deployment was active ground combat. [inaudible] umm, the hardest day was the day before [redacted holiday]. It's when we took the worst casualties... That was the worst day... the worst day ever. That was just literally hell. If you want me to go into it I will, that's just if you want me to… We took five casualties that day. Later in his description he talked about being unable to save a buddy who was burning alive in a Humvee while the enemy who planted the IED that caught that vehicle on fire was pouring intense gunfire on their position. The incoming enemy fire was so bad that they had to call a second QRF (Quick Reaction Force) in order to extract themselves from the ambush. Ron talked about a list of troubling experiences: Umm, we had anything from a, from direct small arms contact with the enemy to a lot of IED contact, and a lot of contact with indirect fire with the enemy. My ahh, 97 (pause) let's see here, I have been hit in… my vehicle that I… my Humvee that I had been in has been hit by IEDs, I've been… my platoon, we've been on dismounted patrols. We had been hit with large IED's. The ones that would like blow up the road out front the whole way across (black top road in front of the office with a total of four lanes). Though he admitted his contact with the enemy was not as heavy as others, Jeremy recalled an incident that was particularly vivid for him: The one big firefight that we had, it was an ambush. We actually lit the ambush site up before we went in there. When we did go in there we started getting lit up, And I remember seeing out in front of me just the whole field in front of me, just right immediately in front of me just getting bullets impacted all over the place. There were thousands and thousands of rounds coming in. You could hear them snapping overhead. Joseph talked about an incident that is known as a Blue on Green incident where his unit was attacked by an Iraqi National Police unit that was supposed to be on the same side, but had been compromised by insurgents. Each of these warriors had seen combat. Every human being has a unique threshold of trauma that they can endure. It is possible that severely traumatized veterans typically have worse and more prolonged exposure to the horrors of combat or that these resilient combat veterans had just not reached the limits of their individual ability to cope, but their experiences were considerable. What do resilient combat veterans believe? (RQ1) At the core of meaning for each of these resilient combat veterans exists a set of comprehensive world assumptions. For these five combat veterans, this amounted to an identifiable belief system which was able to assimilate the experiences of combat into their daily lives in a meaningful way. In each of their cases, this belief system provided not only adequate conceptualization of the events to come, but also mental and 98 behavioral prescriptions for how to respond during the adrenaline rush of the fight response during enemy engagements. Comprehensive world assumptions. All five resilient veterans reported membership in an identifiable belief system as a set of comprehensive world assumptions that consisted of at least three structural attributes: Organization, Certainty, and Adequacy. These were connected to their faith belief systems, and although from different denominations, all five identified with Christianity. John was a well-read protestant Christian who brought the soldier’s Bible he had with him on deployment to the interview, Ron was Lutheran, Matthew was Baptist, and Joseph was Catholic. Jeremy indicated that he was protestant/Christian on the demographic instrument, though denomination did not come up in his narrative. Importantly, what follows are their narratives which illuminate how this worldview provided them with the cognitive, behavioral, emotional, moral, and spiritual tools which helped them find their way to a resilient outcome. For them, a faith-based belief system, as expressed in their own narratives, may not be necessary for resilience, but it does appear to have been sufficient, so far as belief systems go. Organization refers to having a belief system that is identifiable and stable. Being denominationally Christian indicates a belief in a specific higher power and the tenets within the Bible as defined by a specific denomination. This is in contrast to others who identified with a more personally defined sense of religiosity and/or spirituality or lack of spirituality that is more individually defined rather than through the shared beliefs of similarly minded believers. When they had questions they either talked about how they could go to a source (e.g., the Bible) that would give them an answer that they could 99 then accept and apply, or they would mention someone in their lives who shared their global belief system who they could turn to for support. Certainty refers to having a belief system that they trust. In contrast to others who may believe what they have experienced through trial and error, these resilient combat veterans believed in the tenets of their faith-based belief system to the degree that when they had questions they would engage either the Bible directly, or at least their understanding of it, as an authority for answers and then check them against experience afterward. They viewed the Bible as an authority on life through which to appraise or reappraise their experiences. Matthew said it this way: I don’t think combat has really changed me that much for my spiritual beliefs. I guess some people might come back and think ‘I’ve seen the horror of man, how can God let this happen?’ I’m not necessarily that way at all. Men make their own choices and that’s the way… It’s not God dragging us around like puppet pieces. It hasn’t made me question, question spiritually. At least combat hasn’t. This certainty for them led to a sense of relationship with God built on trust and faith that He would either bring them through their circumstance or that their sacrifice, including their death if it came to that, would be for a worthy cause, and they were at peace with this possibility. This is not to say that they never questioned their faith or that they did not need to modify their beliefs or clarify meanings. In fact, the ability to modify their beliefs in light of new information emerges in relation to resilience. This propensity for modification was present for all five of the resilient combat veterans. Four of them, when meanings were in question, described a tendency to modify their beliefs to be more in line with the shared understandings of their faith belief system. Matthew, however, held his faith-based belief system as his core, but was open to scientific evidence when it was presented. This malleability, also known as Accommodation, is 100 exemplified in this statement by Matthew, a Baptist by upbringing, who had just finished talking about how he went to church every week as a youth. Notice his ability to accommodate while tolerating ambiguity without invalidating his existing beliefs: I kind of mesh what science tells me is true and how I'm interpreting what I've learned in the Bible. To me that's how I have to… I can't take everything the Bible says literally. It was written by man, and man… He's not perfect, so there's probably errors in the Bible. As much as this is God's word, which it is… But it was written by man. Adequacy is perhaps the most obvious of the attributes, but possibly more difficult to predict. When a combat veteran returns home and is able to say that combat did not challenge his beliefs, those beliefs are adequate by definition. This was the case for all five resilient combat veterans in the study. Post-combat evidence of adequacy for this sample was evident in the RS-14 scores of these five participants, their selfreported sense of resilience, and the depth with which they were able to articulate their beliefs as unchanged, or even challenged by their combat experiences, while also maintaining levels of PTSD symptoms that were lower than those reporting other outcomes. In their narratives, these resilient combat veterans were easily able to identify the adequacy of their belief system. One main point of adequacy emerged regarding human nature. Though all five in the resilient group reported little to no surprise when they talked about the human ability to participate in the horrors of combat, one veteran’s experience will illustrate the point. When I asked if Matthew’s beliefs had changed any since his first of two combat deployments, he took a long thoughtful pause and then said, “Nothing has really changed about my idea of the world. Like it’s still the same. People are still pretty much the same.” Interestingly, his beliefs about human nature included the idea that people 101 are basically self-interested and at times selfish or worse. This is in contrast with the participants in the highly traumatized group, who reported the initial belief that people were basically good, followed by the post-trauma belief that humans are capable of terrible acts of selfishness which they continued to struggle with during the interview. Matthew believed the self-interested tendency was true about himself, his fellow warriors, and the enemy as well. His beliefs held up because his worldview prepared him for the extreme self-interest and selfishness borne out of a desire for survival he would see while in combat. This lack of negative appraisal or personal judgment about the self-interested desire on the part of the enemy to kill or be killed (as they themselves believed) is expounded upon below. They discuss how they defined their enemies and what it means to take the life of another. Congruently, they believed this self-interest to survive at all costs was the same for their enemies as well as themselves. Intrinsic spirituality or religiosity appeared to be an even more important theme than that of shared meaning as illustrated by Jeremy’s experience. A shared spiritual-religiosity with family and friends was present for four of them and was discussed as being supportive, but having a spiritually grounded family of origin was not a necessary component to having a deep intrinsic Christian belief. Jeremy talked about a salvation moment when he was 12, followed by a search for answers within the Christian faith in spite of his nonspiritual family of origin, or having a support system with shared spiritual meaning. He put it this way: I don't come from a religious background. I did become a Christian when I was 12, but living with a single parent, my mom, and my brother. She did not go to church. Even though I've been a Christian for a long time, I've never really got along with a lot of people from the church, because most of them are fake. Enhancing our understanding of the depth of his faith, he talked about how he 102 put it into action when he returned home: It was right at a time in my life where, I’m a born-again Christian. Before I left I felt the need to find a new church, and other events happened in my life that I had to cut off some friendships and I had to say goodbye to a lot of people and I had to make a lot of changes… I took off four and a half weeks for a road trip around the U.S. Just me and my dog. I took a lot of time off, because I didn’t have a lot of family. My dog was the only person in my life. For him to believe so many church-going Christians are fake indicates a sense that his belief, if a bit cynical, is at least believed by himself to be genuine. For these resilient combat veterans it is not the mere cultural categorization of being a Christian that creates a sense of resilience, but rather a mindset about something that is on the one hand personal and intrinsic and on the other hand externally visible through the way they live their lives. Prescriptive Rumination. Rumination is characterized by compulsively focusing attention on particular aspects of one’s distress and occurs after that distress or trauma. Prescriptive rumination, by contrast occurs beforehand. If the context was negative this construct would have related more to worry, fear, or anxiety, whereas prescriptive rumination as presented here is characterized by forethought with the benefit of preparation for the trauma to come. Before their first wartime deployment, these resilient veterans reported having had an adequate understanding of what their combat experience would be like. In evidence, they talked about their pro-military and spiritual/religious upbringing which held up under the stress and reality of their actual deployments. This is further reinforced by statements from each of them that their combat experience did not change their beliefs about the world, or world assumptions. Ron talked openly about how his belief system growing up fully incorporated the military experience into his spiritual and religious understanding of the world in a way which he 103 felt prepared him for the experience of combat: Umm, I was brought up in a household where I was always around veterans. I was also brought up in a household that… My dad was in the military, he kind of moved around while I was in school. I lived with my grandparents and we stayed in my home state while my dad traveled around and came back every once in a while... My grandma was very very religious. She's a very… I grew up in a Lutheran household. And my mother in turn was very religious as well and my grandfather, he was also a World War II veteran in the Navy. He was kind of my father figure for a lot of my upbringing. So both he and my dad were both veterans so I grew up with that. This dual theme of a faith-based belief system normalized and contextualized the military experience. Also indicating that his sense of right and wrong is dictated by God through the Bible, John put it this way when responding to my question about how he was brought up spiritually regarding war and combat: Umm… negotiations. Using the voice of reason. In that sense, when you have no other options, then war becomes necessary, and even through the book of Joshua and Samuel, where it says…. Second Samuel or First Samuel, (paraphrasing) ‘God has commanded you [the Israelites] to go take these people out, they are evil. I deem they’re evil and you’ve got to do what I say, because I’m God, and you’re my people.’ There’s no wrong in that. To these intrinsically spiritual and religious participants, if the Bible says that war is sometimes necessary, then very likely, it is sometimes necessary. This does not mean that these intrinsically Christian believers did not question controversial issues within their faith, but that in the absence of life experience, they had a template from which to start. The Bible for them prescribed when war was justified and when taking a life was justified. See the following section titled Taking Another’s Life for a more detailed look at this theme. For John and the other resilient participants, it was after the voice of reason was not successful in deterring Saddam Hussein. For these five, this template held up in a way that helped them cope better than the other participants in the study and find deeper meaning in their relationships. For the combat veterans in this sample 104 subscribing to this belief system, their participation in a war is not by itself an act requiring forgiveness. They were participating in a cause greater than themselves. For each of them national defense (the defense of others) was the reason for their service. Resilient participants talked about this in a manner that placed their identifiable belief system at the center of their decision-making process. Even when war and combat were not talked about in the home, this belief system adequately prepared them for the military. Joseph said his family never talked about combat or war, but that he was “a sponge” during his training and that in spite of his lack of previous understanding, he found nothing about combat to violate his beliefs. Benevolent relationship with God. All five resilient veterans reported a personal relationship with a higher power. Each of them referred to that higher power as God. This relationship consistently held the following attributes: Active communication, benevolent vicarious control, and implicit grace and forgiveness, culminating in the belief that if they were to die as a result of combat, a comforting afterlife in heaven awaited them. This relationship with God had a marked effect on two important themes. They concerned themselves with making responsible decisions rather than worry about how things could turn out, because they believed that God was in control. They also view life as a precursor to an afterlife in heaven rather than a terminal event to be feared. Particularly, they placed great emphasis on living their lives congruent with their beliefs. One major theme includes personal sacrifice for causes greater than one’s self. Another emerging theme was congruent appraisal in that they knew (completely believed) that their decisions were sanctioned by the very God they held themselves 105 accountable to and this built considerable internal strength. Likewise, believing he was not going to make it home at one point, Matthew talked to God out loud, praying for safety, “I remember one night specifically when we went out on patrol and I’m like, “Oh… my… God. We are going… to die. Please let me come home safe.” John recalled a statement from a friend. It summed up vicarious control with a focus on choices while leaving the outcomes to God: And my one friend who was killed in 2005, he had a saying that his parents had a saying that “I am bullet proof, until God determines otherwise.” When He determines that He wants me home, that my job is done on earth, [then God would say] “I’m there to welcome you with open arms.” And that even goes back to General Stonewall Jackson, Thomas J. Jackson, Confederate Army, his faith was so intertwined that he felt just as safe in battle that he did in bed. And that’s exactly the way I felt, and the way that I believe all people should feel when they get to combat. It’s not up to us when we die. We’re just supposed to live the best we can now, and the rest of that’s His. At one point I asked Ron about his sense of God being in control. He believed this sense of benevolent vicarious control helped him, and indicated that he further believes that those who do not have this sense of faith are the most vulnerable. He added, “Right, and even if it did go bad I wouldn't be catastrophically impacted like somebody else who didn't have that faith would, over what I had seen.” Joseph talked about how he felt God directly answered his prayers. This sense of vicarious control was very comforting to him. He said it this way: I honestly felt like God directly answered my prayers by getting me home. Like, I should not be standing here today. There are many dangerous things on the routes we were traveling in Baghdad, through Sadr city, down into an area called... But that's how he answered my prayers. He took care of my family, (pause) I have a good relationship with Him. I pray to God… I definitely had the confidence that if I was blown up that I would go to heaven. A system of faith, similar to what these individuals described, may be an 106 important component of mental health during and after trauma, particularly combat trauma, in a society that is becoming increasingly less interested in faith. Sustaining Faith. Belief and faith are different. Much research on religiosity measures belief based on factors like church attendance, which can be misleading due to cultural expectations that one attend regardless of personal desire. The belief that these resilient combat veterans demonstrated and discussed was intrinsically sincere and ran deeper than identification. As an illustration, one can believe a chair will hold them when they sit in it, but faith comes from actually sitting in the chair and seeing that it does what a chair is supposed to do. For these resilient combat veterans having a relationship with God and having faith that they will go to heaven was more powerful than believing in God and that heaven exists. Jeremy went so far as to say that his belief (faith) that he will go to heaven removed his fear of death. When asked how their faith either hindered or sustained them, each one reported directly that their faith was very sustaining. John’s statement is brief and powerful. “It has sustained me, 100%.” And Jeremy felt the same way: [My faith is] a big crutch, more like a stretcher. It is what sustains me when things are questionable, or when you're a big prayer and things are going wrong all over, you've got to have a rock. If you don't have that rock you're in trouble. Ron connected his sustaining faith to how he believed that God kept casualties from one attack to a minimum through the power of prayers: [My faith] has definitely sustained me in that when things were long and we got extended for three more months, and it was a bad time already during the deployment. I knew that I could get through it because I could say a prayer and that would help, well maybe not answer the questions right then and there, and I also knew that through the power of other people's prayers back in the states, it was helping me and my soldiers get through. And in my platoon we had one soldier that was killed where there were opportunities where more soldiers could've been killed. 107 This sustaining faith is in stark contrast with the beliefs of highly traumatized combat veterans. It is a consistent theme that appears to be protective against the effects of extreme situational uncontrollability. Military context. Congruent appraised global meaning of war. For resilient combat veterans, there is a time for war. War to them is not, by definition, a good or evil thing. It is an event that can have either a just purpose or an unjust purpose, but is still always undesirable unless it is as a last resort. John put the military values at the forefront of his own sense of purpose and personal meaning as it related to the war he fought in: ...so it was a sense of purpose that fed the morale, where there really wasn’t a sense of purpose during the Vietnam War, so morale suffered because of that. And the values part of that question is even answered in the morale, where the Army core values of Loyalty, Duty, Respect, Selfless Service, Honor, Integrity, and Personal Courage…I don’t know what the Marine Corps ones are, but I mean… the duty, selfless service, you know, the loyalty of bearing allegiance to the United States and going after the people responsible for war. Some referred to World War II as a righteous war from the standpoint of the Allies who were suffering unprovoked assault by the Axis powers. Others mentioned the American War of Independence. For the resilient veteran, the importance to meaning-making coping is that war itself does not violate any of their world assumptions. Another theme that emerged in the context of the interviews was that of the defense of self and the defense of others. Jeremy gave an account of his experience with a bully that is possibly a perfect metaphor for understanding combat as resilient combat veterans do: When I was in high school a kid hit me from behind and I turned around and I punched him right in the side of the head, and the principal gave us a suspension for one day. Absolutely mandatory for fighting no matter what. So I go home to 108 my mom and explained to my mom what happened, and she went from wanting to punish me even further to: “Here's $20 in quarters, go and have fun with video games.”, because I was defending myself. If I had started the fight, I would have been in deep trouble. If I had failed to defend myself, some corrective training would've been called for. But if I defended myself and used appropriate force, that would be when I would be rewarded. I thought this was succinctly put and was in line with what the other four resilient combat veterans believed. When words fail to stop the bully, something has to be done. John, again quoted from the back of his soldier’s Bible, in an extra piece by Captain Stu Weber who was in Special Forces during the Vietnam conflict, in a piece called “The Man In-Between”: “Many years ago, as a young boy in a cozy little neighborhood in central Washington State, I learned a valuable lesson. Our neighborhood bully, Jimmy C., would never stop throwing dirt clods and using strong-arm tactics to terrorize smaller children. Yes, we complained. In fact, we begged. But time after time ‘negotiation’ failed. Nothing seemed to work. Until one day one of us gathered the courage to stand up to him. Lying flat on his back Jimmy experienced an amazing change of perspective. He suddenly saw the logic in leaving the little people alone.” He then followed up in his own words: Just that little part right there is kinda how I feel about the war. I felt this way really all my life. I have been very very very pro-military. My family has been in the military actually all the way back to the revolution. One of my ancestors was General [a household name] in the civil war. He then continued quoting Captain Weber: “Bully’s never seem to quit until someone takes the initiative to stand between them and their victims. You recall Goliath, Hitler, Saddam, or even the Devil himself. The Christian warrior is the man in-between. “With mind and heart committed to righteous principles, he offers himself as a shield to others.” The image is thoroughly biblical. “When the Philistines occupied the south ridge of the Valley Elah, and the Israeli army the opposite ridge, each day the giant of Gath descended to the valley floor between and taunted the champion of Israel. Saul, head and shoulders above his people, had no heart for the in-between. But Jesse’s kid…” (Jesse’s kid being young David, who would become King) This quote does several things for John, and similarly so for the other resilient combat 109 veterans who all presumably know this most common Biblical story. He is comforted to know that as a Christian warrior in the service of his country, he is given authority by God and his nation to fight back bullies who represent a threat to himself and those he is sworn to defend. When asked about a common pro-military statement that peace comes through superior firepower, Jeremy took a long thoughtful pause and then said, “I agree with it, but it only works if you're willing to use it. Willing, not meaning wanting.” His concern was that people become complacent thinking that the threat of retaliation is enough, when it is really the promise of retaliation that creates peace. This led to a modified statement that I have thought about considerably since this interview, that “Peace comes through the reluctant, willing use of superior firepower.” Ron agreed with Jeremy when asked about his personal view of war: Umm, I’m one of those guys who trains for war, but prays for peace. I am not like the guy that has the attitude that I’m going to go out there and blow things up or go kill people. That’s not why I joined the military. I joined the military as a service to the country and to do my part, similar to my forefathers before me. It is evident in this statement that he, like other resilient combat veterans, saw the role of the military as a worthy sacrifice for the cause of national defense in order to maintain peace, which is, in the context of war, the opposite of warmongering. By contrast, many of the highly traumatized veterans and the growth-oriented veterans in this study reported a time when their behavior would have been considered warmongering. While all of the combat veterans in the study were willing to sacrifice their time, and potentially their health or life, for a cause that they believed was greater then themselves, the resilient combat veterans ascribed the most positive meaning to their service, adding a sense of shared family legacy, meaning, and notably spiritual-religious meaning. Some 110 of these reasons are the foundation of what they believe makes America great. Joseph put this in context with certain ideals that are at odds with the enemies he believed he fought in Iraq: The values embodied by our Constitution, you know, freedom, equality, liberty… The people that tried to attack us, the citizens within the border of the United States, to try to defeat those ideas for that sake. That makes them an enemy, If their goal is to undermine our core values and what we have as a nation. And that’s liberty, that’s not prosperity. That (prosperity) is just something that happens [because of liberty]. But equal opportunity, liberty, freedom, equality, justice… when people try to attack us to defeat those ideas, that makes them an enemy. Congruent appraisal for their war. Resilient combat veterans reported that they agreed with the mission of the war they fought in, though they seemed to also believe that the reasons provided to them initially were at least worthy of some debate. All five of them served tours in Iraq. Four out of five served two tours. The length of their total deployed time averaged over 21 months in Iraq; the shortest total time in country for any one of them was 15 months and Ron served this in one deployment. The length of individual deployments ranged from six to 17 months. They believe that the United States was attacked and we took the fight to those who would continue to do us harm. When I asked Joseph how he processed his combat deployment experiences he answered the question beginning with the importance of his service and the mission: From the first deployment I was proud to have gone over there, get the bad guys. And I bought into the... I was being the typical proud to be an American patriot that's going to defend freedom, we were attacked. So I had this, in a sense, pride. To them, the appraised meaning of their war (Iraq) was about taking on an enemy that had been a state sponsor of terrorism, had ignored numerous United Nations resolutions, and presented as a threat to the region and our allies. 111 Some history will help to underscore why these veterans supported the wars in Afghanistan and Iraq, lest it be lost and their context become misunderstood. Osama bin Laden was the head of Al Qaeda, the terrorist organization that claimed credit for flying the planes into the Twin Towers and the Pentagon. Those attacks constituted an act of war, making Al Qaeda, bin Laden, and those that supported their cause a primary threat. As a self-identified threat, they could be engaged openly. This precipitated the war in Afghanistan against the Taliban, who were supporters of bin Laden and Al Qaeda. So what about Iraq? Iraq did not attack the United States on 9/11, but the justifications at the time were that Iraq had ignored 10 United Nations Security Council Resolutions culminating in Saddam’s refusal to comply with and 11th, UN Resolution 1441, adopted unanimously by the United Nations Security Council. The council offered Saddam Hussein one final opportunity to comply with the UN demands. He refused. Although the media focused on weapons of mass destruction, Resolution 1441 found Iraq to be in material breach by constructing prohibited missile systems (one of the growth-oriented combat veterans produced a picture of himself sitting on one of these illegal missile systems during his deployment), the purchase and import of prohibited armaments, and continued refusal to compensate Kuwait for Iraq’s prior occupation of Kuwait in 1990-1991. This, it was argued, constituted a threat to the United States and the stability of the Middle East region. Though the politics of these two wars have been of much debate and will likely never be a settled issue, what is important to the resilience of combat veterans is that they believed that adequate justifications existed during their combat deployments. 112 Over time, however, this national sentiment began to change in favor of the troops returning home while maintaining stability in Iraq and Afghanistan so as not to undo the accomplishments they had made. With reasoned understanding for those who hold an opposing point of view Ron talked about his process of making sense of the ambiguity: Umm, just at a glance the war in Iraq didn't make [sense]. The reasoning behind it now that I've done the research, now that I kind of understand where the administration was going with going into Iraq, I can understand why and I would rather be proactive than reactive with regards to taking out a source that could have created more terror. With that being said I am supportive of us going into Iraq. I can see the flip side of it of why people question why we were there and why we stayed there as long as we did after we had gotten rid of the regime and things like that. To see how his views might have changed over time after thinking through things, I asked him if his views about the war had changed or remained the same: I think it has pretty much stayed the same. When I was over there I questioned it and was a lot more… Like when I would listen to the president or listen to people talk, I would question it more, but yeah it has pretty much stayed the same. But I've kind of had time to have some retrospective now that I’ve been home a little bit. Jeremy explained how his own view was more important to himself than what others thought. The most important factor that emerged was that the appraisal of the war they were in was in line with their own understanding of what constitutes a just war. When I left the country in 2003 about half the vehicles on the road were donkey carts. I come back six months later, there were no donkey carts. There are a lot of cars. Things are newer, there are billboards and advertisements. In fields there is agriculture growing. No matter how many times I pulled the trigger, it doesn't change… Anybody can come up and say we fought that war because of oil. I thought, it doesn't change the fact that I fought a war to set the Iraqi people free. I could care less what they say in Washington. I know what I did. Recently, this congruent appraisal for war has been changing over the last few years for some. Even resilient combat veterans who were initially in support of both 113 wars believed at the time of the interview that it was time to hand the countries back to their respective leadership. Matthew talked about his initial support and his current view: Well the first time yes I was like, okay this mission needs to be done. This is what we’re doing. I was like yeah I agree with this. The second time I agreed with it, training Iraqi police and helping him get… It was basically helping them get logistics and helping to train them; giving the country back. And I was like okay, well they're doing it. And then of course you see them… 20 police officers sitting around the police station, and I'm like why aren't they out there doing patrols and securing their little area of some block. And they are like well, no IED's, no cars. And of course you see a car blowing up and were like well, us as America we cannot do this for you forever. So towards the end it was like okay, we as a country need to get out of Iraq and say well it's your country you either sink or swim. Taken together, it seems that appraising a war that one is fighting in as being a worthy cause is important. The fact that their views are now changing is less relevant to the meaning-making coping process, likely because these views are not as personal after the fact as they were before and during their combat deployments. When they were in combat, they believed in their mission. Interestingly, however, this support does not have to be overwhelming, but adequate enough to keep from making negative assessments of their own actions. They had little to no discrepancy between the appraised meaning of the war they were fighting and their belief about war in general which included how they viewed their own role in that war. These congruent meanings are in concert with their understanding of who the specific enemy was. John talked about who the enemy was in Iraq: The enemy that I faced, they were terrorists. They were against my political views, my national views. They didn’t want freedom, they didn’t want democracy, and they wanted the hotbed of power there they probably had that really they shouldn’t… At first it was Saddam Hussein, and everybody that followed him, the Baathists, loyalists, and all that. And then once we got rid of that enemy, the enemy became the terrorists, it became Al-Qaeda, it became Al-Qaeda in Iraq. People that bin Laden had sent over, to try to expand his network. 114 As Saddam’s army fell, men flooded in from surrounding nations to fill the void. For the combat veteran an enemy can refer to the opposing force, but when it comes to the taking of lives it takes on a more personal meaning. When our warriors have to decide who is and who is not an enemy, they are making the distinction between who is a target for aggressive action and who is not. Resilient enemy combatant appraisal. Three themes emerged when defining what an enemy was. The first was that a person is not an enemy unless he or she represents a threat. Resilient combat veterans were very meticulous and particular about what constituted a threat, when someone became a threat, and when they stopped being a threat. Although none of the five resilient veterans knew each other, their accounts were unbelievably consistent. The term enemy to me is… anybody that means me harm, my squad harm, my fellow soldiers harm, civilians harm. It's somebody that intends to do harm to somebody else, and me as a soldier I have a way to stop that. So that's to me the enemy. The enemy isn’t the everyday population of Iraq. Jeremy agreed: Somebody who wants to come against me. I have to base it on their actions… Is that guy pointing a weapon at you? Or is he not pointing a weapon at you? Is he wearing a black ski mask, as in some of the Fedayeen after the invasion, they did, or is he not. Is he being a threat? You r-e-a-l-l-y have to think about it, and you only have a nanosecond to think about it. It's pretty hard. And so did Ron, he said, “Enemy: that is somebody that is going to try to take my life, or my friends or family or comrades life in order to further their cause or further weaken mine.” Secondly, resilient combat veterans recognized that any enemy they faced during wartime was just like them. This sameness has implications that are better appreciated in comparison to how others viewed the enemy. This is discussed in later 115 sections as well. Recognizing that one’s enemy is not humanly different than or worse than themselves plays a role in the forgiveness process after losing a buddy, and in the self-reappraisal process. For those who mentioned losing someone from their unit, they presented their view of an enemy without personal or long-lasting malice. Jeremy gave an account that summed up the certainty and adequacy of his beliefs in this area. Since the enemy is basically the same, a threat assessment should be the primary deciding factor when determining who is an appropriate target of aggression and who is not: I think [my combat experience] pretty much reinforced everything I’ve ever believed. I just found that some of my fellow soldiers are more than willing to pull the trigger when it's inappropriate, and your enemy is a lot more friendly than what you've been told. So there's not, you're not that far removed from who your enemy is. Matthew packed a lot into one response. He mentioned that his decision to take a life is predicated upon their being a threat, that both of them made a conscious choice, and that when he killed an enemy combatant he realized they had a family. He also distanced himself from those thoughts through depersonalization while specifically NOT dehumanizing the enemy. Contrasting his view with what he saw others doing, he put it this way: To me, I was engaging a threat that was threatening my life so to keep my life I had to shoot back. And it was a choice he made to shoot at me. It was a choice I made to shoot back at him…To me I like to step back and be… I've never… not that I don't consider that a person. I know he had probably a family, mom and a dad. I distance myself and I'm like… I don't like the ‘deer head on the wall’ thing. Not that I respect him because he’s an enemy, but I respect the fact that he is a human being. That's kinda how I deal with it. Finally, resilient combat veterans discussed the theme of loving your enemy. Though most often understood within the context of day-to-day interactions with those one may simply dislike, the resilient combat veterans in this study took it to another 116 level.. Jeremy put it very well: As a Christian I am told to love my enemies, and the way I take that meaning is: I had a wonderful medic on active duty, and one of the guys was saying we just need to kill and smash the enemy, and we shouldn't take prisoners. And the medic says, “You know, you’ve got it all wrong. The reason why is that we have to destroy their will to fight. In World War II we were gaining ground on the German army and because they were giving up to us because they knew they would be treated well [if taken prisoner], but they stood and fought tooth and nail with the Russians because they knew they were gonna get killed or tortured. The thing of it is, is if you create a caged animal feeling in your enemy, they're gonna fight harder, so if you treat them well and give first aid and you treat them with respect, they will give up easier." In the end, when warriors believe to the point of knowing that their actions are just, and are very conscious of their willingness to fight enemies until those enemies give up their arms, they are afforded some level of protection from emotional, moral, and spiritual judgment. Taking another’s life: Contextual. The idea of taking the life of another human being is one of a few pivotal meaning constructs within the entire study. Belief systems provide the overarching context of what it means to take a life and what or if circumstances matter, but every trained combatant is himself a weapon carrying other weapons designed to kill other combatants and destroy their will to fight back. The concept of war without the taking of lives, although desirable, is a non-starter. Although it is possible, and even probable, that other belief systems exist which may lead to the same resilient outcome, all resilient combat veterans in this study subscribed to the Christian worldview with a fairly firm interpretation. As Christians, they all talked about the authority of God in their lives, but this also extended to the role of government on a religious and spiritual level. John quoted extensively from the back of his soldier’s devotional Bible. To make his point, he went on to read a section in the 117 back which was full of quotes and short writings of former warriors and military men speaking about their experiences as Christians during wartime. One summed up this sentiment, “The Christian warrior is the man in-between. With mind and heart committed to righteous principles, he offers himself as a shield to others.” Like the others, John saw himself as a defender of peace with the authority of God and his government behind him. Each combat veteran needs to answer the question of right and wrong regarding taking the life of another. One can ask simply, is there a difference between asking the question, “Am I a killer?” and “Am I a murderer?” Ron was able to articulate this for himself, but also for the rest of the resilient group: That for me is something that is very… I mean I value life, I believe that it's not “thou shall not kill.” (as in killing in combat does not fall within the commandment not to kill, that killing in combat is not covered by this commandment) The only reason to kill somebody is if they're trying to kill you or you're trying to protect the safety of those around you, your friends, your family, your unit. And it's not something that I take lightly at all. It's not something that I get off on or have some type of desire to do. It's a necessity of what has to be done to further the cause. Jeremy used his own children to explain metaphorically that he believed relationship between God and people was like that of a father to his children: Ahh, a lot of people will say, “If God is an omnipotent being, how can he allow war?” Well I'm now a father, and sometimes my children fight. And I don't want them to fight. But I love them. I cannot control whatever they do, so what happens is that they are committed. And people want to commit and do evil things. And when they go grab a big gang and it becomes an army, then you need to employ an army to conquer that force. That's where war comes in. Sometimes it's bad people, sometimes it’s good people that you have to fight. To me, when I pulled the trigger on that rifle as a soldier I am an agent of the United States Army. I am not a personal human being, in other words I'm not murdering you. I'm acting on behalf of the United States. And for whatever reasons, you're standing in our way. In his account, when he says, “How can He allow war?” he knows that there are others 118 who disagree with him. Evident in the narratives of all resilient combat veterans were the themes of threat, self-defense, and last resort. They all agreed that it was important to assess the threat of each situation, eliminate all other possible courses of action, at least mentally, but not at the expense of protecting themselves and others. Matthew gave this account: I'm not going to take a life during war without absolutely having to do it. To me that's the spiritual side of me. I need a valid reason. I need some type of catalyst to make me make that decision. And that catalyst to me is threat. He also mentioned that in spite of having taken the lives of his enemies, he still did not define himself as a killer on a deeper level, “Yeah, it’s the training. I mean, to me I don’t like to think I have the killer instinct I guess maybe they talk about in the movies or whatever.” To him, taking a life as a wartime veteran was something different entirely. Sometimes the decisions were easier than others and at other times they were difficult. Matthew, a sniper, later gave an account of his decision-making process which sums up all three of these concepts. His simultaneous attention to the overall situation, and the knowledge that his command gave him prior authorization to kill anyone who crossed a certain line were important, but his own belief system which was more important still: My spotter said, “I see a lady carrying a grocery bag.” And of course the grocery bag can hold something… And I’m watching her and she's coming towards the line, coming towards the line. And we’re telling her to halt, but we’re on top of a building kind of back a little where she can't… And my spotter's telling me to engage her and I'm like, “I'm not gonna engage her unless she's a threat.” And lo and behold she crosses the line about five feet, takes a left, and goes to a little hut off in the Bush line. And at that point, yeah I probably had… I mean I was told I could, but then again my situation and my belief structure made it so if she wasn't a direct threat to me or anybody else at that time unless she was carrying a huge bomb in a small package. Finally, these resilient combat veterans believe that being in combat involves a two-way 119 responsibility. Matthew said simply, “He made a conscious decision to shoot at me and I made a conscious decision to shoot at him.” Each resilient combat veteran was very aware of their own sense of responsibility, but as long as they were engaging combatants or some other threat the veteran represented only half of the responsibility within the combat relationship. The same social rules used by resilient combat veterans also form the basis of the Geneva Conventions, standards of international law regarding treatment of non-combatants. For these resilient combat veterans, taking a human life during combat or in defense of self or others was justified at every level from their own personal conscience through the authority of government to include the existential dimension both spiritually and religiously. Resolved personal mortality. The importance of one’s own mortality emerged in spite of no direct questions directed at this idea. It emerged in the highly traumatized section and the growth section with more salience. Only after revisiting the theme in contrast to other outcomes did its significance emerge. Jeremy, quoting a fellow combat veteran while they were in Iraq, said that they both believed that coming to grips with one’s own mortality was a very important factor in combat. He pointed out the importance of coming to grips with one’s own mortality and not taking their faith for granted, but actively pursuing a relationship with God: [My friend said],”You're no good as a soldier until you recognize your own mortality.” Basically when you go out on patrol you're gonna be so afraid that you probably can't do your job until you realize that there is a possibility that you're gonna die. So once you embrace the fact that you're gonna die, you're no longer afraid. Well I have no reason to be afraid because I believe I will go to heaven. And that's where my faith comes in. A lot of people have their own faith and it gets them through what they believe is trouble. It's the people that take their faith for granted, all of a sudden when they get themselves in trouble, they don't have 120 any faith. Ron agreed: I think that was due to my upbringing, knowing that there is a higher good and a higher purpose and even if I would have died I feel like it would be for a good cause so I think that's kind of what I used to get through things like that. John, with family roots going back as far as the civil war, spoke similarly from a religious and even historical perspective: And that even goes back to General Stonewall Jackson, Thomas J. Jackson, Confederate Army, his faith was so intertwined that he felt just as safe in battle that he did in bed. And that’s exactly the way I felt, and the way that I believe all people should feel when they get to combat. For the other combat veterans who adhere to a faith-centered intrinsic Christian belief system, mortality is a resolved issue. Simply put, they believe they will go to heaven when they die. Though other possible methods of resolving personal mortality surely exist, they were not present in this sample of resilient combat veterans. How do resilient combat veterans cope through meaning? (RQ2) Resilient combat veterans coped with their experiences well. This is, after all, the defining feature of resilience. Several related themes emerged concerning how these combat veterans achieved a resilient outcome. The first three coping themes were utilized primarily, but not exclusively during the traumatic experience of combat deployments. The next four themes that emerged were related to post-combat coping. The final theme was significant by its absence. To understand these themes more fully, a rich description of the trauma symptomology of resilient combat veterans will serve as a backdrop. Lower post-trauma symptomology. While it appears that all, or nearly all, combat veterans bring home with them some level of symptomology, the narratives of 121 resilient combat veterans offers a perspective that is often missing in research. What does it look like when things go well? One example of the difference between resilient post-trauma symptomology and that of others relates to sudden loud noises; common occurrences in a combat zone. Anyone who has heard a very loud noise understands that this creates a startle response in nearly everyone. Combine that with the 4th of July celebrations held each year around the country, and you can have a good time. But when our military men and women go off to combat, they gain a new appreciation for how loud noises also invoke very serious fight or flight responses. Since they are warriors, the fight response is most natural, and for combat it is typically the correct response. In order to help each of them survive, they must learn certain reactions deeply within their physiology so that they happen reflexively. Cognitive psychology refers to this as an automatic response. A few seconds of hesitation can mean the difference between life and death. With increased exposure this is only strengthened. Upon returning home, the fight response, which has been repeatedly reinforced over the course of several months, does not automatically go away on its own. Matthew talked about this: Yeah. (a bit of a laugh) and then the first Fourth of July I was back I didn't care for fireworks, now I can deal with the fireworks. As long as I can anticipate, okay now they're shooting a firework and I'll watch it and I can anticipate the explosion of the firework. This new combat normal is at least adaptive in the combat environment and since combat can erupt at any given moment, its level of maladaptivity at home is more a function of the secondary difficulties caused by it such as embarrassment. Joseph provides a great example of this post-combat startle response that is characteristic of 122 resilient combat veterans and not particularly troubling by itself. He gave this account calmly, almost comically, and without great concern: I remember coming back, somebody dropped something at Wal-Mart or something, and it sounded to me like a gunshot. And I’m in the middle of the store with my father. I went down to a knee. And he thought that was the craziest thing on the planet, why did I go down to a knee? Others reported some sleep difficulties and bad dreams with ties to their combat experience, but those reported in the interviews were mostly of the bad-dream variety that did not come close to night-terrors (a PTSD diagnostic indicator) reported by highly traumatized combat veterans. John did report a night terror, but it was not recurring and rather than causing him prolonged distress he went to the VA the very next day: It was right at the one year anniversary, when [a close friend of mine] was killed. I had a bad dream. I woke up screaming in the middle of the night. And my girlfriend I was living with woke up about a minute before, knowing something was wrong. When she heard me screaming, she came in my room to find out what was going on. I had a dream where I was back in Iraq. I was back at the same place and time [of the attack], but right after [he] was killed. Right after the battle...and I was sorting through the bodies, and all of the bodies except for one didn’t have a face… I didn’t know who they were, and when I came across [my friend], that’s when I was screaming and when I woke up. Others reported recurring bad dreams. Matthew reported a recurring dream where he would continually be searching for “his” weapon: I have this recurring dream. It doesn't happen every night, three or four times a month, but I don't know if it's just weird or what? But it's, I'm always in a situation where I need a weapon and I never have a weapon to return fire. And even if I do have a weapon I almost have to acquire one somehow, either off a dead combatant, an enemy combatant in my dream, or off of a dead fellow soldier in my dream. And I’m always pissed off in my dream because it's never my weapon. It's never my weapon I’m used to. I don't know, it's one of those recurring dreams where I wake up and it's always some kind of situation I'm in where I need the weapon. Then he talked about how it was in combat; how having your own weapon gives you a sense of comfort: 123 I mean it always feels weird if you don't have your weapon. Because I had my weapon set up the way I like it... The pistol grip. You're used to your weapon, I guess it gives you… Like I said, a sense of comfort to have your particular weapon. It's like your shoes. You don't want to be running around in someone else's shoes, they're not as comfortable as your shoes. He recalled this recurring dream with simple curiosity rather than worry. He asked me if I knew what it meant. He was intrigued. Further, when I pressed him for what he thought made his time after returning home difficult, he fumbled for an answer for a few minutes and was only able to come up with the recurring dream above. He talked about how being alone and laying still at night before falling asleep allowed his mind to wander into what-ifs from his combat experiences, but that he was always able to linger on these topics for a bit and then push them out of his mind. Jeremy recalled a time when he was riding in a vehicle in his home town when he saw some trash alongside of the road and thought, on a deep physiological level, that it might be an IED: [I had] been back maybe four months. I'm in a carpool and there's three or four of us and we had to take this one Avenue rather than the highway. I know exactly where I am. I know exactly who I'm with. I know exactly what time of day it is. I know what's going on. But there is a bag of trash alongside of the road. I know exactly what's going on. I’m perfectly safe. I could not help myself. I actually curled up in the fetal position and started shaking because my mind was still…part of my mind and my body was still saying that could be an IED. Curious about incongruent contexts, I asked him if that would have happened when he was in Iraq: It wouldn't have happened over there because as a team everybody would've reacted, and we had plans, we would have someone go in. It's just one of those things where the fear… When he trailed off, I began to think, and have continued to think about how often combat veterans have experienced triggers which partially remind them of their combat experiences, but are exacerbated by the incongruence of the rest of the civilian context, 124 not simply the reminder of combat. In this case it was a possible IED which would not have been a problem in Iraq, but since no one was reacting to it, a visceral fear came over him that no one else had seen it and it was about to be too late. Again, this would be a normal response for combat if the driver had indeed failed to heed the signs. Again this differs from symptom-laden experiences reported by the highly traumatized group. The troubles caused by this reaction were momentary rather than debilitating, and gave no indication that it was a recurring problem. Upon returning home, Ron talked about how he had lost patience with people for a time, but this too was eventually handled and got better over time. The combat experience really impacted my patience. I didn't have any patience in dealing with like the little bull shit of life. And people that were very bureaucratic and they are just like getting into the weeds about stupid things kind of pissed me off. I would just kind of clench my jaw, take a deep breath, and walk away. However, now as I've, as I've had years to kind of, five years now I’ve kind of learned from it. Definitely kind of strengthened me and I've been able to know that there's not very much that's gonna get much worse than what I've dealt with there so I can kind of if… If I'm getting frustrated with people, I just take a deep breath now, and at least I'm not getting shot at. It's a lot easier. The combat experience gives you a huge amount of just… outlook. According to these narratives, certain beliefs are related to effective assimilation of traumatic events, which engenders a decreased need for meaning related coping, and appears to lead to symptomology that is less intrusive. Their combat coping strategies and post-combat appraisal strategies are discussed below. Meaning-Making Coping during Deployment. Challenge Appraisal. Challenge Appraisal occurs when a stressor is considered in light of the potential to overcome or even profit from that event (Kibler & Lyons, 2004). Resilient combat veterans secure their sense of personal meaning through making decisions congruent with their beliefs and in the moment, not by judging how 125 well those decisions turned out or worrying about them afterward or by ruminating too long beforehand. This decision-based meaning (challenge appraisal) differs considerably from that of outcome-based meaning (threat appraisal), discussed later, which emphasizes broad generalizations and hyper-thinking about possibilities, what-ifs, and what could have been. Some of this has already been showcased in previous statements by these resilient combat veterans. Continuing the theme, Joseph talked about his process: And I had that focus, well I'm gonna do this. I kind of do things step-by-step by step. I'm gonna do this, complete this. And then do this. Complete this, do this. Complete this, do this. When sometimes that stuff doesn't go as planned. Of course I modify my plans as I see fit, so… So I'm like okay, and I kind of look for the best course of action at any given point. Matthew more or less said the same thing, but he further contextualized his experience against those who did the opposite and worried themselves about possibilities, trying to control the outcomes of situations: Well, what I did is I figured… Because I had seen some people go crazy about, “Well, what if this happens? What if this happens? What if this happens? What do I do if this happens?” And I'm like well, I put that… I know what to do through training but I can't worry about what if's, what-ifs, what-ifs. I have to deal with “When this happens I will do this.” And that's kind of how I guided myself through my deployments. Worry about it when it happens; don't worry about it before, or kind of even after. Deal with things as they come and do them to the best of my ability. When I asked Jeremy how he felt he dealt with his combat experiences he said “Very well.” I asked him what makes him say that he dealt with them very well. He said “I recognized before I even left the theater that I had, maybe not PTSD, but stress from the deployment, and I already naturally had ways to deal with that stress.” So, I asked him what some of those ways were. He said: First, you have to let go. You have to let go, like if somebody… For example, we 126 were sitting there in Kuwait on the way back. I was walking back up to the barracks, and a sergeant comes up to me and he's got a very troubled look on his face. He goes, “Hey did you hear about that [cargo plane] that got shot down out of Baghdad?” I was like, “No.” with some surprise. And he goes, “Yeah, you realize that could’ve been us?” I’m like, “No. It could not have been us. It’s impossible for it to be us. He says, “Why? What do you mean?” I said, “We’re here dude. We made it. What happened back there in Baghdad is back there in Baghdad. We’re safe. There’s no reason to worry about it.” This type of decision-making very much appears to facilitate assimilation while minimizing emotional processing. When talking about how this mindset applied to his combat situations, Jeremy paused a second and then said, “Embrace the suck.” Knowing that complaining about things one cannot control brings morale down, he talked about the importance of accepting those things that cannot be changed in order to focus on problem solving and moving forward with the task at hand. Over a decade ago, I began working as a counselor and then a therapist helping teens and adults heal from addiction. The Serenity Prayer, as it is called, was ever present. It also embodies how resilient combat veterans cope with combat trauma as well. I have included the first four lines which are memorized by thousands of recovering addicts each year: God grant me the serenity to accept the things I cannot change courage to change the things I can; and the wisdom to know the difference. This idea of accepting what cannot be changed, actively changing what can be changed, knowing the difference, and consciously asking a higher power to grant this 127 frame of mind is powerful. Combat normal: Professional, calm. Every veteran handles the intensity of combat differently, but patterns of affect and behavior emerged from the data that differ based on the outcome they report. When a combatant’s belief system tells them that their actions in combat have a higher purpose they are able to compose a sense of focus amid the adrenaline rush of combat, a sort of combat normal that actively manages the fight response. This is not to say that there were not times of ultra-intense fear, anger, elation, or other emotions, but that these were moderated more effectively by resilient combat veterans than by others. This professional calm is in contrast to a recurring heightened emotional state of excitement and/or anger reported by others who fare more poorly. This harnessing of emotion and affect seems to allow them to do their job more effectively. Ron recounts two stories. Although he was not in combat during the first, he did not know it at the time. His story of a failed landing which led some to believe they were being fired upon illustrates the difference in response between threat appraisal and challenge appraisal: I was on a [very large cargo plane] and we're coming in and just as were making our approach, we went full throttle and took off again! And some of the guys are getting really scared, “Oh, we're under fire! We're under fire!” And I'm just like, “It could be any number of things; any number of things.” There's nothing I can do. I'm not gonna worry about it. What am I gonna do sit here in panic? No. We land, come to find out an Army scout helicopter flew across the runway and we got waved off. This illustration of remaining calm and self-aware during stress demonstrates the difference in thinking again, and shows how this sort of decision-making leads to a smaller pile of piled-up stressors. He could not assess a challenge (recall challenge appraisal above) that he could respond to effectively, so he remained calm until such a 128 time as would be appropriate for action. As a leader Ron talked about how this helped him in combat. He initially took things so seriously that he said he was “wound pretty tight”, but when an experienced combat veteran with several tours behind him told him he needed to stay calm he followed that advice: As a leader when I was overseas I realized that I couldn't be like that at all. And I realized that I need to be just able to stay as calm as I was before the major event happened, and just maintain a calm through it so the people around you aren't getting all crazy and… As a leader I found that your soldiers feed off of you. If you're running around like a chicken with your head cut off then it's going to be total mayhem and they're not gonna look to you [as a leader], so I definitely learned that you have to be calm, kind of the guiding light. All kinds of stuff just swirling around, just deal with it. Step outside of your body and look at the situation objectively. Being able to make decisions under pressure (in a combat situation) is paramount to resilience and is only possible because of this Professional Calm that I call Combat Normal. Matthew talked about learning this about himself: I’ve learned that I can make decisions… some people can’t make decisions under pressure. They just have to ask other people, “What do I do? What do I do?” And I make a decision, I’m like “Well, if we’re getting fired at, I can guide the guys under pressure based on experience and training. Hey fire back at that guy.” I can direct a SAW: “Hey, you SAW talk to this other SAW” A SAW, or M-249 Squad Automatic Weapon, can fire at a speed of up to 1000 rounds per minute (though actual firing rates are less) which will easily and quickly melt the barrel of the weapon and cause the warrior to run out of ammunition quickly. Talking SAWs is where one fires a burst and then the other and back and forth so they don’t burn up barrels and they can maintain a sustained rate of fire on the enemy position. Imagine handling your own safety and the safety of those around you, watching the enemy, staying aware of maneuvering enemies, monitoring who is running out of ammunition, watching for breakdowns, injuries, or death and what that means to the 129 group’s vulnerabilities and also the potential to save that warrior’s life, and then making sure that the SAW gunners are being efficient all while managing an adrenaline surge of your own. That is more properly what he meant: Yeah, I do my job and of course you get the adrenaline when you're in the firefight. I've heard some people [say] like, “Yeah!!!” And me, I don't do that. I'm very conscious of where I'm aiming, who I'm aiming at. And what I'm doing at that time. I don't let [the adrenaline take control], and there is the adrenaline there but it's not the adrenaline of like I guess you could say Ted Nugent on the hunt killing a boar. It's not that type of thing to me. It's doing my job and doing it effectively, if that makes any sense. Consistently, the resilient combat veterans in this study talked about how their beliefs made it possible for them to remain calm, seeing events as challenges to be overcome. For them, this freed their thinking up so that they could focus on clear decision-making, a critical precursor of resilient outcomes. This is in contrast to the Threat Appraisal theme found in the highly traumatized narratives where deep visceral emotions inhibit critical thinking. Effective assimilation. Resilient combat veterans, in comparison to others, have successfully coped with their wartime experiences through effective assimilation of these experiences into their existing belief systems. Due to the adequacy of their preexisting belief systems and globally held meanings related to wartime events, much of the meaning-making coping process appears to have happened in real-time. Though events may have been life-threatening, those same events have failed to generate existential trauma or a shattering of world assumptions. The psychological work that remained after returning home could be described as cataloguing and reassessment ending with continued reassurances of existing beliefs. Matthew, who said he had dealt with his experiences well, said that his brother, who had a tougher time of his own 130 combat experiences, asked him how he dealt with them. Matthew said: Like, even my brother, he's like, “How do you deal with it?” I’m like, “I don't know really.” It's just… I kind of worry about what's in front of me and deal with things as they come at me. Though it seems oversimplified, I believe this process of meaning-making when meanings one already holds adequately explain life’s experiences (Assimilation), could be the key to understanding what makes combat veterans resilient. This was consistent for all resilient combat veterans and extended to their existential beliefs. Matthew said, “Spiritually I don't think combat has changed the way I look at God or Jesus or the Bible or anything.” Recall that even after combat John said, “I felt this way really all my life. I have been very very very pro-military.” And Ron agreed that his beliefs about the war he fought in “pretty much stayed the same.” John reported that his combat experiences put small things into perspective right away: All the little things that used to bug me before, even when I was in the Army or even before I deployed, I kind of… Not that I don't care about them, but they're not such a huge deal. I don't worry about them. After combat, small things are no longer stressful for them, yet dealing with people who think small things are stressful tends to be very stressful to them. Of course, during their combat deployment, they had consistently been dealing with life quite seriously so this should not be surprising. Additionally, Joseph reported that important things like family and personal responsibility had taken on even greater meaning. Meaning-making coping after deployment. Deliberate rumination. After returning home, even resilient combat veterans require time to unwind and decompress. This group of veterans reported active selfmanagement of symptoms when possible, and reaching out to others when needed. 131 They did not shy away from the meaning of these experiences, understanding them to be part of the return-to-normal process even if that normal is a new normal. When frustrated with people Ron talked about clenching his jaw, taking a deep breath and walking away, knowing that in spite of his frustration causing problems when he became frustrated with someone was not helpful. Jeremy mentioned one physiological symptomatic event that subsided on its own and another where he made a phone call to another combat veteran friend to talk through a stressful situation until he was calm. A subset of active symptom management, deliberate rumination emerged as a hallmark of post-trauma resiliency. This could be difficult to detect as this came across in statements like “I think about it now and then…” followed by a belief that did not change or a positive congruent belief that the memory had triggered. Or, “If it bothers me I…”, followed by a positive activity like golfing, or talking to a friend. John talked about going to therapy, but he also mentioned prayer and self-reflection. This deliberate rumination about his experiences was helpful to him. Rather than through specific quotes, this section emerged through tuning into the essence of the resilient interviews. Forgiveness and understanding. One component to successful deliberate rumination is forgiveness. These resilient combat veterans demonstrated a high level of forgiveness and a forgiveness mindset when dealing with themselves and others. Their world assumptions account for this. Matthew said it this way, which was both psychospiritually protective and also prescriptive for his interactions with others, “Yeah, I would like to think God can look inside everybody and like… And feel your intent in the type of person you are on the inside.” Forgiveness is difficult to process for many people and even more difficult for 132 many combat veterans who have seen some of the worst that humanity is capable of dishing out. This only increases the importance of not violating one’s own world assumptions. Matthew talked of a time when he had to decide if a boy was a threat or not. The boy was aiming a weapon at him and his men. It turned out that the weapon was a toy, but that wasn’t so obvious in the moment. He was thankful that he made the decision not to shoot him, but troubled enough over the close call to remember it vividly. When I asked Matthew if he thought he could be forgiven if he had taken the boy’s life after assessing his actions as a threat and not realizing it was a toy, he said: I mean, I’m Baptist, so I believe that if you believe in Jesus and you accept him in your heart all sins are forgiven, but could I ever personally forgive myself? There would be that small part of me that would always feel it. I couldn’t forgive myself fully. I would always have that guilt. He indicates here that his focus is on not violating his own world assumptions. It is protective particularly because even though he believes he would be forgiven, he would always carry that guilt personally. This sense of forgiveness and understanding seems to allow them to be more empathic than their highly traumatized counterparts. They judge less deeply, and let go more easily. They did not take others’ inability to understand their wartime experiences personally; they chose to respond differently. John talked about appropriate ways to redirect conversations with friends and family away from topics that these combat veterans did not want to discuss at the time without being upset with them for being curious. Another way I was able to see John’s sense of forgiveness was more by the absence of judgmentalism. In his narrative he spoke of losing a buddy due to the actions of a specific insurgent they knew by name. When they finally captured that person he said they were happy. He wasn’t derogatory about it and he moved right on 133 with the discussion topics without expressing any currently held hostility. Joseph talked about how his Catholic faith prepared him to look at others as equals, but that it was a psychology class where he learned how people are conditioned to either be forgiving or judgmental: I guess that's just a value I had before I had an education… I had the belief of just being understanding of people in caring and loving people, but after I went through psychology when I did a lot of intense study about classical conditioning… I come to the realization that we had no reason for looking down or thinking that were better than other people because we're all a product of our environment. And so after I went through that then I guess I could articulate it better, but why did I have that ability before I went to college? I guess I can only guess at it, that it was my Catholic faith. To contrast with the judgmentalism he saw on the part of some struggling combat veterans, he observed: And they almost expect everybody to just, you know, show some sort of sympathy and give them their chance to talk. They expect that everybody puts them up on a pedestal. I've seen that with some of the guys that are struggling. When they do talk about it, and it's hard for them to talk about it sometimes, but when they do they almost expect that everyone around them feels the exact same way they do and they can't seem to bridge the gap on why. That's an observation that I have. Perhaps forgiveness is even more evident by the absence of judgment and resentment in their narratives. These combat veterans lost friends, some gruesomely, and in spite of the losses and the grief that was expressed, they did not indicate harboring of any currently intense negativity against those that were once their enemies in arms. Little to no therapy needed. Only one of the five resilient combat veterans reported seeking any kind of therapy. John, the one who did seek therapy, mentioned how he went about this: When I do have a flashback and when I do have some reliving moments… I don’t 134 know what else you want to call em… Yeah, that’s mainly where I go and I try to talk to somebody about it. I can still call up my counselor… So a lot of the ways that I dealt with [my combat experience], I processed it, was through counseling. Through counseling not only through the VA, but my church, my pastor, my church, my family. Just helping out there. For the most part, however, resilient combat veterans did not report needing help beyond opening up to a small group of those who could relate to their experiences. When beliefs match experience, what meaning-making is there left to make? Overall, the beliefs of the resilient combat veterans interviewed remained stable, with increased absolution (absence or lessening of guilt) and emotional strength that is evident throughout their narratives. Though the experience of combat instilled in them deep learning which included automatic responses to sudden movements and loud noises that is common to survivors of combat trauma, they experienced far less intrusive rumination than the highly traumatized combat veterans did. What is most striking about their responses when asked how they coped with their experiences overall was the lack of need for coping strategies that other veterans report. Ron summed it up well, and his experience was very similar to the others: Umm, I kinda just let my body kinda, my body and mind kinda think through things. I gave myself time. I was kind of fortunate in that growing up, my parents were… my father was in the military. And then my mom was very very spiritual and religious. So I had a pretty good framework that even if something did happen (pause) over there, that I… me get hurt, or one of my soldiers got hurt or something like that. I didn’t let it become all-encompassing or consuming. Um, I was able to kind of compartmentalize, I think, and move on. And I think that was due to my upbringing, knowing that there is a higher good and a higher purpose and even if I would have died I feel like it would be for a good cause so I think that's kind of what I used to get through things like that. In effect, he was reporting that he had to adjust to civilian life, but that the framework of his family system (experiences, relationships, and beliefs) prepared him for the realities of combat deployment on all levels, in effect making it less traumatic. 135 During combat, his belief system gave him a sense that he would either be kept safe or that his death would become a sacrifice for a cause greater than himself, a sort of existential win-win. After returning home, he did not suffer from the effects of meaning discrepancy. This mirrors the views held by the other resilient combat veterans in the study and is in contrast with the sense of incongruence about the world discussed in the highly traumatized combat veteran section. Lack of negative coping evident in their narratives. Finally, in contrast to other combat veterans, resilient combat veterans in this study did not report utilizing negative coping strategies such as chemical dependency, adrenaline addiction, suicidal ideation, or other avoidance coping strategies of any kind. When I asked John how he had coped with his deployment experiences he replied, “Basically, through prayer. Through self-reflection.” Ron said “Umm, I kinda just let my body kinda, my body and mind kinda think through things. I gave myself time.” Not hearing any negative coping styles emerge I probed the remaining resilient veterans more specifically by asking what they did to cope and adding “both good and bad” to elicit those responses. The last three combat veterans still did not indicate any negative or avoidance coping strategies. Jeremy said “I took off four and a half weeks for a road trip around the U.S. Just me and my dog.” Matthew jumped into college after both tours. He said that focusing on the task at hand helped him readjust to civilian life and when confronted with events which triggered he would politely separate himself, regroup, and return. Joseph said that his belief in American exceptionalism gave him a sense of meaning through the first deployment and afterward. Sometime during the second deployment he replaced his belief in American exceptionalism for a greater appreciation 136 for the Iraqi people he was working with, and people in general, which helped him see how similar people all around the world were. I could not elicit negative coping styles from this group, but not for lack of effort. As each one stated directly when asked, resilient combat veterans coped well overall. They report intact world assumptions, and an ability to cope with their symptomology that has only strengthened their resilience and adherence to their original beliefs. How do resilient combat veterans interact with others? (RQ3) Decreased tolerance for immaturity. Overall, resilient combat veterans tend to interact with others similarly to the way they did before they deployed with a few important differences. First, they have a decreased tolerance for the normal frustrations of daily life. Ron’s account is representative of the others: The combat experience really impacted my patience. I didn't have any patience in dealing with like the little bull shit of life. And people that are very bureaucratic and they are just like getting into the weeds about stupid things kind of pissed me off. I would just kind of clench my jaw, take a deep breath, and walk away. Matthew talked about his interactions with other students in college upon returning home from his second Iraq deployment. He was fairly frustrated with their immaturity: I jumped into school a couple days later after I came back, which was kind of hard doing that. Because I was older going into school and I had to deal with all these kids that were like, ‘I don't like the chow in the chow hall. I don't like my dorm room. I don't like this. I miss home.’ (building comedic affect) I just kinda wanted to go like this (choking motion with hands). Note the frustration, but also the ability to laugh it off at the same time. By the words this does not come across like a positive coping skill, but the affect in his voice was jovial, and he was smiling and laughing. Taking a deep breath and walking away are common positive anger management strategies. These resilient combat veterans tended to utilize 137 healthy coping skills , which lessened the negative effect their experiences could have had on their lives. Keeping it private. The experiences of combat deployments held a solemn quality not to be taken lightly. Each was not typically open to talking about their experiences with others out of respect for those events. This differs again from the highly traumatized group by the lack of judgmentalism present. Allowing family members to speak out of ignorance, which could not be helped, would not have been helpful so they chose to avoid speaking about them. Like others, John talked about how he tended to keep his combat experiences private: Like I said, me and my friends didn't sit down by the coffee table or around the fire like oh, let's hear about John’s war stories today. Because I would be like well I'm not into that, guys, so that's what I would do. I keep a closer knit group of friends. Friends that I would like to think that I can count on if an emergency happens and they can count on me. And that's kind of how I would like to think about my friends. Not that I got rid of some or anything but it's just like we’re closer. Joseph gave enough detail to speak for any combat veteran when he explained a situation that exemplified the thoughts that go through his mind before he opens up to those that he believed could not handle the truthful answer to their question: If I would have told them the story about all of the burning bodies and the nasty smell of hair that got wheeled into the police station one day and I was trying to put pressure bandages on while these women are screaming outside and mortars are coming in... I don't think they could have [understood], because they wouldn't have anything similar, experience... Yeah, to understand. Here, Joseph was indicating that in order for him to share such a gruesome scene with others, they would have to have experienced something which would allow them to truly understand it or he would not feel he could share it appropriately with them. Having a similar experience, while not automatic, may open the door to shared meaning. While 138 even the resilient combat veterans could not share all, it underscores the importance of a shared context when compared with the highly traumatized combat veterans who indicated that they could no longer relate to many of their family members and former friends who still held idealistic global belief systems. Since most people do not have experiences similar to combat, and they do not see a value in sharing particular details just to satiate someone’s curiosity, these combat veterans choose to keep these details private. Post-combat family interaction. Families of origin: Shared meaning. Overall, resilient combat veterans reported greater appreciation for their family members and relationships tended to grow closer. All but Jeremy had a sense of shared meaning with their families of origin. They tended to take life, liberty, friendships, and family relationships more seriously. When I asked John about his interactions with family after deployment, he said: My dad was in the Air Force during the Vietnam War. He never went over, but he was in the service. He knows what was going on. So me and him, (snaps fingers) automatically clicked, and even between me and him, we’ve grown stronger together. His narrative was full of scripture and verse as he was the only participant to bring a bible to the interview. It was difficult to find a quote that captured the essence of his family’s religiosity, but it was evident in the over-abundance of spirituality, religiosity, and family cohesion he displayed and reported. Ron talked about his positive interactions with his family of origin and the importance of shared values. His family showed good communication and understanding: I think that my family has been extremely helpful and encouraging and I go to my 139 mom my dad and my brother, any of them if I need to in order to talk to somebody or get something off my chest or what not… We kind of value the same things due to the fact that we’ve been together. Ron also talked about the religious and pro-military roots within his family: My dad was in the military, he kind of moved around while I was in school. I lived with my grandparents and we stayed in my home state while my dad traveled around and came back every once in a while... My grandma was very very religious. She's a very… I grew up in a Lutheran household. And my mother in turn was very religious as well and my grandfather, he was also a World War II veteran in the Navy. Jeremy talked about the support he had from his father. Though he was not raised particularly religiously, the beliefs from his family of origin were compatible with his spiritual awakening at age 12, and his participation on Christian youth activities was encouraged: My dad never served in the military because of back problems, but he did go to a military Institute during high school and he's always been a very strong supporter of the military. My only other sibling is active also. Joseph’s family was pro-military. He talked about how his father would always try to get him to wear his uniform to church: They were always supportive and very proud of me, especially my father. He would always try to get me to wear my uniform to church or to a wedding, or to anything because he was so proud of me, so that helped in some sense. Joseph felt the importance of even his extended family relationships. His combat deployments led him to become closer to family afterward because he missed them so much. An important emerging component to this was having a shared global belief system with his family. Since they were able to relate to him both before and after his combat experiences, he focused on reconnecting with them upon returning: I felt, you know. From being away from them for so long that I treasured better their company a lot more so it improved my relations in some ways. I would be missing, you know, all of the times I spent with my uncles, and my cousins and I 140 would spend... In order to compensate for it I would spend an overly normal amount of time with them to get caught back up and then I built new types of relationships with them as a result. Although most frequent, relationship growth was not always an outcome of resilience. Matthew believed that since he and his brother had both been to combat in Iraq they would grow closer, but they dealt with their experienced differently, and it seemed that his brother came back considerably more traumatized. As a result they had increased difficulties between them. Regarding the rest of his family he felt his relationships with them were about the same: “I would like to say like with my dad and my mom and my sisters that it hasn't really brought us closer or further apart. It's about the same.” Also, for Matthew, returning to normal was important: I would say that's been helpful. I mean, when… Especially for me, when I come back I don't want people to go like oh you are in Iraq tell me about it. That's not what I want to do. I don't want you to be talking to me because of that alone and then my family has been kind of the same way. It just kinda was easy with my family and my mom and my dad. My dad especially, he knows I've been in Iraq but he doesn't ask me questions about it. He just… It's kind of like, well here's kind of your role in the family. Step back into it and will go on like life is normal. Which to me, I enjoy that. I don't have to worry about them looking at me differently and stuff like that. The families of these resilient combat veterans were supportive of their veterans’ service. Among the resilient combat veterans, those who were most resilient had families that were also religious and pro-military. Intimate relationships: Less supportive. Upon returning, resilient combat veterans interacted with their intimate partners differently than they did with their family of origin relationships. These relationships suffered from a shorter history and often fewer shared meanings, leading even resilient combat veterans to open up less with them. None of the resilient combat veterans were 141 married at the time of their first deployment. Matthew was still single at the time of the interview. Jeremy, Ron, and Joseph were both married at the time of the interview. Jeremy was careful about what he would share. He said he shared what he thought his wife could understand and deal with, but that he had to manage it, “I don't always talk to my wife about certain things, but I talk comfortably about what I can with her. She's not going to understand everything, and I understand that.” Ron’s response put it into perspective: Now I will say that both the girl I was with during the time that I was deployed and then my wife now, a different woman, I think that it's… I wouldn't communicate with either of them in the same way I would with my brother or my mom or my dad about things. In clarifying his response, I asked him if I understood him correctly that his wife now and the girlfriend during deployment were not necessarily negative influences, but that they were not really a resource, he said “Right. Exactly.” The military life is not for every spouse. It is tough and sacrificial. Joseph had also married since his first deployment, and he did not mention his wife in any meaningful way during the interview. He did not indicate that she was either supportive or hindering in any way related to his combat experiences, instead choosing to focus on his family of origin. John, was in the process of divorce. He talked about his wife leaving him. He noted that she could not deal with the culture of what he called the military normal and then he contrasted the terrible experience of divorce with his combat deployments this way: "I’d gladly trade this divorce for another tour in Baghdad or another tour in Afghanistan… in a heartbeat. In a nanosecond I’d do it. Because I know I’ve done it before. I know I can do it, and now I know I will do it again if I have to. And that has brought great pride to myself." 142 His response supports the notion of congruence of meaning in that John adjusted well to the experience of combat, which he could understand in a congruent and meaningful way, but his divorce was more traumatic by comparison. This theme could have been weakened somewhat, however, by the small number of relevant narratives. While John talked about the divorce he was going through at the time of the interview he noted that his soon-to-be ex-wife did not adjust to the military lifestyle well at all. He reported that he was able to work through it and focus on being a dad to his children. Overall, the strength and support of their families of origin did not carry over into their intimate relationships. It appears that these relationships required more of a balanced approach so that the wives of these combat veterans did not feel overwhelmed. More direct attention to intimate relationships in contrast to families of origin would have been ideal, but the natural emergence of families of origin as source of support and shared meaning in their narratives may be of greater importance. Fewer, but stronger friendships. Ron talked about the positive long-term effect combat had on his family and close relationships. He, like other resilient combat veterans tended to report small close networks of friends. For Ron, friends and family were nearly synonymous: … It has enhanced [my relationships] I'm not a person that has a lot of close friends. I'm more of a family person. That's kind of who I hang out with when I'm not at work, I'm not Mr. social butterfly that has a huge friend network. I think I have been able to build connections a lot better and a lot more closer ties with the people I am close with. John reported that he always had a close-knit group of friends which grew closer and that after his combat deployments his friendships sorted themselves out: And friends are just friends. Very few selective friends have been the same way… not exactly the same way, but they have been where they’re paralleling 143 (used hand gesture with palms inward and fingertips up to indicate a congruence or acceptance by those friends). And most of my friends have been, “Okay, whatever. This is still John”. A pattern of small close friendship networks was common. These friendships tended to be deep rather than transient, ones who tended to share the values they held when they left which were only strengthened for the resilient combat veteran by the deployment. Though highly traumatized combat veterans often report an active culling of their social networks, resilient combat veterans tend to be themselves and let relationships occur naturally. Here is John’s account: And then some of my friends, like I said, have dropped off the radar, because they’re trying to live perpendicularly (he used his hands to create a loose cross figure), and they don’t get it. And we just end up falling out. Jeremy had similar experiences with friends who just could not relate anymore. He took their lack of perspective into account, but some still found their way out of his social circle: I don't really have a problem as far as military service, and if people in my life have a problem with military service they usually find that they can't deal with me very well. I don't cut people out of my life, I work with them differently. John mentioned that he didn’t get rid of friends, but that the ones he had became closer or they decided on their own to stop hanging around. I pressed him on whether or not he cut people out of his social circle in order to clarify how this process unfolded. He said “It wasn’t like that.” This is in contrast to the deep judgment and mistrust of others found in deeply traumatized combat veterans. Veteran friendships: Brotherhood. When I asked Ron about his interactions with friends, he immediately talked about his interactions with veterans who were friends, particularly combat veterans. He 144 noted that this was about shared experiences: I have two friends that I knew I could go to with combat related questions. One of them, my buddy that I mentioned before and another one, both of which I worked with in the Army on active duty. He went on to explain that when he met a combat veteran who was also in the infantry, there was an instant bond. They clicked. He snapped his fingers both times he mentioned this sort of connection. Jeremy felt the same way: You get me around a bunch of other veterans and it's kind of like, I don't have to communicate with them; I don't have to talk with them, because they understand. It's almost like a conversation you have without words. This connection as described by these resilient combat veterans was a positive one, and it carried with it none of the judgment of non-combat veterans that was often present with highly traumatized combat veterans. Jeremy also talked about the importance of staying connected to positive mental health: You have got to stay connected. My best friend: 100% PTSD from Bosnia. He holds things in. It wasn't until 10 years after his trip to Bosnia that he actually talked to me. And I'm pretty much the only one other than the VA counselor that he's ever talk to about it. He also discussed how he had to actively make connections with family members who used to be connected through his mother, who had passed away. He felt that staying connected, and being open to others was important to the healing process. Resilient combat veterans return home to build stronger bonds with family, particularly relationships in their family of origin, and friends and nearly indescribable bonds with other combat veterans. This appears to be aided by a shared global belief system which was also able to adequately explain their combat experiences. That intimate relationships did not emerge more prominently as either supportive or hindering is of note. 145 Summary. Their global worldviews and specific beliefs within them held up under their combat experiences. This afforded them the ability to cope more effectively, focusing on immediate tasks at hand without becoming emotionally and cognitively flooded in spite of the adrenaline rush of combat. With global worldviews that they still share with friends, family, and veteran friends after combat, these resilient combat veterans were able to draw even closer to others. Their experiences stand as an example to others. Figure 4.1 shows the progression over time, with Initial Global Beliefs and Shared meanings to the left of the dotted line, representing the beginning of the combat trauma experience. Note that each successive theme reinforces the theme before. In the figure, global beliefs, which were found to be adequate and comprehensive, reinforced the initial global beliefs and shared meanings. These global beliefs were found to be adequate when appraised meanings were congruent with their combat experience. Because their experiences were congruent with expectations they were better able to make challenge appraisals which allowed them to focus on making decisions which were congruent with these appraised meanings and global beliefs. This was also reinforcing for them. Upon returning home, they reported less traumatic outcomes than the other participants in the study leading to effective recovery with remaining symptoms lessening over time while close relationships grew even stronger. 146 Family of Origin Reinforced Initial Global Beliefs Shared Meanings Reinforced Adequate Global Beliefs Reinforced Congruent Appraised Meanings Figure 4.1 Grounded Theory of Resilient Meaning-Making Coping 147 Reinforced Combat Coping Challenge Appraisal Post-Combat Effective Recovery Deeply Traumatized Trajectory The highly traumatized trajectory is characterized by a relatively negative and symptomatic outcome. The existence of high levels of PTSD symptomology indicate more than a natural response to the rigors of combat. The world assumptions, or global beliefs were shattered by the experience and as a result have come to experience continued struggles long after their combat experiences. The highly traumatized group consisted of five male combat veterans reporting the highest PTSD scores which match their narratives in the interviews. All PCL-M scores were in the clinical range (50+) with the exception of one with a score of 46. Three of them reported experiences at the time of the initial phone screening that they were highly traumatized. Two of them reported that they would consider themselves to have undergone some post-traumatic growth. All but the participant with the PCL-M score of 46 scored higher on that scale than all other participants in the study. See Table 3.2 in the previous chapter for a comparison. Several themes emerged related to highly traumatized outcomes. These themes provide the foundation for the conclusions, comparison to other outcomes, and discussion in Chapter 5. Difficult Experiences The five highly traumatized combat veterans reported a range of experiences. Like other combat veterans, they endured significant hardships. I chose not to correct Kevin’s grammar in his responses over concern I might compromise any aspect of meaning. Kevin described a very active combat experience in Iraq: Personally my truck has been hit with an IED on four separate occasions. Usually after you get hit by the IED they like to return AK (AK-47) fire at us but we be in the up armored Humvee so it ain’t really… An IED is worse than gunfire, but umm, we end up givin’ back that gunfire. It usually lasts until they quit shooting, 148 because we don't quit shooting first. That's about it. Wayne talked about the prolonged intensity of his experiences as well: It was right after the big pushes in Ramadi and Fallujah, and it kind of pushed all the bad guys to the area where we were at. I can't remember the day that went by that we didn't have IED's going off. At least one a day, but a lot more at times. (long pause) Uhh, we took contact regularly. I was shooting at least a magazine of bullets every time we went out of the wire. Joshua, talked about the firefights he had been in, but that the worst losses were from IED’s: Yeah, in Afghanistan there were definitely a lot of firefights. One of my platoon mates died who I was pretty close to in Iraq. In another, one of my friends, a guy from another platoon was killed. It was all just IED's that we never saw. No one ever really got hurt in the firefights. Got in a lot of firefights. The Taliban are fucking stupid. They think Allah guides their bullets, so you've got to be stupid to get hit (laughs). They don't know what they're doing. This group had no shortage of combat experiences through which their beliefs were tested and pushed, ultimately, to the point of breaking. What do deeply traumatized combat veterans believe? (RQ1) The PTSD trajectory is characterized by a shattering of world assumptions followed by a relatively stable and negative outcome with diagnosable levels of PTSD symptomology or complex PTSD. Initially idealized world assumptions. Although it was not initially evident, the world assumptions held by this sample of highly traumatized combat veterans before their combat experience were idealistic in comparison to the views expressed at the time of the interview. Kevin recalled growing up in a dangerous city, but he presented his mother’s spiritual worldview as pacifistic. His family interpreted the Bible as propagating the idea of a prohibition of all violence and killing, not the specific interpretation upheld by the resilient group. When he and his brother joined the military, 149 it went against his mother’s desires. Of this group, Steven did not appear to have specifically idealized world assumptions though his post-combat beliefs matched those of the others. A number of indicators of earlier trauma emerged within his narrative also, leading to the tentative conclusion that his world assumptions had been shattered prior to combat. Overall, the highly traumatized group indicated that they found that life was a darker place than they had initially thought. Joshua explained his sense of idealism well: I mean when I joined the military like I was kind of (pause) kind of romantic in a lot of ways. I was reading like SF books (Special Forces). And just was really impressed by like, you know the integrity and professionalism of the guys. I didn't want to go to college, I wanted to do something meaningful. And I thought that if I join the military I had this, you know, hey time of war so I'm serving my country during a time of need and an all-volunteer military. And then be like you know protecting the weak and the innocent from like the evil and tyrannical. And I thought that's what I would be doing. But I had no idea what that would mean on a daily basis… It's never the way anyone imagines. Shattering of world assumptions. Each of these highly traumatized combat veterans gave an account of how combat was nothing like what they had expected. Their narratives were full of indicators that they were not prepared. In many aspects, they indicated a belief that no one can understand the combat experience unless they had been there. When this is compared with the experiences of resilient combat veterans, however, an emerging understanding that this incomprehensibility is a result of a shattered global belief system rather than an objective assessment. Their idealized world assumptions could not hold up against the stresses of combat deployments. It was very common for them to talk about how experiencing combat forced them to see reality. Combat to them was more real than anything they had ever experienced. Most often, this played out in their lives negatively. Kevin 150 mentioned a general loss of meaning: Ever since I had come home from Iraq it feels like all I'm trying to do is make up for lost time, but… that's really what it is… I just feel like I'm trying to make up all that time, but I never will...cuz you ain’t never gonna get those years back. I mean, those are like supposed to be some of the best years of your life from what I’ve been hearing, but they ain’t nothing but the worst of mine.” When I asked him how his combat experiences relate to his beliefs about the world in general, his response was unequivocal, “I probably hate it more. I have a lot of hatred. (long pause) That’s why I want to be left alone. That’s why I just wanna be left alone.” When I asked him what he learned about people as a result of his combat deployment experiences, he replied, “I don’t like them as much as I thought I did. I don’t care about people no more.” Kevin reflected his mother’s spiritually inspired prohibition of violence as well. His connection post-combat spirituality contained a great deal of discrepancy, shame, and judgment by God: …He’s going to hold you accountable for every action you’ve ever done. That’s what I’ve always been told. You can ask for forgiveness, but He’s always going to remember what you did. I believe in God. You know what I’m saying, so… Like I’m saying, I don’t pray for no reason, I hope not anyway (laughing)...” Of the five highly traumatized combat veterans, Steven was the least traumatized by his combat deployment experiences. He reported having what he called an anger problem before he joined the military, and having joined in order to pull himself off of the bad road in life he was on. Highly traumatized combat veterans report most often that the things they experienced in combat did not match what they thought those experiences would be like. Kevin talked about how hard he tried to prepare: Man, I thought every day what it was going to be like, and I wasn’t nowhere 151 close. Honestly, I don’t know how I thought about it. I thought it over and over so many times in my head, I changed it every time I thought about it. Wondering what it would be like and when I got there it was completely different. Joshua considered his Christian upbringing to be idealistic and inadequate to explain his combat experiences or to help him through them. He cast them aside in favor of the reality he experienced. Contrasting this with the views of the resilient combat veterans, one has to wonder how his views were different from theirs. Here is a telling excerpt: How have these experiences affected me? Well, let's see... (pause) I don't really trust people, ever. Umm, jumpy. Tense. Anxious. I was unable to maintain a relationship with my one girlfriend. I'm angry. I hate... I hate ignorant people. [inaudible] I hate... (long pause) pretty much entirely walked away from my Christian upbringing. Throughout his narrative, he continued to be bothered by incidents, people, and experiences which he considered unjust. He carried with him a sense of injustice about the world. He felt betrayed by his command and many of his peers, let down by what he thought the military experience would be all about. In essence, even his Christian upbringing was idealistic. He said he used to believe people were basically good, but he no longer believes that. Wayne Feeling betrayed by the reason for the war he fought in Iraq, thinking that he was going to fight those who attack the United States after 9/11: Like prior to [my deployment], you know, the patriotic flag-waving. That was easy to say we need to go over there, they blew up The World Trade Center. Nobody questioned who they was, let’s just go shoot em all. And then find out that the people that we we’re shooting and fighting weren’t they that blew up the World Trade Center, and that we wouldn’t have been fighting them if we would never have been over there to begin with. Underscoring his discrepancy, Wayne talked about not learning anything new because of his combat experiences, “I don’t think I learned anything I didn’t know. I think I 152 learned more about what I didn’t know if that makes any sense. It clarified things for me. It reinforced things for me about my beliefs.” Reinforcing the lack of any new beliefs, he continued later with, “Well, [my combat experience has] made me question everything. It’s made me question religion, the political system, everything.” While not coming to any new conclusions, his combat experience has only provided him with more questions. In one sense he did not seem to indicate a shattering of world assumptions, but that was followed by existential questioning which at the time of the interview remained unanswered. It was as if he still held the very world assumptions which did not hold up, not changing them, and also not able to assimilate his experiences into them either. After wartime deployments, highly traumatized combat veterans did not have a uniform view of the world as reported by the resilient combat veterans. Kevin talked about his mother’s religiosity and distaste for violence of any kind, but that he was one of the best gunners with heavy weapons in his unit; he was often the lead gunner in convoys. Steven talked about going to church when he was younger, but that he did not consider himself a spiritual person even though the grandfather he barely knew had been a preacher. Wayne reported that spirituality and war do not go together at all. Joshua considered faith and war to have nothing to do with each other sharply contrasting his spirituality against those in the resilient group: I think me personally I don’t mix those views (spirituality and faith) and war. I didn’t really see it as a fit. I guess subconsciously I knew that from growing up like with the Bible. It speaks about war and how it’s not necessarily a bad thing so I never felt guilty about anything that happened… I never felt guilty about having to go. Once I got over there and my beliefs were really brought into question and kind of fragmented I don’t think it really hindered or hurt me. It’s really more like I put it off to the side because I know it’s not gonna help to get me out of here alive… 153 Addressing this paradox is vitally important. Whereas the casual listener may see a simple difference of opinion, there appear to be stark differences between this view and the resilient view. The resilient veterans in the study had a clear system of belief about the meaning of life and life after death. This was a system of belief outside of themselves. But among this highly traumatized group, Joshua indicated a spirituality where it was his decisions rather than faith that would bring him through, that reliance on a higher power was not something he could grasp when things began to unravel around him. Finally, he believed that his spiritual upbringing taught him that people were basically good, but when he got to combat this did not hold to be true so rather than adjust (accommodation / assimilation) he cast it aside for the reality of his experience. In spite of these differences, four themes did emerge after detailed analysis of world assumptions. These themes were intrapsychic world assumptions, judgment, and spirituality as pacifism, which was incongruent with their combat experiences. The final theme makes sense in light of the first three. For both the spiritually minded and the non-spiritually minded, they viewed anything of a spiritual nature to be pacifistic. Intrapsychically defined world assumptions. The first theme was mostly implied rather than directly addressed. Each of them talked about a view of the world that was very personally defined, as contrasted with the externally defined set of world assumptions espoused by the resilient combat veterans. It can be argued that each person has their own worldview. While it is true that everyone measures life events based on their own perception, which is also dynamic over time, the difference here is in the perceived origin. Steven discussed the contrast this way: I have a hard time believing that somebody else wrote this book, so I have a hard 154 time believing that there’s somebody out there that told [the writers of the Bible] to write it that nobody else can hear. So when it’s related to my combat? I had none. I survived because I did what I was supposed to do. (long pause) Since Wayne agreed that it made more sense to him that world assumptions and appraisal of his wartime experiences was an intrapsychic process: (long pause) Umm, I guess my understanding that I've come to understand is that I didn't need anything like [faith] to sustain me. I had to look at myself and either make it through or not make it through. Kevin carried immense existential struggle with him. On the one hand his mother had tried to instill a no-violence world assumption in him. On the other, he believed that his ability to take the lives of his enemies in combat translated into saved lives and he said as much. Faced with this discrepancy, he concluded that while he believed he protected others he would have to accept a fate destined for hell. He believed he was caught between two absolute and incompatible existential propositions. Judgmental world assumptions. Secondly, their world assumptions were consistently judgmental. This included judgment of self, judgment by God, and judgment of others. Kevin felt condemned to Hell by God: I just, from my belief when I was growing up, I feel like I’m probably destined for hell… Just because it ain’t just one (long pause, killing/murder of many people is implied), like that, you know what I’m saying?... It ain’t nothing that will change it now. I can do all the praying that I want to do. I pray every time I eat a meal. I try to pray before I go to bed, but… when it’s all said and done, you know there ain’t nothing I can say going to change nothing. But I don’t even pray for myself. I pray for other people. I don’t ever pray for myself. Like I said, I feel like I’m already destined for [hell].” Steven and Wayne’s narratives were equally judgment laden. Wayne lost all sense of trust for anyone who was not a veteran and specifically not a combat veteran, “You can't trust people that haven't done what you've done.” He took this a step further during a different question, “[My combat experience] makes me realize a lot faster that I 155 don't have or want to have anything to do with them.” This was in reference to the ease with which he could cut people out of his life.” Steven took issue with spirituality in general and the Bible itself: Spiritual-wise? I wasn’t. I mean I was, but… my grandfather was a preacher, but I never got to meet him really. I met him when I was a kid, but that was about it. Other than that? I have a hard time believing that somebody else wrote this book, so I have a hard time believing that there’s somebody out there that told [the writers of the Bible] to write it that nobody else can hear. So when it’s related to my combat? I had none. I survived because I did what I was supposed to do. (long pause) Wayne talked about the civilian population overall. Rather than have understanding for the lack of information they might have gotten during the war in Iraq, he put the responsibility on them for not seeking what he believed to be the truth, “They're spoon-fed the garbage that they get. They don't know reality.” Wayne, who did seek help at the VA was also judgmental of the methods the VA uses to help returning veterans and even cynical of their intent. He was very negative about how they tried to help him. When I tried to clarify by offering that their efforts might have been well-intentioned, he interrupted: I don't think [The VA's way of helping is] well-intentioned it all. I think it's based on money. They want us screwed up so that the VA gets more money… They didn't do anything to [help me such as]… “Here are the things you can do right now today that are gonna help you.” They don't do that. They put you on medication that's going to keep you coming back. And they put you in programs that you have to get long-term. Joshua directed his judgment toward many in the military as his source of frustration was with those that did not uphold the ideals believed were central to an effective fighting force. Ideals the resilient group would agree with. But when he tried to support those ideals by holding himself and others accountable accordingly, he was ostracized by his peers and betrayed by his superiors. This resulted in a shattering of 156 world assumptions which led to a very judgmental worldview: And like some of these fuck heads that come in there (to therapy) with their problems and that's why they are getting out of the military. I'm like, “you're fucking motor T, you've never even deployed there. How is that an excuse for you to be whomping on your girlfriend. That's why I hate veterans. They are just… they were pieces of shit before they came in because the Marine Corps needed numbers and they were just getting anyone they could. They are still pieces of shit now. They've never really had integrity, so it's not a surprise or whatever. This theme of judgmentalism was consistent throughout the highly traumatized narratives, though most directed it to non-combat veterans and civilians. Spirituality incongruent with war. Thirdly, they all viewed spirituality through a pacifistic lens. Kevin believed that he had violated the commandment not to kill so many times that there was no way he could escape Hell and the judgment of God. Steven stated that he really had no real opinion about spirituality and that he used the military rules of engagement as his guide to right and wrong during his combat deployment. Wayne and Joshua both defined spirituality and combat in antithetical terms. Chris’s account was more nuanced and indicated that one can begin with faith, but at some point that faith breaks down. For him it happened on his second deployment. His experience is instructive: I would say it has sustained me. It helped me, especially... Not so much on the second one but the first one. I felt comfort in it. And I felt like He was there because I needed him to be there. That's just how I felt. And the second one I think I had too much on my plate it seemed like to (long pause) just totally rely on God. Like me relying on God was going to take care of me, but who is going to take care of all of my subordinates, so... I mean I can't control this person's [beliefs] and say “You know you needed trust God and you’ll be fine”…. [Like], “So that's what you're telling me boss?” They struggle with faith and spirituality. This struggle existed in some form for all five participants. Steven put this struggle into words and went on to explain what this 157 meant for him on the battlefield: I've been to church, have been to studies, I've been to… I used to go to a youth group from when I was a kid but other than that, the only reason I went to the youth group was because I liked the youth pastor and the people I went there with. Other than that, for the spiritual? I have no preference of having those beliefs. I mean I've talked to a couple of really religious people while I was over there. I still have a hard time with the whole faith thing… Pretty much since I didn't believe in Him the way that they decided to follow Him or have something to follow, I just went off the military guidelines. Wayne had no use for a higher power in any way. When I asked him if he had any spiritual beliefs, he replied, “Oh, a higher power kind of thing? Absolutely not, no.” When I asked him how he was brought up regarding spirituality and war, he said: (long pause) to me, [spiritual beliefs and war] are two different worlds… So, the only way that that would make sense would be to be brought up by a Crusader or was I brought up by a militant Muslim where my spiritual beliefs evolved to control another human being to bring into my spiritual beliefs? I don't see the correlation on that. As a group, the emerging belief is that spirituality is pacifistic. That which is spiritual to them, does not account for the extreme violence of combat. For Kevin, this played out as eternal damnation for being quite good at taking the lives of others. For the others this emerged as distaste for anything spiritual and even more so for the religious as these were antithetical to what they had experienced on the battlefield. Wayne pointed out that for spirituality to be congruent with war, one would have to be brought up similarly to a militant Muslim, essentially a warmonger. Other than the discrepancy expressed by Kevin, arguably the most traumatically affected, there was no place for even the idea of taking a life in self-defense from a spiritual standpoint. Reactive / external locus of control. In contrast to sustaining faith as expressed by the resilient combat veterans, the beliefs of these highly traumatized combat veterans was characterized by fatalism and a sense of loss of personal control 158 which appears to be borne of world assumptions that did not provide a “why” for them. Lacking an adequate existential context they search within those experiences for the context, often not able to find an adequate answer. Kevin put it this way: I don’t know, I guess I just took it and ran with it. Because I was pretty much forced to do what I had to do. I didn’t really have a choice, I mean I had a choice to join the Army and all that, but once I was in the Army they was like ‘you’re going to Iraq.’ And that’s that. So I mean I just dealt with it. I didn’t really... I don’t know, I went there for my year and I came home. I didn’t really know what I was doin’. When I asked Wayne what his view of war and the war on terror was he didn’t really have one. He presented his answer as if his own views were immaterial, “(long pause) I don’t know, I don’t really question it that much. I don’t get paid to question it. I’m not one that decides whether I gotta go somewhere not.” Anger can often be an indicator of powerlessness. Steven talked about his predeployment anger and post-deployment anger, “I’ve always had a temper before, in the first place, but never really that bad, but ever since I got back, but me and my brother both, our tempers were shot. Patience was bad.” Joshua’s post-combat attitude toward people was an indicator of external locus of control. He said he no longer trusted people and did not believe in the goodness of people. The way he presented these statements indicate a sense of loss and powerlessness consistent with the other interviews. Military Context. The military context for this group was inconsistent. Each was willing to serve and was ready to serve to the best of their ability. Their training did not appear to be in question, but their reasons for joining the military often did not hold up. Joshua joined the military to serve like the resilient combat veterans, but like his highly traumatized counterparts his view of the military was highly idealistic. He tried holding 159 others accountable only to have his superiors tell him to look the other way. When men under his command accidentally killed a number of civilians because he did not double check the coordinates for indirect fire (mortars and artillery), he held himself accountable, and still did so at the time of the interview. Unlike the resilient combat veterans who reported serving in the defense of their country, the freedoms they have, and the values they hold, the reasons the others gave for serving were often, but not always, more personally motivated. Steven joined to keep himself off of a negative life trajectory he was on before he joined and specifically to see combat. He believed he was headed for jail unless he made changes. Kevin was in a rebellious phase of life and needed to get out on his own and get away from life on the streets. Steven Absent from their narratives were the themes of shared beliefs with family members after deployment and the military family legacies evident in the resilient combat veteran accounts. Congruent meaning of war. Although even the highly traumatized combat veterans in this sample view the concept of war as a terrible necessity, their narratives, consistent with their world assumptions, did not possess the existential dimension. They viewed war as necessary because of threats by other world powers, but the lack of existential authority here is something in need of further investigation. Their narratives consistently affirmed that they viewed war as a necessity both before and after their combat experience. Kevin said, “I don't think it's changed. Because I still agree with it. I still agree that we should have been there, so I don't think that really has changed. I still feel the same way about it.” Wayne agreed: War in general? War in general is necessary. It's always been there, it's human nature. It's what we do… Even morally and ethically, I'm capable of making those 160 decisions on my own. You know, what people somewhere else might want doesn't change that. It just so happens that my morals and ethics are in line with the general plan of how things are supposed to go. Inconsistent appraisal for their war. Although this group of highly traumatized combat veterans held that war was a terrible necessity as a part of their world assumptions, the appraised meaning of the war they fought in was not as consistent. Kevin had a negative personal view of the war in Iraq while believing that it needed to be done. When I asked him to describe his deployment experiences in general he replied, “Horrible. Probably the worst thing I ever did in my life.” And yet, he held a positive appraisal of the war in Iraq: I don't disagree with the fact that we [are] at war with Iraq and Afghanistan. (long pause) Without us going to war, I mean, I'm pretty sure another 9/11 was sure to happen… And umm, so I definitely agree with it. As a matter of fact. I think it was something that we needed to do. Like the resilient group, Wayne agreed with the initial goal of the war on terror, but not the latest phase, “The war on terror, I think in the beginning it was the right idea, but it's not what we are doing.” Having served in Iraq, he continued: In Iraq, we were shooting at people who were trying to put in an IED's, and they really were trying to put an IED in, but they weren't terrorists. All they were was some poor guy, the real terrorists went into their house, put their wife and kids into a room and held a gun on them and handed them an IED and told them to go put it in." One of his greatest frustrations was that the real terrorists were acting behind the scenes anyway and that those he faced were often pawns who would not have willingly put themselves into harm’s way if not forced or coerced to do so. Steven had a bleaker view of the two wars. “I think some of the things we fight for are stupid. Like we’re fighting now, this war here is all about oil, but I’m not much into the politics so I don’t know much about it. Fighting to make us safe, and freedom makes sense, but over 161 there sticking out nose in other people’s business when we’ve got problems of our own. There ain’t no sense in it.” Overall the discrepancy between their beliefs about war in general and the beliefs they held about the war they fought in was minimal. The meaning of war did not appear to be a source of distress for them, but neither did any mentioned cause for war emerge as a source of personal meaning. Military service as struggle. Finding meaning in military service was a positive theme among resilient combat veterans. For highly traumatized combat veterans this was not the case. Kevin had mentioned that going to combat was probably the worst thing he had done in his life. Steven signed up for military service to stay out of trouble. He did not consider himself particularly informed: I just signed in because I was heading down a bad road and I figured if I sign up for it, I might as well make it my life-line or… it’s helped me out a lot, the military has. When it comes to the political side of it, I don’t know jack about it. Unfortunately his unit was full of leadership that was more focused on looking out for themselves than they were providing the best leadership: In the unit I was in, we were getting a new generation in and we still had the old generation in. So we had the good-ole-boy system. If you weren’t part of that good ole boy system you were just a shit bag that didn’t mean nothing… When you got your leadership at each other’s throats, and us troops are down below… I mean we don’t see it, but we can see the outcome of it, and we’re just sitting there and they’re giving out false information and they’re saying one thing and doing another, and not sticking to their word… He felt this betrayal by his leadership hurt morale tremendously and did nothing for his sense of purpose while on deployment. As stated earlier, Joshua also felt betrayed by leadership, but for him it was when he was trying to do the right thing. The morals and values he held in high regard when 162 he joined, he saw trampled by those around him to such an extent that it destroyed any meaning he could have had. Once tapped for special operations, his dreams of a military career were destroyed by the wrongful selfishness of those around him. Enemy: Dehumanize and judge. The definition of the term enemy was the same for Wayne as it was for the resilient group, “The term enemy is somebody trying to hurt me or my guys… because even if somebody is Taliban, but they're not actively trying to hurt me, then they are not an enemy.” But the lack of conviction was evident when he continued: Throughout every war, from the American Civil War on: Rebs, Yankees, Japs, Nips, Gooks, and Slopes, and Krauts, and… We gotta have a name, a derogatory name for our enemy to dehumanize them because if you can dehumanize them it's okay to kill them. In your head that's just, ‘I didn't kill a human. I killed the Kraut, or a Jap.” So I don't know… I think it's healthy. I think it's necessary for the majority of people. I personally don't need that. This is where the resilient group differed. Each of the resilient combat veterans took great care to depersonalize the context without dehumanizing their enemy. Wayne points out that he only needs to depersonalize his enemies while he also believes in “whatever it takes” for others to be able to pull the trigger, giving a number of examples of labeling in order to dehumanize them. Steven defined the enemy similar to Wayne: Someone who is trying to hurt me (long pause). If they ain't hurtin’ me it don't even matter, but if they hurt me or my family or someone I love, I should say... I don't go looking for it, but if you're gonna come at me with a war I’m gonna give you one, but other than that I'm not gonna go shoving war on you. But when asked to make a distinction between an enemy and a combatant, he believed there was no difference between being an enemy in arms and an enemy through words. He said, “No, they're pretty much the same. If you're gonna come at me fighting or you're gonna come at me with words it’s the same thing.” This also differs from the 163 resilient group, which viewed a verbal disagreement as something completely different than identifying someone as an enemy. Wayne did not over-generalize the enemy, and even came to believe that the enemy was no different than he was: It's like I hear guys, they have a prejudice or racism against Middle Eastern people, and try to justify it by their war experience. And I just feel like they walked away with completely the wrong thing If they walk away with that belief, that prejudice, because they are great and wonderful caring people… I have great respect for their culture and the people. They are no different than any American walking around the street here. They get up in the morning and they want to feed their wife and kids. They have the same hopes and dreams that we do. People are people. And in any society there are bad people. But others did over-generalize the enemy. Steven did not believe that every Iraqi was his enemy, but he did carry with him an over-generalized mistrust: My view is, that I think we made a mistake by pulling out of Iraq. I feel it’s going to come here. We’ve already got em here within our lines. And they’ve pulled us out of Iraq so it’s just given them a chance to regroup and they’re going to come back and do 9/11 all over again. I asked him to clarify what he meant by “in our lines”. He continued: In our borders. We’ve got em all through the whole nation... All these people we got in these party stores and stuff… If they can’t control them people over there, what makes you think they can control them over here! When asked what the term enemy meant, Kevin was even more ominous and racially judgmental: Like the devil. Something that I'm trying to kill. Something I will kill. Something I want dead. Something that’s trying to kill me. Something that wants to harm me so I will harm that first. I mean (long pause) Arabs. (very long pause) He carried with him a deep loathing for Arabic people which he did not have prior to his combat deployment to Iraq. Kevin continued: I go into a restaurant now and there be some Ay-rabs (slang pronunciation), you know where there's food and stuff there. I just know that I can't stand them. I sit 164 with my back to the wall because I really feel like I have to watch them. I don't trust no Ay-rab, never. I don't care who he is, I don't. I trust him as far as I can throw him... If anything, that's what the war did to me, it gave me a big hatred towards Ay-rab people, and then on top of it they own every store in [town]. In short, the definition of an enemy is inconsistent for these highly traumatized combat veterans. The least judgmental participant did not see anything wrong with the need for others to judge an enemy as sub-human. The others took to over-generalizing, dehumanizing, and outright racism. This is very different from the resilient group who were opposed to dehumanizing the enemy or over-generalizing who the enemy was. Taking a life: Deeply personal. Though beliefs varied, for this highly traumatized group of combat veterans, taking a life during combat was a deeply personal event that challenged their beliefs in spite of their own willingness to do so. Beginning with an idealistic worldview they were not prepared for the emotions involved. Afterward, they were left with discrepancy, hate, and judgment. To counter this during combat, some participated in morbid humor to avoid feeling so deeply they could no longer carry on. Others numbed their emotions. Still others allowed their emotions to take over so that the enraged state would cover the softer emotions akin to regret and disbelief. Some broke down under pressure, succumbing to those feelings at times. For Kevin, taking the lives of others was very discrepant from the worldview he grew up with, “Well, for number one, I was always taught that we weren't supposed to kill. But that's the first thing I did when I went to Iraq; started killin' people.” Recalling the earlier theme of Intrapsychically derived world assumptions, he chose to revise his beliefs based on his experiences during wartime: …ultimately I'm going to listen to myself. If I feel like what I'm doing is right, that's what I'm going to do. If I really would have felt like picking a gun up and shooting was wrong then I wouldn't have done it. You know what I mean? But, I know it's 165 wrong, just by my beliefs, but I know it was right, because it was war and I understand what time it is ("what time it is" being slang for knowing what he needed to do in the moment). His sense of meaning discrepancy was driven home further by the following excerpt: …it's not normal to just take a human life, but when you've done it the first time, the second time, and the third time, it gets easier every time… I just feel like my aim was so good… I was real good at that. That's why they made me a gunner, the lead gunner at that. I was the front truck gunner. I loved it. I loved everything about it, I loved the rush. I loved the fact that I was going to be pulling my trigger first, because I didn't trust the people behind me. I knew what I was going to do. I knew how to keep people alive." But taking the lives of enemy combatants did not seem to bother him personally as much as the time when he traumatically injured a young girl by accident. His account underscores the importance of the status of the target that is wounded or killed: For instance, we would throw water bottles at cars… because you didn't know if it was an IED in the car, or whatever, or a bomb… when you hit them, they are supposed to get out of our way… we aren't trying to hurt them or we'd have shot them. Well, in this particular instance I threw a glass apple juice bottle... like a water bottle. I threw it at the car. It was a van actually... there was this little girl in the window lookin’ at us, because everybody looked at us like we were superheroes or something, but the bottle I threw had smashed the window right where the girl was sitting. That bothered me more than some of them people that died over there, because I got a daughter... it was this little girl that wasn't doing nothing to me. Though Wayne’s view of his enemies was most like the resilient group, he seemed to struggle with depersonalizing: Once I got there I didn't randomly shoot innocent people. I shot people that were trying to harm me. Regardless of the political rights and wrongs of everything, I only hurt people that are trying to hurt me… I welcome [the enemy to shoot at me]. Umm, it's Darwinism. If you're stupid enough to shoot at me, then I'm doing the world a favor by shooting you. Unfortunately, this certainty did not diminish the personal difficulty he had with the actual act of taking another’s life: It's not a natural human reaction to kill somebody. I explained the reality of killing 166 to [someone]. It's not good. It's a sick feeling when you shoot somebody. And I think if you don't have that sick feeling, you're kind of a sociopath… (long pause) yeah, I mean the second that round hits, and you know what you did inside. You know, when you were a little kid and you do something stupid, and the second you did it, you have that feeling of, “God, I wish I could take that back.” That's what you get when you shoot somebody, or I do. He validated what the prior statement indicated, that he struggled with depersonalization: It's such a personal thing, I don't even know of a more personal thing you could have a belief on. That transcends your political or religious beliefs. That is down to the core of who and what you are, so I don't think it changed me at all. If anything it just made me understand who and what I am. He explained the importance of sorting out these beliefs ahead of time: If you do something like [murder when you believe it is wrong] that goes so totally against who and what you are? You might break yourself… If you're somewhere in the middle, and you're mature enough or cerebral enough to call it murder, but you are not mature and cerebral enough to get past that and understand that that’s not what it was, when we get stuck in that middle area? Yeah that can hurt you bad. Joshua put the meaning of taking a life in the context of survival, “It’s one of those long-time, I don’t even know where it started from, but I would rather be judged by 12 than carried by 6. It kind of goes into that perspective.” He stated in his interview that he was sure that the lives he was responsible for taking were all threats. He did not have any he wished he could take back, but note in his response that the reason for his justification was survival rather than the greater purpose expressed by the resilient combat veterans, but one does not have to be the one pulling the trigger to feel responsible as evident in this excerpt from his interview: Oh, I was just so disgusted with everyone around me. Basically, um I thought that in war, I mean you follow the rules and you made damn sure the people you killed were the people that need to be killed. Not somebody that got stuck in between. And I realized very quickly that when everyone else around me got scared they’d fucking shoot anything that moves. From livestock, to kids, and 167 women. They don't have a problem with it and I even reported it to my higher-ups and they just said that’s war. I was just crushed by that and even though I was in a leadership position I feel literally responsible for a lot of unnecessary lives that were taken. And it's so frustrating for me because the entire war was a hearts and minds war, so killing these innocent people is not helping our mission. It's not going to get us out of there any sooner, and some of these fucking punk kids joining the military because they think they want to kill somebody... So they're just itching to do it, and they do it so they can come back and... People, like because of war movies they want that thousand yard stare. They want that. Though survival has reasonableness to it, serving a greater purpose appears to be related to better outcomes by comparison. Thematically, the idea that taking a life is “not a natural human reaction” and “not normal” are indicators that becoming highly traumatized is at least correlated with the idea that there is something “not right” with taking another human life even if that same person is willing to do so because it is their job. This goes with the spiritual theme of pacifism, and within this group it was a paradox that caused them a great deal of anguish. Loss of buddies: Hatred and judgment. The final military theme was the loss of buddies. To some it was simply the loss. To others it was the fact that those losses could have been prevented by a decrease in negligence by either themselves or others. Kevin struggled with his own personal losses mightily: (pause) you know the hatred started when we was on a mission. It was a big mission. It was our first overnight mission… the day three of our four people that got killed. Umm (pause) yeah, that's that was rough though, because… Say that again? I forgot where I was even going with that… (continuing a bit later) …When they had killed them people… all I wanted to do was kill them. That's all I had in my mind, because one of them people was a real close friend of mine. Joshua saw so much inappropriate behavior on the part of others it crushed him. He believed that a number of men who died would still be alive if it weren’t for the negligence and carelessness of others. This was visibly evident during the interview as he became visibly animated when he spoke of it. The blame was not always laid on the 168 enemy, but at times a fellow combatant who did not take being a warrior seriously. How do deeply traumatized combat veterans cope? (RQ2) Highly traumatized combat veterans, by definition, reported the highest rate of post-trauma symptomology in the last month prior to the interview. Several related themes emerged concerning how these combat veterans dealt with their combat experiences and how they continue to have difficulties even years after their combat deployments. The first two coping themes were related initially, but not exclusively during the traumatic experience of combat deployments. The next six themes that emerged were related to post-combat coping. To understand the highly traumatized outcome that they faced more fully, a rich description of their trauma symptomology will serve as a backdrop. Deeply Traumatized Symptomology. In spite of scoring highest on the PCL-M, indicating recent and chronic post-combat symptoms, the veterans in this group tended to avoid talking about the specific symptomology listed in their questionnaires, but their struggles were evident and considerable. This is most likely related to their sense of perseverance and grit as they did not see themselves as victims, and so did not want to broadcast their struggles in a manner that made them look like they were asking for sympathy. I asked Kevin, the single veteran who was discharged with 100% disability due to PTSD, how he dealt with his combat experience: Well, I probably dealt with [my combat experiences] not so well. (pause) I don't know really, I don't really know what made it so difficult. Probably because I'm more stubborn than anything, but I feel like that's the way the Army had made me, more stubborn and umm... I mean really, the marijuana [is] really what helps me. It's the best way, because like I said it just calms me down. He was arguably the most negatively affected veteran in the study, struggling 169 with basic life management. He struggled to the point of disability based on his combat related PTSD and deep clinical depression. Life had basically lost all meaning and even his old favorite activities were no longer interesting to him. He wanted to make up for the time he lost in Iraq, but felt that life had even less meaning without being able to work: I wake up, I don't have a job because I'm on disability, but I still feel like I need something to do… like I said I'm still trying to make up for the time that I lost… I mean it gives me time I feel like to catch up, but there ain't nothing to do to catch up. When I asked Steven the same question, he was somewhat contradictory, which would warrant an interpretation of difficulties while also maintaining a sense of grit and perseverance: (pause and a sigh), not really as bad as they put it out to be. I came back, I was pretty much gung ho into forgetting about it. I didn’t think I would ever experience it again so I just forgot about it. Oh, I drank a lot more, umm. A lot of people said I was real irritable. I still am actually, that’s why I quit drinking… Umm, [if someone asked me a] simple question, if I didn’t want to answer it, I’d go off the handle. If I did get into an argument, or a confrontation, I wouldn’t handle it like I used to. I’d go off the handle real quick… real quick. He said he was edgy, irritable, and aggressive. He found that he did not handle his emotions well, exemplified by being banned from a bar he once frequented. He also talked about the effects of hyper-vigilance on his daily living: So now you’re back home, you’re trying to concentrate on something, you’re thinking about this other… either you got what’s going on the rest of the day, what you could be doing. You got just numerous past memories, everything else. What was it like before you left? What was it like now? You’re just constantly… your brain is going a hundred miles an hour. Wayne remained in the National Guard, where he could be assured of employment, but he agreed that the lack of available jobs for returning veterans due to the poor economy was very detrimental to their reintegration process: 170 There's reasons for [guys falling apart]. I believe, you know, our economy is so screwed. A guy goes and serves his country and comes back and he can't get a job. And I believe that that's a big problem, and it's a big contributing factor. You can't get anything. And I think that does, it causes people a lot of problems. Perhaps the most tragic of all is the taking of one’s own life. In this group of combat veterans, suicide too often seems a viable option; a way out of the deep torment. As a final act of avoidance coping, Wayne became suicidal after he stopped his two-year-long drinking binge. He said, “I got suicidal, I was in a fog of depression, totally and completely out of contact with the world. Outside of coming to work, I stayed at my base.” During later questioning, I had asked how his faith had sustained or hindered him. His reply was blunt and shocking, indicative of an existential struggle even though he considered himself an atheist: I had it all planned out. I was going to lay down in a closet, so that when I stuck the shotgun in my head and blow it all over the place I wouldn't leave a big mess to clean up. (long pause) and the day I decided not to do that, there was no… There weren’t angels singing. There was no spectacular revelation or anything. There was me deciding that I want to put one foot in front of the other. Joshua said he would not take his life, but he would rather carry the burden of his experiences so others would not have to and he did admit to having a range of emotions which included suicide ideation on a daily basis. Similarly existential, but from a spiritual point of view, Kevin talked about how he did not really want to live, but that he also did not want to die or commit suicide. One of his reasons for choosing marijuana as his drug of choice was because he could understand the side effects. Citing family examples of dangerous side effects such as “homicide, suicide, and death” linked to the usage of man-made pharmaceuticals, he chose to stay away from them. Recall, that since he believed he would go to Hell, suicide would hold no comfort. 171 Meaning-making coping during deployment. Threat Appraisal. Threat Appraisal occurs when one views an event in light of potential harm rather than as a challenge to be overcome (Kibler & Lyons, 2004). Highly traumatized combat veterans reported much higher emotional states during the experience of combat than their resilient counterparts. What emerged was a focus on the emotional experience and the outcome of each engagement. There was a heightened focus on personal losses and what appeared to be mentally frantic attempts to find purpose through the chaos. The lack of deeper global meaning of the combat experience left these combat veterans to make sense of combat from the point of view that it is just a part of the human experience; that there has always been war, so their participation was coded as nothing unusual existentially. But without a context providing meaning to each threat and challenge, their physiology largely controlled their actions. This is in contrast to others who interpret the adrenaline rush as a physiological response that fosters improved focus on the task at hand. The experience of combat pushes their physiology into overdrive to ensure maximum survival. Interestingly, this physiological threat response did not emerge as a universal anger or rage for these combat veterans. Their initial and most frequent direct responses were more positive, but at other times they talked about hate, anger, and rage which were more about revenge over the loss of friends. Steven talked about his emotional state during firefights: I’d have to say, anxious, shaken, adrenaline going a thousand miles a minute. That gunfight that I was in, that was unreal. I was praying for another one. I don’t know why, but that’s just the way it was. I was excited about it. I was excited about seeing it. (long pause)…We had nowhere to shoot, so the 50 cal’s were just lighting up where the rounds were coming from, so the next thing you know I got rounds going right up my truck. That was pretty wicked, I got excited myself, 172 but most people got scared. Kevin had a similar response, “Hard, but at the same time fun. I enjoyed it. I enjoyed the firefights. It made my heart pump, and I want to keep doing it.” Recall that some of his excitement was related to his sense of vengeance, "…When they had killed them people… all I wanted to do was kill them. That's all I had in my mind, because one of them people was a real close friend of mine.” In order to get past his fear, also recall that he got to a point where he was no longer afraid to die. Wayne was similarly excited. When I asked him what he experienced during his engagements with the enemy, he replied, “Comedy. It was funny every time. Very few times was I not laughing, which may have been a nervous response, I don't know, but just every time [we went outside the wire] I saw something that was just hilarious.” Chris contextualized the excitement he felt: (long pause) it really kind of just depends on the day. There would be days it was just cool. Like this is what we came here to do. This is awesome. This is great. This is it. This is the real deal. Before I went I never understood why guys didn't talk about… like Vietnam vets didn't want to talk about it. But now I get it, because in the moment everything is just so intense and the emotions and the experiences. Visually, auditorily, everything is just… Hmm it's just an incredibly overwhelming experience. And words just never do it justice. Then, because I was asking him to try, he did: The best way I would describe it… just like if you've ever had a moment in your life when you've been absolutely terrified that you were going to die and not make it out of that moment and you survived it. That would be as close as you're ever going to get to it. Notably absent from their narratives was the deliberate processing of actions and choices within any recognizable context of meaning. Or rather, the meaning of combat can be summed up as terrible exhilaration without a sense of higher purpose as reported by their resilient counterparts. Although simplified, the significance of this 173 cannot be overstated. While each one did not feel that fighting during war was exactly wrong, they did not have a positive adequate existential context through which to appraise their experiences. Failed assimilation and accommodation. This terrible exhilaration as a primary response emerges in the absence of deeper assimilation This section regarding the coping of highly traumatized combat veterans speaks to the process that fails to happen as world assumptions are shattered. Refer to the earlier section: Shattering of World Assumptions. The shattering is due to incongruence between appraised meanings and their existing global belief system. The presence of an adrenaline rush in response to combat trauma is the normative response. In the absence of an adequately internalized context that affirms an understanding of the events of combat, the combatant may find himself led to action by the adrenaline rush itself rather than utilizing the adrenaline surge as a trigger to engage in predetermined processes. Some of the related behavioral responses appear to have been overcome by training, but after actions have been taken by each combat veteran must make meaning of these events. Overwhelmingly, these combat veterans reported the experience of combat to be nothing like what they expected. Lacking sufficient context it appears that they were not able to assimilate the appraised meaning of these combat experiences into their global belief system or accommodate by making changes to their belief system in the moment and when they returned home, they continued to struggle. Meaning-Making Coping After Deployment. Failed Assimilation and Accommodation. Having been unsuccessful at 174 assimilating their combat experiences effectively through primary appraisal, they return home to begin the reappraisal process. Unfortunately, the stakes are existentially and interpersonally high. It is psychically incongruent to believe that all things spiritual are particularly pacifistic while acting with extreme violence. Discrepancy requires one to modify their belief system accordingly, but a pattern of avoidance disallows veterans to do so. Paradoxically, having gained a hypersensitivity to the combat environment can make it difficult to experience the safety of homecoming in a manner that might foster this reappraisal process. Upon returning home, Steven said: I don’t know, I never felt afraid over there. I actually was excited. When I got home, I was home for five minutes and I wanted to go back. I was scared to be home. It was noisy here. (pause) noisy, fast paced, didn’t know what was going on. You go from working every day, knowing what you’re doing from sun up to sun down, to chaos. The narratives themselves speak to a failure of assimilation or accommodation. The sense of judgmentalism toward self, others, and the world indicate this. Though this section may be light or even lacking in specific excerpts it serves as an important reminder that intrusive rumination serves a purpose. As these returning combat veterans try to avoid a flood of emotion-laden content, their mind is hard at work trying to make connections, allowing triggers to bring up past unconsolidated memories so that they may be dealt with through assimilation or accommodation. Intrusive rumination / reliving. Unfortunately for these highly traumatized combat veterans, appraised meanings that remain unreconciled with global meanings continue to surface as if to signal that reappraisal must occur until reconciled with global meanings. Kevin talked about reliving certain events, “It's just something that I feel that I'm living it almost every day even though I'm not.” Also, Steven talked about one vivid 175 firefight that he considered exciting, “As in badness? No, not bad-wise. No, I can… but I can pick that gunfight out of my head like it was yesterday.” Joshua talked about how his intrusive memories would surface: Maybe I will just, you know break down and cry and just talk about things where I feel guilty about what happened... having a good time and then open up about something that happened a long time ago and that just kind of like spirals you down... When I drink I tend to reflect… I could be drinking like a Jack and Coke and then... “Fuck it! This guy in my squad, he committed suicide when we got back. He couldn't sleep…” But things like that, I just start thinking… and it snowballs. The others also had reported intrusive memories on the PCL-M, but these narratives emerged organically in response to more general questions without specifically being elicited. Note that the content presents as mostly negative and always deeply emotional, corresponding to the threat appraisal reactions discussed earlier. Low self-awareness. A lack of self-awareness, specifically a prohibition of awareness emerged regarding the methods that they employed in order to cope with their combat experiences once they returned home. Considering the psychic difficulty of dealing with unreconciled traumatic meanings it is no surprise that highly traumatized combat veterans exhibit a low sense of self awareness. Unfortunately, there was no clear cause-effect relationship to be found or even speculated about. Wayne said, “I don't know how I processed [my combat deployment experiences]. When I asked Kevin how his combat experiences had affected him after he returned home he paused: I hate everything… except marijuana. It's the only thing I love... Calms me down. Helps me get through the day. You don't even want a person like myself amped up. So I try to be calm all day long… I'm always angry. I've had… (long pause) I've been in two separate relationships that I probably destroyed both singlehandedly… all I really want to be is left alone, so… I'm happy when I'm alone… ( long pause) I don't know… Each of the highly traumatized combat veterans exhibited some level of awareness 176 avoidance with Kevin’s experience being the worst of all outcomes. His sense of judgment about nearly every aspect of his life snuffed out any desire to attempt to find positive meaning; he was merely existing and waiting for his time to die, after which he expected spiritual judgment. Joshua by contrast, was in many ways highly self-aware. Yet he spoke of a more deliberate lack of self-awareness. A tendency to remain emotionally numb in order to avoid spiraling down into deep depression, anxiety, or negativity. With more meaningful and positive appraisals out of reach, these highly traumatized combat veterans struggle with incongruent memories which surface in unwelcomed attempts to be reconciled with their worldviews. In avoiding this they often reached out to any number of negative coping styles with short-term gains. Dependency coping. Unable to assimilate their experiences successfully, these highly traumatized combat veterans pulled back mentally and often turned to short-term emotional solutions. This resulted in a dependency mindset. While chemical dependency was the most common, other behaviors emerged as a spectrum of failed attempts to cope; avoidance through dependency. I open with adrenaline dependency. Although it was reported less often than other coping, it is perhaps most germane to the prolonged adrenaline states of combat trauma. Though all four of the other highly traumatized combat veterans reported emotional numbing to avoid adrenaline states, some highly traumatized combat veterans embrace the adrenaline rush addictively, seeking out dangerous behaviors that feed the internal chemical dump in much the same way as some external chemical addictions, i.e. amphetamines. For example, after suggesting an adrenaline addiction, 177 Steven removed any remaining doubt “Yeah. Very very much so. Then I got back and wanted to become a fire-fighter. I haven’t done that yet… I don’t know. Just the thought of going into a burning building I guess.” Seeking dangerous activities to pull himself out of a gray funk has been a key component to his post-combat adrenaline dependency. Often, the primary method of avoidance coping was constant maintenance of a chemically induced state. Kevin said: “[marijuana] calms me down. Helps me get through the day. You don't even want a person like myself amped up. So I try to be calm all day long.” Wayne used alcohol in a similar way: Initially on returning home I had a lot of problems. Well, I didn't realize I had a lot of problems, because I pretty much stayed drunk, but then when I wasn't drunk anymore I really started having problems. It was a couple years afterwards that I really had to start getting over shit. After a couple years of constant drinking he began to face his problems, but he was still unprepared for what he would face: Yeah it was weird, but that's when everything got really bad for me initially. Like everything [was] just… Horrible. I got suicidal, I was in a fog of depression, totally and completely out of contact with the world. Outside of coming to work, I stayed at my base. Womanizing has been a part of the military stigma as far back as history will recall. I asked Wayne what else he tried to do in order to cope with his combat experiences beyond just drinking. He replied, “Women. Umm, (pause) I just went from girl to girl. I was kinda looking for something, like I said right about the time I stopped drinking I quit going out with all the girls.” The way he spoke of this, it was clear that he was not talking about building relationships; what emerged for him was a form of sexual dependency. Taken together, this spectrum of avoidance coping through destructive activities 178 provides evidence of a desperation to grasp at anything that will normalize their emotional states. They may try to calm heightened states, pull out of gray bland states, or even walk in fear that if they step outside of their dull mood that they may become destructive. Regardless of the chosen dependency, these behaviors emerge out of desperation. Unsuccessful therapy / suicide ideation. While resilient combat veterans rarely believed they needed to reach out for help through therapy, these highly traumatized reported unsuccessful therapy experiences. A number of reasons for this emerged. When asked if he had talked to anyone, Kevin said: "Yeah, but I don't think I came up with anything yet, that's why I still go to therapists.” If the goal of therapy is to access memories and reappraise them, Kevin was unprepared. He reported that going to therapy made it difficult for him to forget his experiences, a goal he was adamant he needed to be able to do. Wayne talked about going to therapy after his suicide ideation came to a head, but only to get cleared for deployment. He was still avoiding the reappraisal process: Wayne: [I went to a therapist] long enough to get deployed again… Probably four or five months every other week… purpose I wasn't specifically going to him to help myself. That just happened to be a benefit. I was going to him to get cleared because when I had my suicidal episode everybody ended up knowing about, so then I had to get mentally cleared… You know, I had seen [that] shrink for a while, and he told me there's… steps to grieving or something? We only lost like seven guys on that first deployment. All over a period of time, and not long after I got home I lost my mom. And he told me what happened to me was I got stuck on one of the steps and couldn't get out of it. When he told me that things kinda started making sense. As a group, they did not find the help offered by the Veteran’s Administration to be of help. Wanting to know how to get better, Wayne felt that they did not know how to help him. 179 Joshua realized that he needed to work on some things in therapy, but he had no desire to go to the VA. He felt they mistreated the veterans there: I realized that I have some issues to work on in therapy. Not to the VA. I don’t like the VA. I don’t think that the VA really treats anybody like they should. So I am going to like through my parents insurance. I was like I don’t want ot go like veterans just wanna go there and get jerked off like… “Oh you’re so fucking great what you did!” And like, “Oh yeah, you deserve to feel that way. It’s okay for you to get drunk and be a jackass.” I just don’t need that. In spite of not partaking in the negative avoidance strategies when compared to many of his peers, he felt suicidal at times: I haven’t done anything incredibly catastrophic to my own life. I haven’t gotten involved in drugs. I haven’t gotten in any legal trouble. I’m not an alcoholic, but for me I don’t really think I have made much progress yet. On a daily basis I go through a wide range of emotions, like basically from… I wish I would have died overseas, to contemplating blowing my brains out now, so… Perseverance and grit. When I was in the Marine Corps., the motto of one of my units, Second Battalion, Sixth Marine Division was “Never to Quit.” These narratives were full of perseverance and grit. In the face of impossibly difficult dissonance between initial global assumptions and appraised meanings related to combat, putting one foot in front of the other can be a monumental task. While these highly traumatized combat veterans did not display high levels of positive coping or a sense of greater meaning and closeness with others, they still pushed through their struggles. Though they contended with significant levels of symptomology, Kevin for example, still managed to find some benefit in his wartime experience, “it made me stronger, because of all the stuff I had been through. When you go through something like that you really have no choice but to get stronger.” Note that benefit finding is different than post-traumatic growth. In spite of his lack of self-awareness, Wayne was able to identify his own sense 180 of daily determination which exemplified this theme for the group: Processing [my combat experiences]? I just fought my way through it… Just, you just get up every morning and go… I'm still here so I must've dealt with them… (long pause) Umm, I guess my understanding that I've come to understand is that I didn't need anything like faith to sustain me. I had to look at myself and either make it through or not make it through. How do deeply traumatized combat veterans interact? (RQ3) Social dissociation. A central feature of meaning for these highly traumatized combat veterans was their general lack of trust and lack of comfort around others, with their own self-worth and their self-image. This did not come out directly; these men lived their lives exhibiting grit and perseverance. The last thing they would have broadcast was that that they felt they were victims somehow. After all, they chose the military as a profession, and they were not antimilitary. All but one of them was still in the National Guard. This internal dialogue led to social dissociation. Kevin put it this way: I don't have too much interaction with family and friends. When I do, I like to just come and go. I don't want to be there long. I just want to show, and then I want to leave, because there's too many people around and I'm not comfortable, or I just feel like I want to go smoke and then go back. So that way I'm calm. And I can't relax, if not I feel like I'm giddy. Even though it's my own family and friends I feel like I'm just always looking around and watching stuff. Being judgmental played into the dissociation for Wayne: I've always been okay with people having different opinions. What I've come to realize is that I have no respect for opinions that aren't based on reality, ultimately my reality, because everybody has their own sense of reality right? You can't trust people that haven't done what you've done. Steven exhibited his dissociation more directly through his anger toward others: Umm, like I said earlier I've been touchy a lot. If people bug me too much about over there then I shut it down or I will walk away. That but most of the time I just, like I said my temper is real short. It has not been so short since I quit drinking. Before it was like they would start bringing it up where they would just… A lot of things would trigger me and I would just go off on a nut and start swinging 181 Kevin had struggled with authority growing up and he carried this with him when he deployed to Iraq. When he talked about how he dealt with his leadership he referenced four instances where he was punished for his actions. An article 15 is a nonjudicial punishment that is similar to a violation of civil ordinances resulting in fines and similar punishments. He said, “I didn't listen to them… and they gave me four article 15's. Huh… (a chuckle of incredulity)” He continued to struggle with authority; he called it stubbornness. Then he talked about how this affected him after returning home, “So like now I'm a grown man and now I just want to live my own damn life. I don't want nothing to do with nobody… telling me what to do.” Disconnecting socially was a common trend throughout the interviews of these highly traumatized warriors. Disconnected from family. In contrast to members of the other two participant groups, members of this group felt disconnected from family. Steven talked about his experience, highlighting how his struggles caused fear in his family members, which in turn caused him to want to shut down and return to Iraq where his role and expectations were clear: You come back here. You got your family and a whole bunch of freedom, and they’re afraid because they’re afraid you’re gonna hang yourself, so you want to go back to what you know. Wayne, who had already been separated from his wife prior to his homecoming cut her and their son out completely as he struggled with his experience, “I was out of contact with [my family]. My wife and I were separated anyway, and I just completely… her and my kid, I just shut them all out.” His interactions with his family of origin were similarly strained, “I would say [my family was] neither [helpful nor hurtful to my process of making sense of my combat experiences], because I didn't involve anybody until 182 recently.” Choosing to be alone, Kevin had very minimal interactions with his family. He felt severe discomfort with them and being in their presence only highlighted his sense of disconnection, which was at odds with his desire to avoid those same feelings: I don't talk to my family since…I mean my mom I do, but… my dad on seldom occasions. I'd rather be left alone. I go to holiday meals and stuff with the family. I'd be the first one to leave and the last one to show up. Eat and leave type thing. Umm, (long pause) We're not on the same page. You know what I mean? They do different things than what I do. I don't live the way they live no more. I just… we don't have anything in common. Talking about the relationship between his family of origin and his military experience he explained the source of his discrepancy of meaning. Well, my mom never really was the type to want us to go into the military… She believes in God and all that. She don't think that we should be killin' people and stuff like that. And that's how we were brought up, that you shouldn't kill. I mean, just the ten commandments (referring to the interpretation that thou shall not kill, means all killing) During his combat experience he became “good at” killing the enemy. He was most often made the lead gunner; the first gunner in a convoy with the responsibility of making first contact with likely enemies and having to make snap decisions to open up with either a .50 caliber machine gun or a M-19 (grenade launching machine gun). In other words, he was good at it and very well-armed, which put him in the singularly existentially impossible position of simultaneously saving the lives of his fellow soldiers while internally living with the dialogue of self as mass murderer. This caused a nearly impossible struggle for him, which is echoed by other highly traumatized combat veterans returning home. They are forever changed by their experience and unable to reconcile these changes without changing their global beliefs about those events. This is made more difficult as many in their social network are not presented as 183 understanding and those that do not struggle are perceived to not have had the same experience. Active culling of friend network. Friendships, like family relationships were similarly strained beyond repair in many cases. When I asked Wayne what his relationships were like with friends upon returning, he indicated that he was no longer friends with them, "I see them every once in a while. I have no respect for their opinion about anything and I make it very well known." He took an active role in culling his friendships to the point of only remaining friends with other combat veterans. Kevin talked about his friend network of “one and a half friends.” He had one friend that he could relate to because that friend had been to prison, which Kevin believed was similar to his own experiences in Iraq: I got like one and a half friends. If that makes sense, because I don't trust one of them as much as I should. He ain't really a friend to me, he's just there. The other one is probably the only person I trust. I think I'm so close to him because… he'd been in the penitentiary for five years. We're like one. You know what I mean? …that's probably about the only person who understands what I be talking about as far as family and friends. The sense of dissociation these highly traumatized veterans expressed was nearly universal with the exception of other combat veterans. Closest to veteran friends. The most striking finding regarding the interactions that highly traumatized combat veterans share as a group is that they most often feel closer to other combat veterans than their own families of origin. The general trend of closeness appears to be wife and kids, other combat veterans, family of origin, and then others. Rather than growing closer to family and friends, this group of highly traumatized combat veterans grew close to other combat veterans due to their shared experiences. 184 Wayne put it this way: Umm, I've opened up a lot more to certain people around me. Specifically, well… really, only my boss (Active duty post of the Army National Guard). He and I are real close. Outside of the military, I don't have… but I wanted to say close friends, I don't have friends outside of military. Umm, (long pause) because ultimately if you haven't served the country you’re just a sheep. This is a reference to the book On Killing (Grossman 2008) he had been reading that explained the difference between those (sheep dogs) that are willing to defend others who cannot or will not defend themselves (sheep) through the application of force, from those who would harm them (wolves). I have read this original reference, which does not indicate any malice upon those who could not bring themselves to bear arms against an attacker. Wayne’s view that they are “just” sheep carried with it a deep sense of judgment more evident in the inflection he used when making the statement. He carried this sense of judgment further when he spoke of combat veterans who had returned home and did not fare well: I'm not a big believer in this whole, “poor me I got PTSD”, because everybody is screaming that. The VA conditions us to do it from the minute we get off the plane. Now I don't think, you know, “I went to work for my country. My life is ruined.” I don't feel that that's reality. That's just a cop out. You know, I've dealt with some of those that have really fallen apart, and yeah, for the most part it has been a cop out. For Wayne, only other combat veterans who did not fall apart and admit defeat were worthy of positive regard. Curiously, this discrepancy of meaning existed even after he developed a plan to commit suicide and went through months of therapy motivated by no more than a desire to return to duty. Kevin talked about having one and a half friends. The half a friend was not a full friend because he couldn’t be trusted that far. Though not technically a veteran friend, this friendship was based on a shared context from Kevin’s point of view. Although only 185 close to these friends, Kevin admitted that he stayed in touch with one other soldier he served with, “Oh, yeah, the people I went to war with? I care about them. I still stay in contact with one of them (gives the name). He's one of them that I wouldn't want to see nothing happen to him. Unlike the others, Joshua did not draw closer to veteran friends, but his case was unique within the group. He tried to adhere to the values of the military to a level which was far above what his peers were willing to tolerate. When mistakes were made he would report them the way that he was supposed to officially, but when his superiors told him to look the other way he felt betrayed. Then he was further betrayed by his peers who no longer wanted him around. The following two quotes illustrate this: I was getting ready to do MARSOC (Marine Corps special operations). I was putting my pack together for that and then [a man in his squad under his command] kills himself and then I got investigated, saying that I should have seen the PTSD signs of it. When that happened I had generals calling me and like criticizing me for not saving his life. And I’m like I’m fucking done with this. Those idiots don’t even know and I can’t handle this anymore… I guess he drank too much and took like some Xanax. Like in the infantry our job is life and death. Like to treat it any other way didn’t make sense to me. Like they were just… I mean I had some fucked up squad leaders. Like they would break into my room in the night and just beat my ass. I got hazed like nobody’s business. They like didn’t want me in their unit. They tried to get rid of me. What he described as ostracizing, some would call torture and it was definitely ostracizing, which in one of the growth-oriented combat veterans led to suicide ideation. Group cohesion is very important and when it breaks down, these experiences demonstrate how destructive it can be. Overall, this group of highly traumatized combat veterans dissociated themselves from those who they felt could not relate to their combat experiences. Family members 186 seemed generally, but tentatively, supportive of their veteran, though a shared sense of global meaning did not emerge in any of these five cases. Summary The global belief systems of these highly traumatized combat veterans, in their own words, were idealistic, and could not sufficiently explain the experience of combat trauma. They persevered through their experiences, often led by emotions where adequate appraised meanings could not be made. These extreme emotions led to deeply embedded traumatic memories which surfaced after they returned home as intrusive rumination along with other traumatic symptoms. Not prepared to deal with these troubling emotion-laden memories they generally coped through avoidance strategies which generally proved unsuccessful. Figure 4.2 shows the progression over time, with Initial Global Beliefs and Shared meanings to the left of the dotted line, representing the beginning of the combat trauma experience. In the figure, the initial global beliefs and shared meanings of these highly traumatized combat veterans were found to be idealistic when confronted with the experience of combat. This led to their shattering, because the appraised meanings, through the actual experience of combat, did not match these original global beliefs and were incongruent. The shattering of global beliefs led to a series or process failures which culminated in post-combat avoidance coping. Being unable to cope with the combat experience in a congruent and meaningful way through assimilation led to threat appraisal. For this group, threat appraisal focused their attention on survival in a manner which inhibited the complex cognitive-emotional process of accommodation of these new experiences. In the postcombat phase, these combat veterans exhibited avoidance coping strategies, 187 Family of Origin Shattered Initial Global Beliefs Shared Meanings Process Failure Idealistic Global Beliefs Process Failure Incongruent Appraised Meanings Combat Coping Threat Appraisal Figure 4.2 Grounded Theory of Highly Traumatic Meaning-Making Coping 188 Process Failure Post-Combat Avoidance Coping continuing to be unable to successfully accommodate their combat experience meaningfully into a global belief system congruently. Growth-Oriented Trajectory The PTG trajectory is characterized by an initial shattering of world assumptions like that of highly traumatized veterans, but then is followed by a period of personal growth, changes in global and/or appraised meanings, and lessening of negative symptoms. Their more recent reports of symptoms, beliefs, coping styles, and relationship experiences more resemble those of the resilient group. Responses to interview questions were categorized by theme and sub-theme. Several themes emerged related to PTG outcomes which provide the foundation for the tentative conclusions, comparison to other outcomes, and discussion in Chapter 5. Difficult Experiences Like the others, growth oriented combat veterans experienced considerable combat trauma. Kenneth talked about one incident: On our way out, there is only one way in and one way out, they hit us in an ambush, and a far ambush. And we were stuck in the kill zone for 45 min. That sucked, the ambush site itself, because we were in a valley surrounded by high ground, and it was just like… Oh my goodness, but we had to, because it was our mission to go there and we escorted doctors and veterinarians. Speaking of the first time his position was mortared by the enemy, David said, “It was unnerving. The first four or five times we got hit we were just like, everybody is freaking out because we had nothing but tents.” They were without proper defenses. At a later time he described a fear-filled situation while holding security at a busy checkpoint: I had to walk out about a quarter mile probably into a sea of cars. All by myself. And then there's another guy about 100 yards down. And I was thinking at any 189 moment all they would have to do was (points his finger at his own head) and bang. And nobody would know who it came from, I would be dead. They couldn't prove anything. They could take everything that I had on me, I might never even have been found and nobody would ever even know. I was just out that far. That duty, I pulled that one for a little while. That was exceedingly stressful. What do growth-oriented combat veterans believe? (RQ1) Initial global beliefs: Naïve and idealistic. Like the highly traumatized group, the growth-oriented group held naïve and idealistic global beliefs concerning war and their role in it. This is not surprising since both groups would almost certainly have fallen into the highly traumatized group if measured soon after their combat deployments. Anthony believes he was naïve about the world, but didn’t know it. When asked how he was raised regarding spirituality, he said: I can make it that simple. I wasn't, in any way, honestly. My family was split one side Lutheran and one side Catholic. As far as my parents were concerned, we really didn't practice, or go to church. I would say I'm more educated than I was maybe. Before, I thought I knew more than I actually did. Then after is when I started actually giving a crap about finding out the truths of spirituality in itself and what it means to be a Christian quote-unquote... for me, it was Christian beliefs. For him, this change was significant. He went from exposure without internalizing the teachings in a way that affected his daily decisions to making a personal relationship with God a priority that affected every decision he made. Chuck talked about how he used to be much more religious, but that there was confusion around issues such as violence and wartime, “I used to be a much more religious person. I was raised Catholic.” Importantly, he did not espouse a personal relationship with a higher power. Also, he talked about what he learned about people as a result of his combat experiences. “People are still vulnerable and most of them act in their self-interest and they may walk right over you.” Implicit in this statement is that he did not previously believe people could be so callous against others. His view was 190 idealistic prior to deployment. His narrative appears to be in contradiction with that of Anthony, but throughout this section the similarity of his change will become apparent. Kenneth talked about his beliefs before his combat deployment. Based on some of his previous responses I said, “Would you say that your global beliefs have been drastically changed or rearranged?” He replied: Oh my goodness, yes! Obviously! Most definitely, because I used to be so idealistic. And I thought the world was such a happy place with nothing but good. No bad things happened, but you know I was so idealistic and then reality hit me and (pause) I see two sides of the coin, I see both sides of the coin now. Oh dude, you’re digging even deeper. If I see good, I try to flip that coin and look for the dark side. I don't necessarily expect it but I look for it now whereas before I wouldn't look; I wouldn't flip that coin. Awe yes (reminiscing), everything is good. Just blind ideas. I was more of a dreamer, carefree. David talked about his initial world assumptions and contrasted them with the epiphany he had when his view drastically changed: Hmm. Okay, before, people were not equal in my eyes. I was a racist to a point, you know? I kind of looked down on black people, Spanish, whatever, I kind of looked up to Indians because their chicks were hot. (laughing) it was all my personal views, but now this is one of the most amazing things, I don't believe in races of human beings anymore, because genetically they don't exist. Oh!!! There's a big one?! (loudly) A literal slap in the face, almost. God reached down when I was studying this stuff and said hey (smacks one hand into another) races don't exist, what are you doing? In his own words, his initial world assumptions were very selfishly biased, judgmental, and negatively idealistic. This moment of understanding and change came after what he called his “salvation moment”, when he was reappraising his life’s experiences and beliefs through the lens of a new, more positive global belief system. The narratives of the growth-oriented group are at times difficult to separate out and put into sections because their beliefs typically consist of change-talk and contrast between the old and the new, which is why this last excerpt contrasts the old global beliefs with the new ones 191 intended for later. Shattering of world assumptions. Each of these growth-oriented combat veterans was able to articulate a change in their worldview. They talked about what they used to believe and how those beliefs have changed as a result of their combat deployment experiences. The idea of a shattering of one’s own world assumptions emerged from these narratives as both an event and a process. Their lives were negatively affected by combat, and then over time, during the reappraisal phase of this process, they would become increasingly distressed by the cognitive dissonance caused by the incongruence of their experiences and their original beliefs. These incongruent memories would surface in the form of intrusive rumination and reliving moments. This would go on until a significant event occurred where they were finally able to say “This is where it all changed.” Anthony spoke about his exposure to spiritual and religious beliefs. He would have initially considered himself culturally a Christian, but not a Christian by personal choice. Today that has changed for him: I did grow up with religious beliefs, spiritual beliefs… I've grown away from organized religion on the whole… I would say I'm very much so spiritual, I believe in God, Jesus Christ. I very much so believe in most of the things in the Bible. " When he returned home from his combat deployment he discovered within minutes of coming home that something was different, but he was not prepared to face it. He began to drink all day long until a violent incident landed him in prison. He never got to talk to his grandfather, athree tour Vietnam veteran, about their shared experience of combat. He recalled how his grandfather wanted nothing more than to have someone to talk to. Instead, he had become like the father he hated; a father who was still in prison 192 at the time of the interview. He felt deep shame. He underwent a total shattering of world assumptions by becoming truly what he hated most: … the first month or two (in prison), I was so depressed, and so ashamed that I damn near didn't get out of my bunk for nothing, that's all I did was sleep. And that was a sober sleep… I was so detached from reality I didn't want to believe what was happening. I knew what I was facing and it was the worst thing ever for me. Just, the shame was just unbearable. It was absolutely unbearable. While there, he met a chaplain who was also a Vietnam veteran that helped him take a different view of his situation and himself. Recalling what his meetings with that chaplain did for him, he said: I think it has taken me to a different level. Its put me on a different frame is what it’s done because what did change for me was spirituality. Spirituality was different for me going into combat than it was coming out. You have one faith, one religion, one belief (as in a denomination)... After combat I got away from that, I started realizing that it’s not about whether you're a certain religion; it's not about a certain denomination. It's more of a personal relationship. I got away from the church; it was about me and God. That's what it was about. And that’s what I mean about educated." Chuck was not as far along in his growth process. For him, a healthy openness to new answers and being able to question his own world assumptions was both difficult and healing. Interestingly, he was seeking what was real more than what was convenient. While he was becoming less religious he was becoming more spiritually focused. He did not simply want to believe things because he always had. Through deliberate rumination he was searching for answers: I used to be a much more religious person. I was raised Catholic. I identify myself as agnostic right now because I don't know what's true right now. I don't see any benefit in putting faith in a particular field without really convincing myself about it. I'm in the questioning phase right now, so for me the only productive steps I can see myself taking are things I know I can actually have an impact on, like a tangible thing that I'm able to see the results of, so that's where it's kind of gone... I asked Kenneth how his combat experience had affected his beliefs. He replied, 193 “I think I will always question everything, (light heartedly), Umm (long pause) I don’t know.” He had gone from a simple, carefree person to one who now questions everything because of his combat experiences. When Kenneth addressed how his views of the world have changed, he pointed to question 10, a statement meant to be rated, really, from the PTGI-SF, “I learned a great deal about how wonderful people are.” He was not the only participant to point to or laugh at this question. I believe it was the only one commented on organically in the interviews and it stuck out above all of the others. To contextualize the following quote, he had talked throughout his interview about the culture of the Afghan people he came across. In the interview he referred to their cultural acceptability of killing family members, particularly young women for dishonoring the family, pedophilia as a way of life for entire villages, and other similar behaviors he believed were abhorrent. Kenneth, who never wanted to grow up said: The world is a far darker place than I ever had imagined. (long pause) But that's like in the questionnaire that I filled out, that's why I look at that question… How do I answer this? I'd have to look at it. It was like 10 or something, but there are two sides to that coin, you know. We have it so good here, but you don't really realize it until you see over there. The military people are learning a great deal about how wonderful people are. But yes I have, and again it came at a price. How horrible evil, and things that I never… and you read about it, if you read about serial killers you think this is something that they would do, but this is common to these people. Growth-oriented global assumptions. Importantly, after a period of shattered beliefs, these veterans came to a new understanding through either a revisited or newly discovered global belief system. By all accounts in the study, this appears to be the beginning of real and lasting change. Once they had a global belief system that put many of the many of the disconnected pieces together, they then began a period of active and deliberate rumination that, though still stressful, was much less painful than 194 the initially unsuccessful and intrusive rumination of before. A change in global beliefs appears to be the starting point. When I asked David if his belief about the world changed he said, “Oh, oh… dra-matically. Absolutely!” So I asked him what that did for the symptoms he was experiencing. He replied, “Wonders. Wonders. Absolute wonders.” David explained how he began to have a relationship with God while he was in Iraq. He said that he had gotten saved and even baptized, but was not yet maturing spiritually. He talked about remaining judgmental and being, in his own words, a hypocrite. But then, a few years after his deployment he decided to get serious about his beliefs. He was very precise in describing when his life changed: I decided “You know what? I'm gonna be a chaplain...From that instant, now and hopefully for ever and ever, my life is completely changed. (pause) All of the things that I viewed from a perspective based on pre… enlightenment we’ll call it? Pre-that moment… all of my perspective is, was… let’s call it (pause) darkened. That perspective back then was viewed through distorted lenses. Now that I’m viewing those, everything that has ever happened, not just the deployment, through the eyes of “I’m saved.”… Suddenly I’m viewing everything that’s ever happened to me through what we like to call the mind of Christ. In short, his life was no longer about just himself. For him, it was about himself in relation to God and others. Further, he specifically stated in the interview that he believed that global beliefs were more important than what he thought about the war he fought in. Growing relationship with God. Four out of five growth-oriented combat veterans talked about having a growing relationship with God while Chuck was much earlier in the growth phase. He talked about moving away from the religion of Catholicism while being very deliberate and introspective about his reappraisal of all things spiritual. Anthony talked about the beginning of that relationship prior to his 195 military service: I was actually baptized on my own accord when I turned 18. That was nondenominational, and I knew that when I was doing that I was one with God. No matter what anyone else told me about how I should perceive God. He also talked about how this new belief was put to the test through his combat experiences: There was a time that I was… I felt dis-attached from God. I felt as if… you know, I asked the questions that we all ask at times, you know “Why are you doing this to me?” Umm, are you even… By contrast, during the interview Chuck said that he referred to himself as agnostic half the time and a Catholic half the time. His spiritual decision-making process indicated that he was deliberately truth-seeking. He moved away from religion, but when he talked about spirituality he was very specific and personal. Still uncertain about the existence of God, Chuck took an eternal view of life while living a life of practical application so he could be assured that he left a positive legacy in case there was nothing after death or that he would be accepted by God and allowed to pass through the “pearly gates” into heaven mentioned in the Bible when he died: … I still have a moral code that I follow, I just am now at a point where I'm trying to do something that I know is going to make an impact so even if I don't have the answer to what happens after this life or anything like that, I know that at least if nothing does happen I made a positive change in the world when I do leave. His dedication to a positive moral existence as meaning was evident. He wanted to live a life worth living, and while he could not say that God existed, he was careful to make decisions that he could answer adequately within his own global beliefs, but also in a way that he believed would be acceptable if God did exist. Those beliefs emerged within the context of the interview as in line with Christian principles with a focus on what could 196 be verified objectively. His was the least affirming of this theme, though not opposing. When I asked Kenneth about his own spirituality, he said, “Personal.” I followed this with other questions to inquire about a belief or disbelief in God. He responded: Ahh, it’s more inward. I’m my own worst critic. And I try… If I’m going to be judgmental about anybody really, it would be me before anybody else… I do (believe in God), but it’s like…spreading the word and everything… I have a hard time talking about my own beliefs, because it’s so personal with me, and it’s so direct-line, I like to visualize (making a gesture from himself upward). While he did believe in God, the core of this relationship was judgment rather than forgiveness. This was interesting because he said his mother never forced him to go to church when he was younger, she had told him “I’m not going to force you to love this.” An emerging theme throughout the interview was that he was learning to be and think less judgmentally, but still was not to the point of letting go. David’s belief in God was the most evident throughout the interview. He recalled having gone through what he called a salvation experience, becoming an ordained minister after finding out he was too old to become a chaplain in the military. Dennis said that he had an initial belief in God, but that his belief in God was strengthened as a result of his combat experience: There are guys that I talk to that don’t talk about religion at all because of whatever happened. I’m here to tell you that I know that there is a God. It could be named this or that, but I know that there is a God. I believe in him because I’ve seen some crazy shit happen that I know doesn’t happen in your everyday world. Increasing faith. As discussed in the resilience section, faith, as differentiated from belief is putting those beliefs to the test through daily decision-making. Overall, this group expressed an increasing faith. When this notion is challenged, it appears to be in 197 favor of a deliberate process of discovery which has no yet materialized into a direction one can have faith in, but one that is no less deliberate. When Anthony went to combat the first time, his faith was very new. As his personal faith really began at age 18 just before deploying, his narrative gives support to the importance of strengthening that faith over time. He wore a cross on a necklace to the interview and it was displayed on the outside of his shirt at the interview. I asked him what it meant to him and he said, "My sincerity of faith. Not somebody else's faith." The emphasis on the first word was his. Chuck broke his beliefs down to two potential global belief systems, though he was still uncertain which one was true for himself. His experience demonstrates deliberate and active participation in the meaning-making process. Content at the moment to leave the final question unanswered, he accepted two possibilities he could live with until he became more certain. One included God with the associated belief that he would be accepted into heaven based on his virtue as a decent person. The other was nihilism where it wouldn’t matter anyway, so he lived his life in a way that made sense to him in both cases. Note the discrepancy, but also the congruence and deliberate nature of the potential afterlife experiences he considers: During combat deployment, I still aligned myself… I still call myself Catholic half the time and I still believe that there was always going to be, no matter what happened things were going to be okay. It may be the pearly gates of Heaven that I end up experiencing if I die... Even if there was an existentialist approach in there was nothing there (in the afterlife), if there's nothing, there's no suffering either. David responded regarding his faith when I asked him how he had dealt with his combat experiences. His response is significant and characteristic of the helpfulness in believing in vicarious control: 198 In the beginning, not so well. And now? I'm not even the one dealing with them. I leave it up to my faith. Through my faith. Not of my own strength am I dealing with them. And now I deal with them through the strength of the Lord, fantastically. Dennis also said that his faith had helped him. Overall, this group of growthoriented combat veterans demonstrated that they may or may not have been moving away from organized religion, but that they were gravitating to a genuine relationship with the creator if they believed he existed or with humanity at least, just in case that was all there was. Though the resilient combat veterans reported religiosity, the core of their beliefs was in fact the personal relationship with God, indicating that religiosity is secondary to spirituality when it is helpful. For growth-oriented combat veterans, the personal relationship aspect was the focus during their change process. Forgiveness by God, self, others. Initially, these growth-oriented combat veterans did not fare so well. They began with a global belief system that could not account for their combat deployment experiences in an affirming and meaningful way. Instead, they were initially judgmental of themselves and others. When faced with this discrepancy of meaning, unlike their highly traumatized comrades they eventually allowed themselves to consider that they may have been wrong about what they originally believed. They became more flexible. They considered alternative possibilities. When talking about these changes, a central theme was existential forgiveness. This is appropriate in that their actions had life and death consequences for themselves, their fellow warriors, and their enemies. Anthony believed that absolution was necessary. He was either not guilty of any moral crime in God’s eyes or if he was guilty that he would need to believe he was forgiven by God and himself: To be honest with you, when it comes to the spiritual level as far as… I can't say I 199 didn't think about it because I did, all the time I struggled with it… (long pause… about 10 seconds, with tears streaming down his face) I don't think there's any one thing that I really did wrong, but I still struggled with “Will I be forgiven?” I know this is gonna sound like a bit of a contradiction and it is, and I guess it's still that kind of a crossroads for me I still haven't yet figured out that hurdle. I know it's there, I just haven't figured how to navigate it. As I've said before there's a difference between killing and murder, but at the same time you still have that sense that, you don't really know until you actually do it… Maybe it's not even so much that I'm worried about God forgiving me, maybe it's [that] I haven't forgiven myself. It all leads to that. So until you get past that, you're not… can't really get past the war or whatever you've done there. Similarly, David demonstrated an even greater change. He went from being judgmental, even to the point of openly labeling himself a racist prior to the moment he changed his belief system and lifestyle to line up with the Christian God of the Bible. When he did this, he talked about the need for forgiveness by God. He saved this next excerpt for the end of the interview when I asked the catch-all question allowing participants to add whatever they thought I might not have asked them about, but that they felt was important. He was ready: I'm going to make this very short because this is all of this (the interview) in a nutshell. How do we… what was it? Recover from combat? (long pause) I, because I can't say other veterans, (then very calmly, deliberately, and slowly) I recovered from combat through salvation in Christ; Period at the end of the sentence. The emphasis on having recovered as a finished product was his. He believed that the weight he carried as his world was closing in at one point was a deep sense of guilt and shame. Dennis talked about forgiveness from a Christian perspective as well which he believed was the basis for his forgiveness of others, “You know, when you think about the… you know, Jesus Christ. Why he… what went on with Jesus Christ, you know? He gave his life to forgive us for our sins.” 200 Military context. Anthony was pro-military and by his excitement prior to deployment one might have assumed he would return home resilient. He himself though so: I grew up knowing that there was a such thing as war, and there was a sense of pride in it… For me, ever since I was a little kid I knew that one day I was going to wear that uniform… Well, the simple answer for as far as pre-deployment… I was very pro-war, pro American, very patriotic, ready to serve, ready to do my part as a soldier. I got there and that view didn't change. (pause) I was ready to go, and I was ready to get in the shit. I couldn't wait, very foolishly I couldn't wait for the first bullet to fly. I couldn't wait for the first thing to happen. I spent all this time training. Now I finally get to do my job. But you can hear in his response that this was foolish excitement. War provided a sense of reality that he was not ready for. Upon returning home, he reported that it was only minutes before he knew something was wrong. Then he got busy avoiding that feeling. By contrast, the resilient combat veterans were ready to do their part initially, but going in they knew it would be emotionally and morally difficult. No big surprises for them. Anthony was not ready. In retrospect he could see that his excitement demonstrated his idealism. David upheld the importance of military values, but he believed that global beliefs were far more important. He put it this way: (sigh) so you're taught these things. And those values actually work in combat and in situations like that, but... big but, and this is an after-the-fact but... (pause) without a spiritual base, without a base in faith, a base in a belief system, those values are hollow. You can follow them, right? But, in the same aspect that you don’t grab a girls butt while you're walking by her you will still go back to the barracks and go back to the tent and watch porn all night long. So, technically, you’re upholding the values by the Army’s standards, but are you really upholding your values in your mind, in your heart? Not really. This statement both supports the importance of military values and the idea that what one truly believes when no one is looking is more important than the values one is 201 upholding. It is these intrinsic beliefs that form the global belief core for both resilient combat veterans and growth-oriented combat veterans who are noticeably into the growth process. Incongruent military factors. Anthony believed that his military training was partly to blame for improperly preparing himself and others for war. On one hand, the message was for warriors to be professionals, but on the other hand, some parts of training actually encourage access to anger and rage in order to instill a spirit that will overcome the natural aversion to take the life of others: …there's one thing that they're missing. And actually they train you one way, they tell you one way, but they contradict themselves in the very same way, because just in our PT (physical training) cadences alone 'kill, kill, kill, and this and that', but at the end of the day it's 'kill with a purpose. Be nice, this and that, there are rules', but that's not what they're saying to us at this part of the day, it's really contradictory. Then he very solidly made the case for why this is not productive or helpful to the mental health of those who would one-day see combat. He said, "You should never create a killer spirit. Isn't that what they say they don't want on the battlefield? Isn't that why they don't recruit criminals in essence?" Chuck’s narrative illustrated the effects of training warriors to fight without questioning the reasons why, or delving deeply into what it means to take the life of another human being during wartime. He froze during his first combat engagement, but spent the rest of his deployment building a cognitive decision-matrix validated by an ever-growing list of experiences. Though no others reported equipment shortages as particularly problematic Kenneth, recalled the lack of preparation, training, and equipment and it upset him deeply: 202 With us, the first trip was odd, because [when] we first got there we were rolling out in Ford Rangers. No crew served weapons, we had our M9’s and M4’s, and I kid you not, Ford Rangers. Two vehicle convoys, and it was insane. But I think about how things are now and the changes from the first trip to the second trip, I'm like, “Oh my gosh really? I'm a nutcase.” Umm, (pause) I lost my train of thought… Overall, Kenneth believed they were ill-prepared, but his leadership was also equally unprepared in his view and more concerned with enforcing a decision made than the importance of making a good decision that would keep his warriors safe: And when you look at the overall… You can even go to the next higher up [in command], and you can look at the concept of operations level, you can go up to his level and look at the concept of operation and you try to break it down and think, “What the hell is this guy thinking?”… Why would you build a base right in the middle of a bowl surrounded by high ground? Just tactically it doesn't make any sense, that's probably the ego of it… That's part of it. Though not considered important by a large number of these veterans the factors of contradictory training, lack of appropriate equipment, and dangerously poor leadership were noteworthy and find their place in literature elsewhere. Congruent global meaning of war. Each warrior enters combat with a concept of what war means to them. This global meaning is contrasted with the appraised meaning they build for that war. When I asked Anthony what his beliefs were regarding war, he stated that he believed that war was a necessary form of national self-defense: I would say (long pause)… I agree with it, I think it’s a necessity, because there’s so many people out there that want to hurt the American people, or democratic people on the whole, whether that be European, American, whatever the case may be, but obviously more so American because we’re sort of the tip of the sword. You know, we’re the big brother… It is an evil necessity. And it is something that is always going to be there whether we like it or not, because there are selfish people out there. He spontaneously challenged the notion that war could ever become unnecessary. He believed that it is important to stand up to those that wish you harm: 203 To say that human beings are not violent, I think that's irrational, that is an extremely irrational way of thinking… I don't care if it's your 90 year old grandmother, who’s never struck a person in her frickin life, or called anybody a name, that woman's got violence in her if she needs it. It is there. It has to be. When I asked him if his views of war had changed or remained the same he replied, “I would say [my views of war are] not as naïve. I have more educated opinions." Similar to naiveté, Chuck was uncertain about his views of aggression based on the family values he grew up with, but now believes he has become more informed: Yeah, I was raised Catholic. Catholic Irish ancestry family. It's kind of weird, a strange dichotomy. My family and the people in the community I was in where I grew up where it's wrong to harm somebody else... It's like there's this general moral code to go by, but somehow there is this… I was pretty young, when the earliest conflict that I remember was Desert Storm... somehow it was justified or sanctified through the legislative process or however they decide to justify it. They justified conflict all of a sudden and it was then okay... I have a better understanding of how the world views that nowadays. Kenneth had a better understanding of what war was at the time of the interview than he once had before combat, but he could no longer recall what that view was. Still highly conflicted and early in the posttraumatic growth process at the time of the interview he was able to articulate a global belief about war that allowed him to participate in a meaningful way: (thoughtful pause) Any kind of war is an evil necessity. It’s a dirty rotten holy hell… It’s an evil necessity. It’s never something you would want to be in, but it’s a necessity… You know, it’s to the point now where I can’t even fathom what I thought about war before, because I didn’t really experience it yet. Reading the affect in his statement and wanting to clarify I said, “So definitely different?” And he replied, “Oh, for sure. Without a doubt, for sure.” In spite of his family’s military legacy, his experience of war was very different from what he once thought it would be. To this group of growth-oriented combat veterans, their global beliefs about war were once naïve or idealistic. Afterward, they struggled initially, but began gradually to adjust 204 and grow. Within this section, their narratives demonstrate an increasingly realistic appraisal of the concept of war. Increasingly negative war appraisal. Initial appraisals for the war each growthoriented combat veteran experienced were congruent with their global beliefs about war. This theme of later reappraised discrepancy for the war they fought in does not appear to be related to symptoms as their early appraisals were congruent. These later appraisals were less congruent in spite of their growth orientation. It would seem that the emerging negative appraisals resulting from deliberate rumination are made even less problematic in light of their sense of forgiveness and letting go. If these more negative appraisals resonate with the news content which was thought to be incongruent with their combat experiences it would build credibility for the influence of the news media as indicated in the Common Themes section. Though each veterans’ specific war appraisal was unique, the level of initial discrepancy between their own war’s appraisal and that of their global beliefs was low. This lack of initial discrepancy is important in eliminating global vs. appraised meaning of war as a factor for their initial highly traumatized state. Though discrepancy for each of them continued to build most recently, they seemed more emboldened by an increased understanding of their war and the war on terror overall. Anthony began this way: Obviously before combat, I was very pro-uh, heh… 9/11 was very personal to me. It brought tears to my eyes. I was in the 10th grade and I watched it all happen on TV… I will say as far as my role is concerned, like in Iraq, as an example, what Saddam did to his people based on my morals is just completely atrocious. It was wrong, dead wrong, and he needed to be dealt with. Period. By any means necessary. Anthony talked about his unit basing their operations out of one of the palaces Saddam had built. Around one of the large swimming pools was blood of previously murdered 205 Iraqi citizens caked several inches thick. Similarly, other veterans talked about being forbidden to dig on the grounds of one of the Iraqi prisons because it had been discovered that bones of long executed prisoners littered the entire area for unknown distances. What appeared to bother Chuck the most was less about the meaning of war and more about the destructive role of the United States government meddling in foreign politics. He noted that freedom was the hope that we should strive for in order to create peace, “My world view is that I still hope for people, I just think it’s going to be more of a freedom question.” He resonated with the idea that war is sometimes necessary to secure a lasting peace, but the discrepancy he was most recently experiencing was that the war he fought in did not have to happen, and would not have happened if the United States would have meddled less in the affairs of other nations during the prior decades: I know I'm a lot more frustrated nowadays because I see a lot of what has happened over there (Iraq) and what happened with me over there, none of that had to happen in the first place… I know a lot of the war on terror now is a lot of how we had a hand played in using these people. A lot of people we’re fighting today are a direct result from the actions that we went through previously. As far as the war goes with the war on terror, I agree that we need… Well we made mistakes and now are dealing with the results of those mistakes, or the blowback of it, but we still have to deal with the blowback of it we can't just ignore the blowback. Kenneth’s global beliefs supported the appraised meaning of his war, particularly when he was there. He had two reasons. One was the attack on 9/11 and that we went to Afghanistan to take out Osama bin Laden, Al Qaeda, and their allies the Taliban: I walked into work on 9/11. At first I never really watched TV. I never really followed the news. It wasn't in my thinking. I walked into work and they were like, “What the hell are you doing here?” “What do you mean?” I had no clue what happened. Or what was happening. And this guy is turning white, and I'm like, “What the hell?” The TVs were on and I didn't notice it, and then… 206 He saw the Twin Towers on fire. He also believed the Taliban were at the root of what kept Afghanistan in the stone ages, noting for example, that they caked animal dung to the sides of their homes until winter when they would burn it for heat. He reasoned that it was important that we dismantle the Taliban who he found to be responsible for much of the oppression he saw there, “Because nobody should live the way that they live.” He was very supportive of the war in Afghanistan, but he also believed that the strategy to win the peace afterward was far more harmful than helpful and it frustrated him greatly. Taken together, their appraised views of war, the war on terror, and the war they fought in were initially low in discrepancy. The purpose of illustrating this is in tentative elimination of this as a source for their highly traumatized state upon returning home. It is also possible that this congruence in meaning helped to set the stage for their growth orientation in spite of increasing frustrations over the handling of these wars after they had returned home. Enemy: Positive Redefinition. For this group, the definition of what constituted an enemy changed from judgmental toward seeing the enemy as the same. Anthony judged his enemies very broadly in a manner similar to his pre-deployment judgment of troubled combat veterans. “What we don’t know, we don’t like. I was ready to go take out any Muslim that was ready to take me out.” He was not concerned with assessing potential threats and making appropriate decisions. His level of cognition regarding the enemy was very limited. Contrast this with a more thoughtful definition of the term enemy which he now holds. The following is similar to those of the resilient combat veterans in the study: To me the term enemy (pause)… anyone who intends to harm me, whether that 207 be physical harm or emotionally or intellectually, whatever the case may be. Anyone that’s trying to bring me down in some way shape or form… There’s a difference between combatant and enemy. There’s a lot of people out there that can be my enemy, but that doesn’t give me the right to defend myself against every enemy, because you might not need to. This change in definition of an enemy is an indicator that something deeper has changed as he continues his post-traumatic growth trajectory. At different places in the interview he expanded on this theme. Toward the views of the resilient group, his understanding of the enemy had changed from a judgmental view to one that realized the humanity of his enemy was the same as his own: …now that I’ve gone through it, like I said, you know they’re human just like I am. Whether I agree with their motives, how they conduct their way of life in the way that they attack us cowardously (sic), and it gets really frustrating because you don’t have an enemy that’s really willing to stand up and fight you face to face. Umm, and I hate it. At times I hate them, but they’re human just like I am. They’re fathers, sons, brothers, uncles, aunts, mothers... and I have all of those. So who am I to try to dehumanize them. Sensing this change and recalling his claim to Christian spirituality I asked him what he thought about the idea that one must “love their enemy”: I’d say for me ‘love your enemy’, rather than hate your enemy… for me that’s more of a ‘know your enemy’. The more you love your enemy, the more you’re gonna know your enemy, the more you’re going to be willing to know and understand, because you have to know who your enemy is... hate can overpower your better sense of judgment. Taken together, he appears to have begun to see value in depersonalizing his combat experiences while actually deepening the connection with others and specifically opposing the practice of dehumanizing them. Like the resilient combat veterans who held this view from the beginning, these emerging beliefs are correlated with his perception of growth and decreased symptomology. Chuck agreed with Anthony’s post-combat definition of an enemy: 208 I always considered an enemy to be a combatant. An enemy… I guess to take it further, may not necessarily be combative, but there is a potential for them to be combative. That's where I draw the difference. It depends. If it's somebody who is out to potentially kill me, I have… If somebody tries to damage my property or my person, especially my person I have very little quarrels with defending myself or my property by any means necessary to the point where I've neutralized the threat. He also agreed with the importance of humanizing or re-humanizing the enemy, “There is an in alienable human bond. Even when, even though we're in their country and we would wreck the hell out of their infrastructure, and doing what we're doing.” When I asked David what the term enemy meant to him he paused, “There’s two versions. There’s the pre-salvation version and the post.” I asked him to give them both. He did: The pre-salvation, which would be all of the deployment and up to my conversion thing would be: an enemy is anybody who disagreed with what I agreed with. Anybody who the government told me was my enemy. Anybody that had a different religious viewpoint than I did was my enemy. Anybody that harmed other people, like murders, child molesters, those were my enemy. All those people were my enemy. And the various, you know, I guess… severity of how I would treat them, would be based upon my judgment of them. If somebody just cut me off in traffic. You’re my enemy, I’m gonna (pretends, but doesn’t actually, flip the bird) You know. If somebody molested a child, I’d, you know… well, kill ya. So, MY judgment was what defined that. Now post-salvation… my enemy. Well my enemy is Satan. Everybody else is worthy of salvation. He agreed that an enemy combatant would still be his enemy, but with his enemy declared as Satan, it freed him up to love his enemies and treat them with human dignity, allowing them the opportunity to surrender and not killing those who did not pose a particular threat. As a final note, the brutality of the enemies they faced in Iraq and Afghanistan affected them deeply. A number of combat veterans in the study alluded to the effects of this brutality on their ability to remain professional. This sentiment appeared to shed 209 some light on the causes of war crimes and the rare atrocities perpetrated by Americans while not excusing those crimes. Anthony and Chuck both had the most telling things to say about this and Anthony said it well enough for them all. He talked about how the enemy in Iraq respected no rules of engagement, made things deeply personal by their methods of attack, and failed to respect innocent lives the way Americans do by putting non-combatant women and children directly in harm’s way, all of which increased the level of dehumanization and moral confusion. Via the narratives of Anthony, Chuck and others, women and children were used to carry suicide bombs & grenades, innocents were used as human shields and left for dead with the specific goal of allowing them to be filmed by news crews for propaganda and misinformation. “No longer are women and children off the chopping block. All is fair game (for the enemy)… That’s what makes it so easy for a soldier to commit... war crimes.”, he said. These tactics both underscore the importance of our own rules of engagement and also help to explain what has made it more difficult for our warriors to remain professional. Taking a life: From callous to contextual. Defining the enemy precedes what it means to take the life of another human being during wartime. This question was one of the most important in the study. The resilient responses held mostly congruent beliefs between global and appraised meanings. The highly traumatized responses were highly discrepant. Here, the responses were more confused and contradictory, but the direction was toward those of the resilient group. Anthony’s responses were telling and thorough. He talked about his engagements with the enemy as very personal while 210 reporting zero remorse. Unfortunately, his account appears to be more like emotional numbing than the depersonalizing that the resilient combat veterans discussed: (long pause) Every engagement is very personable, obviously, and someone is trying to take your life and you’re trying to take someone else’s life… But for the most part when I was engaging the enemy I had zero remorse. He was then able to talk about the importance of emotional distancing by using his observations of others. In these next two quotes, notice the extreme difference between reporting emotional separation and happiness, an emotion reported by the highly traumatized group, but not the resilient group: Umm, but I have seen guys that would falter during the instance when those emotions would arrive in the instance that they’re engaging and it would deliberately diminish their ability to engage the enemy. …I still have my moments where that’s happened to me, but overall I was very much so separated emotionally. There was a time like I felt like it was my job and I didn’t think it affected me in any way. I was excited. I was happy that I had killed somebody. I was genuinely happy (said with thoughtful and deep sadness). His reflections demonstrate the internal chaos of combat as well as the reappraisal process and possibly the uncertainty of his views during his combat experience: It was literally a roller coaster during my combat experience. I was very ready to get into the shit. And then the shit started flying, I guess I was kind of like a little kid in a candy story. Your very first life, umm (a barely audible sigh, then a long pause has he considers taking that first human life) ... The very first death that was a result of my hands, umm. I had done my job (choked up, nervous), heh. I got my badge of honor. That’s what everybody wanted at the time. Then a couple weeks later two of my guys die. Over these three excerpts, the unsettled nature of his experience emerges. He also talked about what this meant spiritually. He invoked his Christian beliefs in a manner that showed congruence between his global beliefs about war and the appraised meaning of the war in which he fought. Note that this belief is new, in line with the 211 resilient group, and is definitionally specific: For me, a lot of people use the term in the Bible ‘thou shall not kill’. But it’s not ‘thou shall not kill’, it’s ‘thou shall not murder’. There’s a huge difference there. Anybody and everybody who’s read anything in the Bible, there is so much war it’s not even funny. As I said from the beginning, ‘War is an evil necessity.’ …Even outside war, there is a big difference between killing and murder. I could kill anybody if I had to at any given time, if I had to, but I couldn’t murder…What is important is, “What’s the purpose? There has to be purpose in it. There has to be meaning behind it. He was not alone. Chuck’s experience of PTG regarding the meaning of taking a life during combat can be summed up in the excerpt below. I asked him how his spiritual views had been reinforced or changed. They had indeed changed considerably from an idealistic, but callous view toward a more serious and mature assessment: …but now after combat, after having actually gone through it, my view has changed from being this cowboy type, kill ‘em all type 17 year old, into somebody who has experienced war and conflict. I've come out the other side and realized it's more of a survival… with everybody just trying to survive over there. I believe in the nonaggression principle. I’m not a pacifist. I believe in selfdefense. And I also believe that it’s sometimes necessary to make a preemptive strike. However, making that preemptive strike relies heavily on the judgment of the people making that decision. His belief about taking the life of another person during wartime or as self-defense is essentially the same as that of resilient combat veterans, but he also demonstrates a degree of callousness which has unfortunately been a main component of United States military combat training: the emotional gung-ho mentality. By contrast, note that the resilient combat veterans were very deliberate about each decision to take a lifeNote how he did not have the prescriptive rumination that the resilient combat veterans had. He also points to the importance of knowing his actions were in line with his beliefs as more important than if the conflict was in line with his beliefs: 212 In the pre-situation I was so gung-ho-cowboy, then there was that right after the fact, I didn’t have time to really explore why I was doing what I was doing or whether it was justified or not, and I could care less about the label of the organization of the people who we were fighting were… I just knew that they were willing to engage us so, as long as they were playing the game... and now I have more care of the world and I am more able to look at what historically brought us up to that point and probably now, knowing what I know I wouldn’t have agreed with the actions we’ve taken on as a whole there, but I would still say my actions on an individual level were justified. The following exchange I had with Chuck illustrates critical factors regarding meaning and the existential importance that of changes in meaning can have on one’s assessment of self after combat. Recall the extensive treatment of the difference between the translation of killing and murder in different Bible translations. Chuck had just been overt about his heritage as an Irish Catholic. Catholics use the 1611 King James Version of The Bible primarily, which uses the wording of “thou shalt not kill” in the 6th commandment. He was talking about what he believed regarding war and interpersonal aggression, when it was right, and when it was wrong. He asserted in general that he knew there was some sort of precedent for it in his upbringing, but he could not gather these thoughts to nail down the contextual differences. This sort of moment can only be hoped for by any qualitative researcher trying to shed light on the PTG process. Careful not to lead in one direction or the other I contrasted the King James, “Thou shalt not kill.” with other versions that say, “Thou shall not commit murder”, and asked him what he thought: I never really had thought about that. There's a different play on words there and how you look at it. (pause) That's vastly different. “Thou shall not kill”, it's a pacifistic approach as opposed to “thou shall not murder”, is about conflict with a competitor. (enthusiastically) Yeah, that would make more sense as far as… I guess that would rectify the dichotomy that exists between the two. That's kind of interesting, I had never really thought about that (thoughtfully and with barely subdued excitement)." 213 I believe I was witnessing a sentinel moment: accommodation through refined categorization, or a signature moment of meaning-making coping as a post-traumatic growth process right before my eyes. Being aware of bias, I want to be more skeptical, but Chuck’s thoughtfulness and affect present during this moment identified it as a a very important event that continued to resonate throughout the rest of the interview. For the rest of the interview after that PTG moment, Chuck had already consolidated his belief about the difference between killing and murder. He had yet to codify the difference between killing and murder before, but somewhere in his psyche it had long been there waiting for clarification. From that point forward, he spoke with increasing resolve regarding the context of taking a life: Obviously my spiritual views have shifted from organized religion of Catholicism into a more personal questioning introspective type situation right now where I can't contribute to any one particular thought process on it. However the moral function has remained the same. I still believe that, I still believe there is a difference between murder and acting defensively. Kenneth struggled immensely. When I asked him what he thought about taking the life of another during wartime his answer demonstrated an unresolved quality in his appraisal. Note in his narrative that he says the word “taking” but then can’t finish the words. This is tough for him; it is very personal: (very long pause, 13 seconds, then sigh, then) …heh, you know, this might actually be a lot easier for me to answer if I knew for sure that… I'm pretty sure we killed them. We were in a very tight spot (pause)… Nothing’s ever sequential, you're always fluid but it's what's in your heart. Taking… (pause) when I shot, I meant to shoot to eliminate, you know, the dude trying to shoot me. And I didn't have time to think about morality, even after I'm like… Survival, you want to go back home. It's not that you don't chicken out, I didn't chicken out. I fought. I shot. I shot until I was out of ammo. David contrasted his view of taking a life during his combat deployment with that of his current view. He described his view of taking lives during deployment this way, 214 “Kind of a hey, look what I did. I'm a combat vet now, woo hoo! We were like hey remember that firefight, remember the murders and all of that?!” Then he explained his views more recently which differentiated taking a life when it furthered the mission or was in defense of someone from taking a life that did neither: And you know with my conversion experience, that instantly (smacks hands) changed to woah woah woah, wait a minute. Nothing about that is good. Nothing about what I did, you know, was good when it wasn't helping another person. If he’s going to take my life or the guy next to me, well I’m sorry buddy, I hope that you are, you know… have listened to the Lord, because I’m going to make you meet him. In these narratives there is change in the form of meaning-making and post-traumatic growth. There is a sense of confusion and highly judgmental, emotional decisionmaking before and during combat which carried over after their deployment. The result was highly traumatized symptomology after returning home followed by changes in meaning. These changes led to reappraisals that were more about a sense of survival and self-defense with a new global belief that human beings are the same and should not be dehumanized. To partake in this dehumanizing is a form of avoidance coping, discussed in the next section. It may be the epitome of discrepancy of meaning when one sits in judgment of another while engaging in the same activity, especially when that activity is attempting to take each other’s life. The emerging changes here illustrate how they began to better deal with their combat experiences when they reappraised the meaning of killing as being about survival while carrying out their mission. Personal mortality: Positive change. Two major themes regarding their own mortality emerged. One often leads to what is known as survivor’s guilt. Why did I live while others did not? Anthony struggled with this, stating that this was his greatest 215 challenge: Actually what I found most often was, “Why is this happening to someone else and why not me?” That was my biggest challenge. (stammering) what you’d call survivor’s guilt.” The weight of making it home when others did not is a common struggle. Meaningmaking afterward is an important step and naturally takes on an existential quality. Chuck talked about how his experiences have affected him. In spite of initial postdeployment struggles, he was able to make meaning in such a way as to grow closer with others and more connected: I feel like being as close to death as I have been, I feel more in tune with the environment, the reality, in the people in this life in general. I don't feel as disassociated. This response is even more interesting considering the constant ostracizing Chuck faced during his entire deployment and afterward, which is illustrated below. How do growth-oriented combat veterans cope through meaning? (RQ2) The second section deals with the processes used to overcome or make sense of combat trauma by combat veterans experiencing growth-oriented outcomes. Several themes emerged from the data. As a capstone to this section, Chuck summed up the difference between remaining highly traumatized and experiencing posttraumatic growth, “You need to grow from it. If you don't, you're just going to repeat it, or you're just not gonna be any good to anybody because you're gonna let it control your every thought.” Growth-oriented symptomology. The symptomology characteristic of growthoriented combat veterans is best described as a change process or with “a before and after snapshot.” Each of these men experienced a point of bottoming out and also 216 reported fewer symptoms in the last month before the interview. This was after a period of posttraumatic growth. Anthony hadn’t been home long before his struggles with PTSD became problematic. This is evidenced by the following two excerpts. One mentions trouble sleeping due to nightmares, and the other is about the effects of his PTSD overall: …then I realized how bad my sleep was because I was having such bad nightmares. I had trouble getting to sleep. I had trouble staying asleep, and so I did my damnedest not to sleep intentionally. As far as combat I would say it's evenly affected me for the good and the bad. The bad being, I was only home three short weeks before I was incarcerated for assault with a dangerous weapon and that was directly related to my PTSD. I hadn't yet been diagnosed, but it was very much so stress disorder that contributed to my offense on top of other things, but… His reference to good was related to his life having more meaning during the posttraumatic growth process. He was more spiritual, open with others, and honest with himself. When Chuck returned home from his 13 month deployment to Iraq his struggles were not over: I started going to group therapy once a week. I was actually hospitalized twice while I was still in. Suicidal tendencies. They had me pretty drugged up at one point. The high of what they were pumping into me was 300 mg of Wellbutrin a day, 800 mg of Seroquel, 500 at night and 300 in the morning, and 40 mg of Prozac. More recently Chuck’s symptoms were still present, but much improved: I wasn’t one who was really startled really easily by loud noises or anything like that. It didn’t really bring back a lot of memories rushing back. I still dream of the military every night almost. It’s not always bad or necessarily destructive dreams. I just feel like I’m stuck over there again and sometimes I feel like I’m still in the military and even though I’ve been out since late 06 crowds really get me a lot. I get really anxious and impatient and people (at the grocery store) will be just reading labels and I’ll be thinking just pick one and go... I’ll get snippy... That is probably the biggest effect I have is that I get really anxious with a lot of people 217 around. When I asked David how his experiences affected him after returning home, he said: At first, things have changed a lot between first coming home and now. At first (pause), say I did the same things most other people do. I avoided things while I'm driving down the road because that could be an IED even though it's just a paper bag. And in your mind you know it's just a paper bag, yet you still do everything you can to avoid. …My wife tried to scare me from around the corner once and just being punchy just being silly. But before you know it… I didn’t actually contact her with the hand, but you know, this was, it was heading towards her head before you know what's going on. Umm, anger, oh! (with deep emotional affect) instantaneous, unexplainable (pause)… Not really, anger is really the wrong word. (nodding) rage. (pause) Rage, for no reason. I could be walking through the house and if I was carrying a pencil and drop the pencil on the floor that was the trigger. Pretty sure I would pick up that pencil and throw it at the wall or I would punch the wall. Or I would do some sort of violent physical outburst that was sometimes pretty severe. Meaning-Making Coping During Deployment. Threat appraisal and emotional reactivity. The growth-oriented group was not always growth oriented. During their combat experience and afterward they struggled in ways similar to the highly traumatized group. While the following statement applied to Anthony’s attitude while in prison, it also was indicative of his spirit during combat. Note that although this is a personally affirming statement, it is also an indication of threat assessment inherent in the highly traumatized interviews. In prison, "You're either the predator or the prey, and I'm too strong willed of a person to EVER be someone's prey." Appraisals of combat experience for this group were filled with high emotional reactivity and discrepancy consistent with the highly traumatized group. This can be seen between these two excerpts from Anthony’s interview. The first relates to how he felt when he first got to combat. The second illustrates the breakdown of an idealistic worldview after losing close friends he was serving with: 218 It was literally a roller coaster during my combat experience. I was very ready to get into the shit. And then the shit started flying, I guess I was kind of like a little kid in a candy story… There was a lot of hate, there was a lot of depression, there was a lot of sadness. It was a very rough mourning process. I didn't get to mourn. I'm still mourning. (long pause) I mourn for their deaths, for the way they died. I mourn for the fact that I feel helpless, I still feel helpless. I couldn't do any damn thing about it. I couldn't have done nothing to prevent it. I couldn't do nothing to help the situation. I couldn't do nothing after the situation. Absolutely nothing. Kenneth noted a difference between his expectations and his actual experience of combat. Note the threat appraisal and high cognitive and emotional reactivity as he recalls his initial reactions to being fired upon: You always picture, you hear the shots, you hear the booms, you know exactly where it's coming from… You have no idea where the hell it's coming from. So that initial, “Holy shit this is really happening. Where the hell is that coming from?” The next step is, “Oh yeah, dumb ass. Go seek cover.” And then start moving, but where you go. Like, “Oh my God.” Many in this group used emotional numbing during combat, which appears to be due to Threat Appraisal, rather than the professional calm talked about by resilient combat veterans. Note the contrast Anthony describes between emotional separation and the alternative of an emotional crash: …we had to separate ourselves emotionally at the time to do what we do. Because you can't spend a lifetime killing people and be comfortable with that if you're fully emotionally in tune with yourself, unless you're psychotic, you just can't do that. …You have to separate. Because if you feel, you can't be in the middle of crying and bawling and saying 'I'm sorry, forgive me God', and at the same time be pulling the trigger. It's not gonna happen." The intensity of these emotions, while instrumental in his survival and the success of the mission, also put him and others at risk by decreasing his sense of self-control. Note his own reference to being beyond the professional level of emotional control: It was up and down. At times I was a raging frickin bull. I didn't really give a crap about rules of engagement. I was too emotionally in tune then. It's now beyond 219 the professional level. That and (pause) I was ready to kill. There was no (pause) I guess there really was no right and wrong. I mean I knew what I had to do, it started keeping my ass out of trouble and doing the right thing. I knew right from wrong, and I wasn't exactly going to do something intentionally wrong, but if it happens so frikkin what. I didn't give a shit." Lack of peer support: Failure & shame. Unlike the others, Chuck did not experience this highly emotional reactivity while he was in combat. He reported the experience of combat much more like resilient combat veterans, “Let's see here… (long pause). Personally it was just kind of a fight or flight situation. I really went into an automatic reflex; I didn't do a lot of introspection about what was going on obviously.” He went on to describe the prescriptive rumination that is characteristic of the resilient combat veterans in the sample, “I do think it's the right mindset. I think you have to have a clear head and philosophy well sculpted out before you get into an engagement.” His experience illustrated that even resilient combat veterans can be worn down when they do not have the support structure of their peers. Social support during and in between combat operations is also an important factor. During an important opportunity to return fire on the enemy, he let an enemy get away because his racing thoughts could not positively identify the fleeing person as an enemy. They were dressed as civilians. From this point forward he was ostracized by his unit: ...at the time I will really wasn't necessarily thinking clearly in that sense because I think I didn't have the support structure of my peers while I was over there, and if I would have went up to my sergeants and said hey I don't think I'm ready for this or whatever, I think it would have been ostracized even more beyond that or ridiculed more beyond that. Being ostracized placed him in an emotionally vulnerable position where he was unable to experience positive social coping, indicating the importance of peer support during traumatic experiences like combat trauma. 220 Meaning-Making Coping after Deployment. Combat veterans from the growth-oriented group did not fare well upon returning home. Again, their initial meaning-related responses were similar to responses from the highly traumatized group, followed over time by changes that resembled those of the resilient group. Interestingly, although there is some overlap, there is a very strong tendency toward either negative coping or positive coping, but not a mix of the two. David, after undergoing his salvation moment, went from being highly traumatized to pursuing a career in the ministry. He had become an ordained minister prior to the interview. When discussing his immediate post-deployment coping which was overwhelmingly negative, I asked him if he did any positive processing of his struggles. He replied while shaking his head, “Not really. Not really.” This was a characteristic pattern of the group. In fact, while his example of change is the most extreme in the study, each of them could recall that they struggled to a point, and then at some particular point things began to change. This indicated growth as both event and process. Hyper-vigilance and threat appraisal. These veterans perceived their combat experiences to be highly emotional, causing them to either react emotionally or utilize emotional numbing to compensate. When they returned home, this did not appear to change initially. Anthony explained how the hyper-vigilance he displayed in combat was protective and appropriate for combat, but that he understood more recently that it was not appropriate back home: Overall, my vigilance played a huge part [in getting incarcerated for assault with a deadly weapon]… I was way over-vigilant. I perceived a threatening situation to 221 be a lot more dangerous than what it was. And to be honest with you, if I would have reacted the exact same way while I was deployed there's no way in hell I would've ever gotten in trouble. Not one bit. David contrasted the powerlessness during combat with the powerlessness he felt when he returned home, but he had trouble finding the right word until I suggested it based on what he was trying to say: Oh absolute powerless. You bet ya! (pounds hand on the desk)… but you still have these things you have in your head that you don't even know are there and I'm thinking… they are trying to get out in force, they are trying to say “hey, we're still here!” Agh! So little things, whenever you get that sense of helplessness or not being in control of something and, instead of just like “okay it's cool”, it all comes back to you at once. And then you do… You don't know what to do about it, or at least I didn't. So what do I do? I hit a wall, I kick the wall, I punch the door, I threw a pencil, I bite my hand to the point of excruciating pain to make it, to cause… I don't know why, and I couldn’t imagine what the outcome is. I know what the outcome is, it calmed me down. It got rid of it. (pause) what else do you want? I'm sorry. Note how the intensity of the emotion seemed to push the question out of his thinking even as he was describing it. His anger was not just at himself but was over powerlessness: Oh! One thing I didn't mention before was very selfish viewpoints when I first got home. I was holier than thou, in my own mind. Everybody else was a slut or they dressed poorly, or they smoked (he whispered to give effect to his hypocrisy at the time) I smoked at the time. (back to a normal voice) I was doing the same things they were doing. (Belly laughs) I was judgmental, oh my goodness! In ways you could not imagine! And everybody else's blah blah life is out there. You know, and smoke and… While I'm smoking… And that's how I initially processed things when I got home. Present here is his ability to judge his past behaviors, and live forgiven in the way that he claimed, without reliving the shame associated with the past. He was truly happy and having distanced himself considerably from the negative judgmental way he viewed the world, it was no longer shameful to point out those terrible views. Chemical dependency and avoidance coping. Unable to deal with these 222 extreme emotions they became desperate, turning to whatever worked. For Anthony, the inability to calm his hyper vigilance led to emotional numbing and avoidance coping. Note that he was not aware of a problem when he returned to the military base, but also note how immediate his realization was when he returned home to family. The base had the military familiarity and routine, but he was not prepared for homecoming: We did our normal drinking, went out with women and there wasn’t a single problem and I never experienced nightmares, flashbacks, or any separation feelings. Really, none of that. I was just a normal soldier coming home wanting to have fun. But as soon as I got home, very quickly I’m talking within hours, I realized there was a, huh (nervous laugh, followed by choking up and tearing up) there was a problem. …I didn’t know. I didn’t really, I knew something was wrong, but I didn’t really fester about it. I didn’t really dig into myself about it. I didn’t care to. Because I felt like I was a soldier: (long choked up pause) I’m above this. It’s weakness. Umm, whatever’s going on it’s going to pass. It’s normal. Then he talked about what followed: Umm, so I drank, then you know things kind of tumbled over one another, they just kept falling outta place, things just kept getting worse. Then I realized how bad my sleep was because I was having such bad nightmares. I had trouble getting to sleep. I had trouble staying asleep, and so I did my damnedest not to sleep intentionally. So I, the only way to do that was to drink and party, look for the next thing to keep me going. I stayed as busy as I possibly could. Service members take pride in being the ones to look out for the safety of others. They sacrifice their time, and many sacrifice their lives. They take pride in being strong. Asking for help is not a normal response for them. They have been taught to think resiliently and not to accept defeat. It may also be important to note that none of the resilient combat veterans mentioned going to bars or womanizing, nor did they consider it normal behavior for themselves. Anthony went from utilizing drinking and womanizing as avoidance coping strategies to most recently believing these behaviors were not healthy. His growth-oriented attitude toward those behaviors was now similar to that of 223 the resilient group. He makes a strong case for actively facing those fears and emotions in order to recover: You know we [men] don't like dealing with those hurt feelings so we stay away from them. And that's why a lot of soldiers turn into alcoholics and drug addicts. That's exactly what I did, and look where it got me. But from that (referring to prison), I've done leaps and bounds since, and I realized it was just brutal honesty. I had to attack my weaknesses. You have to. It's an absolute necessity. If you are going to successfully integrate into society, into the family life, be a good father, be a good mother, be a good husband, a good wife, you have to be honest with it. No matter how painful... you have to be open to it. David focused on the discomfort of an overactive adrenaline response. It scared him to think what could happen so he did all he could to avoid it. Like many highly traumatized veterans, he tried to numb all emotion because it was the intensity of emotion that scared him: Umm, if anything would happen that would get me startled, you know startled and the adrenaline kicks in, I did not like that sensation so I would back away. Like I used to do the bike riding thing, it was cool, you know I would want to go skydiving and you know, and all this great stuff. I eliminated all of that stuff. Me: emotional numbing? Yeah, very much so. Very much so. Not just emotional numbing, like all encompassing lifestyle. Everything has got to be kind of a baseline boring grey. Yeah, life was grey. That's a good way to put it. Chuck did not report chemical dependency. In fact, his experience demonstrated a loss of meaning through being denied shared meaning with his unit. Recall that he was ostracized for a mistake and that afterward he began to reappraise his actions in an ongoing manner which emulated the resilient combat veterans. His global beliefs regarding his own actions weren’t shattered, but he was denied the ability to consolidate any positive changed through shared meaning with his unit members. Kenneth talked about how he no longer goes out and parties or drinks. He said 224 he used to be the life of the party, singing and being a bit crazy. Dennis talked about when he first realized he was “not the same”, he “wasn’t normal”: Yeah, I started drinking more. I wanted to necessarily… I wanted to avoid certain things that I realized that maybe in the past I enjoyed, but that I didn’t enjoy anymore. The common thread to their negative coping styles was avoidance. They avoided painful memories, daily struggles, and the effect their post-trauma symptoms were having on their lives and relationships. Perseverance / grit. Until one can come to deal with traumatic events with less distress they must persevere through these internal struggles. Like all veterans, but particularly the highly traumatized veterans, this group presented with perseverance and grit. Anthony even tied it to the need for perseverance during the recovery process illustrating again its difficulty: My wartime decisions taught me that I was capable of a lot. I’m a very strong person. I’ve been beaten into the ground by war. I learned a lot about myself. Mainly just how strong I am... how much I can endure, how much, how much further I can prosper. Umm, just overall you know, just nothing but positives about myself. I’m more in tune with myself. I had to be during my recovery process. Chuck demonstrated perseverance throughout his combat deployment. He endured his entire combat deployment mentally and emotionally separated from his peers until he finally broke down, which was after their return. Therapy and suicide ideation. Therapy and pharmaceuticals, either alone or together, constitute the most common approaches to the treatment of post-combat mental health difficulties. Unfortunately, finding the most appropriate approach for each 225 veteran is not always successful. Chuck tried to see a civilian therapist, but it was too expensive: Umm, [initially] I really didn't do anything to process it at all. And when I started getting back into one of those funks; I would have one of those bad dreams, I would wake my fiancée about every other night. She talked me into going to see somebody, but the cost was pretty prohibitive. Eventually I stopped going to see a therapist at that point in time. He tried again at a later time, but found a therapist that really was not experienced at working with veterans: it was really hard when I got into the civilian world a couple years later and tried to do it again because the people I was talking to, the therapist really couldn't relate to the situation much. While some had negative therapy experiences others were more successful. Dennis began seeing a therapist about six months after he returned home because his drinking had gotten out of control. He was still seeing that therapist at the time of the interview and he felt that he had been helped in many ways. When all else failed, some took on a suicide ideation. David described how this process emerged for him, and he speculated tentatively that it was likely similar for many others. It is important to note that as his life was closing in on him, it was paramount to him that whatever happened, he would rather hurt himself terminally than hurt another human being. Though each person contemplating suicide must find their own reason for turning away, David turned toward his belief in a higher power: If you think of it like you're walking down a path. You start out wide, right? As you're walking, you're walking, you're walking, it's like walking into a forest. The trees are getting darker and bigger and scarier and you're walking further and further and the path gets where eventually you're going to get so bound up tight with all of these things that you’re like a watch that's just tightened too much. You have to keep going, but there's gonna come a point where you're gonna break. And unless there's something… and forgive me for saying this or whoever reads this article… Unless there is something beyond what the world can offer then 226 we’re always going to be catching up to help these people. (pause) if you can look beyond what the world has to offer like what I did… well I didn't do it, the Lord guided me to it, then the peace that surpasses understanding, the salvation… and yeah, you know what? There still are problems. There are huge problems. But now I know what to do with them. Does that make any sense? While he found the exit from that dark path through a faith perspective, Chuck found meaning in the search for meaning. He talked about his brush with suicidal tendencies: When I was still in the service I started going to group therapy once a week to deal with the way his unit members ostracized him. I was actually hospitalized twice while I was still in. Suicidal tendencies. They had me pretty drugged up at one point… I kind of became that punching bag for them. Unfortunately when we got back from the theater I couldn't change it. I was being ostracized; I think that led to a lot of problems that I had with trying to deal with the things that I had to deal with at the time. The negative path tended to lead to increasingly negative consequences both internally and externally. Eventually, for David and Chuck, suicide appeared to be the only way out without directly hurting anyone else. Loathe to harm anyone, they simply wanted it all to end. For them, at least, there was an answer in changes to their global belief system and in reappraisal of at least, but typically more than, their combat experiences. Initiation of posttraumatic growth. When I asked David to contrast his experiences when he initially returned with how he most recently felt, he sighed and then said, “Oh, 180°… East from West…” After an initial period of deep struggle, each of these growth-oriented combat veterans experienced a moment when it all began to change and they began to look at life differently. Although the process happened most often over an extended period of time, they could recall a moment when things changed. Beginning at some pivotal moment or identifiable timeframe they began to be able to see that their problems stemmed more from the way they looked at the events of 227 their lives than from the severity of those events. They began to take full responsibility for their own decisions and see the world in a more realistic and less idealized way. Instead of internalizing shame and judgment from the past, they began to make changes, learn from, and growth from those experiences. David had perhaps the most striking experience regarding the initiation of posttraumatic growth. As the final question in the interview, I asked him if there was anything else he would like to add. At the time of the interview, he had grown from a self-proclaimed judgmental racist to an ordained minister. The following statement was utilized earlier when talking about forgiveness. For David it was also the point of initiation of posttraumatic growth: Yep, and I'm going to make this very short because this is all of this (the interview) in a nutshell. How do we… what was it? Recover from combat? (long pause) I, because I can't say other veterans, (then very calmly, deliberately, and slowly) I recovered from combat through salvation in Christ; Period at the end of the sentence. Anthony was, in his own words, very stubborn. He articulated how difficult the first steps of change were for him: For me it's been (long pause), most importantly it was forced on me. I had no damn choice. It was either change or spend the rest of your life in prison, because the attitude I had, believe me, I would have more time (in prison) than I had. Even after initially going into prison he was not ready for change, but a chaplain who was also a Vietnam veteran pushed him hard to look inside in order to begin the change process. He was able to take a look at the direction he was headed and make that change. He credits his time in prison as the catalyst to change because he was too strong-willed to look inside. He credits the work he did with that one Vietnam veteran as the beginning of change. At the interview he articulated a growth-oriented response to 228 both of these effects: I’ve used all the bad for good. I’ve come out of it. With my family life (family legacy of violence) and my track record (2 years in prison for violence), I should be a broken down junkie loser in prison. Chuck experienced major changes overall as well. Not considering his combat experience a good thing, he knew he had grown from it. “I wouldn’t say it was necessarily a good experience. It’s not what I would take from that, but I think it has made me better for who I am today.” His troubles seemed to stem less from the experience of combat and more from what he felt was betrayal by his peers. Recall that many of his beliefs held up during his deployment, but being socially outcast for a mistake during that time hurt him deeply in spite of those beliefs: I think a lot of my mistrust wasn't so much in the operational aspects with that kind of stuff, but my mistrust was being able to confide in my fellow soldiers about some stuff… the problem was when you don't have trust you can't necessarily be on your game. He began to reappraise his combat experiences only after he exited the military and was no longer surrounded by those who ostracized him daily. He had already begun to make the changes after his first combat mistake, but he was not afforded the opportunity to recover socially until he could be surrounded by those who were not holding it against him. When I asked Kenneth how he felt he had dealt with his combat experiences he said, “I, I, (stammering slightly) I make it every day. Umm, (long pause) I don't know. I would be more inclined to answer that more in the middle ground.” Later in the interview he added, “Umm, (pause) it's, no… Not having a release. [I] don't really go out and sing anymore. I'm not really into partying or drinking anymore.” Note his tentativeness and uncertainty as he seemed to be figuring it out as we spoke. Of the 229 growth-oriented combat veterans, Kenneth had the lowest score, while higher scores tended to coincide with a greater sense of certainty and confidence in their new beliefs. He felt like he was growing up, but did not like the idea that this also meant that he was becoming less tolerant: What has gotten better is, I think I'm growing up. I'm not the carefree… spend money; go from payday to payday… I save money now. I look at things like I have a higher value on things. It's a trade-off. (pause) it's a trade-off. (laughs) so in some ways I'm growing, but in other ways I think I'm becoming more closed minded, and not as tolerant. While one part of him wanted to believe in the goodness of doing his own thing, what emerged from his narrative was a realization that he needed to take things more seriously, plan ahead, and make difficult decisions, however uncomfortable. Dennis talked about how his drinking got out of hand and he stopped enjoying things he use to like to do. And then he found a really good therapist: I started seeing [my therapist] about six months after I came back. I started seeing him about twice a month for the first year. It was pretty good. It made me realize some things. For him, this was the beginning of change. He said he still sees this therapist and is helped through ongoing issues ranging from his deployment to his marriage and also managing daily stress. The moment he decided to face his issues he began to see change, but it was a process he was still going through even years later. These combat veterans, like the highly traumatized group, began their military experience with a fairly idealized worldview. In spite of a basic understanding of the realities of war and combat, they were mentally unprepared for those challenges. They did the best they could and persevered, but when it was time to reevaluate themselves and their experiences, most did not initially have effective coping skills. Chuck began to 230 get those coping skills during his combat experience. He began to formulate a decisionmatrix much like the resilient combat veterans, but he was not allowed by his peers to move on. This illustrates the importance of both effective meaning-making coping and social support during and shortly after the experience and trauma of combat. For each of them, however, there was a point when it all changed. Each path of growth began at the level of their global beliefs once they reached a foreclosure on the adequacy of their initial beliefs. From judgmental to forgiveness. As I asked them how they viewed themselves and others, their views indicated a change from an initial judgmental toward a more thoughtful sense of forgiveness of self and others. Anthony challenged his previously rigid beliefs. He said, “I have a better understanding of the importance of both sides. There’s always two sides to a story. There’s always two views.” Chuck demonstrated a sense of forgiveness of himself that was important for his own positive mental health: You may have done something right or wrong. If you did something wrong it's not going to do any good going forward letting that run your life. You need to use that and figure it out and get your mind right again so that when and if it does happen again, you're already ready and prepared to deal with that situation. He continued to make the case that meaning-making coping is of prime importance to recovery. Chuck continued, “You need to grow from it. If you don't, you're just going to repeat it, or you're just not gonna be any good to anybody because you're gonna let it control your every thought. David’s description of how he was judgmental and even racist, but gave that up in exchange for an understanding that all people are the same, could go here as well. Becoming forgiving and learning to let go is a core theme of recovery for growth231 oriented combat veterans. Accessing emotions & deliberate rumination. A number of reasons exist for combat veterans to hide their emotions. Anthony discussed this in terms of the early socialization of boys regarding emotionality: Back to the human nature thing, as little boys growing up we were taught from both our parents that it's never okay to cry. It's not okay to cry really. I'm not saying every single household is that way, but in this society we're taught it's not okay as boys to cry... it's unmanly to cry... it's considered a weakness. This is important, as he cried several times during the interview and it was evident that he now considered crying an important emotional expression. He followed on with emphasis: If you feel like crying, cry. Period. That's all there is to it… Umm, obviously when it comes time to do your job, you have to be in a certain state. There is a right and wrong state to be in, so when you're in that situation, you know? For me, what has worked is I've displayed it in this interview itself. It is openness and honesty, pure openness and honesty. I've engaged the hurtful, the heartbreak, and the painful. Whereas most of the time we stray away from those things. We don't want to feel that. [But] you have to go back to it. You have to go back to it. You have to know how to go back to it. You have to know it's okay to go back to it. Chuck agreed with the importance of sharing his feelings and being open without criticism. He said, “I think what helped me deal with it the best in the past is, to be honest, being able to bounce things off my fiancée without unnecessary criticism. He continued to stress the importance of facing those memories and fears. When asked what he felt was most important for combat veterans to recover, he said: I tell other veterans that there are resources out there, but when it comes down to it, they're just gonna have to understand that this is their fight. They might not be on the battlefield but they still have their own war that they're gonna fight internally and they have to fight with just as much diligence and see their way through it like they saw their way through the desert. They can make it through the desert, there shouldn't be any reason why they can't make it through the aftermath. 232 Dennis talked about the importance of opening up. For him, it was with a therapist who understood his issues and believed in what warriors do. He put it this way: I see a therapist, a head shrinker. I've seen a head shrinker since 2006, since my first deployment. Me: has that been helpful or no? Yes. (emphatically) I see him at least once a month if not more depending on what I have going on. But yeah he's a pretty popular one. A lot of people see him. I thought at first I would have an issue with kind of sharing things you know, because he is like in his late 30s or early 40s, so he's about my age… He believes in what we do and what we've done and people like us, we wouldn't be where we’re at [as a nation]; we wouldn't have the freedom... What appears to be very difficult about this deliberate rumination is the focus on change. While undergoing this process, daily life is under review. While they are already distressed, this is one more task that is discomforting. Chuck talked about how deep his questioning was when he was challenging his previously idealistic worldview: When I used to look at something it was really more clear-cut for me. It was a yes or no answer, good guy – bad guy, there was always polar opposites. And now there's so much damn gray area, I just can't tell you this is a circle (pointing to a circle nearby), I'm gonna look around the circle, I'm gonna look at the outside of it and and I’m gonna go in and hit the circle from about 50 different directions. It's like I'm analyzing a course of action. All right, what am I doing now?... I'm just trying to get a really good grip on what's going on so I can make the right decision. But it used to be so quick (snapping fingers). Now I'm stepping back and looking at things, trying to look a little deeper, like “What are you really saying? What are you trying to really get at?” Though the deliberate rumination process is an integral part of the post-traumatic growth process, his narrative also illustrates the inherent difficulty daily life represents. A highly traumatized person would want to avoid any such added difficulty until or unless they were sold on the benefits of such internal questioning. Anthony was sure of those benefits and his growth seemed to be taking on a momentum of it’s own: 233 I've also learned from my own coping mechanisms. The key to that is knowing your triggers. That's the very first step after you've acknowledged there's a problem. Once you know your triggers, everything else just kind of falls into place behind it, because now you know when something's happening to you. How do growth-oriented combat veterans interact with others? (RQ3) The interactions expressed by this growth-oriented were similar to those of the highly traumatized group in many ways initially, but those interactions changed over time as a part of the growth process. What follows are descriptions of those interactions in their own words. David talked about dissociating from others initially. He also noted his wife’s perseverance in defiance of his attempts to push her away: Yeah, at first I didn't want to be close to people really. And I mean because okay great I'm home but actually, I wasn't married at the time and I had gone to Texas to see my then girlfriend and now wife. And I tried to break up with her, which is funny because she wouldn't let me do it. Perhaps the earliest in the growth process, Kenneth talked about the importance of being open during the growth process. Although in the interview he said he had not opened up to anyone that deeply, he had been afforded the opportunity to share his experiences in ways that regularly helped others, which he said helped him to cope. At the time of the interview he had been a Master Resilience Trainer for the Army program discussed in chapter 3. He was able to talk about his experiences and put them into a valuable context for others. When I asked him about the things he did that helped him cope he simply said, “My teaching. When I give these classes… Teaching has been a hell of a great outlet.” Even though he was only beginning the process of reappraising what his deployment experiences meant to him, teaching others and being open was of prime importance. Still struggling to make connections with others he turned to internet 234 gaming, MMORPGs (Massively Multiplayer Online Role-playing Games). He said, “One thing that sounds really goofy but one thing that has helped is social networking on the PlayStation three, PlayStation home. It’s kind of like The Sims.” For him this was about shared experiences with others. In real life he struggled with connecting with others because of a lack of shared experience, but in the game he would begin with something in common with those he met. Anthony talked about the importance of being open and honest with others. David talked about the importance of seeing others as family and being as kind to them as possible. Both have come a long way as each talked about difficult childhood experiences and learning how to forgive and even build on those relationships as part of their growth process. Pre-deployment judgment. This was a change for Anthony as he had an admittedly abusive childhood where he learned to look out for himself at the expense of others. He was even judgmental toward returning combat veterans who were falling apart mentally and emotionally: To be honest with you, before I deployed I was absolutely sick to my stomach disgusted from stories of hearing soldiers coming home and being locked up or killing their spouses or whatever the case might have been, or killing themselves because they were drinking and driving or riding a bike and drinking... [I felt it was] very much so their fault, that’s exactly how I felt. ‘You’re better than this! What the hell is wrong with you?’ And like, it just, the two didn’t come together for me. (pause) Now I know different... (very somber, choked up, voice catching, and almost in tears) And then I came home… Anthony signed on to be a career soldier. Just prior to returning home he was tapped for special forces, but an incident where he threatened a civilian with a handgun inappropriately landed him in prison. This was where he bottomed out. After a Vietnam veteran-turned chaplain very firmly challenged him to take an honest look into himself 235 he began the post-traumatic growth process, a process he expressed as a growing personal relationship with God. Kenneth talked about his tendency to judge himself and others more deeply prior to deployment. He talked about one particular bad decision which made him feel disqualified to go to church for fear of being a hypocrite, believing somehow that he had to be a better person in order to attend. David took the interview questions about family more deeply into the past. He talked about his mother’s extreme punishments which built a sense of injustice within him. He recalled running away at one point, but most significantly he was able to talk about how his mother very often shamed him, “Throughout my whole life, right.” I asked him if that played into his sense of judgment toward others. He responded with, “Oh yeah. Oh my goodness. Back then I didn’t judge her. I just accepted it, oh, it’s my fault. My fault. I internalized everything to me.” This sense of judgment toward self and others, instilled in them at an early age, played a role in their sense of judgment right up until they began to take important steps toward post-traumatic growth after their deployment. Less Patience For Selfishness. Kenneth talked about having a lot less patience for people who were more concerned with themselves than those things he considered to be more important. This sentiment was pretty wide-spread throughout the interviews, but particularly salient with him: I have a lot less patience for ego. (slowly) it's know-it-all, egotistical, my-way-isfrickin-right no matter what, unnecessary attitudes. I have very little patience for it. I'll start just tuning it out, and I also… I have a better appreciation for [important] things, but [not less important] things… When trying to explain this process he stumbled over his words until he ended with, “It’s 236 a work in progress.” Anthony talked about his loss of patience with others who focused on unimportant issues and were overly selfish and inconsiderate of others. David presented with increased patience with those he came across, but he severed ties with friends he considered self-centered and unable to support the changes he had made in his life. Military family: Struggle and support. For some, having a family history of military service was important. Anthony came from a military family, but one that was deeply wounded by the cognitive-emotional experiences of the Vietnam War and other conflicts. He particularly talked about his grandfather as “the best damn Marine a Marine could be” in spite of being an alcoholic, abusive, and a “piece of shit”. The incongruence is quite evident. On the one hand there is respect for military service like with the resilient group, but very different from that group, being highly emotionally reactive was normalized: I come from an entire military family. Just about every man previous to my generation has served in some way shape or form. My grandfather was a Vietnam veteran in the Marine Corps. Multiple tours. My father, my greatgrandparents, there's a lot of people like my uncles. Everybody served. …My grandfather was a Marine; he served three tours in Vietnam. Was injured; wounded in all three tours, very nasty combat. And he was affected his entire life severely. And I think it’s because the treatment wasn’t there. He continued with how contact with his family was both helpful and hurtful: Umm, one thing that they did while I was there that was helpful, the main thing was, I guess in their own ways, letting me know that they gave a shit. But there were those that wanted me to contact them first”. He found this offensive: There were a lot of people in my circle like that. And it really pissed me off. Those were the ones like, 'You know what? Fuck you! I'm not sending you shit. If I get 237 something from you, you'll hear from me!" Kenneth also came from a military and pro-military family, but like Anthony there was a greater disconnectedness than with the families of the resilient participants. For example, he did not learn of any meaningful wartime events in the life of his uncle until the uncle had passed away: Even my great uncle John, you know. I learned right before he passed away that he was a survivor of the Bataan Death March. I’m like, “Wait a minute, you’re telling me this after he passed away! Your’re telling me this now?! Are you kidding me?!” David’s father was a World War II veteran so his parents helped him to have a context for his experiences. Dennis talked about most of his family being supportive. He also was more specific in his attribution of learning to be open about his problems from his family while he was growing up: As far as dealing with them?, Umm just (long pause), you try to, I've always learned that you don't… if you get big stuff if something is bothering you, get it out in the open. If you got issues or if you feel someone else can help you out when you go through it it's not a bad thing to ask for help… That’s one of the things that I learned. I kind of learned growing up. But there was an element of incongruence in the family that had an effect on him. He had an uncle who was a Jehovah’s Witness. This was an important point in the eyes of Dennis, because what that uncle said came from a spiritual background that was not congruent to his own. He said: I had an uncle; one of my favorite uncles growing up was a Jehovah’s Witness. And he didn't believe... Well my uncle made it a point to… not necessarily out in front of people, but he told me on the side that he didn't believe in what I did. And I’m standing there in my class B uniform with my short sleeve shirt, with my ribbons on, and my unit tag. He made it a point to say to me that he didn't appreciate what I did and what I stood for. After my dad, his brother, served in 238 the Navy after Korea and got out before Vietnam. The sense of family support, including that which comes through shared meaning, emerges from these narratives as important to recovery. It is both helpful when shared meanings exist and hurtful when they do not. At times the veteran and family both must go through a growth process, and at other times adjustments may be more subtle as indicated by these accounts. Keeping it private. Overall, this group tended toward privacy even after they began to undergo their growth process. But with a greater sense of understanding they coped better with the challenges of dealing with others. Chuck put it well: ...as far as friends, they're friends, they asked the typical questions from when your buddy has come back from war. 'How many people did you kill?', that type of thing. All I would do is, I would never answer their question. I understood that they didn't know and they didn't know how to approach the situation so they were just gonna try to ask. What they felt was appropriate necessarily, wasn't. So I would always just make light of it and talk or give them some odd story, ha ha, or give them some funny story, I wouldn't really go on with the bad. Choosing to focus mainly on the reasons he kept things private while he was struggling, Anthony provided two answers. First, “… men don’t typically talk about their feelings. I guess it’s a pride issue, umm it’s something that’s hard to do. It’s not considered a manly thing to do.” He felt that this social construction, the rule that men do not share their feelings, made it difficult for him to open up when he needed to. His second reason was that he felt they would worry about him if they knew what he was struggling with and he didn’t want that. He said, “… I didn’t want my family and friends to fester. I didn’t want them to ask, or be asking questions, or be worried about me or anything.” Kenneth was a very private person. He commented on the ways that many of his 239 family members communicated before his deployment and afterward. He said, “And that's why gossip and all that stuff, I separate myself. I don't want to be a part of it.” He talked about how he used to be carefree and in many ways like them in their open gossip about others. When I asked him about his current relationships he said, “Almost… I mean (long pause) as a pure honest answer, solitude. Because I don't really, I don't really talk that much.” This was as true for his combat experiences as it was for his spiritual and religious views. He kept it all very private: I won’t even talk about religion with my wife. She will start talking to me, and I’ll be just like (puts his hand up indicating a blocking of conversation). You know where this is gonna go. I have no opinion. I just don’t talk about it. (laughs) That’s one of the few times I can actually go like this (puts hand up again as if to signal: stop) and she gets it. (laughs again). Family relationships: Inconsistent growth. When I asked this group of combat veterans about their family relationships they spoke about change before I even asked questions about how those relationships had changed, indicating that changes in relationships were quite evident. Anthony was able to discuss the overall positive change in relation to the initial highly traumatized phase he went through: My family has evolved big time…. [My combat deployment] has brought me and my family and friends a lot closer. (there was) a time it was tearing us apart because of me, because they knew there was something direly wrong with me, but they just didn’t know what the hell to say about it or whatever, and I didn’t know what to do, and they were scared. Overall, Chuck did not seem to think his combat deployment affected his family much, nor did he think they affected him much. In contrast with Anthony, Chuck’s family was more thoughtful in their approach to military issues like the resilient group although his explanation of their interactions with him indicated a tendency to worry. Also keep in mind that his experience with high-symptomology was socially induced through being 240 ostracized by his peers. He said, “I don't think it really affected my family. My only family while I was deployed was my biological family, my parents and my siblings.” He wasn’t married at the time like he was at the time of the interview. He did continue on about some of the family dynamics important to him, however: Umm, [my sister]… tried to be really supportive all the time, but it was to a point where it was sort of annoying, because I felt like she was trying to make me into a victim. And I didn't necessarily appreciate that, like how she would talk to her friends about me... Just treat me how I was and how I am. If I do something goofy because of [my combat experience] fine, recognize it, but I think I'm acting normal. The idea of not being treated like a victim was universal between all of the veterans in the study. Each of them knew they had volunteered, and they owned that decision. Chuck did note, however, that his mother worried consistently while he was deployed: They didn't make any really helpful contribution I don't think. They were just not asking me what I had done. My mom never even asked me once about combat at all. She just showed her support said she worried constantly, had her cell phone glued to her hip, and kept her eyes on the ticker tape on the national news in case my name or something would pop up. Kenneth noted how his brother was so used to him being carefree, impulsive, and “refusing to grow up”, that after Kenneth returned home from his combat deployments they could no longer relate to each other: I think he gets uncomfortable; he's not used to hearing a serious side of me. (pause, then laughing) When I start mentioning it, he's looking at me like “I have no idea what to say to you.” Because he has no idea how to respond, and I just kinda look at him and I shrug and change the subject. In this excerpt, a breakdown in communication has happened with his brother because the dynamic they once had no longer existed. This makes sense if one considers that relationships are built upon prior experiences, but in his case, his experience of combat changed the way that he viewed the world so much that it was as 241 if he was a different person when talking to his own brother. His mother had a similar difficulty accepting the changes he had undergone: Well my mom said for a while she was worried, but then I told her mom your boys growing up. She flat out said that that was one of the things where she said, You know, I never really thought of you as being a man until you came home and said that.” Taken together, these excerpts indicate that families are challenged to undergo the posttraumatic growth process along with their combat veteran in some ways, especially if that veteran undergoes a positive change as a result over time. Universally, this group referred to that change as growth and maturity. Intimate relationships: Mixed responses. Intimate relationships also changed as well. Anthony was divorced while he was deployed, but for him this was a good thing in his eyes, because in retrospect his ex-wife was not a nice person: That’s the opportunity that my ex-wife took was when I was deployed. When I was helpless. I couldn’t fight for the marriage or do anything. I was divorced while I was deployed and that’s changed my life as well for the better. At the time of the interview he was in a much newer relationship, and although he was working through some anger, he was very actively managing it and working to continue to get better. Chuck found it helpful to be able to talk to his wife. He said, “Yeah, I kind of bounced ideas off of her, emotions off her quite a bit. She's been good for that.” He sounded genuinely appreciative. Kenneth and his wife were in very different emotional places when he returned home from Afghanistan: My wife and I didn't connect, it took us time. I mean even intercourse, it took us a while. After the first trip it was hard because it was like, she asked if I had been cheating on her. And I was like, “No, you don't understand, that's a part of me 242 that I absolutely had tuned out my whole trip there. I mean I didn't have time to think about that shit. She did say, “Oh, you're crazy.” This relationship struggle seemed to affect them for some time, but he continued about how he had changed for the better more recently: Ahh, I spend more time with my wife and my son, when she’s not studying or at work. With my son, I get to do more, I’m the authoritarian. I gotta be the bad cop. (laughing) Dennis talked about his relationships with his wife growing as a result of his therapist helping him with stress so that he did not lean on her too much: I try to leave as much heat off of my wife as much as possible. I try to make myself a really small target, you know, hopefully be able to defend myself. The way he presented his relationship with his wife indicated that he needed to maintain more of a balance with her. He gave two main issues his therapist helped him resolve. One was that his combat experiences would likely overburden her and his therapist helped him overcome his tendency to make decisions without her input, to which his reference about being a small target referred. Civilian friendships: Fewer, but closer. A pattern emerged whereby close friendships endured, while wider friend-networks shrank. As they became more serious about life, they pulled back to friends who were either able to relate to their experiences or look beyond them and continue the friendship as best they could in the manner it was before the combat deployment. Overall, less meaningful relationships fell away and more meaningful relationships, which tended to be fewer in number, grew closer. Anthony noted that the personal connection and support of his friends was what pulled them closer together after deployment. Initially they were supportive, but couldn’t help 243 him since he was not reaching back. Then, when he began to change for the better, these relationships grew: As far as my friends go, my real friends… I wouldn't say they personally went hand-in-hand through the struggle with me, but they're still there… I was talking to one of my closest buddies. I never really realized how much they really gave a shit (he began to cry again) but they were actually worried about me. They were really worried about me. Chuck, however, struggled more. Unable to connect as deeply with his friends after having combat experiences to which that they could not relate, he worked at establishing a level of contentment with them based on their shared experiences before combat. His military service in many ways was incongruent with his pre-deployment lifestyle: They just couldn't relate, none of them were in the military. I don't think any of them were even on a sports team let alone in the military, so we just tried to kind of move on with life as kind of how it was before I went. The least growth-oriented veteran in the group, Kenneth struggled with old friends while making new friends who he could relate to in different ways. He still needed a greater degree of social distance than the other growth-oriented veterans in the group. Online gaming allowed positive social ties while affording him greater flexibility and control over the relationships than traditional friendships: My friend list is shrinking… I went from having so many friends, it’s sad. My online friends help, because I don’t really see them, I spend so much time at home that I don’t really go out. Now if I run into people we can reconnect, we can catch up quickly. But that is far and few between. I hardly see any of my old friends… It’s kind of similar to my family, but my family is stuck with me. I don’t think they’re ready for the serious me. I’m so out of character, and I can see it live because I’m so far out of character from even the way I was. I was so frivolous and crazy, crazy but controlled. I’ve always had a crazy side, but my crazy side has been (making a shrinking gesture between his thumb and forefinger) sheeeeewwwwww. Like, holy cow. Being more serious and mature put him at odds with the friends of before who 244 resonated with his “frivolous and crazy” personality. Regarding friendships for this group, post-traumatic growth is aligned with maturity. Becoming more mature and less idealistic, in his understanding, interfered with the shared meaning dynamic of these pre-existing friendships. David had talked about how he had a very small network of friends who were supportive when he was deployed, but “After I came back there was nobody. No friends.” He further talked about how he tended to focus more on family than friends both before and after his deployment. Joseph agreed with the others. He said it this way: The friends that you have you become stronger with and you have a stronger bond with them. I have found that I don’t necessarily hang out with as many people as I used to just because I don’t hang out and have as much free time as I used to. The theme of fewer friends, but with stronger bonds was consistent throughout these growth-oriented narratives. Veteran friendships: Less significant. For the growth-oriented combat veterans, while they were still in a highly traumatized state they held other combat veterans in much higher regard than during the growth phase. Looking at all of the accounts and comparing relationships with the highly traumatized group and the resilient group, one factor emerges as the most likely reason for this. The highly traumatized combat veterans in this study presented as judgmental and distant from others, when combat veterans become growth-oriented they no longer share these judgmental attitudes toward others and begin to focus increasingly on more longstanding friendships and family members they are now able to relate to more easily. David talked about how his interactions with veteran friends have stopped as a 245 result of his growth experience. To clarify the reasons he had mentioned for not maintaining these friendships, I asked if it felt like they were reminiscing in the past and he was moving on. “Yeah! That’s a very good way to put it. A very good way to put it.” Kenneth said that some military friends had been helpful while others had been difficult, “There are friends I’ve lost, I refuse… I can’t talk to them. It’s not that I refuse, I just can’t. They claim this.” He held up a piece of paper he wrote on a few minutes earlier waiting for the time to bring it up. The paper said only, “PTSD”. He was referring to friends who were drawing benefits from the VA, friends he said had not even left Kuwait, or who did not see combat action. Summary The initial global belief systems of these growth-oriented combat veterans, in their own words, were idealistic, and could not sufficiently explain the experience of combat trauma. Like the highly traumatized group, they persevered through their experiences, often led by emotions where adequate appraised meanings could not be made. These extreme emotions led to deeply embedded traumatic memories which attempt to surface after they returned home as intrusive rumination along with other traumatic symptoms. Initially unprepared to deal with these troubling emotion-laden memories they initially coped through avoidance strategies which generally proved unsuccessful. At some point afterward, however, a moment when post-traumatic growth occurred. This was typically a change in global beliefs which led to a reappraisal of not just their combat experiences, but their entire lives through deliberate rumination strategies. Figure 4.3 shows the progression over time, with Initial Global Beliefs and Shared meanings to the left of the dotted line, representing the beginning of the combat 246 trauma experience. Just like the highly traumatized group, the initial global beliefs and shared meanings of these growth-oriented combat veterans were idealistic and unable to account for the experience of combat. This led to a shattering of world assumptions or global beliefs, because the appraised meanings did not match their original global beliefs. There was great discrepancy between what they believed they would experience and what they actually experienced. This shattering of global beliefs led to a series of processes failures which led to initial avoidance coping. Unable to cope with the combat experience through congruent assimilation of events into their global beliefs, they appraised combat as threatening rather than challenging (threat appraisal). This threat appraisal focused their attention on survival which inhibited their ability to make changes in their global belief system. Accommodation was not possible at the same time for them. In the post-combat phase, they exhibited avoidance coping strategies in the same or similar manner as the highly traumatized combat veterans. They were initially unable to successfully accommodate their experiences meaningfully into their global belief systems until a moment when they began to change these global beliefs. This is depicted in Figure 4.3 as the explosion shape when these beliefs changed and the post-traumatic growth process began. During the final phase of reappraisal coping they reported that they did not only reappraise their combat experiences, but a total reappraisal of their entire lives. This top-down total reappraisal supports the finding that global beliefs drive meaning-based growth processes. 247 Family of Origin Shattered Initial Global Beliefs Shared Meanings Change in Global Beliefs PTG Initiated Process Failure Idealistic Global Beliefs Process Failure Incongruent Appraised Meanings Combat Coping Threat Appraisal Total Reappraisal Post-Combat Reappraisal Coping Figure 4.3 Grounded Theory of Growth-Oriented Meaning-Making Coping 248 Process Failure Post-Combat Avoidance Coping Group Comparisons (RQ4) Overall Impression The first three research questions were answered in the previous sections. The beliefs of these combat veterans differed greatly between outcomes. The meaningbased coping methods utilized by these combat veterans differed significantly by outcome as well. Further, the social interactions of these combat veterans differed considerably based on the outcomes they reported. Together, these findings could have important implications for the field of traumatology. Comparison of Beliefs Most importantly, the world assumptions of each combat veteran had the greatest influence over his outcome. For the resilient combat veterans in this study, having a belief system that could adequately explain their experiences was the single most prominent factor. Specific contextual beliefs held great value for them, but these were nestled within their world assumptions, or global belief system, and it appeared that the collective coherence of their worldview was of greater importance than the sum of the parts. In other words, having explanations for different aspects of the experience of trauma is valuable, but having a global belief system which allows for adequate explanation of all or nearly all aspects from the same global perspective is more than just cumulative, because the beliefs support each other as a whole allowing for more detailed and complex deliberate rumination. Global belief systems / world assumptions. The global belief systems contained themes that differed between outcomes. A direct list-wise comparison of global beliefs and appraised meanings can be found in Table 4.1. The resilient combat 249 Table 4.1 Comparison of Global Beliefs and Appraised Meanings. Common Beliefs News Media Society Naïve Resilient Combat Veteran Beliefs Global Beliefs / World Assumptions Comprehensive World Assumptions Prescriptive Rumination Benevolent Relationship with God Sustaining Faith Military Context Congruent appraised global meaning of war Congruent appraisal for their war Resilient enemy combatant appraisal Taking another's life: Contextual Resolved Personal Mortality Highly Traumatized Combat Veteran Beliefs Global Beliefs / World Assumptions Initially Idealized World Assumptions Shattering of World Assumptions Intrapsychically Defined World Assumptions Judgmental World Assumptions Spirituality Incongruent with War Reactive / External Locus of Control Military Context Congruent Meaning of War Inconsistent Appraisal for Their War Military Service as Struggle Enemy: Dehumanize and Judge Taking a life: Deeply Personal Loss of Buddies: Hatred and Judgment Growth-Oriented Combat Veteran Beliefs Global Beliefs / World Assumptions Initial Global Beliefs: Naïve and Idealistic Shattering of World Assumptions Growth-Oriented Global Assumptions Growing relationship with God Increasing Faith Forgiveness by God, Self, Others 250 Table 4.1 (cont’d). Military Context Incongruent Military Factors Congruent Global Meaning of War Increasingly Negative War Appraisal Enemy: Positive Redefinition Taking a Life: From Callous to Contextual Personal Mortality: Positive Change veterans possessed comprehensive global belief systems that adequately explained their combat experiences from a practical, as well as existential perspective. The initial belief systems of the highly traumatized combat veterans in this study, by contrast, were idealistic and naïve by their own estimation. At the time of the interviews they had come to believe that the world was a far darker place than they originally thought. They projected a sense of judgmentalism onto themselves and others. For those that were spiritual, this emerged as a sense that they were under condemnation for their actions. For those highly traumatized veterans that were not spiritual, this emerged from an atheistic perspective with an understanding that if God existed, he could not both be good and allow the horrible events they experienced to have happened. The growth-oriented group generally began with these same naïve world assumptions as the traumatized group, but at some point in their highly traumatized state their global beliefs began to change. This, in turn, allowed them to reappraise their combat experiences and indeed their entire lives. Interestingly, their reappraisal process led to changes in global beliefs in the direction of those from the resilient group. In conclusion, when shattered world assumptions begin to be replaced with world assumptions which adequately explain the events of trauma, particularly combat 251 trauma, the reappraisal process appears to begin to shift from unwanted intrusive rumination toward active deliberate rumination. This deliberate rumination appears to stem from the understanding that the reappraisal will lead to better understandings of the events and decreasing distress. The direction of these new adequate world assumptions was conspicuously, but not exclusively, spiritual. With a more adequate global belief system in place they no longer have to avoid the painful memories. They begin to consider them more constructively. Similarly Appraised Meanings. The Common Themes section in the beginning highlighted two main themes. First, the News and Media was a source of frustration for all of the combat veterans in this study. Second, and in the estimation of many of these combat veterans, American society was considered naïve by them. This they attributed to complacency and misinformation by the news media. Regarding appraised meanings that remained in their individual sections, other comparative themes emerged. The first theme included for each group was the Difficult Experiences theme. Although these themes were similar enough to be placed in the Common Themes section, they remained with their group in order to provide context to the specific participant narratives of that section. One theme ran through all of the interviews regardless of outcome. Every combat veteran in the study still believed that there was a time for war and that war, although horrible, had a place in the world. Their reasons differed, but in general, so long as there will be those who want to attack others, there must be a force able to defend, and defend with overwhelming force. Again, this theme remained with each group, because it provided a context for the congruence or discrepancy found for that group. 252 Regarding similarly appraised meanings, the trend appears to be that these combat veterans were all in agreement that there is a time for war, a sentiment consistent with their military service. As beliefs became more personal, differences began to emerge. These differentially appraised meanings appear to help explain the outcomes that combat veterans achieve after they return home. Differentially Appraised Meanings. Perhaps the most important appraised meaning emerging from the study was the meaning of taking another’s life during combat. To set the stage, however, it will be instrumental to contrast what each group of veterans thought about the enemy. Unanimously, the resilient combat veterans believed that their enemies were just like them. This was important in that it led them to “love their enemy” or at least respect their humanity. They depersonalized the experience through an understanding that both they and their enemy stood on the battlefield for a cause greater than themselves so it was not personal. For this reason, they also refused to dehumanize their enemy. This is in contrast to the highly traumatized group, which defined their enemy more personally and adversarially. The highly traumatized group overall did not express forgiveness, but judgment and dehumanization, in order to overcome the inhibition to take another human life. The growth-oriented group went to combat with a judgmental, cavalier attitude toward their enemy, and in line with the growth process came to believe in the sameness that the resilient combat veterans believed, though more tentatively at times. This leads to the meaning of taking a life during wartime. To each veteran in the resilient group, taking a life during wartime was less about the act and more about the context and the mental process. The highest priority for each of them was the difference 253 between taking out a threat and harming innocents. This was echoed over and over throughout their narratives. They talked about making the decision to pull the trigger based on the actions undertaken by any potential threat. Simply being an enemy combatant did not make them a viable target. This was different for the highly traumatized group. One recalled being taught that all violence was wrong as a child, and he had difficulties letting this go during wartime. Another had no problem taking out the enemy. But afterwards he described the deeply personal feeling that he wished he could take it back, indicating that on a deeper, possibly existential level, he was not so convinced what he was doing was right. Trouble depersonalizing without dehumanizing emerged as a central theme running through these narratives. Again, the growthoriented group’s wartime experience was similar to the highly traumatized group. They talked about how they were more callous, cowboy-like, or unprepared for the events they faced during combat. After returning home, these experiences haunted them for a time, but once they began to reappraise their situation more congruently through a more compatible global belief system their symptomology began to lessen. Taken together, these narratives tentatively indicate that taking a life during combat without deep ensuing traumatization requires the assurance that such an action is for a cause greater than oneself, and for the most resilient outcomes even justified spiritually and religiously. Further, in cases where an atrocity is committed the capacity to feel forgiven through some process congruent with their current global belief system appears to be needed in order to recover from the trauma. Note that the global belief systems of highly traumatized combat veterans did not allow for forgiveness because, presumably the actions undertaken could not be undone. 254 Finally, the appraised meaning of the war(s) each fought differed based on outcome, but this was of lesser importance than both the world assumption that war is acceptable if horrible and the execution of personal agency within the guidelines of one’s belief system. Resilient combat veterans unanimously believed that the war(s) they fought in were justified, though not always soundly planned or carried out. This leads to a tentative conclusion that believing in the cause for war is consistent with resilience. Highly traumatized combat veterans were more inconsistent in their appraisal of the war(s) in which they fought. Uncertainty about the justifications for war or beliefs that are incongruent with the war at hand may play a role in causing one to question the validity of their actions during wartime. Unfortunately, the experience of the growthoriented combat veterans did not seem to move from negative to positive so neatly. They appeared to have learned a lot about their war after their deployment as a component of their deliberate rumination. Although the trend in their assessment was that their war was, in their newer estimation, unjustified or not as clearly justified as they once thought, their new more negative assessment did not appear to inform or hinder their growth, that is, unless having a greater understanding is healing regardless of the negativity of the more-informed view. Other appraised meanings tended to fall in line with the earlier themes, moving from less judgmental toward forgiveness and letting go, but only after a change in the global belief system. Comparison of Meaning-Based Coping Meaning-based coping patterns between outcomes did emerge, and fairly strongly. Table 4.2 lists the meaning-based coping skills utilized by each group. But more importantly, meaning-based coping differed based on the level of meaning 255 Table 4.2 Comparison of Meaning-Based Coping Themes Resilient Combat Veteran Coping During Deployment Challenge Appraisal Combat Normal: Professional Calm Effective Assimilation After Deployment Deliberate Rumination Forgiveness and Understanding Little to No Therapy Needed Lack of Negative Coping Highly Traumatized Combat Veteran Coping During Deployment Threat Appraisal Failed Assimilation and Accommodation After Deployment Failed Assimilation and Accommodation Intrusive Rumination / Reliving Low Self-Awareness Dependency Coping Unsuccessful Therapy / Suicide Ideation Perseverance and Grit Growth-Oriented Combat Veteran Coping During Deployment Threat Appraisal and Emotional Reactivity Lack of Peer Support: Failure & Shame After Deployment: Initially Hyper-vigilance and Threat Appraisal Chemical Dependency and Avoidance Coping Perseverance & Grit Therapy and Suicide Ideation Initiation of Post-traumatic Growth From Judgmental to Forgiveness Accessing Emotions & Deliberate Rumination discrepancy present in their experience. Highly traumatized combat veterans consistently utilized avoidance coping due to the extreme distress of painful memories. Those in the growth-oriented group were able to initiate the growth process through a 256 change in global beliefs which triggered a change in coping strategies from avoidance oriented toward deliberate strategies geared toward reappraisal. Comparison of coping during combat. While these veterans were still in combat they utilized the coping strategies available to them at the time. These resilient combat veterans each had a comprehensive and adequate belief system which allowed potentially traumatic events to be appraised as challenges rather than threats. One significant belief that translated directly into a meaning-based coping mechanism was that each of them believed that if they died they would go to heaven or similar afterlife. As such, each of them was able to appraise events through a focus on their own processes in those moments instead of being overwhelmed with thoughts of mortality for themselves or others. Their beliefs acted as a template or a call to action that they could follow. By focusing on making appropriate decisions within their beliefs they were better able to maintain a professional calm awareness. Since these events were appraised to be within the scope of their global belief system, they were effectively able to assimilate experiences or accommodate through adjustments to that existing system. By contrast, the highly traumatized group tended toward threat appraisal with a focus on existential threat. Becoming highly emotional in these moments was common for them, described with words like terrified, awesome, anxious, comedy, and shaken. These men did not shy away from their duties. What their narratives indicate in contrast to the resilient combat veterans is that their internal dialogue was pushed into emotional overdrive because the threat of negatively existential outcomes made it difficult to focus on their cognitive processes. They had training to fall back on, and this emotional content is no indication of their combat effectiveness, but the accounts of the resilient 257 combat veterans were clearer and more deliberate by comparison. Due to this emotional flooding and the discord between their global beliefs and the events they were experiencing, effective assimilation and accommodation occurred to a far lesser degree than for the resilient group. One veteran reported that he stopped caring if he died in response to this existential threat. He reported that this was protective for him, though he was singularly the most troubled combat veteran in the entire study. The dynamics of his lack of fear of death was very different from that of the resilient veterans. Again the growth-oriented combat veterans in this study reported similar threat appraisal, heightened excitement, and a focus on fear-filled outcomes. This led to assimilation and accommodation failure. In one case, the extreme emotions were coped with through emotional numbing in a state of “zero remorse” at times and through barely controlled rage at other times. For one growth-oriented veteran in the group, a global belief system similar to the resilient combat veterans was broken down by constantly being ostracized by his peers over a mistake pointing to the importance of total unit cohesion even for otherwise resilient combat veterans. Overall, meaning-based coping during combat was similar for both the highly traumatized veterans and those who would eventually become growth-oriented. Comparison of coping after deployment Resilient combat veterans did not suffer the deeply debilitating effects that so many ascribe to combat. Although they each had some level of post-trauma symptomology, the levels they talked about were normal physiological responses such as taking a knee in automatic response to a sudden loud noise. They also reported 258 being able to return to normal very shortly after symptomatic episodes and even laugh at the apparent contradiction within the peaceful context of home. Their narratives were full of themes echoing forgiveness, understanding, and letting go. Only one resilient veteran reported seeking therapy and his reason was symptom management as opposed to emotional crisis. Also of note was a lack of negative coping. Not one resilient combat veteran reported utilizing avoidance coping strategies. After returning home, the highly traumatized combat veterans and those who would become growth-oriented continued to struggle with intrusive rumination. The highly traumatized veterans seemed to have a low sense of self-awareness, which may or may not have preceded their tendency toward avoidance coping. Many struggled with intrusive memories which sometimes came to them more like reliving the past while simultaneously being in the present moment. To deal with these unwanted thoughts and memories and their associated emotions without an adequate global context they resorted to whatever worked. Avoidance coping took on the form of emotional numbing, chemical dependency, adrenaline dependency, and social dissociation. They reported, predictably, that attempts at therapy were unsuccessful with one veteran even reporting that therapy made it difficult for him to forget the past (avoidance). Finally, it needs to be said that this group of highly traumatized combat veterans had one very important coping mechanism. They all exuded some level of perseverance and grit. The ability to go on day after day, with extreme discord between one’s global belief system and deeply troubling events which yet have no answers, is notable. The coping strategies utilized by the growth-oriented group upon their initial return from combat deployment were overall negative. They struggled with hyper- 259 vigilance and continued threat appraisal. They reported emotional numbing and avoidance coping, and chemical dependency. This group, while in their highly traumatized state, also exhibited perseverance and grit until they were able to reappraise their experiences. Every growth-oriented combat veteran can point to identifiable moments when their worldview began to change. Afterward, they began to utilize different meaning-based coping styles. Among the reported growth-oriented coping styles was forgiveness of self and others, becoming more understanding, and having a new openness about their experiences which ranged from discussion to the expression of emotions including deep sadness. They began to shift their meaningbased coping from avoidance-based strategies towards active pursuit and access of emotional content and deliberate rumination in order to reappraise not just their combat experiences, but their entire lives. Comparison of Social Interactions from an Ecological Perspective Interesting group-wise trends in social interactions emerged. Table 4.3 below lists the Social Interaction themes for quick comparison between groups. As expected the resilient combat veterans exhibited the most positive interactions overall, highly traumatized combat veterans struggled the most interpersonally, and the growth oriented group returned home to struggle, but with positive change beginning concurrent with their growth-orientation. News media as macrosystem feedback. Ecologically, a positive feedback loop is one that moves the system away from its equilibrium, making it more unstable. This is confusing nomenclature because the effect of this was negative overall from the perspective of every combat veteran in the study, making the news media in their 260 Table 4.3 Comparison of Social Interaction Themes Resilient Combat Veteran Social Interactions Decreased Tolerance for Immaturity Keeping It Private Post-Combat Family Interaction Families of Origin: Shared Meaning Intimate Relationships: Less Supportive Fewer, but Stronger Friendships Veteran Friendships / Brotherhood Highly Traumatized Combat Veteran Social Interactions Social Dissociation Disconnected From Family Active Culling of Friend Network Closest to Veteran Friends Growth-Oriented Combat Veteran Social Interactions Pre-deployment Judgment Less Patience for Selfishness Military Family: Struggle and Support Keeping It Private Family Relationships: Inconsistent Growth Intimate Relationships: Mixed Responses Civilian Friendships: Fewer, but Closer Veteran Friendships: Less Significant opinion a negative positive feedback mechanism. The overall effect of the news media regarding the wars in Iraq and Afghanistan was to decrease support for them over time through negative and decontextualized coverage. In some ways this theme may seem out of place, but the news coverage of these wars affected them through their interactions with others. As shared meanings were found to be an important theme related to positive coping for each group, coming home to be surrounded by people who have a decreased sense of shared meaning, fostered by news that is at odds with their experiences, seems detrimental. Overwhelmingly, the veterans in this study found the news media to be biased 261 against both wars. Often, when they spoke to civilians back home it was not unusual that a person would take what the news had said over the word of a veteran who had been there. At least one was called a liar because his experience did not match the news that person was watching. One recalled how outraged people were about the mistreatment of Iraqi detainees while the story of the thousands of people murdered by Saddam Hussein in the same prison, Abu Ghraib, went almost unnoticed. Another recalled how the news did not report the finding of weapons of mass destruction. He said there weren’t many, but they were there. The resilient combat veterans were the most understanding. They talked about how it bothered them that the news always went for the negative stories because it is what sells and the news networks survive on ratings. They thought the reporting was not fair to the troops on the ground, who in their own words did far more good for the Iraqi and Afghan people than the news ever showed. The highly traumatized group felt similar to the resilient group about the portrayal of the wars in the news. In line with their highly judgmental belief systems, their narratives described the news as false, filled with ignorance and propaganda. The growth-oriented group fell in the middle with their current opinions about the media being quite negative, with one veteran using the word disgusting to sum up the portrayal of these wars. Aside from the level of judgment, what all of these narratives have in common are as follows: First, that the news was biased in ways to which every combat veteran in the study was able to independently and personally attest. Secondly, the biased news affected the support of the people for both wars. True, society had begun to learn not to 262 hate and ridicule the troops who were doing their job as with Vietnam Veterans, but damage had still been done. With support waning in light of news they believed was largely inaccurate or decontextualized, the effect on the enemy was to embolden them. Further, with news outlets putting information out for the world to see, the enemy had a larger advantage than they otherwise would, putting lives at risk. More than one veteran mentioned the danger posed by this over-indulgence in leaked information-gone-public. The final, and possibly most important concern, was that a lack of public support hurt morale and for the reasons mentioned above, put lives at greater risk. For the veterans in this study unanimously, the news played an overall negative role in the wars they fought. Friendships. Interactions with friends differed by outcome. Resilient combat veterans tended to value close friendships more, deepening these close friendships while allowing a sort of natural selection of more distant friends who had less in common. They found these friendships to be supportive both during and after their combat deployments, indicating that these friendships had an enduring quality. Although some friends could not relate to the specific experiences of the combat veteran, what existed was a sense of mutual respect and often a still-shared worldview. Highly traumatized combat veterans in the study actively culled their friend networks down severely. One maintained “one and a half friends” while another claimed no non-veteran friends after combat at all. It could be reasonably speculated that the reason for this was that their existing friends still held the idealistic worldview that the veteran originally held, and while he did not yet have an adequate worldview with which to make adequate sense of his experiences he could no longer relate to them either. 263 The growth-oriented group tended to shrink their friend networks while deepening the relationships that remained. This appeared to be a function of taking life more seriously and deliberately. Friends who were supportive of this change remained and grew closer. Importantly, friendships depend partially upon shared narratives and shared or similarly understood experiences. Those who could either directly relate to or grow with their combat veteran friend remained in their social network. The most difficult situations appeared to exist for the highly traumatized group, who could only relate to a very few people after their combat experiences. Family Relationships. Families represent a source of initial meanings, initial coping skills, and initial social interactions. The narratives of these combat veterans contained much information on how interactions between combat veteran and family members before, during, and after their combat deployment, played a role in the outcomes they experienced. The resilient combat veterans in this study reported having positive family relationships before, during, and after their combat deployment. In four out of five cases, their family of origin was overtly religious; the 5th participant’s single mother was supportive of him attending youth groups and church with friends. Their families were also pro-military, with all but one having other family members who had served or also were still serving. It was also evident in their narratives that because of these factors they could talk about their experiences openly with at least some family members. The theme running throughout was that military service is honorable as a sacrifice in the defense of others. 264 The highly traumatized group reported more fractured family relationships and inconsistent support. One mother was against all violence and did not approve of either of her sons joining the military. Both went to Iraq. Steven felt disconnected from his family of origin when he returned home. Wayne felt disconnected from family, claiming they were not helpful or hurtful. Overall, these families were supportive of their veteran in a general sense, but could not relate to them meaningfully, highlighting the importance of shared global beliefs in both a spiritual and military sense when compared to the resilient group. The growth-oriented group’s interactions with family members again resembled the highly traumatized group before, during, and immediately after their deployment. Family support, however, was more mixed during and after deployment. One important difference that seems to emerge is how much those in the veteran’s support system understand what they went through either through shared global meaning, shared experiences, or both. Family relationships seemed to grow inconsistently or piece-meal, which would make sense because those family members did not directly experience the life-changing events of their veteran family members. Though the direction was toward becoming similar to those of the resilient group, this was made more difficult by two factors. First, their families of origin did not always share their new global belief system. Secondly, these veterans had already been highly traumatized and unlike the resilient group they had to overcome the difficulties caused by their symptomology while also managing a changing belief system, which is psychologically traumatic in its own way as every belief is reappraised. Overall, the importance of a supportive family was indicated, but in order for that 265 support to be the most helpful to the veteran the support needed to include two factors. First, that support needed to have a shared belief system which included the existential dimension where questions about life and death are answered. Second, that support needed to be able to relate to the military experience, most often by having served, demonstrating a profound respect for service or having been a supporting family member of someone else who had served to demonstrate openly that they understand the military experience. Intimate Partners. Intimate partnerships did not appear to figure prominently regarding meaning-making coping, but some interesting themes emerged which are worthy of mention. Resilient combat veteran partners were supportive, but had a shared global belief system less often than family members and so were not presented as particularly strong supports regarding the meaning-making process. Overall, the resilient combat veterans were guarded with their spouses, careful not to open up too much lest they become secondarily traumatized or begin to ruminate intrusively and worry. For the highly traumatized group, a coherent theme did not emerge regarding meaning making, but taking a step back from the research questions allowed another theme to emerge. Kevin had never married by the time of the interview, but did have two children by two different women with another woman he did believe would stay with him pregnant, indicating difficulties with commitment. Steven was married during his first deployment and was separated at the time of divorce. Wayne indicated on his demographic sheet that he was married, but in the interview it came out that he was separated from his wife for reasons not related to the deployment. Taken together, 266 these intimate relationships indicate a breakdown in family dynamics which needs further investigation. In the words of the veterans themselves, the reasons for the relationship failures did not relate to the deployment. The growth-oriented group’s intimate relationships were mixed. Anthony was glad his wife divorced him while he was deployed. Chuck said his wife was good to bounce ideas off. Kenneth struggled to reconnect with his wife after both deployments and in different ways. For him being in Afghanistan turned off his sex drive to the point that he had a hard time turning it back on when he returned, causing his wife to think he might have been cheating on her. Overall, when communication with partners allows for the combat veteran to share some of their experiences, they become a resource, and the relationship is likely to benefit. Because of the traumatic nature of their experiences, it is often difficult to share with a partner who may be a resource or may become traumatized in turn, and overwhelmingly these combat veterans had no desire to cause that sort of pain to any of their close relationships. Veteran Friendships. Resilient combat veterans in this study overall were able to strengthen relationships based on their experiences. They described the bond between themselves and other combat veterans as nearly indescribable. The term Band of Brothers seems to be only an indicator. The highly traumatized combat veterans in this study were similarly close to their veteran friends. However, the narratives of these interactions was more exclusive, as if to say “no one else understands me now”. Rather than drawing closer to all, they drew closer to only those they knew understood the experience of combat, highlighting the 267 importance of a shared context after combat trauma. The growth-oriented group’s experiences once again highlight aspects simply not available to the other two groups. Growing from the highly-traumatized state toward resilience, they are able to contrast their old way of thinking with the new. They once held onto those veteran relationships where they could reminisce in ways that their growth-oriented selves considered unhealthy and unhelpful. They had grown out of those relationships and could no longer relate to the friends they had been close to during combat. This raises an interesting observation. Having a shared context appears to be important, but only when one goes from the highly traumatized state toward the resilient state as with the growth-oriented veterans.When this happened, the difference in relationships emerged. In other words, not only was the shared context of combat important, but also of great importance was having a shared worldview or compatibly similar global belief system within the subgroup of combat veterans. Summary These findings are far-reaching and considerable. Global beliefs which adequately explain the events of combat emerged as the most salient factor. The second most important factor related to meaning-making coping was the importance of having members of the combat veteran’s support system who shared their global belief system. The five most resilient combat veterans identified as Christians with very similar worldviews. The results suggest that while other pro-resilient global belief systems may exist outside this sample, an intrinsically Christian global belief system appears to have been sufficient for them to handle the mental, emotional, and social rigors of combat. 268 The effectiveness of one’s global belief system to adequately explain the events of combat appears to lead to either a successful navigation of these events as a challenge to be overcome through a focus on processes and decision-making or a threat which induces highly emotional states of existential distress. These emotional states become increasingly more difficult to cope with if one is not adequately able to stand down and adjust their worldview to incorporate these experiences. Whenever a combat veteran is finally able to make adjustments to or completely alter his global belief system to incorporate these events, he moves from avoidance strategies intended to fight unwanted intrusive rumination toward deliberate rumination intended to reappraise life events more congruently within that system. In response to this, their symptomology begins to lessen, they become less judgmental, and their ability and desire to strengthen relationships with meaningful others is increased. 269 CHAPTER FIVE: DISCUSSION AND CONCLUSIONS Revisiting the Purpose of the Study Over 1.6 million service men and women have been deployed to fight the Global War on Terror (Seal et al, 2010), and although the rate is much slower than years prior, the number of combat veterans is still increasing 12 years later. Large numbers of veterans still need help coping with their combat experiences, and meaning-making coping is a major component in the growth that combat veterans experience after the trauma of their deployments (Larner & Blow, 2011; Park, 2008). In spite of renewed research efforts in the last decade to focus on post-traumatic growth, combat trauma in veterans has been largely ignored. Larner and Blow (2011) developed a model that brought several lines of research on combat trauma together, and this model served as a guiding framework for the current study. Increased knowledge of the meaning-making coping processes utilized by combat veterans and the meanings they make of their traumatic combat deployment experiences could prove invaluable to understanding the differences between combat veterans who experience considerably different outcomes in terms of adjusting to the traumas associated with a combat deployment The objective of this research was to compare the meaning-making coping efforts combat veterans make to better our understanding of them, and ultimately improve the treatment of veterans experiencing the trauma of combat. The study utilized grounded theory to allow the combat veterans themselves to inform the research about their meaning-making processes. To accomplish this, individual interviews were conducted with 15 combat veterans from the post-9/11 wars in Iraq and Afghanistan. Prior research has identified three primary outcomes that combat veterans are most 270 likely to experience. Some return home resilient, others return highly traumatized and remain this way, and still others are highly traumatized upon homecoming and at some point begin to change by undergoing a post-traumatic growth process. This growthorientation is of particular interest in order to understand how to help highly traumatized combat veterans recover post deployment. Qualitative data analysis was performed using a grounded theory approach with an analysis of each of the three outcome groups followed by a comparison of themes across these three groups. Approaching each outcome separately allowed for the greatest potential contrast which led to more meaningful explanations for why some veterans do well while others do not so well. Though much of the meaning-making coping process is intrapsychic, an ecological perspective was incorporated in order to provide context regarding the relationship interactions combat veterans have which are also related to the meaning-making coping process. This chapter will discuss the study findings of each research question in relation to the literature. Then the findings will be discussed in light of relevant theory, practice, and future directions. Limitations will also be discussed followed by personal reflections. Revisiting the Research Questions Research Question 1: Beliefs Relevant to Combat Experience The first research question was: What do combat veterans believe about their combat experience and their roles during and after their deployment? The resilient combat veterans had more positive and self-affirming beliefs regarding their combat deployment experiences than the other two groups. The highly traumatized combat veterans in this study had the most negative and judgmental beliefs about nearly every 271 topic they mentioned, including spirituality, family, friends, civilians, their enemies, the government, the VA, and the news media. The growth-oriented combat veterans in the study had initial beliefs that were highly similar to those of the highly traumatized group until they began their growth process. At this point their beliefs began to change and become more like those of the resilient group. They were more understanding and forgiving of others. Discussion of resilient beliefs. The beliefs of the five resilient combat veterans were remarkably similar. Having a definitive system of beliefs is important to resilience. Also the concept of shared meanings with significant others will be addressed more fully in relation to research question three, but its importance cannot be overstated as it relates to resilience specifically. According to the meaning-making coping literature, when global beliefs are congruent with the appraised beliefs related to the traumatic experience, distress is minimized (Park, 2005; Park & Ai, 2006). The resilient group discussed their global beliefs individually, but due to their espousing essentially the same faith-based belief system, their appraised meanings also were very similar to each other. The global belief system each espoused had attributes which were organization, certainty, and adequacy. Organization and certainty were primarily made possible because their beliefs espoused were externally derived. For example, many of these beliefs originated from their respective religious traditions. Organized religious systems such as Christianity and Islam have codified meanings to which believers can refer during difficult times. With each adhering to a faith based belief, system they were able to have meanings they could refer to in order to make sense of their combat deployment experiences. Having adhered to his faith-based belief system for some time 272 prior to their combat experience, each brought with him a level of certainty rooted in their faith tradition that they could turn to find answers when needed. Through their interviews it was determined that each one had used their belief system to adequately explain or come to terms with their combat deployment experiences. These findings indicate what is known as intrinsic religiosity, which has been shown to be correlated with positive outcomes (Ai & Park, 2005) and PTG (Park, Cohen, & Herb, 1990). Recall that intrinsic religiosity was defined in the literature as living out one’s faith as a means unto itself, providing life focus and meaning as opposed to extrinsic religiosity, which is characterized by utilitarian motives such as security and social status. Consistent with the literature, having a benevolent relationship with God and having faith that he would look after them (Kirkpatrick & Shaver, 1992) was protective. The study participants in this group expressed a sense of safety through vicarious control (Heckhausen & Schulz, 1995) in that they believed God would either ensure that they made it home safely or they would be accepted into heaven if they were to be killed. This allowed for greater congruency of meaning in that their lives were meaningful and also their deaths would be meaningful as well. This is in line with Thorson and Powell (1990), who found that intrinsic religiosity was instrumental in reducing death anxiety, and helping individuals not worry as much about what would happen in the present. Their faith belief systems allowed for positive appraisal of the various meanings related to wartime. They believed that there was a time for war and that the prime justification for war was national self-defense. As a group, they believed that the wars in Iraq and Afghanistan fit into this category and as a result they reported low internal 273 conflicts about the war purpose. Their faith system taught them that their enemies are just like themselves and that taking the lives of their enemies during war, unlike murder, was related to a cause greater than themselves and not for personal gain. These beliefs allowed them to depersonalize the experience of combat without dehumanizing the enemy. Kliman and Llerena-Quinn (2002) discuss the psychosocial dangers of dehumanizing others in the wake of the September 11 attacks. They advocate for service members to maintain a human perspective of the enemy and not trensform fear into retaliatory anger. This is viewed as protective. These congruent beliefs in the sample allowed for more effective coping strategies. Discussion of highly traumatized beliefs. The highly traumatized combat veterans in this study held initial global beliefs that they identified as both naïve and idealistic at the time of the interview. One major global belief that they discussed was the pre-combat belief that people were basically good. They also initially believed that spirituality and religiosity were naturally pacifistic. Unlike their resilient counterparts (who defined their global beliefs based on a codified faith system), the highly traumatized veterans defined their global beliefs in relation to only their life and combat experiences, rather than in relation to an externally codified faith-based belief system as with the resilient veterans in the sample. All but one of the highly traumatized combat veterans reported having no belief in a God or higher power. Kevin, the one highly traumatized veteran who said that he believed in God and prayed regularly, reported what Kirkpatrick and Shaver (1992) would call anxious attachment, This is considered a significant predictor of neuroticism and negative affect, which were present with this participant. After experiencing the horrors of combat they could no longer believe that 274 people were basically good. Their post-combat reappraisals were highly judgmental and even cynical towards both people and any notion of a higher power. They still believed that there was a time for war, and that it was for national defense just as the resilient combat veterans did, but the belief that spirituality and religiosity are pacifistic meant that they could not believe in these as they were incongruent with their beliefs about war and aggression. They expressed the experience of combat as deeply personal as opposed to the depersonalized manner which the resilient combat veterans described. This made the process of forgiveness and letting go very difficult for them. Although many combat veterans in the study talked openly about losing buddies, the highly traumatized group reported these losses in conjunction with feelings of hatred and vengeance. At least one study has shown that lack of forgiveness is a detrimental state for both emotional health and well-being and that individuals who hold onto the past do worse than those who are able to let go (Worthington, Witvliet, Pietrini,& Miller, 2007). Their beliefs regarding the war in which they fought were inconsistent between participants, unlike the resilient group. While they all agreed that there was a time for war, this group was not as certain when it came to the war in which they participated, leading to increased discrepancy of meaning which is in line with the meaning-making coping literature (Joseph & Linley, 2005). In addition, two participants in the traumatized group reported struggling with their military service, feeling betrayed by their peers or their leadership. This betrayal interfered directly with the process of shared meaning with their peers, leading to suicide ideation in both cases. It also goes against the values of the military, which espouse quality leadership and unit cohesion. Studies of unit cohesion have indicated 275 that it is a significantly important variable in adjusting to trauma, and is protective against suicide ideation (Mitchell, Gallaway, Millilkan, & Bell, 2012) Compared to the resilient group, the highly personal attribution of combat aggression for the highly traumatized group appears to be driven in part by negative appraisals of their enemies. Esses, Vanvliet, Hodson, and Mihic, (2008) found dehumanization to increase punitiveness and contempt towards refugees. Punitiveness was evident in the narratives of the highly traumatized combat veterans who supported dehumanization of their enemies as well. Due to the personalization of combat, they reported that they were more likely to act outside of their own moral code, feeling initially justified via dehumanization to do so. Unfortunately, once they crossed the line, they seemed to struggle more with negative self-attributions and self-judgment. According to their own moral code, they committed atrocities and were in need of forgiveness. When soldiers commit atrocities, the victims are not the only ones harmed, but so also is the combatant committing them, his unit, the army they represent, and the nation that army is fighting for (Yishay-Krien, 2009). This is made more difficult due to the very judgmentalism which permeated the interviews with the highly traumatized veterans. In short, dehumanization and forgiveness do not stand well together. If their definition of goodness and spirituality are indeed related to pacifism, their very participation in combat continues to be discrepant until they begin to see their actions as not only acceptable, but somehow positive. Faced with such deep negative emotions and discrepant beliefs, these highly traumatized combat veterans, in spite of their ability to endure combat, were not able to make positive meaning of their combat deployment experiences. 276 Discussion of growth-oriented beliefs. The initial beliefs of the growth-oriented combat veterans were in-line with those of the highly traumatized combat veterans. In fact, until the beginning of their post-traumatic growth process their narratives indicated that they were also highly traumatized. They identified their initial global beliefs to be naïve and idealistic, which led to a shattering of these global beliefs when confronted with their wartime experiences. At some point, after they had been home for some time, each reported a moment when they recalled that his beliefs began to change. They began to view their combat experience and indeed their entire lives differently. This deep reappraisal indicates that the process of growth after combat trauma is initiated by a change in global beliefs and not just the appraised beliefs of particular events. This is important and could help to explain the difficulty of instigating the change process. While Chuck was still in a questioning phase, the remaining four marked their growth with a faith-oriented spiritual growth led by a growing relationship with a higher power. All of them referred to their higher power as God. They also reported an increasing sense of faith and forgiveness. They reported that they felt forgiveness by God, which was found to be inversely related to many psychiatric symptoms (Bradshaw, Ellison, & Flannelly, 2008; Flannelly, Gelek, Ellison, & Koenig, 2010). They also forgave others, and they forgave themselves. When they began their growth process they reported genuine remorse for the way their original beliefs led them to act before. As the perpetrators of violence toward others, genuine remorse is the central construct which Gobodo-Madikizela (2002) theorizes transforms the unforgivable into something that can be forgiven. When talking about killing during combat they talked about how their 277 views were very callous. Terms like “Gung-ho” and “cowboy” emerged regarding their pre-deployment views. At the time of the interviews all of them spoke more respectfully about their actions when lives were at stake. Synthesis In conclusion, some beliefs are more amenable to the experience of combat than others. Those who believe that their participation in combat is justified in a positive manner personally, socially, spiritually, and religiously reported the best outcomes. This is supported by the finding by (Başoğlu et al., 1997) that strong convictions are even protective against the psychological damage of torture. For the participants in this study, self-justification for their participation was not adequate to create resilience or posttraumatic growth. Only those who were able to do so socially through shared meaning with significant others and/or through spiritual means, exhibited either resilient or growth-oriented outcomes. Particularly salient for the highly traumatized group was the theme of spirituality as pacifistic. This belief was present only for the highly traumatized group. They were able to persevere through the experience of combat trauma through a focus on survival, but afterward these combat veterans were plagued by intrusive rumination. At some point, however, some of these highly traumatized combat veterans found a way to look at their experiences from a different perspective. When they began the process of changing their global beliefs, they were afforded the opportunity for reappraisal of their combat experiences and also their lives before combat. This is consistent with (Joseph & Linley, 2005), and expands their findings by implicating global beliefs as the initiating change agent. These new global beliefs were not simply different, however. They most resembled the most externally verifiable aspects of the 278 faith-based belief systems of the resilient combat veterans. In other words, they focused on genuine spirituality and began to cultivate an attachment to God (Kirkpatrick & Shaver, 1992), while showing little interest in religious practices which they believed were not nearly as important as intrinsic spiritual transformation. Research Question 2: Meaning-Making Processes Utilized The second research question was: What is the process used by combat veterans to overcome or make sense of combat trauma? Armed with beliefs and associated appraised meanings, resilient combat veterans cope effectively through challenge appraisal (assessing events in a manner that focuses on overcoming or even profiting from them) with a focus on doing tasks to the best of their ability. In contrast, highly traumatized combat veterans reported utilizing threat appraisal (focusing on mortality and the potential to be harmed or even killed), accompanied with emotional flooding, and an inability to assimilate or accommodate their combat experiences. After they return home, some of them began to reappraise their lives through a change in their global beliefs, this post-traumatic growth process is what the growth-oriented combat veterans in the study reported as helping them cope with the entire experience more effectively, lessening symptoms, and encouraging them to rebuild relationships with others. Discussion of resilient meaning-making coping. The resilient combat veterans in the study recalled that combat did not change or even challenge their beliefs. This is in total contrast with the highly traumatized combat veterans who claimed that no one can know what combat is like until they experience it. Combat experiences appeared to strengthen the global beliefs resilient combat veterans held 279 prior to their combat deployment experiences. Because their beliefs were able to adequately explain the experience of combat in a congruent manner, their meaningmaking coping process was minimized. Though the veterans in the other two groups reported considerably more difficulty processing combat experiences, the resilient combat veterans reported that their beliefs afforded them the ability to focus more effectively on process-based decision-making. Overall, they utilized Challenge Appraisal strategies (Kibler & Lyons (2004), which focused on the potential to overcome stressors during combat. With this mindset it was possible for them to remain relatively calm in spite of the adrenaline rush that accompanied life-threatening situations like firefights. The combination of professional calm and challenge appraisal allowed them to assimilate events in the normal fashion. After their deployments the group of resilient veterans reported that they underwent deliberate rumination, a process in which they would become introspective and contemplate their combat deployment experiences. This deliberate rumination allowed them to reconsider their experiences, a form of double-checking, to ensure that they had acted properly or that events were recalled accurately. Interestingly, the difference in deliberate rumination for resilient combat veterans compared to growthoriented combat veterans is that resilient combat veterans were verifying their existing beliefs against their experience, whereas growth-oriented combat veterans were making new meaning. One important process for this group was forgiveness. Forgiveness has been linked to recovery from infidelity in couples for example (Maltby, Day, & Barber, 2004)and reduced mental health symptoms in military veterans (Witvliet, Phipps, 280 Feldman, & Beckham, 2005). Their ability to evaluate events with less affect than the other two groups allowed them to be more empathetic and understanding. It was acceptable to them that the enemy would try to kill them the same as they were trying to kill the enemy, and they did not take this personally. They were fighting for a cause greater than themselves, and they presumed their enemies did the same. This focus on processes led to more acute decision-making. They were very deliberate about who was considered a threat, and they made careful, but quick decisions about when to pull the trigger. Of the five, only John reported seeking psychotherapy. He said he did so episodically. He did not participate for long periods of time, but rather would seek counsel whenever he had surprising situations or symptomology he felt unprepared to deal with alone. None of the others reported seeking or even needing therapy. In support of this, I was unable to elicit any negative coping styles in spite of asking them explicitly after the first two resilient veterans failed to mention any. This only further solidified the differences between the coping strategies utilized by the resilient combat veterans and the other two groups. Discussion of highly traumatized meaning-making coping. The highly traumatized combat veterans reported that combat was nothing like they had imagined. With beliefs that turned out to be idealistic and naïve, the experience of combat was outside the realm of comprehension for them. Assimilation is the process by which people incorporate new experiences into their existing belief systems (Joseph & Linley, 2005). Due to the incongruence of the combat experience this was not possible for these highly traumatized combat veterans. As a result they tended toward threat 281 appraisal, characterized by mortal fear and extreme affect (Kibler & Lyons, 2004). Because of this heightened emotional state, they also were unable to modify their global beliefs or appraised meanings during their combat deployments. After they returned home from their combat deployments, they recalled diagnosable levels of PTSD symptomology and other difficulties. Intrusive rumination and reliving episodes are common among combat veterans (Hackmann, Ehlers, Speckens, & Clark, 2004), and these emerged as troubling obstacles to their meaningmaking process. In fact, intrusive rumination appears to be a cognitive strategy whereby troubling memories periodically resurface in order for reappraisal to occur (Bryant, Moulds, & Guthrie, 2005). When highly traumatized combat veterans are not prepared to deal with these intrusive memories, they utilized avoidance coping strategies. Unfortunately, avoidance coping is most often associated with negative outcomes (Bryant, Moulds, & Guthrie, 2005). These unresolved memories continue to resurface only to be pushed back down by more avoidance coping. Methods of avoidance coping common to these and other highly traumatized veterans included, but were not limited to chemical dependency (Fischer, 2006), adrenaline addiction, sexual addiction, and emotional numbing. Those that did attempt therapy reported that it was unsuccessful. Kevin , not yet convinced that reappraisal of his combat experiences had any positive value, specifically stated that going to therapy made it difficult for him to forget his combat experiences. While it is possible that this particular therapist was unskilled in helping him overcome his traumatic memories, this experience likely leads to individuals like Kevin along with many other combat veterans to feel they can never recover. As of 2012, combat veterans returning from Iraq and Afghanistan have been reported to be 282 taking their own lives at the rate of one every 80 minutes (Kemp & Bossarte, 2012). This highlights the importance of the present research. In spite of such negative experiences, the highly traumatized veterans in this study exhibited one positive coping strategy. Although troubled by the discrepancy of meaning and clinical levels of post-trauma symptomology, they persevere. Discussion of growth-oriented meaning-making coping. Like the highlytraumatized combat veterans in the study, the discrepancy between their global beliefs and their experience of combat inhibited assimilation and accommodation processes. In fact, those interviewed did not report any differences between these two groups until after they returned home. At some point, the growth oriented veterans (previously highly traumatized) reached a point of change that was triggered by inadequacies in their current belief system while they have enough information to contemplate a new belief system in light of concurrent appraisals or reappraisals. A moment when their lives began to change was identified by each growth-oriented combat veteran. At this moment, each of them reported that rumination became instrumental. Instead of avoiding the emotions and memories, they began to face them. This was made possible because the moment when they began the growth process they also began to find new meaning through a change in global beliefs. This would be one form of accommodation, which Joseph and Tudway (2007) asserted as the primary cognitive method of reappraisal if assimilation was not possible. The literature indicates that a decrease in discrepancy is related to reduced stress (Joseph & Linley, 2005). The finding that global beliefs are the first to change prior to the reappraisal process leading to post-traumatic growth is new and may add to the meaning-making coping literature significantly. The 283 growth-oriented combat veterans faced their past in the same manner as the resilient combat veterans, through deliberate rumination (Linley & Joseph, 2004). The difference being that the resilient veterans appraised their experiences as they occurred and growth-oriented combat veterans took much longer. They had a trigger that allowed them to enter a reappraisal process that allowed them to deal with the symptomology they incurred due to their initially shattered world assumptions. This was often a spiritually/existentially oriented focus which allowed them to benefit from meaningmaking coping which fostered forgiveness on a personal, interpersonal, and spiritual level (Davis, Hook, & Wirthington, 2008). This is not dissimilar to negotiating other traumatic events such as illness in one’s life (Blow et al., 2011). Synthesis. In conclusion, congruent beliefs allow combat veterans to focus on their decision-making processes, leading to resilient outcomes through challenge appraisal. Once beliefs are found to inadequately account for the experience of combat, the battle for long-term mental health has begun to unravel. During combat, threat appraisal is dominant, which increases the salience of mortal fears and engages cognitive-emotional processes. These in turn heighten vigilance in order to increase survival, a theme the highly traumatized group held out as the prime justification for aggression against their enemies once in a combat environment. Upon returning home, highly traumatized combat veterans must either face these discrepant memories like the growth-oriented veterans in this sample, and reappraise them more effectively, or remain in a highly traumatized state. The core of meaning-making coping in this sample was a change in global beliefs followed by a growth-phase dominated by deliberate 284 rumination during which discrepant memories are reappraised in light of the new belief system. Research Question 3: Social Interactions and Meaning-Making The third research question was: How is meaning-making coping related to the relationships veterans have with family members and other people who are significant in their lives? Resilient combat veterans overall drew closer to their significant relationships while highly traumatized combat veterans tended toward dissociation/disconnection and growth-oriented combat veterans moved from initial dissociation/disconnection toward reconciliation and restoration of significant relationships. Discussion of resilient social interactions. Social support has long been associated with greater coping after trauma (Irving, Telfer, & Blake, 1997). These resilient combat veterans talked about how their families of origin were very supportive of them. In fact, the family of origin (rather than family of choice) was most often a source of shared meaning related to both intrinsic religiosity and a pro-military worldview. A family legacy of both of these factors provided a level of cohesion not present in the other two groups, demonstrating the importance of both family-based social support and shared meaning. This is in agreement with Hook and Paolucci’s (1970) assertion that one’s family is a life-support system that provides support, quality of life, and life-meaning. Intimate relationships were different, however. Even resilient combat veterans were careful not to overburden their spouses if they were married. Their narratives indicated that as a source of social support these relationships were not as strong as 285 one’s family of origin, especially when it came to shaping ones views on war or values including religious beliefs. In some cases, these family of origin beliefs created conflict in intimate relationships. Intimate relationships are newer and dependent on equity and reciprocity (MacDermid Wadsworth, 2010) which is made very difficult during a deployment. This can furtherbe easily thrown off balance when a combat veteran needs significantly more support than he or she is able to provide in return. All of the resilient combat veterans in the study were single during their first deployment, so their marriages were relatively new during their subsequent deployment/s. Ron, Jeremy, and Joseph were married and were careful with how much of their experience they shared with their wives. John was in the process of a divorce and he openly stated that his wife was leaving him because she could not handle the life of a military wife apart from any support he might have needed from her. These resilient combat veterans reported that they had small friendships networks, but that these friendships continued to grow closer after their combat deployments. This appeared to be due to shared meanings, which were not so different after the deployment than before. Recall that resilient combat veterans reported that their combat experiences did not challenge their global beliefs significantly so the shared meanings their friends had when they left would have been highly compatible even after the experience of combat. With a greater appreciation for life, drawing closer to friends easily followed. The resilient combat veterans also talked about close veteran friendships. They felt that the experience of combat had created an inseparable bond like a brotherhood that is often spoken of even colloquially (Greden et al., 2010). 286 Discussion of highly traumatized social interactions. In direct contrast with the social experience of resilient combat veterans, highly traumatized combat veterans did not draw closer to friends, family, or intimate partners. Lepore, Ragan, and Jones (2000) found that environments indicated by disapproval or disinterest are related to greater levels of distress. Their narratives were full of references to social dissociation, a listed symptom of post-traumatic stress. This was true of their interactions with others in general, but they particularly felt disconnected from other family members. In the words of Kevin, “I don’t really care to go and smile in their face, because I’m not happy.” This disconnectedness would support the findings of MacDonald, Saltzman, and Leary (2003), who found self-worth related to both self-judgments but also the judgments of others. They did not talk about shared meanings like the resilient group. In fact, they indicated that their friends and family could no longer relate to them. This appeared to be due at least in part to a lack of shared meanings since their global beliefs had been shattered by the experience of combat. One very important finding regarding the social interactions of combat veterans is that they feel closest to other combat veterans. This group of highly traumatized combat veterans reported that they felt considerably closer to other combat veterans than even their family of origin. One important note is that the combat veterans with whom they associated were also highly traumatized, which would make sense in light of the second point. They would have more in common with this group than any other since their families of origin, pre-war friendships, and intimate partners were unable to relate to the extreme existential struggle they went through daily after their combat deployments. This finding appears to demonstrate that shared meanings may be more protective and 287 important than the presence of particular relationships and is in agreement with previous findings (Greden et al., 2010). Discussion of growth-oriented social interactions. Again, the growth-oriented combat veterans described their pre-deployment relationships and early postdeployment relationships in much the same manner as the highly traumatized group. Primarily they were highly judgmental of others and tended toward dissociation. Once they began the post-traumatic growth process, their social interactions began to change. Relationship change is more complex than intrapsychic change. Their family of origin relationships were marked with inconsistent growth. Sometimes families grow along with their veteran and sometimes they do not, creating greater difficulties. Though families of origin were most often discussed, descriptions of intimate relationships were similarly mixed when they emerged. Civilian friendship networks were reported as smaller than they once were, but that they were closer to the friends they still had. This would make sense as they tended to initially separate from friends who they could no longer relate to like those in the highly traumatized group, but when they began to change and grow through meaningmaking coping, they began to appreciate meaningful relationships more, causing them to draw closer to those that remain. Interestingly, they did not report being very close to other veterans. As a rule, they felt these relationships were increasingly less significant (Mitchell, Gallaway, Millilkan, & Bell, 2012). As they had more in common with these veteran friends prior to their growth-orientation, this made sense. While he was not the only one, David 288 expressed this changing sentiment well. He had gone to visit one of his veteran friends with his wife one day and described what he felt when he arrived: We go to his house… we get there and they’re drinking, they're smoking, they are cussing, they are telling war stories because it is that group of people... I felt like a fish out of water. I want nothing to do with this. He recalled that at that moment he returned home and simply made no further attempts to reach out to these veteran friends who he felt he no longer had much in common with. Of course they had been deployed together, but his beliefs had changed significantly. Synthesis. Though the literature indicates that social support by those close to the survivors of trauma is important to recovery from trauma (Ehlers & Clark, 2000), these findings indicate that shared meanings with significant others, which were most often one’s family of origin for veterans in this study, may be even be a more important factor. Harvey, (1996) found that social support helped facilitate the meaning-making coping process through the opportunity to process the events with others, which would support the shared meaning theme in the present study. This position is strengthened particularly when it supersedes even one’s family of origin as with the highly traumatized combat veterans who draw close to each other even before family. In conjunction with this shared meaning, a pro-military family legacy was present for the resilient group along with a faith-based belief system which allowed for shared meaning among family members. While some of the others in the study mentioned the occasional military tie, these instances did not rise to the level of military family legacy. The military legacy for the resilient veterans in this study was also overwhelmingly 289 positive and optimistic where those of the other two groups were not. Shared meanings also need to be congruent with the experience they relate to. Faith, as opposed to belief, emerged as another important theme. While some of the highly traumatized combat veterans indicated that they used to have spiritual or religious beliefs, I cannot recall any of them referring to a sense of protective faith in the manner characteristic of the resilient combat veterans. The resilient combat veterans regularly talked about their sense of faith as protective in a number of ways. It connected them to family, their sense of military purpose, vicarious control by God, and their connection to him through prayer. It also connected them to the sense that they would either make it back home safely or they would know they had given their life for a cause greater than themselves while also believing they would be in heaven united with God. Overall, this seemed to give them the clarity of purpose and safety to focus more easily on the task at hand and see events as challenges (challenge appraisal) instead of threats (threat appraisal). Implications for Theory The findings have important implications for Meaning-Making Coping theory, the application of Bronfenbrenner’s ecological model to veteran populations, and human development theories such as Erikson’s stage theory of psychosocial development. This section will address each of these as examples of the many potential applications these findings support with particular attention paid to the guiding framework developed by Larner and Blow (2011; Figure 2.1). Specific points of support for meaning-making coping in combat veteran populations are presented below. Much theory and research has focused on the 290 behavioral and physiological components of the recovery process after combat trauma. Although valuable, these data indicate that effective and long-lasting treatments should also address what troubled combat veterans believe about their experiences. The growth-oriented combat veterans themselves said that it was the change in their global beliefs that led to lower symptom levels and improved relationships with others. These findings validate the study of meaning-making coping as a centrally important theoretical construct regarding combat trauma. Research applying meaning-making coping is indicated for other traumas as well. In the Larner and Blow model, consistent with earlier literature, when global beliefs are congruent with appraised meanings related to combat trauma, distress is minimized leading to resilience. The findings of this study indicate certain global beliefs are most protective when they are shared with significant others, particularly one’s family of origin, which remains a resource (well to draw from) as well as a source of support after the combat deployment. First, the resilient combat veterans in the study indicated that their families were simultaneously and intrinsically religious and promilitary. Secondly, their global belief systems were comprised of three attributes. The first is organization, which refers to external verifiability, which enhances shared meanings via texts such as the Bible for Christians or the Koran for Muslims. The second is certainty, as with intrinsic religiosity, which is characterized by life quality and life meaning which is gained through adherence to the principles of a religion rather than through benefitting from social status or cultural inclusion. The third is adequacy, which may be validated vicariously through other combat veterans who are able to attest to the adequacy of these beliefs. Particular beliefs, or patterns of beliefs, may be 291 more protective than others, and these findings indicate that an investigation of specific beliefs may prove beneficial. The model displays that when appraised meanings violate global meanings, a crisis likely occurs. The present findings support this assertion. Also according to the model, during the post-deployment phase highly traumatized combat veterans either utilize avoidance coping strategies or they begin to face these distressing memories. The present findings support this and add to the model by making the case that avoidance coping is utilized specifically to fight against intrusive rumination and that deliberate rumination occurs in order to reappraise combat experiences in light of a new global belief system, but not until then. Secondly, shared meanings regardless of outcome were found to be important, but the group with whom combat veterans choose to associate differs by outcome and could be incorporated into the model. These findings indicate that resilient combat veterans are more likely to associate with and share meanings with their family of origin, friendship network, and other combat veterans. Highly traumatized combat veterans are most likely to associate with and share meanings with other combat veterans exclusively, particularly other highly traumatized combat veterans. Growth oriented combat veterans suffer from dissociation from friends and family initially, but when they begin to undergo the post-traumatic growth process they begin to pull away from veteran friends and rebuild relationships within their friend network and their family of origin. The social aspects of the shared meaning theme are not accounted for in the model, but could indicate a modification of the model to account for them. 292 Implications for ecological theory are also evident (see Figure 5.1). Of note was the ubiquitous attitude towards the national news media. The news media resides within the exosystem of American society and acts as a feedback mechanism on a national level for the entire population. While resilient combat veterans were significantly displeased with their perceived bias and inaccuracy of the news media they were more understanding of the need for news outlets to cater to ratings and viewership. The highly traumatized veterans carried their sense of judgmentalism into this view, using descriptors for the media that sometimes went as far as to call it propaganda. Taken together these views represent a concern that the primary feedback mechanism for American society overall was at odds with the views of all of the combat veterans in this sample, and through their narratives, a great many other veterans. Although other views certainly exist, the implications for such a universal sentiment of meaning over such a widely disparate range of outcomes are significant and cannot be understated. Most felt that such a negative portrayal of the wars in Iraq and Afghanistan after 9/11 had a negative effect on the war efforts. Some gave personal examples of how the news negatively affected morale, emboldened their enemies, and put actual lives in danger. None of the veterans in the study felt the news media portrayed the war accurately. The importance of and long-term consequences of the role of news media during wartime cannot be understated and deserves continued attention, especially given the pervasive availability of news from all sources in the digital age. At the other extreme of the ecological context, the global beliefs and shared meanings within the home microsystem of the combat veteran tended to be the most 293 Figure 5.1 Revised Ecological Model 294 important. The deployment microsystem seemed to be fairly consistent in that the positive and negative themes indicated by participants did not emerge in any systematic way regarding outcomes. In fact, one veteran speaking about military values as an example, said it well for the entire group of participants. He made it a point to say that the values that the military espouses are good for that context, but that it is the deeper beliefs held by each individual which account for how they cope. A soldier can act one way in front of others, all the while holding their true beliefs in secret. Internalized global beliefs, shared by others within one’s microsystem, are most important both before and after military service. These global beliefs are a hold-over from the home microsystem. Other deployment microsystem factors emerged individually, but inconsistently so, and did not present with any clarity to be related to outcomes. Viewing meaning-making coping from an ecological perspective helped in the drafting of the original questions and also provided context to help clarify how the different systems relate to the individual combat veteran. Some important ecological connections were identified in the results chapter advancing the trauma literature from an ecological perspective. Shared global beliefs within a combat veteran’s microsystem play a role more important than other factors and may be more important than all but their own global beliefs. Human development from a psychosocial perspective (Crain, 2011) is also informed by the results of this study. In the United States, most men and women join the military at the age of 18 or 19, and serve for an average of around 4 years. For this reason particular emphasis is placed on the fifth stage (age 13-19) where identity vs. 295 role confusion is the psychosocial crisis and the sixth stage (age 20-24) where intimacy vs. isolation is the crisis. The newest military recruits are just finishing up the fifth stage. Many young men and women consider military service because their family’s sense of shared meaning is tied to it while others may consider it as a way to pay for college on their own or a way out of hardships or negative life trajectories. The results of this study indicated that joining the military out of a positive sense of personal obligation to serve or family legacy, (i.e. shared meaning), was most related to resilience. The narratives of participants in the highly traumatized group tended to indicate a lower sense of identity through their military service. This is not initially evident as each of them talked about their willingness to serve and their continued belief that military service is a worthy sacrifice. Unfortunately, without the depth of meaning and sense of faith shared by the resilient group, other more personally centered meanings such as college tuition and escaping a negative life trajectory tended to relate more to role confusion after the experience of combat. Interestingly, intimacy vs. isolation as psychosocial struggle from age 20 to 24 coincides with the timeframe when most service members end their enlistment and return to their civilian roles. The resilient veterans in the study discussed drawing closer to friends and family as a result of their combat experience indicating some level of success in this stage. The highly traumatized group moved toward social isolation. They separated from their families, spouses, friends, and even their own children. While they clung to friendships with other veterans this could be seen as a form of group isolation, choosing as a group to self-segregate. Overall, the outcomes of meaning-making 296 coping after combat trauma seem to coincide with the psychsocial struggles associated with these two stages. The level of success or failure to negotiate them also corresponded respectively to the outcomes of resilience or high traumatization. Future psychosocial inquiry is warranted. Implications for Practitioners These data have considerable and wide-reaching implications for both prevention and treatment of highly debilitating outcomes of trauma. These preliminary findings suggest that prevention could benefit from a focus on pre-combat beliefs. Rather than assume that any potential combat veteran is prepared due to training or a willingness to serve, preventative measures could ascertain how deeply internalized any combat veteran’s conviction is on particular beliefs, or more appropriately, provide information related to the beliefs of the most resilient combat veterans and the meaning-making coping processes growth-oriented combat veterans utilized should they become necessary. Although many combat veterans said in the study that one never knows how they will react until the moment they pull the trigger, those combat veterans who could account for their sense of clarity and purpose personally, socially, and existentially, existed exclusively in the resilient group. Those in the growth-oriented group were gaining a sense of clarity and purpose from a social and existential perspective after their combat deployments. Though in retrospect, there do appear to be ways of making meaning of the experience of combat which are more helpful and prescriptive than others. Unfortunately, there is a down side to this. While it may be noble to be able to potentially know who will be most susceptible to traumatization, it would be easy to misuse such information and should be contemplated with great caution. It is 297 unimaginable and discriminatory to even consider denying military enlistment on the grounds of one’s beliefs, which can change over time, especially when it is compulsory at present for all males age 18 and older to register for selective service. One way to address this may be through information sharing by those that have demonstrated resilience through difficult combat experiences. From a treatment perspective, this grounded theory study indicates that when possible, resources should be allocated to those treatments which address one’s beliefs. Richards and Bergin (2000) pointed out the importance of clinicians incorporating the religious meaning systems of their clients. The findings of this study help to move this research forward regarding veteran populations and is in addition to psychopharamacological and cognitive behavioral treatments which have already been demonstrated to be effective for many. This is also a potentially difficult professional stance to take, as deeply held beliefs can be difficult or inappropriate to challenge effectively and appropriately. However, when it comes to issues such as life and death, war and killing, existentially oriented spiritual issues inevitably arise and need to be addressed. Along these lines, there does seem to be a difference between personally constructed global belief systems which are unique to that individual and those that are externally verifiable and codified in such a way so as to increase the salience of shared meaning. The example of this which appeared in the study was intrinsic Christianity. Other potential examples may include religious systems such as Islam, Judaism, and Shintoism, spiritual-cultural beliefs such as those of the many Native American tribes, and philosophies such as Buddhism. Even with individual interpretation, when groups of 298 individuals are able to point to large lists of related appraised beliefs and agree upon them, the certainty and conviction that a combat veteran holds appears to be protective. Though the utility of such an observation appears unrealistic, presenting it makes it available for future investigators to consider. Helping professionals would do well to consider screening for and addressing spirituality even when spirituality is not indicated by clients initially. Taking the life of another human being during wartime certainly calls these beliefs into question, and checking into them is very likely to be informative. Even a desire not to discuss spiritual or existential issues is informative. These data could help to explain why programs such as vet-to-vet or buddy-tobuddy have become so successful. Veterans who have worked through a number of issues and are ready to share their change experiences with others may be among the best prepared to challenge the very judgmental beliefs that they themselves may have once held. The sense of shared meanings, even those being challenged, between those who have served is perhaps the core component of these interventions. The military has dedicated considerable resources to helping families of combat veterans, but the definition of family (regarding access to these resources) too often does not extend to families of origin, but rather spouses and children of the veteran. While helping out spouses and children is very important, these findings strongly suggest that supporting families of origin and the relationship they have with their veteran is of prime importance to resilience and recovery. Support and information for the family of origin may help the family system more directly by assisting those family members who are in a better position to support the veteran or service member which 299 would have lasting effects on the entire family system. These findings indicate that the shared meanings of one’s family of origin and the longer-term relationships that they represent are most helpful. These findings have implications beyond the military as well. Law enforcement officers have legal authorization to use lethal force domestically and face similar circumstances. The may find themselves in a position to take the life of an armed or unarmed citizen and their decisions have considerable ramifications in their home environment / microsystem context. Each individual must then appraise the meaning of such situations in light of the specific context and his or her overall global belief system. The meaning of actions such as taking a life during a law enforcement engagement and the meaning-making coping process during and after these experiences is anticipated to be very similar. Other traumas can benefit as well. These findings should lead researchers to consider the role of global beliefs more thoroughly, and the importance of shared meaning with significant others. Though other traumas do not share the same interpersonal burden of combat trauma, these findings demonstrate that the process of meaning-making coping is likely to be a key factor in understanding these traumas as well. Though the specific appraised meanings and global beliefs may be different, the process overall should be instructive. Limitations The goal of this study was to investigate the meaning-making coping process of combat veterans with a focus on the growth process. The greatest limitation of the study lies in the overall design. Three groups of combat veterans were compared in order to 300 answer 4 research questions with 20 interview questions. This proved to be a daunting task. On the one hand, it allowed for a very thorough sweep for relevant themes. On the other hand the volume and breadth of data made it exponentially more difficult to be parsimonious. It also created a recurring scenario where each potential theme received limited time before moving on. Although this potentially made for thinner thematic structures, it did appear to allow the participants to guide the research more directly because there was less time for researcher follow-up to lead to bias. Demographically, the sample was quite homogenous, limiting generalizability. Though the selected participants were intentionally male, the rest of the demographics were quite incidental, unavoidable, or impractical to control for. The entire sample was from Lower Michigan, making geographic diversity a potential limiting factor. Fourteen out of fifteen participants were Caucasian, while only one participant was Hispanic. All but a few participants were still serving in some capacity, leaving open the probability that even worse outcomes were not well-represented. Further, those who are struggling the most are less likely to reach out to participate in research. Those faring the very worst may have already taken their own lives; the ultimate expression of unsuccessful coping. This leads to self-selection bias. Though non-probability sampling is appropriate for use with difficult to reach populations like combat veterans, self-selection bias is still a concern. We still do not know what veterans who did not elect to participate believe about their combat experiences, though this is unavoidable. 301 Also, all responses were in retrospect. No pre-deployment measures were available for these participants. The results do suggest that this would be an appropriate direction for future research. The resilient group’s responses were much more uniform than the other groups, to the extent that all five reported belonging to and following the tenets of Christianity, and most within a denominational context. This appeared to be due to shared meanings held by both the support system of each participant, but also the fact that these combat veterans appeared to also have shared meanings between them based on their interview responses. This could appear to signal a potential problem for the study. The flyer, however, did not mention spirituality or religiosity in any way. All participants who completed the ISI and were indicated for one of the groups remaining at the time of their recruitment were placed into the appropriate group without researcher knowledge of their beliefs. All participants in the study were accepted on a first-available basis. This left no room for selection bias on the part of the researcher According to Flanagan (1981), reflexivity complicates the research process through the bidirectional relationship between researcher and participant. During this process I was a qualitative researcher, but I had other roles that also required consideration. Like the resilient combat veterans in the study I identify with the faithbased Christian belief system. This represented an opportunity for bias, but it also afforded me a depth of understanding which was instrumental in capturing nuance of meaning between participants. Also, I needed to be aware of how I presented the questions and followed up with responses so as to minimize leading participants one way or another. 302 Also, I am a former United States Marine with a combat related specialty. This allowed me to understand all but the most unique or new military terminology so that the participants could tell their stories without having to explain every detail. I had to consider my own past role in the military as both potentially helpful and hurtful to the interview process. Finally, I am a Marriage and Family Therapist licensed in the state of Michigan. This role of therapist presented unique challenges through my desire to help rather than investigate. I was able to overcome this by ensuring that any veteran who appeared to struggle during the session had access to therapeutic services and checking with them about their current cognitive/emotional state as they left the interview site. This reflexive role as therapist also helped me know how to ask questions to get meaningful and relevant responses. Bias on the part of the researcher is still a consideration, however. I conducted all of the interviews, coded the data, and analyzed the data. This, however, also had the added benefits of consistency and shared context. I was able to relate to daily life as a combat-trained veteran. For the resilient group in particular, a Christian worldview made it possible to understand the nuance of the meanings shared by this group, but it also made bias an even greater consideration. The committee chair’s input was instrumental in this regard, helping to protect against bias whenever possible. Further, having not always been a Christian, I was better able to understand the context of the spiritual and non-spiritual beliefs of the highly traumatized group and the change process of the growth-oriented group. It is believed that this was a strength overall. Further, as the same person conducting all of the interviews I was able to become intimately familiar 303 with the data and the collection process, thereby allowing me more opportunities to have insights for analysis. The audit trail gave some representation of these processes, which should prove helpful in understanding how I came to the conclusions I arrived at. Research is considered to be more valid when more people are able to look at and evaluate the data (Miles & Huberman, 1994). I was therefore taking a risk that the data would be less accurate or complete than it could have been. Though prompts were modified as the needs of any particular interview dictated, the basic questions were not so modified. This provided some level of standardization which was important in order to not lead responses in too many directions across three different strata in the sample. This could have potentially limited the responses, but the perceived payoff was that more standard questions would lead to more comparable answers as long as those questions were relevant to the content of each interview. One example was modifying any statement about faith to add “or lack of faith” when that participant had already indicated that he had no faith in anything spiritual or religious. Finally, the number of participants was small for each group. Qualitative research of this type would often have six or more participants per group. For the resilient group, however this proved to be more than enough to reach saturation. For the highly traumatized group, it was enough to reach saturation and allow beliefs which ranged from the unspiritual (four out of five participants) to the one spiritual participant who demonstrated by his inclusion the specific components he had in common with the others. For the growth-oriented group it was enough to reach a saturation point which illustrated the meaning-making processes responsible for their post-traumatic growth. It 304 is believed that these limitations do not detract substantially from the value of the findings. Future Directions The results of this research advance the study of post-combat trauma in a number of ways. However, grounded theory research is just the beginning. There is much left to be learned about meaning-making coping after combat trauma. Up to this point there has been little comparison of outcomes. This needs to continue. The results here suggest that outcomes vary in systematic ways which may be predictable. More qualitative comparison is indicated with larger samples in each group, but these present findings should also lead the way to deeper questioning. Longitudinal Research with pre and post measures is a next logical step. This would validate that the beliefs one holds before combat are in fact changed or remain the same without the potential for perceptual misrepresentations post-trauma. Traumatology on the whole is lacking in longitudinal research because most traumas are very difficult if not impossible to predict. Combat trauma is unique in that veterans know ahead of time that they are at least highly likely to be participating in the horrors of war and researchers would do well to take advantage of this singularly valuable resource of foreknowledge. All five of the resilient combat veterans in this study were intrinsically Christian. Future research should seek out other global belief systems to see if they also hold the keys to resilience and how they differ. These could be researched explicitly and/or compared directly to see how they differentially relate to resilience, high traumatization, and growth. 305 The Master Resilience program instituted by the United States Army (Reivich, Seligman, & McBride, 2011) could utilize aspects of this research to enhance resilience to those who participate. The specific way this would be done also needs to be determined as well. Other demographic groups would benefit from direct attention. While the present study included all males who were predominantly Caucasian, future research would do well to see how women or different minority groups fare. These groups may be found to respond differently to various aspects of meaning-making coping, but this is not yet known. While the present research appears to indicate that a shattering of world assumptions or a loss of meaning runs hand in hand with high traumatization, even more highly traumatized combat veterans need to be included in order to improve our understanding of meaning-making coping when combat veterans are having the very hardest of times coping. These combat veterans may be hospitalized or otherwise psychologically incapacitated. Their stories need to be addressed as well. Of particular note, this qualitative inquiry should be discussed in light of the Larner and Blow model (2011). Though beyond the scope of the research goals here, the research was intended to lend itself toward integration into that model or the modification of that model depending on how the results are related to it. The next step would clearly be the conceptualization and inclusion of these findings in a way that moves the field forward. These findings cause a new and important question to emerge. What causes a person to give up a worldview they have likely constructed over a lifetime? What is the 306 trigger? These narratives highlight that there are indeed moments when each growthoriented combat veteran recalls a change in global beliefs; a paradigm shift. What is significant about these events? What causes them to lead the person to change in those moments since the new belief system already appears to have been present in their cognition? Perhaps it is more like an epiphany; a moment of clarity after the dust has settled, so to speak. It could be that the old system, which was shattered, still remains until it is finally rendered useless by the weight of realizations that occur during the reappraisal and rumination processes. Perhaps it is a combination of these points or something different. I add these questions and statements as the result of my immersion in the data in the hopes that others will accept them as leads to be followed up or challenged. This research takes post-trauma inquiry into new territory, and the directions that are indicated are many. As a field, the different angles of research need to be brought together by inclusion of known factors so that advances can be made more effectively. Personal Reflections As a veteran I have long been interested in the reasons why some combat veterans fare very well while others struggle. Having the chance to research this question has been personally fulfilling to me. Hearing the stories these men shared gave me a priceless insight into this dynamic. The idea first came to me when I thought about my own life. I’m a former Marine, a marriage and family therapist, and there had been two wars going on for several years. I have always been interested in how a person’s beliefs affect his or her life and meaning-making coping had come to my attention some time ago, which led to the 307 development of the model of meaning-making coping and growth in combat veterans (Larner & Blow, 2011). This model set the foundation for a program of research which would investigate the differences in outcomes of combat veterans. The beliefs of combat veterans had not yet been investigated or compared in this manner and quantitative instruments could not adequately address the myriad of themes related to belief systems and meaning-making coping. Thus, I set out to investigate what these beliefs and processes were using a grounded theory approach. Utilizing a stratified sample was logical, but it did carry with it an added layer of complexity which I did not forsee. I had considered myself fairly well connected to local military and veteran organizations so I believed that recruitment would be no problem. I was mistaken. In the initial months of recruitment, I had come across only three combat veterans, who interestingly represented the range of outcomes I was interested in. One of them fit into each of the groups so I had a good beginning. This is when I became both excited and discouraged. After these three participants were interviewed and their interviews were transcribed, I no longer received further participant inquiries. Initially I thought it was about cost so I changed the compensation from $25 to $50. Still, no further recruitment was to be had. Then, after making contact with the family readiness coordinator for the Michigan National Guard, a contact received through by my committee chair, Dr. Blow, I got a literal flood of participants. I had more interviews and data than I knew what to do with. I waded through it all and after a few requests for participants I had all but the last two participants interviewed. During this time, I found that the money in fact a nonfactor. Many of the participants did not even care if they received the gift certificate. 308 Every participant who completed the interview said that they wanted to do so in order for their experience to help others. The time lost in the middle of the recruitment period set the whole process back, but ultimately I was able to recruit the remaining two participants in time to finish the process of data collection. There were a couple of months in the middle of the process where I should have been more diligent in my recruitment efforts. Some terminology changed for me during the course of this study. Initially, the highly traumatized group was labeled PTSD, pathology, and decline at different times… these did not seem to capture the essence of their experience. I eventually settled on defining this group as the highly traumatized group. Their experiences were broader than an over-simplified PTSD diagnosis, labeling their experiences as pathology eventually became distasteful to me as they did not see themselves as victims. They were survivors. They had been highly traumatized by their experience, but they continued on. The PTG or posttraumatic growth group evolved similarly. Their experiences were no less traumatic than the highly traumatized group, but they were in a phase of growth. I labeled their group the growth-oriented group accordingly, choosing this spoke more to their process than to an oversimplified label. In writing the dissertation I realized fairly quickly that it would be a daunting task. I asked many questions of three groups compared via four research questions. The results chapter took quite a while and was intentionally exhaustive because narratives of this sort are rare enough that I wanted them to be accessible to those who may be interested in looking further into the data. When formulating the grounded theories for 309 each outcome, I then hoped that I could still make them parsimonious. I believe I was still able to do this. Talking about combat trauma can be very difficult, and I am thankful that these men chose to open up to me. They shared that others might be helped. It is my hope that they were similarly helped by the way I simply listened and let them tell their story. 310 APPENDICES 311 APPENDIX A: INITIAL SCREENING INSTRUMENT (ISI) Initial Statement “I wanted to thank you for your interest. I am researching how meaning-making is related to the way that combat veterans deal with their experiences. I have prepared a few questions that will help me determine if I am able to recruit you for this study, but your answers will not be used as part of the actual research. Is it okay to ask them?” Combat Exposure and Other Qualifying Questions Did you directly participate in firefights in either Iraq (Operation Iraqi Freedom) or Afghanistan (Operation Enduring Freedom)? Would you measure your combat experience in minutes, or hours, or days? Primary Stratification Question Although most veterans are likely to feel some sense of each of the following statements, which one of the three do you think you most identify with? 1 Overall, do you feel like you have been primarily strengthened and life has more meaning as a result of your combat deployment experiences? 2 Overall, do you feel like your life has been heavily affected in a negative way as a result of your combat deployment experiences by troubling memories and difficulties with relationships? 3 Overall, do you feel like your life had initially been made more difficult as a result of your combat deployment experiences, but that you have begun to change and grow stronger personally or spiritually, or closer to people more recently? 312 APPENDIX B: INFORMATIONAL FLYER Earn a $30 VISA gift card for participating in research on the personal meaning of combat deployments. Help your fellow veterans and the professionals who work with them. You are eligible if:  You are a male combat veteran.  You have directly participated in firefights during OEF or OIF. What will be needed from combat veterans who choose to participate:  Participate in a 1 ½ to 2-hour interview, where I will ask you to talk about your combat deployment experience.  Complete 3 assessment instruments that will provide some information about how you have dealt with your combat experience. These will take approximately 10 to 15 minutes.  Your answers will be confidential, and identifying information will be excluded. For more information, please contact: Brad Larner, LMFT, Former Marine and Doctoral Candidate in Family Studies, Michigan State University, 989-280-3685, larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu Brad Larner 989-280-3685 larnerbr@msu.edu 313 APPENDIX C: OUTCOME DEFINITION HANDOUT This handout is to help you recruit potential participants for the study. It is important to the study to recruit participants representing three broad categories of outcomes after participating in direct combat action. To assist you in deciding if a particular combat veteran you know may be appropriate for participation in this study I have included a definition of each category. If a category is crossed off by me when I hand this to you, it means I am no longer recruiting for that group. Thank you for your help with this research project and feel free to remind the veterans you refer that their participation will help other veterans in the future. Resilience These are combat veterans who have fared the best among their peers after returning home from combat deployment. Any symptoms they may have are being managed better than others. Negative Outcomes These are combat veterans who have fared the worst among their peers after returning home from combat deployment. Typically this is in the form of the most severe PTSD symptoms. Post-traumatic Growth These combat veterans may have struggled considerably after returning home, but they have worked hard at recovery (with or without professional help) and they now manage their lives considerably better than they did initially. 314 APPENDIX D: RESEARCH CONSENT AUTHORIZATION FORM A Grounded Theory Study of Meaning-Making Coping and Growth in Combat Veterans My name is Brad Larner. I am a Family Studies Doctoral Candidate at MSU. This research is being conducted through the College of Social Sciences at Michigan State University. I want to thank you for your participation in this research study that will focus on the meaning-making coping process after combat trauma. I am conducting this research to help better understand how meaning-making coping is related to the different outcomes that combat veterans experience. If you choose to participate, you will be asked to individually fill out questionnaires about resilience, PTSD, and posttraumatic growth (PTG). You will also be asked to complete a basic demographic questionnaire. The questionnaires should take between 10 and 15 minutes total to fill out. You will also be asked to participate in an interview that will be audio recorded. During this interview, you will be asked questions about your beliefs related to various aspects of combat, wartime deployment, and interactions with family members and others. I, Brad Larner, will conduct the interview myself. The interview will take place at either an office on the MSU campus in East Lansing, my private practice office in Saginaw, or another mutually acceptable location at your convenience. Expected Duration The interview portion will last no more than 2 hours for a total of 2 ½ hours. A follow-up phone call will be made in order to address questions and comments you may have or clarify responses from the interview. Potential risks of participating in this study: Talking about combat experiences is often stressful. In case of distress and you would like to talk with a professional, I have included a list of resources that you may utilize. You may also talk to me about any issues you may have resulting from the interviews or the research process. Compensation for participating in this study: As a compensation for your time, you will receive a $50 gift card at the completion of the interview. Potential benefits of participating in this study: By discussing your combat experiences you may gain a better understanding of them. You are also taking part in an opportunity to help other veterans and the professionals that work with them. Ultimately, this should help improve the lives of combat veterans and their families. Your participation in this study is completely voluntary, and you may choose to withdraw or not answer questions at any time. You will still receive the gift card, even if you withdraw from the study early, and your information will not be used in the study. Your confidentiality will be protected to the maximum extent allowable by low. Your 315 name and contact information will be kept in a different locked file drawer, separate from the data. It will be destroyed at the conclusion of the research study. Electronic data (i.e. interview transcriptions, digital audio recordings of interviews, data coding, etc.) will be stored on my personal laptop computer. This laptop is passwordprotected. All hard copies of data (i.e. assessments instruments, researcher notes, etc.) will be kept in a locked file drawer. All hard copies of data will be stored for a minimum of 3 years then it will be destroyed. Electronic data will also be stored for 3 years with the exception of the audio recordings, which will be destroyed at the conclusion of the study. Contact information for questions and concerns about this study or how to do any part of it please contact the researcher or the research supervisor: Brad Larner, Ph.D. Candidate (Researcher) FTFS 3144 Davenport Ave. Saginaw, MI 48602 989-280-3685 larnerbr@msu.edu Dr. Adrian Blow (Research Supervisor) Michigan State University 3B Human Ecology East Lansing, MI 48824 517-432-7092 blowa@msu.edu If you have concerns or questions about this study, such as scientific issues, how to do any part of it, or to report an injury, please contact the researcher: If you have questions or concerns about your role and rights as a research participant, would like to obtain information or offer input, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State University’s Human Research Protection Program at 517-355-2180, Fax 517-432-4503, e-mail irb@msu.edu, or regular mail at 207 Olds Hall, MSU, East Lansing, MI 48824. If you agree to participate in this study, please sign and sate here: Name _________________________ Date ___________________ If you agree to allow the interview to be audio recorded for this study, please sign here: Name _________________________ Date ___________________ 316 APPENDIX E: DEMOGRAPHIC INFORMATION SHEET All information on this form is strictly confidential and will not be for any purpose not directly related to the current research. Please fill in every blank. Participant # (researcher use only): ______________ Current Marital Status: married divorced Age: _________ widowed never married Marital Status During first deployment: married widowed divorced never married Ethnicity (check one, check the one you most identify with if mixed): = Caucasian (non-Hispanic) Black / African American (non-Hispanic) Hispanic / Latino Asian-American Native American Middle Eastern Other (specify) _______________________ Religious or Spiritual Affiliation / Orientation (if any): ______________________ Highest Education Achieved (check one): Grade School High School Technical / Trade School Some College Bachelors Degree Masters Degree Doctorate Current Occupation: _______________________________________________ How many incomes support your home (count each part time job as half): 1 1.5 2 2.5 More Gross (before deductions and taxes) yearly household income (check best estimate): Under $20,000 $20,000 to $30,000 $30,000 to $40,000 $40,000 to $50,000 $50,000 to $60,000 $60,000 to $70,000 $70,000 to $80,000 Over $80,000 Number of Children: ________ Number of children living with you: _________ List tours in OEF/OIF in order and by indicating the number of months deployed: Order OEF or OIF? How many months? Combat Action (Yes / No) 1st 2nd 3rd 4th Please indicate your branch of service: _____________________________ National Guard, Reserve, or Active Duty: ___________________________ Rank at first deployment: __________________ Highest rank: ___________________ 317 APPENDIX F: RESILIENCE SCALE (RS-14) Please read the following statements. To the right of each you will find seven numbers, ranging from "1" (Strongly Disagree) on the left to "7" (Strongly Agree) on the right. Circle the number which best indicates your feelings about that statement. For example, if you strongly disagree with a statement, circle "1". If you are neutral, circle "4", and if you strongly agree, circle "7", etc. Circle the number in the appropriate column Strongly Disagree Strongly Agree 1. I usually manage one way or another. 1 2 3 4 5 6 7 2. I feel proud that I have accomplished things in life. 1 2 3 4 5 6 7 3. I usually take things in stride. 1 2 3 4 5 6 7 4. I am friends with myself. 1 2 3 4 5 6 7 5. I feel that I can handle many things at a time. 1 2 3 4 5 6 7 6. I am determined. 1 2 3 4 5 6 7 7. I can get through difficult times because I’ve experienced difficulty before. 1 2 3 4 5 6 7 8. I have self-discipline. 1 2 3 4 5 6 7 9. I keep interested in things. 1 2 3 4 5 6 7 10. I can usually find something to laugh about. 1 2 3 4 5 6 7 11. My belief in myself gets me through hard times. 1 2 3 4 5 6 7 12. In an emergency, I’m someone people can generally rely on. 1 2 3 4 5 6 7 13. My life has meaning. 1 2 3 4 5 6 7 14. When I’m in a difficult situation, I can usually 1 2 3 4 5 6 7 find my way out of it. ©2009 Gail M. Wagnild and Heather M. Young. Used by permission. All rights reserved. “The Resilience Scale” is an international trademark of Gail M. Wagnild & Heather M. Young, 1993 318 APPENDIX G: POST-TRAUMATIC GROWTH INVENTORY-SHORT FORM (PTGI-SF) To what degree have you experienced these changes as a result of your combat experience. Not at Very great all degree 1. I changed my priorities about what is important in life. 0 1 2 3 4 5 2. I have a greater appreciation for the value of my own life. 0 1 2 3 4 5 3. I am able to do better things with my life. 0 1 2 3 4 5 4. I have a better understanding of spiritual matters. 0 1 2 3 4 5 5. I have a greater sense of closeness with others. 0 1 2 3 4 5 6. I established a new path for my life. 0 1 2 3 4 5 7. I know better that I can handle difficulties. 0 1 2 3 4 5 8. I have a stronger religious faith. 0 1 2 3 4 5 9. I discovered that I’m stronger than I thought I was. 0 1 2 3 4 5 10. I learned a great deal about how 0 1 2 3 4 5 wonderful people are. Cann, A., Calhoun, L. G., Tedeschi, R. G., Taku, K., Vishnevsky, T., Triplet, K. N., Danhauer, S. C. (2010). A short form of the posttraumatic growth inventory. Anxiety, Stress, & Coping, 23(2), 127-137. 319 APPENDIX H: PTSD CHECKLIST – MILITARY (PCL-M) INSTRUCTIONS: Below is a list of problems and complaints that veterans sometimes have in response to stressful military experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. Not at all 1. Repeated, disturbing memories, thoughts, or images of a stressful military experience? 2. Repeated, disturbing dreams of a stressful military experience? 3. Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)? 4. 7. 8. 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 320 5 1 Trouble remembering important parts of a stressful military experience? 4 1 Avoiding activities or situations because they reminded you of a stressful military experience? 3 1 Avoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it? 2 1 Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience? 6. Extremely 1 Feeling very upset when something reminded you of a stressful military experience? 5. Moderate 2 3 4 5 9. Loss of interest in activities that you used to enjoy? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 12. Feeling as if your future will somehow be cut short? 1 2 3 4 5 13. Trouble falling or staying asleep? 1 2 3 4 5 14. Feeling irritable or having angry outbursts? 1 2 3 4 5 15. Having difficulty concentrating? 1 2 3 4 5 16. Being "super-alert" or watchful or on guard? 1 2 3 4 5 1 2 3 4 5 10. Feeling distant or cut off from other people? 11. Feeling emotionally numb or being unable to have loving feelings for those close to you? 17. Feeling jumpy or easily startled? PCL-M for DSM-IV (11/1/94) Weathers, Litz, Huska, & Keane PTSD - Behavioral Science Division 321 National Center for APPENDIX I: INTERVIEW GUIDE Read to clients: During the interview you will not be obligated to answer any of the questions and declining to answer them will not be reflected on you negatively at any time. However, I would like to mention that the following questions have been chosen carefully based on their importance to understanding the meaning-making process after combat. Further, when it comes to surviving traumatic experiences, highly emotional issues tend to be the most important be they positive or negative so if some of these questions are difficult to answer it is because they relate to important issues. Finally, your answers to the following questions will help other veterans because the results of this study will be distributed as widely as possible and built into future efforts to understand how veterans deal with the trauma of combat. Also, I want to note that your privacy is a very important concern. All answers will be combined with those of others and kept confidential so that neither your identity nor identifying information will be made public. Any details, locations, or military units that could potentially be used to identify yourself or others will be changed or omitted to preserve your anonymity to the greatest extent possible. I will be the only person who has direct access to both the interview data and the associated contact information. Only myself, my dissertation chair, and the IRB board will be able to view information from your interview and survey instruments, but any data that they review will be deidentified. The audio files will be deleted at the end of the research project and transcriptions will be maintained in a locked and secured filing cabinet. At any time, feel free to have me repeat the question as often as needed or even feel free to give more than one answer to any question. Research Goal: Beliefs, meanings, and meaning-making processes have been shown to be important to how veterans cope with the trauma and stress of their combat experiences. The goal of this study is to ask you and other veterans to talk about your beliefs regarding war, combat, and your own personal experiences to improve our understanding of how you and others have dealt with it. I believe your contribution along with those of the other combat veterans is critical to understanding the meaningmaking process and will help many other returning wartime veterans. Q: Any questions before we begin? CHECK RECORDING DEVICE Deployment Context 1: In order to give me a sense of context, would you describe your deployment experiences? Prompt: When were you there, what did you do, where did you go? 322 2: Though I understand that you may not want to go into detail, can you generally describe what you experienced during engagements with the enemy? 3: How have these experiences affected you after returning home? 4: How did you process your combat deployment experiences? 5: Do you believe you have dealt with them well or not so well? If no: What have you tried? What has made it difficult to deal with your experiences? If yes: What has worked? CHECK RECORDING DEVICE Overall-meaning 6: Would you share your own personal view of war and the war on terror in general? Prompt: Has this changed since before your own combat deployment? 7: When you think about your combat deployment experiences, how do they relate to your beliefs about the world in general? Prompt: How have your beliefs been either reinforced (strengthened) or changed compared to what they were before your combat deployment? CHECK RECORDING DEVICE Self-meaning 8: Can you talk about what your combat experience meant to you personally and emotionally? Prompt: What did your own decisions while on deployment teach you about yourself or others? CHECK RECORDING DEVICE Family & Friends (Meaning in the Microsystem) 9: How has your combat experience affected your interactions with family and close friends and what does it all mean to you? 10: How have your family/friends been helpful or hurtful to your process of making sense of your combat deployment experiences? 323 CHECK RECORDING DEVICE Military Context (from unit meaning to their oath to defend the constitution) 11: Think about things like the military values you were taught, the quality of information passed down, equipment shortages, your training, or other factors. Could you talk about how your combat experience has been influenced by these or other military factors? Prompt: What do you think about the morale of the unit or units you belonged to? Prompt: What do you think about the quality of leadership you were under? Prompt: How would you rate the level of trust and closeness you had or did not have with others? CHECK RECORDING DEVICE Macro-system Context (your perception of society via direct interaction and media) 12: What did you learn about people in general as a result of your combat experience? 13: Considering the news, other media programming, or your casual interactions with others, how has the civilian portrayal of the war(s) you fought in has affected you? CHECK RECORDING DEVICE Taking the life of another person and the meaning of “the enemy” The following questions are of paramount importance to the study and stand to be the most helpful to future combat veterans. The following questions are also the most difficult for me to ask you. I consider your answers to these, maybe even more than the other questions, to be “sacred ground” and would not ask them if I did not believe they were of utmost value. Remember also, that you are not obligated to answer these questions and there will be no negative consequences for refusing to answer them. These questions have been carefully crafted after consulting with other combat veterans (from Vietnam and OEF/OIF) in order to have the most sensitive and appropriate line of questioning possible. I also wanted to remind you of the confidentiality of your answers and the safeguards in place to ensure that confidentiality. 14: What does the term “enemy” mean to you? 15: Would you share what you believe it means to take the life of another human being during wartime? 324 16: How have these beliefs changed from, or remained the same as, before you experienced combat? CHECK RECORDING DEVICE Spiritual/Existential meaning Asking the next few questions is difficult because we all have different beliefs. Some do not believe in spirituality or religious things at all and others are deeply spiritual or religious. I will use the words spiritual and faith for simplicity. Talking about these beliefs are deeply personal. For this reason, they are also critical to understanding how you have made sense of your experiences during and after your combat deployment. 17a: How were you brought up spiritually regarding war and combat in general? 17b: How has going to combat affected these beliefs (by changing, strengthening, or questioning them)? 18: Would you share how your faith has either sustained you or hindered you during and after combat deployment? Concluding Questions 19: I am most interested in how veterans recover from combat. Is there anything else you would like to add? 325 APPENDIX J: CONTACT SUMMARY To be completed by the researcher within 1 hour of completed interview Participant #: _______________ Date: _____________________ Participant Group: ___________ Interview Site: ______________ Start Time: ________________ End Time: _________________ A. What were the main issues / themes that were most impressive about the interview? B. 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